Integrated Management of Childhood Illness: distance learning course

Integrated Management of Childhood Illness

Chart Booklet

March 2014

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: - Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3 (NLM classification: WS 200) © World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or  of  certain  manufacturers’  products  does  not  imply  that   they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

Integrated Management of Childhood Illness

SICK CHILD AGE 2 MONTHS UP TO 5 YEARS ASSESS AND CLASSIFY THE SICK CHILD ASSESS ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS 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:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS Ask: Look: Is the child able to drink or See if the child is lethargic breastfeed? or unconscious. Does the child vomit Is the child convulsing everything? now? Has the child had convulsions? Any general danger sign URGENT attention Pink: VERY SEVERE DISEASE Give diazepam if convulsing now Quickly complete the assessment Give any pre-referal treatment immediately Treat to prevent low blood sugar Keep the child warm Refer URGENTLY.

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? If yes, ask: For how long? Look, listen, feel*: Count the breaths in one minute. Look for chest indrawing. Look and listen for stridor. Look and listen for wheezing. Classify COUGH or DIFFICULT BREATHING CHILD MUST BE CALM Any general danger sign or Stridor in calm child. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA Give first dose of an appropriate antibiotic Refer URGENTLY to hospital**

Chest indrawing or Fast breathing.

If wheezing with either fast breathing or chest indrawing: Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again, and then classify. If the child is: 2 months up to 12 months 12 Months up to 5 years Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more

Give oral Amoxicillin for 5 days*** If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** If chest indrawing in HIV exposed/infected child, give first dose of amoxicillin and refer. Soothe the throat and relieve the cough with a 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 Follow-up in 3 days If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** Soothe the throat and relieve the cough with a 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 Follow-up in 5 days if not improving

No signs of pneumonia or very severe disease.

Green: COUGH OR COLD

*If pulse oximeter is available, determine oxygen saturation and refer if < 90%. ** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children. ***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings. **** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze.

Does the child have diarrhoea? If yes, ask: Look and feel: For how long? Look at the child's general condition. Is the child: Is there blood in the stool? Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If child has no other severe classification: Give fluid for severe dehydration (Plan C) OR If child also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way 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, zinc supplements, and food for some 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 not improving 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 not improving Treat dehydration before referral unless the child has another severe classification Refer to hospital Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

for DEHYDRATION Classify DIARRHOEA

Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

Dehydration present. and if diarrhoea 14 days or more No dehydration.

Pink: SEVERE PERSISTENT DIARRHOEA Yellow: PERSISTENT DIARRHOEA

and if blood in stool

Blood in the stool.

Yellow: DYSENTERY

Give ciprofloxacin for 3 days Follow-up in 3 days

Does the child have fever?

If yes: Decide Malaria Risk: high or low High or Low Malaria Then ask: Look and feel: Risk For how long? Look or feel for stiff neck. If more than 7 days, has fever been Look for runny nose. Classify FEVER present every day? Look for any bacterial cause of Has the child had measles within the fever**. last 3 months? Look for signs of MEASLES. Generalized rash and One of these: cough, runny nose, or red eyes. Do a malaria test***: If NO severe classification In all fever cases if High malaria risk. In Low malaria risk if no obvious cause of fever present.

Any general danger sign or Stiff neck.

Pink: VERY SEVERE FEBRILE DISEASE

Give first dose of artesunate or quinine for severe malaria Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar or above) Refer URGENTLY to hospital

Malaria test POSITIVE.

Yellow: MALARIA

Give recommended first line oral antimalarial or above) Give appropriate antibiotic treatment for an identified bacterial cause of fever Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment

Malaria test NEGATIVE Other cause of fever PRESENT.

Green: FEVER: NO MALARIA

or above) Give appropriate antibiotic treatment for an identified bacterial cause of fever Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment

No Malaria Risk and No Travel to Malaria Risk Area

Any general danger sign Stiff neck.

Pink: VERY SEVERE FEBRILE DISEASE

Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. or above). Refer URGENTLY to hospital.

No general danger signs No stiff neck.

Green: FEVER or above) Give appropriate antibiotic treatment for any identified bacterial cause of fever Advise mother when to return immediately Follow-up in 2 days if fever persists If fever is present every day for more than 7 days, refer for assessment Give Vitamin A treatment Give first dose of an appropriate antibiotic If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment Refer URGENTLY to hospital Give Vitamin A treatment If pus draining from the eye, treat eye infection with tetracycline eye ointment If mouth ulcers, treat with gentian violet Follow-up in 3 days Give Vitamin A treatment MEASLES

If the child has measles now or within the last 3 months:

Look for mouth ulcers. Are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea.

If MEASLES now or within last 3 months, Classify

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

Pink: SEVERE COMPLICATED MEASLES****

Pus draining from the eye or Mouth ulcers.

Yellow: MEASLES WITH EYE OR MOUTH COMPLICATIONS**** Green:

Measles now or within the last 3 months.

**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children. *** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA. **** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables.

Does the child have an ear problem? If yes, ask: Is there ear pain? Is there ear discharge? If yes, for how long? Look and feel: Look for pus draining from the ear. Feel for tender swelling behind the ear. Tender swelling behind the ear. Classify EAR PROBLEM Pus is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain. Pus is seen draining from the ear and discharge is reported for 14 days or more. No ear pain and No pus seen draining from the ear. Yellow: ACUTE EAR INFECTION Pink: MASTOIDITIS Give first dose of an appropriate antibiotic Give first dose of paracetamol for pain Refer URGENTLY to hospital Give an antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Follow-up in 5 days Dry the ear by wicking Treat with topical quinolone eardrops for 14 days Follow-up in 5 days No treatment

Yellow: CHRONIC EAR INFECTION Green: NO EAR INFECTION

THEN CHECK FOR ACUTE MALNUTRITION CHECK FOR ACUTE MALNUTRITION LOOK AND FEEL: Look for signs of acute malnutrition Look for oedema of both feet. Determine WFH/L* ___ z-score. Measure MUAC**____ mm in a child 6 months or older. If WFH/L less than -3 z-scores or MUAC less than 115 mm, then: Check for any medical complication present: Any general danger signs Any severe classification Pneumonia with chest indrawing If no medical complications present: Child is 6 months or older, offer RUTF*** to eat. Is the child: Not able to finish RUTF portion? Able to finish RUTF portion? Child is less than 6 months, assess breastfeeding: Does the child have a breastfeeding problem? Classify NUTRITIONAL STATUS Oedema of both feet OR WFH/L less than -3 zscores OR MUAC less than 115 mm AND any one of the following: Medical complication present or Not able to finish RUTF or Breastfeeding problem. WFH/L less than -3 zscores OR MUAC less than 115 mm AND Able to finish RUTF. WFH/L between -3 and 2 z-scores OR MUAC 115 up to 125 mm. Yellow: MODERATE ACUTE MALNUTRITION Pink: COMPLICATED SEVERE ACUTE MALNUTRITION Give first dose appropriate antibiotic Treat the child to prevent low blood sugar Keep the child warm Refer URGENTLY to hospital

Yellow: UNCOMPLICATED SEVERE ACUTE MALNUTRITION

Give oral antibiotics for 5 days Give ready-to-use therapeutic food 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 Assess the child's feeding and counsel the mother on the feeding recommendations If feeding problem, follow up in 7 days Assess for possible TB infection. Advise mother when to return immediately Follow-up in 30 days If child is less than 2 years old, assess the child's feeding and counsel the mother on feeding according to the feeding recommendations If feeding problem, follow-up in 7 days

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

Green: NO ACUTE MALNUTRITION

*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 or older. ***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.

THEN CHECK FOR ANAEMIA Check for anaemia Look for palmar pallor. Is it: Severe palmar pallor*? Some palmar pallor? Severe palmar pallor Classify ANAEMIA Classification arrow Some pallor Pink: SEVERE ANAEMIA Yellow: ANAEMIA Refer URGENTLY to hopsital Give iron** 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 If child is less than 2 years old, assess the child's feeding and counsel the mother according to the feeding recommendations If feeding problem, follow-up in 5 days

No palmar pallor

Green: NO ANAEMIA

*Assess for sickle cell anaemia if common in your area. **If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.

THEN CHECK FOR HIV INFECTION Use this chart if the child is NOT enrolled in HIV care. Positive virological test in child Classify HIV status OR Positive serological test in a child 18 months or older Yellow: CONFIRMED HIV INFECTION Initiate ART treatment and HIV care Give cotrimoxazole prophylaxis* counselling to the mother Advise the mother on home care Asess or refer for TB assessment and INH preventive therapy 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 old Negative HIV test in mother or child Green: HIV INFECTION UNLIKELY Treat, counsel and follow-up existing infections Yellow: HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended Do virological test to confirm HIV status** counselling to the mother Advise the mother on home care Follow-up regularly as per national guidelines

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 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? IF NO, THEN TEST: Mother and child status unknown: TEST mother. Mother HIV positive and child status unknown: TEST child.

* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative after cessation of breastfeeding. ** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.

THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS IMMUNIZATION SCHEDULE: Follow national guidelines AGE VACCINE Birth BCG* 6 weeks DPT+HIB-1 10 weeks DPT+HIB-2

OPV-0 OPV-1 OPV-2

Hep B0 Hep B1 Hep B2

RTV1 RTV2

PCV1*** PCV2

VITAMIN A SUPPLEMENTATION Give every child a dose of Vitamin A every six months from the age of 6 months. Record the dose on the child's chart. ROUTINE WORM TREATMENT Give every child mebendazole every 6 months from the age of one year. Record the dose on the child's card.

14 weeks

DPT+HIB-3

OPV-3

Hep B3

RTV3

PCV3

9 months

Measles **

18 months

DPT

*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated. **Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose. ***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.

ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low blood sugar.

HIV TESTING AND INTERPRENTING RESULTS HIV testing is RECOMMENDED for:

Types of HIV Tests What does the test detect? SEROLOGICAL These tests detect antibodies made by TESTS immune cells in response to HIV. (Including rapid They do not detect the HIV virus itself. tests) VIROLOGICAL These tests directly detect the presence of TESTS the HIV virus or products of the virus in the (Including DNA blood. or RNA PCR) For HIV exposed children less than 18 months of age: If PCR or other virological test is available, test from 4 - 6 weeks of age. A positive result means the child is infected. A negative result means the child is not infected, but could become infected if they are still breast feeding. If PCR or other virological test is not available, use HIV antibody test. A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected. Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age Breastfeeding status POSITIVE (+) test NEGATIVE (-) test How to interpret the test? HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not disappear until the child is 18 months of age. This means that a positive serological test in children less than 18 months in NOT a reliable way to check for infection of the child. Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old. If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected.

For HIV exposed children 18 months or older, a positive HIV antibody test result means the child is infected.

NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected last 6 weeks Repeat test at 18 months. BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they could be infected. Repeat test at 18 months or once breastfeeding has been discontinued for more than 6 weeks. Child can still be infected by breastfeeding. Repeat test once breastfeeding has been discontinued for more than 6 weeks.

WHO PAEDIATRIC STAGING FOR HIV INFECTION

Stage 1 Asymptomatic -

Stage 2 Mild Disease -

Stage 3 Moderate Disease Unexplained severe acute malnutrition not responding to standard therapy

Stage 4 Severe Disease (AIDS) Severe unexplained wasting/stunting/severe acute malnutrition not responding to standard therapy

Symptoms/Signs No symptoms, or only: Persistent generalized lymphadenopathy (PGL)

Enlarged liver and/or spleen Enlarged parotid Skin conditions (prurigo, seborraic dermatitis, extensive molluscum contagiosum or warts, fungal nail infection herpes zoster) Mouth conditions recurrent mouth ulcerations, linea gingival Erythema) Recurrent or chronic upper respiratory tract infections (sinusitis, ear infection, tonsilitis, ortorrhea)

Oral thrush (outside neonatal period). Oral hairy leukoplakia. Unexplained and unresponsive to standard therapy: Diarhoea for over 14 days Fever for over 1 month Thrombocytopenia*(under 50,000/mm3 for 1month Neutropenia* (under 500/mm3 for 1 month) Anaemia for over 1 month (haemoglobin under 8 gm)* Recurrent severe bacterial pneumonia Pulmonary TB Lymp node TB Symptomatic lymphoid interstitial pneumonitis (LIP)* Acute necrotising ulcerative gingivitis/periodontitis Chronic HIV associated lung diseses including bronchiectasis*

Oesophageal thrush More than one month of herpes simplex ulcerations. Severe multiple or recurrent bacteria infections > 2 episodes in a year (not including pneumonia) pneumocystis pneumonia (PCP)* Kaposi's sarcoma. Extrapulmonary tuberculosis. Toxoplasma brain abscess* Cryptococcal meningitis* Acquired HIVassociated rectal fistula HIV encephalopathy*

*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.

TREAT THE CHILD CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table. Determine the appropriate drugs and dosage for the child's age or weight. Tell the mother the reason for giving the drug to the child. Demonstrate how to measure a dose. Watch the mother practise measuring a dose by herself. Ask the mother to give the first dose to her child. Explain carefully how to give the drug, then label and package the drug. If more than one drug will be given, collect, count and package each drug separately. Explain that all the oral drug tablets or syrups must be used to finish the course of treatment, even if the child gets better. Check the mother's understanding before she leaves the clinic.

Give an Appropriate Oral Antibiotic FOR PNEUMONIA, ACUTE EAR INFECTION: FIRST-LINE ANTIBIOTIC: Oral Amoxicillin AMOXICILLIN* Give two times daily for 5 days TABLET 250 mg 1 2 3 SYRUP 250mg/5 ml 5 ml 10 ml 15 ml

AGE or WEIGHT

2 months up to 12 months (4 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14-19 kg)

* Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy and increasing high resistance to cotrimoxazole. FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD: ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole COTRIMOXAZOLE (trimethoprim + sulfamethoxazole)

AGE Syrup (40/200 mg/5ml) Less than 6 months 6 months up to 5 years 2.5 ml 5 ml

Give once a day starting at 4-6 weeks of age Paediatric tablet (Single strength 20/100 mg) 1 2 Adult tablet (Single strength 80/400 mg) 1/2

FOR DYSENTERY give Ciprofloxacine FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine AGE Less than 6 months 6 months up to 5 years CIPROFLOXACINE Give 15mg/kg two times daily for 3 days 250 mg tablet 500 mg tablet 1/2 1/4 1 1/2

FOR CHOLERA: FIRST-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________ SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________ ERYTHROMYCIN Give four times daily for 3 days TABLET 250 mg 1 TETRACYCLINE Give four times daily for 3 days TABLET 250 mg 1

AGE or WEIGHT

2 years up to 5 years (10 - 19 kg)

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.

Give Oral Antimalarial for MALARIA If Artemether-Lumefantrine (AL) Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child vomits within an hour repeat the dose. Give second dose at home after 8 hours. Then twice daily for further two days as shown below. Artemether-lumefantrine should be taken with food. If Artesunate Amodiaquine (AS+AQ) Give first dose in the clinic and observe for an hour, if a child vomits within an hour repeat the dose. Then daily for two days as per table below using the fixed dose combination. Artemether-Lumefantrine tablets (20 mg artemether and 120 mg lumefantrine) Give two times daily for 3 days Day 1 5 - <10 kg (2 months up to 12 months) 10 - <14 kg (12 months up to 3 years) 14 - <19 kg (3 years up to 5 years) 1 1 2 Day 2 1 1 2 day 3 1 1 2 Artesunate plus Amodiaquine tablets Give Once a day for 3 days (25 mg AS/67.5 mg AQ) (50 mg AS/135 mg AQ)

Give Inhaled Salbutamol for Wheezing USE OF A SPACER* A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. Repeat up to 3 times every 15 minutes before classifying pneumonia. Spacers can be made in the following way: Use a 500ml drink bottle or similar. Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. This can be done using a sharp knife. Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the bottle. Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as a mask. Flame the edge of the cut bottle with a candle or a lighter to soften it. In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. Alternatively commercial spacers can be used if available. To use an inhaler with a spacer: Remove the inhaler cap. Shake the inhaler well. Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. The child should put the opening of the bottle into his mouth and breath in and out through the mouth. A carer then presses down the inhaler and sprays into the bottle while the child continues to breath normally. Wait for three to four breaths and repeat. For younger children place the cup over the child's mouth and use as a spacer in the same way. * If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.

WEIGHT (age)

Day Day Day 2 Day 3 Day 2 Day 3 1 1 1 1 1 1 1 1 1 1 1

Give paracetamol every 6 hours until high fever or ear pain is gone. AGE or WEIGHT 2 months up to 3 years (4 - <14 kg) 3 years up to 5 years (14 - <19 kg) PARACETAMOL TABLET (100 mg) 1 1 1/2 TABLET (500 mg) 1/4 1/2

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the instructions below for every oral drug to be given at home. Also follow the instructions listed with each drug's dosage table.

Give Iron* Give one dose daily for 14 days. IRON/FOLATE TABLET AGE or WEIGHT Ferrous sulfate Folate (60 mg elemental iron) 2 months up to 4 months (4 <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 19 kg) 1/2 tablet 1/2 tablet Ferrous fumarate 100 mg per 5 ml (20 mg elemental iron per ml) 1.00 ml (< 1/4 tsp.) 1.25 ml (1/4 tsp.) 2.00 ml (<1/2 tsp.) 2.5 ml (1/2 tsp.) IRON SYRUP

* Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should not be given Iron.

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME Explain to the mother what the treatment is and why it should be given. Describe the treatment steps listed in the appropriate box. Watch the mother as she does the first treatment in the clinic (except for remedy for cough or sore throat). Tell her how often to do the treatment at home. If needed for treatment at home, give mother the tube of tetracycline ointment or a small bottle of gentian violet. Check the mothers understanding before she leaves the clinic.

Treat for Mouth Ulcers with Gentian Violet (GV) Treat for mouth ulcers twice daily. Wash hands. Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water. Paint the mouth with half-strength gentian violet (0.25% dilution). Wash hands again. Continue using GV for 48 hours after the ulcers have been cured. Give paracetamol for pain relief.

Soothe the Throat, Relieve the Cough with a Safe Remedy Safe remedies to recommend: Breast milk for a breastfed infant. _____________________________________________________________________________ _____________________________________________________________________________ Harmful remedies to discourage: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Treat Thrush with Nystatin Treat thrush four times daily for 7 days Wash hands Instill nystatin 1ml four times a day Avoid feeding for 20 minutes after medication Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon Give paracetamol if needed for pain

Treat Eye Infection with Tetracycline Eye Ointment Clean both eyes 4 times daily. Wash hands. Use clean cloth and water to gently wipe away pus. Then apply tetracycline eye ointment in both eyes 4 times daily. Squirt a small amount of ointment on the inside of the lower lid. Wash hands again. Treat until there is no pus discharge. Do not put anything else in the eye.

Clear the Ear by Dry Wicking and Give Eardrops* Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, strong tissue paper into a wick. Place the wick in the child's ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry. Instill quinolone eardrops after dry wicking three times daily for two weeks. * Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.

GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC Explain to the mother why the drug is given Determine the dose appropriate for the child's weight (or age) Measure the dose accurately

Give Vitamin A Supplementation and Treatment VITAMIN A SUPPLEMENTATION: Give first dose any time after 6 months of age to ALL CHILDREN Thereafter vitamin A every six months to ALL CHILDREN VITAMIN A TREATMENT: Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A within the past month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A. Always record the dose of Vitamin A given on the child's card. AGE 6 up to 12 months One year and older VITAMIN A DOSE 100 000 IU 200 000 IU

Give Mebendazole Give 500 mg mebendazole as a single dose in clinic if: hookworm/whipworm are a problem in children in your area, and the child is 1 years of age or older, and the child has not had a dose in the previous 6 months.

GIVE THESE TREATMENTS IN THE CLINIC ONLY Explain to the mother why the drug is given. Determine the dose appropriate for the child's weight (or age). Use a sterile needle and sterile syringe when giving an injection. Measure the dose accurately. Give the drug as an intramuscular injection. If child cannot be referred, follow the instructions provided.

Give Artesunate Suppositories or Intramuscular Artesunate or Quinine for Severe Malaria FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE: Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories, artesunate injection or quinine). Artesunate suppository: Insert first dose of the suppository and refer child urgently Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital. IF REFERRAL IS NOT POSSIBLE: For artesunate injection: Give first dose of artesunate intramuscular injection Repeat dose after 12 hrs and daily until the child can take orally Give full dose of oral antimlarial as soon as the child is able to take orally. For artesunate suppository: Give first dose of suppository Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial. Give full dose of oral antimalarial as soon as the child is able to take orally For quinine: Give first dose of intramuscular quinine. The child should remain lying down for one hour. Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able to take an oral antimalarial. Do not continue quinine injections for more than 1 week. If low risk of malaria, do not give quinine to a child less than 4 months of age. RECTAL ARTESUNATE SUPPOSITORY AGE or WEIGHT INTRAMUSCULAR ARTESUNATE INTRAMUSCULAR QUININE 150 mg/ml* (in 2 ml ampoules) 0.4 ml 0.6 ml 0.8 ml 1.0 ml 1.2 ml 300 mg/ml* (in 2 ml ampoules) 0.2 ml 0.3 ml 0.4 ml 0.5 ml 0.6 ml

Give Intramuscular Antibiotics GIVE TO CHILDREN BEING REFERRED URGENTLY Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). AMPICILLIN Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml). IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours. Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4 times. GENTAMICIN 7.5 mg/kg/day once daily AGE or WEIGHT 2 up to 4 months (4 - <6 kg) 4 up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg) AMPICILLIN 500 mg vial 1m 2 ml 3 ml 5m GENTAMICIN 2ml/40 mg/ml vial 0.5-1.0 ml 1.1-1.8 ml 1.9-2.7 ml 2.8-3.5 ml

50 mg 200 mg 60 mg suppositories suppositories vial (20mg/ml) 2.4 Dosage 10 Dosage 10 mg/kg mg/kg mg/kg 1 2 2 3 3 1 1 1/2 ml 1 ml 1.5 ml 1.5 ml 2 ml

2 months up to 4 months (4 - <6 kg)

Give Diazepam to Stop Convulsions Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a tuberculin syringe) or using a catheter. Check for low blood sugar, then treat or prevent. Give oxygen and REFER If convulsions have not stopped after 10 minutes repeat diazepam dose AGE or WEIGHT 2 months up to 6 months (5 - 7 kg) 6 months up to 12months (7 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14-19 kg) DIAZEPAM 10mg/2mls 0.5 ml 1.0 ml 1.5 ml 2.0 ml

4 months up to 12 months (6 - <10 kg) 12 months up to 2 years (10 - <12 kg) 2 years up to 3 years (12 - <14 kg) 3 years up to 5 years (14 - 19 kg) * quinine salt

GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Child to Prevent Low Blood Sugar If the child is able to breastfeed: Ask the mother to breastfeed the child. If the child is not able to breastfeed but is able to swallow: Give expressed breast milk or a breast-milk substitute. If neither of these is available, give sugar water*. Give 30 - 50 ml of milk or sugar water* before departure. If the child is not able to swallow: Give 50 ml of milk or sugar water* by nasogastric tube. 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. * To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water.

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING (See FOOD advice on COUNSEL THE MOTHER chart)

PLAN B: TREAT SOME DEHYDRATION WITH ORS In the clinic, give recommended amount of ORS over 4-hour period DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS WEIGHT < 6 kg AGE* Up to 4 months In ml 200 - 450 6 - <10 kg 4 months up to 12 months 450 - 800 10 - <12 kg 12 months up to 2 years 800 - 960 12 - 19 kg 2 years up to 5 years 960 - 1600

PLAN A: TREAT DIARRHOEA AT HOME Counsel the mother on the 4 Rules of Home Treatment: 1. Give Extra Fluid 2. Give Zinc Supplements (age 2 months up to 5 years) 3. Continue Feeding 4. When to Return. 1. GIVE EXTRA FLUID (as much as the child will take) TELL THE MOTHER: Breastfeed frequently and for longer at each feed. If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water. It is especially important to give ORS at home when: the child has been treated with Plan B or Plan C during this visit. the child cannot return to a clinic if the diarrhoea gets worse. TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME. SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother to: Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue giving extra fluid until the diarrhoea stops. 2. GIVE ZINC (age 2 months up to 5 years) TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab): 2 months up to 6 months 1/2 tablet daily for 14 days 6 months or more 1 tablet daily for 14 days SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup. Older children - tablets can be chewed or dissolved in a small amount of water. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN

* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75. If the child wants more ORS than shown, give more. For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this period if you use standard ORS. This is not needed if you use new low osmolarity ORS. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding whenever the child wants. AFTER 4 HOURS: Reassess the child and classify the child for dehydration. Select the appropriate plan to continue treatment. Begin feeding the child in clinic. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT: Show her how to prepare ORS solution at home. Show her how much ORS to give to finish 4-hour treatment at home. Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A. Explain the 4 Rules of Home Treatment: 1. GIVE EXTRA FLUID 2. GIVE ZINC (age 2 months up to 5 years) 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months) 4. WHEN TO RETURN

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO DOWN. START HERE Can you give intravenous (IV) fluid immediately? NO Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normal saline), divided as follows AGE First give Then give 30 ml/kg in: 70 ml/kg in: Infants (under 12 1 hour* 5 hours months) Children (12 months up 30 minutes* 2 1/2 hours to 5 years) * Repeat once if radial pulse is still very weak or not detectable. Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip or give ORS by naso-gastric tube. Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours while waiting for transfer: If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. If hydration status is not improving after 3 hours, send the child for IV therapy. After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment. NOTE: If the child is not referred to hospital, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.

Is IV treatment available nearby (within 30 minutes)? NO Are you trained to use a naso-gastric (NG) tube for rehydration? NO Can the child drink? NO

Refer URGENTLY to hospital for IV or NG treatment

GIVE READY-TO-USE THERAPEUTIC FOOD Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION Wash hands before giving the ready-to-use therapeutic food (RUTF). Sit with the child on the lap and gently offer the ready-to-use therapeutic food. Encourage the child to eat the RUTF without forced feeding. If still breastfeeding, continue by offering breast milk first before every RUTF feed. Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE MOTHER chart). When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods. Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food. Recommended Amounts of Ready-to-Use Therapeutic Food CHILD'S WEIGHT (kg) 4.0-4.9 kg 5.0-6.9 kg 7.0-8.4 kg 8.5-9.4 kg 9.5-10.4 kg 10.5-11.9 kg >12.0 kg Packets per day (92 g Packets Containing 500 kcal) 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Packets per Week Supply 14 18 21 25 28 32 35

TREAT THE HIV INFECTED CHILD Steps when Initiating ART in Children All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage. Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first. STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION Child is under 18 months: HIV infection is confirmed if virological test (PCR) is positive Child is over 18 months: Two different serological tests are positive Send any further confirmatory tests required If results are discordant, refer If HIV infection is confirmed, and child is in stable condition, GO TO STEP 2 STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART Check that the caregiver is willing and able to give ART. The to another adult who can assist with providing ART, or be part of a support group. Caregiver able to give ART: GO TO STEP 3 Caregiver not able: classify as CONFIRMED HIV INFECTION but NOT ON ART. Counsel and support the caregiver. Follow-up regularly. Move to the step 3 once the caregiver is willing and able to give ART. STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD Record the following information: Weight and height Pallor if present Feeding problem if present Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests that are required. Do not wait for results. GO TO STEP 5 STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY If child is less than 3 kg or has TB, Refer for ART initiation. If child weighs 3 kg or more and does not have TB, GO TO STEP 4

STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS Initiate ART treatement: Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen. Give co-trimoxazole prophylaxis Give other routine treatments, including Vitamin A and immunizations Follow-up regularly as per national guidelines

TREAT THE HIV INFECTED CHILD Preferred and Alternative ARV Regimens AGE Preferred Alternative Children with TB/HIV Infection

Birth up to 3 YEARS

ABC or AZT + 3TC + LPV/r

ABC or AZT + 3TC + NVP

ABC or AZT + 3TC + NVP AZT + 3TC + ABC

3 years and older

ABC + 3TC + EFV

ABC or AZT + 3TC + EFV or NVP

ABC or AZT + 3TC + EFV AZT + 3TC + ABC

Give Antiretroviral Drugs (Fixed Dose Combinations) AZT/3TC WEIGHT (Kg) 3 - 5.9 6 - 9.9 10 - 13.9 14 - 19.9 20 - 24.9 25 - 34.9 1 1.5 2 2.5 3 Twice daily 60/30 mg tablet 300/150 mg tablet 1 AZT/3TC/NVP Twice daily 60/30/50 mg tablet 1 1.5 2 2.5 3 300/150/200 mg tablet 1 ABC/AZT/3TC Twice daily 60/60/30 mg tablet 1 1.5 2 2.5 3 300/300/150 mg tablet 1 ABC/3TC Twice daily 60/30 mg tablet 1 1.5 2 2.5 3 600/300 mg tablet 0.5

TREAT THE HIV INFECTED CHILD Give Antiretroviral Drugs LOPINAVIR / RITONAVIR (LPV/r), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)

LOPINAVIR / RITONAVIR (LPV/r) WEIGHT (KG) 80/20 mg liquid 3 - 5.9 6 - 9.9 10 - 13.9 14 - 19.9 20 - 24.9 25 - 34.9 Twice daily 1 ml 1.5 ml 2 ml 2.5 ml 3 ml 100/25 mg tablet Twice daily 2 2 2 3 Twice daily 5 ml 8 ml 10 ml -

NE VIR AP INE (NVP ) 10 mg/ml liquid 50 mg tablet Twice daily 1 1.5 2 2.5 3 -

EFAVIRENZ (EFV) T arget dos e 15 mg/Konc g e da ily

200 mg tablet Twice daily 1

200 mg tablet Once daily 1 1.5 1.5 2

ABACAVIR (ABC), ZIDOVUDINE (AZT or ZDV) & LAMIVUDINE (3TC)

WEIGHT (KG)

T arget dos e: 8mg/K g/dos e twice daily 20 mg/ml liquid Twice daily 3 ml 4 ml 6 ml 60 mg dispersible tablet Twice daily 1 1.5 2 2.5 3 300 mg tablet Twice daily 1 10 mg/ml liquid Twice daily 6 ml 9 ml 12 ml 60 mg tablet Twice daily 1 1.5 2 2.5 3 300 mg tablet Twice daily 1

AB AC AVIR (AB C )

Z IDO VUDINE (AZ T or Z DV)

L AMIVUDINE (3T C ) 10 mg/ml liquid Twice daily 3 ml 4 ml 6 ml 30 mg tablet Twice daily 1 1.5 2 2.5 3 150 mg tablet Twice daily 1

3 - 5.9 6 - 9.9 10 - 13.9 14 - 19.9 20 - 24.9 25 - 34.9

TREAT THE HIV INFECTED CHILD Side Effects ARV Drugs Very common side-effets: warn patients and suggest ways patients can manage; manage when patients seek care Abacavir (ABC) Potentially serious side effects: warn patients and tell them to seek care Side effects occurring later during treatment: discuss with patients

Seek care urgently: Fever, vomiting, rash - this may indicate hypersensitivity to abacavir Diarrhoea

Lamivudine (3TC) Nausea Lopinavir/ritonavir Nausea Vomiting Diarrhoea Nevirapine (NVP) Nausea Diarrhoea Seek care urgently: Yellow eyes Severe skin rash Fatigue AND shortness of breath Fever Zidovudine (ZDV or AZT) Nausea Diarrhoea Headache Fatigue Muscle pain Efavirenz (EFV) Nausea Diarrhoea Strange dreams Difficulty sleeping Memory problems Headache Dizziness Seek care urgently: Yellow eyes Psychosis or confusion Severe skin rash Seek care urgently: Pallor (anaemia) Changes in fat distribution: Arms, legs, buttocks, cheeks become THIN Breasts, tummy, back of neck become FAT Elevated blood cholesterol and glucose

TREAT THE HIV INFECTED CHILD Manage Side Effects of ARV Drugs SIGNS or SYMPTOMS Yellow eyes (jaundice) or abdominal pain Rash Nausea Vomiting APPROPRIATE CARE RESPONSE Stop drugs and REFER URGENTLY If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is associated with fever or vomiting: stop drugs and REFER URGENTLY Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer. Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being given. If vomiting persists, the caregiver should bring the child to clinic for evaluation. If vomiting everything, or vomiting associated with severe abdominal pain or difficulty breathing, REFER URGENTLY. Diarrhoea Fever Headache Sleep disturbances, nightmares, anxiety Tingling, numb or painful feet or legs Changes in fat distribution Assess, classify, and treat using diarrhoea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If not improved after two weeks, call for advice or refer. Assess, classify, and treat using feve chart. Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or refer. This may be due to efavirenz. Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for advice or refer. If new or worse on treatment, call for advice or refer. Consider switching from stavudine to abacavir, consider to viral load. Refer if needed.

TREAT THE HIV INFECTED CHILD Give Pain Relief to HIV Infected Child Give paracetamol or ibuprofen every 6 hours if pain persists. For severe pain, morphine syrup can be given. AGE or WEIGHT 2 up to 4 months (4 - <6 kg) 4 up to 12 months (6 - <10 kg) 12 months up to 2 years (10 - <12 kg) 2 up to 3 years (12 - <14 kg) 3 up to 5 years (14 -<19 kg) Recommended dosages for ibuprofen ibuprofen in children under the age of 3 months. PARACETAMOL TABLET (100 mg) 1 1 1/2 2 2 SYRUP (120 mg/5ml) 2 ml 2.5 ml 5 ml 7.5 ml 10 ml ORAL MORPHINE (0.5 mg/5 ml) 0.5 ml 2 ml 3 ml 4 ml 5 ml

IMMUNIZE EVERY SICK CHILD AS NEEDED

FOLLOW-UP GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS Care for the child who returns for follow-up using all the boxes that match the child's previous classifications. If the child has any new problem, assess, classify and treat the new problem as on the ASSESS AND CLASSIFY chart.

DYSENTERY After 3 days: Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart. Ask: Are there fewer stools? Is there less blood in the stool? Is there less fever? Is there less abdominal pain? Is the child eating better? Treatment: If the child is dehydrated, treat dehydration. If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or the same: Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days. Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to hospital. Exceptions - if the child: is less than 12 months old, or was dehydrated on the first visit, or REFER to hospital. if he had measles within the last 3 months If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving ciprofloxacin until finished. Ensure that mother understands the oral rehydration method fully and that she also understands the need for an extra meal each day for a week.

PNEUMONIA After 3 days: Check the child for general danger signs. Assess the child for cough or difficult breathing. Ask: Is the child breathing slower? Is there a chest indrawing? Is there less fever? Is the child eating better? See ASSESS & CLASSIFY chart.

Treatment: If any general danger sign or stridor, refer URGENTLY to hospital. If chest indrawing and/or breathing rate, fever and eating are the same or worse, refer URGENTLY to hospital. If breathing slower, no chest indrawing, less fever, and eating better, complete the 5 days of antibiotic.

PERSISTENT DIARRHOEA After 5 days: Ask: Has the diarrhoea stopped? How many loose stools is the child having per day? Treatment: If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Treat for dehydration if present. Then refer to hospital. If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child's age.

MALARIA If fever persists after 3 days: Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit. Treatment: If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If the child has any othercause of fever other than malaria, provide appropriate treatment. If there is no other apparent cause of fever: If fever has been present for 7 days, refer for assessment. Do microscopy to look for malaria parasites. If parasites are present and the child has finished a full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the child to a hospital. If there is no other apparent cause of fever and you do not have a microscopy to check for parasites, refer the child to a hospital.

GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

EAR INFECTION FEVER: NO MALARIA If fever persists after 3 days: Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Repeat the malaria test. Treatment: If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3 days if the fever persists. If the child has any other cause of fever other than malaria, provide treatment. If there is no other apparent cause of fever: If the fever has been present for 7 days, refer for assessment. After 5 days: Reassess for ear problem. > See ASSESS & CLASSIFY chart. Measure the child's temperature. Treatment: If there is , refer URGENTLY to hospital. Acute ear infection: If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days. If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the 5 days of antibiotic, tell her to use all of it before stopping. Chronic ear infection: Check that the mother is wicking the ear correctly and giving quinolone drops tree times a day. Encourage her to continue.

MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR MOUTH ULCERS, OR THRUSH After 3 days: Look for red eyes and pus draining from the eyes. Look at mouth ulcers or white patches in the mouth (thrush). Smell the mouth. Treatment for eye infection: If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct treatment. If the pus is gone but redness remains, continue the treatment. If no pus or redness, stop the treatment. Treatment for mouth ulcers: If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital. If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5 days. Treatment for thrush: If thrush is worse check that treatment is being given correctly. If the child has problems with swallowing, refer to hospital. If thrush is the same or better, and the child is feeding well, continue nystatine for a total of 7 days.

FEEDING PROBLEM After 7 days: Reassess feeding. > See questions in the COUNSEL THE MOTHER chart. Ask about any feeding problems found on the initial visit. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the child back again. If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to return 30 days after the initial visit to measure the child's WFH/L, MUAC.

ANAEMIA After 14 days: Give iron. Advise mother to return in 14 days for more iron. Continue giving iron every 14 days for 2 months. If the child has palmar pallor after 2 months, refer for assessment.

GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

UNCOMPLICATED SEVERE ACUTE MALNUTRITION After 14 days or during regular follow up: Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Assess child with the same measurements (WFH/L, MUAC) as on the initial visit. Check for oedema of both feet. Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older. Treatment: If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication or oedema, or fails the appetite test), refer URGENTLY to hospital. If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask mother to return again in 14 days. If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell scores or more, and/or MUAC is 125 mm or more. If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart).

MODERATE ACUTE MALNUTRITION After 30 days: Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit: If WFH/L, weigh the child, measure height or length and determine if WFH/L. If MUAC, measure using MUAC tape. Check the child for oedema of both feet. Reassess feeding. See questions in the COUNSEL THE MOTHER chart. Treatment: If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and encourage her to continue. If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any feeding problem found. Ask the mother to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or MUAC is 125 mm. or more. Exception: If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has diminished, refer the child.

GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD

CONFIRMED HIV INFECTION NOT ON ART HIV EXPOSED Follow up regularly as per national guidelines. At each follow-up visit follow these instructions: Ask the mother: Does the child have any problems? Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any new problem Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and counselling Continue cotrimoxazole prophylaxis Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How often, if ever, does the child/mother miss a dose? Plan for the next follow-up visit HIV testing: If new HIV test result became available since the last visit, reclassify the child for HIV according to the test result. to the test result. If child is confirmed HIV infected Start on ART and enrol in chronic HIV care. Continue follow-up as for CONFIRMED HIV INFECTION ON ART If child is confirmed uninfected Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks of cessation of breastfeeding. Counsel mother on preventing HIV infection through breastfeeding and about her own health Follow up regularly as per national guidelines. At each follow-up visit follow these instructions: Ask the mother: Does the child have any problems? Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any new problem Counsel and check if mother able or willing now to initiate ART for the child. Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and counselling Continue cotrimoxazole prophylaxis if indicated. Initiate or continue isoniazid preventive therapy if indicated. If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children) Monitor CD4 count and percentage. Home care: Counsel the mother about any new or continuing problems If appropriate, put the family in touch with organizations or people who could provide support Advise the mother about hygiene in the home, in particular when preparing food Plan for the next follow-up visit

GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF FOLLOW-UP CARE Follow up regularly as per national guidelines. STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART ASK: Does the child have any IF ANY OF FOLLOWING PRESENT, REFER problems? NON-URGENTLY: Has the child received care at another If any of these health facility since the last visit? present, refer NONCHECK: for general danger signs - If URGENTLY: present, complete assessment, give Record the Child's weight Not gaining pre-referral treatment, REFER and height weight for 3 URGENTLY. months Assess adherence ASSESS, CLASSIFY, TREAT and Loss of Ask about adherence: how COUNSEL any sick child as milestones often, if ever, does the appropriate. child miss a dose? Record Poor CHECK for ART severe side effects your assessment. adherence Stage Assess and record clinical Severe worse than stage skin rash before Assess clinical stage. Difficulty CD4 count breathing lower than stage at previous visits. and If present, give before severe Monitor laboratory results any preLDL higher abdominal Record results of tests referral than 3.5 pain that have been sent. treatment, mmol/L Yellow REFER TG higher eyes URGENTLY than 5.6 Fever, mmol/L vomiting, Manage side effects rash (only Send tests that are due if on Abacavir) Check for other ART side effects STEP 3: PROVIDE ART, STEP 4: COUNSEL THE MOTHER OR CAREGIVER COTRIMOXAZOLE AND ROUTINE Use every visit to educate and provide support to TREATMENTS the mother or caregiver If child is stable: continue with the ART regimen and cotrimoxazole doses. Key issues to discuss include: Check for appropriate doses: remember these will need to increase How the child is progressing, feeding, adherence, as the child grows side-effects and correct management, disclosure Give routine care: Vitamin A (to others and the child), support for the caregiver supplementation, deworming, and Remember to check that the mother and other immunization as needed family members are receiving the care that they need Set a follow-up visit: if well, follow-up as per nastional guidelines. If problems, follow-up as indicated.

COUNSEL THE MOTHER FEEDING COUNSELLING Assess Child's Appetite All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (oedema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical complication should be assessed for appetite. Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed to eating the RUTF. Usually the child eats the RUTF portion in 30 minutes. Explain to the mother: The purpose of assessing the child's appetite. What is ready-to-use-therapeutic food (RUTF). How to give RUTF: Wash hands before giving the RUTF. Sit with the child on the lap and gently offer the child RUTF to eat. Encourage the child to eat the RUTF without feeding by force. Offer plenty of clean water to drink from a cup when the child is eating the RUTF. Offer appropriate amount of RUTF to the child to eat: After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide: Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes. Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.

FEEDING COUNSELLING Assess Child's Feeding Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED. Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age. ASK - How are you feeding your child? If the child is receiving any breast milk, ASK: How many times during the day? Do you also breastfeed during the night?

Does the child take any other food or fluids? What food or fluids? How many times per day? What do you use to feed the child? If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK: How large are servings? Does the child receive his own serving? Who feeds the child and how? What foods are available in the home? During this illness, has the child's feeding changed? If yes, how?

In addition, for HIV EXPOSED child: If mother and child are on ARV treatment or prophylaxis and child breastfeeding, ASK: Do you take ARV drugs? Do you take all doses, miss doses, do not take medication? Does the child take ARV drugs (If the policy is to take ARV prophylaxis until 1 week after breastfeeding has stopped)? Does he or she take all doses, missed doses, does not take medication? If child not breastfeeding, ASK: What milk are you giving? How many times during the day and night? How much is given at each feed? How are you preparing the milk? Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant. Are you giving any breast milk at all? Are you able to get new supplies of milk before you run out? How is the milk being given? Cup or bottle? How are you cleaning the feeding utensils?

FEEDING COUNSELLING Feeding Recommendations Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis Newborn, birth up to 1 week 1 week up to 6 months 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older

Immediately after birth, put your baby in skin to skin contact with you. Allow your baby to take the breast within the first hour. Give your baby colostrum, the first yellowish, thick milk. It protects the baby from many Illnesses. Breastfeed day and night, as often as your baby wants, at least 8 times In 24 hours. Frequent feeding produces more milk. If your baby is small (low birth weight), feed at least every 2 to 3 hours. Wake the baby for feeding after 3 hours, if baby does not wake self. DO NOT give other foods or fluids. Breast milk is all your baby needs. This is especially important for infants of HIVpositive mothers. Mixed feeding increases the risk of HIV mother-to-child transmission when compared to exclusive breastfeeding.

Breastfeed as often as your child wants. Look for signs of hunger, such as beginning to fuss, sucking fingers, or moving lips. Breastfeed day and night whenever your baby wants, at least 8 times in 24 hours. Frequent feeding produces more milk. Do not give other foods or fluids. Breast milk is all your baby needs.

Breastfeed as often as your child wants. Also give thick porridge or wellmashed foods, including animalsource foods and vitamin A-rich fruits and vegetables. Start by giving 2 to 3 tablespoons of food. Gradually increase to 1/2 cups (1 cup = 250 ml). Give 2 to 3 meals each day. Offer 1 or 2 snacks each day between meals when the child seems hungry.

Breastfeed as often as your child wants. Also give a variety of mashed or finely chopped family food, including animalsource foods and vitamin A-rich fruits and vegetables. Give 1/2 cup at each meal(1 cup = 250 ml). Give 3 to 4 meals each day. Offer 1 or 2 snacks between meals. The child will eat if hungry. For snacks, give small chewable items that the child can hold. Let your child try to eat the snack, but provide help if needed.

Breastfeed as often as your child wants. Also give a variety of mashed or finely chopped family food, including animalsource foods and vitamin A-rich fruits and vegetables. Give 3/4 cup at each meal (1 cup = 250 ml). Give 3 to 4 meals each day. Offer 1 to 2 snacks between meals. Continue to feed your child slowly, patiently. Encourage your child to eat.

Give a variety of family foods to your child, including animalsource foods and vitamin A-rich fruits and vegetables. Give at least 1 full cup (250 ml) at each meal. Give 3 to 4 meals each day. Offer 1 or 2 snacks between meals. If your child refuses a new food, offer "tastes" several times. Show that you like the food. Be patient. Talk with your child during a meal, and keep eye contact.

A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.

FEEDING COUNSELLING Feeding Recommendations for HIV EXPOSED Child on Infant Formula These feeding recommendations are for HIV EXPOSED children in setting where the national authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding. PMTCT: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age. Up to 6 months 6 up to 12 monts 12 months up to 2 years Safe preparation of replacement feeding

Infant formula Always use a marked cup or glass and spoon to measure water and the scoop to measure the formula powder. Wash your hands before preparing a feed. Bring the water to boil and then let it cool. Keep it covered while it cools. Measure the formula powder into a marked cup or glass. Make the scoops level. Put in one scoop for every 25 ml of water. Add a small amount of the cooled boiled water and stir. Fill the cup or glass to the mark with the water. Stir well. Feed the infant using a cup. Wash the utensils.

FORMULA FEED exclusively. Do not give any breast milk. Other foods or fluids are not necessary. Prepare correct strength and amount just before use. Use milk within two can store formula for 24 hours. Cup feeding is safer than bottle feeding. Clean the cup and utensils with hot soapy water. Give the following amounts of formula 8 to 6 times per day: Age in months Approx. amount and times per day 0 up to 1 60 ml x 8 1 up to 2 90 ml x 7 2 up to 4 120 ml x 6 4 up to 6 150 ml x 6

Give 1-2 cups (250 - 500 ml) of infant formula or boiled, then cooled, full cream milk. Give milk with a cup, not a bottle. Give:

Give 1-2 cups (250 - 500 ml) of boiled, then cooled, full cream milk or infant formula. Give milk with a cup, not a bottle. Give:

* Start by giving 2-3 tablespoons of food 2 - 3 times a day. Gradually increase to 1/2 cup (1 cup = 250 ml) at each meal and to giving meals 3-4 times a day. Offer 1-2 snacks each day when the child seems hungry. For snacks give small chewable items that the child can hold. Let your child try to eat the snack, but provide help if needed.

* or family foods 3 or 4 times per day. Give 3/4 cup (1 cup = 250 ml) at each meal. Offer 1-2 snacks between meals. Continue to feed your child slowly, patiently. Encourage - but do not force - your child to eat.

Cow' s or other animal milks are not suitable for infants below 6 months of age (even modified). For a child between 6 and 12 month of age: boil the milk and let it cool (even if pasteurized). Feed the baby using a cup.

* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.

FEEDING COUNSELLING Stopping Breastfeeding STOPPING BREASTFEEDING means changing from all breast milk to no breast milk. This should happen gradually over one month. Plan in advance for a safe transition. 1. HELP MOTHER PREPARE: Mother should discuss and plan in advance with her family, if possible Express milk and give by cup Learn how to prepare a store milk safely at home 2. HELP MOTHER MAKE TRANSITION: Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2 months) Clean all utensils with soap and water 3. STOP BREASTFEEDING COMPLETELY: Express and discard enough breast milk to keep comfortable until lactation stops

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA If still breastfeeding, give more frequent, longer breastfeeds, day and night. If taking other milk: replace with increased breastfeeding OR replace with fermented milk products, such as yoghurt OR replace half the milk with nutrient-rich semisolid food. For other foods, follow feeding recommendations for the child's age.

EXTRA FLUIDS AND MOTHER'S HEALTH Advise the Mother to Increase Fluid During Illness FOR ANY SICK CHILD: Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given. Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water. FOR CHILD WITH DIARRHOEA: Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

Counsel the Mother about her Own Health If the mother is sick, provide care for her, or refer her for help. If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help. Advise her to eat well to keep up her own strength and health. Check the mother's immunization status and give her tetanus toxoid if needed. Make sure she has access to: Family planning Counselling on STD and AIDS prevention. Give additional counselling if the mother is HIV-positive Emphasize good hygiene, and early treatment of illnesses

WHEN TO RETURN Advise the Mother When to Return to Health Worker FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the child's problems. If the child has: PNEUMONIA DYSENTERY MALARIA, if fever persists FEVER: NO MALARIA, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS MOUTH OR GUM ULCERS OR THRUSH PERSISTENT DIARRHOEA ACUTE EAR INFECTION CHRONIC EAR INFECTION COUGH OR COLD, if not improving UNCOMPLICATED SEVERE ACUTE MALNUTRITION FEEDING PROBLEM ANAEMIA MODERATE ACUTE MALNUTRITION CONFIRMED HIV INFECTION HIV EXPOSED Return for follow-up in: 3 days

WHEN TO RETURN IMMEDIATELY Advise mother to return immediately if the child has any of these signs: Any sick child Not able to drink or breastfeed Becomes sicker Develops a fever If child has COUGH OR COLD, also return if: Fast breathing Difficult breathing If child has diarrhoea, also return if: Blood in stool Drinking poorly

5 days

14 days

14 days 30 days According to national recommendations

NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to immunization schedule.

SICK YOUNG INFANT AGE UP TO 2 MONTHS ASSESS AND CLASSIFY THE SICK YOUNG INFANT ASSESS DO A RAPID APRAISAL OF ALL WAITING INFANTS ASK THE MOTHER WHAT THE YOUNG INFANT'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this problem. if follow-up visit, use the follow-up instructions. if initial visit, assess the child as follows:

CLASSIFY

IDENTIFY TREATMENT

USE ALL BOXES THAT MATCH THE INFANT'S SYMPTOMS AND PROBLEMS TO CLASSIFY THE ILLNESS

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION ASK: Is the infant having difficulty in feeding? Has the infant had convulsions (fits)? LOOK, LISTEN, FEEL: Count the breaths in one YOUNG minute. Repeat INFANT the count if more MUST than 60 breaths BE per minute. CALM Look for severe chest indrawing. Measure axillary temperature. Look at the umbilicus. Is it red or draining pus? Look for skin pustules. Look at the young infant's movements. If infant is sleeping, ask the mother to wake him/her. Does the infant move on his/her own? If the young infant is not moving, gently stimulate him/her. Does the infant not move at all? Classify ALL YOUNG INFANTS Any one of the following signs Not feeding well or Convulsions or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or or Low body temperature (less or Movement only when stimulated or no movement at all. Pink: VERY SEVERE DISEASE Give first dose of intramuscular antibiotics Treat to prevent low blood sugar Refer URGENTLY to hospital ** Advise mother how to keep the infant warm on the way to the hospital

Umbilicus red or draining pus Yellow: Skin pustules LOCAL BACTERIAL INFECTION None of the signs of very severe disease or local bacterial infection Green: SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

Give an appropriate oral antibiotic Teach the mother to treat local infections at home Advise mother to give home care for the young infant Follow up in 2 days Advise mother to give home care.

** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.

CHECK FOR JAUNDICE If jaundice present, ASK: When did the jaundice appear first? LOOK AND FEEL: Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Any jaundice if age less than 24 hours or Yellow palms and soles at any age Pink: SEVERE JAUNDICE Treat to prevent low blood sugar Refer URGENTLY to hospital Advise mother how to keep the infant warm on the way to the hospital Advise the mother to give home care for the young infant Advise mother to return immediately if palms and soles appear yellow. If the young infant is older than 14 days, refer to a hospital for assessment Follow-up in 1 day Advise the mother to give home care for the young infant

CLASSIFY

JAUNDICE

Jaundice appearing after 24 Yellow: hours of age and JAUNDICE Palms and soles not yellow

No jaundice

Green: NO JAUNDICE

THEN ASK: Does the young infant have diarrhoea*? IF YES, LOOK AND FEEL: Look at the young infant's general condition: Infant's movements Does the infant move on his/her own? Does the infant not move even when stimulated but then stops? Does the infant not move at all? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? or slowly? Two of the following signs: Movement only when stimulated or no movement at all Sunken eyes Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If infant has no other severe classification: Give fluid for severe dehydration (Plan C) OR If infant also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Give fluid and breast milk for some dehydration (Plan B) If infant has any 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 2 days if not improving Give fluids to treat diarrhoea at home and continue breastfeeding (Plan A) Advise mother when to return immediately Follow-up in 2 days if not improving

Classify DIARRHOEA for DEHYDRATION

Two of the following signs: Restless and irritable Sunken eyes Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

* What is diarrhoea in a young infant? A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter). The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

THEN CHECK FOR HIV INFECTION ASK Has the mother and/or young infant had an HIV test? IF YES: What is the mother's HIV status?: Serological test POSITIVE or NEGATIVE What is the young infant's HIV status?: Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE OR If mother is HIV positive and NO positive virological test in child ASK: Is the young infant breastfeeding now? Was the young infant breastfeeding at the time of test or before it? Is the mother and young infant on PMTCT ARV prophylaxis?* OR Positive serological test in young infant Negative HIV test in mother or young infant Green: HIV INFECTION UNLIKELY Treat, counsel and follow-up existing infections Mother HIV positive, young infant not yet tested Classify HIV status Mother HIV positive AND negative virological test in young infant breastfeeding or if only stopped less than 6 weeks ago. Positive virological test in young infant Yellow: CONFIRMED HIV INFECTION Give cotrimoxazole prophylaxis from age 4-6 weeks Give HIV ART and care Advise the mother on home care Follow-up regularly as per national guidelines Give cotrimoxazole prophylaxis from age 4-6 weeks Start or continue PMTCT ARV prophylaxis as per national recommendations** Do virological test at age 4-6 weeks or repeat 6 weeks after the child stops breastfeeding Advise the mother on home care Follow-up regularly as per national guidelines

Yellow: HIV EXPOSED

IF NO test: Mother and young infant status unknown Perform HIV test for the mother; if positive, perform virological test for the young infant

* Prevention of Maternal-To-Child-Transmission (PMTCT) ART prophylaxis. **Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis from birth for 6 weeks if breastfeeding or 4-6 weeks if on replacement feeding.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS" If an infant has no indications to refer urgently to hospital: Ask: LOOK, LISTEN, FEEL: Is the infant breastfed? If Determine weight for age. yes, how many times in 24 Look for ulcers or white hours? patches in the mouth Does the infant usually (thrush). receive any other foods or drinks? If yes, how often? If yes, what do you use to feed the infant? 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). Yellow: FEEDING PROBLEM OR LOW WEIGHT If not well attached or not suckling effectively, teach correct positioning and attachment If not able to attach well immediately, teach the mother to express breast milk and feed by a cup If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. Advise the mother to breastfeed as often and as long as the infant wants, day and night If receiving other foods or drinks, counsel the 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 preparing breast-milk substitutes and using a cup Advise the mother how to feed and keep the low weight infant warm at home 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 Not low weight for age and no other signs of inadequate feeding. Green: NO FEEDING PROBLEM Advise mother to give home care for the young infant Praise the mother for feeding the infant well

Classify FEEDING

ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (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 well attached? not well attached good attachment TO CHECK ATTACHMENT, LOOK FOR: Chin touching breast Mouth wide open Lower lip turned outwards More areola visible above than below the mouth (All of these signs should be present if the attachment is good.) Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding. * Unless not breastfeeding because the mother is HIV positive.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS Use this chart for HIV EXPOSED infants not breastfeeding AND the infant has no indications to refer urgently to hospital: Ask: LOOK, LISTEN, FEEL: What milk are you giving? Determine weight for age. How many times during the Look for ulcers or white day and night? patches in the mouth (thrush). How much is given at each feed? How are you preparing the milk? Let mother demonstrate or explain how a feed is prepared, and how it is given to the infant. Are you giving any breast milk at all? What foods and fluids in addition to replacement feeds is given? How is the milk being given? Cup or bottle? How are you cleaning the feeding utensils? Milk incorrectly or unhygienically prepared or Classify FEEDING Giving inappropriate replacement feeds or Giving insufficient replacement feeds or An HIV positive mother mixing breast and other feeds before 6 months or Using a feeding bottle 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. Green: NO FEEDING PROBLEM Yellow: FEEDING PROBLEM OR LOW WEIGHT Counsel about feeding Explain the guidelines for safe replacement feeding Identify concerns of mother and family about feeding. If mother is using a bottle, teach cup feeding Advise the mother how to feed and keep the low weight infant warm at home 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 Praise the mother for feeding the infant well

THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS: IMMUNIZATION SCHEDULE: AGE Birth VACCINE BCG OPV-0 Hep B0 VITAMIN A 200 000 IU to the mother within 6 weeks of delivery RTV1 PCV1

6 weeks Give all missed doses on this visit. Include sick infants unless being referred. Advise the caretaker when to return for the next dose.

DPT+HIB-1

OPV-1

Hep B1

ASSESS OTHER PROBLEMS

Nutritional status and anaemia, contraception. Check hygienic practices.

TREAT AND COUNSEL TREAT THE YOUNG INFANT GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS Give first dose of both ampicillin and gentamicin intramuscularly. AMPICILLIN Dose: 50 mg per kg To a vial of 250 mg WEIGHT Add 1.3 ml sterile water = 250 mg/1.5ml 1-<1.5 kg 1.5-<2 kg 2-<2.5 kg 2.5-<3 kg 3-<3.5 kg 3.5-<4 kg 4-<4.5 kg * Avoid using undiluted 40 mg/ml gentamicin.

GENTAMICIN Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 ml sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml AGE <7 days AGE >= 7 days Dose: 5 mg per kg Dose: 7.5 mg per kg 0.6 ml* 0.9 ml* 0.9 ml* 1.3 ml* 1.1 ml* 1.7 ml* 1.4 ml* 2.0 ml* 1.6 ml* 2.4 ml* 1.9 ml* 2.8 ml* 2.1 ml* 3.2 ml*

0.4 ml 0.5 ml 0.7 ml 0.8 ml 1.0 ml 1.1 ml 1.3 ml

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.

TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR If the young infant is able to breastfeed: Ask the mother to breastfeed the young infant. If the young infant is not able to breastfeed but is able to swallow: Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10 ml/kg) sugar water (To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water). If the young infant is not able to swallow: Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.

TREAT THE YOUNG INFANT TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM ON THE WAY TO THE HOSPITAL Provide skin to skin contact OR Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL BACTERIAL INFECTION First-line antibiotic: ___________________________________________________________________________________________ Second-line antibiotic:_________________________________________________________________________________________ AGE or WEIGHT Birth up to 1 month (<4 kg) 1 month up to 2 months (4-<6 kg) . AMOXICILLIN Give 2 times daily for 5 days Tablet 250 mg 1/4 1/2 Syrup 125 mg in 5 ml 2.5 ml 5 ml

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME Explain how the treatment is given. Watch her as she does the first treatment in the clinic. Tell her to return to the clinic if the infection worsens. To Treat Skin Pustules or Umbilical Infection The mother should do the treatment twice daily for 5 days: Wash hands Gently wash off pus and crusts with soap and water Dry the area Paint the skin or umbilicus/cord with full strength gentian violet (0.5%) Wash hands To Treat Thrush (ulcers or white patches in mouth) The mother should do the treatment four times daily for 7 days: Wash hands Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger Wash hands

To Treat Diarrhoea, See TREAT THE CHILD Chart.

TREAT THE YOUNG INFANT Immunize Every Sick Young Infant, as Needed

GIVE ARV FOR PMTCT PROPHYLAXIS Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis*: Nevirapine or zidovudine are provided to young infant classified as HIV EXPOSED to minimize the risk of mother-to-child HIV transmission (PMTCT). If breast feeding: Give NVP for 6 weeks beginning at birth or when HIV exposure is recognized. If not breast feeding: Give NVP or ZDV for 4-6 weeks beginning at birth or when HIV exposure is recognized. AGE Birth up to 6 weeks: Birth weight 2000 - 2499 g Birth weight > 2500 g Over 6 weeks: 10 mg 15 mg 20 mg 10 mg 15 mg NEVIRAPINE Give once daily. ZIDOVUDINE (AZT) Give once daily

* PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART PROPHYLAXIS: OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING. OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NVP OR AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.

COUNSEL THE MOTHER

TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING Show the mother how to hold her infant. with the infant's head and body in line. with the infant approaching breast with nose opposite to the nipple. with the infant held close to the mother's body. with the infant's whole body supported, not just neck and shoulders. Show her how to help the infant to attach. She should: touch her infant's lips with her nipple wait until her infant's mouth is opening wide move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple. Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT WARM AT HOME Keep the young infant in the same bed with the mother. of cold air. Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing and clothe the young infant immediately. Change clothes (e.g. nappies) whenever they are wet. Provide skin to skin contact as much as possible, day and night. For skin to skin contact: Dress the infant in a warm shirt open at the front, a nappy, hat and socks. Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's head turned to one side. Cover the infant with mother's clothes (and an additional warm blanket in cold weather). When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket. Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact. Breastfeed the infant frequently (or give expressed breast milk by cup).

TEACH THE MOTHER HOW TO EXPRESS BREAST MILK Ask the mother to: Wash her hands thoroughly. Make herself comfortable. Hold a wide necked container under her nipple and areola. Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other (at least 4 cm from the tip of the nipple). Compress and release the breast tissue between her finger and thumb a few times. If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before. Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on the skin. Express one breast until the milk just drips, then express the other breast until the milk just drips. Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes. Stop expressing when the milk no longer flows but drips from the start.

TEACH THE MOTHER HOW TO FEED BY A CUP Put a cloth on the infant's front to protect his clothes as some milk can spill. Hold the infant semi-upright on the lap. Put a measured amount of milk in the cup. Hold the cup so that it rests lightly on the infant's lower lip. Tip the cup so that the milk just reaches the infant's lips. Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.

COUNSEL THE MOTHER

ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG INFANT 1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the infant wants. 2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES. In cool weather cover the infant's head and feet and dress the infant with extra clothing. 3. WHEN TO RETURN: Follow up visit If the infant has: Return for first follow-up in: 1 day JAUNDICE 2 days LOCAL BACTERIAL INFECTION FEEDING PROBLEM THRUSH DIARRHOEA 14 days LOW WEIGHT FOR AGE CONFIRMED HIV INFECTION HIV EXPOSED WHEN TO RETURN IMMEDIATELY: Advise the mother to return immediately if the young infant has any of these signs: Breastfeeding poorly Reduced activity Becomes sicker Develops a fever Feels unusually cold Fast breathing Difficult breathing Palms and soles appear yellow According to national recommendations

FOLLOW-UP GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT

LOCAL BACTERIAL INFECTION After 2 days: Look at the umbilicus. Is it red or draining pus? Look at the skin pustules. Treatment: If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home. If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

DIARRHOEA After 2 days: Ask: Has the diarrhoea stopped? Treatment If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?" If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT JAUNDICE After 1 day: Look for jaundice. Are palms and soles yellow? Treatment: If palms and soles are yellow, refer to hospital. If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day. If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer the young infant to a hospital for further assessment.

FEEDING PROBLEM After 2 days: Reassess feeding. > See "Then Check for Feeding Problem or Low Weight". Ask about any feeding problems found on the initial visit. Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the young infant back again. If the young infant is low weight for age, ask the mother to return 14 days of this follow up visit. Continue follow-up until the infant is gaining weight well. Exception: If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

LOW WEIGHT FOR AGE After 14 days: Weigh the young infant and determine if the infant is still low weight for age. Reassess feeding. > See "Then Check for Feeding Problem or Low Weight". If the infant is no longer low weight for age, praise the mother and encourage her to continue. If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within 14 days or when she returns for immunization, whichever is the earlier. If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she returns for immunization, if this is within 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly and is no longer low weight for age. Exception: If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT THRUSH After 2 days: Look for ulcers or white patches in the mouth (thrush). Reassess feeding. > See "Then Check for Feeding Problem or Low Weight". If thrush is worse check that treatment is being given correctly. If the infant has problems with attachment or suckling, refer to hospital. If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.

CONFIRMED HIV INFECTION OR HIV EXPOSED A young infant classified as CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits regularly as per national guidelines. Follow the instructions for follow-up care for child aged 2 months up to 5 years.

Annex: Skin Problems IDENTIFY SKIN PROBLEM

IDENTIFY SKIN PROBLEM IF SKIN IS ITCHING SIGNS Itching rash with small papules and scratch marks. Dark spots with pale centres CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV Is a clinical stage 2 defining case

PAPULAR Treat itching: ITCHING Calamine lotion RASH Antihistamine oral (PRURIGO) If not improves 1% hydrocortisone Can be early sign of HIV and needs assessment for HIV

An itchy circular lesion with a raised edge and fine scaly area in the centre with loss of hair. May also be found on body or web on feet

RING WORM (TINEA)

Whitfield ointment or other antifungal cream if few patches If extensive refer, if not give: Ketoconazole for 2 up to 12 months(6-10 kg) 40mg per day for 12 months up to 5 years give 60 mg per day or give griseofulvin 10mg/kg/day if in hair shave hair treat itching as above

Extensive: There is a high incidence of co existing nail infection which has to be treated adequately to prevent recurrence of tinea infections of skin. Fungal nail infection is a clinical stage 2 defining disease

Rash and excoriations on torso; burrows in web space and wrists. face spared

SCABIES

Treat itching as above manage with anti scabies: 25% topical Benzyl Benzoate at night, repeat for 3 days after washing and or 1% lindane cream or lotion once wash off after 12 hours

In HIV positive individuals scabies may manifest as crust scabies. Crusted scabies presents as extensive areas of crusting mainly on the scalp, face back and feet. Patients may not complain of itching. The scales will teeming with mites

IDENTIFY SKIN PROBLEM IF SKIN HAS BLISTERS/SORES/PUSTULES SIGNS Vesicles over body. Vesicles appear progressively over days and form scabs after they rupture CLASSIFY AS: CHIKEN POX TREATMENT Treat itching as above Refer URGENTLY if pneumonia or jaundice appear UNIQUE FEATURES IN HIV Presentation atypical only if child is immunocompromised Duration of disease longer Complications more frequent Chronic infection with continued appearance of new lesions for >1 month; typical vesicles evolve into nonhealing ulcers that become necrotic, crusted, and hyperkeratotic.

Vesicles in one area on one side of body with intense pain or scars plus shooting pain. Herpes zoster is uncommon in children except where they are immuno-compromised, for example if infected with HIV

HERPES ZOSTER

Keep lesions clean and dry. Use local antiseptic If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Give pain relief Follow-up in 7 days

Duration of disease longer Haemorrhagic vesicles, necrotic ulceration Rarely recurrent, disseminated or multi-dermatomal Is a Clinical stage 2 defining disease

Red, tender, warm crusts or small lesions

IMPETIGO OR FOLLICULITIS

Clean sores with antiseptic Drain pus if fluctuant Start cloxacillin if size >4cm or red streaks or tender nodes or multiple abscesses for 5 days ( 25-50 mg/kg every 6 hours) Refer URGENTLY if child has fever and / or if infection extends to the muscle.

IDENTIFY SKIN PROBLEM NON-ITCHY SIGNS Skin coloured pearly white papules with a central umblication. It is most commonly seen on the face and trunk in children. CLASSIFY AS: MOLLUSCUM CONTAGIOSUM TREATMENT Can be treated by various modalities: Leave them alone unless superinfected Use of phenol: Pricking each lesion with a needle or sharpened orange stick and dabbing the lesion with phenol Electrodesiccation Liquid nitrogen application (using orange stick) Curettage The common wart appears as papules or nodules with a rough (verrucous) surface WARTS Treatment: Topical salicylic acid preparations ( eg. Duofilm) Liquid nitrogen cryotherapy. Electrocautery UNIQUE FEATURES IN HIV Incidence is higher Giant molluscum (>1cm in size), or coalescent Pouble or triple lesions may be seen More than 100 lesions may be seen. Lesions often chronic and difficult to eradicate Extensive molluscum contagiosum is a Clinical stage 2 defining disease Lesions more numerous and recalcitrant to therapy Extensive viral warts is a Clinical stage 2 defining disease

Greasy scales and redness on central face, body folds

SEBBHORREA

Ketoconazole shampoo If severe, refer or provide tropical steroids For seborrheic dermatitis: 1% hydrocortisone cream X 2 daily If severe, refer

Seborrheic dermatitis may be severe in HIV infection. Secondary infection may be common

CLINICAL REACTION TO DRUGS DRUG AND ALLERGIC REACTIONS SIGNS Generalized red, wide spread with small bumps or blisters; or one or more dark skin areas (fixed drug reactions) CLASSIFY AS: FIXED DRUG REACTIONS TREATMENT Stop medications give oral antihistamines, if pealing rash refer UNIQUE FEATURES IN HIV Could be a sign of reactions to ARVs

Wet, oozing sores or excoriated, thick patches

ECZEMA

Soak sores with clean water to remove crusts(no soap) Dry skin gently Short time use of topical steroid cream not on face. Treat itching

Severe reaction due to cotrimoxazole or NVP involving the skin as well as the eyes and the mouth. Might cause difficulty in breathing

STEVEN JOHNSON SYNDROME

Stop medication refer urgently

The most lethal reaction to NVP, Cotrimoxazole or even Efavirens

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? Age: Weight (kg): Initial Visit? Height/Length (cm): Follow-up Visit?

ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool? Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer then 2 seconds)? Slowly?

Yes __ No __

Yes __ No __ Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measles within the last 3 months? Do a malaria test, if NO general danger sign in all cases in high malaria risk or NO obvious cause of fever in low malaria risk: Test POSITIVE? P. falciparum P. vivax NEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes __ No __ Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L z-score: Less than -3? Between -3 and -2? -2 or more ? Child 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? Any severe classification? Pneumonia with chest indrawing? Child 6 months or older: Offer RUTF to eat. Is the child: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem?

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores:

CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 PCV-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 PCV-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 PCV-3 Measles1 Measles 2 Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

TREAT Remember to refer any child who has a danger sign and no other severe classification

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.

ART INITIATION RECORDING FORM FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL Name: Age: Weight (kg): TREAT YES ____ NO ____ Date: ASSESS (Circle all findings)

STEP 1: CONFIRM HIV INFECTION Child under 18 months: Virological test positive Send tests that are required Send confirmation test Check that child has not breastfed for at least 6 weeks If HIV infection confirmed, and child is in stable condition, GO TO STEP 2 Child 18 months and over: Serological test positive Second serological test positive Check that child has not breastfed for at least 6 weeks

STEP 2: CAREGIVER ABLE TO GIVE ART Caregiver available and willing to give medication Caregiver has disclosed to another adult, or is part of a support group Weight under 3 kg Child has TB Weight: _____ kg Height/length _____ cm Feeding problem WHO clinical stage today: _____ CD4 count: _____ cells/mm3 VL (if available): _____ Hb: _____ g/dl If yes: GO TO STEP 3. If no: COUNSEL AND SUPPORT THE CAREGIVER.

YES ____ NO ____

STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL If any present: REFER If none present: GO TO STEP 4 Send tests that are required and GO TO STEP 5

YES ____ NO ____

STEP 4: RECORD BASELINE INFORMATION

CD4%: _____

STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE: other recommended first-line regimen 1. ____________________________________________________________ 3 years and older: initiate ABC+3TC+ EFV, or other 2. ____________________________________________________________ recommended first-line 3. ____________________________________________________________ Follow-up according to national guidelines PROVIDE FOLLOW-UP CARE

NEXT FOLLOW-UP DATE: _______

RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS Name: Circle all findings Age: Weight (kg): Height/legth (cm): Date:

STEP 1: ASSESS AND CLASSIFY ASK: does the child have any problems? ASK: has the child received care at another health facility since the last visit? Check for general danger signs: NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW Check for ART severe side effects: Severe skin rash Yellow eyes Difficulty breathing and severe abdominal pain Fever, vomiting, rash (only if on Abacavir) Check for main symptoms: Cough or difficulty breathing Diarrhoea Fever Ear problem Other problems

RECORD If yes, record here: ___________________________________________________ ACTIONS TAKEN: YES ____ NO ____

If general danger signs or ART severe side effects, provide pre-referral treatment and REFER URGENTLY

Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines. Refer if necessary.

STEP 2: MONITOR ARV TREATMENT Assess adherence: Takes all doses - Frequently misses doses Occasionally misses a dose Not taking medication Assess side-effects Nausea - Tingling, numb, or painful hands, feet, or legs - Sleep disturbances Diarrhoea - Dizziness - Abnormal distribution of fat - Rash - Other Assess clinical condition: Progressed to higher stage Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here: DATE: _____ CD4 COUNT:________cells/mm3 CD4%: __________ Viral load: _________ If on LPV/r: LDL Cholesterol: _________ TGs: ____________ ABC+3TC+LPV/r ABC+3TC+EFV Cotrimaoxazole Vitamin A Other Medication 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: Not gaining weight for 3 months Loss of milestones Poor adherence despite adherence counselling Significant side-effects despite appropriate management Higher clinical stage than before CD4 count significantly lower than before LDL higher than 3.5 mmol/L Triglycerides (TGs) higher than 5.6 mmol/L 2. MANAGE MILD SIDE-EFFECTS 3. SEND TESTS THAT ARE DUE CD4 count Viral load, if available LDL cholesterol and triglycerides OTHERWISE, GO TO STEP 3

RECORD ACTIONS TAKEN:

STEP 3: PROVIDE ART AND OTHER MEDICATION RECORD ART DOSAGES: 1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ COTRIMOXAZOLE DOSAGE:_______________________________________ VITAMIN A DOSAGE: _____________________________________________ OTHER MEDICATION DOSAGE: 1. __________________________________________________________ 2. __________________________________________________________ 3. ___________________________________________________________ DATE OF NEXT VISIT:

STEP 4: COUNSEL RECORD ISSUES DISCUSSED: Use every visit to educate the caregiver and provide support, key issues include: How is child progressing - Adherence - Support to caregiver - Disclosure (to others & child) - Sideeffects and correct management

RECORD ACTIONS TAKEN:

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Is the infant having difficulty in feeding? Has the infant had convulsions? Age: Weight (kg): Initial Visit? Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for severe chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated?

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis?

ASSESS BREASTFEEDING Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 1 Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2

ASSESS OTHER PROBLEMS:

Ask about mother's own health

TREAT

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.

Weight-for-age GIRLS Birth to 6 month s (z-sco res)

WHO Child Growth Standards

Weight-for-age BOYS Birth t o 6 month s (z-scores)

WHO Child Growth Standards

Weight-for-Iength GIRLS Birth to 2 years (z-scores)

WHO Child Growth Standards

Weight-for-Iength BOYS Birth to 2 yea rs (z-scores)

i

i

W HO Child Growth Standards

Weight-for-Height GIRLS 2 to 5 years (z-scores)

Organization

Work! Health

WHO Chi ld Growth Standards

Weight-for-height BOYS 2 to 5 yea rs (z-scores)

WHO Child Growth Standards

GIVE GOOD H OME CARE FOR YOUR CHILD

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IMCI clinical guidelines are based on the following principles: o Examining all sick children aged up to five years of age fo r general danger signs and all young infants for signs of very severe disease . These signs indicate sever e illness and the need for immediate referral or admission to hospital. f)

o

Only a limited number of clinical signs are used. selected on the basis of theil' sensitivity and specificity to detect disease through classification .

The children and infants are then assessed for

main symptoms: • In • • • • In • • • older children the main symptoms include: Cough o r difficulty breathing, Diarrhoea. Fever, and Ear infection. young infants, the main symptoms include: Local bacterial infection, Diarrhoea, and Jaundice,

A combination of individual signs leads to a child's classification within one or m ore symptom groups rather than a diagnosis. The classification of illness is based on a colou r -coded triage system : • "PINK" indicates urgent hospital referral 01' admission, indicates in iti ation of s pecific o utpatient treatment. • "GREEN " indicates supportive home care,

•

•

o

IMCI management procedUl'es use a limited number of essential drugs and encourage a ctive parti ci pation of caregivers in the treatment of their children.

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The n in addition , all sick children are routinely checked for: • Nutritional and immunization status, • HIV statu s in high HIV settings, and • Other pote ntial pl'Oblems.

at An essential component of IMCI is the counselling of caregivers regarding h o me care: • Appropr iate feeding and fluids , • When to retu rn to the clinic immediat ely, a nd • When to retu rn for follow -up



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Logbook

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | LOGBOOK

n CONTENTS Acknowledgements 4 Instructions 5 Checklist of signs Module exercises MODULE 1 – General danger signs MODULE 2 – IMCI for the sick young infant MODULE 3 – Cough & difficult breathing MODULE 4 – Diarrhoea MODULE 5 – Fever MODULE 6 – Malnutrition & anaemia MODULE 7 – Ear problems MODULE 8 – HIV/AIDS MODULE 9 – Well child care 6 9 10 16 26 29 32 34 37 39 43

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

INSTRUCTIONS WHAT IS THE LOGBOOK? This logbook is an important tool for your distance learning. It helps you practice what you have learned in the modules. Your facilitators will also use this logbook to give you a mark for the course. There are three parts to the logbook: assessment exercises, recording forms, and checklists of signs

HOW DO I COMPLETE THE LOGBOOK? There are two instructions for this logbook. 1. Complete assessment exercises for each module There are about 20 multiple-choice and true-false questions for each module. You should answer all of these questions once you have finished studying a module. You should do these exercises on your own. You can use your Chart Booklet when answering questions. You should not use your study materials. 3. Complete recording forms for each module During this course, you should be practicing IMCI in your clinic and using IMCI recording forms as you practice. Recording forms for Modules 1 and 2 are located after the Module Exercises. The remaining recording forms for the sick child are in the back of the logbook. You should record at least 2 clinical cases for each module. Your facilitator will tell you the exact number of recording forms expected during each study period. However, the more forms you complete, the better, because you will discuss these cases with your facilitators during face-to-face meetings, study groups, and mentors. Their feedback on the cases will improve your learning and practice. 3. Keep notes on the checklist of signs On the following two pages you will find a checklist of signs for the sick child and the sick young infant. As you practice in your clinic, check signs that you see. You can also record notes about the case, like which recording form was used. This checklist is helpful for two reasons: (a) it allows you to track what signs you have seen, and which are still required, and (b) it gives your facilitator a sense of what clinical exposure you have. REMEMBER TO BRING YOUR LOGBOOK TO EACH FACE-TO-FACE MEETING

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

Checklist of signs

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

CHECKLIST OF CLINICAL SIGNS SICK CHILD AGE 2 MONTHS UP TO 5 YEARS SIGN   Not able to drink or breastfeed   Vomits everything   History of convulsions (with this illness)   Convulsions now   Lethargic or unconscious   Fast breathing   Chest indrawing   Stridor in calm child  Wheezing   Restless and irritable   Sunken eyes   Drinking poorly   Drinking eagerly thirsty   Very slow skin pinch   Slow skin pinch   Stiff neck   Runny nose   Generalized rash of measles   Red eyes   Mouth ulcers   Deep and extensive mouth ulcers   Pus draining from eye   Clouding of the cornea   Pus draining from ear   Tender swelling behind the ear   Oedema of both feet   Severe palmar pallor   Some palmar pallor  MUAC?  WFH/L? CHECK WHEN SEEN (include notes)

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

CHECKLIST OF CLINICAL SIGNS YOUNG INFANTS UP TO 2 MONTHS SIGN   Mild chest indrawing in young infant (normal)   Severe chest indrawing in young infant   Fast breathing in young infant   Low body temperature  Fever  Convulsions   Movement only when stimulated   No movement even when stimulated   Restless and irritable   Red umbilicus   Umbilicus draining pus   Skin pustules   Yellow palms and soles   Jaundice at any age   Sunken eyes   Skin pinch – very slow   Skin pinch – slow   Skin pinch – normal  Thrush   No attachment at all   Not well attached to breast   Good attachment   Not sucking at all   Not suckling effectively   Suckling effectively   Positive virological test   Positive serological test   Very low birth weight   Low birth weight CHECK WHEN SEEN (include notes)

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Module exercises

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

MODULE 1 – GENERAL DANGER SIGNS

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. According to IMCI charts, a sick child is: a. Under two months of age b. Under 5 years of age c. 2 months up to 5 years of age 2. What is the first thing you do when a caregiver and child enter your clinic room? a. Take the child and examine him b. Greet the caregiver to make her feel welcome c. Give the child treatment 3. Sami is 2 months old. Sami is a: a. A sick young infant b. A sick child c. Neither 4. What important information do you need about the child before you begin your assessment? a. If the child has general danger signs b. Age, weight, temperature, child’s problem according to caregiver, and if the visit is initial or follow-up c. Why the caregiver came to the clinic 5. What is a general danger sign? a. A sign that a sick young infant is ill b. A sign that the child is beginning to get sick, so the mother should watch him more carefully at home c. A sign of very serious illness in a sick child, which requires urgent referral 6. Which of the following is a general danger sign in sick children? a. Vomiting frequently b. Fast breathing c. Unable to breastfeed, eat, or drink 7. How do you check if a child is unable to breastfeed or drink? a. You can tell by looking because the child will be small b. Ask the caregiver to give a drink or clean water or breast milk. See if the child will take the liquid into his mouth and swallow it. c. Look at the child’s lips to see if they are dry

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8. How would you explain “convulsions” to a caregiver? a. The child’s arms and legs stiffen, and he might lose consciousness. b. The child will fall on the floor and his body will shake violently. c. The child’s face muscles will twitch. 9. How will you determine if a child is vomiting everything? a. Ask if the child has been vomiting frequently. b. Ask the caregiver if the child has vomited everything that they swallowed or drank. If they are unsure, give the child something to drink and see if they vomit. c. Ask if the child has vomited at least 5 times in the past 24 hours, because the frequency of vomiting determines this sign. 10. If a child is lethargic, how does he look and act? a. He is drowsy and is not alert or awake. He will not show interest in what is happening around him, he only stares ahead. b. His eyes are closed, and he appears unconscious. c. He will respond once you speak or clap. 11. If a child is unconscious, how does he look and act? a. His eyes follow your hand if you wave in front of his face. b. He acts very sleepy. c. He will not wake, even when someone shakes him. His eyes could be closed or open. If they are open, they do not follow any objects. 12. If a child has a general danger sign, what are the steps taken? a. Stop everything and send the child to the hospital. b. Complete the IMCI assessment without delay so that you can determine if the child has any other critical health issues. Identify and give pre-referral treatments, and prepare a referral note. c. Counsel the mother on home treatment and feeding 13. If a child has a severe (RED) classification and needs to be urgently referred, how do you determine the pre-referral treatment? a. Use your best guess to decide on a treatment for whatever is causing the severe illness b. No pre-referral treatment needed, send the child immediately to the hospital to not delay. c. Pre-referral treatments are listed in bold type in the classification tables. Give all pre-referral treatments for all classifications. 14. Important pre-referral treatments include: a. Treating low blood sugar b. Breastfeeding assessments and counselling for feeding problems c. Oral rehydration therapy in the clinic

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Are the statements about this module true or false? Circle your answer. 15. Every child is checked for general danger signs. TRUE FALSE 16. Only children who are unconscious require urgent referral. TRUE FALSE 17. A child whose nose is blocked may have trouble breastfeeding. You must clear the nose to check if the child is able to drink. TRUE FALSE 18. If a child has a general danger sign, stop the assessment immediately and send them to the hospital. TRUE FALSE 19. If referral is not possible, there is not much you can do, so you should send the child home. TRUE FALSE 20. IMCI for the sick child and young infant are exactly the same. TRUE FALSE

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RECORDING FORMS: MODULE 1 ONLY Complete these recording forms as you practice IMCI in your clinic. As MODULE 1 deals with general danger signs, only the top portion of the recording form is enclosed here. If you want to record more cases as you check children in your clinic for general danger signs, use additional forms.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Lookpoints, and listen forthings wheezing Use this space to record questions, interesting or that were difficult or confusing.

NOTES ON CASE

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Name: Do malaria test if NO general danger sign Ask: What are the child's problems? High risk: all fever cases ASSESS (Circle all signs present) Low risk: if NO obvious cause of fever CHECK FOR GENERAL SIGNS Test POSITIVE? P. falciparum DANGER P. vivaxNEGATIVE? NOT ABLE TO DRINK OR BREASTFEED If the child has measles now or within the VOMITS EVERYTHING last 3 months: CONVULSIONS

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting Yes __ No __ classifications Yes __ No __

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look Age: for any other cause of fever. Weight (kg): Initial Visit?

Yes __ No __

LETHARGIC OR UNCONSCIOUS Look for mouth ulcers. CONVULSING NOW If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? If Yes, for how ___ long? ___ Days For how long? Days

Is there earCHILD discharge? Feel for tender swelling behind the ear DOES THE HAVE COUGH OR DIFFICULT BREATHING?

Count the breaths in one minute Look for oedema of bothFast feet.breathing? ___ breaths per minute. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L _____ Z score. Look for chest indrawing AND ANAEMIA For children 6 months or older measure MUAC ____ mm. Look and listen for stridor Look for palmar pallor. Look and listen for wheezing Use this space to record questions, interesting points, or things that were difficult or confusing. Severe palmar pallor? Some palmar pallor? DOES THE CHILD HAVE DIARRHOEA? Is there complication? If child has MUAC less than 115 mm or For how long? ___ Days Look atany the medical childs general condition. Is the child: General danger sign? Is there blood in the-3 stool? Lethargic or unconscious? WFH/L less than Z scores or oedema of Any severe classification? Restless and irritable? both feet: Pneumonia chest indrawing? Look for sunkenwith eyes. For a child 6 months or the older offer RUTF to eat. Is the child: Offer the child fluid. Is child: Not able able to to drink finishor ordrinking able to finish? Not poorly? For a child less than 6thirsty? months is there a breastfeeding problem? Drinking eagerly, Pinch the skin of the abdomen. Does it go back: CHECK FOR HIV INFECTION Very slowsly (longer then 2 seconds)? Note mother's and/or child's HIV status Slowly? Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) test: Low NEGATIVE POSITIVE NOT DONE Look or feel for stiff neck Decide Child's malariaserological risk: High ___ ___ No___ If mother is HIV-positive and NO positive virological test in child: Look for runny nose For how long? ___ Days Is the child breastfeeding now? Look for signs of MEASLES: If more than 7 days, has fever been present every Was the child breastfeeding at the time of test or 6 weeks before it? Generalized rash and day? If breastfeeding: Is the mother and child on ARV prophylaxis? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? for any other cause of fever. CHECK STATUS Look (Circle immunizations needed today) Do malaria THE test if CHILD'S NO general IMMUNIZATION danger sign Measles1 Measles 2 Vitamin A DPT+HIB-3 DPT+HIB-2 BCG DPT+HIB-1 High risk: all fever cases Mebendazole OPV-3 OPV-2 OPV-0 OPV-1 Low risk: if NO obvious Hep B3 Hepcause B1 of fever Hep B2 Hep B0

NOTES ON CASE

Yes __ No __

Yes __ No __

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Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | LOGBOOK

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Lookpoints, and listen forthings wheezing Use this space to record questions, interesting or that were difficult or confusing.

NOTES ON CASE

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Name: Do malaria test if NO general danger sign Ask: What are the child's problems? High risk: all fever cases ASSESS (Circle all signs present) Low risk: if NO obvious cause of fever CHECK FOR GENERAL SIGNS Test POSITIVE? P. falciparum DANGER P. vivaxNEGATIVE? NOT ABLE TO DRINK OR BREASTFEED If the child has measles now or within the VOMITS EVERYTHING last 3 months: CONVULSIONS

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting Yes __ No __ classifications Yes __ No __

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look Age: for any other cause of fever. Weight (kg): Initial Visit?

Yes __ No __

LETHARGIC OR UNCONSCIOUS Look for mouth ulcers. CONVULSING NOW If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? If Yes, for how ___ long? ___ Days For how long? Days

Is there earCHILD discharge? Feel for tender swelling behind the ear DOES THE HAVE COUGH OR DIFFICULT BREATHING?

Count the breaths in one minute Look for oedema of bothFast feet.breathing? ___ breaths per minute. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L _____ Z score. Look for chest indrawing AND ANAEMIA For children 6 months or older measure MUAC ____ mm. Look and listen for stridor Look for palmar pallor. Look and listen for wheezing Use this space to record questions, interesting points, or things that were difficult or confusing. Severe palmar pallor? Some palmar pallor? DOES THE CHILD HAVE DIARRHOEA? Is there complication? If child has MUAC less than 115 mm or For how long? ___ Days Look atany the medical childs general condition. Is the child: General danger sign? Is there blood in the-3 stool? Lethargic or unconscious? WFH/L less than Z scores or oedema of Any severe classification? Restless and irritable? both feet: Pneumonia chest indrawing? Look for sunkenwith eyes. For a child 6 months or the older offer RUTF to eat. Is the child: Offer the child fluid. Is child: Not able able to to drink finishor ordrinking able to finish? Not poorly? For a child less than 6thirsty? months is there a breastfeeding problem? Drinking eagerly, Pinch the skin of the abdomen. Does it go back: CHECK FOR HIV INFECTION Very slowsly (longer then 2 seconds)? Note mother's and/or child's HIV status Slowly? Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) test: Low NEGATIVE POSITIVE NOT DONE Look or feel for stiff neck Decide Child's malariaserological risk: High ___ ___ No___ If mother is HIV-positive and NO positive virological test in child: Look for runny nose For how long? ___ Days Is the child breastfeeding now? Look for signs of MEASLES: If more than 7 days, has fever been present every Was the child breastfeeding at the time of test or 6 weeks before it? Generalized rash and day? If breastfeeding: Is the mother and child on ARV prophylaxis? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? for any other cause of fever. CHECK STATUS Look (Circle immunizations needed today) Do malaria THE test if CHILD'S NO general IMMUNIZATION danger sign Measles1 Measles 2 Vitamin A DPT+HIB-3 DPT+HIB-2 BCG DPT+HIB-1 High risk: all fever cases Mebendazole OPV-3 OPV-2 OPV-0 OPV-1 Low risk: if NO obvious Hep B3 Hepcause B1 of fever Hep B2 Hep B0 Test POSITIVE? P. RTV-1 falciparum P. vivaxNEGATIVE? RTV-3 RTV-2 Look for mouth ulcers. If the child hasPneumo-1 measles now Pneumo-2 or within the Pneumo-3 If yes, are they deep and extensive? last 3 months: Look for pus draining from the eye. Look for clouding of the cornea.

NOTES ON CASE

Yes __ No __

Yes __ No __

Return for next immunization on: ________________ (Date)

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

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Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score.

Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

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IMCI DISTANCE LEARNING COURSE | LOGBOOK

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Lookpoints, and listen forthings wheezing Use this space to record questions, interesting or that were difficult or confusing.

NOTES ON CASE

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Name: Do malaria test if NO general danger sign Ask: What are the child's problems? High risk: all fever cases ASSESS (Circle all signs present) Low risk: if NO obvious cause of fever CHECK FOR GENERAL SIGNS Test POSITIVE? P. falciparum DANGER P. vivaxNEGATIVE? NOT ABLE TO DRINK OR BREASTFEED If the child has measles now or within the VOMITS EVERYTHING last 3 months: CONVULSIONS

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting Yes __ No __ classifications Yes __ No __

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look Age: for any other cause of fever. Weight (kg): Initial Visit?

Yes __ No __

LETHARGIC OR UNCONSCIOUS Look for mouth ulcers. CONVULSING NOW If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? If Yes, for how ___ long? ___ Days For how long? Days

Is there earCHILD discharge? Feel for tender swelling behind the ear DOES THE HAVE COUGH OR DIFFICULT BREATHING?

Count the breaths in one minute Look for oedema of bothFast feet.breathing? ___ breaths per minute. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L _____ Z score. Look for chest indrawing AND ANAEMIA For children 6 months or older measure MUAC ____ mm. Look and listen for stridor Look for palmar pallor. Look and listen for wheezing Use this space to record questions, interesting points, or things that were difficult or confusing. Severe palmar pallor? Some palmar pallor? DOES THE CHILD HAVE DIARRHOEA? Is there complication? If child has MUAC less than 115 mm or For how long? ___ Days Look atany the medical childs general condition. Is the child: General danger sign? Is there blood in the-3 stool? Lethargic or unconscious? WFH/L less than Z scores or oedema of Any severe classification? Restless and irritable? both feet: Pneumonia chest indrawing? Look for sunkenwith eyes. For a child 6 months or the older offer RUTF to eat. Is the child: Offer the child fluid. Is child: Not able able to to drink finishor ordrinking able to finish? Not poorly? For a child less than 6thirsty? months is there a breastfeeding problem? Drinking eagerly, Pinch the skin of the abdomen. Does it go back: CHECK FOR HIV INFECTION Very slowsly (longer then 2 seconds)? Note mother's and/or child's HIV status Slowly? Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) test: Low NEGATIVE POSITIVE NOT DONE Look or feel for stiff neck Decide Child's malariaserological risk: High ___ ___ No___ If mother is HIV-positive and NO positive virological test in child: Look for runny nose For how long? ___ Days Is the child breastfeeding now? Look for signs of MEASLES: If more than 7 days, has fever been present every Was the child breastfeeding at the time of test or 6 weeks before it? Generalized rash and day? If breastfeeding: Is the mother and child on ARV prophylaxis? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? for any other cause of fever. CHECK STATUS Look (Circle immunizations needed today) Do malaria THE test if CHILD'S NO general IMMUNIZATION danger sign Measles1 Measles 2 Vitamin A DPT+HIB-3 DPT+HIB-2 BCG DPT+HIB-1 High risk: all fever cases Mebendazole OPV-3 OPV-2 OPV-0 OPV-1 Low risk: if NO obvious Hep B3 Hepcause B1 of fever Hep B2 Hep B0 Test POSITIVE? P. RTV-1 falciparum P. vivaxNEGATIVE? RTV-3 RTV-2 Look for mouth ulcers. If the child hasPneumo-1 measles now Pneumo-2 or within the Pneumo-3 If yes, are they deep and extensive? last 3 months: Look for pus draining from the eye. Look for clouding of the cornea.

NOTES ON CASE

Yes __ No __

Yes __ No __

Return for next immunization on: ________________ (Date)

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

15

Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score.

Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

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MODULE 2 – IMCI FOR THE SICK YOUNG INFANT

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. In IMCI, the sick young infant refers to: a. First month after birth b. Aged up to 2 months c. First 7 days after birth 2. Which of the following signs are signs of VERY SEVERE DISEASE in a young infant? a. Chest indrawing, either mild or severe b. Red umbilicus c. Fast breathing, counted twice 3. Which of the following signs are signs of local BACTERIAL infection in a young infant? a. Fever b. 3 skin pustules on the infant’s shoulder c. No movement 4. A 2 week old has fast breathing if he is breathing: a. 50 breaths per minute or more, counted twice b. 60 breaths or more per minute, and the same in a second count c. 66 breaths per minute, counted once 5. A 7 week old classified as VERY SEVERE DISEASE: a. Should be assessed for correct position and attachment for breast feeding b. Can improve at the clinic level and does not need urgent referral c. Needs to be given first dose of IM antibiotic before urgent referral 6. A 1 month old with diarrhoea for 2 days or more can be classified as having SEVERE DEHYDRATION if: a. Child had very low weight for age b. Child was lethargic even though no other sign of dehydration c. Child had at least two signs of dehydration 7. Thato is 14 days old. His palms appear yellow in colour. How do you classify, and what actions will you take? a. SEVERE JAUNDICE, treat Thato in the clinic b. JAUNDICE, and refer if Thato returns to the clinic after 1 week with jaundice c. SEVERE JAUNDICE, refer urgently

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8. An infant has good attachment if: a. His lower lip is turned in and more areola is visible below than above the mouth b. The chin is touching the breast and his lower lip is turned outward c. More areola is showing above the infant’s mouth and his mouth is narrow 9. An infant may not suckle effectively if: a. Her mouth is wide open when she is attached b. She is taking slow, deep sucks c. There is blocked nose or she is classified as VERY SEVERE DISEASE 10. If an infant has a feeding problem, this could mean he is: a. Not well attached, having less than 8 breastfeeds in 24 hours, or is receiving other foods or drinks b. Receiving only breastmilk from the mother, and feeding on demand c. Receiving expressed breastmilk from a cup Is the statement true or false? Circle your answer. 11. An infant that is 2 months old infant is a young infant. TRUE FALSE 12. A young infant who was brought to clinic because of difficulty feeding can be treated by the clinic nurse. TRUE FALSE 13. A young infant with cough or difficult breathing and presenting with severe chest indrawing is classified as having SEVERE PNEUMONIA. TRUE FALSE 14. If a young infant was brought to your clinic while convulsing, you need to rush the baby to the hospital and not spend time giving treatments. TRUE FALSE 15. A young infant age 6 weeks with jaundice may have a serious problem, and needs to be referred to a hospital. TRUE FALSE 16. A young infant presenting with severe chest indrawing can be classified as having VERY SEVERE DISEASE TRUE FALSE 17. Umbilicus care and good hygiene are very important to keeping a young infant healthy. TRUE FALSE 18. Correct positioning and attachment for breastfeeding is very important. One important sign of good attachment is if the infant’s mouth is wide open. TRUE FALSE 19. You need to give the young infant water frequently to prevent dehydration. TRUE FALSE 20. Skin-to-skin contact keeps an infant warm. TRUE FALSE

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RECORDING FORMS: MODULE 2 ONLY Complete these recording forms for the sick young infant as you practice IMCI in your clinic. If you want to record more cases as you practice in your clinic, you can use additional, loose forms. You facilitator will tell you how many recording forms you are expected to bring to the second face-to-face meeting.

PRACTICE CASE 1

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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TREAT THE SICK YOUNG INFANT

Return for follow-up in: Give any immunization today:

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PRACTICE CASE 2

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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TREAT THE SICK YOUNG INFANT

Return for follow-up in: Give any immunization today:

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PRACTICE CASE 3

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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TREAT THE SICK YOUNG INFANT

Return for follow-up in: Give any immunization today:

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PRACTICE CASE 4

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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TREAT THE SICK YOUNG INFANT

Return for follow-up in: Give any immunization today:

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MODULE 3 – COUGH & DIFFICULT BREATHING

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. When using IMCI, what clinical signs help identify pneumonia? a. Wheeze and wet cough b. Fast breathing and chest indrawing c. Chest indrawing and blood when coughing 2. A child is classified with SEVERE PNEUMONIA OR VERY SEVERE DISEASE when which of the following signs are present: a. Wheeze b. Fast breathing c. Stridor when the child is calm 3. Raj is 7 months old. He has fast breathing if: a. 40 or more breaths per minute b. 50 or more breaths per minute c. 60 or more breaths per minute 4. Chest indrawing is when: a. The lower ribs move in when the child breathes out. b. The lower ribs move in when the child breathes in. c. The lower ribs are always pushed in, no matter when the child is breathing in or out. 5. Poorvaja is 3 years old. She has fast breathing if: a. 60 or more breaths per minute b. 40 or more breaths per minute c. 50 or more breaths per minute 6. What is stridor? a. A wheezing noise when the child breathes out b. A wet noise when the child is sitting still and breathing c. A harsh noise, caused by swelling, heard when the child breathes in 7. Ntebo is 12 months old. He has fast breathing if: a. 40 or more breaths per minute b. 50 or more breaths per minute c. 60 or more breaths per minute

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8. Roma is 3 months old. You count 57 breaths in one minute. You do not hear stridor. When Roma breathes in, his lower ribs move in. How would you classify Roma’s cough? a. SEVERE PNEUMONIA b. PNEUMONIA c. COUGH OR COLD 9. Which of the following are good teaching steps when explaining home treatment for a cough? a. Give the caregiver some printed information and send the treatment home b. Ask questions like “Will you give this medicine correctly?” c. Explain how to give treatment, demonstrate giving treatment, and ask caregiver to practice while you give feedback 10. If the child has had a cough for more than 3 weeks, what steps should be taken? a. Refer for TB or asthma assessment b. Send the child home with a soothing remedy c. Check for stridor Is the statement true or false? Circle your answer. 11. When giving antibiotics using IMCI, it is important to consider all four of these issues: schedule, dosage, combining treatment if more than one illness can be treated with a single antibiotic, and only using the second line medicines if first line is not available to the child did not respond to first line. TRUE FALSE 12. You will only assess a child for a cough or difficult breathing if the caregiver specifically says that cough is the reason they came to the clinic. TRUE FALSE 13. A child with a cough but no signs of pneumonia can be treated at home. TRUE FALSE 14. Oral antibiotics are given to children with pneumonia. TRUE FALSE 15. It is best to count breaths for fast breathing when the child is active and moving around. TRUE FALSE 16. If a child has fast breathing and no other signs, they are classified PNEUMONIA. TRUE FALSE 17. A child with chest indrawing can be treated in the clinic. TRUE FALSE 18. A child with PNEUMONIA should return to the clinic in 2 days. TRUE FALSE

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19. If a child with pneumonia returns for follow-up and has not improved, and they have been receiving the first line antibiotic correctly, start second-line antibiotic if it is available. TRUE FALSE 20. Pneumonia and other acute respiratory infections are major killers of children worldwide. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE AT LEAST 2 RECORDING FORMS FOR THIS MODULE.

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MODULE 4 – DIARRHOEA

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. Diarrhoea is an important childhood disease because: a. It is a major killer of children worldwide b. It is a nuisance because the child has to go to the toilet frequently c. Its treatment is very complicated 2. Dehydration can be treated by replacement of water and salt using: a. Zinc b. Low osmolarity ORS or IV fluids c. Antibiotics 3. Why is dehydration a cause for serious concern? a. It can cause shock to vital organs, and possibly death b. It gives the child a headache c. Dehydration is not a very serious health issue 4. What is in ORS? a. Copper and zinc b. Antibiotics c. Sodium (salts) and glucose (sugars) 5. What signs do you assess for dehydration? a. Blood in the stool or diarrhoea that persists for 14 days b. Sunken eyes, loose skin (turgor), and lethargy c. Swollen abdomen and sunken eyes 6. Persistent diarrhoea can be classified as SEVERE PERSISTENT DIARRHOEA if the child: a. Has diarrhoea for 10 days or more b. Is dehydrated c. Has blood in the stool 7. What are the 4 rules of home treatment in Plan A? a. Give extra fluid, give oral antibiotics, give zinc, counsel for when to return b. Give extra fluid, reduce feeding, keep the child warm, counsel for when to return c. Give extra fluid, continue feeding, give zinc, and counsel for when to return

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8. An infant is 11 months of age and weighs 9.6 kg. She is classified as having SOME DEHYDRATION. How much ORS should she receive in the next 4 hours? a. At least 450 ml, up to 800 ml b. At least 200 ml, up to 960 ml c. At least 800 ml, up to 960 ml 9. Lily is restless, but drinks quickly when you give her water. How would you classify her dehydration? a. SEVERE DEHYDRATION b. SOME DEHYDRATION c. NO DEHYDRATION 10. Why is zinc important in the treatment of diarrhoea? a. It reduces stool volume b. It replaces sodium, potassium, and other electrolytes c. It is useful only in those infants shown to be zinc-deficient 11. What antibiotic should be given for dysentery? a. Ciprofloxacin b. Cotrimoxazole c. Amoxicillin Is the statement true or false? Circle your answer. 12. Diarrhoea is when there is more water than normal in the stool and may occur at least 3 times per day. TRUE FALSE 13. Dehydration can be recognized by making a rapid stool examination. TRUE FALSE 14. Dysentery is when there is blood in the stool. TRUE FALSE 15. Diarrhoea causes death because of dehydration i.e. the loss of water and salt. TRUE FALSE 16. You need at least two signs to classify an infant with diarrhoea as having SOME DEHYDRATION. TRUE FALSE 17. You can classify a 3 month old infant with diarrhoea as having SEVERE DEHYDRATION if she has sunken eyes and lethargy. TRUE FALSE 18. Persistent diarrhoea is when diarrhoea occurs for 3 months continuously. TRUE FALSE

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19. Shigella bacteria is the most common cause of blood in stool in children. TRUE FALSE 20. You do not need to give antibiotics for a child with watery diarrhoea. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE AT LEAST 2 RECORDING FORMS FOR THIS MODULE.

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MODULE 5 – FEVER

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. Which of the following signs is used in IMCI to determine if a child has a fever? a. She is sweating b. She has a rectal temperature of 37.5 °C or above c. She has a history of fever 2. One of the possible causes of a fever include: a. Pneumonia b. Urinary tract infections c. Dehydration 3. In high risk malaria areas, a malaria test should be done: a. When a child has a fever and a stiff neck b. Never, you can presume the fever is due to malaria c. In all cases when the child has a fever and no general danger signs or a stiff neck 4. When should you do a malaria test in an area of low malaria risk? a. When the child has a fever with no other clear causes b. Never, the odds of malaria are too low c. When the child has a fever with a stiff neck 5. How does measles contribute to malnutrition? a. Measles is not related to malnutrition. b. Measles causes diarrhoea, high fever, and mouth ulcers. These problems interfere with feeding. c. Measles causes a rash on the skin so the child is not interested in eating. 6. When assessing for measles, you will look for a generalized rash and: a. Cough, runny nose, and red eyes b. Jaundice and watery eyes c. Chills and a runny nose 7. A child with a stiff neck is classified with: a. Meningitis b. Very severe febrile disease c. Malaria 8. A child with measles and pus draining from the eye is classified with: a. SEVERE COMPLICATED MEASLES b. BACTERIAL INFECTION c. MEASLES WITH EYE COMPLICATIONS

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9. Signs of measles with complications include: a. Clouding of cornea b. Skin pustules c. Scabies Is the statement true or false? Circle your answer. 10. Malaria and measles are two causes of fever. They are two major killers of children under 5. TRUE FALSE 11. Malaria is caused by parasites called “plasmodia” that enter the blood. The parasites are transmitted between people by mosquito bite. TRUE FALSE 12. The most dangerous species of malaria parasite is P. vivax. TRUE FALSE 13. Signs of the P. falciparum parasite include fever, sweating, shivering, and vomiting. TRUE FALSE 14. You will mark on your recording form that a malaria test is POSITIVE when there are no malaria parasites seen in the microscopy. TRUE FALSE 15. Measles is caused by a virus that damages the immune system. It leaves the child vulnerable to other infections for weeks after the onset of measles. TRUE FALSE 16. Complications of measles occur in about 30% of all measles cases. TRUE FALSE 17. If you give the first dose of an antimalarial in the clinic, and the child vomits within an hour, give him two doses. TRUE FALSE 18. Vitamin A is an important treatment for measles. TRUE FALSE 19. Malaria risk can change by region in the country, season, and the extent of malaria control in the country. TRUE FALSE 20. Children with fever only need to return for follow-up if the fever persists beyond 2 days. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE AT LEAST 2 RECORDING FORMS FOR THIS MODULE.

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MODULE 6 – MALNUTRITION & ANAEMIA

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. Why do you check every child for malnutrition and anaemia? a. Malnutrition is a major underlying cause of death in children, even though many caregivers and children do not have specific complaints that point to malnutrition b. It is only necessary to check for malnutrition if you have identified a feeding problem, or they appear too small c. All children are malnourished, and most have anaemia 2. What is malnutrition? a. When a child is always hungry or thirsty b. A condition that may be due to several reasons which include inadequate dietary intake, inefficient utilization of nutrients, and infection c. When the child does not want to eat 3. Which of the signs below do you use when assessing for malnutrition? a. The child is restless or irritable b. Oedema, or swelling, of both feet c. Child looks pale 4. What is palmar pallor? a. Paleness of the skin of a child’s legs b. Cloudiness of a child’s cornea c. An unusual paleness of the child’s palms 5. Palmar pallor is a sign of: a. HIV b. Anaemia c. Vitamin A deficiency 6. A child with severe wasting may have the following signs: a. A large or round abdomen b. The child’s face is very puffy and swollen c. The child looks thinner than usual 7. A child with MUAC of 119 and no other signs is classified with: a. SEVERE ACUTE MALNUTRITION b. MODERATE ACUTE MALNUTRITION c. NO ACUTE MALNUTRITION

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8. A child with oedema of both feet is classified as: a. COMPLICATED SEVERE ACUTE MALNUTRITION b. SEVERE ACUTE MALNUTRITION c. SEVERE ANAEMIA 9. What treatments are identified for a child with severe ACUTE malnutrition? a. Iron supplements b. Therapeutic feeding c. Vitamin A dose 10. An 18 month old child does not have any signs of acute malnutrition or anaemia. You will: a. Examine the child’s nutritional status more closely during his next visit b. No action is needed, the child is fine c. Assess the child’s feeding and counsel the caregiver on feeding recommendations 11. A child with anaemia needs: a. Salt b. Iron c. Vitamin A 12. How can this question be asked as a checking question after you counsel a caregiver: “Will you give your child more nutritious foods? ” a. Do you have nutritious foods at home? b. What foods will you give your child so that they are receiving more important vitamins for their body? c. Do you understand the recommendations I just gave you? 13. Why is mebendazole given to a child with anaemia? a. Mebendazole is given to children without anaemia to prevent anaemia b. Mebendazole provides important iron supplements c. Mebendazole deworms children Is the statement true or false? Circle your answer. 14. Jiva is a 26 month old boy and weighs 9.3 kg. He is 83 cm in height. He is classified as MODERATE ACUTE MALNUTRITION. TRUE FALSE 15. Severe anaemia can be treated in the clinic with iron supplementation. TRUE FALSE 16. Maria has a -3 Z-score and did not eat enough RUTF during her appetite test. She is classified SEVERE ACUTE MALNUTRITION. TRUE FALSE 17. Malnutrition is an underlying cause in over 50% of child deaths. TRUE FALSE

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18. A child that is low weight for height should stop breastfeeding. TRUE FALSE 19. A young boy is 107 cm tall and weighs 10.2 kg. His Z-score is under -3. TRUE FALSE 20. General feeding recommendations are for infants to breastfeed exclusively until 6 months of age, on demand. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE AT LEAST 2 RECORDING FORMS FOR THIS MODULE.

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MODULE 7 – EAR PROBLEMS

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. Why do you check every child for ear problems? a. Ear infections can become very serious if it causes the eardrum to burst, or the infection spreads to the bone behind the ear or even to the brain. b. Ear infections usually clear up without any treatment. c. Ear infections are not serious, so you only check the child for an infection if the caregiver already told you it was a problem. 2. What is an acute ear infection? a. If the discharge has been consistent for up to 30 days. b. When the child has discharge and pain for less than 2 weeks c. If the child has had ear pain and discharge for up to a year 3. What signs will you look for to identify mastoiditis? a. Bulging fontanelle b. Pus draining from the ear c. Tender swelling behind the ear 4. What is a chronic ear infection? a. The child has had ear pain and discharge for 1 week b. The child’s ear is always in terrible pain c. The child has had discharge from the ear and ear pain for longer than 2 weeks 5. If the mother says “no, the child has no ear problem” what will you do? a. Continue the assessment on to malnutrition and anaemia b. Assess the child for ear problems c. Classify the child for ear problems 6. When you ASSESS for ear problems, what step is included? a. Check if the child has a fever b. Feel for tender swelling behind the ear c. Observe the child for irritability 7. A child with pus draining from the ear and ear pain at night is classified with: a. MASTOIDITIS b. ACUTE EAR INFECTION c. CHRONIC EAR INFECTION

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8. Thebo has pus draining from the ear. His mother says this has only been happening on and off for 2 months. How will you classify? a. CHRONIC EAR INFECTION b. ACUTE EAR INFECTION c. NO EAR INFECTION 9. Liam has pus draining from the ear. His mother says this has only been happening for 3 days. How will you classify? a. MASTOIDITIS b. ACUTE EAR INFECTION c. CHRONIC EAR INFECTION 10. You feel swelling of the mastoid bone. How will you classify? a. MASTOIDITIS b. ACUTE EAR INFECTION c. NO EAR INFECTION 11. How frequently should a caregiver wick the ear? a. Once a day b. Only when pus begins draining c. 3 times a day Is the statement true or false? Circle your answer. 12. A child with an ear problem classified as MASTOIDITIS needs urgent prereferral treatment and referral. TRUE FALSE 13. A caregiver should use a stiff piece of newspaper to wick the ear. TRUE FALSE 14. 3 important steps when teaching caregivers about home treatment are: give information, show an example, and ask her to practice. TRUE FALSE 15. A child with an ear problem should follow-up in 14 days. TRUE FALSE 16. Ceftriaxone should only be given in the clinic. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE AT LEAST 2 RECORDING FORMS FOR THIS MODULE.

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MODULE 8 – HIV/AIDS

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. HIV: a. Attacks red blood cells b. Attacks white blood cells (CD4) c. Attacks the liver 2. What is an opportunistic infection? a. An infection that takes advantage of the weakness of the immune system to cause disease b. An infection that takes advantage of an open lesion in a person’s body to cause disease c. A disease for which home care is the only treatment 3. When counselling an HIV-positive woman about preventing mother-to-child transmission of HIV, you educate her on all the modes of transmission, which include: a. At the time of delivery and after birth when kissing the child b. Pregnancy, at the time of delivery, and after birth when hugging or holding the child c. Pregnancy, at the time of delivery, and after birth through breastfeeding 4. If nothing is done to prevent transmission from mother-to-child, the chance of transmission is: a. About 50% b. About 35% c. About 80% 5. If 20 HIV-positive women get pregnant and deliver 20 babies, and they have no interventions to prevent HIV transmission: a. About 7 of them will be HIV infected if mother continues to breastfeed b. About half of them will be HIV infected if mother does not breast feed at all c. About two-thirds of them will be HIV infected if mother stops breastfeeding at 6 months 6. In advising about HIV care, you should tell the caregiver and/or the child: a. ART medicines can be taken anytime during the day. b. ART medicines must be taken everyday for life at the exact same time. c. Drug doses can be doubled if he/she forgets to take it one day.

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7. In an infant born to an HIV infected mother, a rapid antibody test can surely confirm infection when done at or after the age of: a. 6 months b. 9 months c. 18 months 8. Sari is 2 months old. You have used a rapid antibody test, and the test is positive. She is breastfeeding. Which of the following steps will you take? a. Initiate ART today and provide feeding recommendations b. Start co-trimoxazole prophylaxis, do a PCR test (at least 6 weeks after breastfeeding has stopped), and arrange for counselling on feeding c. Do a PCR test today, and plan a follow-up visit to give nevirapine 9. Biki is 12 months old. You administered an antibody test, which was positive, and you classified him HIV EXPOSED. Now it is important to ensure that: a. Co-trimoxazole prophylaxis is given until HIV is definitely ruled out b. Biki is assessed for the WHO paediatric clinical staging c. Give Nevirapine prophylaxis once a day 10. Which of the following is an ART severe sign? a. Fever b. Diarrhoea c. Severe skin rash 11. Which of the following medicines cause severe skin reaction that could be fatal: a. Co-trimoxazole b. ABC c. NVP 12. Maria is 4 weeks old, and born to an HIV positive woman. Her mother delivered at home and was not given any interventions to lower the risk of HIV transmission at birth. You have classified Maria as HIV EXPOSED. Maria weighs 3.2 kg. Today you will: a. Give 1.5 ml Nevirapine b. Give 1.5 ml Nevirapine once daily and 2.5 ml co-trimoxazole once daily c. Give 1.0 ml Nevirapine once daily and 2.5 ml co-trimoxazole once daily 13. Maria is later confirmed HIV positive with a virological (PCR) test. You will begin her on the following ARV regimen: a. First line medicines: ABC or AZT+3TC+LPV/r b. Second line medicines, as she is so young this will prevent development of resistance c. Maria is not yet eligible to initiate ART 14. When Maria turns 3 years old, you will take the following steps: a. Immediately change her regimen to first line medicines appropriate for her age group b. Keep her on the same first line medicines as long as she is stable c. Initiate a second-line regimen

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15. The principles of good chronic care can be applied using the 5A’s systematically. What are the 5As in the correct order? 1. 2. 3. 4. 5. Are the statements about this module true or false? Circle your answer. 16. Co-trimoxazole prophylaxis has been effective in reducing mortality of HIV infected children. TRUE FALSE 17. All children who are CONFIRMED HIV INFECTION should be initiated on ART. You will use the 6 steps. TRUE FALSE 18. When a child on ART comes for a follow-up visit, you only need to re-assess the child when he is looking unwell, or his mother says there is a problem. TRUE FALSE 19. Tina is 4 weeks old. She was born to an HIV-positive mother, but Tina has not been tested. You will begin Tina on cotrimoxazole today. TRUE FALSE 20. ART will cure HIV after 2 years. TRUE FALSE 21. The WHO recommends that HIV positive mothers breastfeed their child exclusively for 6 months, and then begin complementary feeding. TRUE FALSE 22. The CD4 count is a measure of how much damage HIV has caused to the immune system. TRUE FALSE 23. If an HIV positive caregiver does not understand what HIV is and doesn’t understand the treatment, this could cause a problem with adherence to the long-term treatment. TRUE FALSE 24. Antiretroviral therapy (ART) is a lifelong drug. TRUE FALSE 25. ART is given in combination in order to aggressively fight HIV and reduce the risk of resistance. TRUE FALSE

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REMEMBER TO PRACTICE IN YOUR CLINIC! YOU ARE EXPECTED TO COMPLETE IMCI AND ART RECORDING FORMS DURING PRACTICE.

As you will remember, there are 4 recording forms that are relevant to this module: 1. IMCI recording form for the sick child, as you’ve used previously 2. IMCI recording form for the sick young infant, as you’ve used previously 3. ART initiation form, new to this module 4. ART follow-up form, new to this module For this module, you are asked to complete the following: ✔✔ Complete IMCI recording forms for the sick child and sick young infant. You will assess and classify for HIV. Your facilitator will specify how many cases you should record and bring to the next face-to-face meeting. Use these in your clinical practice to assess and classify, including HIV status. Record additional cases on additional IMCI recording forms. ✔✔ Complete ART initiation forms for children or young infants who require ART. Your facilitator will specify how many cases you should record and bring to the next face-to-face meeting. Complete these during your clinical practice and send copies with the child when you refer to an ART centre. Bring these forms to your face-to-face meeting. ✔✔ Complete ART follow-up forms as time allows. Your facilitator will specify how many cases you should record and bring to the next face-to-face meeting. Complete these during your clinical practice and send copies with the child when you refer to the initiating centre.

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MODULE 9 – WELL CHILD CARE

ASSESSMENT QUESTIONS Below are questions about the module. You are allowed to use your Chart Booklet as you answer these questions. You should not use your study modules. Circle the best answer. 1. What is the importance of growth monitoring and promotion? a. Research has not shown the importance yet b. The growth chart prevents the child from falling sick c. It helps health workers identify poor growth, analyze causes, and support the family’s actions to improve child’s growth and health 2. Child development is not improved by: a. Interaction b. Isolation c. Activities 3. How will you monitor the growth of children under 5 years of age? a. Length/Height for age b. Weight for length/height c. Weight for age 4. What is the recommended schedule for growth monitoring for a child under 5 years? a. From birth to 2 years, monitoring should be done every 3 months. Weight is measured monthly, while length/height is measured at every appointment. b. From 2 to 5 years, monitoring should be done every 3 months. Weight is measured monthly, while length/height is measured every 3 months. c. From 2 to 5 years, attendance should be monthly. Monitor weight and length/ height on every attendance. 5. Among the following which one is not a tool used to monitor growth: a. Weighing Scale b. Length board c. MUAC strip 6. Which of the following correctly describes a contraindication to vaccine administration? a. Do not give OPV to a child who is HIV infected. b. Do not give DTP-HepB-Hib2 and DTP-HepB-Hib3 to a child who has had convulsions or shock within 3 days of the last dose of the vaccine. c. Do not give DTP-HepB-Hib to a child with persistent diarrhoea

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7. The first dose of deworming in under fives, should be given at the age of: a. 6 months b. 3 months up to 6 months c. At the age of 12 months 8. All children aged 12 months or older need to be given Mebendazole or Albendazole a. Every 3 months to treat intestinal parasites, especially hookworm and whipworm infections b. Every 6 months to treat intestinal parasites, especially hookworm and whipworm infections c. Every 12 months to treat intestinal parasites, especially hookworm and whipworm infections Is the statement true or false? Circle your answer. 9. Creating pedestrian sidewalks away from the main traffic helps to prevent road traffic accidents. TRUE FALSE 10. Ensuring all children riding bicycles or on motorcycles wears helmets all the time decreases the severity of injuries. TRUE FALSE 11. In order to prevent accidents in children, child should be under supervision, and discourage child-child caretaking especially for pre-school children. TRUE FALSE 12. All hazardous water bodies in the residential areas (e.g. toilet pits, wells, ponds) should either be removed or covered properly to prevent drowning. TRUE FALSE 13. Raising or enclosing cooking areas increases incidences of burns in children. TRUE FALSE 14. In order to prevent burns in children, never leave candle or traditional kerosene lamp lit while sleeping. TRUE FALSE 15. Keeping all medicines out of reach of children helps to prevent poisoning in children. TRUE FALSE 16. Poisonous agents or petroleum distillates such as kerosene should be kept on soda or mineral water bottles because they are more difficult to open. TRUE FALSE 17. To prevent poisoning in children, ensuring that all medicines and poisons are packaged in child resistant packs/bottles. TRUE FALSE

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18. BCG and Polio 0 is given at birth. TRUE FALSE 19. The second and third dose of DPT-Hep-Hib, Pneumococcal,Rota and OPV is given at the interval of 4 weeks from the previous vaccination. TRUE FALSE 20. If you give repeated doses of Vitamin A in in less than 6 months, it is not recommended, but it is safe for the child. TRUE FALSE REMEMBER TO PRACTICE IN YOUR CLINIC!

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MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? Age: Weight (kg): Initial Visit? Height/Length (cm): Follow-up Visit? Temperature (°C):

ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer then 2 seconds)? Slowly? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measles within the last 3 months? Do a malaria test, if NO general danger sign in all cases in high malaria risk or NO obvious cause of fever in low malaria risk: Test POSITIVE? P. falciparum P. vivax NEGATIVE?

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L z-score:____ Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? Any severe classification? Pneumonia with chest indrawing? Child 6 months or older: Offer RUTF to eat. Is the child: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem? Yes __ No __

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet: CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2 Vitamin A Mebendazole

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

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Enclose recording forms here Include the appropriate number of forms for practice according to module requirements

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Implementation INTRODUCTION AND ROLL OUT

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

n CONTENTS Acknowledgements 4 Key terms PART I. INTRODUCTION TO DISTANCE LEARNING IMCI Introduction to IMCI training approaches Core concepts in distance learning dIMCI course structure dIMCI benefits PART II. ROLLING OUT dIMCI Step One. Orientation Step Two. Adaptation Step Three. Planning for roll-out Step Four. Evaluating implementation 18 20 22 26 6 10 11 12 5

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Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

KEY TERMS In addition to the language used in the standard IMCI course, the distance learning course introduces some new course terms: dIMCI Facilitator Distance-learning IMCI course dIMCI course facilitators have previously been trained as IMCI facilitations, and have extensive experience clinically and with IMCI, as well as national policy

Face-to-face meeting A meeting between facilitators and participants during the dIMCI course Logbook Mentor A learning tool that accompanies the dIMCI self-study modules An IMCI-trained colleague, in-charge, or supervisor that a participant can identify as an IMCI mentor during selfstudy dIMCI course participant Printed learning modules on IMCI symptoms that participants read on their own

Participant Self-study modules

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

Introduction to distance learning IMCI

PART I

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

INTRODUCTION TO IMCI TRAINING APPROACHES Over 100 countries have adopted the Integrated Management of Childhood Illness (IMCI) strategy for reducing child mortality and improving child health and development. Since IMCI was developed in the early 1990s by the WHO and UNICEF, thousands of healthcare providers have been trained in using nationally adapted IMCI guidelines. The strategy aims not only to improve case management skills at the facility level, but also strengthen health systems and improve home and community health practices for prevention and mangement. The strategy has demonstrated success in reducing child mortality, improve nutrition status among children, enhance health worker performance, improve the use of health services, and strengthen care at lower costs per child correctly managed. Yet, challenges remain for IMCI scale-up.1 Internationally IMCI coverage is generally low (Figure 1). Financial constraints have hindered training scale-up, and once staff are trained, high turnover poses an additional challenge. Lastly, private practitioners have not been widely engaged in IMCI training, despite providing significant proportions of care in many countries. Countries have responded with a number of strategies to increase coverage. A survey of 37 countries emphasized that the duration of the standard 11-day IMCI course was difficult for the length – health workers were required to leave their clinics and homes for too long – and expensive as a resource-intensive residential training programme. Many countries had shortened the IMCI course ranging from three to eight days; however the content was largely not reduced, and in some cases, was even increased. A meta-analysis that examined shortened IMCI courses demonstrated that the standard course was superior in terms of health work performance.2 A global technical consultation in Geneva examined the challenges around IMCI scale-up and recommended several strategies, including the implementation of alternative and innovation training approaches like distance learning. An expert group on IMCI training approaches further clarified three possible training approaches (Figure 2) for IMCI given these recommended strategies. Distance learning is especially appropriate: (a) for training that precedes clinical skills acquisition, and (b) for training that combines clinical knowledge and skills. It is not appropriate for learning specific clinical procedures, for example. Given these parameters, IMCI is well suited for a distance learning approach.

WHO SHOULD USE THIS GUIDE? This guide is intended for use by national child health policymakers, officials involved in planning and implementation of primary health systems development and training scale-up, and course directors. This planning and implementation guide is a supplement to other materials developed for delivering dIMCI, as detailed below. Goga et al. 2009. Results of a multi-country exploratory survey of approaches and methods for IMCI case management training. Health Research Policy and Systems, 7:18. Goga and Muhe. 2011. Global challenges with scale-up of the integrated management of childhood illness strategy: results of a multi-country survey. BMC Public Health, 11:503. 2 Rowe et al. 2012. Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review. Health Policy and Planning. 27(3):179–93. 1

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

Figure 1. International IMCI training coverage as reported by countries at end of 2009

Countries  repor,ng  to  have  ini,ated  IMCI  training  in:                      75%  or  more  of  their  districts                      Less  than  75%  of  their  districts                      No  IMCI  training  or  no  data  reported     SOURCE  Department  of  Child  and  Adolescent  Health  and  Development,  World  Health  OrganizaBon     Disclaimer:  The  presentaBon  of  material  on  the  map  contained  herein  does  not  imply  the  expression  of  any  opinion   whatsoever  on  the  part  of  the  World  Health  OrganizaBon  concerning  the  legal  status  of  any  country,  territory,  city,   or  areas,  or  its  authoriBes  of  its  fronBers,  or  boundaries.  

Figure 2. WHO training approaches for IMCI

1   Pre-­‐service   Several  approaches  

2   In-­‐service   •  11-­‐day  conBnuous  course   •  Abridged  course  only  for   core  competencies  

Self-­‐learning  with   facilitator  interacBon  

Distance-­‐ learning    

3  

ICATT  (IMCI  computer-­‐based  adaptaBon  training  tool)  can  be  used  across  all   training  approaches    

ICATT    

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

WHAT MATERIALS ARE USED FOR DISTANCE LEARNING IMCI? This course draws upon IMCI materials specially adapted for distance learning, and nationally adapted IMCI tools.

FACILITATORS dIMCI Facilitator Guide dIMCI PowerPoint slides dIMCI Excel planning tool

PARTICIPANTS dIMCI Self-Study Modules dIMCI Logbook

NATIONAL TOOLS IMCI Chart Booklet IMCI Recording Forms IMCI Clinical Practice Guides IMCI DVD

RESOURCES This guide is intended for policy makers, programme managers and senior child health experts who need to consider the specific features of distance learning IMCI in planning implementation of IMCI. It does not replace the standard tools and guides for planning and implementing IMCI as well the broad child health programmes. For a more in-depth reading on planning these aspects, please refer to previously published WHO guides on various areas: •• Standard IMCI – refer to IMCI planning guide- gaining experience with the IMCI strategy in a country found at http://www.who.int/maternal_child_adolescent/ documents/chs_cah_99_1/en/index.html •• Pre-service IMCI – refer to IMCI planning, implementing and evaluating preservice training at http://www.who.int/maternal_child_adolescent/documents/ planning_implementing_evaluating/en/index.html •• Adaptation of IMCI – refer to IMCI adaptation guide- A guide to identifying necessary adaptations of clinical policies and guidelines, and to adapting the charts and modules for the WHO/UNICEF course at http://www.who.int/ maternal_child_adolescent/documents/imci_adatation/en/index.html •• Tool for follow up of IMCI trained health professionals – refer to Guidelines for follow-up after training in the WHO/UNICEF course on IMCI for first-level health workers at: http://www.who.int/maternal_child_adolescent/documents/ fch_cah_99_1a/en/index.html •• Tool to evaluate performance of IMCI, refer to Health facility surveyTool to evaluate the quality of care delivered to sick children attending outpatient facilities at http://www.who.int/maternal_child_adolescent/documents/9241545860/en/ index.html •• Broader child health programming, refer to Planning implementation and managing implementation of programmes to improve child health 4 modules at http://www.who.int/maternal_child_adolescent/documents/planning/en/ index.html

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

CORE CONCEPTS IN DISTANCE LEARNING The participants primarily drive learning in the distance learning IMCI course, from here called dIMCI. The course is designed on an inquiry model that emphasizes group learning, mentoring, mutual respect, and reward to the learners. In adult self-learning, intrinsic motivation is important for producing more pervasive and permanent learning and skills development. Learning occurs over a longer time period, and participants are expected to practice their course knowledge in the clinic and apply skills to real-life cases. There are several core concepts in distance learning approaches: ✔✔ The learners and trainers are not together in a classroom for most of the course period. This flexibility allows for wider geographical spaces to be covered, and the time and travel saved supports more health workers being trained. ✔✔ Instruction is facilitated with intentionally designed materials supplied directly to individual learners. In this course, these are the dIMCI self-study modules; they are designed to support distance learning in a way the standard IMCI modules are not. ✔✔ It is primarily a learner-driven model. Learners can organize their own study to fit their own work and timetables. ✔✔ Group learning and mentor support are building into the course design for use by learned preference. It is strongly recommended that a learner support system is established to provide ongoing tutorial support and supervised practical learning during the self-study periods, and after the course is completed. ✔✔ Participants should commit to the significant personal motivation and time commitment before the course begins. They must also be encouraged to seek support, mentorship, and help when required.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

dIMCI COURSE STRUCTURE The dIMCI learning structure has several key learning components (Figure 3) discussed below. 1. Face-to-face meetings: one day meetings that bring together facilitators and participants to introduce IMCI content, practice in the clinic, and address problems from self-study. Meetings usually last about 6 hours, and the generic course recommends 3 meetings, with the flexibility to add additional meetings as required for incorporating additional modules. Face-to-face meetings should examine the previous self-study period, including learner needs and progressive assessments. Figure 3. dIMCI course structure Orientation 1st face-to-face meeting (today) 3–4 weeks Review & practice 2nd face-to-face meeting (1 day) 6–8 weeks Final synthesis 3rd face-to-face meeting (1 day)

Self-study period 1 (Modules 1 & 2)

Self-study period 2 (Remaining modules)

Practice IMCI in clinic, using Chart Booklets and recording forms Review with study groups Work with mentors 2 to 3 months

2. Self-study modules: dIMCI modules are designed for self-learning and been re-written so that they are self-contained modules, e.g. from assess to follow-up for a particular main symptom (Box 1). They are designed to be easily adaptable and flexible within a course structure depending on national requirements. Modules include learning tools like case studies, self-assessment exercises, and photo or video exercises and demonstrations. A dIMCI logbook created to accompany the self-study modules captures a progressive assessment during the course. BOX I. dIMCI STUDY MODULES Module 1. General danger signs Module 2. Care of the sick young infant Module 3. Cough or difficult breathing Module 4. Diarrhoea Module 5. Fever Module 6. Malnutrition and anaemia Module 7. Ear problems (optional) Module 8. HIV/AIDS (optional) Module 9. Well child care (optional)

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

2. Clinical practice and support in home clinic: Participants are guided on applying knowledge from the self-study modules in the clinical setting (Figure 4). Practice arrangements at off-site facilities, like nearby district hospitals, might also be coordinated for caseload exposure. They are also encouraged to work with mentors previously trained in IMCI (e.g. supervisors, colleagues). IMCI mentors were widely utilized during field testing. They are also encouraged to study and practice in groups with other dIMCI participants. At the orientation meeting participants will form study groups with local participants. Groups are encouraged to practice together and review self-assessment exercises. Groups are encouraged to meet weekly during selfstudy. Guidance tools for clinical practice and study groups are provided in the self-study modules and logbook.

Figure 4. dIMCI model for clinical practice and group work

Participants will be assessed in the course both for their retention of IMCI knowledge and skills – conducted in a written and clinical skills examination at the end of the course – but also the effort they put into their self-study. This effort is measured at each face-to-face meeting by completion of content exercises in the dIMCI logbook, and submission of recording forms from their clinical practice. The dIMCI course also has notable innovations, including: (a) the use of mobile phones for course reminders and mentorship or peer learning connections, (b) the use of take-home videos for learning signs and practicing IMCI, (c) the use of IMCI mentors to help guide study and answers questions, and (d) the use of peer-learning through study groups and group practice arrangements, which are an opportunity to bring questions, highlight confusions and clarifications, and apply the material by teaching colleagues.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

dIMCI BENEFITS DIMCI PILOTS Anticipated benefits of the dIMCI course structure were elucidated during pilots and initial scale-up in South Africa (2010), Tanzania (2011), and Zanzibar (2011). Over 150 participants were trained during field-testing of the generic modules, and some sessions, the HIV module. During field-testing, course feasibility was measured both from facilitators and participants. Facilitators were all established IMCI trainers with the standard IMCI course. Facilitators anecdotally reported that the dIMCI model was quite feasible, and while a different process to adapt to, found the course model and outcomes very positive. Participants also provided formal feedback in registration forms and evaluations at each face-to-face meeting. This feedback especially focused on concerns policymakers and programme managers might have in dIMCI scale-up, including ability to complete module content and experiences practicing in the clinic alone, with IMCI mentors, and in group study.

KEY BENEFITS Several programmatic benefits were highlighted during the field tests. 1. dIMCI is comparatively low resource dIMCI has significantly lower cost requirements than a residential training model, especially given the reductions in human resource requirements, large training spaces, accommodations, and other venue costs (Table 1). The table below broadly outlines a comparison between budget requirements for the dIMCI and residential courses. In South Africa’s field testing and early implementation, the dIMCI course was one-third the cost in Rand and human resources; estimated costs per participant in dIMCI is about 100 USD. In Tanzania and Zanzibar, the unit cost per dIMCI participant is about one fifth of the standard IMCI course; unit cost per participant is about 200 USD. Table 1. Budget line comparisons between standand IMCI and dIMCI courses STANDARD IMCI ~11 days out of clinic ~11 days facilitation x 5 facilitators Facility requires accommodations near to training and clinical space ~10 days of room and board for all participants and facilitators IMCI chart booklet IMCI modules Return trip for each participant and facilitator dIMCI ~3 days out of clinic 3 days facilitation x ~4 facilitators HR: facilitator 1 day administration for course director 2 clinical facilitators x 2 hours x 3 days, if required Training space Accommodation and catering Printing Transport Facility requires single room for meeting and nearby clinic for practice 3 lunches for all participants and facilitators, if provided IMCI chart booklet IMCI modules 3 return trips for each participant and facilitator

BUDGET LINE HR: participants

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

2. Effective use of participant time •• Less disruption to clinical and personal life promote participation: the dIMCI learning model causes significantly less disruption to clinical work, as it requires less than one third of the time out of work required for the standard course. The course also causes less disruption to social and family life. As such, the course supports participation from those who cannot leave clinics for extended periods of time that have not been well targeted in the standard IMCI course, despite considerable need (e.g. child caregivers, private practitioners). It is also an efficient model for continued learning, for example, those needing refresher training after pre-service IMCI, or those needing orientation to significant, recent technical updates and new policies. •• Enables colleagues to train together: standard IMCI courses do not always support colleagues training together because clinics cannot relieve multiple staff for training at a time. However the dIMCI model allows for multiple batches to run in the same area on staggered days, so that participants can group study and practice with colleagues, but clinics do not face serious disruptions. This has the potential to build collaboration between colleagues and facilities in systems strengthening, skills development, and continued education. 3. Effective use of facilitator time increases training coverage dIMCI requires about 15–20% of the facilitator time required for the standard course. Additionally, it is recommended that facilitators cluster trainings in a local area to rapidly train multiple batches in a geographical area (Figure 5). For example, Tanzania used parallel sessions – five sessions per district – to achieve up to 85% training coverage in a single go. Clustered trainings minimize travel requirements for the facilitators. This also significantly reduces facilitators’ orientation and planning burden, as they are administering the same content several days in a row. Figure 5. Clustering trainings for efficient facilitation and peer study.

1st  face-­‐to-­‐face   10  May   11  May   12  May  

2nd  face-­‐to-­‐face     15  June   16  June   17  June  

District  X  I   District  X  II   District  Y  

Mul,ple  staff  from  same  facility   can  train  in  staggered  batches  

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

dIMCI course design allows for additional facilitator time and resources to re-focus on key gaps in health training, namely supervision, follow-up, and monitoring. Trainees require support to ensure that IMCI skills are integrated into the clinical setting, and quality is high. Facilitators can play a key role in ensuring a more comprehensive, long-term, and clinic-based training strategy. As post-course monitoring is such an important (yet to date poorly implemented) component of IMCI training, this dIMCI guide will include significant resources and best practices for providing high quality performance management and on-the-job training. 4. Promotes facilitator quality The dIMCI course model, especially if trainings are clustered to maximize training outcomes, does not rely significantly on cascade training, which can dilute facilitator quality. Instead, the training model builds a core of expert dIMCI facilitators. 5. Sustainability measures of a local training model Clinical time in home clinic is important for skills application, while also identifying local mentors and peer learners that can continue after the course. Participants spend nearly all of their clinical training time in a ‘real life’ setting as they practice in their home clinics, and not an unfamiliar, non-local facility during residential trainings. It is hoped that this will make IMCI implementation and practice more sustainable, as problems in the home clinic setting are being identified, and hopefully dealt with, during the longer learning period. The course is also designed to help participants build mentorship and continued support in their home clinic environment; these mentors are intended to help in problem-solving during self-study, observe clinical practice, and further support IMCI skills development post-course. In the same vein, the dIMCI format allows for multiple participants from a single facility or local area without overburdening the health system. This has the potential to build collaboration between colleagues and facilities in skills development and continued education. The dIMCI mentorship model has the potential to build stronger, more local networks of mentorship and collaboration between those practicing IMCI. This has strong implications for higher quality care and referral systems. The majority of participants in field tests designated IMCI mentors (colleagues or supervisors) and study groups were widely used, especially among rural participants. 6. dIMCI produces strong participant performance Strong performance from participants in dIMCI pilots addressed concerns around participant motivation to complete the course, literacy and ability to cope with material, and development of core competencies in IMCI. Most participants find the page of self-study aggressive, but feasible. Key performance indicators from the pilots demonstrated: ■■ High course retention: the courses had high rates of retention, despite the significant commitment required for self-study and practice. In South Africa’s pilots and early course implementation, 81% of total participants starting dIMCI completed the full course; several of those needing to drop out had to for

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

unforeseen reasons, and not due to the course. The pilots’ retention rates also emphasize the importance of appropriate selection (see Part II). ■■ Course assessment demonstrates strong skills recognition and knowledge retention: As previously discussed, participants are evaluated by logbook completion, clinical practice demonstrated on IMCI recording forms, and a written and clinical course assessment modeled off of the standard IMCI course assessment. Signs recognition during audiovisual skills stations is uniformly strong, an average of 81% scores across pilot sites (maximum 98%, minimum 42%, standard deviation 10.3). Written examination results show wider spread and an overall 68% score (90% maximum, 27% minimum, standard deviation 12.1). There was little performance difference between participants from rural and semi-urban, or clinic and hospital nurses. ■■ Post-course monitoring demonstrated use of IMCI skills: South Africa and Tanzania dispatched IMCI facilitators and supervisors to conduct post-course site visits with minimal warning. During the visit the monitoring team observed case management and conducted the IMCI facility support assessment, a caregiver exit interview, and a brief interview to capture the participants’ own understanding of course outcomes. Visits demonstrated that all participants are implementing IMCI and are using the IMCI chart booklet. In South Africa, participants were using the national health card to track records and plot growth. Most participants showed strong IMCI case management skills. Results in Tanzania demonstrated comparable results to the standard IMCI course (Figure 6). There are not yet comparative assessments of skills and care delivery between trainees from dIMCI versus other IMCI course models. Future evaluations can more rigorously examine pre- and post-course skills. Figure 6. Case management follow-up results comparing dIMCI and standard IMCI participants (Tanzania) 100  

80  

dIMCI   60  

40  

Standard  IMCI   (March  2006)   Standard  IMCI   (January  2007)  

20  

0  

Correctly   Correctly   Correctly   assessed   assessed  for   assessed   danger  signs   all  main   cough,   symptoms   diarrhoea,  &   fever  

Correctly   Correctly   Correctly   Correctly   Pneumonia   Diarrhoea   Diarrhoea   Cases   Caretakers   checked   checked   assessed  for   assessed  for   cases   cases   cases  treated   assessed  for   advised  on   weight   immunizaAon     malnutriAon   HIV  infecAon   receiving   receiving  ORS   with  zinc   feeding   giving  extra   anAbioAc  in   in  facility   problem   fluid  and   facility   conAnue   feeding  

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

Rolling out dIMCI

PART II

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

STEP ONE. ORIENTATION TECHNICAL WORKING GROUP Establish a technical working group to guide the process of national dIMCI orientation and adaptation.

SITUATIONAL ANALYSIS This analysis should determine the need for IMCI training in the country, and especially help to inform how training can be best targeted. It is recommended that this process involve mapping of all health facilities with staff profiles that would detail training. This should specify who has not received IMCI training, and information on those who have, like the type of training (e.g. pre-service, in-service, ICATT) and year trained (to determine need for technical updates). As a health systems strengthening measure, this training inventory should be maintained to ensure the availability of real-time information on training requirements in the country.

PRIORITIZING TRAINING TARGETS Prioritizing and targeting training is especially important for resource efficiency and impact. A situational analysis should create an inventory on training needs in the country. It is necessary to determine criteria for prioritization. Suggested criteria for establishing broad training targets include the following. In STEP THREE, more detailed planning on sites and participant criteria will be revisited. Geographic targeting indicators ✔✔ High under-five mortality ✔✔ Burden of death ✔✔ Poor health services access ✔✔ High population and caseloads ✔✔ Low pediatric HIV coverage Participant targeting criteria ✔✔ Health worker cadre ✔✔ Paediatric caseload (U5 clinics, health facilities’ paediatric outpatient load) ✔✔ Availability of training opportunities (e.g. staff in isolated areas where skills development does not frequently reach) ✔✔ IMCI training (e.g. never trained, in need of refreshers, confidence building after pre-service IMCI ) ✔✔ Supervisory role, if any, for health workers with paediatric loads

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

FACILITATION It is important to establish and engage a core national team of facilitators to support dIMCI adaptation and create buy-in. Similar to the mapping of IMCI-trained health workers in the country, it is important to take inventory on the availability of IMCI facilitators. Given the dIMCI model’s reliance on a core group of expert facilitators, this inventory can help inform what facilitators are available where, and provide key information to determine facilitator quality (e.g. frequency of IMCI training, when trained as a facilitator, available feedback on facilitation skills, engagement with national child health policy).

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

STEP TWO. ADAPTATION There are several key considerations for the adaptation of dIMCI. These are outlined below.

TECHNICAL CONTENT A technical working group should determine technical content to be included in the dIMCI course. This primarily involves decision-making around the optional modules: ear problems, HIV/AIDS, and care of the well child. The HIV/AIDS module requires further decision making around the inclusion of ART initiation at primary care levels. Decisions to include technical content should reflect national burden of disease evidence and gaps in health worker skills ascertained during supervision or the IMCI situational analysis.

TECHNICAL UPDATES Generic dIMCI materials include the 2012 WHO Technical Updates to IMCI, especially in managing cough or difficult breathing, fever, malnutrition, sick young infants, and HIV care. A technical working group should determine where national IMCI management algorithms and child health policies should be adopted or revised accordingly.

COURSE STRUCTURE Decisions about dIMCI technical content will inform how the course will be structured. The course format is designed to be highly adaptable depending on national requirements. The core components of the structure that must be decided upon are the following, in order: ■■ Sequencing of modules ■■ Number of face-to-face meetings: three face-to-face meetings are recom­ mended, but another could be added in the case of adding additional, larger modules like HIV. ■■ Number and duration of self-study periods: this is determined by the module sequencing and face-to-face meetings. The modules vary by length; most modules take about one week to complete, while sick young infant and HIV/AIDS take an estimated two to three weeks each. ■■ Mentorship structures and on-the-job training: determine how supportive supervision structures or other mentorship arrangements can support dIMCI learning. First, this involves determining how dIMCI facilitators will communicate with participants during self-study. Second, course structures for IMCI mentors and supportive supervision during the course should be designed according to national context. Mentors were widely used during field testing; most participants selected a colleague or supervisor. ■■ Assessment structure : determine how participants will be assessed; recommended methods include clinical skills stations, case studies, and a written multiple choice exam. It is also necessary to determine what is required for

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

adequate course completion, what participants receive after completion of the course, and any incentives for participation. ■■ Post-course monitoring: what follow-up will be provided after the training, when, for how long, and using what tools. It should also be decided if the results from post-course monitoring will factor into a participant’s certificate of completion.

MATERIALS As previously outlined, the generic dIMCI materials available for national adaptation include: ✔✔ Facilitator’s guide ✔✔ Facilitator PowerPoint slide decks ✔✔ Facilitator excel tool ✔✔ Participant self-study modules ✔✔ Participant logbook National tools that will require revisiting for technical updates include: ✔✔ IMCI chart booklet ✔✔ IMCI recording forms ✔✔ IMCI videos, as available The generic dIMCI materials are built in a way so that countries can edit country specificity directly into them, instead of countries having to convert their standard IMCI materials into the dIMCI formats. This minimizes adaptation workload. The modules are written very intentionally for adult self-learning, and were field tested with very positive results. Countries should not just copy and paste their previously written IMCI content into the modules. It is important to maintain the questionanswer format, simple language, and learning aids like self-assessment questions and visuals. Material adaptations, including some specific requirements for dIMCI, include: ■■ Technical updates in study modules, exercises, logbooks, assessments, PPT decks, and videos ■■ Details on dIMCI design, like course structure, calendars, and module numbering ■■ Contextual considerations for case studies and exercises, e.g. local names ■■ Language translations ■■ Production considerations, e.g. combining or separating modules

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

STEP THREE. PLANNING FOR ROLL-OUT Drawing upon the situational analysis and training targets established in STEP ONE, a scale-up plan must be developed.

1. SETTING TRAINING TARGETS As per the situational analysis and national IMCI goals, targets should be established for dIMCI scale-up. This will establish parameters to determine the pace and breadth of scale-up. Targets should be SMART: specific to dIMCI training for the target audience, measurable, attainable given available resources, relevant, and time-bound.

2. PRIORITIZATION OF TRAINING SITES Geographic areas can be prioritized by training need as outlined in the STEP ONE situational analysis.

3. TRAINING CALENDAR AND PARALLEL COURSES STEP ONE outlined indicators for prioritizing training either geographically, by participant, or likely a combination of both. The situational analysis should provide data on how many participants should be trained in each area, which will help collate requirements for facilitators and a training calendar.

4. REQUIREMENTS FOR FACILITATORS dIMCI recommends four facilitators for 25–30 participants. Depending on national training targets and the established training calendar, facilitator requirements must be calculated. Data from the situational analysis on availability of quality facilitators in STEP ONE should inform selection. A core of national expert facilitators should have been established in STEP ONE. These expert facilitators should be oriented to dIMCI in a recommended two-day session (Box 2). Depending on facilitator requirements, expert facilitators should serve as lead dIMCI facilitators in each course, and also train local teams of IMCI facilitators on dIMCI. The pilot experiences emphasize that facilitators found dIMCI very feasible, but that it is quite a different pace and style of facilitation that requires careful orientation and planning. There are unique requirements for face-to-face meetings (e.g. prioritizing information and not overloading participants, providing quality clinical observations given limited interactions). Facilitators must also be trained on best practices in communication, mentorship, and support during self-study and group study.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

BOX 2. ORIENTATION FOR IMCI FACILITATORS ON dIMCI DAY 1. DAY 2. Introduction to dIMCI rationale, course structure, materials, and training targets Re-orientation session on IMCI Technical Updates and relevant national child health policies Run-through of each face-to-face meeting by section, focusing on key planning issues for dIMCI (e.g. presenting information briefly and effectively, clinical practice sessions)

5. SELECTION CRITERIA FOR PARTICIPANTS dIMCI field testing has emphasized how critical appropriate participant selection is for retention rates and course effort. These selection criteria must be made clear, and should informed by the situational analysis in STEP ONE. Participants should see paediatric patients; the course could also engage nurse managers that directly supervise health workers with paediatric caseloads. The field tests also emphasized that participants who do not usually have much training exposure or regular opportunities for training were especially motivated in the course. Clear participant expectations should also be defined, and could require an agreement from the participant before he/she is accepted for a place.

6. ENSURING QUALITY CLINICAL PRACTICE There are several requirements to ensure quality clinical practice opportunities during (a) face-to-face meetings and (b) self-study. Applying course knowledge to real-life cases is at the heart of building IMCI competencies. In the course of regular clinical practice, participants are likely to encounter many of the health conditions and problems addressed in the modules. Clinical practice during face-to-face meetings: meeting should be held at locations to ensure an adequate caseload of paediatric patients for demonstration and individual or group practice. Please refer to the Clinical Practice Guide in the annex of the dIMCI Facilitator Guide for practical recommendations on planning and facilitating each clinical practice session. Clinical practice during self-study: Independent clinical practice during the self-study periods is a critical component to dIMCI. There are three primary considerations outlined below. ■■ Measures to ensure support and mentorship during individual or group practice: Facilitators should assist participants in establishing IMCI mentors and study groups to support their self-study period. The dIMCI mentorship model has the potential to build stronger, more local networks of mentorship and collaboration between those practicing IMCI. This has strong implications for higher quality care and referral systems. ■■ If supplementary clinical practice is required for additional exposure: course planners may choose to make alternate practice arrangements – for example, at a nearby referral facility or district hospital – in order to increase caseload exposure. Course participants do not often have significant exposure to severe illness and sick young infants, not unlike the residential course.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

Arrangements with larger, but still local, facilities might diversify the caseload participants are able to practice with, in addition to the primary level care exposure in their home facilities. These arrangements might also be achieved if study groups practice together in their various health centres. ■■ Monitoring clinical practice to ascertain issues: Each face-to-face should also serve as a check-in about who is practicing and using mentors/study groups, and how. Participants are requested to submit IMCI recording forms and a checklist of clinical signs from their clinical practice periods, which facilitators can review during the face-to-face meetings to highlight any issues. Facilitators can also provide more direct support during self-study by visits or by distance. In South Africa, facilitators arranged an observation visit with each participant during the self-study period. Additionally, facilitators could be in direct contact with supervisors or IMCI mentors to discuss practice periods.

7. PREPARING LOGISTICS Given the potentially rapid pace at which dIMCI can be rolled out, meticulous planning and logistics preparation is required for high quality, efficiency trainings. Several are reviewed below. Face-to-face meeting locations: once geographical sites are prioritized, meeting locations should be selected that have adequate: (a) caseloads for clinical practice, (b) meeting spaces for the group, (c) accessibility for participants, and (d) accessibility for facilitators (e.g. accommodations as required). Local support: this is especially important for preparations for clinical practice, and necessary agreement and approvals from the hosting facility (for additional details see Clinical Practice Guide, dIMCI Facilitator Guide annex). Additionally, it is recommended that participants’ sub-district managers and in-charge supervisors be fully notified of the course’s requirements for self-study, clinical practice, alternate clinical arrangements, and the specific travel requirements for face-toface meetings, including dates and times. A formal letter should be issued on behalf of all participants so that all managers are fully aware of course requirements and expectations. Materials production and dissemination: the generic dIMCI materials are bound by module for carrying ease. It is also recommended that logbooks be bound well, and include the IMCI recording forms for clinical practice, as they are heavily used in the clinic. Facilitators will also require the latest printed versions of IMCI chart booklets and other recommended materials.1 Using DVD videos: IMCI DVDs are an important learning tool in dIMCI. It is recommended that IMCI videos be updated and packaged for the dIMCI course. During field tests, participants supplemented reading materials with IMCI DVD clips as recommended, and found this very helpful for learning. In South Africa, 76% of participants regularly used the IMCI DVD distributed to them during the first meeting; the large majority used their own DVD players or a friend’s. 1

See meeting checklists in Facilitator’s Guide.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

Using mobile phones: mobile phone technologies play an important role in dIMCI. It is recommended that facilitators stay connected to participants and mentors (once established at the participant’s practice clinic). Some recommended ideas for using mobile phones includes: ✔✔ Facilitators should send regular SMS reminders during self-study periods on course timelines to keep participants on track, especially with module reading material and logbooks. ✔✔ Facilitators could regularly pose questions to the group – perhaps as a contest among participants – on relevant study material. ✔✔ Facilitators should be available on mobile and SMS for concerns or clarifications during practice. Course budgeting: the dIMCI excel tool provides a budget format for course planners to use as a starting point when estimating costs and tracking expenditures. Course budgets should also plan for the use of technology in dIMCI, as a lesstraditional budget line when preparing for trainings, including regular SMS and mobile communications between facilitators and participants. While course budgeting should allocate funding for facilitators, it might also consider that some participants will not use mobile phones to stay connected if it is a prohibitive cost, as it was in some field test sites.

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IMCI DISTANCE LEARNING COURSE | IMPLEMENTATION – INTRODUCTION AND ROLL OUT

STEP FOUR. EVALUATING IMPLEMENTATION It is critical to analyze the implementation of dIMCI in order to provide real-time information on training quality, efficiency, and coverage, and in order to take corrective action. There are several areas for evaluation while implementing dIMCI, outlined below. ■■ COVERAGE: Percentage of health workers requiring IMCI that have been trained The situational analysis and SMART training targets set early in the planning process should serve as the foundation of this assessment. ■■ RESOURCE EFFECTIVENESS: Cost per participant; facilitator hours per participant This data can especially serve as a comparison for the standard IMCI course or other training methods. Indicators require an accurate tracking of course expenditures and human resource time. ■■ COURSE PERFORMANCE: Health worker marks on course assessments Data on health workers’ performance can be analyzed by progressive assessment (logbooks) and course assessment (clinical skills and written examination). ■■ POST-COURSE PERFORMANCE: Percentage of health workers correctly practicing IMCI in clinic Post-course monitoring should utilize IMCI course tools, including the facility survey assessment. Qualitative data can also be gathered through client exit interviews, and the health workers themselves. ■■ COURSE ADMINISTRATION: feedback from check-in forms and meeting/ course evaluations At the face-to-face meetings, check-in forms and course evaluations collect data the participant experience. Check-in forms collect information on the self-study period, for example, time spent on modules and reaction to content, or the use of video, mentors, and study groups. The dIMCI excel tool is designed to capture the information from these forms and provide data visuals for facilitators’ use. Course evaluations provide feedback for the meetings’ content and facilitators. These should be reviewed for corrective action in the days’ proceedings.

26

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Paediatric HIV SUPPLEMENTARY FACILITATOR GUIDE

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

n WHEN IS THIS SUPPLEMENTARY FACILITATOR GUIDE NEEDED? This guide is for settings and countries that decide to have a separate, additional one-day face-to-face meeting on paediatric HIV for introducing the paediatric HIV module. In most situations, the facilitator guide should be adequate for all modules including paediatric HIV and all countries are incouraged to plan for 3 face-to-face meetings.

n CONTENTS Acknowledgements 4 1.1 Overview 1.2 Proposed agenda 5 7 8 11 15 24 25 30 32 35 36

Section 1 – Introduction & review of self-study period Section 2 – Introducing HIV/AIDS Section 3 – Assess & classify HIV status Section 4 – Clinical demonstration & practice Section 5 – Treatment & preventative prophylaxis Section 6 – Infant feeding Section 7 – Next steps Sample meeting evaluation Handout for feeding roleplay (Section 6)

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

1.1 OVERVIEW HOW DOES THIS MEETING FIT IN THE DIMCI COURSE STRUCTURE? When policymakers decide to hold a supplementary HIV meeting in the dIMCI course, this meeting is held as the third of four face-to-face meetings. When participants arrive at this meeting, they will have completed all other dIMCI modules. This meeting focuses on introducing content from the HIV module. It should also prepare participants for the third self-study period, during which they should practice material from the HIV module but also all other modules up to this point, in order to prepare for the Final Synthesis meeting and course examination.

dIMCI  course  structure   Review  &  prac(ce     2nd  face-­‐to-­‐face     mee,ng  

1st  face-­‐to-­‐face     mee,ng     (today)   3-­‐4  weeks  

Orienta(on    

(1  day)   6-­‐8  weeks  

 

 

  3rd  face-­‐to-­‐face     mee,ng      

HIV  mee(ng  

Final  synthesis     4th  face-­‐to-­‐face     mee,ng      

(1  day)  

(1  day)   3-­‐4  weeks  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

Self-­‐study  period  3     (HIV  and  all  modules)  

Prac(ce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance  learning  IMCI  

3  to  4  months  

WHAT ARE THE OBJECTIVES OF THIS MEETING? This meeting serves as an introduction to content in the HIV module. At the end of this meeting, participants should be able to: ✔✔ Explain how HIV affects the immune system ✔✔ Explain how children are infected with HIV ✔✔ Assess and classify a child for HIV ✔✔ Assess and classify a young infant for HIV ✔✔ Explain principles of counseling an HIV positive mother about feeding ✔✔ Describe measures to prevent common infections in children with HIV ✔✔ Explain what ART does ✔✔ Identify ART drug combinations and dosages ✔✔ Explain when children should be initiated on ART

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

WHAT MATERIALS WILL YOU REQUIRE TO FACILITATE THIS FACE-TO-FACE MEETING? Please refer to Planning and Preparing Section 0.12 of the dIMCI Facilitator Guide for a standard checklist of recommended materials for face-to-face meetings. This supplementary meeting will require the following additional materials:

MATERIAL FOR FACILITATION dIMCI Supplementary Facilitator Guide on Paediatric HIV dIMCI PPT slides for Supplementary HIV meeting STUDY MATERIALS FOR DISTRIBUTION dIMCI self-study HIV module IMCI ART charts (chart booklet or supplementation) dIMCI logbook HIV section, including ART initiation and follow-up forms for self-study clinical practice FOR USE IN MEETING ART initiation forms ART follow-up forms Firstline ARV drugs for group exercise in Section 6

NUMBER

✔ LIST

1 per facilitator 1 electronic file

* Participants bring meetings 1 per participant/facilitator 1 per participant/facilitator 1 per participant/facilitator

1 1 1 of every drug in combination therapy for each participant

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

1.2

PROPOSED AGENDA REGISTRATION SECTION 1 INTRODUCTION & REVIEW OF SELF-STUDY (30 minutes) Review self-learning period and introduce today’s objectives. SECTION 2 INTRODUCING HIV/AIDS (15 minutes) Review of HIV/AIDS epidemiology and transmission. SECTION 3 HIV TESTING, ASSESSING, & CLASSIFYING HIV STATUS (75 minutes) HIV testing: methods and interpretation Review IMCI process, and how to assess and classify HIV TEA BREAK and MOVE TO CLINICAL PRACTICE (30 minutes) SECTION 4 CLINICAL DEMONSTRATION & PRACTICE (90 minutes) Demonstrate assessing and classifying HIV status, and facilitate small group practice. PLANNING NOTES PLANNING NOTES

08:00–08:30 09:00–09:30

09:30–09:45

PLANNING NOTES

09:45–11:00 09:45–10:30 10:30–11:00 11:00–11:30 11:30–13:00

PLANNING NOTES

13:00–14:00 14:00–15:30

LUNCH BREAK SECTION 5 PREVENTATIVE PROPHYLAXIS & TREATMENT (90 minutes) Review preventative measures feeding, treatment. Exercises on treatment. TEA BREAK (15 minutes) PLANNING NOTES

15:30–16:00

SECTION 6 INFANT FEEDING (30 minutes) Infant feeding for the HIV exposed and infected child. SECTION 7 NEXT STEPS (30 minutes) Review expectations for self-learning period and next meeting. CLOSE MEETING

PLANNING NOTES

16:00–16:30

PLANNING NOTES

16:30

PLANNING NOTES

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 1. INTRODUCTION & REVIEW OF SELF-STUDY PERIOD TIME – 30 minutes FACILITATOR SUMMARY In this section you will review this meeting’s objectives and the day’s agenda. Participants should understand how this supplementary course fits within the course structure and expectations. This section is also critical opportunity for facilitators to review the self-study period. Please refer to the dIMCI Facilitator Guide, Sections 2 in the Review & Practice and Final Synthesis meeting for guidance on this activity. SECTION OBJECTIVES •• Set a welcoming learning environment during facilitator and participant introductions •• Introduce HIV module within context of distance learning course •• Distribute and review modules and logbooks •• Provide an opportunity to reflect on distance learning experience and participants’ progress in understanding and using IMCI •• Assess how well participants are using IMCI in their clinical practice •• Address problem areas in self-study and challenging cases from clinical practice MATERIALS ■■ PowerPoint slides ■■ HIV study module for distribution ■■ HIV logbook section for distribution ■■ Flipchart

1.1 WELCOME PARTICIPANTS Welcome participants to third face-to-face meeting. Present the meeting as an opportunity to assess progress in self-study, address any challenges the group is having, and practice together. 1. Re-introduce yourself and co-facilitators 2. Invite participants to re-introduce themselves (FLIPCHART) •• Name •• Workplace and role •• One thing that you have found particularly beneficial about IMCI so far in your self-study, group learning, or clinical practice 3. SUMMARIZE participant comments about course benefits

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

1.2 REVIEW COURSE STRUCTURE 1. Review course objectives SLIDE 2. Review course structure SLIDE – briefly review what components of the course have been completed, and what is upcoming. The upcoming self-study period should cover both HIV study and a review of all other modules in preparation for the final meeting. CLARIFY: any questions from the group about the course structure? FOR SECTIONS 1.3–1.5 BELOW: REFER TO SECTION 2 IN REVIEW & PRACTICE MEETING

1.3 FACILITATORS REVIEW LOGBOOKS & RECORDING FORMS (AT SAME TIME AS 1.4) 1.4 PLENARY DISCUSSION – OUR REFLECTIONS ON SELF-STUDY (AT SAME TIME AS 1.3) 1.5 ADDRESSING PROBLEMS FROM LOGBOOKS 1.6 TODAY’S OBJECTIVES & AGENDA SLIDE 1. REVIEW: objectives of the face-to-face meeting

Paediatric  HIV  meeCng  objecCves   At  the  end  of  today,  you  should  be  able  to:       Explain  how  HIV  affects  the  immune  system     Explain  how  children  are  infected  with  HIV     Assess  and  classify  a  child  for  HIV     Assess  and  classify  a  young  infant  for  HIV     Explain  principles  of  counseling  an  HIV  posi.ve  mother  about  feeding     Describe  measures  to  prevent  common  infec.ons  in  children  with  HIV     Explain  what  ART  does     Iden.fy  ART  drug  combina.ons  and  dosages     Explain  when  children  should  be  ini.ated  on  ART  

Distance  learning  IMCI  

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

2. REVIEW: in brief the agenda for today Emphasize that it is a busy day and will require discipline to stay on task n MORNING: we will review our experiences in the past few weeks with selfstudy and begin HIV content n LATE MORNING: we will practice IMCI in the clinic together If required at this time, describe how group will move and/or transition to clinical setting. Otherwise wait until the actual session to discuss. n AFTERNOON: we will review HIV prophylaxis and treatment, and infant feeding 3. REVIEW: administrative announcements as required

1.7 DISTRIBUTE HIV SELF-STUDY MODULE BOOKS & LOGBOOK Explain purpose of books and ask participants to open to key sections with you. 1. HIV module: follows same format as other dIMCI modules 2. HIV logbook section: Important to point out where participants can find ART initiation and follow-up forms. While these are reviewed in the module, participants should understand that there are two additional IMCI tools to use with HIV.

1.8 REINFORCE KEY PRINCIPLES ✔✔ Today is an opportunity to address any content or practice areas that you have found particularly challenging – so do not be afraid to ask questions. ✔✔ We will prepare for the upcoming self-study period by introducing HIV testing, assessing and classifying, prophylaxis, and treatment. ✔✔ The HIV module has a lot of content, so it is important to pay attention today and ask questions about any issues. ✔✔ Your upcoming self-study will only become more difficult if you have confusions about IMCI or the material.

1.9 TRANSITION TO NEXT SESSION We’ll begin our day by quickly discussing what HIV is and how children are infected. We will also discuss why HIV is included in IMCI.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 2. INTRODUCING HIV/AIDS TIME – 15 minutes FACILITATOR SUMMARY In this section, facilitators will introduce review HIV in simple terms so that participants can, by the end of this brief session, be able to explain in basic terms how HIV affects the body, and how children are infected. OBJECTIVES •• Explain how HIV damages the body, in a way that participants can use to explain to caretakers and children •• Explain how children infected with HIV MATERIALS ■■ Powerpoint slides ■■ Flipchart

2.1 WHAT IS HIV? CLARIFY: define HIV Human Immunodeficiency Virus is a virus that infects and takes over cells of the immune system. Although HIV infects a variety of cells, its main target is the CD4 lymphocyte. CLARIFY: national and regional prevalence and impact

2.2 WHAT DOES HIV DO ONCE IT IS IN THE BODY? SLIDE

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

2.3 HOW DOES HIV ATTACK THE BODY AND DAMAGE THE IMMUNE SYSTEM? SLIDE

2.4 GROUP EXERCISE: HOW DO WE DEFINE THESE IMPORTANT TERMS? (RECORD ON FLIPCHART) ✔✔ CD4 cell Answer: A CD4 cell is a special type of white blood cell in the body that helps to fight against infection. The CD4 cell has a special receptor on its surface called the CD4 receptor. The HIV virus attaches to this receptor to enter the white blood cell. Answer: The immune system is the body’s defence system to fight infection. White blood cells form part of the human immune system. Answer: An opportunistic infection is an infection that causes disease only in people whose immune system is not functioning well. Thus an opportunistic infection will not cause illness and disease in healthy people. Oral thrush and tuberculosis are examples of opportunistic infections.

✔✔ Immune system

✔✔ Opportunistic infection

CLARIFY: What questions do we have before moving on?

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

2.5 HIV INFECTIONS IN CHILDREN è PRACTICE WITH GROUP DISCUSSION: how do children become infected with HIV? 1. Record participant answers on FLIPCHART 2. For each response, ask prompts to further discussion: ✔✔ What do you think is the risk of this transmission? ✔✔ Do all children born to HIV-positive mothers get infected with HIV? ✔✔ Do all children breastfed by HIV-positive mothers get infected with HIV? CLARIFY: Review the actual risks SLIDE

If  20  women  deliver  babies  without  any  intervenCon   to  reduce  mother-­‐to-­‐child  HIV  transmission:     How  many  on  average  will  be  infected?  7  out  of  20      

PREGNANCY   &  DELIVERY   4  out  of  20  

BREASTFEEDING   3  out  of  20  

NOT  INFECTED   13  out  of  20  

CLARIFY: what questions do we have about transmission to children? Ensure that participants understand the concept of risk.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

2.6 HIV IN CHILDREN CLARIFY: what if I already see adults who have HIV—what makes HIV/AIDS care for children different? SLIDE

What  is  special  about  HIV/AIDS   care  in  children?   1. 

HIV  can  progress  very  quickly  in  children          

Early  iden.fica.on  is  cri.cal   Preventa.ve  prophylaxis  to  minimize  infec.on   Rapid  management  of  opportunis.c  infec.ons   Ini.a.ng  ART  when  required  

2.  3.  4. 

HIV  tesCng  methods  are  different  than  adults   ART  formulaCons  are  different  than  adults   Child  need  special  care  to  make  sure  they  are   growing  and  developing  opCmally  

2.7 REINFORCE KEY PRINCIPLES •• HIV in the body: CD4 cells protect the body. HIV invades the body by entering CD4 cells and making new copies of itself. It uses the CD4 as a factory for more HIV. Once CD4 cells are damaged, the body is less able to defend itself. It becomes vulnerable to common illnesses like cough, diarrhoea, and others. •• Transmission to children: most common way is from mother-to-child •• MTCT: can occur during pregnancy, labour, delivery, and breastfeeding. •• PMTCT: there are important interventions to reduce the risk of MTCT. If 20 mothers deliver babies without any interventions, about 7 babies will be infected with HIV.

2.8 TRANSITION TO NEXT SECTION Now we will learn about using IMCI for HIV. We will learn how to assess and classify HIV status in children and young infants using the same IMCI process.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 3. ASSESS & CLASSIFY HIV STATUS TIME – 60 minutes FACILITATOR SUMMARY You will explain how HIV fits into the IMCI process, and why HIV is important to be included in IMCI. You will review testing methods, signs to assess for, and classifications. You will facilitate opportunities to practice with written case studies. OBJECTIVES •• Emphasize the age specificity of testing methods •• Review how these tests are used in ASSESS a sick child or infant •• Explain the signs used to ASSESS a sick child or infant •• Explain classifications •• Provide opportunities to practice in written exercises and cases MATERIALS ■■ Copies of IMCI recording forms (child and sick young infant) – distribute before you begin ■■ PowerPoint slides ■■ Flipchart

3.1 REVIEWING IMCI è PRACTICE: who can walk us through the IMCI process? CLARIFY: review key points or corrections SLIDE

ASSESS   CLASSIFY   &  IDENTIFY   TREATMENT  

ASK,  LOOK,  LISTEN,  and  FEEL  for:   •  Signs  of  severe  illness   •  Main  symptoms  and  common  health  issues   BASED  ON  SEVERITY  OF  CLASSIFICATION:   •  RED:  severe,  urgent  referral  required   •  YELLOW:  treat  in  clinic   •  GREEN:  home  treatment  

TREAT   COUNSEL   FOLLOW-­‐UP   Distance  learning  IMCI  

INTEGRATED  TREATMENT  FOR  ALL  CLASSIFICATIONS  

THE  CARETAKER  ON  HOME  TREATMENT  &  FOLLOW-­‐UP  

ON  CARE  AND  RE-­‐ASSESS  

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

3.2 WHY USE IMCI FOR HIV? The scope of this introduction depends on national level policies and priorities (see example Box 1). CLARIFY: how does IMCI help health workers provide better care for HIV? SLIDE •• There is a global effort to eliminate new paediatric HIV infections and keep mothers alive. •• There is a global effort to reach universal access to HIV prevention, care, treatment. •• In many countries, HIV contributes to a very significant level of childhood mortality. •• HIV also underlies the other major causes of morbidity and mortality in many countries, including malnutrition, pneumonia, and diarrhoea. •• It is important to confirm HIV status and initiate ART early in children. •• Early infant diagnosis coverage is poor international, as is ART coverage in children. •• Follow-up and monitoring of those on treatment is important to ensure quality of life.

Why  is  IMCI  an  approach  to  improve   paediatric  access  to  treatment  and  care?   BIG  ISSUES:     Coverage  of  child  tes.ng  is  low     Coverage  of  early  infant   diagnosis  is  low     Interna.onal  ART  coverage  is   low:  only  28%  of  children  who   should  be  receiving  ART  are     HIV  requires  quick  management,   especially  for  opportunis.c   infec.ons  and  nutri.on     Children  can  be  lost  in  follow-­‐up   Distance-­‐learning  IMCI  

IMCI  HELPS  HEALTH   WORKERS  TO:   IdenCfy  HIV-­‐exposed  and  infected   children  because  you  will  assess   every  child  you  see   Determine  when  children  should   be  iniCated  on  ART  at  primary  care   level   Provides  guidance  on  management   of  common  issues  for  HIV  infected   children   Provide  close  follow-­‐up  at  primary   care  level  

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

BOX 1: SLIDE EXAMPLE FROM SOUTH AFRICA

Why  include  HIV  in  IMCI?   1.  HIV  causes  30%  of  child  deaths  in  South  Africa   2.  IMCI  addresses  the  major  problems  seen  in         children   3.  Primary  level  faciliDes  see  high  HIV                                                     prevalence  and  paDent  loads   4.  HIV  requires  quick  management:  early  idenDficaDon   and  treaDng  opportunisDc  infecDons   5.  South  African  nurses  can  now  iniDate  ART   6.  HIV  requires  close  follow-­‐up  at  primary  level  

3.3 WHERE DOES HIV FIT INTO IMCI? CLARIFY: when will you assess and classify for HIV? You’re learned the IMCI process for the following signs and symptoms. Here is where HIV fits. Walk through process. SLIDE CLARIFY: where will you record your HIV assessment? SLIDE IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  ini.al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breasceed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS           Even  if  present  

  Cough  or  difficult  breathing          Diarrhoea     Fever                              Ear  problems     Malnutri.on  &  anaemia                        HIV  status     Check  immuniza.ons                            Others  

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

CLARIFY: show the same for the sick young infant SLIDES

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

3.4 HIV TESTING CLARIFY: what are the types of tests? SLIDE ✔✔ HIV infection in children less than 18 months of age is confirmed through virological tests which detect the actual virus. ✔✔ In children older than 18 months of age, serological tests are used. Serological tests detect antibodies to HIV. This is why they cannot be used to confirm HIV infection in children less that 18 months of age, as the children may have maternal antibodies in their system. A positive serological test in a child less than 18 months of age only confirms that the child is HIV exposed.

Types  of  HIV  tes.ng       SEROLOGICAL   TESTS   including  rapid   tests         VIROLOGICAL   TESTS   including  DNA   or  RNA  PCR        

    PRESENCE  OF  HIV   ANTIBODIES          

What  does  test  detect?  

      HIV  an.bodies  pass  from  mother  to  child     An.bodies  can  stay  with  child  up  to  18   months  of  age    

How  can  you  interpret  the  test?  

PRESENCE  OF  HIV   VIRUS        

 

POSITIVE  TEST  IN  CHILD  UNDER  18   MONTHS  IS  NOT  RELIABLE  TO  CONFIRM   INFECTION       Directly  tests  presence  of  virus     Must  be  conducted  ager  child  has   stopped  breasceeding  for  at  least  6   weeks    

POSITIVE  TEST  ANY  ANY  AGE  CAN   CONFIRM  INFECTION  

CLARIFY: why do you have to consider infant feeding when testing? SLIDE Discuss considerations for breastfeeding and HIV testing accuracy

HIV  tes.ng  and  infant  feeding   Is  child   breasSeeding?   NOT  BREASTFEEDING,  and   has  not  in  last  6  weeks  

POSITIVE  (+)  test   NEGATIVE  (-­‐)  test   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months.   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months  or   once  breasceeding  has  been   discon.nued  for  more  than  6   weeks.   HIV  NEGATIVE   Child  is  not  HIV  infected      

BREASTFEEDING  

Child  can  sCll  be  infected  by   breasgeeding.  Repeat  test   once  breasceeding  has  been   discon.nued  for  more  than  6   weeks.  

Distance-­‐learning  IMCI  

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CLARIFY: What is EID? Establishing the presence of HIV infection in HIV-exposed infants and children less than 18 months of age. CLARIFY: What is our national EID algorithm? SLIDE Review  Below the  e infant   diagnosis   algorithm   below:   isarly   algorithm adapted from Antiretroviral therapy for HIV infection in infants and This  flow  c harts   h elp   y ou   m ake   d ecisions   a bout   t he   t esting   course   of  action   for  children   children: towards universal access. Recommendations for a public health approach. 2010 under   18  months.   I t   p rovides   s ome   m ore   s pecifics   i n   a ddition   t o   t he   i nformation   y ou   r ead   on  the   revision. Geneva, World Health Organization.  

previous  page.    

HIV-­‐exposed  Infant  or  child  <18  months   Conduct  diagnostic  v iral  testa   Viral  test  available   Positive   Viral  test  not  available  

Negative  

Infant/child  is  likely  infected    

Never  breastfed  

Ever  breastfed  or  currently   breastfeeding   Infant  /child  remains   at  risk   for  acquiring  HIV  infection   until  complete  cessation  of   breastfeedingc   Regular  and  periodic   clinical  monitoring  

<24   months:  immediately   start  ARTb    

Infant/child  is   uninfected  

And  repeat  viral  test   to  confirm  infection  

Infant/child  develops  signs  or  symptoms   suggestive  of  HIV  

Infant  remains  well  and  reaches  9   months  of  age  

Viral  test  not  available  

Conduct  HIV  antibody  test  at     approximately  9  months  of  age  

Viral  test  available       Negative   Positive  

Positive  

Negative  

sick  

Infant/child  is  infected  

 

Viral  test  not  available   assume  infected  if  sick   assume  uninfected  if  well   well  

Start  ARTb   And  repeat  viral  test  to  confirm   infection    

HIV  unlikely  unless   still   breastfeedingc  

For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant diagnosis. b Start ART, if indicated, without delay. At the same time, retest to confirm infection. c The risk of HIV transmission remains as long as breastfeeding continues. a

 

Repeat  antibody   test  at  18  months  of  age   and/or  6  weeks  after  cessation  of   breastfeeding    

 

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

è PRACTICE (if time allows): are these children confirmed infected? SLIDE

HIV  TESTING   PRACTICE  QUESTIONS:  Is  the  child  confirmed  posi.ve?   1. 

A  2  month  old  baby  has  a  posi.ve  virological  (PCR)   test.     A  7  month  old  breasceeding  baby  has  a  posi.ve   an.body  test.     An  18  month  old  breasceeding  child  has  a  posi.ve   HIV  rapid  an.body  test.     An  18  month  old  child  has  a  nega.ve  an.body  test.   The  baby  last  breasced  one  week  ago.    

2. 

3. 

4. 

ANSWERS: 1. CONFIRMED POSITIVE – Viral particles have been detected in this baby’s blood. 2. NOT CONFIRMED – the antibodies may have come from the mother. The antibody test will have to be repeated after 18 months and at least 6 weeks after breastfeeding stops. If it is still positive at this stage, then the baby is positive. A virological test can be done at least 6 weeks after breastfeeding stops and at any age. If this virological test (done at least 6 weeks after breastfeeding stops) is positive then the baby is confirmed HIV positive. 3. CONFIRMED POSITIVE – maternal antibodies should have disappeared by the age of 18 months; hence the antibody test at age 18 months is measuring antibodies developed by the child and this means that he is HIV infected. 4. NOT CONFIRMED – although the antibody test did not detect antibodies to HIV the child was last exposed to HIV infection one week ago and may still have acquired an infection during that time. The antibody test will have to be repeated in 5 weeks time (i.e. 6 weeks after breastfeeding stops) to determine whether the child is truly HIV uninfected.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

3.5 ASSESS & CLASSIFY THE SICK CHILD CLARIFY: Open your ASSESS charts for the sick child to HIV. What do you observe? SLIDE ✔✔ Assessing requires a test result from the child. ✔✔ If the child does not have a test result, test now.

ASSESS  CHILD  FOR  HIV  

CLARIFY: how will you CLASSIFY? SLIDE ✔✔ Ask checking questions to review the concept of exposure and being HIV EXPOSED

CLASSIFY  &  IDENTIFY  TREATMENTS  

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

3.6 ASSESS & CLASSIFY THE YOUNG INFANT CLARIFY: What is different about HIV in the young infant and child? SLIDE

How  is  assessing  a  young  infant   different?    Young  infants  with  HIV  may  look  well,  but  they  can  

die  very  quickly    Young  infants  do  not  show  signs  and  symptoms  of   HIV  like  a  sick  child    Young  infants  will  show  common  signs  like   diarrhoea   criCcal  

 Therefore,  early  idenCficaCon  with  PCR  tesCng  is  

CLARIFY: Open your ASSESS charts for the sick child to HIV. What do you observe? SLIDE CLARIFY: how will you CLASSIFY? SLIDE ✔✔ Ask checking questions to review the concept of exposure and being HIV EXPOSED è PRACTICE (if time allows): how would you classify? SLIDES Show first slide with only case questions. Show second slide to review answers.

ASSESS  &  CLASSIFY   PRACTICE  QUESTIONS:  how  would  you  classify?  

1.  6  week  old,  mother  is  posi.ve  and  breasceeding.   No  test  for  child.  HIV  EXPOSED:  perform  virological   ajer  breasgeeding  stopped  for  6  weeks.     2.  12  months,  s.ll  breasceeding.  Posi.ve   serological  test.  HIV  EXPOSED:  perform  virological   ajer  breasgeeding  stopped  for  6  weeks.     3.  25  months,  posi.ve  serological.  CONFIRMED  HIV   INFECTION.    

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3.7 REINFORCE KEY PRINCIPLES RETURN TO SLIDES AS REQUIRED ✔✔ Importance of early identification ✔✔ Importance of test results by age ✔✔ Importance of breastfeeding status ✔✔ National testing procedures ✔✔ CLASSIFYING with a test result ✔✔ CLASSIFYING without a test result: HIV EXPOSED, sending for test CLARIFY: What questions do you have about ASSESSING and CLASSIFYING?

3.8 TRANSITION TO NEXT SECTION SLIDE Explain how the group will move into tea and then to the clinic. Brief the participants on the clinical experience as required.

SECTION  4   CLINICAL  PRACTICE   Important  notes  for  clinical  pracCce:    

  This  is  an  important  chance  to  prac.ce  HIV—clarify   any  ques.ons  or  concerns!     Bring  your  IMCI  chart  booklets     Bring  IMCI  recording  forms     Bring  ART  ini.a.on  forms     Bring  materials  for  notes  as  required     Our  plans  for  genng  to  the  clinic  and  lunch   Distance-­‐learning  IMCI  

STOP FOR TEA BREAK (15 MINUTES)

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 4. CLINICAL DEMONSTRATION & PRACTICE TIME – 90 minutes FACILITATOR SUMMARY This section is a critical opportunity to observe how participants are using IMCI in the clinical setting. In today’s session it is important for facilitators observe participants as they practice IMCI and conduct full assessments. Depending on caseload and availability, facilitators could observe a participant one-to-one, or assign participants into groups that all observe and mentor as participants take turn conducting assessments. Please refer to the FACILITATOR GUIDE ANNEX for more guidance on clinical practice sessions. Today’s practice sessions should demonstrate full comprehension of the IMCI process, and all symptoms covered in the course material thus far. If practice highlights key gaps or issues, the facilitator should demonstrate good practices. Given the confidentiality required during HIV testing, counselling, and interventions, it is recommended that HIV clinical practice be addressed during individual mentoring between facilitator and participant. SESSION OBJECTIVES •• Conduct full IMCI assessments of sick young infants, if available, with full grasp of material and IMCI process •• Conduct full IMCI assessments of sick children and all main symptoms, with full grasp of material and IMCI process •• Demonstrate good skills in using the IMCI charts and recording forms •• Receive concrete feedback from facilitators or peers about use of IMCI in clinical assessments. Every participant should receive feedback from the session. MATERIALS ■■ Participants should bring Chart Booklets and recording forms (logbook or copies provided) ■■ Participants should bring recording forms (logbook or copies provided) ■■ Any other materials required for clinical setting

TRANSITION: Summarize session as required. Explain transportation and lunch plans. Break for lunch if 45 minutes. During lunch, facilitators should regroup (as required) and also spend time with participants to discuss their self-study and clinical practice.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 5. TREATMENT & PREVENTATIVE PROPHYLAXIS TIME – 90 minutes FACILITATOR SUMMARY In this session, you will introduce important measures for preventing and treatment illness in HIV exposed and infected children and young infants. These are important measures of follow-up care. This section will also introduce ART and review the steps of initiation. Participants will complete a hands-on activity preparing ART combination therapy dosages. OBJECTIVES •• Review opportunistic infections and why prophylaxis is important •• Introduce nevirapine prophylaxis and when children are eligible •• Introduce cotrimoxazole prophylaxis and when children are eligible MATERIALS ■■ PowerPoint slides ■■ Flipchart

5.1 INTRODUCE PROPHYLAXIS DISCUSSION: Record responses and discussion points on FLIPCHART. ✔✔ What is an opportunistic infection? ✔✔ Why are HIV exposed or infected children more vulnerable to infection? ✔✔ Why is it critical to prevent and manage illness? CLARIFY: what is ‘prophylaxis’? Record key points on FLIPCHART. CLARIFY: what are the important kinds of prophylaxis in HIV care that you will learn about in your module? ✔✔ ART prophylaxis ✔✔ Cotrimoxazole ✔✔ INH ✔✔ Other regular interventions: vitamin A, deworming

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

5.2 ART PROPHYLAXIS SLIDE CLARIFY: what is ART prophylaxis? CLARIFY: when will exposed infants receive prophylaxis?

When  will  HIV-­‐exposed  infants  receive   ART  prophylaxis?   !"#$%&'##()*+, !"#$$%&"'(")*(+*,"-.'-/01+2)&" #),/"'*3$45+)10"678" "

"#-.$/#0#*&,'##()*+, 9:!"#$$%&"'(")*(+*," -.'-/01+2)&"#),/"'*3$45+)10" 678";'.",#)3$45+)10"<=>?"

NOTE:  this  is  the  recommenda.on  for  both  OpFon  B   and  OpFon  B+  PMTCT  na.onal  policies   Distance-­‐learning  IMCI  

5.3 INTRODUCE COTRIMOXAZOLE SLIDE CLARIFY: what is cotrimoxazole prophylaxis? CLARIFY: when will infants and children receive prophylaxis?

When  will  infants  and  children  begin   cotrimoxazole  prophylaxis?   THESE  YOUNG  INFANTS…   SHOULD  START…   CONFIRMED  HIV  INFECTION   From  4-­‐6  weeks   HIV  EXPOSED   From  4-­‐6  weeks   THESE  CHILDREN…   SHOULD  START…   CONFIRMED  HIV  INFECTION     As  soon  as  possible   Less  than  12  months  old   1.  When  at  WHO  clinical   CONFIRMED  HIV  INFECTION     stages  2-­‐3-­‐4,  regardless  of   12  months  up  to  5  years   CD4%   2.  When  CD4%  less  than  25%   HIV  EXPOSED   As  soon  as  possible   WHY?   Infant  is  HIV  infected   Infant  is  born  to  HIV   infected  mother   WHY?   Child  is  HIV  infected   This  is  regardless  of   whether  the  child  is   on  ART  or  not.       Child  is  exposed  to   HIV  

Distance  learning  IMCI  

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5.4 PRACTICE CASES SLIDE Ask the participants to complete the exercise individually or in a group. Provide time for participants to review cases. DISCUSS answers and clarifying any questions.

 Sami  is  6  weeks  old  and  weighs  4.5  kg.  He  was  born  in  the  local   hospital.  Because  his  mother  had  tested  HIV  posi.ve,  Sami   received  Nevirapine  from  birth.  His  mother  was  also  started  on   lifelong  ART  during  pregnancy.  Sami  is  breasced.    His  mother   has  brought  him  for  his  six  week  visit  today.  What  care  and   treatment  does  he  require?  

CASE  STUDY:  SAMI  

 Nthabeleng  is  four  months  old.  Her  mother  tested  HIV-­‐posi.ve   during  pregnancy.  Nthabeleng  is  breasced,  but  never  received   Nevirapine.  She  weighs  6  kg.  She  has  not  been  tested  for  HIV   infec.on.  What  care  and  treatment  does  he  require?  

CASE  STUDY:  NTHABELENG  

DISCUSSION: What steps will you take? What preventative prophylaxis is required today? How will you manage this?

5.5 INTRODUCING ART DISCUSSION: What does ART stand for? What do ARV drugs do? CLARIFY: what are the recommended national drugs? SLIDE

An.retroviral  drugs   Nucleoside   reverse   transcriptase   inhibitors   (NsRTI)   lamivudine   (3TC)   stavudine  (d4T)   zidovudine   (AZT)   didanosine  (ddI)   abacavir  (ABC)   NucleoCde   reverse   transcriptase   inhibitors   (NtRTI)   tenofovir   disoproxil   fumarate  (TDF)       Non-­‐nucleoside   reverse   transcriptase   inhibitors   (NNRTI)   nevirapine  (NVP)   efavirenz  (EFV)       Protease   inhibitors  (PI)  

lopinavir  (LPV)   indinavir  (IDV)   retonavir  (RTV)*   atazanavir  (ATV)   darunavir  

*ritonavir  is  used  as  a  ‘helper’  for  one  PI  to  make  the  effect  of  a  second   PI  stronger  

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5.6 INITIATING ART IN CHILDREN CLARIFY: what children are eligible to initiate ART? SLIDE

Using  IMCI  to  ini.ate  pediatric  ART        Who  is  eligible  to  ini.ate  ART?  

 

 All  children  who  are  classified  CONFIRMED    HIV  INFECTION      What  is  the  preferred  first  line  ART  regimen?  

Distance-­‐learning  IMCI  

 For  children  under  3  years:      ABC  or  AZT  +  3TC  +  LPV/r        For  children  3  years  and  older  (but  under  35  kg):      ABC  +  3TC  +  EFV      

 

CLARIFY: how will you initiate ART? SLIDE ✔✔ Distribute the ART charts and the ART initiation form, if not already distributed ✔✔ Review the 5 steps of initiation and follow along with recording form

5  steps  of  ART  iniCaCon   !"#$%&'%(#)*(#%*+%",#%),*-(%,.!%)/0+*12#(%,*3%*0+#)"*/0% !"#$%B'%(#)*(#%*+%.1"%).0%C#%*0*"*."#(%*0%D/E1%+*1!"%-#3#-% % +.)*-*"D%% )4567%58%9:7;<%&=%>?:@48'% !" #$%&'()*+,'-(&'.&+-()'/0*1&')&2'/-3-4'+53&6789:&'.&;-.','2*& <" 8=*+>&,=5,&+='31&=5.&(-,&?/*5.,)*1&)-/&5,&3*5.,&@&A**>.& ! %

!" $)&+='31&A*'4=.&3*..&,=5(&G>4&-/&=5.&BIH&/*)*/&)-/&J9B&'(','5,'-(& <" *F%G4567%H;5I48%B%JI%?<%>?<;%K:7%7?;8%:?@%4KA;%"CL%-+5(!*+!6789!;% % &

)4567%58%?A;<%&=%>?:@48'% !" BA-&1'))*/*(,&.*/-3-4'+53&,*.,.&5/*&;-.','2*& <" C*(1&5(D&)E/,=*/&+-()'/05,-/D&,*.,.&/*FE'/*1& G" $)&/*.E3,.&5/*&1'.+-/15(,H&/*)*/& ! "#!$"%!&'#()*&+'!)+'#&,-(./!0'.!)1&2.!&3!3*042(/!-+5(!*+!6789!:! !

!"#$%M'%(#)*(#%*+%).1#N*3#1%*!%.C-#%"/%N*3#%.1"% 8=*+>&,=5,&,=*&+5/*4'2*/&'.&A'33'(4&5(1&5?3*&,-&4'2*&J9B"&&B=*&+5/*4'2*/& .=-E31&'1*533D&=52*&1'.+3-.*1&,=*&+='31K.&#$%&.,5,E.&,-&5(-,=*/&51E3,&A=-& +5(&5..'.,&A',=&;/-2'1'(4&J9BH&-/&?*&;5/,&-)&5&.E;;-/,&4/-E;"& & !" *F%GK<;I5A;<%KO6;%@?%I5A;%.1"'%-+5(!*+!6789!<% <" $)&+5/*4'2*/&(-,&5?3*L&+35..')D&5.&8MNO$9PQR&#$%&$NOQ8B$MN&(-,&-(& J9B"&&O-33-ASE;&/*4E35/3D"&&CE;;-/,&+5/*4'2*/&5(1&0-2*&)-/A5/1&-(+*& .=*&'.&A'33'(4&5(1&5?3*&,-&4'2*&J9B"&&! !

!"#$%P'%1#)/1(%C.!#-*0#%*0+/12."*/0%/0%",#%),*-(Q!%,*3% "1#."2#0"%).1(% 1;G?<7%@4;%F?66?H5:I%5:F?<>K@5?:'% !" T*'4=,&5(1&=*'4=,U&;533-/&5(1&)**1'(4&;/-?3*0&"#!$%&'&()! <" V5?-/5,-/D&/*.E3,.&6')&525'35?3*:L&#?H&2'/53&3-51H&8RW&+-E(,&5(1&8RWX& G" C*(1&5(D&35?-/5,-/D&,*.,.&,=5,&5/*&/*FE'/*1"&&$)&,=*&+='31&'.&+-()'/0*1&#$%& '()*+,'-(H&1-&(-,&A5',&)-/&/*.E3,."& & =+5(!*+!6789!>!

!"#$%R'%!".1"%/0%.1"%"1#."2#0"%.0(%)/"1*2/S.T/-#%$1/$,D-.S*!% • • •

)4567%58%9U%@?%B%V;K<8%?67L&'(','5,*&;/*)*//*1&J9B&,/*5,0*(,L&JI8&-/&JYB&ZGB8Z&V7%[9&-/&-,=*/&/*+-00*(1*1&)'/.,S3'(*&/*4'0*(& )4567%58%B%V;K<8%?<%?67;<%O9@%6;88%@4K:%BR%JI'%'(','5,*&;/*)*//*1&J9B&,/*5,0*(,L&JI8&Z&GB8&Z&QO%H&-/&-,=*/&/*+-00*(1*1&)'/.,S3'(*&/*4'0*(& N5A;%G?W@<5>?XKY?6;%U<?U4V6KX58%K:7%?@4;<%<?9@5:;%@<;K@>;:@8L%'(+3E1'(4&2',50'(&J&5(1&'00E('\5,'-(.% % Distance  learning  IMCI  

&

CLARIFY: what questions are there about initiation?

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

5.7 ART DOSING EXERCISE SLIDE In this section the facilitator will lead a group discussion and individual exercise where participants should: (a) identify each ARV drug in the recommended first line therapy, and (b) prepare dosing. Details of dosages (e.g. child weight, single dosages versus daily dosage) can be determined by the quantity of drugs available. This helps health workers better identify drugs, and also receive mentorship on preparing dosages and methods for doing so (e.g. if pills need to be broken, etc). Facilitators can also roleplay good counseling skills with a caretaker and teaching how to give ART: (1) give information, (2) demonstrate, (3) let caretaker practice and provide feedback.

INSTRUCTIONS  FOR  EXERCISE   ANTIRETROVIRAL  TREATMENT     Find  the  ART  dosing  tables  in  your  chart  booklet     Using  the  drugs  provided,  prepare  the  dose  for   each  drug  in  the  combina.on  therapy     Call  facilitator  to  check  your  drugs  when  you  are   done  

Distance  learning  IMCI  

5.8 REINFORCE KEY PRINCIPLES OF ART ✔✔ The need for prophylaxis and integrated management ✔✔ Why give ART? What are the benefits, what does it do? ✔✔ 5 steps for initiation ✔✔ First line drugs ✔✔ Paediatric dosing ✔✔ Adherence is critical to ART effectiveness CLARIFY: Any questions about ART?

5.9 TRANSITION TO NEXT SECTION Next we will review an important counseling topic: feeding for HIV exposed and infected children. STOP FOR TEA BREAK (15 MINUTES)

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 6. INFANT FEEDING TIME – 30 minutes FACILITATOR SUMMARY This section provides a brief review of national policies for infant feeding for HIV exposed and infected children. Facilitators should walk through available support materials, like the chart booklet, and answer any questions. Participants will then conduct roleplays to practice key counselling skills. OBJECTIVES •• Explain the benefits of exclusive breastfeeding, even for HIV exposed children •• Introduce feeding recommendations for HIV-positive mothers •• Facilitate a counselling roleplay on infant feeding MATERIALS ■■ PowerPoint slides ■■ Roleplay handout from ANNEX, if using ■■ Roleplay props (as necessary) ■■ Flipchart

6.1 INTRODUCTORY REVIEW OF INFANT FEEDING OPTIONS CLARIFY: What are important things we need to consider when thinking about feeding options for families? Record answers on FLIPCHART to initiate discussion. Points to cover include: ✔✔ Exclusive breastfeeding versus mixed feeding ✔✔ Risk of transmission during breastfeeding ✔✔ Breastfeeding even when the mother is HIV-positive—benefit to child survival ✔✔ Interventions have made it safer for women to breastfeed (e.g. Nevirapine and cotrimoxazole prophylaxis, ART for the mother) ✔✔ Replacement feeding is not always an option for families and must be thoroughly considered ✔✔ Feeding options require counselling and continued support ✔✔ Good feeding is vital to optimal growth and development, disease prevention, and fighting infection, especially in HIV affected children

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

6.2 FEEDING RECOMMENDATIONS FOR THE HIV EXPOSED OR INFECTED CHILD Walk through important recommendations in the chart booklet. Ask checking questions. CLARIFY: what are the key feeding recommendations for HIV exposed children? CLARIFY: what are the key feeding recommendations for HIV infected children?

6.3 ROLEPLAY EXERCISE Facilitate roleplay to practice counselling a mother on feeding options. Note that this case study is for a woman who has not yet delivered. You can show the roleplay using SLIDE or the handout in the ANNEX.

ROLEPLAY:  INFANT  FEEDING   Lungile  is  26  years  old.  She  is  37  weeks  pregnant.  She  just  learned  that  she  is  HIV   posi.ve.    Lungile  lives  alone  in  the  centre  of  the  city.  She  gets  water  from  a  tap   near  her  house.  Her  partner  works  in  another  city  and  comes  home  at  weekends.   Lungiles  returns  to  her  village  once  a  year.  Lungile  is  working  in  temporary  jobs.       Ager  the  baby  is  born  she  does  not  know  if  she  will  go  back  to  work.  Maybe  she   will  go  back  home  for  a  while  before  she  returns  to  work.  When  she  returns  to  the   city  her  mother  will  look  ager  her  baby.  Neither  her  mother  nor  her  partner   knows  that  she  is  HIV  infected.  She  wants  to  tell  her  partner  but  she  is  scared  as   maybe  he  will  get  angry  with  her  and  he  will  not  give  her  any  money  for  this  baby.    

  HEALTH  WORKER:  Counsel  Lungile  on  how  she  might  feed  her   baby  once  he  or  she  is  born       MOTHER:  Try  to  behave  as  Lungile  would  in  a  real  situaCon.       OBSERVERS:    Watch  the  roleplay  and  take  notes.  These  will  be   useful  for  the  group  discussion.  

DISCUSSION: After the roleplay facilitate a group discussion about the issues around counselling on infant feeding practices. ✔✔ What did the health worker do that was particularly helpful in this counselling session? ✔✔ What would you have done differently if you encountered this situation in your clinic? ✔✔ What are good strategies for counselling mothers on feeding options? ✔✔ Let’s pretend that Lungile came to you after she already had the baby. The baby is one week old. How would you counsel her? CLARIFY: what questions do we have before moving on to the next section?

6.4 REINFORCE KEY PRINCIPLES OF INFANT FEEDING (refer to 5.3 discussion on FLIPCHART) 31

IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SECTION 7. NEXT STEPS TIME – 30 minutes FACILITATOR SUMMARY This section will review the course calendar and expectations for the second selfstudy learning period. At the conclusion of this section, you will administer an evaluation of the day. OBJECTIVES Reinforce course structure and expectations for the upcoming self-study period: (a) completing the HIV module, (b) continuing to work on all modules Review how to involve mentors and study groups Administer meeting evaluation MATERIALS ■■ PowerPoint slides ■■ Evaluation handout

7.1 EXPECTATIONS FOR SELF-STUDY PERIOD SLIDE Review what is expected during the following several weeks of self-study.

NEXT  STEPS:  self-­‐study  phase  3   •  Complete  HIV  module     Read  HIV  module     Complete  logbook     Complete  ART  and  follow-­‐up  forms   •  ConCnue  work  on  all  other  IMCI  modules     Prac.ce  in  clinic   For  HIV  and  all  modules:   •   Prac.ce  in  clinic  using  recording  forms   •   Stay  in  contact  with  mentors  and  facilitators   •   Meet  with  study  group   Distance-­‐learning  IMCI  

CLARIFY: what is expected for the logbooks and recording forms? Practice content in clinics and use recording forms. Bring two recording forms per modules to the next meeting that demonstrate examples of integrated management for young infant and child. CLARIFY: what is expected for the logbooks and recording forms? What questions or concerns do you have about these tasks? Are there any issues to discuss?

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

7.2 DEVELOPING STUDY PLANS FOR STUDY PERIOD 3 SLIDE Based on feedback from morning plenary, discuss how participants should pace their work. Facilitators may choose to recommend a study plan for each week to keep participants on track. If so, slide should be edited to reflect this.

SAMPLE  AGENDA:  self-­‐study  phase  3   SAMPLE  INDIVIDUAL  STUDY  PLAN   WEEK  

1!

2! 4! 3!

Module 3 (assess, classify, and treat) + 13 August! 1 form! Module 3 (remaining) + logbook + 1 form!

STUDY  PLAN  

GROUP  

20 August! 27 August!

5   ! 6! 7!

Module 5 (all) + logbook + 2 forms! Module 6 (all) + logbook + 2 forms! Module 7 (all) + logbook + 2 forms! Prepare for exam!

Module 4 (all) + logbook + 2 forms!

4 September! 11 September! 19 September! 24 September!

Distance-­‐learning  IMCI  

7.3 PREPARING FOR 4TH FACE-TO-FACE MEETING SLIDE Participants should take out their study module calendars to fill in dates or details as required.

NEXT  MEETING:  Final  synthesis     DATE     LOCATION  

   

   

   

   

     

   

  TO  BRING  COMPLETED  –    

  Logbook  exercises:  20  for  each  module     Recording  forms  from  clinic:  per  facilitator  request  

  AT  THE  NEXT  MEETING  WE  WILL  -­‐       Prac.ce  IMCI  in  clinical  senng     Review  content  from  main  symptoms  and  condi.ons     Complete  examina.on  of  your  IMCI  skills     Complete  the  course     Distance-­‐learning  IMCI  

CLARIFY: what questions do we have about our next steps or this meeting?

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7.4 EVALUATION Facilitators are recommended to ask participants for feedback on specific topics before giving a printed evaluation. Conversational evaluations can also provide useful information that is not included in a written evaluation. As participants finish the evaluation, be available to answer any individual questions. *DISTRIBUTE EVALUATION FORM*

CLOSE MEETING: Affirm participants’ work in the course thus far. Provide time to complete the evaluation. Affirm participants’ engagement in the course. Congratulate participants, or close with an activity to revive energy.

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IMCI DISTANCE LEARNING COURSE | SUPPLEMENTARY FACILITATOR GUIDE FOR PAEDIATRIC HIV

SAMPLE MEETING EVALUATION 1. Why are you interested in improving your skills in HIV care for children?

2. What was most useful in Section 2, the overview of HIV/AIDS and how children are infected? What can be improved?

3. What was most useful in Section 3 on HIV testing? What can be improved?

4. What was most useful in Section 3 on assessing and classifying HIV using IMCI? What can be improved?

5. What was most useful in about the clinical practice session today? What can be improved?

6. What was most useful in Sections 5 about prophylaxis and treatment, including ART? What can be improved?

7. What was most useful in Section 6 about infant feeding? What can be improved?

8. What are your recommendations to the facilitator?

9. Do you have any other comments about the session today?

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HANDOUT FOR FEEDING ROLEPLAY (SECTION 6) n  CASE STUDY TO READ: Lungile is 26 years old. She is 37 weeks pregnant. She just learned that she is HIV positive. Lungile lives alone in the centre of the city. She gets water from a tap near her house. Her partner works in another city and comes home at weekends. Lungiles returns to her village once a year. Lungile is working in temporary jobs. After the baby is born she does not know if she will go back to work. Maybe she will go back home for a while before she returns to work. When she returns to the city her mother will look after her baby. Neither her mother nor her partner knows that she is HIV infected. She wants to tell her partner but she is scared as maybe he will get angry with her and he will not give her any money for this baby.

INSTRUCTIONS FOR ROLEPLAY: WHAT SHOULD I DO? ✔✔ HEALTH WORKER: Counsel Lungile on how she might feed her baby once he or she is born ✔✔ LUNGILE: Try to behave as Lungile would in a real situation. ✔✔ OBSERVERS: Watch the role play and note anything that may be important in the group discussion that will follow the roleplay.

DISCUSSION AFTER ROLE PLAY After the roleplay you should have a group discussion about the issues around counselling on infant feeding practices. Some example discussion questions are below: •• What did the health worker do that was particularly helpful in this counselling session? •• What would you have done differently if you encountered this situation in your clinic? •• What are good strategies for counselling mothers on feeding options? •• Let’s pretend that Lungile came to you after she already had the baby. The baby is one week old. How would you counsel her?

36

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Facilitator guide

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

n WHAT IS IN THIS GUIDE? This guide explains course structure and expectations for facilitators. It also outlines the content for each face-to-face meeting, particularly the materials and activities used in learning. These include demonstrations, group activities, clinical practice sessions, exercises, and assessments.

n CONTENTS Acknowledgements 6 PLANNING & PREPARING 7 0.1 Introduction 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0.10 0.11 0.12 This distance learning course Course calendar Face-to-face meetings Self-study modules & logbook Support during self-study Expectations for participants Assessing participants Preparing to be a facilitator How to use this guide Preparations for each face-to-face meeting Meeting checklist of materials 8 9 11 12 14 16 17 19 21 25 28 31

ORIENTATION 32 1.1 1.2 Meeting objectives Proposed agenda 33 34 35 40 42 46 3

Section 1 – Introduction & course overview Section 2 – Creating a welcoming environment Section 3 – Causes of childhood illness Section 4 – The IMCI strategy

IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

Section 5 – Clinical practice Section 6 – Using IMCI with the sick young infant Section 7 – Good communication & counselling skills Section 8 – Next steps

62 63 69 77

REVIEW & PRACTICE 83 2.1 2.2 Meeting objectives Proposed agenda 84 85 86 89 92 96 97 110 115

Section 1 – Overview Section 2 – Reviewing self-study period 1 Section 3 – Assess & classify the sick child (Part 1) Section 4 – Clinical practice Section 5 – Assess & classify the sick child (Part 2) Section 6 – Integrating treatment, counselling the caretaker, and follow-up Section 7 – Next steps

FINAL SYNTHESIS 118 3.1 3.2 Meeting objectives Proposed agenda 119 120 121 123

Section 1 – Welcome & overview Section 2 – Reviewing self-study period 2

Section 3 – Reviewing the integrated case management process 125 Section 4 – Clinical practice Section 5 – Skills stations assessment Section 6 – Multiple-choice examination Section 7 – Next steps & formal closing ANNEXES Annex 1. Reference A1.1 Planning and managing study groups 4

127 128 133 135

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A1.2

Planning clinical practice sessions

140 151 152 153 156 159 160 162 163 164 165 166 167 168 169 170 173 175 181 185 186 187 189 190 191 217 237

Annex 2. Orientation A2.1 A2.2 A2.3 A2.4 A2.5 DIMCI course registration form Section 7. Facilitator role-plays (optional) Participant communications role-play handouts Orientation meeting evaluation Recording forms

Annex 3. Review & Practice A3.1 A3.2 A3.3 A3.4 Check-in form: Review & Practice meeting Logbook exercises answer key (Modules 1–2) Worksheet: dosages activity Review & Practice meeting evaluation

Annex 4. Final Synthesis A4.1 A4.2 A4.3 A4.4 A4.5 A4.6 A4.7 A4.8 A4.9 Check-in form: Final Synthesis meeting Logbook exercises answer key (Modules 3–7) Skills stations answer sheet Skills station answer key Written examination Written examination: questions for optional modules Written examination answer sheet Multiple-choice examination answer key Individual action plan

A4.10 Course evaluation Annex 5. PowerPoint presentations A5.1 Orientation A5.2 A5.4 Review & Practice Final Synthesis

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

Planning & preparing CONTENTS 0.1 Introduction 0.2 This distance learning course 0.3 Course calendar 0.4 Face-to-face meetings 0.5 Self-study modules & logbook 0.6 Support during self-study 0.7 Expectations for participants 0.8 Assessing participants 0.9 Preparing to be a facilitator 0.10 How to use this guide 0.11 Preparations for each face-to-face meeting 0.12 Meeting checklist of materials 8 9 11 12 14 16 17 19 21 25 28 31

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

0.1 INTRODUCTION Welcome to this distance-learning course for Integrated Management of Childhood Illness (IMCI). This course is an exciting initiative to bring IMCI training to even more healthcare professionals.

WHY IMCI? The Integrated Management of Childhood Illness (World Health Organization, United Nations Children’s Fund) guidelines offer simple, effective methods to manage the leading causes of serious illness and mortality in young children. Since IMCI was developed in the early 1990s, over 100 countries have adopted IMCI and adapted the guidelines for country needs. Thousands of healthcare providers have been trained in IMCI. Wide implementation of IMCI has improved quality of care and has contributed to reductions in childhood mortality.

REVIEWING IMCI: WHAT ARE THE KEY POINTS? •• Integrated case management means that health workers assess all aspects of the child’s health. Integrated management looks at common health issues, feeding and nutrition, immunizations, and other problems. •• IMCI focuses on the most common health problems in children , particularly those that are the most important causes of health. These include acute respiratory infections, diarrhoea, malaria, measles, malnutrition, and HIV. •• IMCI is designed for first-level settings such as community clinics, health centres, or outpatient facilities at a hospital. Doctors, nurses, and other health professionals who see sick infants and children can use IMCI. •• Guidelines are age-specific. A sick young infant is up to 2 months of age. A sick child is 2 months up to 5 years of age. This means a child has not reached his or her fifth birthday. •• IMCI includes instructions to do the following: —— Check clinical signs that indicate severe illness. These are called general danger signs in sick children and signs of severe illness in young infants. —— Assess for symptoms and signs of common illnesses and causes of death. —— Assess a child’s nutrition, immunization status, and feeding —— Classify each condition and identify treatment —— Decide on appropriate treatment for all conditions —— Teach caretakers how to care for a child at home —— Counsel caretakers to solve feeding problems —— Advise caretakers about when to return to a health facility —— Provide follow-up care when the infant or child returns •• IMCI classifications are action-oriented. They determine if a child should be urgently referred to another health facility, treated at the first-level facility, or safely managed at home. •• Treatments are identified with action-oriented classifications, rather than exact diagnosis. The treatments cover the most likely diseases represented by each classification.

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

0.2

THE DISTANCE LEARNING COURSE

n  What are the objectives of this course? At the end of this distance learning course, you will be able to: •• Implement integrated case management for common health problems in sick young infants and children •• Use the IMCI chart booklet and recording forms in clinical practice •• Counsel caretakers on home treatment, feeding, well child care, and disease prevention

WHY DISTANCE LEARNING? Traditional IMCI courses have required health workers to travel and spend two weeks in classroom and inpatient/outpatient practice sessions. This was a barrier for some healthcare providers to participate in the training. Distance learning integrates study into clinical practice. Participants learn on their own time, at their own pace, and in their own clinical facilities. Effective distance learning requires participants to study and practice on their own, but also work with mentors and colleagues. Your role as the course facilitator is critical to ensuring that distance learning is effective and participants will use IMCI tools in their home clinics. If you are interested in reading more about the distance learning model – and national experiences in introducing the distance IMCI course – please read the IMPLEMENTION GUIDE TO IMCI DISTANCE LEARNING that accompanies these course materials.

WHAT ARE THE CORE COMPONENTS OF DISTANCE LEARNING FOR IMCI (DIMCI)? There are two core learning components of this distance learning course: 1. Face-to-face meetings The face-to-face meetings are an opportunity for the facilitators to introduce new material, review self-study periods, and facilitate clinical practice. As participants are learning most content on their own during self-study, these meetings are critical opportunities to clarify questions, address problems, explain content, and practice IMCI together. 2. Self-study periods Participants will be given self-study modules to read on their own between the face-to-face meetings. They are expected to practice IMCI in their clinics and report back on progress. This approach allows participants to learn at their own pace. Participants learn on their own through reading, study, and clinical practice. They are also expected to work with IMCI mentors, arrange study groups with fellow participants in their area, and seek support within their facility. These components are later discussed in Section 0.6.

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

HOW IS THE COURSE STRUCTURED? The recommended dIMCI course runs for two to three months. It includes three face-to-face meetings, and two self-study periods.1

Orientation 1st face-to-face meeting (today) 3–4 weeks

Review & practice 2nd face-to-face meeting (1 day) 6–8 weeks

Final synthesis 3rd face-to-face meeting (1 day)

Self-study period 1 (Modules 1 & 2)

Self-study period 2 (Remaining modules)

Practice IMCI in clinic, using Chart Booklets and recording forms Review with study groups Work with mentors 2 to 3 months

1

Depending on the national adaptation of dIMCI, additional face-to-face meetings could be added to the course structure, particularly if additional modules like HIV/AIDS are included in the dIMCI course.

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

0.3

COURSE CALENDAR

The course calendar below details course activities, and is also provided to the participants. Facilitators should fill in the dates and meeting locations with participants.1

COURSE CALENDAR SESSIONS ORIENTATION 1st face-to-face meeting OBJECTIVES  Introduce IMCI process  Distribute learning materials and introduce content to Modules 1 and 2  Review distance learning course structure and expectations  Clinical practice with group  Read modules and complete self-assessment exercises as you read  Practice in clinic and record cases on recording forms in logbook  Complete logbook assessment exercises  Meet with study group  Maintain contact with mentors and facilitators     Review progress and issues in self-study Examine cases from clinical practice Introduce content from upcoming modules Clinical practice with group LOCATION DATE

Meeting place

To fill

SELF-STUDY PERIOD 1 Modules 1 & 2

Home facilities

3–4 weeks

REVIEW & PRACTICE 2nd face-to-face meeting

Meeting place

To fill

SELF-STUDY PERIOD 2 Remaining modules

 Read modules and complete self-assessment exercises as you read  Practice in clinic and record cases on recording forms in logbook  Complete logbook assessment exercises  Meet with study group  Maintain contact with mentors and facilitators       Review progress & issues in self-study Examine cases from clinical practice Review content from all modules Clinical practice with group Course assessment Individual plans for continued learning

Home facilities

8–9 weeks

FINAL SYNTHESIS 3rd face-to-face meeting

Meeting place

To fill

1

If the national dIMCI adaptation includes additional face-to-face meetings, additional ‘Review and Practice’ meetings can be added to the calendar. The agenda should reflect the first ‘Review and Practice’ process, where the facilitator will introduce upcoming content and lead clinical practice. The ‘Final Synthesis’ meeting is the last meeting, with the same agenda as above.

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IMCI DISTANCE LEARNING COURSE | FACILITATOR GUIDE

0.4

FACE-TO-FACE MEETINGS

Facilitators will hold three face-to-face meetings with participants. During these meetings, facilitators will present new IMCI content and provide practice/ demonstrations in a clinical setting. Your constructive feedback during these meetings is critical to effective mentorship, particularly in a distance-learning format.

n  1st meeting – ORIENTATION The first meeting is an orientation to IMCI, the course structure, and course materials. Participants will be given self-study modules. As a facilitator you will introduce the IMCI process in videos and during clinical demonstrations.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Explain the objectives and structure of this distance learning course, including the importance of clinical practice, mentors, and study groups •• Identify key causes of childhood mortality •• Explain the meaning and purpose of integrated case management •• Describe the major steps in the IMCI strategy •• Demonstrate how chart booklets and recording forms are job aids for the IMCI strategy •• Recognize the general danger signs in children •• Identify important care for young infants •• Explain the importance of assessing for signs of severe disease and feeding problems in young infants •• Describe how a welcoming environment is important for case management •• Explain and demonstrate key communication skills •• Plan self-study, group study, and clinical practice for Modules 1 and 2

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n  2nd meeting – REVIEW AND PRACTICE During the second face-to-face meeting you will review self-study of Modules 1 and 2 with participants and address issues. Participants should bring logbooks and clinical cases from their own practice. Facilitators will arrange opportunities for clinical demonstration and practice; accordingly, this meeting might be arranged on-site in order to practice clinical skills. During the sessions facilitators will introduce materials from the remaining Modules.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Review self-study period 1, including cases from clinical practice, and address problem areas •• Demonstrate skills from Modules 1 and 2 in a clinical setting •• Explain and demonstrate how to use IMCI chart instructions to assess, classify, and treat main symptoms and conditions in a sick child •• Plan self-study, group study, work with mentors, and clinical practice for remaining modules

n  3rd meeting – FINAL SYNTHESIS All participants will return 6-8 weeks later for the Final Synthesis meeting. This meeting finishes the course. It will take place about 3 months after the first face-to-face meeting. During this meeting participants will review their self-study, and you will help participants with any difficult areas. Facilitators will arrange opportunities for clinical demonstration and practice. Participants complete an assessment and receive certificates of completion. Participants should be made aware of post-course monitoring or follow-up, and can create individual action plans.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Review self-study period 2, including cases, and address problem areas •• Explain and demonstrate IMCI clinical process with sick children and young infants •• Demonstrate good use of IMCI charts and recording forms in clinical practice •• Design an individual action plan for using IMCI and continuing to improve skills

What should participants bring to each face-to-face meeting? It is important that participants bring the following materials to meetings: 1. Modules – including any notes on reading, exercises, or review questions 2. Logbook – with completed written exercises and recording forms 3. IMCI Chart Booklet

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0.5

SELF-STUDY MODULES & LOGBOOK

WHAT ARE THE SELF-STUDY MODULES? Self-study modules provide the content of this course. During distance learning, participants will study on their own time. Participants will also reinforce what they have learned through clinical practice, group study, and working with mentors. Distance learning provides flexibility, but also requires participants to manage their time and study responsibly.

WHAT IS THE STUDY PACE FOR THE MODULES? Participants should complete all modules by the end of this course. They are able to complete the modules at their own pace. However they are asked to complete Module 1 and Module 2 before the 2nd face-to-face meeting. If additional modules are used, the course 3-month timeline might need to be adjusted to allow for more time.

SELF-STUDY MODULES 1 General danger signs Identifying signs of severe illness in sick children Care of the sick young infant Using the IMCI strategy with sick young infants Part I: Assess, classify, and treat the young infant Part II: Infant feeding and counselling the caregiver Cough or difficult breathing Assess, classify, and treat cough or difficult breathing in sick child Diarrhoea Assess, classify, and treat diarrhoea and dehydration in sick child Fever Assess, classify, and treat fever in sick child Malnutrition and anaemia Assess nutritional status and address malnutrition, anaemia, or feeding problems Selfstudy period 2 Selfstudy period 1

2

3 4 5 6

ADDITIONAL, OPTIONAL MODULES: 7 8 9 Ear problems HIV/AIDS Well child care

WHAT CONTENT IS INCLUDED IN EACH MODULE? The modules include reading material, recommendations for DVD clips, video practices, and self-assessment exercises. The self-assessment exercises have an answer key in each module so participants can check their own answers.

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HOW MUCH TIME SHOULD PARTICIPANTS TAKE FOR EACH MODULE? Participants should set a personal study calendar with goals for studying modules. This will help set a pace that best suits schedule and work demands. It will help keep them on track for completing the course. It may be best to take about a week to work through each module, although some modules might take more time to study than others.

WHAT IS THE COURSE LOGBOOK? The logbook is an important tool for participants to practice material and record cases as they study. Facilitators should review the logbook at each face-to-face meeting to check if participants are having any challenges, and to address these with each participant. Facilitators will also use the logbook to mark participants for the course based on how well they complete the logbook. Course assessments are further explained in Section 0.8, including how the logbook is marked.

WHAT IS CONTAINED IN THE COURSE LOGBOOK? The logbook contains the following: ■■ EXERCISES: after reading each module, participants should complete the exercises in the logbook on their own. These are to test knowledge on the material just completed. Each module has about 20 multiple-choice and true/ false questions in the logbook. You have an answer key for each module in Annex. You can use this key to mark exercises at the face-to-face meetings. ■■ RECORDING FORMS: as participants practice in the clinic, they will use these IMCI recording forms. The facilitator will indicate how many recording forms should be completed for each module, or self-study period. As a minimum, 2 recording forms are completed for each module. Participants will bring these forms to the 2nd and 3rd meetings. Facilitators will review these forms to identify any problem areas. These problem areas can be reinforced with additional information, demonstration, or clinical practice. ■■ CHECKLIST OF CLINICAL SIGNS: participants should be instructed to check the clinical signs that they see during self-study. Facilitators can review these checklists at meetings to highlight any issues, e.g. if participants are not seeing particular signs in their clinic, and if any other exposure can be arranged during clinical practice sessions or by video.

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0.6

SUPPORT DURING SELF-STUDY

Participants should involve others in their learning process. These individuals can help explain reading material, facilitate opportunities to see cases or clinical signs, and help with any challenges. Supporters are particularly important for effective distance learning. This course recommends several types of support during self-study: ■■ Study groups: facilitators should help participants form study groups during the Orientation meeting. Study groups will depend on participants’ home locations. The study group is a very important element to distance learning. It provides participants with an opportunity to meet regularly to review content, answer questions, explain confusing topics, and practice skills together as necessary. Groups should meet regularly (e.g. weekly or twice a week) during self-study. In the Annex there is a section on advice for planning and managing study groups. The participants’ modules book has the same information. ■■ Mentors: participants will be asked to identify mentors that they can approach during self-study. These mentors should be IMCI-trained healthcare providers or more experienced professionals that can explain cases, challenging material, or the IMCI process. Mentors can be colleagues, in-charge officers, or other professionals outside of a participant’s facility (e.g. at the district hospital). ■■ In-charge officers: in-charge officers are the doctors or nurses responsible for clinical service in the facility. Participants should debrief in-charge officers after each face-to-face meeting. In-charge officers should be aware of the IMCI guidelines and tools that participants will be using in the clinic. ■■ Off-site practice: course facilitators may arrange for participants to travel to nearby district hospitals to practice IMCI or observe care. Participants should be given a written document to carry to the hospital. This document should certify that they are participating in the IMCI distance-learning course and arrangements for clinical practice have been made with the facility. ■■ Course facilitators: Facilitators should be clear about expectations for communication during self-study periods. These will depend on your arrangements as a facilitator. Participants should know in what situations they should contact you (example: only when there is an issue in clinical practice). You should also tell them how and when you are best reached. You should also advise participants on how to seek support in their home facilities. These situations will vary depending on the arrangements made for each participant.

USING MOBILE PHONES Mobile phones are a useful way to stay in touch with your course participants. Some examples used in countries: •• Send weekly SMS/text messages to remind participants where they should be in terms of reading and clinical practice. •• Encourage participants to contact you by SMS or phone call if they have any questions or issues. You can also call weekly to check in.

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0.7

EXPECTATIONS FOR PARTICIPANTS

WHO ARE THE PARTICIPANTS IN THIS COURSE? This course is designed for health professionals who manage children at first-level facilities. This includes nurses, nurse assistants, and clinical health workers.

WHAT IS EXPECTED OF PARTICIPANTS? In order to successfully complete this course, participants are expected to: ✔✔ Attend all face-to-face meetings ✔✔ Read all self-study materials ✔✔ Complete exercises in logbook ✔✔ Practice IMCI in home facilities ✔✔ Use recording forms during clinical practice ✔✔ Demonstrate eager participation in the course ✔✔ Learn with others as much as possible and seek mentors at home facilities ✔✔ Demonstrate professionalism and courtesy to facilitators, other participants, and patients during clinical practice ✔✔ Practice with ethnical and professional conduct standards of the facilities

WHAT SHOULD PARTICIPANTS PLAN TO COMMIT TO THIS COURSE? Before the course begins, participants and in-charge officers should understand that the course requires a significant commitment of time and attention. Participants will be out of the clinic one day for each of the face-to-face meetings. Participants will also need time to study and practice IMCI in their clinic. Ideally, in-charge officers will offer encouragement to participants who are trying to improve their clinical skills.

HOW WILL PARTICIPANTS BE ASSESSED? Assessments will check that participants have developed skills to use IMCI with patients. Please Section 0.8 to learn more about the course assessment and how to mark participants.

WHAT DO PARTICIPANTS RECEIVE AFTER COMPLETING THE COURSE? If participants fully satisfy the course requirements they will receive a certificate of completion. This will certify that they are trained in Integrated Management of Childhood Illness through the distance-learning course offered by the government and the WHO.

WHAT FEEDBACK SHOULD BE GATHERED FROM PARTICIPANTS? It is important for facilitators to gather feedback on the distance learning process, course materials, and use of IMCI in clinics. There are three recommended ways for facilitators to get feedback from participants:

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1. Meeting evaluations Participant evaluations at the end of each face-to-face meeting can identify gaps in the course or learning process. Evaluations can also recommend changes for the facilitators. Evaluation samples for each meeting are included in the annex of each meeting’s materials. 2. Check-in forms At check-in for each face-to-face meeting (post Orientation meeting), participants should be given a check-in form that collects feedback on their experience during the self-study period. This form will help gather important information about a participant’s ability to read and practice the materials in a timely way. The dIMCI excel tool provides a sheet for you to input key feedback data from the form for each participant. This information should also be tracked to provide suggestions for improving the course structure in your area. 3. Course evaluation This evaluation is similar in format to the meeting evaluations. Participants should be asked to complete the course evaluation before certificates are provided.

WHY IS FEEDBACK IMPORTANT? There are three important uses for feedback from participants. First, it can help facilitators better serve the needs of current participants. Second, course feedback should help facilitators prepare for future courses, or change the course structure as required. Third, facilitators should provide feedback to those who are planning the distance learning courses at regional and national levels. It is particularly useful for facilitators to share any good practices, course logistics issues, or other details from the course so that policymakers and planners can use the feedback to better scale-up this course.

WHAT FOLLOW-UP OCCURS AFTER THE COURSE IS COMPLETED? After participants finish the course, there are two parts of follow-up: 1. In the final meeting, participants will create individual action plans, if the facilitators choose to conduct this activity. These are their personal plans for continued learning (skills advanced and refresher training), implementing IMCI in the clinic, working with IMCI mentors, and disseminating tools in their home facilities. 2. In the months following the course, participants will be monitored for implementing IMCI into clinical practice.

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0.8

ASSESSING PARTICIPANTS

Participants’ performance in the course is marked in three parts. Each part has equal weighting in the final course mark, which means each part is about 1/3 of the total mark. Please see the summary table on the next page for more details.

1.

LOGBOOK ASSESSMENT

Participants are expected to complete the logbook during their self-study. Therefore, it is used as a measure of how seriously the participant was reviewing and practicing the content they are reading in the modules. •• What it includes: There are two parts of the logbook. First, there are assessment exercises for each module, which include multiple-choice and true-false questions. Second, there are recording forms for practicing IMCI during clinical cases. The facilitator will set a target number of recording forms for each module and/or self-study period. •• How it is marked : The logbook assessment is marked for ‘completion’. Facilitators will review the logbook during each face-to-face meeting and give the participant a mark based on how completely they have answered the exercises and submitted the requested number of forms.

2.

CLINICAL SKILLS ASSESSMENT

The clinical skills assessment is conducted during the final face-to-face meeting. It uses the OSCE1 approach in order to assess a participant’s clinical skills using IMCI. •• What it includes: There are two possibilities for conducing the clinical skills assessment. First, if there is an appropriate clinical setting available, participants can be assessed on their clinical examination skills. Second, participants can rotate between skills stations. This second option is the most likely scenario in many course settings. Skills stations will assess participants on different skills using video, photos, or clinical case studies. In settings where rotating between stations is too complicated, facilitators can present each station to the group as a whole. For example, the facilitator can project photo exercises or a video case study for all participants to work on at the same time. Depending on time, space, and group size, there should be 2–4 assessment activities. •• How it is marked: If using skills stations, facilitators will mark answer sheets for accuracy.

3.

MULTIPLE-CHOICE EXAM

The multiple-choice written exam is given to participants during the final face-toface meeting. •• What it includes: The examination includes about 30 questions and will cover content from all modules.

1

Objective structured clinical examination.

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•• How it is marked: Facilitators will mark participants’ answer sheets for accuracy. USING THE dIMCI EXCEL TOOL TO ASSESS The dIMCI excel tool includes a sheet to enter marks for each participant. Course marks are automatically calculated.

dIMCI COURSE ASSESSMENT STRUCTURE ASSESSMENTS ASSESSMENT PARTS a. Assessment exercises for each module 1. Logbook assessment b. 2 recording forms for each module completed during self-study clinical practice c. Video cases to identify IMCI signs (18 cases) d. Photos of IMCI signs and breastfeeding technique (15 cases) Multiple-choice questions on written exam 33% 33% % OF TOTAL MARK HOW TO MARK Give participants a ‘completion’ score of up to 10 points for each module. Mark for accuracy: 1 point for each correct answer Mark for accuracy: 1 point for each correct answer

2. Clinical skills assessment 3. Multiple-choice exam Total POSSIBLE *Pass mark*

33% 100 *50*

IT IS POSSIBLE TO ASSESS PARTICIPANTS AFTER THEY HAVE COMPLETED THE COURSE? Post-course monitoring of participants is strongly recommended, particularly for the distance learning course. These on-site sessions allow the facilitator to work more closely with the participant on how well they use IMCI in the clinic. There are two support tools from the WHO that help countries design post-course monitoring: 1. Health facility survey: Tool to evaluate the quality of care delivered to sick children attending outpatient facilities, World Health Organization, 2003. 2. Follow-up after training: Reinforcing the IMCI skills of first-level health workers, World Health Organization, 1999.

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0.9

PREPARING TO BE A FACILITATOR

WHO SHOULD FACILITATE THIS COURSE? Course facilitators should have already completed the IMCI case management course and the IMCI facilitator course in your country. The appropriate facilitator will be a seasoned clinician with an ability to teach. He or she should also have a strong knowledge of clinical practice and national policies in child health. In addition to clinical skills, facilitators require other important skills. The facilitator should have a strong willingness to facilitate discussion and learning. The facilitator should serve as a mentor in addition to an instructor. Your role is to facilitate learning by providing encouragement, information, and guidance – while prompting participants to develop their abilities.

WHAT IS IMPORTANT ABOUT FACILITATING A DISTANCE-LEARNING COURSE? The distance-learning course is a self-learning course. As a facilitator, you should promote self-learning. For example, during the face-to-face meetings, it is important to not overload participants with too much information in a short time. Instead, it is important during these meetings to introduce wider topics and skill sets, and prepare participants to read in more detail during the self-study period. During the self-study periods, facilitators should ensure that participants are receiving appropriate support and mentorship as they study the modules and practice in their home clinic. Support and guidance from a facilitator is critical if a distance-learning course is going to build clinical capacity.

WHERE SHOULD FACILITATORS HOLD MEETINGS? Face-to-face meetings are optimized if held at space in or near health facilities with good caseloads. This maximises the time in clinical practice, which is a critical component of building and observing IMCI skills. Additionally, the meeting is quite fast-paced and cannot lose time to transitions between spaces.

HOW MANY FACILITATORS ARE REQUIRED? It is recommended that there are two facilitators for every 15 participants in the course. In a typical course of 25–30 participants, four facilitators are recommended.

HOW WILL YOU BE TRAINED TO FACILITATE THIS COURSE? As a facilitator of this course, you will be expected to have previously completed the courses in IMCI case management and IMCI course facilitation. You should also participate in a two-day training in facilitating the IMCI distance-learning course. This training is important to review the tasks you will be responsible for in the distance learning process, which is quite different from the traditional IMCI courses.

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WHAT DOES A FACILITATOR DO? As a facilitator, you are expected to do three basic things 1. YOU INSTRUCT •• Explain content in full. Provide engaging learning examples and draw from clinical experiences to relate content to clinical practice. •• Answer questions in full and as they occur. •• Provide constructive feedback. •• During meetings, ensure that participants understand what is expected from a module, exercise, discussion, or activity. •• Diversify the learning process to emphasize content in different ways.

Explain content clearly, and with visual notes to highlight key points

Practice roleplays, demonstrations, or clinical practice

Show examples video, photo, or case studies

Reinforce answer questions, group discussions, constructive feedback

•• Identify gaps in a participant’s understanding or skills. Provide additional explanation and practice opportunities to reinforce and improve. •• Revisit the learning objectives to ensure that all have been met. •• Model good clinical and communication skills during face-to-face meetings and clinical practice sessions or demonstrations. •• Ensure that participants understand expectations for completing the course materials, integrating skills into clinical practice, and working with others during their self-study. •• Give participants concrete advice, examples, and practice on integrating IMCI into their own clinical practice. 2. YOU MOTIVATE •• Affirm and acknowledge participants’ correct answers, constructive teamwork, and personal improvements and progress.

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•• Engage participants in your meetings. Bring the material alive. Introduce exciting and dynamic activities. Share (and encourage participants to share) clinical experiences and reflections. •• Encourage participants to ask questions and clarifications so that they can move forward in self-study without confusion. •• Eliminate any learning obstacles like noisy learning environments, low lighting, and distractions from mobile phones. •• Ensure that participants are supported during their self-study and are receiving mentorship (e.g. IMCI mentors, colleagues, course facilitators, group study). •• Encourage ownership during self-study and practice. 3. YOU MANAGE •• Plan ahead for the face-to-face meetings. Outline your notes, obtain all necessary materials, prepare the clinical practice sessions, and prepare required content. •• Monitor each participant’s progress. The success of this course, as with most adult learning, is linked to the facilitator’s abilities to assess participant needs, and use materials and activities that will address these needs. This should be ongoing throughout the course. You can monitor progress by asking direct questions, reviewing participants’ work (e.g. recording forms, written exercises), and observing during practice sessions. Ideally facilitators will also administer a pre-training needs assessment. •• Provide on-site mentorship, or assist participants’ mentors as required during self-study periods.

HOW DOES A FACILITATOR INSTRUCT, MOTIVE, AND MANAGE WELL? There are several tips for instructing, motivating, and managing a course well. Some are below. TIPS FOR BEING AVAILABLE TO PARTICIPANTS: •• Show enthusiasm for the course material and the participants’ learning process •• Give the course your undivided attention. Do not work on or discuss unrelated matters, or use your mobile phone and email during the sessions or breaks. Encourage the participants to do the same. It is important that you are available to mentor participants during breaks. •• Be attentive to participant needs and questions. Be available to participants and encourage them to come to you with questions or feedback

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TIPS FOR CREATING A GOOD LEARNING ENVIRONMENT: •• Promote a friendly, cooperative relationship through active listening and affirmations (e.g. “yes, I see what you mean,” or “that is a good question”) •• Observe participants as they work, and offer help if you notice someone not engaged •• Encourage participants to ask questions or seek clarification with openended questions (e.g. “what questions do we have about chest indrawing?” instead of “does anyone have a question?”) •• Give enough time to answer questions – so that both you and the participant are satisfied •• Be respectful, and promote a respectful learning environment. Do not allow anyone to condescend or embarrass another, and be mindful that you do not do this as facilitator. TIPS FOR KEEPING PARTICIPANTS ENGAGED AND EXCITED: •• Bring the content alive with your own inputs and experiences. Do not read directly from the slides or your notes. These are only intended to be useful references. •• Encourage participants to share experiences, questions, and feedback. You should not lead the show. •• Reach out to participants to engage them in the material or check their understanding. However, it is recommended that you not directly call on participants to answer questions like in a traditional classroom. This might embarrass them if they do not know the answers. If you have specific questions for a participant – or want to reinforce that he or she understands content if you think they do not – then reach out during individual time. •• Use this guide as an outline for materials, content, and flow. This guide has a great deal of information and support for you. Do not be apprehensive.

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0.10 HOW TO USE THIS GUIDE WHAT MATERIALS WILL YOU REQUIRE TO FACILITATE THIS COURSE? All facilitators will require the following resources for this distance-learning course. Parts 1 through 3 of this guide include specific material lists for each of the faceto-face meetings. 1. This dIMCI facilitator guide, which includes a chapter for each face-toface meeting This facilitator guide provides key information for each meeting. There is more information about this guide on the following page. 2. dIMCI PowerPoint presentation slides for each face-to-face meeting PowerPoint slides are designed as a training tool during your meetings with participants. However, do not rely heavily on these slides. They are meant to provide visuals and key points only. In settings where a projector or computer screen is not available, or where power outages might be an issue, it is recommended that facilitators print slides for reference. Participants’ self-study modules have material from the slides for their reference. 3. dIMCI excel tool The dIMCI excel tool has several tools that you may find useful. One sheet includes a template to track participant information collected in the check-in forms. One sheet includes a template to record and calculate participant marks as you assess the logbook, recording forms, and course examinations. One sheet includes a budgeting template for the course. 4. Distance learning IMCI Implementation Guide This document is targeted for national policymakers and planners who are preparing to introduce dIMCI to a country. However, the document can be helpful reference for a facilitator as well, especially to double-check that all preparations have been completed for sessions, and that sessions are scheduled in order to maximize the number of those trained. This video demonstrates clinical practice and signs. It provides opportunities for practice. Videos can be used to stimulate group discussion, or revisit problem areas. Each participant should receive a DVD with the self-study modules. The modules recommend video segments to watch as they read. IMPORTANT NOTE: The generic IMCI DVD does not include most recent updates to the IMCI algorithm, e.g. for fever or malnutrition assessments. As such, the DVD should be used more to show the process of an IMCI assessment. The IMCI Computerized Adaptation and Training Tool (ICATT) is a helpful complementary training package to this course. Facilitators should be familiar with ICATT and are encouraged to use videos and graphics from the software to complement IMCI DVD videos during face-to-face meetings.

5. IMCI training DVD (for distribution)

6. ICATT

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7. dIMCI participant self-study modules and logbook (for distribution) Participant self-study modules should be bound in a book. The introduction to this book will include a review of the IMCI process and course overview. This content will be covered during the Orientation meeting. This book should be distributed and explained early in the first face-to-face meeting, and sent home with participants. The logbook should accompany this book. The logbook includes written exercises and recording forms that should be completed during the self-study periods. The logbook will be submitted during the face-to-face meetings for the facilitators to review. The IMCI chart booklet is an essential tool for this course and IMCI implementation. This course will use either the WHO “generic” chart booklet or one adapted with national IMCI guidelines.

8. IMCI chart booklets (for distribution)

WHAT IS INCLUDED IN EACH CHAPTER OF THE FACE-TO-FACE MEETINGS? This guide contains a chapter for each face-to-face meeting. Each chapter includes the following information about the meeting: 1. MEETING OBJECTIVES 2. PROPOSED AGENDA: This agenda outlines the meeting’s sections of content. Facilitators can take notes on who will cover each section. It also recommends timing for each section. 3. CONTENT FOR THE DAY: Each section of the day’s meeting includes section objectives, activities, and content to be discussed. Each section is divided into several sub-topics or sub-activities, like video demonstration, written exercises, or discussions. These each have their own number, for example, Section 5 is divided into activities by 5.1, etc. Each sub-section and activity should reinforce a learning process.

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WHAT IS A LEARNING PROCESS? Introduce the topic with excitement, and in an engaging manner. Open with questions that check your participants’ experiences or understanding about the particular topic you are about to cover.

HOW IS THIS GUIDE WRITTEN? n Advice to facilitator is given in italics. n Suggestions about what to say, like discussion questions and prompts for the group, are not italicized.

 CLARIFY includes key questions or common issues Field questions and confirm understanding when you are done with each topic, before you move on to the next. Reflect and reinforce the content covered in an activity or a discussion. This can include follow-up questions or feedback from participants.  PRACTICE includes small questions to check understanding n Guidance on when to use materials includes: SLIDE when there are accompanying slides in dIMCI Powerpoint FLIPCHART when notetaking for group is recommended

Summarize after a period of questions or discussion, in order to focus on the most important points.

r IMCI DVD clips are recommended

4. ANNEX: includes materials required for the day that will need pre-printing, including: ✔✔ REGISTRATION/CHECK IN FORMS: to collect participant data at the start of the day ✔✔ OPTIONAL ACTIVITIES: lengthier role-plays or activities that are not detailed in guide ✔✔ HANDOUTS: worksheets for activities (if applicable) and assessments for Final Synthesis ✔✔ MEETING EVALUATION: form gathers participant’s feedback at the end of the meeting

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0.11

PREPARATIONS FOR EACH FACE-TO-FACE MEETING WHY PREPARATIONS ARE ESPECIALLY IMPORTANT IN dIMCI

Face-to-face meetings in the dIMCI course are full of information. The flow is quite different from the standard IMCI course. In order for the meeting to run efficiently and smoothly, and that all necessary information is covered, it is important that facilitators prepare well.

WHAT MATERIALS SHOULD BE PRE-PURCHASED AND READY FOR PARTICIPANTS? Supplies for participants should be purchased and available to participants on registration. These might include: ■■ Note book or paper for notes ■■ Pens and pencils ■■ Nametag or nameplate

WHAT MATERIALS SHOULD BE READY TO DISTRIBUTE FOR PARTICIPANTS’ SELF-STUDY? There should be sufficient time made for printing and preparing study materials before the course begins. This is particularly important because self-study sessions require very specific study materials, so it is important all participants receive these materials at the Orientation session. These materials include: ■■ IMCI Chart Booklets ■■ dIMCI self-study modules ■■ dIMCI logbooks ■■ IMCI DVD

WHAT MATERIALS ARE REQUIRED FOR SPECIFIC MEETINGS’ ACTIVITIES? Each meeting will require some printed materials specific to the day’s activities. These are indicated in the ‘MATERIALS’ list of each agenda section. These will also vary with the activities prepared by the facilitators and national adaptation of dIMCI. These materials include: ■■ Registration form (Orientation) or Check-in form (all other meetings) available at arrival ■■ Copies of IMCI recording forms (both for child and young infant) for clinical practice session or other activities, like video exercises or roleplays ■■ Handouts for activities (ANNEX) ■■ Meeting evaluations forms (ANNEX)

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■■ Printed PowerPoint slides, recommended in case of power outages (dIMCI PPT) ■■ Course assessment materials during Final Synthesis meeting (ANNEX)

HOW SHOULD PARTICIPANTS REGISTER AT THE ORIENTATION MEETING? All participants should complete a REGISTRATION FORM on arrival. A sample form is in the Annex. TIP:  A ‘list of participants’ format is available in the dIMCI excel. During the day, these forms should be typed into a list of participants, including complete contact information for each participant. This should be distributed to everyone by the end of the day. This can be used for reference for study groups. Facilitators should keep a copy for their records.

HOW SHOULD PARTICIPANTS REGISTER AT SUBSEQUENT MEETINGS? In the following meetings, participants will complete a CHECK-IN FORM on arrival. This is included in the Annex. This form tracks valuable information about the participant’s self-study experience. The information from this form should be entered into the prepared dIMCI excel tool. This tool will give facilitators and planners a useful assessment of course details, e.g. how long participants took on modules, and how many used videos during self-study.

WHAT OTHER PREPARATIONS ARE IMPORTANT TO ENSURE A SMOOTH MEETING? Each dIMCI face-to-face meeting involves several transitions, for example, to clinical practice sessions, or to videos. It is important that facilitators prepare appropriately in the various spaces used for the meetings. ■■ Preparing computers for videos and slides: If you are using videos, check that the IMCI DVD runs properly on the available computer or DVD system. If you are using PowerPoint slides and showing the IMCI DVD on the same equipment and projector, you will need to switch between them during the day. If you are using one laptop for both, it is best to have the slides open and the IMCI DVD disc 1 in your computer and at the main menu. It will be easier to switch between them if both are ready on the computer. Load IMCI DVD disc 2 at the lunch break. NOTE: If this meeting is happening at facility level with a small group of health workers, you can use a laptop, without a projector, to show the videos. ■■ Lighting: Know where the lighting is if you need to lower lights when showing the DVD. As you test lighting, ensure that the slides are easily to read on the projector from different points in the room. ■■ Audio: Test all audio equipment. Ensure that videos are audible throughout the room. ■■ Arrange space: Ensure that the space provides a comfortable learning environment for participants. For example, participants need space to sit, and to

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write notes. All participants should be able to hear the facilitator, and contribute to group discussions. If you are planning for breakout activities like group work, roleplays, or skills stations, prepare for this. Ensure that participants have necessary privacy and space for completing the course written examination and skills stations, if applicable. ■■ Anticipate issues: Prepare for issues that might affect learning, like frequent power outages. In case it is not possible to view slides, facilitators should have printed powerpoint slides for use. Depending on the meeting, many slides are available in the self-study modules and participants can refer to these. However facilitators may choose to print slides for participants as well. Another example when anticipating power issues is printing pictures and case studies for the Final Analysis skills stations. ■■ Ensure all equipment is available for the day: This might include a projector, projector screen, and computers. Refer to your checklist of materials in Section 0.11 for other materials required.

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0.12 MEETING CHECKLIST OF MATERIALS NOTES n Materials should be ready and available for distribution at points during the day. n When distributing a material, explain the content in full to the participants.

MATERIAL For facilitation dIMCI facilitator’s guide dIMCI PPT slides dIMCI excel tool IMCI Guide for Clinical Practice in Inpatient Ward IMCI Guide for Clinical Practice in Outpatient Ward IMCI DVD Other videos: communications skills and newborn care Study materials for distribution dIMCI self-study modules dIMCI logbook IMCI Chart Booklet (national adaptation) IMCI DVD for take-home study FOR LEADING ALL MEETINGs Laptop or computer for slides Projector, television, or computer screen for viewing Clock or stopwatch for timekeeping Flipchart or large paper Flipchart markers Tape, for hanging papers or displays Roleplay props, models, or other display materials Name tags or name placards Notebook Pens or pencils Tea (morning and afternoon) and lunch supplies IMCI Recording Forms Registration or check-in forms (ANNEX) Handouts for activities (ANNEX) Evaluation forms for end of day ADDITIONAL MATERIALS FOR CERTAIN MEETINGS (REVIEW & PRACTICE) Drugs for demonstrating dosing (FINAL SYNTHESIS) Multiple-choice examination (FINAL SYNTHESIS) Multiple-choice answer sheet (FINAL SYNTHESIS) Skills station print-out (FINAL SYNTHESIS) Skills station answer sheet

NUMBER 1 per facilitator 1 electronic file 1 electronic file 1 per facilitator 1 per facilitator 1 DVD (2 discs) * Participants should bring to following meetings 1 per participant/facilitator 1 per participant/facilitator 1 per participant/facilitator 1 per participant/facilitator 1 1 1 per facilitator 5-10 sheets As required As required As required 1 per participant/facilitator 1 per participant/facilitator 1 per participant/facilitator As necessary Copies as necessary 1 per participant 1 per participant/facilitator 1 per participant See activity in meeting Section 6 I copy for each participant I copy for each participant I copy for each participant I copy for each participant

✔ LIST

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1ST FACE-TO-FACE MEETING CONTENTS 1.1 Meeting objectives 1.2 Proposed agenda Section 1 – Introduction & course overview Section 2 – Creating a welcoming environment Section 3 – Causes of childhood illness Section 4 – The IMCI strategy Section 5 – Clinical practice Section 6 – Using IMCI with the sick young infant Section 7 – Good communication & counselling skills Section 8 – Next steps 33 34 35 40 42 46 62 63 69 77

Orientation

PART 1

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1.1

MEETING OBJECTIVES

MEETING SUMMARY Participants meet for their first orientation with the course facilitator and fellow participants. The facilitator briefs them on the objectives and structure of this distance-learning course, introduces them to the IMCI approach and Chart Booklet, and sets a plan for the self-study period. This self-study period will include Modules 1 (general danger signs) and 2 (sick young infant).

WHAT ARE THE OBJECTIVES OF THIS MEETING? By the end of the first face-to-face meeting, participants will: •• Explain the objectives and structure of this distance learning course, including the importance of clinical practice, mentors, and study groups •• Identify key causes of childhood mortality •• Explain the meaning and purpose of integrated case management •• Describe the major steps in the IMCI process (ASSESS, CLASSIFY & IDENTIFY TREATMENT, TREAT, COUNSEL THE PARENT, and PROVIDE FOLLOW-UP CARE) •• Demonstrate how chart booklets and recording forms are job aids for the IMCI process •• Recognize the general danger signs in children •• Identify important care for young infants •• Explain the importance of assessing for signs of severe disease and feeding problems in young infants •• Describe how a welcoming environment is important for case management •• Explain and demonstrate key communication skills •• Plan self-study, group study, and clinical practice for Modules 1 and 2

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1.2

PROPOSED AGENDA

NOTE: It is critical to keep time, especially to ensure that there is enough time for clinical practice. This course is learner-driven: spend time on issues raised by the participants. 8:00–8:30 9:00–9:30 REGISTRATION SECTION 1 INTRODUCTION & OVERVIEW (30 minutes) Facilitate introductions, discuss “why are we here?” and review course objectives, structure, and expectations 9:30–10:00 SECTION 2 CREATING A WELCOME ENVIRONMENT (30 minutes) Facilitate role play scenario and discussion on emotional needs of families and patients, and role as health workers to create welcoming environment 10:00–10:15 SECTION 3 CAUSES OF CHILDHOOD ILLNESS (15 minutes) Identify key causes of mortality as background for IMCI. 10:15–10:30 10:30–11:30 Tea break (15 minutes) SECTION 4 THE IMCI PROCESS (60 minutes) Introduce IMCI process, chart booklets, and recording forms. Facilitate opportunities to practice with video and activities. 11:30-12:30 12:30–13:15 13:15–14:15 SECTION 5 CLINICAL DEMONSTRATION & PRACTICE (60 minutes) Lunch (45 minutes) SECTION 6 USING IMCI WITH THE SICK YOUNG INFANT (60 minutes) Reinforce the IMCI approach with sick young infant. Emphasis special care for young infant, including feeding. 14:15–15:45 SECTION 7 COMMUNICATION SKILLS (75 minutes, break for tea midway) Review key communications skills and facilitate role plays to demonstrate communications skills and practice assessment. 14:45–15:00 15:45–16:30 Tea break (15 minutes) SECTION 8 NEXT STEPS (45 minutes) Review expectations for self-learning. Administer evaluation. 16:30 CLOSE MEETING PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES PLANNING NOTES

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SECTION 1. INTRODUCTION & COURSE OVERVIEW TIME – 30 minutes FACILITATOR SUMMARY In this section you will facilitate group introductions. Then you will review the course’s structure and objectives, and the plans for today. SECTION OBJECTIVES •• Set a welcoming learning environment during facilitator and participant introductions •• Introduce concept of distance learning •• Explain course structure, emphasizing the 3 face-to-face meetings and selfstudy periods •• Distribute and review participant self-study modules MATERIALS ■■ PowerPoint slides ■■ Participant self-study module books for distribution ■■ Flipchart

1.1 WELCOME PARTICIPANTS 1. Introduce yourself and co-facilitators, describing: •• •• •• •• Your clinical background Your experience with IMCI Your relevant experience as a trainer and mentor How you will serve this role as a course facilitator

2. Invite participants to introduce themselves and record their names on FLIPCHART •• Preferred name •• Workplace and role •• Hopes for this training, or other icebreaker question (i.e. interesting fact about yourself)

1.2 SET THE STAGE: WHY ARE WE HERE? 1. What is IMCI? Briefly introduce IMCI to set the stage for the course. •• IMCI is a strategy for integrated case management for the most common symptoms and conditions that cause illness and death in children under 5 years of age. •• IMCI strategy has been adapted in over 100 countries around the world. Thousands of healthcare professionals have trained to use IMCI in their care. •• The IMCI strategy seeks to improve health worker skills, health systems, and family and community practices in childcare.

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2. What will we be doing together? Introduce distance learning, but will discuss in detail later. •• 3-month distance learning course •• At home, participants will be studying materials, practicing IMCI in clinics, and working with mentors and study groups as they learn. •• This group will meet 2 more times.

1.3 DISTRIBUTE PARTICIPANTS SELF-STUDY MODULE BOOKS & LOGBOOK SLIDE Explain purpose of books and ask participants to open to key sections with you. 1. STUDY MODULES INTRODUCTION (important to read as they begin self-study!) •• PART 1 – Course overview: this section follows today’s review of course structure, calendar, and expectations. Participants should follow along in book to take notes. •• PART 2 – Introduction to IMCI: this section follows today’s meeting, so participants should follow along when discussing IMCI approach to view graphics and take notes. 2. SELF-STUDY MODULES: you will explain this portion at the end of the day, during the “Next Steps” section. Flip through modules to highlight topic of each. 3. LOGBOOK: participants will document notes and exercises as you study and practice. Will review in greater depth at the end of the day.

1.4 COURSE OVERVIEW Direct participants to follow along in their self-study modules: PART 2 Course Overview. 1. Review objectives of this distance learning course SLIDE

Course  objec+ves   At  the  end  of  this  distance  learning  course,  you  will  be  able  to:    

Implement  integrated  case  management  for   common  health  problems  in  sick  young  infants   and  children     Use  the  IMCI  chart  booklet  and  recording  forms   in  your  clinical  prac;ce     Counsel  caretakers  on  home  treatment,   feeding,  well  child  care,  and  disease  preven;on    

Distance-­‐learning  IMCI  

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2. Why distance learning? SLIDE

Why  distance  learning?     Flexibility:  allows  you  study  on  your  own  .me  

and  saves  on  travel  =  more  healthcare  providers   can  be  trained  in  IMCI       Learner-­‐driven:  you  focus  with  facilitators  on  the   issues  you  are  facing     Learning  involves:      3  face-­‐to-­‐face  mee.ngs  with  facilitators      studying  modules  on  your  own      prac.cing  IMCI  skills  in  your  home  facili.es            working  with  a  mentor  during  prac.ce      group  studying   Distance-­‐learning  IMCI  

1.5 COURSE STRUCTURE SLIDE Direct participants to follow along in their self-study modules: PART 2 Course Overview.

dIMCI  course  structure   1st  face-­‐to-­‐face     mee.ng     (today)   3-­‐4  weeks  

Orienta>on    

Review  &  prac>ce     2nd  face-­‐to-­‐face     mee.ng  

Final  synthesis     3rd  face-­‐to-­‐face     mee.ng      

(1  day)   6-­‐8  weeks  

 

 

(1  day)  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

Prac>ce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance-­‐learning  IMCI  

2  to  3  months  

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1.6 SUCCESS IN DIMCI SLIDE Review expectations for participants. Set a tone for the course: hard work, motivation, teamwork, and pursuing learning. Answer any questions as required. Facilitator discussion as required.

What  do  you  need  to  succeed  in  dIMCI?      You  need  to  devote  +me,  energy,  and  commi4ment  –  

IMPORTANT!  

you  need  to  be  mo+vated!   IMCI  tools  

   You  need  to  prac+ce  seeing  children  and  using  the      You  need  to  work  with  others  (colleagues,  study  

groups,  and  mentors)  –  this  is  cri+cal  for  learning  and   skills  development  

   If  you  do  not  know  something  -­‐>  ASK!  SEEK  HELP!   Distance-­‐learning  IMCI  

1.7 OBJECTIVES FOR TODAY’S ORIENTATION MEETING SLIDE Direct participants to follow along in their self-study modules: PART 2 Course Overview.

Orienta(on  objec&ves   At  the  end  of  today,  you  should  be  able  to:       Explain  the  objec&ves  and  structure  of  this  distance  learning  course,  including  the   importance  of  clinical  prac&ce,  mentors,  and  study  groups                      

Iden&fy  key  causes  of  childhood  mortality   Explain  the  meaning  and  purpose  of  integrated  case  management   Describe  the  major  steps  in  the  IMCI  process   Demonstrate  how  chart  booklets  and  recording  forms  are  IMCI  job  aids   Recognize  the  general  danger  signs  in  children   Iden&fy  important  care  for  young  infants   Explain  the  importance  of  assessing  for  signs  of  severe  disease  and  feeding  problems   in  young  infants   Describe  how  a  welcoming  environment  is  important  for  case  management   Explain  and  demonstrate  key  communica&on  skills   Plan  self-­‐study,  group  study,  and  clinical  prac&ce  for  Modules  1  and  2  

  Distance-­‐learning  IMCI  

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1.8 ANNOUNCEMENTS FOR THE DAY •• Ask participants to set ground rules for the day (use FLIPCHART to record suggested ground rules and display on wall ). •• Emphasize that mobile phones should be turned off, and use should be limited during breaks. •• Complete attention is required for the day’s busy schedule and learning objectives. •• Meeting runs until 4:30pm •• Breaks in morning and afternoon, lunch at 12:30pm. Note if provided. •• Review facilities in this building – toilets, access to phones or computers •• Are there any administrative questions for today?

1.9 REINFORCE KEY PRINCIPLES •• Effective distance learning requires significant motivation, time, and energy •• Effective distance learning requires participants to practice in the clinic and use IMCI tools •• Effective distance learning requires participants to involve others in their study, and should reach out to mentors, study group members, colleagues, and in-charge officers. •• Much of learning happens through feedback and problem solving together.

1.10 TRANSITION TO NEXT SESSION Next we will get a feel for IMCI and how it can improve your clinical work. We will also discuss the importance of setting a welcoming environment in your clinic.

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SECTION 2. CREATING A WELCOMING ENVIRONMENT TIME – 30 minutes FACILITATOR SUMMARY In this section, facilitators will use an IMCI video and discussion to create interest in the IMCI process. The idea of this session is to grab the participants’ interest in IMCI. It is also to emphasize that what they are doing with IMCI is critical. OBJECTIVES •• Engage participants in the IMCI process. This is an opportunity to grab their attention and start the day off with an energetic session. •• Emphasize that good communication skills with families create a welcoming and enabling environment for case management. MATERIALS ■■ IMCI DVD ■■ Flipchart

2.1 INTRODUCTION TO IMCI PROCESS INTRODUCTION: Integrated case management might sound confusing. The important thing you need to know is the IMCI strategy has a very specific process that walks you through examining children, identifying their health problems, and giving appropriate treatment. PLAY IMCI DVD “General danger signs – convulsions” Disc 1, 4:00 minutes Instructions for participants: open your Chart Booklets to the correct chart for the sick child. Take out a recording form for the sick child; these signs are the first box. Facilitation: lower lights as needed IMPORTANT TO NOTE: this video has not been updated. It contains signs that are not included in the current chart booklets. This video is helpful to see the process in a clinical setting.

2.2 DISCUSSION Example questions included below. Record notes on FLIPCHART. •• What did you observe in this video? •• From your observations, what does IMCI help you do in the clinic? •• When a child enters the clinic, what do you do in your clinic to make families feel welcome? •• Do you have any useful examples to share with the group about how to create a welcome environment?

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2.3 REINFORCE KEY PRINCIPLES •• Caretakers are very emotional when a child is sick. •• Healthcare providers play a critical role in creating a welcoming environment. It is important to be sensitive to families’ and children’s emotional needs and personal situations. •• Good communications skills build rapport and trust with caretakers. This helps the caretakers share more information about the child’s illness and the household situation. •• Reinforce good practices shared during the discussion about creating a welcome environment. For example, asking open-ended questions, sitting next to the mother, making personal contact by asking names and about their situation, listening to the mother’s responses.

2.4 TRANSITION TO NEXT SECTION The IMCI process emphasizes the responsibilities we have to the families and children who enter our clinics. Additionally, creating welcoming environments for our patients and their caretakers help us get more information better case management. Now we will take a step back and look at what causes many of these families to bring their children into our clinics. In other words, what are the health problems that we are trying to address as health workers? Then we will learn how IMCI is a strategy for managing these common health problems.

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SECTION 3. CAUSES OF CHILDHOOD ILLNESS TIME – 15 minutes FACILITATOR SUMMARY In this section, you will present data and discuss causes of childhood illness and mortality. This provides a context for the course by describing the problem. In this next section, you will introduce IMCI as a strategy for solving this problem. This section provides an outline for you, but you will be expected to bring your own expertise to guide the discussion. You should also provide relevant data from your region, country, province, or district. OBJECTIVES •• Emphasize that the majority of children die from preventable causes. These include acute respiratory infections, diarrhoea, malnutrition, measles, malaria, HIV, and perinatal causes. •• Emphasize that children often suffer from overlapping conditions. Malnutrition and HIV are particularly common underlying causes of other illness. •• Explain how factors of inequity cause higher childhood mortality in rural communities and poorer households. MATERIALS ■■ PowerPoint slides (need adaptation if you are including slides on national or local data) ■■ Flipchart

3.1 DISCUSSION: WHAT CAUSES ILLNESS AND DEATH IN OUR CHILDREN? It is best for the group to think about causes and discuss what they see in their facilities before showing them actual data, which might be surprising for some. TIP for suggested presentation method: on FLIPCHART draw a pie chart, that roughly represents the major causes of childhood mortality in your country or region. Ask participants to fill the chart in. As they suggest causes of death, fill them into the correct slice of the pie chart. They will probably be surprised about the proportions!

3.2 DISCUSSION: COMPARING OUR LOCAL AREA TO GLOBAL DATA SLIDE 1. How does global data compare to what we have discussed about our area? 2. What surprises us?

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What  causes  children  to  die  globally?   Measles   1%   AIDS   2%   NCD   4%   Injury   5%   Malaria   7%   Diarrhoea   10%   Other   16%  

Undernutri)on   Underlying  cause  in   up  to  50%  of   childhood  deaths  

Perinatal   39%  

ARI   16%  

ARI:  acute  respiratory  infec)on   NCD:  non-­‐communicable  disease  

Distance-­‐learning  IMCI  

Source:  WHO  Global  Health  Observatory,  2010  

CLARIFY: Review data and make any clarifications as required. You will need to explain how underlying causes like malnutrition and HIV contribute to illness and mortality. For example: When children are missing key nutrients, it impacts their physical and mental development. It can cause poor growth and immune function. HIV/AIDS reduces a child’s immune function.

3.3 DISCUSSION: INEQUITY & HEALTH SLIDE Most health workers will be familiar with the economic, social, cultural, and political environments where they work. It is important to relate these bigger issues to how caretakers seek healthcare services and care for the child in their home. Briefly discuss how inequity impacts child health. This discussion should provide a context for health problems outside of the clinic. This discussion should introduce the topic that inequity is important when looking at the different levels of health between groups. 1. What are factors that impact child health? 2. Globally, we know that children have a higher risk of dying before age 5 if they are from poorer households, live in rural areas, and have mothers with lower education. How does living in a poor household, in a rural area, or with a mother with less education impact a child’s health? SLIDE 3. For those of us working in urban settings, how does this relate to your patients?

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How  does  inequity  relate  to  health?   Children  have  a  higher  risk  of   dying  before  age  5  if  they:      

•  live  in  poorer  households   •  live  in  rural  areas   •  their  mothers  have  less   educa6on    

Source:  UNICEF/WHO  Child  Mortality  Report  2011   Distance-­‐learning  IMCI  

Factors participants might discuss: •• •• •• •• •• •• •• •• rural transportation fewer clinics in rural areas access to health information access to education, especially for women food insecurity due to poverty, access to food, poor farming, drought and weather poverty, few employment opportunities women’s ability to make decisions in the home and community lack of basic supplies like clean water or sanitation services

3.4 SUMMARIZE: INEQUITY & HEALTH CLARIFY: after discussing these factors, how would we define inequity? Inequity is the uneven distribution of health caused by conditions that may be avoidable, as well as unjust and unfair. For example, differences in health between two social classes. CLARIFY: RELATING THIS TO OUR WORK: what other inequities impact health in your home areas? Record responses on the FLIPCHART, e.g. gender, disparities between racial, ethnic, or religious communities.

3.5 REINFORCE KEY POINTS SLIDE INTRODUCTION: It is important to consider the wider environment of our patients and families’ lives. There are many factors that impact a child’s health and ability to seek services. CLARIFY: What questions do we have?

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Key  points  about  child  mortality   1.  2. 

Most  children  die  of  preventable  causes   Major  killers  of  children  under  5     Neonatal  condi6ons  (infec6ons,  asphyxia,  prematurity).    Babies  

with  low  birthweight  account  for  70%  of  all  newborn  deaths.       Diarrhoea     Pneumonias  

3.  4.  5. 

Malnutri<on  is  an  underlying  cause  in  up  to  half  of  deaths     HIV  is  an  underlying  cause  in  many  countries   Economic,  social,  poli6cal,  and  cultural  factors  impact  child   health.    Poorer  households  and  rural  communi6es  have  higher   child  mortality.    Women’s  educa6on  is  important  to  child  health.  

Distance-­‐learning  IMCI  

3.6 TRANSITION TO NEXT SECTION SLIDE INTRODUCTION: We have seen that children often die from preventable, overlapping causes. Integrated case management examines children for all common health issues.

What  is  the  PROBLEM     that  IMCI  wants  to  address?   Common  (and  o:en  overlapping)   causes  of  childhood  mortality  

Fever  

Cough  

Diarrhoea   Distance-­‐learning  IMCI  

Ear  problems  

In the next session, we will begin to see how the IMCI strategy is designed to focus on the most common symptoms of childhood illness. STOP FOR TEA BREAK (15 MINUTES)

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SECTION 4. THE IMCI STRATEGY TIME – 60 minutes FACILITATOR SUMMARY This section is the most important of the day. You will introduce the IMCI strategy, which is the foundation for the entire course. It is critical that participants are very clear on the IMCI process and the use of Chart Booklets and recording forms before they begin their self-study. There is a lot of information in this section. Encourage participants to follow along and take notes in their Chart Booklets and their modules PART 2: INTRODUCTION TO IMCI. Assess their comprehension by asking questions and presenting examples. OBJECTIVES •• Explain the IMCI strategy and the meaning of integrated case management •• Introduce the IMCI process •• Demonstrate how Chart Booklets and recording forms are supporting tools in the clinic. •• Introduce general danger signs in sick children. •• Provide opportunities to practice the IMCI process with video. MATERIALS ■■ Chart Booklets for distribution ■■ Copies of (sick child) recording forms for distribution – 2 for each participant ■■ PowerPoint slides ■■ IMCI DVD disc 1 ■■ Flipchart

4.1 DEFINING IMCI 1. What is IMCI? IMCI is the Integrated Management of Childhood Illnesses. 2. What is integrated case management? This means that the IMCI approach does not look at one symptom, or only at what the parent tells you is the problem. •• In your normal clinical practice, you might only evaluate a child for the problem that they present with – for example, diarrhoea. However, by only focusing on this one presentation, we might miss that the child also has a fever and is malnourished. •• Instead, IMCI assesses all children and infants for the major causes of childhood illness and death. We saw in the last slide that these include diarrhoea, cough and difficult breathing, fever, and malnutrition. •• By assessing children and infants for all major health issues, we provide more holistic care. •• We can identify issues that we might not have, if we only treated the symptoms that the child presents with, or what the caretaker tells us about. There might be more issues, and IMCI gives us instructions about how to look for these issues.

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4.2 INTRODUCE THE IMCI PROCESS SLIDE Participants should follow along using the flow charts in their self-study modules PART 2, section 2.

ASSESS   CLASSIFY   &  IDENTIFY   TREATMENT  

ASK,  LOOK,  LISTEN,  and  FEEL  for:   •  Signs  of  severe  illness   •  Main  symptoms  and  common  health  issues   BASED  ON  SEVERITY  OF  CLASSIFICATION:   •  RED:  severe,  urgent  referral  required   •  YELLOW:  treat  in  clinic   •  GREEN:  home  treatment  

TREAT   COUNSEL   FOLLOW-­‐UP  

INTEGRATED  TREATMENT  FOR  ALL  CLASSIFICATIONS  

THE  CARETAKER  ON  HOME  TREATMENT  &  FOLLOW-­‐UP  

ON  CARE  AND  RE-­‐ASSESS  

IMCI gives you valuable instructions for a process every time a child under 5 comes into your clinic. Here are the steps: 1 2 GREET THE CARETAKER ASSESS FOR SIGNS OF SEVERE ILLNESS ASSESS FOR COMMON MAIN SYMPTOMS Ask why they are bringing the child to the health clinic Ask this is an initial or follow-up visit A child with these signs will require an urgent referral These signs depend on the age group We will learn more about them soon Ask the caretaker questions and make your own observations about the child The main symptoms are different for age groups You will assess for main symptoms and underlying health problems like malnutrition We will learn more about them soon WHEN YOU ASSESS REMEMBER KEY ACTIONS: ASK, LOOK, LISTEN, FEEL: •• ASK the caretaker is the child has a certain problem. ASK questions for more information. •• LOOK, LISTEN, and FEEL to observe certain signs in a child. For example: LOOK to see if a child is unconscious, LISTEN for signs of respiratory distress, FEEL for swelling. 4 CLASSIFY & IDENTIFY TREATMENT Based on what signs the child shows, you will use IMCI charts to CLASSIFY the severity of the illness The charts are colour coded RED, YELLOW, and GREEN by severity, and instruct us on what action to take

3

CLARIFY: What do these colours remind us of? Streetlights directing traffic. •• RED – the condition is very serious and requires urgent referral •• YELLOW – the condition can be treated in the clinic •• GREEN – can be treated in the home 5 6 7 TREAT COUNSEL FOLLOW-UP Based on all of the conditions you identify, you will treat the child for everything Counsel the caretaker on providing treatment if the home, if necessary, and on feeding and other care You will counsel on when to bring the child back to the clinic When the child returns to the clinic, IMCI provides instructions on how to provide care

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4.3 INTRODUCE THE CHART BOOKLET AND RECORDING FORM Now that you have seen the overall steps of the IMCI process, here are two important job aids: 1. IMCI Chart Booklet: a book of charts with instructions on IMCI. These booklets are used all over the world. Advise participants which national adaptation of chart booklets you are using, and what year it was revised. 2. IMCI recording form: form for you to take notes as you use your Chart Booklets (see Annex A2.5, pages 160–162). TIP: As you introduce the chart booklet and recording form, it is useful to share your personal experiences using them in the clinic. It is helpful to emphasize that it is an easyto-use guide and recording system.

Make sure everyone has a Chart Booklet and recording forms (1 child, 1 young infant)

4.4 USING THE AGE-APPROPRIATE CHART SLIDE Participants can follow along in their Chart Booklets and self-study modules PART 2, section 3.

Age-­‐specific  charts   FOR  ALL  SICK  CHILDREN  up  to  5  years  who  are  brought  to  the  clinic   GREET  THE  CARETAKER  and  ASK  THE  CHILD’S  AGE  

If  child  is  up  to  2  MONTHS  

If  child  is  from     2  MONTHS  up  to  5  YEARS   Use  the  charts:   !ASSESS  &  CLASSIFY  THE  SICK  CHILD   !TREAT  THE  CHILD   !COUNSEL  THE  MOTHER   In  this  course,  read  more  in:   !MODULES  1,  3,  4,  5,  6,  and  7    

Use  the  chart:   !ASSESS,  CLASSIFY,  AND  TREAT  THE   SICK  YOUNG  INFANT   In  this  course,  read  more  in:   !MODULE  2    

INTRODUCTION: Your Chart Booklet is divided into two separate books. This is because there are different sets of charts for different age groups. Open to both sections (sick child, sick young infant) with the participants so they know where to locate in their booklets. 1. Charts for young infant are for children up to 2 months 2. Charts for children are for children 2 months up to 5 years

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CLARIFY: What does “up to 5 years” mean? The child has not reached his/her fifth birthday; same for “up to 2 months.”  PRACTICE: what charts are used for these example children? •• •• •• •• •• 6 weeks old? Sick young infant 2 months old? Sick child 14 days old? Sick young infant 4 years and 11 months? Sick child Child has 5th birthday last month? Not included

SUMMARIZE: •• The IMCI process we just reviewed is the same for both groups: assess for serious signs, assess for main symptoms, classify and identify treatment, treat, counsel, and follow-up •• The different sections of charts are important because children and young infants differ in the signs and symptoms you assess, and in some treatments. •• This is why it is critical that you must immediately determine the child’s age. TRANSITION: we will focus on the sick child now, and will learn more about the young infant this afternoon.

4.5 GREET: USING THE CHART BOOKLET & RECORDING FORM Ensure participants are following along in chart booklet open to first page of sick child charts, and on recording form for the sick child. INTRODUCTION: Now we will review how Chart Booklets and recording forms are useful tools for integrated case management. Let us picture a child and mother coming into our clinic room. We will walk through our Chart Booklets and recording forms. First, we need some important information about the child, and why they are visiting. This is above the chart, and at the top of your recording form. 1. Greet the child and caretaker. Can refer to helpful tips from morning session on creating a welcoming environment. 2. What is important information you need to know about the child before you assess? The child’s age, so we know what assess and classify charts to use. Let us say we are dealing with a child, so we will stay in this section. 3. ASK the caretaker why she is bringing the child to the clinic: what are the child’s problems? 4. We want to know: is this an initial or follow-up visit for this problem? •• Initial visit: If this is child’s first visit for this episode of an illness or problem •• Follow-up visit: If the child was seen a few days ago for the same illness. During a follow-up visit, you determine if the treatment given during the initial visit is helping the child. You will learn how to conduct follow-up visits in your self-study modules. 5. We record weight and temperature.

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4.6 ASSESS: USING THE CHART BOOKLET & RECORDING FORM A. INTRODUCTION TO CHART: Next, you begin to ASSESS the child. You see the top of the coloured chart reads: ASSESS, CLASSIFY, and IDENTIFY TREATMENT SLIDE

Assess and classify the sick child aged 2 months up to 5 years ASSESS AND CLASSIFY ASSESS ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS 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:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS Ask: Look: Is the child able to drink or See if the child is lethargic breastfeed? or unconscious. Does the child vomit Is the child convulsing everything? now? Has the child had convulsions? Any general danger sign Pink: VERY SEVERE DISEASE Give diazepam if convulsing now Quickly complete the assessment Give any pre-referal treatment immediately Treat to prevent low blood sugar Keep the child warm Refer URGENTLY.

URGENT attention

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? If yes, ask: For how long? Look, listen, feel: Count the breaths in one minute*. Look for chest indrawing. Look and listen for stridor. Look and listen for wheezing. CHILD MUST BE CALM Classify COUGH or DIFFICULT BREATHING Any general danger sign or Stridor in calm child. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA Give first dose of an appropriate antibiotic Refer URGENTLY to hospital**

Chest indrawing or Fast breathing.  




Distance-­‐learning  IMCI  

Give oral Amoxicillin for 5 days*** If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** If chest indrawing in HIV infected child, give first dose of amoxicillin and refer to hospital. Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for further assessment or consider TB or asthma Advise mother when to return immediately Follow-up in 3 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 5 days if not improving

Under the ASSESS column you will see instructions to: If wheezing and either fast breathing or chest indrawing:

No signs of pneumonia or very severe disease.

Green: COUGH OR COLD

•• Check children for general danger signs, which we will discuss in a few minutes. •• Assess for main symptoms and other conditions. On the first page here we have the symptom cough or difficult breathing. Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again, and then classify. If the child is: 2 months up to 12 months 12 Months up to 5 years Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more

CLARIFY: Instructions in the ASSESS column tell us to ASK about, or LOOK , LISTEN, and FEEL for certain signs and symptoms. *If pulse oximeter is available, determine oxygen saturation and refer if < 90%. ** If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care. ***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings. **** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried.  




•• We ASK about the child’s symptoms, and then ASK further details if clarification needed. •• We LOOK, LISTEN, and FEEL to make our own observations CLARIFY: What is the difference between a sign and symptom? IMCI talks about both and this might be confusing. •• Symptom: The child will present with a symptom like a fever, diarrhoea, or a cough. This is the presenting complaint that the child or the caretaker tells you. •• Signs: In order to determine the cause of this symptom, we assess for a number of signs. Signs are smaller pieces of information. In the symptom cough, you will look for the sign of fast breathing.  PRACTICE: what other ‘signs’ do you see in the ASSESS box for the symptom cough? Chest indrawing, fast breathing, wheezing.

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B. INTRODUCTION TO FORM Now let us see how the ASSESS charts relate to our recording forms. Look at your ASSESS column for cough and difficult breathing. Find the related section on cough and difficult breathing on your form SLIDE CLARIFY: how do you mark on the form if a child does or does not have a sign or symptom? If a child has a sign or symptom, you can check “YES” on signs you see, or circle them. If the child does not have the sign, you do not mark anything.

Assess  &  classify  (charts)  

Distance-­‐learning  IMCI  

4.7 CLASSIFY: USING THE CHART BOOKLET & RECORDING FORM PREVIOUS SLIDE INTRODUCTION (Demonstrate this on chart): We use the CLASSIFY column to match the signs a child shows with a coloured classification.  PRACTICE: do you remember what the colour coding means? •• RED CLASSIFICATION: most serious health problems, immediate pre-referral treatment and referral required •• YELLOW CLASSIFICATION: can be managed within the clinic, because they require attention but do not have the same risk of death as the severe classifications in the red section •• GREEN CLASSIFICATION: the child can be managed at home and clinic can do follow-up care  PRACTICE: let us practice the SIGNS and CLASSIFY AS columns. As you walk through examples below, ask questions to be sure participants comprehend. 1. Let us look at the chart to pretend we are assessing and classifying a child with cough and difficult breathing. With these signs, how do we classify? What colour is the classification? What does this tell us about the actions we need to take?

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a. Child only shows the sign fast breathing: pneumonia; yellow, treat in clinic b. What if we observe the signs fast breathing and lethargy? Very severe pneumonia or disease; red, urgent pre-referral treatment and refer 2. Let us turn to the next symptom, diarrhoea. Look at the first chart for dehydration. a. What if we observe the signs lethargy and a very slow skin pinch? Severe dehydration; red, urgent pre-referral treatment and refer b. If a child is restless but shows no other signs? No dehydration; green, home treatment c. What if the child is restless, but drinks eagerly, and shows no other severe signs? Some dehydration; yellow, treat in clinic CLARIFY: Always immediately CLASSIFY each symptom and write your classification on the form before you move to the next symptom on your chart, and the next section on your form. Ensure that participants understand how to record the classification on the recording form.

4.8 IDENTIFY TREATMENT: USING THE CHART BOOKLET & RECORDING FORM SLIDE INTRODUCTION: The TREATMENT column on our chart recommends an appropriate treatment for each classification. It also tells you where to treat – referral, clinic, or at home. We record this on the back of our recording forms.  PRACTICE: let us look at the chart for the symptom cough and difficult breathing a. If we classify pneumonia, what are the identified treatments we would record? b. What if we classify cough or cold?

Iden%fy  treatment  (column)  

Distance-­‐learning  IMCI  

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4.9 CONTINUE IMCI PROCESS: USING THE CHART BOOKLET & RECORDING FORM INTRODUCTION: We have been looking at the first symptom, cough and difficult breathing. After we ASSESS, CLASSIFY, and IDENTIFY TREATMENT for this symptom, we move to the next one and repeat the process. Let us flip through the Booklet to see everything we will assess for with a sick child. Flip through each symptom and condition. Main symptoms: ✔✔ Next is diarrhoea ✔✔ Fever ✔✔ Ear problems And then we check for other health issues: ✔✔ Malnutrition and anaemia ✔✔ HIV infection ✔✔ Consider TB ✔✔ Status for immunizations, Vitamin A, and deworming ✔✔ Finally we ask about other problems REMEMBER: Signs and symptoms are different for young infants. We will review in the afternoon.

4.10 TREAT: USING THE CHART BOOKLET & RECORDING FORM SLIDE INTRODUCTION: After completing all classifications, we use the TREAT THE CHILD section of charts to determine how we will treat. Ensure all participants locate this section of charts in the booklet.

Treat  the  child  (charts)  

CLARIFY: what happens when a child has more than one classification? Distance-­‐learning  IMCI  

✔✔ You must look at more than one table to find the appropriate treatments. ✔✔ You will write all treatments identified for each classification on the reverse side of the case recording form.

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✔✔ Once you have identified all of the recommended treatments, you will need to review all of them in total, and decide on the appropriate treatment for the child. This is called integrated treatment. SHARE: facilitator, offer your own experiences about using the form to record treatments. How did you use this in your own clinic? What is most useful?  PRACTICE: provide an example to connect the TREATMENT column on the classification charts with content in the TREAT THE CHILD section. ✔ Example: A few minutes ago we looked at the charts for classifying dehydration with diarrhoea. We looked at SOME DEHYDRATION from diarrhoea, which was a yellow classification to be managed in the clinic. Review that classification row and IDENTIFY TREATMENT. We see it requires Plan B for treating dehydration. Now let us flip to Plan B in our TREAT THE CHILD section.

4.11 COUNSEL THE CARETAKER: USING THE CHART BOOKLET & RECORDING FORM SLIDE INTRODUCTION: Once we have determined treatment we will COUNSEL THE CARETAKER with instructions in the next section of charts COUNSEL THE MOTHER. ✔✔ Counselling will review (a) instructions for home treatment, (b) instructions for follow-up care, and (c) overall counselling on feeding, good care in the home, and disease prevention. ✔✔ You will record the earliest date to follow-up on the back of the case recording form.  PRACTICE: Review a counselling example from the COUNSEL THE MOTHER chart. Relate to an example from treatment.

Counsel  the  caretaker  (charts)    

Distance-­‐learning  IMCI  

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4.12 PROVIDE FOLLOW-UP CARE: USING THE CHART BOOKLET & RECORDING FORM SLIDE INTRODUCTION: Several treatments in the ASSESS AND CLASSIFY chart include a follow-up visit. At a follow-up visit you can see if the child is improving on the treatment that was given.

Provide  follow-­‐up  care  (charts)   At  bo&om  of  TREAT  THE  CHILD  charts  

Distance-­‐learning  IMCI  

CLARIFY: how do you know when the child should follow-up? Review classifications in total, and select the earliest follow-up date. ✔✔ You will have recorded the earliest date to return for “follow-up” on the reverse side of the case recording form. ✔✔ Caretakers should also know when children should immediately return for follow-up. REVIEW CHARTS: The TREAT THE CHILD chart includes a section on GIVING FOLLOW-UP CARE with instructions for conducting each type of follow-up visit. ✔✔ Headings in this section correspond to the child’s previous classification(s). ✔✔ During follow-up you will re-assess the child’s conditions to see if they are: improving, the same, or worsening. Then you will do a full re-assessment to check for other conditions. CLARIFY: do you record the follow-up assessment on the same recording form? You will use a second recording form for this assessment. See on our recording form where we will check “ follow up visit” this time.

4.13 ANNEX MATERIALS: USING THE CHART BOOKLET & RECORDING FORM To finish this ‘tour’ of the Chart Booklet, quickly review what annex materials or references are available in the booklet. For example, this might include pictures.

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4.14 TIPS FOR USING THESE TOOLS AS YOU STUDY ✔✔ Study these tools closely as you read your self-study modules. For example, as you read about diarrhoea in a child, follow along in your Chart Booklet and form so you can picture how the material will apply in your clinical practice, and you can picture the process. ✔✔ Take these tools to your in-charge officer to show him/her how you will use them in the clinic. ✔✔ Practice, practice, practice: The more you practice with the Chart Booklet and form, the quicker you will learn the process and get comfortable using these tools correctly in your clinical room. ✔✔ If it makes you more comfortable, you can tell the caretaker that you will be taking notes as you ask questions and speak with him/her. CLARIFY: ✔✔ Any questions about the Chart Booklet and recording forms? ✔✔ What questions do we have about using these tools on the job? This concludes the introduction to the Chart Booklet and recording forms. You will now begin to use the process with general danger signs.

4.15 INTRODUCING GENERAL DANGER SIGNS SLIDE

General  Danger  Signs   1.  2.  3. 

ASK:  is  child  unable  to  drink  or  breas;eed?   ASK:  does  the  child  vomit  everything?   ASK:  has  child  had  convulsions  during  the  current  illness,  or   LOOK:  is  child  convulsing  now?    

Muscles  are  contrac.ng,  arms  and  legs  s.ffen,  and  child  may  lose   consciousness  or  cannot  respond  

4. 

LOOK:  is  child  lethargic  or  unconscious?    

Child  doesn't  respond  or  show  interest,  cannot  be  wakened  if   unconscious.    Eyes  might  be  open.    

  Distance-­‐learning  IMCI  

These  are  signs  of  very  serious  illness.       If  one  or  more  present,  urgently  refer.  

REFRESH: when do you look for general danger signs? Our first step in assessing is to look for signs of serious illness that will require referral. We said that these signs are different for the sick young infant and the sick child.

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Now we will look at those signs for the sick child, called GENERAL DANGER SIGNS. Module 1 is about general danger signs. You will complete to this module before next meeting. Ask participants to flip to Module 1 with you.

1. CHILD IS NOT ABLE TO DRINK OR BREASTFEED This child is not able to suck or swallow when offered a drink or breast milk. n  ASK: Is your child able to drink or breastfeed? n  Suggestions for asking the caretaker: When you ask the mother if the child is able to drink, make sure that she understands the question. Ask her to describe what happens when she offers the child something to drink. For example, is the child able to take fluid into his mouth and swallow it? n  Check: If you are not sure about the mother’s answer, ask her to offer the child a drink of clean water or breast milk. Look to see if the child is swallowing the water or breast milk. n  Important notes: A child who is breastfed may have difficulty sucking when his nose is blocked. If the child’s nose is blocked, clear it. If the child can breastfeed after the nose is cleared, the child does not have the danger sign.

2. CHILD VOMITS EVERYTHING This child is not able to hold anything down at all. Everything that goes down comes back up. The child is not able to hold down food, fluids, or oral drugs. n  ASK: is your child vomiting everything? n  Suggestions for asking the caretaker: use words that the mother understands. Give her time to answer. If the mother is not sure if the child is vomiting everything, help her to make her answer clear. For example, ask the mother how often the child vomits. Also ask if each time the child swallows food or fluids, does he vomit? n  Check: If you are not sure of the mother’s answers, ask her to offer the child a drink. See if the child vomits. n  Important notes: A child who vomits several times but can hold down some fluids does not have this general danger sign.

3. CHILD HAS HAD CONVULSIONS IN THIS ILLNESS, OR IS CONVULSING NOW During a convulsion, the child’s arms and legs stiffen because the muscles are contracting. The child may lose consciousness or not be able to respond to spoken directions. n ASK: Has your child had convulsions during this illness? n  Suggestions for asking the caretaker: Use words the mother understands. For example, the mother may call convulsions “fits” or “spasms.” n  Important notes: What is the local word(s) we would use to explain a convulsion?

4. CHILD IS LETHARGIC OR UNCONSCIOUS A lethargic child is not awake and alert when she should be. The child is drowsy and does not show interest in what is happening around her. Often the lethargic child does not look at his mother or watch your face when you talk. The child may stare blankly and appear not to notice what is going on nearby. An unconscious child cannot be wakened. Does not respond when he is touched, shaken, or spoken to. n  LOOK: is the child is lethargic or unconscious? n  Suggestions for asking the caretaker: Ask if the child seems unusually sleepy or if she cannot wake the child. Look to see if the child wakens if someone talks to or shakes the child, or when you clap your hands. n  Important notes: A child might have his eyes open but still be lethargic or unconscious.

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4.16 VIDEO REVIEW OF GENERAL DANGER SIGNS PLAY IMCI DVD “General danger signs” Disc 1, 4:00 minutes Instructions for participants: open your Chart Booklets to the correct chart for the sick child. Take out a recording form for the sick child; these signs are the first box. Facilitation: lower lights as needed IMPORTANT TO NOTE: this video has not been updated. It contains signs that are not included in the current chart booklets. This video is helpful to see the process in a clinical setting.

4.17 PRACTICING GENERAL DANGER SIGNS You will lead two short activities to practice assessing general danger signs, and using the recording form. If time does not allow, you can select from the activities below. VIDEO PRACTICE PLAY IMCI DVD “Assess general condition” Disc 1, 6:00 minutes Instructions for participants: you will evaluate 4 children for the general danger sign lethargy or unconsciousness. Write your answers down. Facilitation: stop at 4:15 to discuss participant answers before playing video through

n  CASE STUDY BIKI •• Instructions for participants: you will practice using a recording form to check for GENERAL DANGER SIGNS. As I read a case aloud, use your form like you would in your clinic. •• Facilitation: Read the below case aloud. Speak slowly and clearly. This takes about 2 minutes to read. A grandmother named Victoria brings her grandson Biki into your clinic. He is 7 months old. His temperature is 37 degrees Celsius. You weigh him and he is 9 kg. You ask her what Biki’s problem is. She tells you that he isn’t feeding well. You ask if she is coming to the clinic for the first time with this problem. She says they have come to this clinic before, but this is the first time for this feeding problem. You ask Victoria if Biki if he is able to drink anything or breastfeed. She tells you his mother has passed away, so she gives him milk. You ask her to describe the feeding problem. She says that tarting this morning, he is too weak and will not take the milk when she tries to give it. She says that his head leans back and he won’t open his mouth for the cup of milk. The milk just dribbles onto his face. You ask Victoria if he is vomiting everything. She says no. You ask Victoria if he is having (local word for convulsions) or fits while he has been unwell. She says no. You sit Biki up on Victoria’s lap and unwrap his blanket so you can watch him better. Biki looks very tired and lays back into her arms. As you snap your fingers and move your hand in front of Biki, his eyes follow you. You ask Victoria to speak to Biki. She says “hi baby!” down to him, but he does not look up at her.

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n  CHECK UNDERSTANDING SLIDE

CASE  STUDY:  BIKI   How  does  your  form  compare?   What  ques5ons  do  we  have  about  Biki’s  case  and  the  form?   MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME   Biki AGE   7 mo WEIGHT   9 kg TEMP    37°C ASK:  what  are  the  child's  problems?   Not feeding well Grandma gives milk, won’t take today ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS       CONVULSIONS     CONVULSING  NOW   IniLal   X visit      Follow-­‐up   CLASSIFY   General  danger  signs   present?   X  YES                  NO    

Distance-­‐learning  IMCI  

•• Review participant answers. Show the SLIDE of Biki’s recording form so they can compare.

How  well  did  the  health  worker  use  the  form?  

MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME   AGE   6 wks WEIGHT   3.2kg TEMP   IniMal  visit   X Follow-­‐up      CLASSIFY   General  danger   signs  present?   X YES                  NO     Use  when  classifying          

       °C  

ASK:  what  are  the  child's  problems?  

Not feeding well

ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS   Distance-­‐learning  IMCI  

    CONVULSIONS     CONVULSING  NOW  

•• •• •• ••

How does your form compare to this form? What questions do we have about Biki’s case? Do we have questions about the decision on the general danger signs? What questions do we have about the recording form?

4.18 PRACTICING RECORDING FORMS SLIDE INTRODUCTION: In this session we have learned about the IMCI process and using IMCI job aids. We also learned about checking for general danger signs. Now we will do a short practice to check our understanding.

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FACILITATORS: There are two practice cases, and two versions of the slide for each case (4 slides in total). One slide version is blank, and should be shown to participants for discussion. When you are ready to review answers, move to the next slide. This version has markings to show what is incorrect about the slide. CASE 1 This case is a bit of a trick to see if participants realize they are seeing a sick infant, but using the sick child form.

How  well  did  the  health  worker  use  the  form?   Incorrect  form!    This  is  a  sick  young  infant  under  2  months  of  age   Name  not  recorded   NAME   AGE   6 wks

No  temperature  recorded   WEIGHT   3.2kg TEMP   IniRal  visit   X        °C  

MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS  

ASK:  what  are  the  child's  problems?  

Follow-­‐up      Not feeding well Young  infants  show  different  signs  of  severe  illness   ASSESS  (circle  all  signs  present)   CLASSIFY   General  danger   signs  present?   X YES                  NO     Use  when  classifying          

1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS   Distance-­‐learning  IMCI  

    CONVULSIONS     CONVULSING  NOW  

CASE 2 This case demonstrates poor documentation on the form.

How  well  did  the  health  worker  use  the  form?   No  weight  recorded   MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME  

Sara

AGE   3 mo

WEIGHT  

kg TEMP  

36

°C

ASK:  what  are  the  child's  problems?  

Need  to  ask  caretaker  about  the  child’s  problems   and  record   ASSESS  (circle  all  signs  present)       CONVULSIONS     CONVULSING  NOW  

IniJal  visit   Follow-­‐up  

X   

CLASSIFY   General  danger   signs  present?     YES              X NO     Use  when  classifying          

1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS  

Unclear  if  child  does  or  doesn’t   have  sign;  should  circle  if  sign   present   IMCI   Distance-­‐learning  

Child  has  a  general  danger  sign,   but  it’s  incorrectly  marked  

4.19 CHECK UNDERSTANDING OF IMCI PROCESS This session on IMCI has introduced a lot of content. As a facilitator, take a few minutes to review the process, and identify/address any confusion before the clinical practice session. The facilitator should present review questions to check understanding in the group. The questions should cover all key points of the IMCI process to summarize the session. Example questions are below. Refer back to SLIDES or the Chart Booklet as required.

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n  SAMPLE REVIEW QUESTIONS ✔✔ When do we use IMCI in our clinics? For every sick child under the age of 5. ✔✔ Why do you greet the caretaker? ✔✔ What are the two IMCI age groups? Young infant (up to 2 months), child (2 months up to 5 years) ✔✔ What does “up to 5 years” mean? The child has not reached his/her fifth birthday ✔✔ What charts do we use for a child: — 6 weeks old? Sick young infant — 2 months old? Sick child — 4 years and 11 months? Sick child — 5 years old? Not included

✔✔ What is important information we want from caretakers? Name, age, problem, initial or follow-up ✔✔ Can someone show us on their chart where the steps for assessing sick children are located? Have participant come to front and show the boxes in the ASSESS column. ✔✔ Can someone use their Chart Booklet to explain the ASSESS-CLASSIFY-TREAT process? ✔✔ What do the ASSESS boxes contain? Instructions on signs to ask, look, listen, and feel for ✔✔ Where do you look first when you classify the child’s illness? You look at the SIGNS column in classification table to see what signs the child is presenting with. Remember that if the child has signs from more than one classification, you “classify up” to the more severe. ✔✔ Where are the classifications located? CLASSIFY AS column ✔✔ What do the 3 colours of the classification table mean? Red is an urgent condition, refer. Yellow is serious but can be treated in the clinic. Green requires home treatment. ✔✔ What happens if a child has signs from both the RED and YELLOW classification boxes? You always “classify up” to the more severe condition. So you will classify using the red box instead of the yellow, or the yellow instead of the green. ✔✔ If I have assessed and classified a child’s cough, what do I do next? Use the classification table to identify the treatments, write on the recording form, and then assess and classify the next symptom. After assessing all, decide what treatments are necessary for all identified health problems. Decide where this treatment is given – urgent referral, in clinic, or at home. ✔✔ How do we identify treatment for a classification? TREATMENT column in classification table ✔✔ What is the first thing we assess for using IMCI? Signs of severe illness that require urgent referral. In the sick child, these are called general danger signs. ✔✔ What are the general danger signs for the sick child? Not able to breastfeed or drink anything, vomiting everything, lethargic or unconscious, convulsing or convulsions with this illness ✔✔ Why do general danger signs require urgent referral? ✔✔ What do we do if we identify at least one general danger sign? They need pre-referral treatment in the clinic – these are the bold treatments in the TREATMENT column. Then they must be referred. ✔✔ Each caretaker is asked about main symptoms – what are they? Cough or difficult breathing, diarrhoea, fever, ear problem ✔✔ After main symptoms, what do you check for? Malnutrition, anaemia, immunization status, HIV, and other problems that the caretaker mentions.

TRANSITION: review plan for moving to clinical practice, and lunch afterwards.

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SECTION 5. CLINICAL PRACTICE TIME – 60 minutes FACILITATOR SUMMARY This section is a critical opportunity to demonstrate IMCI with the sick child. Please refer to the ANNEX for more guidance on the clinical practice sessions. As this is the first clinical practice session with IMCI, facilitators should spend enough time on demonstration of a good case. Facilitators may choose either inpatient wards or outpatient clinics depending on availability of patients. SESSION OBJECTIVES The objectives of today should be that participants: •• See demonstrations of using the IMCI Chart Booklet and recording forms with patients •• Check children for general danger signs •• Practice greeting a caretaker and getting information about a child •• Use the Chart Booklet and recording form with a caretaker •• See demonstrations of IMCI process with other sick children or sick young infants, as participants have not learned content is best for facilitators to demonstrate and for participants to follow along in job aids MATERIALS ■■ Participants should bring Chart Booklets and recording forms (logbook or copies provided) ■■ Participants should bring recording forms (logbook or copies provided) ■■ Any other materials required for clinical setting TRANSITION: Summarize session as required. Explain transportation and lunch plans. Break for lunch if 45 minutes. During lunch, facilitators should regroup (as required) and also spend time with participants to discuss their self-study and clinical practice.

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SECTION 6. USING IMCI WITH THE SICK YOUNG INFANT TIME – 60 minutes FACILITATOR SUMMARY This section will continue with the IMCI approach, but focus on IMCI for the sick young infant. This section will not cover all of Module 2, which participants will complete before the next meeting. It is important that participants leave the Orientation meeting with a strong understanding of the IMCI process for both children and infants before they begin self-study. OBJECTIVES •• Explain why young infants have special care considerations. •• Emphasize benefits of exclusive breastfeeding. •• Reinforce the major steps in the IMCI process while emphasizing distinctions in sick young infant, including general danger signs for VERY SEVERE DISEASE and the emphasis on infant feeding. •• Connect IMCI for the sick young infant to the infant charts and recording forms. •• Introduce assessments for signs of VERY SEVERE DISEASE, jaundice, and for feeding. MATERIALS ■■ PowerPoint slides ■■ IMCI DVD (disc 2) ■■ Flipchart

6.1 WELCOME TO AFTERNOON SESSION CLARIFY: wrap-up of morning session •• Are there any questions that came up during lunch that I can answer? •• Tell me what you think so far about IMCI. How do you think it will be useful in your clinic? INTRODUCTION: Open to self-study Module 2. This entire module deals with the IMCI process for the sick young infant – all of the steps we reviewed on the flow chart. You will complete this Module before our next meeting.

6.2 INTRODUCE THE SICK YOUNG INFANT 1. REFRESH: Can someone remind us how we define a sick young infant? Review specification between child and young infant (up to 2 months), and remind that each has own charts and recording forms. 2. DISCUSSION: Young infants are special and need special attention. Do you know why? Record answers on FLIPCHART. Include notes from content below if participants do not mention.

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•• Young infants differ from older infants and children in the way they show signs of illness. Young infants have special characteristics that must be considered when classifying. •• They become sick and die very quickly from serious bacterial infections. Severe infections are the most common serious illness during first 2 months of life. Infections are particularly dangerous in low birthweight infants. •• They frequently have only general signs such as difficulty in feeding, reduced movements, fever or low body temperature. Even though these signs are general, each is a sign of very serious illness. •• Lower chest indrawing is different in young infants. Only severe lower chest indrawing is an important sign of severe disease. Mild chest indrawing is normal in young infants because their chest wall is soft. •• Newborn infants are often sick from conditions related to labour and delivery in the first few days of life. These conditions include birth asphyxia, birth trauma, preterm birth and early-onset infections such as sepsis from premature ruptured membranes. They may have trouble in breathing due to immature lungs. Newborns who have any of these conditions need immediate attention.

6.3 WHAT OTHER SPECIAL CARE DO YOUNG INFANTS REQUIRE? SLIDE DISCUSSION: Infants are special cases and need special care. What are important types of care for young infants? List important care practices on SLIDE and answer any questions. You will explain more about breastfeeding and signs of severe disease later in the section.

Important  young  infant  care    

Breas3eed  exclusively,  and  every  0me  infants   wants  to  feed  (day  and  night)   Keep  infants  warm  by  skin-­‐to-­‐skin  contact   Maintain  good  hygiene      

   

 

Wash  hands  before  holding  infant   Clean  umbilical  cord  and  area  

   

Immuniza:ons   Seek  immediate  care  if  signs  of  severe  disease  

Distance-­‐learning  IMCI  

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6.4 IMCI PROCESS WITH THE SICK YOUNG INFANT SLIDE REFRESH: Remember that the IMCI process is the same for both age groups in its basic steps. Participants should refer to same flow chart in study modules PART 2, section 2.

IMCI  FOR  THE  SICK  YOUNG  INFANT  (up  to  2  months  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  young  infant)     ASK:  what  are  the  infant's  problems?    

GREET  THE  CARETAKER  

 ASK:  ini3al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

ASSESS  for     GENERAL  DANGER  SIGNS    for  very  severe  disease   All  danger  signs   require  urgent   referral  

Even  if  present  

CLASSIFY  

  Jaundice       Diarrhoea     HIV  status  or  mother’s  HIV  status       Feeding  problem  and  growth     Check  immuniza3ons             Assess  other  problems  &  mother’s  health  

ASSESS  MAIN  SYMPTOMS  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

  in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED  

  at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

CLARIFY: some differences in the young infant to note •• General danger signs are signs of serious illness that require urgent referral. In young infants the signs are different. We look especially for signs of bacterial infection and jaundice. •• REVIEW MODULE 2: After we assess and classify the young infant for serious illness, what do we do next? Flip through young infant section with participants. •• Assess for common problems in young infants. We check feeding here because good feeding is so critical in this young age.

6.5 INTRODUCING GENERAL DANGER SIGNS OF VERY SEVERE DISEASE IN YOUNG INFANTS INTRODUCE: we have learned that the first step is to check all sick young infants for general danger signs of serious disease. We’ve learned that severe infections are the most common serious illness during first 2 months of life. This step is similar to assessing general danger signs first in sick children. These signs require urgent referral. PLAY IMCI DVD “Demonstration: assessment of sick young infant” Disc 2, 14:00 minutes Instructions for participants: this video does not have the same signs as your Chart Booklet and recording form, because these were recently changed. The idea of watching the video is to see the process of assessing a young infant. Facilitation: lower lights as needed IMPORTANT TO NOTE: an alternate option is the WHO Newborn Care video

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 PRACTICE: let us practice the classification table for serious disease. We will discuss certain signs and how we would classify and identify treatment. ✔ How to classify a young infant with skin pustules, but nothing else? What is our course of action? Local bacterial infection; yellow classification, manage in clinic ✔ What if the infant is breathing more than 60 breaths in one minute? POSSIBLE SEVERE bacterial infection; red classification, pre-referral treatment and refer ✔ What if the infant has a body temperature of 35.3 degrees C? Low body temperature sign of VERY SEVERE DISEASE; red, pre-referral treatment and refer ✔ What if the infant shows no signs that we assessed for? NO Bacterial infection; green classification, advise on home care ✔ What if the infant has yellow palms? JAUNDICE; yellow classification, refer for Hb test

6.6 PROMOTING BREASTFEEDING AS HEALTH WORKERS INTRODUCE: The first point of important care for infants that we discussed is breastfeeding. We will discuss this further because early and exclusive breastfeeding is so important for an infant’s healthy growth and development. PREVIOUS SLIDE DISCUSSION: facilitate group discussion about personal experiences with breastfeeding. This discussion should personalise the issue of feeding, particularly breastfeeding. It is important to discuss the difficult aspects of breastfeeding; for example many expect breastfeeding to be easy and natural, it actually requires a great deal of support. Example discussion questions: •• How many of you have kids? How many of you breastfed, or have worked with a partner or a family member during breastfeeding? •• What were your experiences? Where did you seek help? Summarize conversation. •• In your clinic what issues do mothers have with feeding (e.g. fear that they are not making enough milk, nipple pain)? CLARIFY: how do health workers have an important role in promoting good feeding practices? •• Less than 40% of infants around the world breastfeed exclusively. So there is clearly a need for us as health workers to encourage and support breastfeeding. •• When we shared our personal experiences, it emphasized the important role health workers play in encouraging breastfeeding and supporting mothers to feed properly. •• It is particularly important to help HIV-positive women find safe feeding options. SUMMARIZE: Our personal experiences reinforce that as health workers, we have a critical role to play in supporting breastfeeding. Remind participants that they will learn more about feeding, and counselling caretakers on feeding, in Module 2.

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6.7 KEY POINTS FOR BREASTFEEDING Lead brief review of breastfeeding benefits as you think necessary. Record responses and key points on FLIPCHART as you feel necessary. Sample conversation questions are below.

n  SAMPLE REVIEW QUESTIONS What are some of the reasons breastfeeding is so important for young infants? ✔✔ Breastfeeding is one of most effective ways to ensure child health and survival ✔✔ Needed nutrients for healthy development and lifetime of good health ✔✔ Contains antibodies that help protect children from common childhood illnesses ✔✔ Benefits for family – breastmilk is readily available and affordable, health benefits for mother ✔✔ Lack of exclusive breastfeeding contributes to over a million avoidable deaths each year What are the important guidelines for breastfeeding? Exclusive until 6 months old, early initiation, on demand What do we mean by exclusive? Can I still give water? Breastmilk and nothing else. When should breastfeeding begin? Early – breastfeeding should begin with an hour of birth. What does breastfeeding “on demand” mean? As often as child wants, day and night Why is breastfeeding better than infant formula for young infants? ✔✔ Does not contain antibodies found in breast milk ✔✔ Potential for water-bourne diseases when mixing formula with unsafe water ✔✔ Infant feeding requires feeding bottles, and keeping them very clean ✔✔ Poor nutrition if dilute too much ✔✔ Many families cannot access or afford ✔✔ Breast milk supply changes when child isn’t frequently feeding (so if formula becomes unavailable might not be able to return to breastfeeding) What are feeding options for HIV-positive mothers? ✔✔ Exclusive breastfeeding (and safe transition to replacement at 4–6 months, expressing and heat-treating breastmilk) ✔✔ Wet nursing from known HIV-negative woman ✔✔ Exclusive replacement feeding Any questions on breastfeeding?

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6.8 USING IMCI TO SUPPORT INFANT FEEDING PLAY IMCI DVD “Demonstration: breastfeeding assessment” Disc 2, 9:00 minutes Instructions for participants: Open to your charts on assessing breastfeeding. Follow your chart booklets and recording forms to see how these tools guide you through the assessment. Facilitation: lower lights as needed. After video concludes, field questions.

6.9 REINFORCE KEY PRINCIPLES •• IMCI for the sick young infant uses the same process as the sick child, but uses signs that are most common and serious in young infants •• Why do infants have special considerations? They can die quickly from infection, and show signs of health problems differently than older infants or children. •• Good feeding is a particularly important for young infants. IMCI gives guidance to the health worker to assess feeding and counsel on problems. •• Assessing feeding and counselling mothers on feeding problems is an important focus in IMCI for the young infant. We have learned how to assess for correct positioning and attachment during breastfeeding. •• Breastfeeding is critically important for infants’ growth and development. Breastfeeding requires significant support from partners and family members, and correct positioning and attachment. Health workers have an important role to play in counselling mothers on correct feeding.

6.10 TRANSITION TO NEXT SECTION We need good communication skills in order to counsel mothers on feeding, home treatment, and providing other care. In the next section we will learn some of these important communications skills.

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SECTION 7. GOOD COMMUNICATION & COUNSELLING SKILLS TIME – 75 minutes, with a tea break (30 minutes session + 15 minutes tea + 30 minutes session) FACILITATOR SUMMARY In this session, you will introduce good skills in communication and counselling. You will explain these skills and then reinforce them with a video and/or facilitator role-plays. When explaining skills, it is important to provide concrete examples of using these skills within the clinic. There are also (optional) role-plays for participants to practice skills. OBJECTIVES •• •• •• •• •• Emphasize how good communication skills facilitate integrated case management Introduce APAC process Introduce 3 teaching steps Review checking questions for checking understanding Relate skills to everyday clinical use through video, (optional) facilitator-led demonstrations, and (optional) participant role-play scenarios

MATERIALS ■■ PowerPoint slides ■■ Flipchart If doing role-plays: ■■ Role play handouts copied for participants (ANNEX) ■■ Recording form copies (1 sick child and 1 sick infant required for each role play group) ■■ Props for role plays (1 cup, a rolled blanket to look like a baby)

7.1 INTRODUCE SESSION INTRODUCTION: We will be discussing useful communications skills for using IMCI in our clinics. DISCUSS: Why are good communication skills important to integrated case management? Possible discussion points: creating a welcoming environment, building trust and rapport, getting information about a child by asking the right questions and listening to answers, advising and counselling families on care.

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7.2 APAC PROCESS SLIDE INTRODUCTION: the APAC process is a helpful word tool to help you remember some simple and effective communication skills.

APAC  process    ASK  &  LISTEN  to  what  the  child’s  problems  

are  and  what  the  caretaker  is  already  doing  

 PRAISE  caretaker  for  what  she  has  done  well    ADVISE  her  how  to  care  for  her  child  at  home  

and  when  to  return  

 CHECK  the  caretaker’s  understanding  

  Distance-­‐learning  IMCI  

ASK and LISTEN – this helps us gather complete information about a child’s symptoms and signs •• Asking questions is very important for assessing the child’s problems. •• Listen carefully to find out what the child’s problems are and what the caretaker is already doing for the child. •• When you listen to the caretaker you will know what she is doing well, and what practices need to be changed. PRAISE – this recognizes good practices and builds a caretaker’s confidence in things she is doing well •• It is likely that the caretaker is doing something helpful for the child. •• Praise the mother for something helpful she has done. •• Give genuine praise – only praise actions that are indeed helpful to the child. ADVISE – there are many good skills when advising caretakers, which you will learn shortly •• Some advice is simple – for example, telling a caretaker to return with child in 2 days. •• Other advice requires you to teach the caretaker how to do something. We will learn skills about how to do this teaching in a minute. CHECK understanding •• After you advise a caretaker you want to be sure they understood you correctly. •• You will ask questions to check understanding and see if you need to explain more.

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7.3 GOOD SKILLS WHEN TEACHING A CARETAKER SLIDE INTRODUCTION: The second ‘A’ in the APAC process is ADVISE. Sometimes you will need to teach a caretaker how to do something. For example, how to give medicine doses at home, or change the way they breastfeed so that the infant attaches better.

Teaching  caretakers:   ♦ 

Ask  &  listen   Praise   Advise   Check  

Use  understandable  words   Focus  on  most  important   messages   Be  calm  and  reassuring   Show  an  example,  using  familiar   items   Give  feedback  during  prac?ce   and  affirm.     Encourage  ques?ons.    Answer  all   of  them.  

1.  Give   informa1on  

♦ 

♦  ♦ 

3.  Let   caregiver   prac1ce  

2.  Show  an   example  

♦ 

♦  Distance-­‐learning  IMCI  

THERE ARE 3 BASIC TEACHING STEPS: 1 2 3 GIVE INFORMATION by explaining how to do something, like apply eye ointment, prepare ORS, or soothe a sore throat SHOW AN EXAMPLE by doing the task yourself, like how to mix ORS, or hold the child still and apply eye ointment ASK HER TO PRACTICE as you watch and give feedback. For example, ask her to mix ORS, apply eye ointment, or describe how she would make a solution for a sore throat. This is the most important step of teaching.

IMPORTANT TIPS: Use words she understands Focus on most important messages If possible use real objects or pictures Use common teaching aids A caretaker is more likely to remember something she has practiced As she practices you will be able to observe that she understands and what is difficult Calmly answer all questions, reassure

7.3 CHECKING THAT A CARETAKER UNDERSTANDS SLIDE INTRODUCTION: Checking a caretaker’s understanding is critical to counselling. After you teach, you want to be sure that she understands how to give the treatment correctly. CLARIFY: how do you check understanding? •• Ask questions to find out what she understands, and what needs further explanation. •• If you get an unclear response, ask another checking question. •• Praise the mother for correct understanding. •• Explain more if she does not understand.

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Checking  ques-ons:   have  explained  

Ask  &  listen   Praise   Advise   Check  

  Use  these  to  check  that  a  caretaker  understands  what  you     These  are  open-­‐ended  ques-ons  (begin  how,  what,  why)     Avoid  ques:ons  that  can  be  answered  yes  or  no,  or  that  

 

lead  to  right  answer  

Are  these  good  checking  ques1ons?   → How  will  you  prepare  ORS?   → Should  you  breasBeed  your  child?   → How  much  extra  fluid  will  you  give  aEer  each  loose  stool?   → Will  you  remember  to  wash  your  hands?   Distance-­‐learning  IMCI  

→ Where  on  the  eye  will  you  put  the  ointment?  

CLARIFY: what are checking questions? •• Good questions begin with words like how, why, what, when, where •• These are open-ended, which means they cannot be answered YES or NO. For example, “should you wash your hands before giving the medicine?” can be answered with YES or NO •• Questions should not lead to the right answer. For example a question that is leading: “you will remember to wash your hands, won’t you?”  PRACTICE: Are these good checking questions? PREVIOUS SLIDE ✔ How will you prepare ORS? Yes, it is open ended and checks what she remembers ✔ Should you breastfeed your child? No, it can be answered “yes” ✔ How much extra fluid will you give after each loose stool? Yes ✔ Will you remember to wash your hands? No, it can be answered “yes” ✔ Where on the eye will you put the ointment? Yes CLARIFY: what are important actions when asking good checking questions? Summarize the discussion using FLIPCHART and emphasize the following: •• Pause to give her time to answer. Do not rush ahead or give the answer, she might be afraid to answer or is shy of authority, she might be afraid her answer is wrong, encourage her to answer •• If she answers incorrectly, do not make her feel uncomfortable. Teach her again using information, examples, and practice

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7.5 DEMONSTRATION OF GOOD COMMUNICATION SKILLS Facilitators can also supplement video with OPTIONAL FACILITATOR ROLE-PLAY IN ANNEX A2.2 PLAY VIDEO “Good communication skills: making things clear” 13:00 minutes This video shows two scenarios in a clinic. In the first scenario, the health worker does not use most of the communication skills discussed in this section. The second scenario is improved. The narrator provides analysis after each scenario. Instructions for participants: this video will review many of the communication skills we have just learned about. Take notes on the skills that you recognize. Take notes on areas where the health worker does well, or where the health worker could improve. Facilitation: lower lights as needed. After video concludes, field questions. NOTE: this video is not on the IMCI DVD

 PRACTICE: what important communication skills have we learned up to now? Record notes on FLIPCHART ✔ What is the APAC process? Ask (and listen), praise, advise, check understanding ✔ What are 3 important steps when teaching a caretaker? Give information, show example, let her practice ✔ Can someone give me an example of a good checking question? Of a poor question? ✔ What are some other useful tips when we are communicating with caretakers? Use words that are easily to understand, use common teaching aids, be reassuring, affirm correct answers and good practice, ask for questions and answer all, focus on important messages and don’t overwhelm with information BREAK FOR TEA (15 MINUTES)

7.6 PARTICIPANT ROLE PLAYS (OPTIONAL) SLIDE INTRODUCTION: We will now role-play case scenarios in order to practice our communication skills and the IMCI process that we have learned today. The objectives for these role-play are to practice communications skills, practice IMCI, and to provide constructive feedback to each other.

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Discussion  ques+ons  for  role-­‐play   1.  2. 

Did    the  health  worker  get  all  important  informa6on?   Did  the  health  worker:        

Use  the  APAC  process   Use  the  3  teaching  steps  (explain,  demonstrate,  ask  to  prac6ce)   Use  checking  ques6ons  to  check  caretaker’s  understanding  

3. 

Caretaker:  what  did  the  health  worker  do  well?    What   could  be  improved?   Observer:  what  did  the  health  worker  do  well?    What  could   be  improved?   Health  worker:  what  would  you  do  differently  next  6me?  

4. 

5. 

Distance-­‐learning  IMCI  

INSTRUCTIONS: explain set-up to participants ✔✔ Participants should divide into groups of three people. ✔✔ Everyone bring their Chart Booklets, recording forms, and notebooks to their group. ✔✔ There are three roles in each role-play. There are three different role-play scenarios. Each group will do three role-plays, and will rotate roles in each. TEAMS OF 3 WILL ROTATE BETWEEN ROLES: 1. Health worker: you will be assessing a child with a caretaker during each role-play. Your handout has background information about the child. Your task is to use good communications skills, assess the child, and counsel the caretaker. 2. Caretaker: you will be given a handout with background information about your child. It is important that you only give the healthcare provider the information if they ask for it. This is an exercise for them to ask you the right questions, so do not give the information away too quickly. You want the best for your child, but you are not offering up information. 3. Observer: while the health worker and caretaker are interacting, take notes. Focus on how well the health worker used the IMCI strategy. The slide has helpful questions. DISTRIBUTE to each group of three: •• 1 copy each of handouts A, B, and C (ANNEX) •• 1 recording form each of the sick child and sick infant (used in role-play B) TIMING 10 minutes per role-play: 5 minutes for role-play and 5 for discussion. Most will not take this long. Then each group member will rotate roles and use the next handout. Facilitator should give 1 minute warning during group discussion, and alert groups when to switch roles. MONITORING Facilitators should rotate between groups to monitor and contribute to each group’s post-discussion. Continue to show the SLIDE so that the observers can review appropriate questions.

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ROLE-PLAY CLOSING DISCUSSION Groups should discuss amongst themselves, but facilitators might want to conclude the group discussions 2 minutes early and gather thoughts from the entire group. 1. How effectively did the health worker communicate? The group discussions should begin by addressing overall questions from the slide about how effectively the health worker interacted with the caretaker. Constructive feedback is the most important part of this activity. All group members should provide feedback on what the health worker did well, and what could improve next time. 2. How well did the health worker assess and classify? Record group notes on FLIPCHART.

ROLE PLAY A SLIDE Objective: assess a sick child using IMCI 1. How was the health worker successful in getting the necessary information from the caretaker? 2. How did you classify the child’s general danger signs and cough? NO GENERAL DANGER SIGNS, VERY SEVERE PNEUMONIA 3. What does the colour-coded classification tell about the course of action required? Red/urgent referral required

JON  exercise   MANAGEMENT  OF  THE  SICK  CHILD  AGE  2  MONTHS  TO  5  YEARS   NAME  

Jon

AGE  

12

mo

WEIGHT  

10

kg

TEMP   IniJal  visit   Follow-­‐up  

37°C

ASK:  what  are  the  child's  problems?  

Cough for several days, worsening ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS                NOT  ABLE  TO  DRINK  OR  BREASTFEED                VOMITS  EVERYTHING                CONVULSIONS     LETHARGIC  OR  UNCONSCIOUS   CONVULSING  NOW  

x

  

CLASSIFY   Danger  sign  present?   Remember  to  use  danger   sign  when  selec4ng   classifica4ons          

YES              x NO  

2.  DOES  THE  CHILD  HAVE  COUGH  OR  DIFFICULT  BREATHING?  X YES      NO   Count  number  of  breaths  in  one  minute:  48/min Fast  breathing?  X YES        NO   Look  for  chest  indrawing   Look  and  listen  for  stridor/wheeze   Distance-­‐learning  IMCI  

For  how  many  days?  3-4

ROLE PLAY B SLIDE Objective: assess a young infant for general danger signs. 1. How was the health worker successful in getting the necessary information from the caretaker? 2. How did you classify the infant – does she have signs of severe disease or bacterial infection? VERY SEVERE DISEASE 3. What does the colour-coded classification tell about the course of action required? Red/urgent referral 4. What did you counsel the caretaker about? Counsel caretaker on keeping infant warm on the way to hospital

AMIRA  exercise   MANAGEMENT  OF  THE  SICK  YOUNG  INFANT  AGE  UP  TO  2  MONTHS   NAME  

Amira

AGE  

4 wks

WEIGHT  

3

kg

TEMP  

38 X   

°

C

ASK:  what  are  the  child's  problems?  

Baby is feverish

IniGal  visit   Follow-­‐up  

53  

Possible severe bacterial infection  

Distance-­‐learning  IMCI  

ROLE PLAY C Objective: counsel the caretaker on treating a local infection at home using the APAC process, 3 teaching steps, and checking the caretaker’s understanding 1. How did the health worker use the APAC process? 2. The 3 steps of the teaching method? 3. Checking questions?

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7.7 REINFORCE KEY PRINCIPLES Lead group summary discussion. Use FLIPCHART to record key notes. Example questions are included below. 1. Why are communication skills important when using IMCI? •• Integrated case management relies on us getting thorough information from the caretaker in order to properly assess and classify the child. •• Communication skills help us effectively counsel the caretaker on important home treatment, feeding, follow-up instructions, and other preventative care in the home. •• We can take important steps to make a caretaker feel welcome and less anxious, which helps us build trust and rapport, and helps them to remember the advice we give about care for the child. •• We remember from our own experiences as caretakers, and we know from our time working in the clinic, that it is very emotionally difficult when a child is sick. 2. What is the APAC process? Ask (and listen), praise, advise, check understanding 3. Can someone give me an example of praising a caretaker? Why is praise important? It affirms good practices and builds rapport with a caretaker 4. What are 3 important steps when teaching a caretaker? Give information, show example, let him/her practice 5. What are important skills to remember when we are teaching? Use clear language, use familiar teaching objects, allow more practice if necessary, affirm good practice and give feedback, emphasize take home messages and do not overwhelm with too much information 6. Can 3 people give me an example of a good checking question? Can 2 people give me a poor checking question?

7.9 TRANSITION TO NEXT SECTION We have completed our content for today. In our last session will review the important details of this course and plan our next steps. We will then do a meeting evaluation and close for today.

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SECTION 8. NEXT STEPS TIME – 45 minutes FACILITATOR SUMMARY This section will review the course structure and calendar, and set plans for the next steps of the course. Participants should be very clear about expectations for the first self-study period, who they are asked to involve in their study, and what materials they will be using. At the conclusion of this section, you will administer an evaluation of the day. OBJECTIVES •• Reinforce course structure and expectations for the upcoming self-study period – completion of modules 1 and 2, practice in clinics and use of recording forms, identifying mentors and communicating with in-charge officers •• Ensure that all participants have necessary materials and know what to prepare for next meeting •• Administer meeting evaluation MATERIALS ■■ PowerPoint slides ■■ Evaluation form handout

8.1 REVIEW OF COURSE MATERIALS SLIDE You will have distributed all materials at the beginning of the meeting. Before the meeting closing, it is important to do a final review of modules and logbook with participants. This also connects the day’s content to the upcoming self-study period.

Course  materials   1. 

STUDY  MODULES   LOGBOOK  

   Includes  overview  of  course  and  IMCI      Prac5ce  exercises  as  you  read  

2. 

   Complete  exercises  for  each  module  

   Complete  2  recording  forms  for  each  module      Use  checklist  of  clinical  signs  

from  cases  that  you  prac5ce  in  your  clinic  

You  will  submit  your  logbook  at  each  mee4ng;  the  exercises   and  recording  forms  count  for  up  to  33%  of  your  course  mark  

3. 

CHART  BOOKLET  

Distance-­‐learning  IMCI  

YOUR STUDY MODULES Flip through modules with participants and describe key content: 1. Reading material: should read all material. An opening case study also follows through the whole module to help you apply the material to one child’s story.

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2. Self-assessment exercises: you should complete these as you read. They help you test your understanding of each small topic after you read it. ✔✔ Some exercises are written, some are DVD videos, and others are case studies. ✔✔ You should answer these to the best of your ability – do not look for the answers. ✔✔ After you complete, there is an answer key in the module to check yourself. LOGBOOK Flip through the logbook with participants to show that it contains: 1. Exercises: these should be completed after you have finished a module. ✔✔ Do not refer to your study modules to answer these questions. ✔✔ You should answer based on what you remember from your study. 2. Recording forms: for every module you complete, you should fill out at least 2 recording forms from related cases that you see during your clinical practice. 3. Checklist of clinical signs: helps facilitators understand what exposure you have at your clinic, and what needs to be arranged for group clinical practice; also helps you keep track of what signs you have and haven’t seen yet CLARIFY: IMPORTANT NOTES ON LOGBOOK •• You will bring your logbook to each meeting and submit it to facilitators. •• About 33% of your mark will be the logbook exercises and recoding forms from practice. •• It is important that you complete the exercises and recording forms with good effort.

8.2 PREPARE FOR SELF-STUDY PERIOD 1 Participants should follow along in their books PART 2, SECTION 3 to fill in dates. CLARIFY: date and location for remaining face-to-face meetings in course SLIDE COURSE  CALENDAR   Orienta5on   1st  face-­‐to-­‐face   mee,ng   SESSIONS           Introduce  IMCI  process   Distribute  learning  materials  &  introduce  content  to   Modules  1  and  2   Review  distance  learning  course  structure  &   expecta,ons   Provide  clinical  prac,ce   Read  modules     Self-­‐assessment  exercises  in  modules  as  you  read   Prac,ce  in  clinic  and  record  cases  on  recording   forms  in  logbook   Hold  study  group  discussions   Maintain  contact  with  mentors  &  facilitators   Complete  assessment  exercises  in  logbook   Review  progress  &  issues  in  self-­‐study   Examine  cases  from  clinical  prac,ce   Introduce  content  from  upcoming  modules   Provide  clinical  prac,ce   Read  modules     Self-­‐assessment  exercises  in  modules  as  you  read   Prac,ce  in  clinic  and  record  cases  on  recording   forms  in  logbook   Hold  study  group  discussions   Maintain  contact  with  mentors  &  facilitators   Complete  assessment  exercises  in  logbook   Review  progress  &  issues  in  self-­‐study   Examine  cases  from  clinical  prac,ce   Review  content  from  all  modules   Provide  clinical  prac,ce   Individual  plans  for  con,nued  learning   Course  assessment  (skills  sta,ons  and  wriPen  exam)  

OBJECTIVES  

LOCATION  

  TBD      

   

DATE  

TBD           (3-­‐4  weeks)  

  Self-­‐study  period  1        Modules  1  &  2        

      Home  facili,es     TBD             Home  facili,es       TBD                

Review  &  prac5ce   2nd  face-­‐to-­‐face   mee,ng    

           

TBD            (8-­‐9  weeks)  

  Self-­‐study  period  2        Remaining   modules                 Final  synthesis            3rd  face-­‐to-­‐face     mee,ng           Distance-­‐learning  IMCI  

TBD    

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CLARIFY: expectations for self-study period 1 SLIDE BELOW AND PREVIOUS SLIDE •• •• •• •• •• •• Read and study modules 1 and 2 Complete self-assessment and practice exercises in modules as you read Complete logbook exercises after finishing the module Practice IMCI in clinics and use recording forms Meet with study group members as much as possible Identify IMCI mentors and work with them on any problems or questions you have during self-study and clinical practice •• Make a study schedule and keep visual where you are studying

SELF-­‐STUDY  MODULES    

1   General  danger  signs      

 

 

2   Care  of  the  sick  young  infant   3   Cough  or  difficult  breathing   4   Diarrhoea   5   Fever   6   Malnutri;on  and  anaemia   Addi$onal,  op$onal  modules:   7   Ear  problems   8   HIV/AIDS   9   Well  child  care   Distance-­‐learning  IMCI  

Study  period  1  

 

Study  period  2  

8.3 IDENTIFYING IMCI MENTORS SLIDE Participants can follow along in PART 1, section 2. INTRODUCTION: Effective distance learning requires you to involve others in your studying. It is important for you to involve people at your facility. You should also identify an IMCI mentor.

Involving  others  in  learning   →     Debrief  your  in-­‐charge  officer  about  the  course  materials  and  how   you  will  use  IMCI  in  your  clinical  prac:ce    

AT  YOUR  CLINIC  

→  •  • 

Mentors  should  be  willing  to  demonstrate  IMCI  skills  in  the  clinic   and  can  help  you  understand  and  apply  the  new  skills   Could  be  a  senior  provider  in  the  district  hospital  or  your  facility,   or  a  colleague  (nurse,  doctor)  who  trained  in  IMCI  

IDENTIFY  A  MENTOR    

 

→ 

 Develop  a  study  plan  

FORM  A  STUDY  GROUP  

Distance-­‐learning  IMCI  

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CLARIFY: What are your (facilitator) expectations for staying in touch with participants?

8.4 FORMING STUDY GROUPS SLIDE Participants can follow along in PART 1, section 5. CLARIFY: Why do you think we are arranging study groups for this group? What is the benefit of group learning? Facilitate brief discussion around group studying, referring to your materials about study groups in this guide SECTION 0.6 and the ANNEX.

Tips  for  study  groups   →  →  →  →  →  →  → 

Agree  on  date  and  2mes  for  regular  mee,ngs   Set  detailed  reading  goals  (page  numbers)   Read  material  in  advance  &  complete  exercises   Note  down  ideas  that  you  find  confusing   Bring  ques2ons  to  the  group   Talk  about  cases  you  have  seen   Prac2ce  together  in  the  clinic,  as  necessary  

Distance-­‐learning  IMCI  

8.5 PREPARING FOR STUDY PERIOD 1 SLIDE 1. TIPS FOR CREATING A STUDY PLAN: it is critical to create study plans for your self-study period. 1. Mark your calendar for this self-study period ✔✔ Date of the next face-to-face meeting ✔✔ Study group meetings ✔✔ Any events that will disrupt your study time (e.g. a period of travel). 2. Determine weekly study plans: goals can include many items of self-study. Recommended that facilitators set reading goals for this first self-study period, especially given how many participants struggle to complete all of Module 2 ✔✔ Page numbers of reading and module practice exercises ✔✔ When you want to complete recording forms in the clinic ✔✔ When you want to complete logbook exercises ✔✔ Write schedule down and post somewhere you will see while you study

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Planning  self-­‐study  period  1   SAMPLE  INDIVIDUAL  STUDY  PLAN   WEEK   2! 4! 3! 1! STUDY  PLAN   Module 1 + 2 recording forms + logbook exercises! Read Module 2 (p. 21-48) + 2 recording forms! Read Module 2 (p. 1-21)! GROUP   13 August! 20 August!

Read Module 2 (p. 48-76) + logbook exercises! SAMPLE  STUDY  GROUP  PLAN   DATE  &  TIME   20 Aug, 5-6pm! 27 Aug, 5-6pm! 13 Aug, 5-6pm! LOCATION   Bisho! Bisho! Bisho! MATERIAL   All Module 1 !

27 August!

LEADER   L.M.! S.T.!

Module 2, assess & classify up to feeding (p.1-21)! Module 2, assess feeding & treat (p.21-48)!

M.T.!

Distance-­‐learning  IMCI  

CLARIFY: Why is so important to be very organized in your self-study? ✔✔ There is a lot of content to cover in this period, especially Module 2 ✔✔ Study plans help you set goals. ✔✔ Study plans ensure that you don’t wait until the last minute. ✔✔ Study plans help you prepare for your group study sessions. 2. CREATE STUDY GROUPS & SET STUDY PLANS: arrange participants into study groups by locality, facility, and access to DVD player (pair up if necessary). Make sure everyone has a study group. •• •• •• •• Provide 10–15 minutes for groups to meet Review how study groups should create a study calendar together Encourage everyone to exchange contact information Encourage study groups to meet as many times as they can

8.6 NEXT STEPS SLIDE Review all take-home messages for the upcoming self-study period and preparations for the next meeting. CLARIFY: What questions do we have about our next steps?

Next  mee'ng   DATE            LOCATION            

WHAT  DO  I  BRING?     Study  modules       Logbook  (module  1  and  2  exercises  completed)     Recording  forms  from  your  clinical  prac'ce  (4  total  =   2  each  from  modules  1  and  2)     Your  ques'ons  (challenging  cases,  confusing  material)    

AT  THE  NEXT  MEETING  WE  WILL–       Review  self-­‐study  progress     Prac'ce  IMCI  in  clinic     Introduce  new  content  from  upcoming  modules   Distance-­‐learning  IMCI  

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8.7 MEETING EVALUATION 1. Group discussion for feedback Lead a discussion in the group to gather feedback on the day’s content, presentation, and clarity. We recommend that facilitators ask participants for feedback on specific topics before giving a printed evaluation. Conversational evaluations can also provide useful information that is not included in a written evaluation. 2. Distribute meeting evaluation handout Provide time for participants to complete the evaluation and hand in. As participants finish the evaluation, check in with them to make sure each is feeling comfortable about their self-study, and if you can answer any individual questions.

8.8 CLOSE MEETING Affirm participants’ engagement in the course and express your energy and anticipation for the following three months. 1. DISTRIBUTE PARTICIPANT CONTANT INFORMATION SHEET 2. Review how participants should best stay in touch with you, and your availability.

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Review & Practice 2ND FACE-TO-FACE MEETING CONTENTS 2.1 Meeting objectives 2.2 Proposed agenda Section 1 – OVerview Section 2 – Reviewing self-study period 1 Section 3 – Assess & classify the sick child (Part 1) Section 4 – Clinical practice Section 5 – Assess & classify the sick child (Part 2) Section 6 – Integrating treatment, counselling the caretaker, and follow-up Section 7 – Next steps 84 85 86 89 92 96 97 110 115

PART 2

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2.1

MEETING OBJECTIVES

MEETING SUMMARY The second face-to-face meeting aims to assess participants’ progress during the first self-study period, to address any challenges, and to introduce content from the remaining self-study modules. The afternoon sessions are less structured in the event that facilitators need to work with participants to address problem areas by giving more information or practice.

WHAT ARE THE OBJECTIVES OF THIS MEETING? By the end of this meeting, participants should be able to: •• Demonstrate skills from Modules 1 and 2 in a clinical setting •• Explain and demonstrate how to use IMCI chart instructions to assess, classify, and treat main symptoms and conditions in a sick child (cough or difficult breathing, diarrhoea, fever, malnutrition, and anaemia). •• Plan self-study, group study, work with mentors, and clinical practice for remaining modules

WHERE WILL THIS MEETING TAKE PLACE? The meeting is designed to take place on-site so that the facilitators and participants can practice together in a clinical setting. This could take place at the district hospital, at a centrally located facility, or during site visits with the facilitator.

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2.2 9:00 9:00–9:15

PROPOSED AGENDA CHECK-IN & FEEDBACK SECTION 1 OVERVIEW (15 minutes) Review course objectives and outline the day’s objectives and agenda. SECTION 2 REVIEWING SELF-STUDY PERIOD 1 (45 minutes) Group discussion about self-study experiences, review recording forms, and problem solving around difficult cases. PLANNING NOTES PLANNING NOTES

9:15–10:00

PLANNING NOTES

10:00–10:15 10:15–11:00

Tea break (15 minutes) SECTION 3 ASSESS & CLASSIFY THE SICK CHILD (PART 1) (45 minutes) Introduce main symptoms cough or difficult breathing and diarrhoea using video demonstrations. PLANNING NOTES

11:00–12:30

SECTION 4 CLINICAL PRACTICE (90 minutes) Clinical demonstrations and skills practice focusing on the sick young infant, and general danger signs, cough or difficult breathing, and diarrhoea in the sick child.

PLANNING NOTES

12:30–13:30 13:30–14:45

Lunch (1 hour) SECTION 5 ASSESS & CLASSIFY THE SICK CHILD (PART 2) (75 minutes) Introduce material on fever, malnutrition, anaemia, and other modules included (e.g. well child, HIV, ear) in self-study period 2. PLANNING NOTES

14:45–15:00 15:00–15:30

Tea break (15 minutes) SECTION 6 INTEGRATING TREATMENT, COUNSELLING THE CARETAKER, & FOLLOW-UP (30 minutes) Review treatment for integrated case management, good counselling skills, and instructions for follow-up. You will lead an activity on dosages. PLANNING NOTES

15:30–16:00

SECTION 7 NEXT STEPS (30 minutes) Review expectations for study period 2, and administer evaluation. CLOSE MEETING

PLANNING NOTES

6:00

PLANNING NOTES

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SECTION 1. OVERVIEW TIME – 15 minutes FACILITATOR SUMMARY You will facilitate re-introductions of the facilitators and course participants, and welcome the group to the second face-to-face meeting. You will review the course objectives and structure, and provide an outline for the day’s objectives and activities. SECTION OBJECTIVES •• Set a welcoming learning environment during facilitator and participant introductions •• Review course structure to emphasize what was covered during self-study period 1, and how the course will move forward in self-study period 2 •• Introduce meeting objectives and brief agenda for the day MATERIALS ■■ PowerPoint slides ■■ Flipchart

1.1 WELCOME PARTICIPANTS Welcome participants to second face-to-face meeting. Present the meeting as an opportunity to assess progress in self-study, address any challenges the group is having, and practice together. 1. Re-introduce yourself and co-facilitators 2. Invite participants to re-introduce themselves (FLIPCHART) •• Name •• Workplace and role •• One thing that you have found particularly beneficial about IMCI so far in your self-study, group learning, or clinical practice 3. SUMMARIZE participant comments about course benefits

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1.2 REVIEW COURSE STRUCTURE Participants should follow along in books PART 2, section 2. 1. Review course objectives SLIDE

Course  objecCves   At  the  end  of  this  distance  learning  course,  you  will  be  able  to:    

Implement  integrated  case  management  for   common  health  problems  in  sick  young  infants   and  children     Use  the  IMCI  chart  booklet  and  recording  forms   in  your  clinical  prac/ce     Counsel  caretakers  on  home  treatment,   feeding,  well  child  care,  and  disease  preven/on    

Distance-­‐learning  IMCI  

2. Review course structure SLIDE – briefly review what components of the course have been completed, and what is upcoming.

dIMCI  course  structure   OrientaCon     1st  face-­‐to-­‐face     mee/ng     3-­‐4  weeks  

Review  &  pracCce     2nd  face-­‐to-­‐face     mee/ng     6-­‐8  weeks  

Final  synthesis     3rd  face-­‐to-­‐face     mee/ng      

(1  day)  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

PracCce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance-­‐learning  IMCI  

2  to  3  months  

CLARIFY: any questions from the group about the course structure?

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1.3 TODAY’S OBJECTIVES & AGENDA SLIDE 1. REVIEW: objectives of the second face-to-face meeting

Review  &  prac;ce  objec/ves   At  the  end  of  today,  you  should  be  able  to:    Demonstrate  skills  from  Modules  1  and  2  in  a  clinical  

seOng  

 Explain  and  demonstrate  how  to  use  IMCI  chart  

instruc/ons  to  assess,  classify,  and  treat  main   symptoms  and  condi/ons  in  a  sick  child     clinical  prac/ce  for  remaining  modules  

 Plan  self-­‐study,  group  study,  work  with  mentors,  and  

 

Distance-­‐learning  IMCI  

2. REVIEW: in brief the agenda for today Emphasize that it is a busy day and will require discipline to stay on task n MORNING: we will review our experiences in the past few weeks with selfstudy n LATE MORNING: we will practice IMCI in the clinic together If required at this time, describe how group will move and/or transition to clinical setting. Otherwise wait until the actual session to discuss. n AFTERNOON: we will review the IMCI process with common symptoms and conditions in children, which is the focus of your upcoming modules 3. REVIEW: administrative announcements as required

1.4 REINFORCE KEY PRINCIPLES ✔✔ Today is an opportunity to address any content or practice areas that you have found particularly challenging – so do not be afraid to ask questions. ✔✔ Your upcoming self-study will only become more difficult if you have confusions about IMCI or the material. ✔✔ Today is also an opportunity to share our experiences practicing IMCI thus far, and to learn from each other’s good practices. ✔✔ We will prepare for the upcoming self-study period by introducing material on assessing, classifying, and treating common symptoms and conditions in children.

1.5 TRANSITION TO NEXT SESSION We will begin our day reviewing our experiences from the past few weeks of studying and practicing IMCI.

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SECTION 2. REVIEWING SELF-STUDY PERIOD 1 TIME – 45 minutes FACILITATOR SUMMARY This section is a critical opportunity for facilitators to: (a) assess how well participants are using IMCI material in their clinical practice, (b) assess how well participants understand IMCI strategies and content from Modules 1 and 2, and (c) assess and address any “big picture” issues in the distance learning course arrangements, including self-study, study groups, and mentorship. There is a lot to be accomplished during this session, so it is recommended that the facilitators split into two activities: 1. One facilitator leads the plenary discussion 2. Remaining facilitators collect the logbooks/recording forms from each participant and: (a) mark participants for completeness, and (b) identify common problems to discuss with group. After reviewed, logbooks should be returned. Answer key is included in ANNEX. SECTION OBJECTIVES •• Provide an opportunity to reflect on distance learning experience and participants’ progress in understanding and using IMCI •• Assess how well participants are using IMCI in their clinical practice •• Address problem areas in self-study and challenging cases from clinical practice •• As a facilitator, note where additional facilitation and support is required. This should include any course issues that should be addressed in future courses. MATERIALS ■■ Logbook answer key (ANNEX) ■■ Flipchart

2.1 FACILITATORS REVIEW LOGBOOKS & RECORDING FORMS (at same time as 2.2) Facilitators not leading the plenary discussion should review logbook and recording forms. The logbook answer key is included in the ANNEX. Your review of the materials should accomplish two things: 1. Give participants marks for completeness on their logbook exercises and recording forms. Please refer to the following for further information: 1. Section 0.8 of this guide, “Assessing Participants” 2. dIMCI Excel Tool, where you can record your marks for participants 2. Identify any problem areas with using IMCI for the sick young infant or to check general danger signs. Make note of issues you see. You will rejoin the group to discuss and address these problem areas.

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2.2 PLENARY DISCUSSION – OUR REFLECTIONS ON SELF-STUDY (at same time as 2.1) INTRODUCE DISCUSSION ✔✔ This is an opportunity to share your experiences with the self-study modules, clinical practice, working with mentors, and study groups. ✔✔ We want to discuss any challenges you have encountered and address them as a group. ✔✔ This is a valuable time to deal with problem areas now before the next study period. TIPS FOR LEADING DISCUSSION: •• Identify problem areas in content, self-study, and clinical practice. •• Before you address an issue, encourage fellow participants to answer questions, share useful experiences, give advice, or solve the problem as a group. •• Record key points on FLIPCHART.

SAMPLE QUESTIONS MODULE CONTENT ✔✔ What were your experiences reading and doing exercises in Module 1? Module 2? ✔✔ What components of the modules did you find particularly useful (i.e. exercises, cases) ✔✔ Who wants to share a practice that they found beneficial or effective in their studying? CHECKING MODULE UNDERSTANDING ✔✔ What about Module 1 was challenging? Module 2? ✔✔ What questions can we discuss and explain as a group now? CLINICAL PRACTICE ✔✔ ✔✔ ✔✔ ✔✔ What were your experiences using IMCI in the clinic? How did you use your Chart Booklets and recording forms? What is challenging about integrating the material from Modules 1 and 2 in the clinic? Where are you facing problems?

CHALLENGING CASES ✔✔ What particularly challenging cases did we see? ✔✔ Who wants to review a case and their recording form so we can discuss your case? INVOLVING OTHERS IN STUDY ✔✔ ✔✔ ✔✔ ✔✔ ✔✔ ✔✔ What were your experiences working with study groups? What were you experiences in identifying an IMCI mentors? Who are these mentors? How have you reached out to them thus far? How will they be able to mentor you in your study? Who wants to share how they shared the IMCI course with their in-charge officer or colleagues?

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2.3 ADDRESSING PROBLEMS FROM LOGBOOKS Facilitators reviewing recording forms should address problem areas from logbook exercises or recording forms. Use FLIPCHART or slides as you find useful for visual explanations.

TRANSITION: summarize the discussion, including problem areas identified and solutions reached as a group. Emphasize good practices, particularly those shared from self-study.

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SECTION 3. ASSESS & CLASSIFY THE SICK CHILD (PART 1) TIME – 45 minutes FACILITATOR SUMMARY You will be introducing the first two main symptoms in the sick child – cough or difficult breathing, and diarrhoea. This will be a brief introduction so that these symptoms can be included in the clinical practice session. Participants will learn more in Modules 3 and 4. There are IMCI DVD clips for assessing and classifying both cough or difficult breathing and diarrhoea. You can choose to only show one of these if time does not permit. Participants can watch the other video during self-study. SECTION OBJECTIVES •• Briefly review IMCI for the sick child – emphasize what steps have been covered ( greet, general danger signs) and what is forthcoming in the modules. •• Introduce assessing and classifying cough or difficult breathing and diarrhoea with video demonstrations and brief content discussions. MATERIALS ■■ IMCI DVD (disc 1) ■■ PowerPoint slides

3.1 REFRESH: IMCI FOR THE SICK CHILD SLIDE Briefly review IMCI for the sick child, and that today they will begin to look at main symptoms. IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  ini/al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breas^eed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS           Even  if  present  

  Cough  or  difficult  breathing          Diarrhoea     Fever                              Ear  problems     Malnutri/on  &  anaemia                        HIV  status     Check  immuniza/ons                            Others  

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

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REVIEW: sample questions about the IMCI process 1. What important information do we want to obtain when greeting the caretaker? 2. Without looking – what are the general danger signs? 3. What actions do we take with a red classification? 4. Walk us through the important steps of the IMCI process: participant should walk group through assessing and classifying main symptoms and other conditions, identifying treatment, treating in clinic or advising on home treatment, counselling caretaker, and providing follow-up care)

TRANSITION: In this section, we will look at the first two main symptoms – cough and difficult breathing, and diarrhoea. You certainly see these symptoms frequently in your clinics.

3.2 SIGNS FOR ASSESSING COUGH OR DIFFICULT BREATHING Present questions to participants and follow-up to explain content as necessary. This discussion should familiarize participants with signs before they see them in the video. INTRODUCE: Let us now look at assessing and classifying our first main symptom: cough or difficult breathing. You will learn more in Module 3. Open Chart Booklets to chart on cough or difficult breathing. è PRACTICE: Open Chart Booklets to ASSESS chart for cough or difficult breathing. Review instructions for assessing. Ask questions of participants so that they need to review their Chart Booklet. ✔✔ What do we ASK when assessing for cough or difficult breathing? Does your child have cough or difficult breathing? For how long? ✔✔ What signs do we LOOK and LISTEN for? Fast breathing, chest indrawing, and wheeze ✔✔ What is fast breathing in a child? 2–12 months over 40/minute, 12 months– 5 years 50/minute è PRACTICE: what are the signs we look for? ✔✔ Fast breathing and chest indrawing are two signs of pneumonia. ✔✔ What is fast breathing? The child is breathing faster than she normal should. Describe where to look when you count for fast breathing. ✔✔ What is chest indrawing in a child? Briefly describe chest indrawing. ✔✔ What is stridor and wheezing? Briefly describe both symptoms and provide examples from your clinical experience (i.e. to emphasize how harsh stridor sounds).

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PLAY VIDEO “Demonstration: cough and difficult breathing” Disc 1, 12:00 minutes Instructions for participants: follow along with Chart Booklet and recording form Facilitation: lower lights as needed. Stop video at stages of the assessment to demonstrate how it is following the Chart Booklet and recording form NOTE: there is also a video demonstration for diarrhoea. You can choose to only show one of these videos if time does not permit. Participants can watch the other video during self-study.

CLARIFY: any questions about cough or difficult breathing?

3.3 SIGNS FOR ASSESSING DIARRHOEA INTRODUCTION: Let’s continue to the next main symptom, diarrhoea. You will learn more about assessing and classifying diarrhoea in Module 4. We will introduce it today so that we can look for diarrhoea in the clinic this afternoon. è PRACTICE: Open Chart Booklets to ASSESS chart for diarrhoea. Review instructions for assessing. Ask questions of participants so that they need to review their Chart Booklet. ✔✔ What do we ASK when assessing for diarrhoea? Does your child have diarrhoea? For how long? Is there blood in the stool? ✔✔ What signs do we LOOK for? Look for lethargy, unconsciousness, or if the child is restless or irritable; look for sunken eyes; look to see how the child drinks fluid ✔✔ What sign do we FEEL for? Skin pinch of abdomen CLARIFY: what questions do we have about the signs of dehydration or diarrhoea? Let’s briefly review any questions we have about these signs so that we know what to look for when we practice this afternoon. ✔✔ Why do we do a skin pinch? To test dehydration; briefly explain how to do a skin pinch ✔✔ Do you have any questions about the conditions we look for – lethargy, unconsciousness, restlessness, irritability? About how the child drinks? ✔✔ How would you describe blood in the stool if the caretaker is unsure? PLAY VIDEO “Demonstration: assess and classify diarrhoea” Disc 1, 9:30 minutes Instructions for participants: follow along with Chart Booklet and recording form Facilitation: lower lights as needed. Stop video at stages of the assessment to demonstrate how it is following the Chart Booklet and recording form

CLARIFY: any questions about diarrhoea?

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3.4 TRANSITION TO NEXT SECTION This section introduced us to the first two main symptoms we assess and classify in IMCI. We will move to clinical setting to practice what we have learned thus far about using IMCI. ✔✔ REMINDER TO BRING chart booklets and IMCI recording forms ✔✔ REVIEW AGENDA •• •• •• •• •• Transportation and transitions, need to keep time Describe where you will be seeing patients (i.e. outpatient, inpatient) Briefly describe how you will be seeing patients Outline any expectations for participants Group will meet to return for lunch

TRANSITION: break for tea, and then move to clinical practice.

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SECTION 4. CLINICAL PRACTICE TIME – 90 minutes in clinic FACILITATOR SUMMARY This section is a critical opportunity to demonstrate IMCI with the sick child. Please refer to the ANNEX for more guidance on the clinical practice sessions. In today’s session it is important for facilitators to choose a sick young infant and or a sick child and demonstrate how to assess and classify (general danger signs, cough or difficult breathing, or diarrhoea). After demonstrations, depending on time and number of patients, you may choose to: 1. To continue demonstrating key skills with other children, but asking participants for their inputs and questions during, or 2. To assign participants individually or in groups, and then observe and mentor. SESSION OBJECTIVES The objectives of today should be that participants: •• See demonstrations of a sick young infant assessment, if available •• See demonstrations of a sick child assessment, especially assessing, classifying, treating, and counselling in cases of cough or difficult breathing or diarrhoea •• Practice greeting a caretaker and getting information about a child •• Check children for general danger signs •• Assess, classify, treat, and counsel cases of cough or difficult breathing or diarrhoea •• Assess, classify, treat, and counsel in cases of sick young infants •• Use the Chart Booklet and recording form with a caretaker •• Receive one piece of feedback from facilitators about an interaction with a child or infant, including their use of the Chart Booklet during assessment, making the appropriate classification, recommending the necessary treatment, and counselling the mother on appropriate topics. Every participant should receive feedback from the session. •• Demonstrate good skills in using the IMCI charts and recording forms MATERIALS ■■ Participants should bring Chart Booklets and recording forms (logbook or copies provided) ■■ Any other materials required for clinical setting

TRANSITION: Summarize session as required. Explain transportation and lunch plans. Break for lunch if 45 minutes. During lunch, facilitators should regroup (as required) and also spend time with participants to discuss their self-study and clinical practice.

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SECTION 5. ASSESS & CLASSIFY THE SICK CHILD (PART 2) TIME – 90 minutes, including a break for tea FACILITATOR SUMMARY In this section you will introduce content from forthcoming modules on fever, malnutrition and anaemia, and all other optional modules being included (e.g. ear problems, HIV, well child care). While this introduction is brief, it is important that you reinforce how these symptoms and conditions fit into integrated management of the sick child. This is an important opportunity to review the IMCI process again with each symptom. You should fill in the content with your own observations, or by asking questions. You should also answer all questions the participants have. Each section should try to accomplish the following: •• INTRODUCE the symptom or problem: why should you care about this health issue? Why is it included in IMCI? •• Review the ASSESS instructions •• Review what signs are used to CLASSIFY •• Examine the TREAT THE CHILD and COUNSEL THE MOTHER charts as you require. Share your own clinical experiences. SECTION OBJECTIVES •• •• •• •• •• Introduce how to assess, classify, and treat fever Introduce how to check malnutrition and anaemia Introduce how to assess, classify, and treat ear problems (optional) Introduce HIV (optional) Introduce well child care (optional)

MATERIALS ■■ IMCI DVD (disc 1 and 2)

5.1 ASSESSING FEVER INTRODUCTION: Fever is another common symptom we see in our clinics. CLARIFY: what questions do we have about the signs of dehydration or diarrhoea? ✔✔ What can cause a fever in children? Primary causes are malaria, measles, and other infections ✔✔ How do we determine if a child has a fever? History, feels hot, temperature 37.5 degrees Celsius or above ✔✔ We decide if the area is high or low risk for malaria. If more than 5% of fever cases in child are due to malaria, the area is high risk. If less than 5% of cases are due to malaria, the area is low risk. ✔✔ Are we considered a high or low risk area for malaria?

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è PRACTICE: what signs do we assess for fever? Review ASSESS chart in chart booklets with participants. ✔✔ What questions do we ASK? Does the child have a fever? For how long? If for longer than 7 days, has fever been present every day? Has the child had measles within the past 3 months? ✔✔ What do we LOOK and FEEL for? Stiff neck, runny noses, signs of measles (generalized rash and either cough, runny nose, or red eyes) ✔✔ If the child had measles within the last 3 months or has measles now, let’s look at the measles chart. What do we LOOK for? Deep and extensive mouth ulcers, pus draining from eye, clouding of cornea PLAY VIDEO “Assess and classify fever” Disc 1, 9:30 minutes Instructions for participants: follow along with Chart Booklet and recording form Facilitation: lower lights as needed. NOTE: this video is optional. The signs are also not updated in this video.

5.2 CHECKING FOR MALNUTRITION & ANAEMIA INTRODUCTION: We learned in the first face-to-face meeting that undernutrition is an underlying cause of death in up to 50% of all child deaths. You should assess every child for malnutrition and anaemia. There are important signs of undernutrition that we or the caretaker might not notice. Even children with mild and moderate malnutrition have an increased risk of illness and death. CLARIFY: Why are children malnourished? Malnutrition may be due to several reasons, including inadequate dietary intake, inefficient utilization or nutrients, and infections. Poor nutrition affects a child’s growth and development CLARIFY: What signs do we assess for malnutrition? Review chart in chart booklets. ✔✔ What do we LOOK for? Oedema of both feet – both to be described in video. We also measure WFH/L and a child’s MUAC. ✔✔ We also need to determine weight for height. You learned this in the sick young infant module, but there are separate charts for children. Find your weight-for-height charts in the Annex. There is a chart for boys, and one for girls. DEMONSTRATE: SLIDES the nutrition assessment involves measuring several important pieces of information about the child. These can be complicated and are not often done correctly. I will demonstrate how to measure them now. We will also review how to analyse the results. 1. Measuring weight: appropriate scale, where to place, if child can stand, if small child who cannot stand

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2. Measuring height SLIDE 3. Measuring length SLIDE

For  children  under  2  years  or  weak

Measuring  length  

 

For  children  2  years  and  older

Measuring  height    

Distance-­‐learning  IMCI  

4. Plotting weight-for-height/length and determining Z-score SLIDE

Determining  Z  scores  

You  need:  weight  (kg),  height  or  length  (cm)   7iˆ}…̇vœÀ‡…iˆ}…ÌÊ "9ÓÊ̜ÊxÊÞi>ÀÃÊ­â‡ÃVœÀiî 7iˆ}…̇vœÀ‡iˆ}…ÌÊ, 

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Distance-­‐learning  IMCI  

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7"Ê …ˆ`ÊÀœÜ̅Ê-Ì>˜`>À`à 7"Ê …ˆ`ÊÀœÜ̅Ê-Ì>˜`>À`Ã

5. Measuring MUAC: show with MUAC strip è PRACTICE: let’s practice measuring ✔✔ Who can explain to the group how to find weight-for-height? ✔✔ Who can explain to the group how to measure MUAC?

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è PRACTICE: let’s practice charting weight-for-height. What are the following Z scores? Use charts, slide, and FLIPCHART to record answers •• •• •• •• Girl, 105 cm, 13.5 kg – below -2 SD Girl, 80 cm, 10 kg – between 0 and -1 SD Boy, 118 cm, 16 kg – below -3 SD Boy, 100 cm, 13 kg – below -2 SD

CLARIFY: What is anaemia? Anaemia is a condition in which the number of red blood cells in inadequate to meet physiological needs. Children can develop anaemia as a result of infections, malaria, or parasites that can cause blood loss from the gut, like hookworm. Anaemia can also be due to deficiencies in iron, Vitamin B12, folate, and Vitamin A deficiencies. Iron deficiency anaemia is among the most common. CLARIFY: what do we LOOK for when assessing for anaemia? Palmor pallor – to be discussed in video PLAY VIDEO “Assess for malnutrition, anaemia, and ear problems” Disc 2, 8:30 minutes Instructions for participants: follow along with Chart Booklet and recording form Facilitation: lower lights as needed. Ask for questions or clarifications after video. NOTE: This video is optional.

5.3 EAR PROBLEMS (OPTIONAL) CLARIFY: what signs do we assess for ear problems? Review ASSESS chart in chart booklets. ✔✔ What questions do we ASK? Does the child have drainage from ears? For how long? Is there ear pain? ✔✔ What do we LOOK and FEEL for? Tender swelling behind ear, discharge/pus from ear CLARIFY: ✔✔ Why do we care about ear problems, aren’t they too common to worry about? Can cause deafness, ear damage, and possible serious infection ✔✔ What is mastoiditis? An infection of the mastoid bone behind the ear, explain this.

5.4 INTRODUCTION TO HIV (OPTIONAL) The scope of this introduction depends on national level policies and priorities (See example Box 1). CLARIFY: how does IMCI help health workers provide better care for HIV? SLIDE •• There is a global effort to eliminate new paediatric HIV infections and keep mothers alive. •• There is a global effort to reach universal access to HIV prevention, care, treatment.

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Why  is  IMCI  an  approach  to  improve   paediatric  access  to  treatment  and  care?   BIG  ISSUES:     Coverage  of  child  tes/ng  is  low     Coverage  of  early  infant   diagnosis  is  low     Interna/onal  ART  coverage  is   low:  only  28%  of  children  who   should  be  receiving  ART  are     HIV  requires  quick  management,   especially  for  opportunis/c   infec/ons  and  nutri/on     Children  can  be  lost  in  follow-­‐up   Distance-­‐learning  IMCI  

IMCI  HELPS  HEALTH   WORKERS  TO:   IdenCfy  HIV-­‐exposed  and  infected   children  because  you  will  assess   every  child  you  see   Determine  when  children  should   be  iniCated  on  ART  at  primary  care   level   Provides  guidance  on  management   of  common  issues  for  HIV  infected   children   Provide  close  follow-­‐up  at  primary   care  level  

•• In many countries, HIV contributes to a very significant level of childhood mortality. •• HIV also underlies the other major causes of morbidity and mortality in many countries, including malnutrition, pneumonia, and diarrhoea. •• It is important to confirm HIV status and initiate ART early in children. •• Early infant diagnosis coverage is poor international, as is ART coverage in children. •• Follow-up and monitoring of those on treatment is important to ensure quality of life.

BOX 1: SLIDE EXAMPLE FROM SOUTH AFRICA

Why  include  HIV  in  IMCI?   1.  HIV  causes  30%  of  child  deaths  in  South  Africa   2.  IMCI  addresses  the  major  problems  seen  in         children   3.  Primary  level  faciliDes  see  high  HIV                                                     prevalence  and  paDent  loads   4.  HIV  requires  quick  management:  early  idenDficaDon   and  treaDng  opportunisDc  infecDons   5.  South  African  nurses  can  now  iniDate  ART   6.  HIV  requires  close  follow-­‐up  at  primary  level  

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CLARIFY: what if I already see adults who have HIV – what makes HIV/AIDS care for children different? SLIDE

What  is  special  about  HIV/AIDS   care  in  children?   1. 

HIV  can  progress  very  quickly  in  children          

Early  iden/fica/on  is  cri/cal   Preventa/ve  prophylaxis  to  minimize  infec/on   Rapid  management  of  opportunis/c  infec/ons   Ini/a/ng  ART  when  required  

2.  3.  4. 

HIV  tesCng  methods  are  different  than  adults   ART  formulaCons  are  different  than  adults   Child  need  special  care  to  make  sure  they  are   growing  and  developing  opCmally  

5.4.1

PEDIATRIC HIV TESTING

CLARIFY: what are the types of tests? SLIDE ✔✔ HIV infection in children less than 18 months of age is confirmed through virological tests which detect the actual virus. ✔✔ In children older than 18 months of age, serological tests are used. Serological tests detect antibodies to HIV. This is why they cannot be used to confirm HIV infection in children less that 18 months of age, as the children may have maternal antibodies in their system. A positive serological test in a child less than 18 months of age only confirms that the child is HIV exposed.

Types  of  HIV  tes/ng       SEROLOGICAL   TESTS   including  rapid   tests         VIROLOGICAL   TESTS   including  DNA   or  RNA  PCR        

    PRESENCE  OF  HIV   ANTIBODIES          

What  does  test  detect?  

      HIV  an/bodies  pass  from  mother  to  child     An/bodies  can  stay  with  child  up  to  18   months  of  age    

How  can  you  interpret  the  test?  

 

PRESENCE  OF  HIV   VIRUS        

POSITIVE  TEST  IN  CHILD  UNDER  18   MONTHS  IS  NOT  RELIABLE  TO  CONFIRM   INFECTION       Directly  tests  presence  of  virus     Must  be  conducted  aler  child  has   stopped  breas^eeding  for  at  least  6   weeks    

POSITIVE  TEST  ANY  ANY  AGE  CAN   CONFIRM  INFECTION  

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CLARIFY: why do you have to consider infant feeding when testing? SLIDE Discuss considerations for breastfeeding and HIV testing accuracy

HIV  tes/ng  and  breas^eeding   Is  child   breasTeeding?   NOT  BREASTFEEDING,  and   has  not  in  last  6  weeks  

POSITIVE  (+)  test   NEGATIVE  (-­‐)  test   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months.   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months  or   once  breas^eeding  has  been   discon/nued  for  more  than  6   weeks.   HIV  NEGATIVE   Child  is  not  HIV  infected      

BREASTFEEDING  

Child  can  sCll  be  infected  by   breasjeeding.  Repeat  test   once  breas^eeding  has  been   discon/nued  for  more  than  6   weeks.  

Distance-­‐learning  IMCI  

5.4.2 EARLY INFANT DIAGNOSIS CLARIFY: What is EID? Establishing the presence of HIV infection in HIV-exposed infants and children less than 18 months of age. CLARIFY: What is our national EID algorithm? SLIDE Below is algorithm adapted from Antiretroviral therapy for HIV infection in infants and children: towards universal access. Recommendations for a public health approach. 2010 revision. Geneva, World Health Organization.

Early   infant   diagnosis  

HIV-­‐exposed  Infant  or  child  <18  months   Conduct  diagnosCc  viral  testa   Viral  test  available   PosiIve   NegaIve   Viral  test  not  available  

Infant/child  is  likely   infected     <24  months:  immediately   start  ARTb   And  repeat  viral  test   to  confirm  infecCon  

Never  breasjed  

Ever  breasjed  or  currently   breasjeeding   Infant  /child  remains  at  risk   for  acquiring  HIV  infecCon   unCl  complete  cessaCon  of   breasjeedingc   Regular  and  periodic   clinical  monitoring  

   

Infant/child  is   uninfected  

Infant/child  develops  signs  or  symptoms   suggesCve  of  HIV  

Infant  remains  well  and  reaches  9  months  of   age  

Viral  test  not  available  

Conduct  HIV  anCbody  test  at     approximately  9  months  of  age  

Viral  test  available       NegaIve   PosiIve  

PosiIve  

NegaIve  

Viral  test  not  available   assume  infected  if  sick   assume  uninfected  if  well   sick well

Infant/child  is  infected  

Start  ARTb   And  repeat  viral  test  to  confirm   infecCon    

HIV  unlikely  unless  sCll   breasjeedingc  

Distance-­‐learning  IMCI  

Repeat  anCbody  test  at  18  months  of  age   and/or  6  weeks  amer  cessaCon  of   breasjeeding    

a

b c

For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant diagnosis. Start ART, if indicated, without delay. At the same time, retest to confirm infection. The risk of HIV transmission remains as long as breastfeeding continues.

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5.4.3 PROPHYLAXIS MEASURES AND INITIATING TREATMENT CLARIFY: What are prophylaxis measures for HIV-exposed and infected children? ✔✔ Care for the HIV exposed and infected includes several types of prophylaxis and other preventive measures seek to keep the child’s immune system strong. ✔✔ Prophylactic ARVs, given to the exposed babies from birth, can help in preventing HIV infection in infants. SLIDE

When  will  HIV-­‐exposed  infants  receive   ART  prophylaxis?   !"#$%&'##()*+, !"#$$%&"'(")*(+*,"-.'-/01+2)&" #),/"'*3$45+)10"678" "

"#-.$/#0#*&,'##()*+, 9:!"#$$%&"'(")*(+*," -.'-/01+2)&"#),/"'*3$45+)10" 678";'.",#)3$45+)10"<=>?"

NOTE:  this  is  the  recommenda/on  for  both  Op;on  B   and  Op;on  B+  PMTCT  na/onal  policies   Distance-­‐learning  IMCI  

✔✔ Cotrimoxazole provided to children with suspected or confirmed HIV infection will decrease sickness and death due to PCP and other common bacterial infections. SLIDE

When  will  infants  and  children  begin   cotrimoxazole  prophylaxis?   THESE  YOUNG  INFANTS…   SHOULD  START…   CONFIRMED  HIV  INFECTION   From  4-­‐6  weeks   HIV  EXPOSED   From  4-­‐6  weeks   THESE  CHILDREN…   SHOULD  START…   CONFIRMED  HIV  INFECTION     As  soon  as  possible   Less  than  12  months  old   1.  When  at  WHO  clinical   CONFIRMED  HIV  INFECTION     stages  2-­‐3-­‐4,  regardless  of   12  months  up  to  5  years   CD4%   2.  When  CD4%  less  than  25%   HIV  EXPOSED   As  soon  as  possible   WHY?   Infant  is  HIV  infected   Infant  is  born  to  HIV   infected  mother   WHY?   Child  is  HIV  infected   This  is  regardless  of   whether  the  child  is   on  ART  or  not.       Child  is  exposed  to   HIV  

Distance  learning  IMCI  

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✔✔ IPT is an important intervention for preventing and reducing active TB in children living with HIV. ✔✔ Young infants and children exposed and infected with HIV should follow the same immunization and vitamin A supplementation schedule. CLARIFY: What is antiretroviral therapy? ✔✔ Antiretroviral drugs interfere with the life cycle of HIV, thus preventing it from replicating. ✔✔ ART does not cure HIV but prevents immune system damage and improves the quality of life and life expectancy of the patient. ✔✔ The use of a combination of 3 ARVs, with strict adherence, helps to reduce the risk of drug resistance. ✔✔ Refer to current guidelines for the preferred first line regimen CLARIFY: Who is eligible to initiate ART? SLIDE ✔✔ All children confirmed HIV infected

Using  IMCI  to  ini/ate  pediatric  ART        Who  is  eligible  to  ini/ate  ART?  

 

 All  children  who  are  classified  CONFIRMED    HIV  INFECTION      What  is  the  preferred  first  line  ART  regimen?  

Distance-­‐learning  IMCI  

 For  children  under  3  years:      ABC  or  AZT  +  3TC  +  LPV/r        For  children  3  years  and  older  (but  under  35  kg):      ABC  +  3TC  +  EFV      

 

CLARIFY: What are the key steps to initiating ART? The following steps should be taken towards initiating ART in a child with confirmed HIV infection: ✔✔ Confirm HIV infection ✔✔ Ensure the caregiver is able to give ART ✔✔ Decide if ART can be initiated at this level of care ✔✔ Record the baseline information on the child’s HIV treatment card ✔✔ Start ART and cotrimoxazole prophylaxis 5.4.4 ART DOSING EXERCISE SLIDE

In this section the facilitator will lead a group discussion and individual exercise where participants should: (a) identify each ARV drug in the recommended first line therapy, and (b) prepare dosing.

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Details of dosages (e.g. child weight, single dosages versus daily dosage) can be determined by the quantity of drugs available. This helps health workers better identify drugs, and also receive mentorship on preparing dosages and methods for doing so (e.g. if pills need to be broken, etc). Facilitators can also roleplay good counseling skills with a caretaker and teaching how to give ART: (1) give information, (2) demonstrate, (3) let caretaker practice and provide feedback.

INSTRUCTIONS  FOR  EXERCISE   ANTIRETROVIRAL  TREATMENT     Find  the  ART  dosing  tables  in  your  chart  booklet     Using  the  drugs  provided,  prepare  the  dose  for   each  drug  in  the  combina/on  therapy     Call  facilitator  to  check  your  drugs  when  you  are   done  

Distance  learning  IMCI  

5.4.5 REINFORCE KEY PRINCIPLES OF ART ✔✔ The need for prophylaxis and integrated management ✔✔ Why give ART? What are the benefits, what does it do? ✔✔ 5 steps for initiation ✔✔ First line drugs ✔✔ Paediatric dosing ✔✔ Adherence is critical to ART effectiveness CLARIFY: Any questions about ART?

5.5 INTRODUCTION TO WELL CHILD CARE (OPTIONAL) INTRODUCTION: IMCI up to this point has dealt with children who are sick. In this module, you will learn to care for the well child who visits your clinic. This is an extremely important area of care that many health workers are not trained in, but has significant impacts on a child’s health and development. CLARIFY: Why is well child care important? This is an extremely important area of care that many health workers are not trained in, but has significant impacts on a child’s health and development.

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CLARIFY: What issues are covered in well child care? SLIDE First you will learn about the concepts of childhood development and growth. Second you will learn about important prevention measures for children, including prevention of accidents in the home and community, and immunizations.

What  is  well  child  care?      Child  development      Child  growth      Preven/on  of  childhood  accidents  

(poison,  road  accident,  drowning,  fall,   burns)  

   Immuniza/ons        Regular  Vitamin  A  and  deworming      Feeding  recommenda/ons  by  age   Distance-­‐learning  IMCI  

CLARIFY: What is child growth and development? SLIDE Define scope of growth and development, and how each are measured and monitored in the clinical setting.

What  is  child  growth?  

Physical  development,  changes  in  body   and  strength   Measured  and  monitored:   •  Regular  growth  monitoring  by  weight  and  height/length  

What  is  child  development?   Measured  and  monitored:   •  Development  milestones   •  Play  and  communica/on  

?  

Development  of  mental,  crea/ve,  social,   and  adap/ve  skills  

Distance-­‐learning  IMCI  

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CLARIFY: What are important areas of child development? SLIDE Emphasize how health workers can monitor and intervene in improving how children and caregivers interact, bond, communication, and play.

+   Important  concepts  in  child   development      

   

 

Bonding  between  a  mother  and  child   InteracCons  between  a  child  and  caregivers   (where  caregivers  are  aware  and  sensi;ve  to   child,  and  respond  to  needs)   CommunicaCon  between  caregiver  and  child   Crea/ng  ways  for  the  child  to  play  and  develop   skills  (especially  with  homemade  or   inexpensive  items)   Observing  child’s  development  and  milestones  

Distance-­‐learning  IMCI  

CLARIFY: What job aids are available to help you with well child care? SLIDE Briefly review the descriptions of play and communication available in the care for child development charts. This is explained in depth in the module.

Distance-­‐learning  IMCI  

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CLARIFY: how would you use this job aid in your clinic? Give me an example. Participants will not be familiar with this yet, but stimulates thinking about application. DISCUSSION: Who has had experience in their clinic with issues of child development? Can you share you experiences? You can also provide personal experiences into using these materials with families. Important for participants to visualize this material’s application in the clinic. CLARIFY: Any questions or concerns? Summarize key discussion points.

TRANSITION: break for tea, 15 minutes

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SECTION 6. INTEGRATING TREATMENT, COUNSELLING THE CARETAKER, AND FOLLOW-UP TIME – 30 minutes FACILITATOR SUMMARY The day’s content has focused on assessing and classifying. This section should reinforce treatment for integrated case management, counselling the caretaker, and providing followup care. This discussion should ensure that participants are confident to utilize the IMCI algorithm in its entirety during their clinical practice in home facilities. SECTION OBJECTIVES •• Reinforce instructions in the TREAT THE CHILD charts •• Review key counselling skills, particularly the 3 steps when teaching a caretaker, and using checking questions to ensure that they understand •• Review how to manage a child during follow-up care MATERIALS ■■ PowerPoint slides ■■ Flipchart ■■ Prepared tray with medicines ■■ Worksheet on dosages (ANNEX)

6.1 INTEGRATED TREATMENT SLIDE INTRODUCTION: In our sessions and clinical practice today we have focused on assessing and classifying. Now we will review how to IMCI to TREAT, COUNSEL, and provide FOLLOW-UP.

IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  iniCal  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breasjeed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS       Even  if  present  

   

  Cough  or  difficult  breathing            Diarrhoea     Fever                              Ear  problems     MalnutriCon  &  anaemia                        HIV  status     Check  immunizaCons                            Others    

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

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è PRACTICE: let us consider a case study. We have a child named Sam who does not have any general danger signs. He is classified as PNEUMONIA and ACUTE EAR INFECTION. Record notes on FLIPCHART. ✔✔ What treatments are identified for each classification? Note that both classifications require antibiotics. This will be discussed more in a few minutes. ✔✔ According to the classifications, where will he be treated? ✔✔ How would we proceed with treatment today? Explain what actions you would take. ✔✔ What are two things we would want to counsel Sam’s caretaker about? ✔✔ When should he return for follow-up care?

6.2 GIVING ANTIBIOTICS IN INTEGRATED CARE INTRODUCTION: Several classifications identify antibiotics for treatment. Let us look more closely at antibiotics. The TREAT THE CHILD chart indicates the schedule and dose for giving the antibiotic. Participants should follow along with TREAT THE CHILD charts. CLARIFY: What is the schedule? The schedule tells you how many days and how many times each day to give the antibiotic. Most antibiotics should be given for 5 days. CLARIFY: How do you determine an antibiotic dose with this chart? Look at the column that lists the concentration of tablets or syrup available in your clinic. Choose the row for the child’s weight or age. The weight is better than the age when choosing the correct dose. The correct dose is listed at the intersection of the column and row. CLARIFY: what do we do when children have more than one illness that requires antibiotic treatment? ✔✔ When possible, select one antibiotic that can treat all of the child’s illnesses. For example, let’s consider a child with DYSENTERY and ACUTE EAR INFECTION. Cotrimoxazole is a first-line antibiotic for an ACUTE EAR INFECTION and also a first- or second-line antibiotic for DYSENTERY. ✔✔ When treating a child with more than one illness requiring the same antibiotic, do not double the size of each dose or give the antibiotic for a longer period of time. ✔✔ However, sometimes more than one antibiotic must be given to treat the illness(es). For example, the antibiotics used to treat PNEUMONIA may not be effective against DYSENTERY in your country. In this situation, a child who needs treatment for DYSENTERY and PNEUMONIA must be treated with two antibiotics. CLARIFY: what treatments can be given in the home? Oral drugs, treating local infection. These treatments require good counselling skills with the caretakers.

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6.3 GIVING TREATMENTS IN THE CLINIC INTRODUCTION: Remember that some treatments are given in the clinic. These treatments are often required when a child has a severe classification and must be referred urgently. CLARIFY: what are treatments listed in bold? Urgent pre-referral treatments given at clinic. CLARIFY: what are examples of treatments given in the clinic? ✔✔ Intramuscular antibiotic if the child cannot take an oral antibiotic ✔✔ Diazepam to stop convulsions ✔✔ Quinine for severe malaria ✔✔ Breastmilk or sugar water to prevent low blood sugar CLARIFY: what are examples of treatments given in the clinic?

6.4 ACTIVITY: PRACTICE PREPARING DRUG DOSAGES INSTRUCTIONS FOR FACILITATORS Participants will be asked to show you the proper dosages of drugs using the worksheet in the ANNEX. You should have prepared the tray of medicines before the activity begins. INSTRUCTIONS TO PARTICIPANTS 1. In this activity you will take medicines from this tray and prepare dosages for certain children. 2. The worksheet has the child’s age and weight to calculate dosage. 3. You will use the drugs on this tray to prepare the dosage, and set it into the box of your worksheet. For intramuscular drugs dilute the powder with sterile water and draw up the correct amount in the appropriate syringe. 4. You will have 10 minutes for the activity. 5. Ask one of the facilitators when you are ready to have your dosages checked. CLARIFY: Do we see any drugs that are similar? What can we do to make sure this is not confusing to us, or to caretakers? Take note of any tablets that look similar and could cause confusion when one or more drugs are dispensed. ALLOW 10 MINUTES FOR ACTIVITY

6.5 COUNSELLING THE CARETAKER This should serve as a quick revisit of good counselling and communication skills from the Orientation meeting. INTRODUCTION: Now that you have practiced integrated treatment, let us quickly review good counselling and communication skills with the caretaker. We discussed this in the last meeting. You also have information about this in your self-study modules. è PRACTICE: What are some examples of what we counsel a caretaker for? Home treatment, feeding practices, keeping an infant warm, making ORS, etc.

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è PRACTICE: When we advise a caretaker, sometimes we have to teach them how to do a task. What are the 3 basic teaching steps? Record steps as a flow chart on FLIPCHART. ✔✔ What are some important things to keep in mind when giving information? Use words caretaker understands, do not overwhelm with too much information, affirm ✔✔ What are some important things to keep in mind when showing an example? Use visual aids that are common in the household ✔✔ What are some important things to keep in mind when he/she practices? Affirm during practice, give feedback, give more practice if required è PRACTICE: What should we do when checking that a caretaker understood us? Use checking questions ✔✔ Give me 5 examples of good checking questions. Write key words (why, how, when, where) on FLIPCHART to emphasize asking open-ended questions. CLARIFY: what happens when you have to give the caretaker a lot of information? SLIDE

+   Giving  the  most  important  advice    

Determine:   1.  2.  3. 

How  much  can  this  caretaker  understand  &  remember?   Is  she  likely  to  come  back  for  follow-­‐up  treatment?    If   so,  some  advice  can  wait.   What  advice  is  most  important  to  get  the  child  well?  

 

Select  instrucCons  essenCal  to  child’s  survival  if   caretaker  confused  or  can’t  remember      

EssenCal:  an/bio/cs,  an/malarial,  fluids  with  diarrhoea   Can  delete  or  delay:  feeding  assessment,  feeding   counselling,  soothing  remedies,  iron  treatment,  etc.  

Distance-­‐learning  IMCI  

6.6 PROVIDING FOLLOW-UP CARE SLIDE INTRODUCTION: One important thing we counsel the caretaker about is when to bring the child back to the clinic for follow-up, or when to return to the clinic immediately. Open to the charts on follow-up care in the TREAT THE CHILD section. CLARIFY: What are the steps when in follow-up care? What do we want to accomplish?

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Providing  FOLLOW-­‐UP  care    

Follow-­‐up  on  condiCon.    Is  it:            Improving?    Worsening?        The  same?  

   

Re-­‐assess  child  for  any  new  symptoms  or   condiCons   Use  new  recording  form:        FOLLOW  UP  VISIT  

Distance-­‐learning  IMCI  

è PRACTICE: return to Sam’s case that we discussed earlier. ✔✔ When did we recommend that Sam return for follow-up care? ✔✔ When he returns, how will we provide care? Let us walk through the steps in our charts.

6.7 TRANSITION TO NEXT SECTION We have completed reviewing IMCI for the sick child. We will now finish our day by reviewing what you will be doing in the upcoming self-study period, and when we will meet to conclude the course.

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SECTION 7. NEXT STEPS TIME – 30 minutes FACILITATOR SUMMARY This section will review the course calendar and expectations for the second self-study learning period. At the conclusion of this section, you will administer an evaluation of the day. OBJECTIVES •• Reinforce course structure and expectations for the upcoming self-study period – completion of remaining modules, practice in clinics and use of recording forms, identifying mentors and communicating with in-charge officers •• Administer meeting evaluation MATERIALS ■■ PowerPoint slides ■■ Evaluation handout

7.1 EXPECTATIONS FOR SELF-STUDY PERIOD 2 SLIDE Review what is expected during the following several weeks of self-study.

NEXT  STEPS:  self-­‐study  phase  2   •   Read  modules  and  do  wrieen  exercises   3   Cough  or  difficult  breathing  

 

4   Diarrhoea   5   Fever   6   Malnutri/on  and  anaemia    

Study  period  2  

    •   Prac/ce  in  clinic  using  recording  forms   •   Stay  in  contact  with  mentors  and  facilitators   •   Meet  with  study  group   Distance-­‐learning  IMCI  

CLARIFY: what is expected for the logbooks and recording forms? Practice content in clinics and use recording forms. Bring two recording forms per modules to the next meeting that demonstrate examples of integrated management for young infant and child. CLARIFY: what is expected for the logbooks and recording forms? What questions or concerns do you have about these tasks? Are there any issues to discuss?

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7.2 DEVELOPING STUDY PLANS FOR STUDY PERIOD 2 SLIDE Based on feedback from morning plenary, discuss how participants should pace their work. Facilitators may choose to recommend a study plan for each week to keep participants on track. If so, slide should be edited to reflect this.

SAMPLE  AGENDA:  self-­‐study  phase  2   SAMPLE  INDIVIDUAL  STUDY  PLAN   WEEK  

1!

2! 4! 3!

Module 3 (assess, classify, and treat) + 13 August! 1 form! Module 3 (remaining) + logbook + 1 form!

STUDY  PLAN  

GROUP  

20 August! 27 August!

5   ! 6! 7!

Module 5 (all) + logbook + 2 forms! Module 6 (all) + logbook + 2 forms! Module 7 (all) + logbook + 2 forms! Prepare for exam!

Module 4 (all) + logbook + 2 forms!

4 September! 11 September! 19 September! 24 September!

Distance-­‐learning  IMCI  

7.3 PREPARING FOR 3RD FACE-TO-FACE MEETING SLIDE Participants should take out their study module calendars to fill in dates or details as required.

NEXT  MEETING:  Final  synthesis     DATE     LOCATION  

   

   

   

   

     

   

  TO  BRING  COMPLETED  –    

  Logbook  exercises:  20  for  each  module     Recording  forms  from  clinic:  2  from  each  module  

  AT  THE  NEXT  MEETING  WE  WILL  -­‐       Prac/ce  IMCI  in  clinical  seOng     Review  content  from  main  symptoms  and  condi/ons     Complete  examina/on  of  your  IMCI  skills     Complete  the  course     Distance-­‐learning  IMCI  

CLARIFY: what questions do we have about our next steps or this meeting?

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7.4 EVALUATION Facilitators are recommended to ask participants for feedback on specific topics before giving a printed evaluation. Conversational evaluations can also provide useful information that is not included in a written evaluation. *DISTRIBUTE EVALUATION FORM* CLOSE MEETING: Affirm participants’ work in the course thus far. Provide time to complete the evaluation. As participants finish the evaluation, be available to answer any individual questions.

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Final synthesis 3RD FACE-TO-FACE MEETING CONTENTS .1 Meeting objectives 119 120 121 123 125 127 128 133 135 3.2 Proposed agenda Section 1 – Welcome & overview Section 2 – Reviewing self-study period 2 Section 3 – Reviewing the integrated case management process Section 4 – Clinical practice Section 5 – Skills stations assessment Section 6 – Multiple-choice examination Section 7 – Next steps & formal closing

PART 3

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3.1

MEETING OBJECTIVES

MEETING SUMMARY The third face-to-face meeting will bring together several months of working with these course participants. You will have been gauging participant progress and needs during the two previous face-to-face meetings, and during check-in contact with participants. It is important that this final meeting synthesize material and address any outstanding problem areas. This is particularly important when you facilitate clinical practice sessions in the afternoon. This meeting will also assess participants’ skills.

WHAT ARE THE OBJECTIVES OF THIS MEETING? By the end of this meeting, participants should be able to: •• Explain and demonstrate IMCI clinical process with sick children and young infants •• Demonstrate good use of IMCI charts and recording forms in clinical practice •• Design an action plan for continuing using IMCI and other continuing education using same process

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3.2 9:00–9:15

PROPOSED AGENDA CHECK-IN & FEEDBACK SECTION 1 WELCOME & OVERVIEW (15 minutes) Welcome participants, review course objectives and agenda. SECTION 2 REVIEWING SELF-STUDY PERIOD 2 (45 minutes) Plenary discussion about self-study experiences, and problem solving around difficult cases from clinical practice. PLANNING NOTES PLANNING NOTES

8:30–9:00

9:15–10:00

PLANNING NOTES

10:00–10:30

SECTION 3 REVIEWING INTEGRATED TREATMENT (30 minutes) Video or written case study review to review integrated process. Tea break (15 minutes) SECTION 4 CLINICAL PRACTICE (90 minutes) Clinical demonstrations and skills practice focusing on IMCI for the sick child and young infant.

PLANNING NOTES

10:30–10:45 11:00–12:30

PLANNING NOTES

12:30–13:30 13:30–14:45

Lunch (1 hour) SECTION 5 SKILLS STATIONS ASSESSMENT (75 minutes) Skills stations with photo exercises, video demonstrations, and case studies. Facilitators will mark as completed. PLANNING NOTES

14:45–15:00 15:00–15:45

Tea break (15 minutes) SECTION 6 MULTIPLE-CHOICE EXAMINATION (45 minutes) Multiple-choice exam. Facilitators will mark as completed. SECTION 7 NEXT STEPS & FORMAL CLOSING (45 minutes) Participants create and discuss their (optional) individual action plans, administer course evaluation. Facilitators award certificates of completion. PLANNING NOTES

15:45–16:30

PLANNING NOTES

16:30

CLOSE MEETING

PLANNING NOTES

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SECTION 1. WELCOME & OVERVIEW TIME – 15 minutes FACILITATOR SUMMARY You will facilitate re-introductions of the facilitators and course participants, and welcome the group to the final face-to-face meeting. You will review the course objectives and outline the day’s objectives and activities, particularly the assessments. SECTION OBJECTIVES •• Set a welcoming learning environment during facilitator and participant introductions •• Review course objectives •• Introduce meeting objectives and brief agenda for the day, especially the assessments MATERIALS ■■ PowerPoint slides ■■ Flipchart

1.1 WELCOME PARTICIPANTS Welcome participants to second face-to-face meeting. Present the meeting as an opportunity to assess progress in self-study, address any challenges the group is having, and practice together. 1. Re-introduce yourself and co-facilitators 2. Invite participants to re-introduce themselves (FLIPCHART ) •• Name •• One way this course has changed the way you are practicing in your clinic •• One challenge, or a question, from practicing IMCI in your clinic 3. SUMMARIZE participant comments about course benefits

1.2 REVIEW COURSE STRUCTURE Participants should follow along in books PART 2, section 2. 1. Review course objectives SLIDE ✔✔ How do you feel about where you’re at with these objectives? ✔✔ What areas are you feeling weak? 2. Review course structure SLIDE – briefly review what components of the course have been completed, and what is upcoming. CLARIFY: any questions from the group?

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1.3 TODAY’S OBJECTIVES & AGENDA SLIDE 1. REVIEW: objectives of the second face-to-face meeting

Final  Synthesis  objecFves   At  the  end  of  today,  you  should  be  able  to:       Explain  and  demonstrate  IMCI  clinical  process  with  sick  children  

and  young  infants   clinical  prac.ce  

  Demonstrate  good  use  of  IMCI  charts  and  recording  forms  in  

  Design  an  individual  ac.on  plan  for  using  IMCI  and  con.nuing  

 

to  improve  skills  

2. REVIEW: in brief the agenda for today. Emphasize that it is a busy day and will require discipline to stay on task. n MORNING we will review our experiences in the past few weeks with selfstudy. You will also meet individually with a facilitator to review your logbook and discuss your clinical practice. Your logbook exercises and recording forms will be assessed. n LATE MORNING we will practice IMCI in the clinic together – describe how group will move and/or transition to clinical setting n AFTERNOON you will be assessed on your IMCI skills. You will be assessed in skills stations and a written examination. n We will finish the day with a celebration as we award your certificates of completion. 3. REVIEW: administrative announcements, as required

Distance  learning  IMCI  

1.4 REINFORCE KEY PRINCIPLES ✔✔ Today is an opportunity to address any content or practice areas that you have found particularly challenging– so do not be afraid to ask questions. ✔✔ Today is our last opportunity together to review important points in integrated treatment and case management. Please share your clinic experiences. ✔✔ In the afternoon you will be assessed on your skills in IMCI through skills stations and a written examination. You will also be assessed based on your logbook exercises and the recording forms you brought from clinical cases.

1.5 TRANSITION TO NEXT SESSION We’ll begin by reviewing our self-study and practice like we did last meeting. This is an important time to address any issues or challenges.

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SECTION 2. REVIEWING SELF-STUDY PERIOD 2 TIME – 45 minutes FACILITATOR SUMMARY This section is a critical opportunity for facilitator to assess how well participants are understanding and using IMCI. During the plenary discussion, facilitators not leading should review and mark logbooks and recording forms. This session reflects the same plenary discussion in the Review & Practice meeting. For further information please consult this section. SECTION OBJECTIVES •• Provide an opportunity to reflect on distance learning experience and progress in IMCI •• Assess how well participants are integrating material into their clinical practice •• Address problem areas and challenging cases as a group •• As a facilitator, note where support is required post-course, or in future courses MATERIALS ■■ Logbook answer key (ANNEX) ■■ Flipchart

2.1 FACILITATORS REVIEW LOGBOOKS & RECORDING FORMS (at same time as 2.2) See Review & Practice meeting, Section 2; Facilitator Guide Section 0.8; or dIMCI excel tool.

2.2 PLENARY DISCUSSION – OUR REFLECTIONS ON SELF-STUDY (at same time as 2.1) If clear problem areas identified, show suitable videos or present information to explain content. IMCI algorithm SLIDES are available for reference if required.

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n  SAMPLE QUESTIONS MODULE CONTENT ✔✔ Who wants to share a practice that they found beneficial or effective in their studying?

CHECKING MODULE UNDERSTANDING ✔✔ What about Module 3 was challenging? 4? 5? 6? Others?

CLINICAL PRACTICE ✔✔ What were your experiences using IMCI in the clinic? ✔✔ Where are you facing problems?

CHALLENGING CASES ✔✔ Who wants to review a case and their recording form so we can discuss your case?

INVOLVING OTHERS IN STUDY ✔✔ What were your experiences working with study groups? ✔✔ How did you work with IMCI mentors?

2.3 SUMMARIZE PLENARY & TRANSITION Review problem areas identified and solutions reached as group, or areas still outstanding. Affirm efforts to use IMCI in clinical practice. Emphasize good practices discussed.

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SECTION 3. REVIEWING THE INTEGRATED CASE MANAGEMENT PROCESS TIME – 30 minutes FACILITATOR SUMMARY This section is an opportunity for additional before the clinical sessions and afternoon assessments. Participants should practice a complete integrated process either on a video case or a case scenario shown on slides, in preparation for the clinical practice session. If there are outstanding problem areas from Section 2, these can be discussed or reviewed with a case. SECTION OBJECTIVES •• Review the integrated treatment process (or synthesis) using video and written case studies •• Use the case studies and discussion, provide additional practice for any problem areas identified – review necessary videos or cases MATERIALS ■■ IMCI DVD (disc 1 and 2) ■■ PowerPoint slides ■■ Copies of IMCI recording forms for the sick child (1 for video case, 1 for written case)

3.1 IMCI PRACTICE: VIDEO CASE STUDY This video case study and the following case should focus on issues with content or IMCI process. Facilitators should push participants. PLAY VIDEO “Summary case study: Martha” Disc 2, 17:00 minutes Instructions for participants: follow along with Chart Booklet and recording form Facilitation: lower lights as needed. Stop video at before classification to discuss with group. After discussion, play classifications. NOTE: some of the video assessment if out of date.

CLARIFY: let us further discuss our Martha case. Record notes on FLIPCHART. ✔✔ How did you classify Martha? ✔✔ What treatments were identified? ✔✔ What are your recommendations for integrated treatment? ✔✔ How will you counsel the caretaker? ✔✔ What will you recommend for follow-up? ✔✔ When Martha returns for follow-up, what will you do?

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3.2 (OPTIONAL) IMCI PRACTICE: KALI CASE STUDY SLIDES This case study is additional practice for the group. If there is not time, it is optional. INTRODUCTION: This case is an example of integrated management. We will begin with a written case for you to read. Assess and classify this case. Allow participants time to read each slide in the case and answer. Discuss each question in case (answers below) and ask further questions. 1. PNEUMONIA, SOME DEHYDRATION  Seven  month  old  (7  kg)  Kali  was  brought  to  the  clinic  because   she  is  coughing  and  seems  very  sick.  Aeer  assessing  Kali,  the   health  worker  finds  that  she  has  no  general  danger  signs,  no   fever  and  no  ear  problem.    

Kali  case:  ASSESS  &  CLASSIFY    

 She  has  cough  with  fast  breathing,  but  no  chest  indrawing  and   no  stridor  or  wheeze.  She  has  never  had  a  chest  infec.on   before.        She  has  has  diarrhoea  for  5  days,  but  there  is  no  blood.    She   has  sunken  eyes  and  a  slow  skin  pinch.    She  has  no  pallor.        

QuesFon  1:  How  do  you  classify  Kali?    

Distance  learning  IMCI  

Kali  case:  TREAT   1.  What  is  the  appropriate     treatment   for  Kali?   2. 

1. Amoxicillin for PNEUMONIA, plan B for SOME DEHYDRATION 2. Refer to TREAT section with participants. 3. 1. Give information, 2. Demonstrate how to give, 3. Let her practice and give feedback 4. Discuss drug envelope with participants.

What  are  the  drug  dosages  and   schedules  required?     What  are  the  major  steps  for   teaching  Kali’s  mother  to  give   oral  an.bio.cs?   How  will  you  label  the  drug   envelope?  

3. 

4. 

Distance  learning  IMCI  

Kali  case:  COUNSEL     1.  What  are  3  checking  ques.ons  to  ask  Kali’s   2. 

1. Discuss the checking questions that participants have written down. 2. 2 days 3. Not able to feed, becomes sicker, develops a fever, blood in stool, drinking poorly

mother  to  make  sure  she  understands  how  to   give  the  oral  drugs?  

When  should  the  mother  bring  Kali  back  to   the  clinic  for  a  follow-­‐up  visit?     When  should  the  mother  bring  Kali  back   immediately?  

3. 

Distance  learning  IMCI  

Outline expectations for clinical practice session, break for tea (15 minutes)

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SECTION 4. CLINICAL PRACTICE TIME – 90 minutes in clinic FACILITATOR SUMMARY This section is a critical last opportunity to observe how participants are using IMCI in the clinical setting. In today’s session it is important for facilitators observe participants as they practice IMCI and conduct full assessments. Depending on caseload and availability, facilitators could observe a participant one-to-one, or assign participants into groups that all observe and mentor as participants take turn conducting assessments. Today’s practice sessions should demonstrate full comprehension of the IMCI process, and all symptoms covered. If practice highlights key gaps or issues, the facilitator should demonstrate good practices. Please refer to the ANNEX for more guidance on the clinical practice sessions. SESSION OBJECTIVES The objectives of today should be that participants: •• Conduct full IMCI assessments of sick young infants, if available, with full grasp of material and IMCI process •• Conduct full IMCI assessments of sick children and all main symptoms, with full grasp of material and IMCI process •• Demonstrate good skills in using the IMCI charts and recording forms •• Receive concrete feedback from facilitators or peers about use of IMCI in clinical assessments. Every participant should receive feedback from the session. MATERIALS ■■ Participants should bring Chart Booklets and recording forms (logbook or copies provided) ■■ Any other materials required for clinical setting

TRANSITION: Summarize session as required. Explain transportation and lunch plans. Break for lunch if 45 minutes. During lunch, facilitators should regroup (as required) and also spend time with participants to discuss their self-study and clinical practice.

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SECTION 5. SKILLS STATIONS ASSESSMENT TIME – 75 minutes SECTION OBJECTIVE Assess participant skills in IMCI to ensure that they have met the course’s learning objectives FACILITATOR SUMMARY This is the first part of a two-part assessment. There will be two to four skills stations, to be selected on time and also availability of power. This assessment is intended to demonstrate the range of skills required for integrated case management. The participant answer sheets and facilitator answer keys are located in the ANNEX. It is recommended that the punch-out method be used for quick marking. Two stations are written case studies, one is a video case study, and one has short photo exercises. There are two options for conducting the skills stations. 1. ROTATING: Participants can be divided into two to four groups (depending on number of stations) and rotate at a set time for each station (e.g. every 15 minutes). Requires: •• Areas of room(s) designated for each station. Stations will require one table and chairs. •• Stations with videos should ideally be in a separate space for noise considerations. •• Video and pictures at each station. Pictures can also be printed and laminated. 2. AS A GROUP: If space or logistics are difficult for rotating stations, run as an entire group. •• Powerpoint slides introduce each station type. Facilitators can display slides, photos, and the videos from the same projector screen and moderate time for each station. FACILITATION NOTES ✔✔ It is important to keep a silent environment, as participants are reviewing the same exercises and should not share or indicate answers. You must keep order and quiet. ✔✔ You are expected to facilitate the timing (e.g. movement between stations). ✔✔ You can answer clarifying questions as necessary. Be careful not to lead to answers. MATERIALS ■■ Materials for each station are in following pages, depending on which are selected for exam. ■■ Copies of skills station answer sheet (ANNEX) ■■ Facilitator skills station answer key for marking (ANNEX) ■■ Visible clock or stopwatch to display time remaining

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INSTRUCTIONS FOR FACILITATORS: 1. Introduce skills station flow and participant instructions as outlined in following pages. 2. Distribute skills station answer sheet and recording forms, as required. 3. At the completion of each station, collect sheets and begin marking with key (ANNEX). 4. Facilitators should also enter scores into dIMCI excel tool. 5. Announce time warnings as required. 6. When participants have completed stations, break for tea (15 MINUTES)

STATION 1 MATERIALS n n n TIMING

PHOTO EXERCISE Introductory SLIDE 8 SLIDES with photographs (have ready to show), or Printed photos from slides or IMCI photo booklets, NOTE: if using IMCI photo booklets, the skills station answer sheets must be revised for these photos

OVERVIEW Participants will view photos to identify clinical signs and assess breastfeeding.

There are 15 photographs on 8 slides. Show each slide for about 90 seconds. If using photo booklets allow 15 minutes for participants to complete exercise.

INSTRUCTIONS FOR PARTICIPANTS 1. Photos 1–10 will show clinical signs. Record your observations on the answer sheet. 2. Photos 10–15 will show breastfeeding photos. Record your observations on attachment. INSTRUCTIONS FOR FACILITATORS Ensure that all participants can see the photos well. It can be frustrating if the screen or print out is not big enough to see signs well.

Skills  sta.on  1    

PHOTO  EXERCISE     PHOTOS  1-­‐10  

  Shows  clinical  signs  

  On  your  answer  sheet,  record  the   sign  that  you  iden.fy  in  each  photo  

PHOTOS  10-­‐15     Shows  infants  breas\eeding     On  your  answer  sheet,  record  your   observa.ons  about  aoachment   Distance  learning  IMCI  

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STATION 2 OVERVIEW Participants will review three IMCI videos and identify clinical signs. MATERIALS n Introductory SLIDE n IMCI DVD disc 2 (Have “Review exercise: chest indrawing” ready to play) TIMING

VIDEO EXERCISE

The three videos in total take about 15 minutes.

INSTRUCTIONS FOR PARTICIPANTS 1. You will view three videos and decide if the children you see have a particular sign. 2. Record your answers on the answer sheet. INSTRUCTIONS FOR FACILITATORS Play the three videos listed below. Stop each video before the answers are given. Ensure that all participants can see the videos clearly. It can be frustrating if the screen is not big enough to see signs well. VIDEO CLIP (all disc 2) 1. Review exercise: chest indrawing 2. Sunken eyes exercise G 3. Skin pinch exercise G STOP VIDEO AT: 6:00 minutes 4:00 minutes 3:00 minutes

Skills  sta.on  2    

VIDEO  EXERCISE      You  will  watch  3  videos  about  3  

different  clinical  signs.     Does  each  child  in  the  video  have   the  sign?     Record  your  answers  on  the  answer   sheet:  YES  or  NO.    

Distance  learning  IMCI  

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STATION 3 (OPTIONAL)

CASE STUDY ZINET

OVERVIEW Participants will assess and classify a case study of a sick child, and answer a question about treatment. MATERIALS n Case study SLIDE, case study is also typed on answer sheet TIMING Allow 15 minutes to complete. Give a 3-minute warning. INSTRUCTIONS FOR PARTICIPANTS 1. Read case study (on slide or answer sheet) 2. Use your recording form and chart booklet to assess and classify. 3. Answer the two questions about the case on your answer sheet.

Skills  sta.on  3    

CASE  STUDY  ZINET   Read  the  case  and  answer  the  quesPons  on  your  answer  sheet:   Zinet  is  2  years  old.    Her  mother  brought  her  for  an  ini.al  visit  for   cough  and  bloody  diarrhoea.    She  has  had  the  diarrhoea  for  2  days.   Her  weight  is  9.0  kg.    She  has  a  temperature  of  38.6oC.           On  assessment  you  find  that  Zinet  breathes  54  breaths  per  minute.     You  do  not  observe  chest  indrawing,  wheeze,  stridor  or  general   danger  signs.  She  has  sunken  eyes,  and  she  is  restless  and  irritable.     She  has  palmar  pallor,  but  no  visible  was.ng.    She  never  received   any  immuniza.ons.    She  is  s.ll  breas\eeding,  but  eats  other  foods   as  well.    She  has  had  ear  discharge  for  the  last  3  weeks.   Distance  learning  IMCI  

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STATION 4 (OPTIONAL)

CASE STUDY MITU

OVERVIEW Participants will assess and classify a case study of a sick young infant, and answer a question about treatment. MATERIALS n Case study SLIDE, case study is also typed on answer sheet TIMING Allow 15 minutes to complete. Give a 3-minute warning. INSTRUCTIONS FOR PARTICIPANTS 1. Read case study (on slide or answer sheet) 2. Use your recording form and chart booklet to assess and classify. 3. Answer the two questions about the case on your answer sheet.

Skills  sta.on  4    

CASE  STUDY  MITU   Read  the  case  and  answer  the  quesPons  on  your  answer  sheet:  

Mitu  was  born  3  days  ago  aeer  prolonged  labour.  Her   mother  says  she  has  not  been  sucking  the  breast  at  all  in   the  past  24  hours.         Mitu  breathes  with  difficulty.    You  measure  her   breathing  twice.    She  breathes  86  and  90  breaths  per   minute  in  the  two  counts.    She  has  chest  indrawing.    She   does  not  move  at  all.    Her  palms  are  very  yellow.   Distance  learning  IMCI  

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SECTION 6. MULTIPLE-CHOICE EXAMINATION TIME – 45 minutes SECTION OBJECTIVE Assess participant skills in IMCI to ensure that they have met the course’s learning objectives FACILITATOR SUMMARY This 30-minute multiple-choice examination if the second part of a two-part course assessment. You must ensure a good testing environment, including silence and adequate space between participants. NOTE: This section is scheduled for 45 minutes so that you can allow extra time for the exam if the entire group is having trouble finishing the exam in 30 minutes. MARKING EXAMS Participants will write all of their answers on a single answer sheet. This is intended to make marking easier and quicker for facilitators, and also allows you to re-use the copies of the examination. The examination and answer sheets for printing are available in the ANNEX. At least two facilitators are required to mark exams and enter marks into the dIMCI excel tool. The examination answer key is also available in the ANNEX. As a method for marking all exams quickly, it is recommended that facilitators punch out the correct answers of the bubble sheet, and then overlay this answer key on the participant’s answer sheet. It is quick to mark which answers do not line up correctly. See Section 0.8 for more information about marking. MATERIALS (in ANNEX) ■■ Copies of exam (ANNEX) ■■ Copies of answer sheet (ANNEX) ■■ Facilitator answer key for marking (ANNEX) ■■ Visible clock or stopwatch to display time remaining

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INSTRUCTIONS FOR PARTICIPANTS (can also be shown on SLIDE): 1. You have 30 minutes to complete the exam. Show stopwatch or clock visible to all. 2. You must respect silence during the assessment. 3. Read the examination instructions carefully. You will mark your answers on the answer sheet. Please do not mark on the examination papers. 4. Any questions before we begin?

SECTION  6   ASSESSMENT:  WRITTEN  EXAMINATION   INSTRUCTIONS  FOR  WRITTEN  EXAMINATION:   You  have  30  minutes  to  complete  the  exam.       You  must  respect  silence  during  the  assessment.    If  you   have  ques.ons  for  the  facilitator,  do  not  disturb  others.           Read  the  examina.on  instruc.ons  carefully.    You  will   mark  your  answers  on  the  answer  sheet.    Please  do  not   mark  on  the  examina.on  papers.   Distance  learning  IMCI  

*DISTRIBUTE COURSE EXAM and ANSWER SHEET*

INSTRUCTIONS FOR FACILITATORS: 1. If participants ask clarification questions, but be sure to not lead to the answers. 2. Announce a 10 and 5 minute warning. 3. Once participants turn in their answer sheets, all facilitators should begin marking and entering into dIMCI excel. This must be done quickly so all are marked by the closing.

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SECTION 7. NEXT STEPS & FORMAL CLOSING TIME – 45 minutes FACILITATOR SUMMARY You will review the course goals and facilitate a discussion about next steps for participants. If decided to do so, participants will complete individual action plans for continued learning, practice, and work with others. You will administer the course evaluation. If participants are given a certificate of completion, these are awarded. During this section, facilitators not leading the session should be marking examinations. Answer keys are in the ANNEX. Marks can be entered and calculated in the dIMCI excel tool. SECTION OBJECTIVES •• •• •• •• Re-examine course objectives and discuss how they have been met Discuss and plan how participants can continue to work on the learning objectives Administer course evaluation Discuss how facilitators will follow-up with participants after the course

MATERIALS ■■ PowerPoint slides ■■ Flipchart ■■ Certificates of completion, if being provided ■■ Individual action plan forms (ANNEX) ■■ Course evaluation (ANNEX)

7.1 RETURNING TO COURSE OBJECTIVES SLIDE Facilitators can summarize thoughts on course objectives, progress, and key lessons. 1. How have we met these objectives? 2. How will we continue to move forward with these objectives? Discuss continued education opportunities and other IMCI learning opportunities as available.

7.2 INDIVIDUAL ACTION PLANS (OPTIONAL) The action plan is an opportunity for participants and group to discuss options for continued learning, using IMCI in clinics, and work with mentors. Introduce concept, distribute action plan form, and provide 10 minutes for participants to think through plans. DISCUSS: who wants to share ideas from their action plans? Record notes on FLIPCHART.

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✔✔ Using IMCI everyday in their clinics, with every sick child and young infant they see? ✔✔ Learning more about IMCI and health topics? What continued training will you pursue? ✔✔ Working with mentors if you have questions about IMCI? ✔✔ Sharing IMCI with colleagues and in-charge officers?

7.3 AWARD CERTIFICATES Ask each participant forward, and recognize one thing about them (a trait, skill, or characteristic they have shown). Invite each participant to offer a brief reflection on their learning.

7.4 GROUP REFLECTIONS Facilitation group reflections about the course. For example, you might ask: what thoughts do each of you have for the group before we close the course?

7.5 ADMINISTER COURSE EVALUATION Distribute course evaluation (ANNEX) and allow adequate time (around 15 minutes) to complete. INTRODUCTION: Honest and detailed feedback on the course evaluation is the only way to improve the course and make important changes. This evaluation will be reviewed by facilitators and IMCI administrators.

7.6 FORMAL COURSE CLOSING Offer your closing thoughts, thank participants for their time and energy, and close the meeting.

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Reference CONTENTS These are materials for facilitators’ reference when planning. Unlike Annexes 2–4, these materials do not require extra copies. A1.1 Planning and managing study groups A1.2 Planning clinical practice sessions 138 140

ANNEX 1

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A1.1 PLANNING AND MANAGING STUDY GROUPS WHY IS GROUP LEARNING IMPORTANT? Working with others is very important for effective distance learning. Group study can benefit your studying in two ways: 1. GROUP STUDY CAN IMPROVE THE QUALITY OF YOUR LEARNING During group learning you learn from each other. You will be required to test your knowledge as you explain material to your peers. Discussing questions and problems with your group helps to improve your understanding of concepts. Working in a group can also motivate you. You have a sense of responsibility to your group and finishing your work so that you can contribute to the group study. 2. GROUP STUDY CAN HELP DEVELOP SKILLS •• Teamwork skills – leadership skills, doing activities as a group, supporting group members •• Analytical skills – critical thinking, problem solving, analyzing tasks and requirements, evaluating the work of others, understanding material •• Collaborative skills – conflict management, negotiating, compromising, accepting feedback •• Organisational skills – time management, working efficiently (i.e. not leaving work until the last minute, preparing for group studying with plenty of time), planning and managing a group study session •• Clinical skills – study groups are encouraged to set some meetings in venues where they can practice together

HOW DO YOU MANAGE STUDY GROUPS? Group study has the above benefits if the group is well planned and managed. Steps for managing study groups are below. Ideally, groups will meet regularly (e.g. once or twice a week) to review modules and cases from the clinic. Groups might want to review the self-assessment exercises, or decide its own ways to study together. STEP 1: DETERMINE WHO WILL BE IN THE STUDY GROUP Groups manage best with two to four members. Groups over five members are not recommended. They are too big to work efficiently. It also requires many people to coordinate travel over distances. The course facilitators will help participants organize into study groups. Study group arrangements will depend on where participants live and work. Groups should take into account participants’: (a) locality, (b) clinical setting, and (c) access to DVD player (possible to pair up those who do not have access). STEP 2: ESTABLISH GROUP MEMBERS’ ROLE(S) AND RESPONSIBILITIES Efficient groups divide tasks so that each member has a certain role or responsibility. For example, these roles might include: a group leader, a scheduler, or a note-taker.

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STEP 3: DEFINE GROUP PROCEDURES It is important to have clear, detailed guidelines and procedures for group that all members should follow. Each activity should be clear in purpose and function. STEP 4: SCHEDULE GROUP MEETINGS When organizing meetings, groups must consider: •• travel time and cost from multiple locations •• part-time or full-time work commitments •• family responsibilities •• disabilities among members These are not minor issues. Group study requires additional time and energy for attending and contributing to group meetings. Planning must consider each member’s available time and work schedule. Below is a sample schedule for group study. When scheduling meetings, it is best to agree on the specific date, time, location, timing of meeting, the material to be prepared before the meeting, and the material that will be covered during the group study. This will make the group meeting time as effective as possible for all group members. Remember to schedule some meetings at a venue where there are enough patients to see together. Practicing in the clinic as a group is strongly recommended for learning. MEETING DATE & TIME LOCATION CHAPTER & SECTION TIME

July 24, 2010 5:00 PM July 31, 2010 5:00 PM August 7, 2010 5:00 PM

District Part 1: Course overview Part 2: resource centre Introduction to IMCI District Self-study module 1: General resource centre danger signs District Self-study module: Young resource centre infant, section 1 and 2

1 hour 1 hour 1 hour 1 hour

Self-study module: Young August 14, 2010 5:00 PM District resource centre infant, section 3 and 4 NOTE: The material covered should be specific to sections or page numbers covered. Facilitators may also choose to recommend weekly goals, especially during the Orientation meeting, in order to ensure participants have enough time to finish Module 2.

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A1.2 PLANNING CLINICAL PRACTICE SESSIONS OVERVIEW Clinical practice is an essential part of the dIMCI course. The course provides opportunities to practice sign recognition and case management skills so that participants can perform proficiently in their own clinics. In the learning process, participants read about the skills in modules and see demonstrations in the clinic or on video. They apply this knowledge in written exercises and case studies. Finally, and most importantly, participants practice these skills with sick children and young infants in the clinical setting. In dIMCI, clinical practice for participants happens in two arenas: 1. Clinical practice during face-to-face meetings 2. Clinical practice during the self-study period The purpose of this guide is therefore to orient facilitators on how to support participants acquire skills during the two phases. STRUCTURE The structure of clinical practice depends on the structure of the dIMCI course, as there is flexibility based on national requirements. The main determinants are: 1. Course duration 2. Number of face-to-face meetings 3. Duration of each self-study period 4. The arrangement, flow, and number of modules used in the course

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PART I. CLINICAL PRACTICE DURING FACE-TO-FACE MEETINGS OVERVIEW Each face-to-face meeting includes a clinical practice session (proposed 60-90 minutes) midday to give participants an opportunity to see demonstrations and practice case management skills. Given that most clinical practice in this course happens at a distance, this face-to-face practice time is a critical opportunity for facilitators to mentor participants in skills and ensure that they can perform proficiently when independently practicing. As such, observations from clinical practice should be shared immediately, as it impacts self-learning and practice. Facilitators may choose either inpatient wards or outpatient clinics depending on availability of patients. If you have not facilitated clinical practice recently, please refer to the IMCI facilitator guide for outpatient clinical practice and the IMCI guide for clinical practice in the inpatient ward for guidance on how to facilitate time in the clinic. These arrangements will depend on the facility, caseload, and prior agreements with the facility or patients. PREPARATION Detailed preparations are important for any IMCI clinical practice session, but especially critical for dIMCI given the short time frame of the face-to-face meetings. These meetings are designed to last 6-8 hours to allow participants to travel, so clinical sessions must be arranged well in advance to minimize any time wastage. Given this, it is recommended to conduct the meetings in close proximity to – or better yet, within – a clinical site. Early preparations: When a site has been identified, contact the hospital director to explain how clinical sessions work. Describe what the participants would do. Ask permission to conduct sessions in the hospital. Permission should be obtained from all those responsible if multiple wards will be used during the course. Facilitator review: During the planning meeting and dIMCI orientation for facilitators, normally held shortly before the face-to-face meeting, one or two days hich is normally done one or two days before the encounters, it would be important to also review and even practice some of the clinical practices. Site visits: A day before the face-to-face meeting, facilitators should visit the clinical site where the practice session will be conducted. This visit allows for introductions and making necessary arrangements for an efficient session, including the following: ✔✔ Note the patient load (both inpatient and outpatient) ✔✔ Note the patient peak where you can see more patients, and determine a possible schedule for clinical sessions accordingly ✔✔ Observe patient flow (e.g. separate OPD and wards for children) ✔✔ Inquire about availability of IMCI-trained persons who can support clinical practice ✔✔ Assess the space available for group demonstrations and group or individual practice

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✔✔ Meet with clinic staff to confirm all previously made administrative and logistical arrangements. Ensure that permission is obtained for using all wards required, both from the doctor in-charge and also ward staff. ✔✔ Brief any staff that will be in the clinical area about what you will be doing, and the training sessions that will take place there. ✔✔ Check to see if the facility has the drugs and supplies available that are essential for clinical practice activities. If any drugs or supplies are required in addition to what is available in the clinic, those need to be brought for the session. Please see Box 1 for recommended supplies. ✔✔ Ensure that a regular staff member from the clinic, such as a nurse, has been identified to assist with the clinical practical activities. Please see Box 2 for the duties outlined for this session administrator.

BOX 1: RECOMMENDED SUPPLIES FOR CLINICAL SESSIONS •• IMCI sick child recording forms •• IMCI sick young infant recording forms •• Thermometers •• Scales for weighing children and infants •• Cups, spoons, and clean water for offering fluid to assess thirst •• Drugs necessary for clinical practice activities; drugs should be in the most common formulation on the IMCI chart.

BOX 2: DUTIES OF IDENTIFIED SESSION ADMINISTRATOR •• Identify children and young infants who are appropriate for the clinical session as they come into the outpatient or inpatient department. •• Arrange for the child and mother to leave the regular clinic line and be seen by the participants. •• Return the child to the appropriate station in the clinic for treatment and care. •• Confirm plans for making sure that patient seen during the outpatient session receives the treatment required. •• Determine whether participants or facilitators will dispense drugs to mothers and give the first dose, or whether patients will be passed to regular clinic staff for treatment. •• Check to see that clinic staff has been briefed on what participants will be doing during the practice sessions.

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OBJECTIVES During the clinical practice sessions, participants should learn the complete case management process: 1. See examples of signs of illness in real children and infants. 2. See demonstrations from facilitators in how to manage sick children and young infants according to case management charts. 3. Practice assessing, classifying, and treating sick children and young infants, and counselling mothers about food, fluids, and when to return. 4. Gain experience using the ASSESS and CLASSIFY charts, IDENTIFY TREATMENT column, TREAT charts, and COUNSEL and FOLLOW-UP chart material. 5. Practice good counselling skills with caretakers. 6. Gain experience and confidence in using IMCI skills. 7. Receive feedback from facilitators and IMCI mentors about how well they have performed the skill and guidance about how to strengthen particular skills. CONDUCTING CLINICAL SESSIONS Facilitation In clinical practice sessions there should be one to two facilitators for every group of 2 to 6 participants. These facilitators can include dIMCI course facilitators and identified IMCI-trained staff at the facility, depending on arrangements made. In the distance training approach, all facilitators are intended to support clinical sessions; as such, is it important for the facilitators to manage time and duties well between them so attention is paid to the clinical session preparations (some on the day of the session itself), the classroom sessions, and the clinical practice experience.

IMPORTANT FACILITATOR NOTES ✔✔ Time keeping is very important ✔✔ Ensure that transport is ready to pick participants from the classroom and vice versa ✔✔ Participants should carry their chart booklets and recording forms ✔✔ Be available to answer questions, observe, and provide active and constructive feedback

Skills focus Participants are expected to practice all steps in the complete case management process. The clinical practice skills are presented in the order they are being learned in the modules. In each clinical session, participants use the skills they have learned up to and including that day’s session. Refer to the QUICK REFERENCE SHEETS for additional detail for each meeting.

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Case selection on day of session: Some important recommendations for case selection and management are as follows: ✔✔ Select children, on the whole, so that there is a variety of signs present, allowing for a variety of classifications. This can draw from both outpatient and inpatient loads. ✔✔ Select cases that demonstrate an appropriate variety of signs for participants to assess and classify. Ideally, one case can be selected per participant so that they each have a patient to assess and classify during the session. ✔✔ Select cases that provide good demonstrations of clinical signs for any group demonstration. Good demonstration examples include: (a) children with infrequently seen signs,1 and (b) signs that have been emphasized during that day’s session and the previous self-study period. See the QUICK REFERENCE SHEETS. ✔✔ Ask the caregivers’ permission for participants to see their children that day. Session structure: Some important recommendations for session flow are as follows, though will vary according to time allotted and arrangements at the facility: 1. DEMONSTRATE: At the beginning of each session conduct a demonstration, preferably with the whole group. If the group is large, participants can be divided into smaller groups for demonstrations with co-facilitators. Demonstrations can focus on infrequently seen signs, and/or new skills (e.g. an assessment, signs) that will be emphasized in the day’s clinical practice session. 2. PRACTICE: Each participant should be assigned at least one patient to practice the IMCI process. If there are not enough children, participants can practice in pairs or small groups. Allow about 20 to 30 minutes for the participants to complete the IMCI process with the patient, and adequate time for discussion and review of the case. If there are cases of severe signs or signs that are difficult to assess, ensure that more participants are able to practice, or observe, this case. 3. MONITOR AND FEEDBACK: Conduct rounds and observe while participants assess and classify the children. To make sure that participants receive as much guidance as possible in mastering the clinical skills, the facilitator should give particular attention and feedback to the new skills being practiced that day. Ensure that the participants are using the recording form and chart booklets correctly. If any participant struggles with a skill, it is important to work with the participant until they can perform the skill with confidence. 4. SUMMARIZE: Summarize the session. Reinforce participants for new or difficult steps that they did correctly, and give those suggestions and encouragement to help them improve. 1

Participants’ checklist of signs should be reviewed prior to the clinical session to determine which signs are infrequently seen in home clinics. Special attention can be paid to these signs and cases during the demonstration. Depending on the context, participants might commonly have difficulty seeing sick young infants, and severe signs in sick children.

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QUICK REFERENCE SHEET | ORIENTATION | 1ST FACE-TO-FACE MEETING FACILITATOR PLANNING NOTES SKILLS FOCUS ✔✔ Overview of IMCI case management ✔✔ Checking for general danger signs ✔✔ Use of recording form and charts ✔✔ Assess and classify young infant and child TO PREPARE DAY-OF FACILITATOR PROCEDURES ✔✔ Identify children (or notify staff of requirement for) children with general danger signs ✔✔ Identify sick young infants 1. Explain to participants before session: •• Materials to bring •• Flow, time keeping, and space •• Explain who will be facilitating in outpatient and inpatient sessions (e.g. dIMCI facilitators, facility staff) •• Explain how facilitators will be available to observe, provide feedback, and answer questions. Clarify how you will discuss the case with them. •• Answer any questions that participants have about general procedures, where they will be working, or use of IMCI materials. 2. Demonstrate an assessment: (a) greeting a caretaker and collecting/recording information, (b) checking a child for general danger signs, (c) assessing a sick young infant (participants have not learned signs or skills so should follow along in chart booklet), or (d) show any children with infrequently seen signs as appropriate. 3. Assign participant to patients. Observe and assist as needed while participants assess and classify. Conduct rounds. PARTICIPANT OBJECTIVES Greet the caretaker and record important information about the child Check all children for general danger signs Use IMCI chart booklets and record information on recording form SESSION END Summarize the clinical session, especially: •• Importance of greeting the caretaker and creating a welcoming environment •• The IMCI process •• Using the chart booklet and recording form

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QUICK REFERENCE SHEET | REVIEW & PRACTICE | 2ND FACE-TO-FACE MEETING FACILITATOR PLANNING NOTES SKILLS FOCUS ✔✔ Review of IMCI case management process ✔✔ Checking for general danger signs ✔✔ IMCI for the sick young infant ✔✔ Signs and symptoms covered in day’s session: cough or difficult breathing, diarrhoea and dehydration TO PREPARE DAY-OF ✔✔ Identify children (or notify staff of requirement for) children with general danger signs ✔✔ Identify children with cough or difficult breathing ✔✔ Identify children with diarrhea or dehydration ✔✔ Identify sick young infants ✔✔ Identify signs that participants have not seen frequently, according to logbooks FACILITATOR PROCEDURES 1. Explain session details as outlined in the Orientation reference sheet 2. Demonstrate an assessment: (a) greeting a caretaker and collecting/recording information, (b) checking a child for general danger signs, (c) assessing a sick young infant (participants have not learned signs or skills so should follow along in chart booklet), or (d) show any children with infrequently seen signs as appropriate. 3. Assign participant to patients. Observe and assist as needed while participants assess and classify. Conduct rounds. PARTICIPANT OBJECTIVES Greet the caretaker and record important information about the child Check all children for general danger signs Use IMCI chart booklets and record information on recording form SESSION END Summarize the clinical session, especially: •• Importance of greeting the caretaker and creating a welcoming environment •• The IMCI process •• Using the chart booklet and recording form

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DEMONSTRATION 1: COUGH OR DIFFICULT BREATHING •• Explain to the participants that you will do the steps on the ASSESS & CLASSIFY chart through assessing and classifying cough or difficult breathing •• Review the assessment steps for checking for danger signs •• Then describe the steps for assessing and classifying a child with cough. Mention the signs you will assess for: fast breathing, chest indrawing, stridor, wheeze. •• Review the technique for counting breathing for fast breathing. •• Review the classifications and treatments identified. DEMONSTRATION 2: DIARRHOEA •• Explain to the participants that you will do the steps on the ASSESS & CLASSIFY chart through assessing and classifying diarrhoea •• Review the assessment steps for checking for danger signs, and for assessing and classifying cough or difficult breathing •• Then describe the steps for assessing and classifying a child for diarrhoea. Mention the signs of dehydration that you will assess: the child’s general condition, whether the child has sunken eyes, the child’s thirst and a skin pinch. •• Review the technique for doing a skin pinch. Remind participants that they should: —— Use their thumb and first finger —— The fold of the skin should be in a line up and down the child’s body —— Pick up all the layers of skin and the tissue underneath them —— Hold the pinch for one second and then release it —— Look to see if the skin pinch goes back very slow (more than 2 seconds) or slowly or immediately. •• Quickly review that dehydrated children are treated with fluids, but that this practice session will focus on assessing and classifying signs of dehydration, dysentery, and persistent diarrhoea. •• If a child with SOME DEHYDRATION or SEVERE DEHYDRATION presents during the practice session, gather all the participants to observe the signs. •• If during the session a child can be rehydrated to the extent that participants can see improvement in his clinical signs, demonstrated reassessment of his signs and discuss the improvements. •• Since the participants are not yet prepared to treat patient with diarrhoea, return the children with a note to the regular clinic staff for treatment. If time allows and there is no other patient to assess and classify, the participants can observe a child’s treatment in the ORT corner.

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QUICK REFERENCE SHEET | FINAL SYNTHESIS | 3RD FACE-TO-FACE MEETING FACILITATOR PLANNING NOTES SKILLS FOCUS ✔✔ Review of IMCI case management process ✔✔ Checking for general danger signs ✔✔ IMCI for the sick young infant ✔✔ Signs and symptoms covered in day’s session: cough or difficult breathing, diarrhoea and dehydration TO PREPARE DAY-OF ✔✔ Identify children (or notify staff of requirement for) children with general danger signs or signs of serious illness in young infants ✔✔ Identify sick young infants ✔✔ Identify children with cough or difficult breathing ✔✔ Identify children with diarrhea or dehydration ✔✔ Identify children with fever ✔✔ Identify children with malnutrition or anaemia ✔✔ Identify children with ear problems ✔✔ Identify children for HIV assessments or well child care screenings, as required ✔✔ Identify signs that participants have seen frequently, according to logbooks FACILITATOR PROCEDURES 1. Explain session details as outlined in Orientation reference sheet 2. Demonstrate at least one assessment, either of the (a) assessments of the children above, or (b) signs participants have not seen frequently in their home clinics. 3. Assign participant to patients. Observe and assist as needed while participants assess and classify. Conduct rounds. PARTICIPANT OBJECTIVES Greet the caretaker and record important information about the child Check all children for general danger signs Use IMCI chart booklets and record information on recording form NOTES ABOUT HIV It should be noted that using IMCI with HIV is difficult during this brief clinical session, as most facilities do not offer the space for confidentiality required for participants to practice. It is recommended that HIV be reviewed during self-study clinical practice, and ideally with a mentor or visiting facilitator. Summarize the clinical session, especially: •• Importance of greeting the caretaker and creating a welcoming environment •• The IMCI process •• Using the chart booklet and recording form

SESSION END

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PART II. CLINICAL PRACTICE DURING SELF-STUDY PERIOD OVERVIEW Clinical practice during the face-to-face meetings are brief experiences, and serve to orient the participant to the IMCI skills needed to continue learning and practicing on their own, and in groups, during the self-study period. In the dIMCI learning model, the self-study period is the most significant time for participants to gain skills in IMCI. Who: clinical practice during self-study is conducted: (a) independently in a home clinic, (b) during group practice with study groups, and (c) in consultation with IMCI mentors like a supervisor or colleague. Where: As discussed previously in this facilitator’s guide, participants will practice during the self-study period in their home clinics. In some cases, arrangements might be made for participants to practice on occasion at another local facility that has a higher caseload and exposure to different cases. EXPECTATIONS FOR FACILITATORS •• Explain what is expected of participants during self-study practice •• Assess each participants’ opportunity to appropriately conduct clinical practice, and if experience should be supplemented with alternate clinical arrangements •• Ensure that participants know your availability for questions and help •• Provide on-site mentoring, as possible. If this will not be possible in your course arrangements, the facilitator can play an important role in communicating with an on-site mentor for the participant. EXPECTATIONS FOR PARTICIPANTS (this section is also in the logbook) •• Using your materials: bring your modules, chart booklet, and recording forms with you to the clinic. You can reference these materials while you practice. You should always use the chart booklet and recording form with your cases. •• Pace of practice: you should practice at the same rate as you read the material. It is not recommended that you ‘cram’ reading for this course, as it does not allow you to practice skills over a period of time. If you spend about one week per module, you should be reviewing those same skills. •• Expected cases completed: you will be told during each face-to-face meeting how many recording forms you are expected to complete. Do not leave these to the last minute! To ensure that you practice enough cases, and see enough signs, you must practice throughout the self-study period. •• Group study is very important: arrange some of your study groups in venues that will allow you to practice together. You can work as partners or in small groups, with some observing and providing feedback to each other. They can also follow along with the materials to make sure the participant practicing is using IMCI thoroughly. •• Use mentors: practicing with others who are experienced with IMCI is one of the most helpful things you can do for your self-study.

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PRACTICAL WAYS TO GAIN EXPERIENCE (this section is also in the logbook) ✔✔ Make a study calendar and keep it in your clinic to remind me of the pace you have set for yourself ✔✔ Fill out the recording form and use IMCI as you see patients – ideally for every child you see in the clinic ✔✔ Set targets for how many cases you want to practice each day you are in the clinic ✔✔ Inform your colleagues that you want to see certain kinds of cases (especially those that might be difficult to see, like a sick young infant), so that they can inform you if those cases come to the clinic ✔✔ Ask for your mentors to observe you in the clinic and give their feedback ✔✔ Set group study sessions in venues where you can practice together ASSESSMENT OF CLINICAL PRACTICE (this section is also in the logbook) Your efforts to practice in the clinic will be assessed in two ways: •• Recording forms from cases (Located in logbook) •• Checklist of clinical signs, to be completed as you see signs (Located in logbook)

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Orientation CONTENTS Annexes 2–4 include materials for each face-to-face meeting. If a material is intended for printing and distribution to participants, it is indicated on the annex cover page. These materials are marked discretely in the annex and formatted so that they can be directly copied for participants. A2.1 DIMCI course registration form A2.2 Section 7. Facilitator role-plays (optional) A2.3 Participant communications role-play handouts A2.4 Orientation meeting evaluation 152 153 156 159

ANNEX 2

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A2.1 dIMCI COURSE REGISTRATION FORM COURSE LOCATION DATE

FULL NAME

PREFERRED NAME (If different)

WORK STATION

TITLE

How is it best to stay in touch with you?

  SMS/text message mobile   Call mobile   Call other phone:  Email

MOBILE PHONE

OTHER PHONE

EMAIL ADDRESS

POST ADDRESS

What IMCI background do you have, if any?

Have you done a distancelearning course before?

Do you have access to a DVD player to watch videos?

 Yes  No

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A2.2 SECTION 7 FACILITATOR ROLE-PLAYS (OPTIONAL) INSTRUCTIONS FOR FACILITATORS These role-plays are an alternate activity to showing an IMCI video, if facilitators feel comfortable demonstrating through role-play. Two facilitators can role-play counselling sessions between a health worker and a mother. The descriptions below include a script and discussion questions for three role-play scenarios. Facilitators should adapt the scenes as needed. Facilitators should present these scenarios at the front of the room, and stop after each role-play to discuss reactions. For consistency, the facilitator playing the health worker should play this role in all of the scenarios. Each role-play and discussion should only last a few minutes. ROLE-PLAY OBJECTIVES •• Present short, realistic clinical scenarios that demonstrate good communication skills. •• Demonstrate communication skills discussed in this section, including the APAC process, 3 teaching steps, and checking questions. •• Discuss ways the health worker could improve communication skills.

n  SCENARIO 1: teaching a mother to treat skin pustules Summary: in this scenario, the health worker does not use the 3 teaching steps or checking questions.

SCRIPT This is an example script. Actions are in italics. HW: You say your child has had these skin pustules. How have you been caring for this? Mother: I am putting oil on the skin at night. HW: The oil will not help this problem. I will tell you of a different way you must treat. You need to wash the skin with soap and water. Wash away any pus. Then dry him off. Wash your hands before and after. You should do all of this twice a day, for 5 days. Does that make sense? Mother nods

n  DISCUSSION FOR SCENARIO 1 Ask the participants their reactions. Below are some points that the facilitators can emphasize.

What skills did the health worker use? •• The HW asked the mother how she had been treating the problem (ASK in APAC process). This provided background information on the previous treatment.

How could the health worker improve his/her communication skills? •• The health worker did not use the 3 teaching steps when teaching the mother how to treat skin pustules at home. HW only gave information, but did not demonstrate or let mother practice. •• The health worker did not check the mother’s understanding by using checking questions. •• The health worker said that treating with oil was not helpful, but did not explain why.

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n  SCENARIO 2: feeding from a cup Summary: this scenario should demonstrate a health worker using the 3 teaching steps.

SCRIPT This is an example script. Actions are in italics. HW: I have showed you how to express breastmilk. You have some here in the cup (lifts cup). I will show you how to give the milk in a cup. Health worker takes “baby” (rolled blanket or other prop) from mother to demonstrate the following steps. Explain the steps aloud. HW says: •• First, put a cloth on his front to protect his clothes if some milk spills. •• Then, hold your baby upright in your lap. •• Measure the milk into the cup so you know how much you are giving. •• Hold the cup so it rests on the lower lip. •• Tip the cup so that the milk just reaches his lips. •• He should take the milk himself, you do not pour the milk into his mouth. •• Now will you try? Mother takes child and demonstrates steps, talking through them. The mother should have trouble when she tries to sit the infant up. The health worker should remind her how to sit the baby upright in her lap. Then the mother should continue through the steps. HW: very good, we are done with this. You are very good to be giving breastmilk, even if you have been having trouble with the attachment. Your breastmilk is so important for your baby boy’s growth. Mother: Thank you

n  DISCUSSION FOR SCENARIO 2 Ask the participants their reactions. Below are some points that the facilitators can emphasize.

What things did the health worker do well? She used the 3 teaching skills – explain, show example, and let the mother practice. When the mother needed help during practice, she explained more. The health worker affirmed the mother when her practice was done. The health worker praised the mother for giving expressed breastmilk even though she is having trouble with attachment. •• The health worker used common items – a cup – to demonstrate the practice. •• •• •• ••

What else should the health worker do in this scenario – what skills were not used? •• The health worker did not check the mother’s understanding after they were finished – for example, how often the feeding should occur, or why the milk should be measured.

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n  SCENARIO 3: increased fluid during illness This scenario should demonstrate better use of checking questions.

SCRIPT This is an example script. Actions are in italics. HW: Your girl is sick, so it is important that she gets a lot of fluid. You should be giving her more than usual. More nutrients and fluid will give her strength to fight the infection. You have been really good to keep breastfeeding her, this is very important. What other foods or drink do you give her? Mother: She also takes rice and sometimes fruits. I boil water for her sometimes when the water is dirty. HW: Boiling water is very important, you are very good to do this, and should keep doing it. You should keep giving her rice with water, soup, yogurt drinks, and more clean water. Can you tell me how you will give her more fluids? Mother pauses: I do not understand? HW: can you give me some examples of what you will feed her? Mother: I will keep giving breast milk. I will also give water and mix it with rice or yogurt. HW: This is very good. This is exactly what you should do.

n  DISCUSSION FOR SCENARIO 3 Ask the participants their reactions. Below are some points that the facilitators can emphasize.

What things did the health worker do well? •• The health worker asked for more information about how the mother was feeding, and praised the mother for breastfeeding and boiling water for complementary feeding. •• The health worker used a checking question to make sure the mother understood. •• When the mother did not understand the question, the health worker encouraged her.

What else should the health worker do in this scenario – what skills were not used? •• The health worker might use a teaching card or give the mother a picture to take home with the recommended foods for increased fluids.

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A2.3 PARTICIPANT COMMUNICATIONS ROLE-PLAY HANDOUTS n  ROLEPLAY ROUND 1 CARETAKER Remember that this is an exercise for the health worker to ask the right questions to get information about your child. Only give the information that is asked. Health worker might ask for this: Child’s name? His age? Your initial or follow-up visit? What is your child’s problem? Does your child have these symptoms? Unable to drink or breastfeed? Vomiting everything? Had convulsions during this illness? No, he can drink No, he is not vomiting No convulsions The information you have for response: Jon (boy) 12 months Initial visit My child has a cough that worries me. He has had a cough for several days (3–4), and it is getting worse.

n  ROLEPLAY ROUND 1 HEALTH WORKER Remember that this is an exercise in good communication skills as you use the IMCI process. Use your Chart Booklet and a recording form as you assess the child for signs of severe illness and the presenting symptom. You measure:   Temperature: 37 degrees Celsius   Weight: 10 kg Your observations about the child:   Child is not lethargic or unconscious   You count 48 breaths/minute   Child has chest indrawing Based on the signs you observe and the information you gather about the child, how would you classify the child?

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n  ROLEPLAY ROUND 2 CARETAKER Remember that this is an exercise for the health worker to ask the right questions to get information about your child. Only give the information that is asked. Health worker might ask for this: Child’s name? His age? Your initial or follow-up visit? What is your child’s problem? Is child having difficulty feeding? Has child had convulsions during this illness? The information you have for response: Amira (girl) 4 weeks Initial visit The baby seems feverish and is very unhappy No, she can breastfeed No convulsions

n  ROLEPLAY ROUND 2 HEALTH WORKER Remember that this is an exercise in good communication skills as you use the IMCI process. Use your Chart Booklet and a recording form as you assess for signs of severe illness. You measure:   Temperature: 38 degrees Celsius   Weight: 3 kg Your observations about the child:   You count 53 breaths/minute   You observe chest indrawing   The umbilicus is not red or draining pus.   There are no skin pustules. Eyes are not draining pus.   The child moves only when stimulated.   No bulging fontanelle   No nasal flaring or grunting   No jaundice evident. ✔✔ Based on the signs you observe and the information you gather about the child, how would you classify? ✔✔ What is your course of action? ✔✔ How could you counsel the caretaker?

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n  ROLEPLAY ROUND 3 CARETAKER This exercise differs slightly from the previous role plays, and focuses on communication skills with a caretaker. You should not disclose information or do anything that the health worker does not ask of you – for example, do not volunteer to practice the home treatment unless they ask you to do it. You do not need to immediately volunteer information to the health worker, and can ask for clarifications. In this scenario, your infant has been classified with a local BACTERIAL infection around the umbilicus. The umbilicus is red. The health worker will counsel you about treating the local infection at home.

n  ROLEPLAY ROUND 3 HEALTH WORKER This exercise differs slightly from the previous role plays, and focuses on communication skills with a caretaker. You will be asked to use your Chart Booklet and counsel the caretaker on a particular home treatment, which would happen after you have classified the child and determined the appropriate treatment. In this scenario, you have classified an infant with a local bacterial infection of the umbilicus. The umbilicus is red. This classification is on the first chart for infants, for severe disease and local infection. Use your COUNSEL THE MOTHER section in your Chart Booklet to advise the mother how to treat the infection around the umbilicus. You can take a minute to review the instructions for treating a local infection before you begin to counsel the mother.

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A2.4 ORIENTATION MEETING EVALUATION NAME MEETING SITE DATE

1. Please provide your feedback on Section 1 of today’s meeting, the overview of the distance IMCI course. What was useful? What can be improved?

2. What was most useful about today’s discussions about creating a welcoming environment and using good communication skills? What can be improved?

3. Please provide your feedback about today’s sessions that discussed the IMCI process. These discussions also included an introduction to the Chart Booklet and recording forms. What was useful? What can be improved?

4. Please provide your feedback about today’s clinical practice session. What was useful? What can be improved?

5. What are your recommendations to the facilitator?

6. Do you have any other comments about the meeting today?

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A2.5 Recording forms

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Is the infant having difficulty in feeding? Has the infant had convulsions? Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis?

ASSESS BREASTFEEDING Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 1 Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? Age: Weight (kg): Initial Visit? Height/Length (cm): Follow-up Visit? Temperature (°C):

ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool? Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measles within the last 3 months? Do a malaria test, if NO general danger sign in all cases in high malaria risk or NO obvious cause of fever in low malaria risk: Test POSITIVE? P. falciparum P. vivax NEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes __ No __ Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L z-score:____ Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? Any severe classification? Pneumonia with chest indrawing? Child 6 months or older: Offer RUTF to eat. Is the child: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem?

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet: CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2 Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

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Review & Practice CONTENTS A3.1 Check-in form: Review & Practice meeting A3.2 Logbook exercises answer key (Modules 1–2) A3.3 Worksheet: dosages activity A3.4 Review & Practice meeting evaluation 161 162 163 164

ANNEX 3

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A3.1 CHECK-IN FORM: REVIEW & PRACTICE MEETING NAME MEETING SITE IF ‘NO’, WHY NOT?  YES  YES  NO  NO DATE

MODULE 1 1.1 How many hours did it take to read? 1.2 Did you complete all logbook exercises? 1.3 How many hours to complete the exercises? 1.4 Did you complete at least 2 recording forms?

MODULE 2 2.1 How many hours did it take to read? 2.2 Did you complete all logbook exercises? 2.3 How many hours to complete the exercises? 2.4 Did you complete at least 2 recording forms?  YES  NO  YES  NO

CONTENT OVERALL 3.1 Was the language easy to understand? 3.2 Were there enough pictures and graphics to help understand concepts? 3.3 Were the videos helpful for learning? 3.4 Where did you use the DVD player? 3.5 Was the opening case study very helpful with learning the module’s material?  YES  YES  YES  Own  YES  NO  NO  NO  Friend  NO  Didn’t use

SELF-STUDY PERIOD 4.1 Was there enough time to complete study? 4.2 Did you practice IMCI in your clinic? 4.3 Did you use your chart booklet? 4.4 Did you use your recording forms? 4.5 Did the modules prepare you to practice? 4.6 Did you meet with study group? 4.7 Did you practice in clinic as a group? 4.8 Did you have an IMCI mentor during study? 4.8.1 Who was this mentor? 4.8.2 How many times did you interact? 4.8.3 How did you communicate?  In person  SMS  Phone calls  YES  YES  YES  YES  YES  YES  YES  YES  NO  NO  NO  NO  NO  NO  NO  NO

4.7 How many times?

 Facilitator  In-charge  Colleague  Other:

SUMMARY 5.1 What were your main challenges when studying and practicing in the clinic? 5.2 What can the facilitators help you with?

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A3.2 LOGBOOK EXERCISES ANSWER KEY (Modules 1–2) The logbook exercise includes 20 multiple choice and true/false questions. You can review these for completion at this time.

MODULE 1 1. C 2. B 3. B 4. B 5. C 6. C 7. B 8. A 9. B 10. A 11. C 12. B 13. C 14. A 15. TRUE 16. FALSE 17. TRUE 18. FALSE 19. FALSE 20. FALSE

MODULE 2 1. B 2. C 3. B 4. B 5. C 6. C 7. C 8. B 9. C 10. A 11. FALSE 12. FALSE 13. FALSE 14. FALSE 15. FALSE 16. TRUE 17. TRUE 18. TRUE 19. FALSE 20. TRUE

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A3.3 WORKSHEET: DOSAGES ACTIVITY 1. Cotrimoxazole for a 6-kg child

2. Iron tablet for a 12-kg child

3. Chloramphenicol for a 6-kg child

4. Mebendazole for a 3-year-old child

5. Paracetamol for a 14-kg child

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A3.4 REVIEW & PRACTICE MEETING EVALUATION NAME MEETING SITE DATE

1. Please provide your feedback on this morning’s group discussion about the distance learning process. How did this discussion help you? How do you feel your questions and concerns were answered?

2. Do you have any issues with the self-study and practice that have not been addressed?

3. What is your feedback on the clinical practice experience? What about this time in the clinic was most useful? What can be improved next time?

4. What was most useful in the introduction to main IMCI symptoms (cough or difficult breathing, diarrhoea, fever, ear problems, malnutrition)? What can be improved?

5. What was most useful in our section on treatment, counselling, and follow-up? What can be improved? Are any areas still challenging for you?

6. What was most useful in our discussion about expectations for your distance learning? What can be improved or clarified?

7. Do you have any other questions or concerns?

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Final Synthesis CONTENTS A4.1 Check-in form: Final Synthesis meeting A4.2 Logbook exercises answer key (Modules 3–7) A4.3 Skills stations answer sheet A4.4 Skills station answer key A4.5 Written examination A4.6 Written examination: questions for optional modules A4.7 Written examination answer sheet A4.8 Multiple-choice examination answer key A4.9 Individual action plan A4.10 Course evaluation 166 167 168 171 174 179 183 184 186 187

ANNEX 4

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A4.1 CHECK-IN FORM: FINAL SYNTHESIS MEETING NAME MEETING SITE IF ‘NO’, WHY NOT? DATE

MODULES 1.1 How many hours did it take to read each (average)? 1.2 Did any modules take longer to study than others, or we more difficult for some reason? 1.3 Did you complete all logbook exercises? 1.4 Did you complete at least 2 recording forms for each module?  YES  YES  NO  NO

CONTENT OVERALL 2.1 Was the language easy to understand? 2.2 Were there enough pictures and graphics to help understand concepts? 2.3 Were the videos helpful for learning? 2.4 Where did you use the DVD player? 2.5 What videos were especially helpful? 2.6 Was the opening case study helpful?  YES  NO  YES  YES  YES  Own  NO  NO  NO  Friend  Didn’t use

SELF-STUDY PERIOD 3.1 Was there enough time to complete study? 3.2 Did you practice IMCI in your clinic? 3.3 Did you use your chart booklet? 3.4 Did you use your recording forms? 3.5 Did the modules prepare you to practice? 3.7 Did you meet with study group? 3.7.2 What were advantages of a study group? 3.7.3 Did you practice in clinic as a group? 3.8.1 Who was this mentor? 3.8.2 How many times did you interact? 3.8.3 How did you communicate? 3.8.4 How did he/she help you? Give example.  In person  SMS  Phone calls  YES  YES  NO  NO  YES  YES  YES  YES  YES  YES  NO  NO  NO  NO  NO  NO

3.6 What difficulties did you face during practice? 3.7.1 How many times?

3.8 Did you have an IMCI mentor during study?

 Facilitator  In-charge  Colleague  Other:

SUMMARY 4.1 What were your challenges during this period? 4.2 What can the facilitators help you with?

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A4.2 LOGBOOK EXERCISES ANSWER KEY (Modules 3–9) The logbook exercise includes 20 multiple choice and true/false questions. You can review these for completion at this time. MODULE 3 – COUGH 1. B 2. C 3. B 4. B 5. B 6. C 7. A 8. B 9. C 10. A 11. TRUE 12. FALSE 13. TRUE 14. TRUE 15. FALSE 16. TRUE 17. TRUE 18. FALSE 19. TRUE 20. TRUE MODULE 4 – DIARRHOA 1. A 2. B 3. A 4. C 5. B 6. B 7. C 8. A 9. B 10. A 11. A 12. TRUE 13. FALSE 14. TRUE 15. TRUE 16. TRUE 17. TRUE 18. FALSE 19. TRUE 20. TRUE MODULE 8 – WELL CHILD 1. C 2. B 3. C 4. B 5. C 6. B 7. C 8. B 9. TRUE 10. TRUE 11. TRUE 12. TRUE 13. FALSE 14. TRUE 15. TRUE 16. FALSE 17. TRUE 18. TRUE 19. TRUE 20. FALSE MODULE 5 – FEVER 1. C 2. A 3. C 4. A 5. B 6. A 7. B 8. C 9. A 10. TRUE 11. TRUE 12. FALSE 13. TRUE 14. FALSE 15. TRUE 16. TRUE 17. FALSE 18. TRUE 19. TRUE 20. TRUE MODULE 6 – NUTRITION 1. A 2. B 3. B 4. C 5. B 6. A 7. C 8. A 9. B 10. C 11. B 12. B 13. C 14. TRUE 15. FALSE 16. FALSE 17. TRUE 18. FALSE 19. TRUE 20. TRUE

MODULE 7 – EAR 1. A 2. B 3. C 4. C 5. A 6. B 7. B 8. A 9. B 10. A 11. C 12. TRUE 13. FALSE 14. TRUE 15. FALSE 16. TRUE

MODULE 9 – HIV/AIDS 1. B 2. A 3. C 4. B 5. A 6. B 7. C 8. B 9. A 10. C 11. B 12. A 13. A 14. B

15. (1) ASSESS, (2) ADVISE, (3) AGREE, (4) ASSIST, (5) ARRANGE 16. TRUE 17. TRUE 18. FALSE 19. TRUE 20. FALSE 21. TRUE 22. TRUE 23. TRUE 24. TRUE

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A4.3 SKILLS STATIONS ANSWER SHEET IMCI DISTANCE LEARNING COURSE NAME MEETING SITE DATE

INSTRUCTIONS: Completely fill the circle of the best answer. You may use your IMCI Chart Booklet and recording forms.

CORRECT INCORRECT



✔ ✘ a b

STATION 1 – PHOTO EXERCISE INSTRUCTIONS: Identify the clinical sign from the photos. Fill the answer for the best answer for the clinical sign and likely classification. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

a a a a a a a a a a a a a a a

Lethargy GENERAL DANGER SIGN Very slow skin pinch DEHYDRATION Ear problem ACUTE EAR INFECTION Oral thrush FEEDING PROBLEM Not feeding well GENERAL DANGER SIGN Clouding of cornea COMPLICATED MEASLES Some palmar pallor FEVER Slow skin pinch SOME DEHYDRATION Swelling LOCAL INFECTION Skin pustules LOCAL INFECTION Good attachment Good attachment Good attachment Good attachment Good attachment

b b b b b b b b b b b b b b b

Sunken eyes DEHYDRATION Very slow skin pinch FEEDING PROBLEM Red eyes, rash MEASLES Oral thrush LOCAL INFECTION Severe wasting SEVERE MALNUTRITION Pus draining from eye MEASLES Severe palmar pallor SEVERE ANAEMIA Lethargy SERIOUS ILLNESS Oedema SEVERE MALNUTRITION Rash MEASLES Poor attachment Poor attachment Poor attachment Poor attachment Poor attachment

c c c c c c c c c c

Sunken eyes PERSISTEN DIARRHOEA Vomiting everything GENERAL DANGER SIGN Clouding of cornea COMPLICATED MEASLES Not feeding SERIOUS ILLNESS Pallor palmor SEVERE ANAEMIA Lethargy GENERAL DANGER SIGN Minimal palmar pallor NO ANAEMIA Very slow skin pinch SEVERE DEHYDRATION Oedema MALNUTRITION Red umbilicus LOCAL INFECTION

SKILLS STATION ANSWER SHEET

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NAME

MEETING SITE

DATE

STATION 2 – VIDEO EXERCISES INSTRUCTIONS: Answer the questions below about the children you see in the videos. VIDEO EXERCISE 1 Do the seven children have chest indrawing? 1. 2. 3. 4. 5. 6. 7.

a a a a a a a

YES YES YES YES YES YES YES

b b b b b b b

NO NO NO NO NO NO NO

VIDEO EXERCISE 2 Do the six children have sunken eyes? 1. 2. 3. 4. 5. 6.

a a a a a a

YES YES YES YES YES YES

b b b b b b

NO NO NO NO NO NO

VIDEO EXERCISE 3 How quickly does the child’s skin pinch return? 1. 2. 3. 4. 5.

a a a a a

Immediately Immediately Immediately Immediately Immediately

b b b b b

Slowly Slowly Slowly Slowly Slowly

c c c c c

Very slowly Very slowly Very slowly Very slowly Very slowly

SKILLS STATION ANSWER SHEET

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NAME

MEETING SITE

DATE

STATION 3 – ZINET CASE STUDY INSTRUCTIONS: Read the case study. You can use your chart booklet to answer the two questions below. Zinet is 2 years old. Her mother brought her for an initial visit for cough and bloody diarrhoea. She has had the diarrhoea for 2 days. Her weight is 9.0 kg. She has a temperature of 38.6 degrees Celsius. On assessment you find that Zinet breathes 54 breaths per minute. You do not observe chest indrawing, wheeze, stridor or general danger signs. She has sunken eyes, and she is restless and irritable. She has palmar pallor, but no visible wasting. She never received any immunizations. She is still breastfeeding, but eats other foods as well. She has had ear discharge for the last 3 weeks.

1. How would you classify Zinet? 2. List the priority treatments you will give this visit:

STATION 4 – MITU CASE STUDY INSTRUCTIONS: Read the case study. You can use your chart booklet to answer the two questions below. Mitu was born 3 days ago after prolonged labour. Her mother says she has not been sucking the breast at all in the past 24 hours. Mitu breathes with difficulty. You measure her breathing twice. She breathes 86 and 90 breaths per minute in the two counts. She has chest indrawing. She does not move at all. Her palms are very yellow.

1. How would you classify Mitu? 2. What actions will you take immediately?

SKILLS STATION ANSWER SHEET

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A4.4 SKILLS STATION ANSWER KEY RECOMMENDATION: The correct answers have been noted below. Print an answer key for each grading facilitator, and punch out the correct answers. Facilitators can overlay the answer key on the participant’s answer sheet for quicker marking. Facilitators are recommended to begin marking as soon as participants have completed each exercise.

STATION 1 – PHOTO EXERCISE INSTRUCTIONS: Identify the clinical sign from the photos. Fill the answer for the best answer for the clinical sign and likely classification. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

a

Lethargy GENERAL DANGER SIGN Very slow skin pinch DEHYDRATION

Sunken eyes DEHYDRATION

c c c c c c c

Sunken eye PERSISTEN DIARRHOEA Vomiting everything GENERAL DANGER SIGN Clouding of cornea COMPLICATED MEASLES Not feeding SERIOUS ILLNESS Pallor palmor SEVERE ANAEMIA Lethargy GENERAL DANGER SIGN Minimal palmar pallor NO ANAEMIA Very slow skin pinch SEVERE DEHYDRATION

b

Very slow skin pinch FEEDING PROBLEM Red eyes, rash MEASLES

a

Ear problem ACUTE EAR INFECTION Oral thrush FEEDING PROBLEM

b

Oral thrush LOCAL INFECTION Severe wasting SEVERE MALNUTRITION

a

Not feeding well GENERAL DANGER SIGN Clouding of cornea COMPLICATED MEASLES

b

Pus draining from eye MEASLES Severe palmar pallor SEVERE ANAEMIA

a a a a a a a

Some palmar pallor FEVER Slow skin pinch SOME DEHYDRATION Swelling LOCAL INFECTION Skin pustules LOCAL INFECTION Good attachment Good attachment Good attachment Good attachment Good attachment

b

Lethargy SERIOUS ILLNESS Oedema SEVERE MALNUTRITION

c

Oedema MALNUTRITION Red umbilicus LOCAL INFECTION

b

Rash MEASLES Poor attachment Poor attachment

b b

Poor attachment Poor attachment Poor attachment

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STATION 2 – VIDEO EXERCISES INSTRUCTIONS: Answer the questions below about the children you see in the videos. VIDEO EXERCISE 1 Do the seven children have chest indrawing? 1. 2. 3. 4. 5. 6. 7. YES

b b b b

NO NO NO NO NO NO NO

a

YES YES YES

a a

YES YES YES

VIDEO EXERCISE 2 Do the six children have sunken eyes? 1. 2. 3. 4. 5. 6. YES

b b b

NO NO NO NO NO NO

a a a

YES YES YES YES YES

VIDEO EXERCISE 3 How quickly does the child’s skin pinch return? 1. 2. 3. 4. 5.

a a a a

Immediately Immediately Immediately Immediately Immediately

Slowly

b b b

Slowly Slowly Slowly Slowly

c c c

Very slowly Very slowly Very slowly Very slowly Very slowly

SKILLS STATION ANSWER KEY continued

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STATION 3 – ZINET CASE STUDY These case studies can be graded on a range depending on national preference. For example, each question could receive one point for each correct classification or treatment. Alternatively, the scale could be simplified to 1=all correct, 0=not all correct; or 2=all correct or exceptional work, 1=partially correct but needs improvement, 0=incorrect or missing too much. 1. How would you classify Zinet? 2. List the priority treatments you will give this visit:  Antibiotic for pneumonia and ear infection – amoxicillin for 5 days  Plan B to manage some dehydration  Zinc for 2 weeks  Antibiotic for dysentery – ciprofloxacin for 3 days  Advice when to return immediately ✔ PNEUMONIA ✔ SOME DEHYDRATION ✔ DYSENTERY ✔ CHRONIC EAR INFECTION ✔ ANAEMIA ✔ Not immunized

 Follow up in 2 days – at that stage, if child has improved continue same treatment, and begin treatment for anaemia and chronic ear infection

STATION 4 – MITU CASE STUDY See grading note above in STATION 3. 1. How would you classify Mitu? 2. What actions will you take immediately?  Give oxygen  Give first dose ceftriaxone IM  Test for low blood sugar and treat  Refer urgently  Keep infant warm on the way ✔ POSSIBLE SERIOUS BACTERIAL INFECTION ✔ JAUNDICE

SKILLS STATION ANSWER KEY continued

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A4.5 WRITTEN EXAMINATION IMCI DISTANCE LEARNING COURSE INSTRUCTIONS: 1. Mark your answers by completely filling in the circle on the answer sheet. 2. Please do not make any marks on this examination printout. 3. You may use your IMCI Chart Booklet and recording form during this exam. 4. You will have 30 minutes to complete the exam.

1. Which of the following is a major killer of children? a. Neonatal conditions b. Ear infections c. Rubella virus 2. The IMCI guidelines are designed to be used at where in the health system? a. In the inpatient ward of a hospital b. At first-level health facilities c. In specialized hospitals 3. The IMCI clinical guidelines describe how to manage: a. Common childhood illnesses that cause high morbidity and mortality b. Sick children with injuries c. Chronic illnesses 4. The IMCI clinical guidelines are designed for use with which age group? a. 2 months up to 5 years b. 1 month up to 6 years c. Birth up to 5 years 5. When a child is brought to a health facility you should always check for general danger signs. Which of the following is a general danger sign? a. Child is restless or nervous b. Child is lethargic or unconscious c. Child vomits frequently 6. What of the following is a main symptom for which every sick child should be checked? a. Fever b. Pneumonia c. Local bacterial infection 7. What is the cut-off rate for fast breathing in a child who is 10 months old: a. 60 breaths per minute or more b. 50 breaths per minute or more c. 40 breaths per minute or more

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8. To classify the dehydration status of a child with diarrhoea you should LOOK and FEEL for the following: a. Sunken eyes b. Blood in stool c. Distended abdomen 9. In addition to assessing dehydration status, the mothers of ALL children with diarrhoea should be asked: a. What did the child eat before the diarrhoea started? b. Do other family members have diarrhoea? c. For how long has the child had diarrhoea? 10. A child should be assessed for the main symptom of FEVER if the child: a. Has temperature 37 °C b. Has a history of fever c. Does not feel well 11. Which children should be checked for malnutrition and anaemia? a. All children with feeding problem(s) b. All children who are less than 12 months of age c. All children brought to the clinic 12. Read the case: Pemba is 18 months old. He weighs 9 kg, and his temperature is 37 °C. His mother says he has had a cough for 3 days. Pemba’s mother said that he is able to drink and has not vomited anything. He has not had convulsions. Pemba was not lethargic or unconscious. You counted 45 breaths per minute. The mother lifted the child’s shirt and you did not see chest indrawing. You did not hear stridor when you listened to the child’s breathing. How would you classify Pemba? a. GENERAL DANGER SIGN and SEVERE PNEUMONIA b. PNEUMONIA c. COLD OR COUGH 13. Read the case: Heera is 3 years old. She weighs 10 kg. Her temperature is 37 °C. Her mother came today because Heera has diarrhoea. She does not have any general danger signs. She does not have cough or difficult breathing. When you asked how long Heera has had diarrhoea, the mother said, “For more than 2 weeks.” There is blood in the stool. Heera is irritable during the visit. Her eyes are not sunken. She is able to drink, but she is not thirsty. A skin pinch goes back slowly. How would you classify Heera? a. SEVERE DYSENTERY, SOME DEHYDRATION b. SEVERE DEHYDRATION, DYSENTERY, PERSISTENT DIARRHOEA c. SEVERE PERSISTENT DIARRHOEA, DYSENTERY, SOME DEHYDRATION

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14. Read the case: Anders is 3 years old. He weighs 10.2 kg. His temperature is 37.5 °C. His mother says he feels hot. He also has a cough, she says. Anders was able to drink, had not vomited, did not have convulsions, and was not lethargic or unconscious. The mother said Anders had been coughing for 3 days. You counted 51 breaths a minute. You did not see chest indrawing. There was no stridor when Anders was calm. Anders does not have diarrhoea. Because Anders’ temperature was 37.5 °C you assessed the child further for signs of fever. The risk of malaria is high. The child has felt hot for 5 days, the mother said. The child did not have a stiff neck, but there was runny nose, and generalized rash. There is no clouding of cornea, pus draining from the eye, or mouth ulcers. How would you classify Anders? a. COUGH OR COLD, MEASLES b. MEASLES WITH EYE COMPLICATIONS c. PNEUMONIA, MEASLES 15. Zach, a young boy, is 99 cm tall and weighs 12.5 kg. Based on his z-score, how will you classify? a. SEVERE ACUTE MALNUTRITION b. MODERATE ACUTE MALNUTRITION c. NO ACUTE MALNUTRITION 16. A child classified as SOME DEHYDRATION requires the following: a. 4-hour rehydration at the clinic using ORS b. Fluids by IV at the clinic c. RUTF and ORS for home treatment 17. Read the case: Kalisa is 11 months old. He weighs 8 kg. His temperature is 37 °C. His mother says he has had a dry cough for about a month. Kalisa does not have any general danger signs. You assessed his cough. You counted 45 breaths per minute. You do not see chest indrawing. There is no stridor when the child is calm. Kalisa does not have diarrhoea. He has not had a fever during this illness. He does not have an ear problem. You checked Kalisa for malnutrition and anaemia. Kalisa does not have visible severe wasting. His palms are very pale and appear almost white. There is no oedema of both feet. Kalisa’s MUAC is 122 mm. How would you classify Kalisa? a. PNEUMONIA, SEVERE ACUTE MALNUTRITION, SEVERE ANAEMIA b. COUGH OR COLD, MODERATE ACUTE MALNUTRITION, SEVERE ANAEMIA c. COUGH OR COLD, SOME ANAEMIA 18. Sara is 11 months and has no general danger signs. She is classified with PNEUMONIA, ACUTE EAR INFECTION, MODERATE ACUTE MALNUTRITION, NO ANAEMIA. She requires urgent referral today. a. TRUE b. FALSE

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19. David is 7 months old. He has no general danger signs. He is classified with: MASTOIDITIS, MALARIA, NO ACUTE MALNUTRITION, NO ANAEMIA. He requires urgent referral today. a. TRUE b. FALSE 20. Isoke is 2 years old. She has no general danger signs. She is classified with: diarrhoea with SEVERE DEHYDRATION, and SEVERE ACUTE MALNUTRITION. Your clinic is able to give fluids by IV. She requires urgent referral today. a. TRUE b. FALSE 21. Read the following case: Ahmed has been brought for a follow-up visit for PNEUMONIA. Last visit he had fast breathing. He has been taking amoxicillin. His mother says he is still sick and has vomited twice today. What is one sign you will you look for when you reassess Ahmed today? a. Stridor b. Dry cough c. If the child is restless or irritable 22. Oko is 2 years old. He is classified with VERY SEVERE FEBRILE DISEASE, CHRONIC EAR INFECTION, and ANAEMIA. He needs referral for his severe classification. Of his identified treatments listed below, which are the urgent, pre-referral treatments that he requires immediately? a. Treat the child to prevent low blood sugar b. Dry the ear by wicking c. Assess feeding and counsel the mother on feeding 23. A 6-month-old (7.4 kg) child has PNEUMONIA and MASTOIDITIS. What treatments and dosages will you provide at the clinic right now? a. Ceftriazone IM, 500 mg (dilute in 2 ml sterile water) b. Amoxicillin syrup, 15 ml (125 mg/5 ml) c. Cotrimoxazole syrup, 5 ml (40/200 mg) 24. Which of the following is one of the 4 rules of home treatment of diarrhoea? a. Give zinc supplements b. Give iron c. Maintain feeding 25. A child has the following classifications: no general danger signs, diarrhoea with NO DEHYDRATION, PERSISTENT DIARRHOEA, NO ANAEMIA, and NO SEVERE ACUTE MALNUTRITION. What signs will you teach the mother to watch for, to return immediately? a. Child vomits more than 4 times a day b. Not able to drink or breastfeed c. If palmor pallor doesn’t improve in 30 days

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26. Read the description of the following case and answer the questions. Rena is 5 months old and weighs 4 kilograms. She is classified SEVERE ACUTE MALNUTRITION. When you assess Rena’s feeding, her mother tells you that she breastfeeds 4 times in 24 hours and also gives Rena cow’s milk by feeding bottle 2 times per day. The mother explains that she gives no other foods to Rena and her feeding did not change during this illness. What are Rena’s feeding problems? a. She is not being breastfed enough – she should breastfeed at least 8 times in 24 hours. b. She should be receiving more cow’s milk. c. Rena has no feeding problems. 27. What feeding advice is needed? a. Rena should be receiving cow’s milk in addition to breastfeeding b. If fluid other than breastfeeding is given, it is safest to give by bottle, not cup c. Breastfeeding should be exclusive until 6 months. 28. Read this discussion. The health worker asks the mother a checking question to check her understanding. Health worker: What foods will you provide to the child? Mother: Nutritious foods. How would you ask a second checking question of the mother? a. Do you remember what foods are nutritious? b. What are these nutritious foods that you can give the child? c. Yes, you will give nutrition foods. 29. It is important to ask good checking questions to ensure that a mother understood well your treatment instructions. How could you ask: “Do you remember how to give the syrup? ” as a checking question? a. Do you know what syrup to give? b. Will you remember to give the syrup twice a day? c. How will you give the syrup? 30. A child returns for follow-up care with PNEUMONIA and still has fast breathing. Before making any treatment decisions you need to determine if the caretaker was giving the oral antibiotic properly. a. TRUE b. FALSE

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A4.6 WRITTEN EXAMINATION: QUESTIONS FOR OPTIONAL MODULES EAR PROBLEMS 1. Read the case: Dana is 18 months old. She weighs 9 kg. Her temperature is 37 °C. Her mother said that Dana had discharge coming from her ear for the last 3 days. Dana does not have any general danger signs. She does not have cough or difficult breathing. She does not have diarrhoea and she does not have fever. You asked about Dana’s ear problem. The mother said that Dana does not have ear pain, but the discharge has been coming from the ear for 3 or 4 days. You can see pus draining from the child’s right ear. You do not feel any tender swelling behind either ear. How would you classify Dana? a. FEVER OTHER CAUSE, MASTOIDITIS b. ACUTE EAR INFECTION c. CHRONIC EAR INFECTION 2. To be classified as having MASTOIDITIS a child must have the following signs: a. Tender swelling behind the ear b. Severe ear pain and redness behind the ear c. Pus draining from one of child’s ear WELL CHILD CARE 1. What is the interval for administering Pneumococcal vaccine in children? a. 4 weeks b. 6 weeks c. 8 weeks 2. At what age do we begin giving Vitamin A to children? a. 12 months b. 9 months c. 6 months 3. What activities would you recommend for play for child between 6–9 months? a. Making noises with household objects b. Stacking objects and putting them inside of each other c. Identifying simple words, like household objects 4. A child beginning to crawl is an example of what kind of skill? a. Cognitive b. Adaptive c. Motor

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5. What will you recommend to families about storing chemicals and medicines in the home: a. Store in clear water or soda bottles so it is easily identifiable b. Store in child-resistant bottles and out of reach c. Tell children to stay out of parent’s things HIV/AIDS 1. What is the role of the immune system? a. Ridding the body of toxins via urine b. Protecting the body against infections c. Circulating oxygen flow throughout the body 2. What does a CD4 count or percentage tell you? a. The amount of HIV in the body b. How much HIV virus has been destroyed by co-trimoxazole c. The severity of damage to the body’s immune system that HIV has caused 3. What is an example of an opportunistic infection? a. Herpes zoster b. Measles virus c. Rubella virus 4. A child can be infected with HIV from his mother: a. At the time of delivery and after birth when kissing the child b. During pregnancy, at the time of delivery, and after birth when hugging or holding the child c. Pregnancy, at the time of delivery, and after birth through breastfeeding 5. Methods to reduce the risk of transmission from mother-to-child include: a. Delivering at home b. Breastfeeding with complementary foods at a young age to enhance the child’s nutritional status c. Prophylaxis to lower the mother’s viral loads during pregnancy, delivery, and breastfeeding 6. Tsidi is 13 months old, and her mother is HIV positive. Tsidi has not been tested before. She has not breastfed for the last 7 months. What test will you provide? a. Virological (PCR) b. Antibody (rapid) c. She does not require testing

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7. What is a virological (PCR) test? a. An HIV test that detects antibodies of the virus in the body. It is recommended for all testing of children under 18 months old. b. A virological test that is recommended for all children who are currently breastfeeding. c. An HIV test that detects that actual presence of the virus. It is recommended for all testing of children under 18 months old. 8. Zinsi is 8 months old, and is still breastfeeding. Her mother is HIV positive. Zinsi’s PCR test is negative, and she has no features of HIV infection. a. She should be assumed to be free of HIV infection b. The PCR test needs to be repeated after stopping breastfeeding for 6 weeks c. The PCR should be repeated after Zinsi is 18 months old 9. Leboheng is 3 months old. His mother is HIV positive, but he has not been tested. How will you classify? a. CONFIRMED HIV INFECTION b. HIV EXPOSED c. HIV UNLIKELY 10. An 8 week old boy is brought to your clinic. He was abandoned at birth. He had a PCR test done at 6 weeks, and it was negative. How will you classify? a. CONFIRMED HIV INFECTION b. HIV EXPOSED c. HIV UNLIKELY 11. Greg is 20 months old. You administered an antibody test, which was positive, and you classified him CONFIRMED HIV INFECTION. Now it is important to ensure that: a. Give Nevirapine prophylaxis once a day b. Determine his clinical stage c. Begin co-trimoxazole prophylaxis immediately 12. Which of the following is an ART severe sign? a. Runny nose b. Severe abdominal pain c. Nausea 13. In advising about HIV care, you should tell the caretaker and/or the child: a. ART drugs can be taken anytime during the day. b. ART drugs must be taken everyday for life at the exact same time. c. Drug doses can be doubled if he/she forgets to take it one day.

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14. Liam is 7 months old, and tested negative (PCR) at 6 months of age. He stopped breastfeeding at 3 months. He weighs 8kg today. Should he begin cotrimoxazole? a. Yes, 2.5 mL daily b. No c. Yes, 5 mL daily 15. Jo began first-line ART 6 weeks ago, and his mother brought him to the clinic today because he has yellow eyes. What actions will you take? a. Stop the medications and refer urgently b. Change the dosing of Abacavir c. Give paracetamol 16. All children confirmed HIV positive will immediately begin ART. You will use the 6 steps. a. TRUE b. FALSE 17. Co-trimoxazole prophylaxis has been effective in reducing mortality of HIV infected children. a. TRUE b. FALSE 18. ART can cure HIV with good adherence a. TRUE b. FALSE 19. Working with a caretaker on drug adherence is a critical step in HIV care for the child. You may have to delay ART initiation if you feel the caretaker is not ready. a. TRUE b. FALSE 20. Once a child starts ART, they usually respond very well. The child does not need regular follow-up. a. TRUE b. FALSE

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A4.7 WRITTEN EXAMINATION ANSWER SHEET IMCI DISTANCE LEARNING COURSE NAME MEETING SITE DATE

INSTRUCTIONS: Completely fill the circle of the best answer. Be careful to mark the correct question number. You may use your IMCI Chart Booklet and recording forms. You will have 30 minutes to complete the exam.

CORRECT INCORRECT



✔ ✘ a b

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

a a a a a a a a a a a a a a a

b b b b b b b b b b b b b b b

c c c c c c c c c c c c c c c

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

a a a a a a a a a a a a a a a

b b b b b b b b b b b b b b b

c c c c c c c c c c c c c c c

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A4.8 MULTIPLE-CHOICE EXAMINATION ANSWER KEY RECOMMENDATION: The correct answers have been noted below. Print an answer key for each grading facilitator, and punch out the correct answers. Facilitators can overlay the answer key on the participant’s answer sheet for quicker marking. THIS ANSWER KEY INCLUDES THE STANDARD 30-QUESTION EXAMINATION (ANNEX 4.5). ON THE FOLLOWING PAGE THERE ARE ANSWERS TO THE OPTIONAL MODULES’ QUESTIONS (ANNEX 4.6).

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

b a b a a b a b a a a a a a a b b b b b

c c c

16. 17. 18. 19.

b a a b a b b a b b a b a a a b b b

c c c c c c c

c c c c

20. 21. 22. 23. 24.

c c c

c

25. 26.

c

27. 28. 29.

c

c

30.

c

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OPTIONAL MODULES: EAR PROBLEMS 1. 2.

HIV/AIDS

a b

c c

1. 2. 3. 4.

a a b b a a b b b a a a a a a a a b b b b a b a b b b

c

WELL CHILD CARE 1. 2. 3. 4. 5.

c

b a b

c 5. 6.

b a a b

c 7. 8.

c

c 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

c c

c

c

c c c c c c

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A4.9 INDIVIDUAL ACTION PLAN OVERVIEW: This is an opportunity for you to think about your continued goals for using IMCI in your clinic, and continued learning. This is a personal plan that you will keep. Take this time to record some of your thoughts before the group discusses ideas and opportunities.

USING IMCI IN YOUR CLINIC 1. How do I want to use IMCI in my clinic?

2. How do I want to improve the ways I am using IMCI in my work?

CONTINUED LEARNING & REFRESHING SKILLS 3. How will I continue to learn new skills in integrated case management and caring for sick children and young infants?

4. How will I refresh my skills in IMCI?

WORKING WITH OTHERS 5. How will I work with mentors? What mentors are available to me, especially if I have questions or problems with a case using IMCI?

6. How will I share IMCI and the IMCI job aids with colleagues and others in my work environment?

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A4.10 COURSE EVALUATION NAME MEETING SITE DATE

1. As you finish this course, do you feel prepared to use integrated case management with children in your clinic?

2. What areas or skills do you still have concerns about?

3. What are two things that you found the most useful during your self-study?

4. What are two things you would improve about the self-study process?

5. What did you find most useful during the face-to-face meetings?

6. How can the facilitators improve the face-to-face meetings?

7. Would you recommend this course to colleagues? Why or why not?

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PowerPoint slides CONTENTS A5.1 Orientation A5.2 Review & Practice A5.4 Final Synthesis 189 215 235

ANNEX 5

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A5.1 ORIENTATION POWERPOINT SLIDES

DISTANCE   LEARNING   COURSE    

Integrated   Management  of   Childhood  Illness  

Orienta>on    

1st  of  three  face-­‐to-­‐face  mee.ngs  

Distance-­‐learning  IMCI  

Materials  you  are  geCng  today:    

1. 

SELF  STUDY  MODULES   Introduc>on  

2.    LOGBOOK  

     

Module  1   Module  2  

Distance-­‐learning  IMCI  

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Course  objec>ves   At  the  end  of  this  distance  learning  course,  you  will  be  able  to:    

Implement  integrated  case  management  for   common  health  problems  in  sick  young  infants   and  children     Use  the  IMCI  chart  booklet  and  recording  forms   in  your  clinical  prac.ce     Counsel  caretakers  on  home  treatment,   feeding,  well  child  care,  and  disease  preven.on    

Distance-­‐learning  IMCI  

Why  distance  learning?     Flexibility:  allows  you  study  on  your  own  .me  

and  saves  on  travel  =  more  healthcare  providers   can  be  trained  in  IMCI       Learner-­‐driven:  you  focus  with  facilitators  on  the   issues  you  are  facing     Learning  involves:      3  face-­‐to-­‐face  mee.ngs  with  facilitators      studying  modules  on  your  own      prac.cing  IMCI  skills  in  your  home  facili.es            working  with  a  mentor  during  prac.ce      group  studying   Distance-­‐learning  IMCI  

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dIMCI  course  structure   1st  face-­‐to-­‐face     mee.ng     (today)   3-­‐4  weeks  

Orienta>on    

Review  &  prac>ce     2nd  face-­‐to-­‐face     mee.ng  

Final  synthesis     3rd  face-­‐to-­‐face     mee.ng      

(1  day)   6-­‐8  weeks  

 

 

(1  day)  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

Prac>ce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance-­‐learning  IMCI  

2  to  3  months  

What  do  you  need  to  succeed  in  dIMCI?      You  need  to  devote  .me,  energy,  and  commiJment  –  

IMPORTANT!  

you  need  to  be  mo.vated!   IMCI  tools  

   You  need  to  prac.ce  seeing  children  and  using  the      You  need  to  work  with  others  (colleagues,  study  

groups,  and  mentors)  –  this  is  cri.cal  for  learning  and   skills  development  

   If  you  do  not  know  something  -­‐>  ASK!  SEEK  HELP!   Distance-­‐learning  IMCI  

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Orienta>on  objec.ves   At  the  end  of  today,  you  should  be  able  to:       Explain  the  objec.ves  and  structure  of  this  distance  learning  course,  including  the   importance  of  clinical  prac.ce,  mentors,  and  study  groups                      

Iden.fy  key  causes  of  childhood  mortality   Explain  the  meaning  and  purpose  of  integrated  case  management   Describe  the  major  steps  in  the  IMCI  process   Demonstrate  how  chart  booklets  and  recording  forms  are  IMCI  job  aids   Recognize  the  general  danger  signs  in  children   Iden.fy  important  care  for  young  infants   Explain  the  importance  of  assessing  for  signs  of  severe  disease  and  feeding  problems   in  young  infants   Describe  how  a  welcoming  environment  is  important  for  case  management   Explain  and  demonstrate  key  communica.on  skills   Plan  self-­‐study,  group  study,  and  clinical  prac.ce  for  Modules  1  and  2  

  Distance-­‐learning  IMCI  

SECTION  2   Crea.ng  a  welcoming  environment  

TBD        IMCI  DVD  “General  danger  signs”    Disc  1,  4:00  minutes      

Instruc>ons  for  par>cipants:  open  your  Chart  Booklets  to  the  correct  chart  for   the  sick  child.    Take  out  a  recording  form  for  the  sick  child;  these  signs  are  the   first  box.  

Distance-­‐learning  IMCI  

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SECTION  3   CAUSES  OF  CHILDHOOD  ILLNESS  

Distance-­‐learning  IMCI  

What  causes  children  to  die  globally?   Measles   1%   AIDS   2%   NCD   4%   Injury   5%   Malaria   7%   Diarrhoea   10%   Other   16%  

Undernutri>on   Underlying  cause  in   up  to  50%  of   childhood  deaths  

Perinatal   39%  

ARI   16%  

ARI:  acute  respiratory  infec>on   NCD:  non-­‐communicable  disease  

Source:  WHO  Global  Health  Observatory,  2010   Distance-­‐learning  IMCI  

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How  does  inequity  relate  to  health?   Children  have  a  higher  risk  of   dying  before  age  5  if  they:      

•  live  in  poorer  households   •  live  in  rural  areas   •  their  mothers  have  less   educa>on    

Source:   UNICEF/WHO   Child  Mortality  Report  2011   Distance-­‐learning   IMCI  

Key  points  about  child  mortality   1.  2. 

Most  children  die  of  preventable  causes   Major  killers  of  children  under  5     Neonatal  condi.ons  (infec.ons,  asphyxia,  prematurity).    Babies  

with  low  birthweight  account  for  70%  of  all  newborn  deaths.       Diarrhoea     Pneumonias   3.  4.  5. 

Malnutri>on  is  an  underlying  cause  in  up  to  half  of  deaths     HIV  is  an  underlying  cause  in  many  countries   Economic,  social,  poli.cal,  and  cultural  factors  impact  child   health.    Poorer  households  and  rural  communi.es  have  higher   child  mortality.    Women’s  educa.on  is  important  to  child  health.  

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What  is  the  PROBLEM     that  IMCI  wants  to  address?   Common  (and  oken  overlapping)   causes  of  childhood  mortality  

Fever  

Cough  

Diarrhoea   Distance-­‐learning  IMCI  

Ear  problems  

SECTION  4   THE  IMCI  STRATEGY  

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ASSESS   CLASSIFY   &  IDENTIFY   TREATMENT  

ASK,  LOOK,  LISTEN,  and  FEEL  for:   •  Signs  of  severe  illness   •  Main  symptoms  and  common  health  issues   BASED  ON  SEVERITY  OF  CLASSIFICATION:   •  RED:  severe,  urgent  referral  required   •  YELLOW:  treat  in  clinic   •  GREEN:  home  treatment  

TREAT   COUNSEL   FOLLOW-­‐UP   Distance-­‐learning  IMCI  

INTEGRATED  TREATMENT  FOR  ALL  CLASSIFICATIONS  

THE  CARETAKER  ON  HOME  TREATMENT  &  FOLLOW-­‐UP  

ON  CARE  AND  RE-­‐ASSESS  

Age-­‐specific  charts   FOR  ALL  SICK  CHILDREN  up  to  5  years  who  are  brought  to  the  clinic   GREET  THE  CARETAKER  and  ASK  THE  CHILD’S  AGE  

If  child  is  up  to  2  MONTHS  

If  child  is  from     2  MONTHS  up  to  5  YEARS   Use  the  charts:   !ASSESS  &  CLASSIFY  THE  SICK  CHILD   !TREAT  THE  CHILD   !COUNSEL  THE  MOTHER   In  this  course,  read  more  in:   !MODULES  1,  3,  4,  5,  6,  and  7    

Use  the  chart:   !ASSESS,  CLASSIFY,  AND  TREAT  THE   SICK  YOUNG  INFANT   In  this  course,  read  more  in:   !MODULE  2     Distance-­‐learning  IMCI  

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Assess and classify the sick child aged 2 months up to 5 years ASSESS AND CLASSIFY ASSESS ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE CHILD'S SYMPTOMS AND PROBLEMS 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:

CLASSIFY

IDENTIFY TREATMENT

CHECK FOR GENERAL DANGER SIGNS Ask: Look: Is the child able to drink or See if the child is lethargic breastfeed? or unconscious. Does the child vomit Is the child convulsing everything? now? Has the child had convulsions? Any general danger sign URGENT attention Pink: VERY SEVERE DISEASE Give diazepam if convulsing now Quickly complete the assessment Give any pre-referal treatment immediately Treat to prevent low blood sugar Keep the child warm Refer URGENTLY.

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS: Does the child have cough or difficult breathing? If yes, ask: For how long? Look, listen, feel: Count the breaths in one minute*. Look for chest indrawing. Look and listen for stridor. Look and listen for wheezing. CHILD MUST BE CALM Classify COUGH or DIFFICULT BREATHING Any general danger sign or Stridor in calm child. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA Give first dose of an appropriate antibiotic Refer URGENTLY to hospital**

Chest indrawing or Fast breathing.  




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Give oral Amoxicillin for 5 days*** If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** If chest indrawing in HIV infected child, give first dose of amoxicillin and refer to hospital. Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for further assessment or consider TB or asthma Advise mother when to return immediately Follow-up in 3 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 5 days if not improving

No signs of pneumonia or very severe disease.

Green: COUGH OR COLD

Assess  &  classify  (charts)   If wheezing and either fast breathing or chest indrawing: Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for chest indrawing again, and then classify. If the child is: 2 months up to 12 months 12 Months up to 5 years Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more *If pulse oximeter is available, determine oxygen saturation and refer if < 90%. ***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings. **** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried.

** If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care.

 




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Iden>fy  treatment  (column)  

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Treat  the  child  (charts)  

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Counsel  the  caretaker  (charts)    

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Provide  follow-­‐up  care  (charts)   At  boCom  of  TREAT  THE  CHILD  charts  

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General  Danger  Signs   1.  2.  3. 

ASK:  is  child  unable  to  drink  or  breasieed?   ASK:  does  the  child  vomit  everything?   ASK:  has  child  had  convulsions  during  the  current  illness,  or   LOOK:  is  child  convulsing  now?    

Muscles  are  contrac.ng,  arms  and  legs  s.ffen,  and  child  may  lose   consciousness  or  cannot  respond  

4. 

LOOK:  is  child  lethargic  or  unconscious?    

Child  doesn't  respond  or  show  interest,  cannot  be  wakened  if   unconscious.    Eyes  might  be  open.    

  Distance-­‐learning  IMCI  

These  are  signs  of  very  serious  illness.       If  one  or  more  present,  urgently  refer.  

   

 VIDEO  REVIEW      IMCI  DVD  “General  danger  signs”    Disc  1,  4:00  minutes

 

 

Instruc>ons  for  par>cipants:  open  your  Chart  Booklets  to  the  correct  chart   for  the  sick  child.    Take  out  a  recording  form  for  the  sick  child;  these  signs   are  the  first  box.  

   

 VIDEO  EXERCISE    IMCI  DVD  “Assess  general  condiHon”    Disc  1,  6:00  minutes

 

Instruc>ons  for  par>cipants:  you  will  evaluate  4  children  for  the  general   danger  sign  lethargy  or  unconsciousness.    Write  your  answers  down.

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SECTION  4   THE  IMCI  STRATEGY  

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CASE  STUDY:  BIKI   How  does  your  form  compare?   What  quesHons  do  we  have  about  Biki’s  case  and  the  form?   MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME   Biki AGE   7 mo WEIGHT   9 kg TEMP    37°C ASK:  what  are  the  child's  problems?   Not feeding well Grandma gives milk, won’t take today ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS       CONVULSIONS     CONVULSING  NOW   Ini>al   X visit      Follow-­‐up   CLASSIFY   General  danger  signs   present?   X  YES                  NO    

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How  well  did  the  health  worker  use  the  form?  

MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME   AGE   6 wks WEIGHT   3.2kg TEMP   Ini>al  visit   X Follow-­‐up      CLASSIFY   General  danger   signs  present?   X YES                  NO     Use  when  classifying          

       °C  

ASK:  what  are  the  child's  problems?  

Not feeding well

ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS   Distance-­‐learning  IMCI  

    CONVULSIONS     CONVULSING  NOW  

How  well  did  the  health  worker  use  the  form?   Incorrect  form!    This  is  a  sick  young  infant  under  2  months  of  age   Name  not  recorded   NAME   AGE   6 wks

No  temperature  recorded   WEIGHT   3.2kg TEMP   Ini>al  visit   X Follow-­‐up      CLASSIFY   General  danger   signs  present?   X YES                  NO     Use  when  classifying          

MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS          °C  

ASK:  what  are  the  child's  problems?  

Not feeding well Young  infants  show  different  signs  of  severe  illness   ASSESS  (circle  all  signs  present)       CONVULSIONS     CONVULSING  NOW  

1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS   Distance-­‐learning  IMCI  

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How  well  did  the  health  worker  use  the  form?   MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME  

Sara

AGE   3 mo

WEIGHT  

kg TEMP  

36

°C

ASK:  what  are  the  child's  problems?  

Ini>al  visit   Follow-­‐up  

X   

ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS       CONVULSIONS     CONVULSING  NOW  

CLASSIFY   General  danger   signs  present?     YES              X NO     Use  when  classifying          

Distance-­‐learning  IMCI  

How  well  did  the  health  worker  use  the  form?   No  weight  recorded   MANAGEMENT  OF  THE  SICK  CHILD  AGED  2  MONTHS  TO  5  YEARS   NAME  

Sara

AGE   3 mo

WEIGHT  

kg TEMP  

36

°C

ASK:  what  are  the  child's  problems?  

Need  to  ask  caretaker  about  the  child’s  problems   and  record   ASSESS  (circle  all  signs  present)       CONVULSIONS     CONVULSING  NOW  

Ini>al  visit   Follow-­‐up  

X   

CLASSIFY   General  danger   signs  present?     YES              X NO     Use  when  classifying          

1.  CHECK  FOR  GENERAL  DANGER  SIGNS   UNABLE  TO  DRINK/BREASTFEED   VOMITS  EVERYTHING   LETHARGIC  OR  UNCONSCIOUS  

Unclear  if  child  does  or  doesn’t   have  sign;  should  circle  if  sign   present   IMCI   Distance-­‐learning  

Child  has  a  general  danger  sign,   but  it’s  incorrectly  marked  

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SECTION  5   CLINICAL  PRACTICE   Important  notes  for  clinical  prac>ce:     Our  .me  is  limited  –  it  is  important  to  move  quickly,   pay  aJen.on,  and  ask  ques.ons!     Bring  your  IMCI  chart  booklets     Bring  IMCI  recording  forms     Bring  materials  for  notes  as  required     Our  plans  for  gerng  to  the  clinic  and  lunch   Distance-­‐learning  IMCI  

SECTION  6   USING  IMCI  WITH  THE  SICK  YOUNG  INFANT  

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Important  young  infant  care    

Breasieed  exclusively,  and  every  .me  infants   wants  to  feed  (day  and  night)   Keep  infants  warm  by  skin-­‐to-­‐skin  contact   Maintain  good  hygiene      

   

 

Wash  hands  before  holding  infant   Clean  umbilical  cord  and  area  

   

Immuniza>ons   Seek  immediate  care  if  signs  of  severe  disease  

Distance-­‐learning  IMCI  

IMCI  FOR  THE  SICK  YOUNG  INFANT  (up  to  2  months  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  young  infant)     ASK:  what  are  the  infant's  problems?    

GREET  THE  CARETAKER  

 ASK:  ini.al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

ASSESS  for     GENERAL  DANGER  SIGNS    for  very  severe  disease   All  danger  signs   require  urgent   referral  

Even  if  present  

CLASSIFY  

  Jaundice       Diarrhoea     HIV  status  or  mother’s  HIV  status       Feeding  problem  and  growth     Check  immuniza.ons             Assess  other  problems  &  mother’s  health  

ASSESS  MAIN  SYMPTOMS  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral         (RED)  

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

  in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED  

  at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

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   

 VIDEO  REVIEW      IMCI  DVD  “DemonstraHon:  assessment  of  sick  young  infant”    

Disc  2,  14:00  minutes  

Instruc>ons  for  par>cipants:  this  video  does  not  have  the  same  signs  as  your   Chart  Booklet  and  recording  form,  because  these  were  recently  changed.     The  idea  of  watching  the  video  is  to  see  the  process  of  assessing  a  young   infant.      

   

 VIDEO  REVIEW      IMCI  DVD  “DemonstraHon:  breasWeeding  assessment”    

Disc  2,  9:00  minutes  

Instruc>ons  for  par>cipants:  Open  to  your  charts  on  assessing  breasueeding.     Follow  your  chart  booklets  and  recording  forms  to  see  how  these  tools  guide   you  through  the  assessment.      

Distance-­‐learning  IMCI  

SECTION  7   GOOD  COMMUNICATION  &  COUNSELLING  SKILLS  

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APAC  process    ASK  &  LISTEN  to  what  the  child’s  problems  

are  and  what  the  caretaker  is  already  doing  

 PRAISE  caretaker  for  what  she  has  done  well    ADVISE  her  how  to  care  for  her  child  at  home  

and  when  to  return  

 CHECK  the  caretaker’s  understanding  

  Distance-­‐learning  IMCI  

Teaching  caretakers:   ♦ 

Ask  &  listen   Praise   Advise   Check  

Use  understandable  words   Focus  on  most  important   messages   Be  calm  and  reassuring   Show  an  example,  using  familiar   items   Give  feedback  during  prac.ce   and  affirm.     Encourage  ques.ons.    Answer  all   of  them.  

1.  Give   informa>on  

♦ 

♦  ♦ 

3.  Let   caregiver   prac>ce  

2.  Show  an   example  

♦ 

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Checking  ques>ons:  

Ask  &  listen   Praise   Advise   Check  

  Use  these  to  check  that  a  caretaker  understands  what  you  

have  explained     These  are  open-­‐ended  ques>ons  (begin  how,  what,  why)     Avoid  ques.ons  that  can  be  answered  yes  or  no,  or  that   lead  to  right  answer    

Distance-­‐learning  IMCI  

Are  these  good  checking  quesHons?   → How  will  you  prepare  ORS?   → Should  you  breasueed  your  child?   → How  much  extra  fluid  will  you  give  aker  each  loose  stool?   → Will  you  remember  to  wash  your  hands?   → Where  on  the  eye  will  you  put  the  ointment?  

       

 VIDEO  REVIEW      WHO  “Good  communicaHon  skills”  

   

Instruc>ons  for  par>cipants:  this  video  will  review  many  of  the  skills  we  have   just  learned  about.    Take  notes  on  the  skills  that  you  recognize.    Take  notes   on  areas  where  the  health  worker  does  well,  or  where  the  health  worker   could  improve.      

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IF  PARTICIPANT  ROLE-­‐PLAYS  WILL  BE  USED  THE   FOLLOWING  3  SLIDES  APPLY:  

Distance-­‐learning  IMCI  

Discussion  ques>ons  for  role-­‐play   1.  2. 

Did    the  health  worker  get  all  important  informa.on?   Did  the  health  worker:        

Use  the  APAC  process   Use  the  3  teaching  steps  (explain,  demonstrate,  ask  to  prac.ce)   Use  checking  ques.ons  to  check  caretaker’s  understanding  

3. 

Caretaker:  what  did  the  health  worker  do  well?    What   could  be  improved?   Observer:  what  did  the  health  worker  do  well?    What  could   be  improved?   Health  worker:  what  would  you  do  differently  next  .me?  

4. 

5. 

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JON  exercise   MANAGEMENT  OF  THE  SICK  CHILD  AGE  2  MONTHS  TO  5  YEARS   NAME  

Jon

AGE  

12

mo

WEIGHT  

10

kg

TEMP   Ini>al  visit   Follow-­‐up  

37°C

ASK:  what  are  the  child's  problems?  

Cough for several days, worsening ASSESS  (circle  all  signs  present)   1.  CHECK  FOR  GENERAL  DANGER  SIGNS                NOT  ABLE  TO  DRINK  OR  BREASTFEED                VOMITS  EVERYTHING                CONVULSIONS     LETHARGIC  OR  UNCONSCIOUS   CONVULSING  NOW  

x

  

CLASSIFY   Danger  sign  present?   Remember  to  use  danger   sign  when  selecHng   classificaHons          

YES              

x NO  

2.  DOES  THE  CHILD  HAVE  COUGH  OR  DIFFICULT  BREATHING?  X YES      NO   For  how  many  days?  

3-4

Count  number  of  breaths  in  one  minute:   Fast  breathing?   YES        NO   Look  for  chest  indrawing   Look  and  listen  for  stridor/wheeze   Distance-­‐learning  IMCI  

X

48/min

AMIRA  exercise   MANAGEMENT  OF  THE  SICK  YOUNG  INFANT  AGE  UP  TO  2  MONTHS   NAME  

Amira

AGE  

4 wks

WEIGHT  

3

kg

TEMP  

38 X   

°

C

ASK:  what  are  the  child's  problems?  

Baby is feverish

Ini>al  visit   Follow-­‐up  

53  

Possible severe bacterial infection  

Distance-­‐learning  IMCI  

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SECTION  8   NEXT  STEPS  

Distance-­‐learning  IMCI  

COURSE  CALENDAR   Orienta>on   1st  face-­‐to-­‐face   mee.ng   SESSIONS           Introduce  IMCI  process   Distribute  learning  materials  &  introduce  content  to   Modules  1  and  2   Review  distance  learning  course  structure  &   expecta.ons   Provide  clinical  prac.ce   Read  modules     Self-­‐assessment  exercises  in  modules  as  you  read   Prac.ce  in  clinic  and  record  cases  on  recording   forms  in  logbook   Hold  study  group  discussions   Maintain  contact  with  mentors  &  facilitators   Complete  assessment  exercises  in  logbook   Review  progress  &  issues  in  self-­‐study   Examine  cases  from  clinical  prac.ce   Introduce  content  from  upcoming  modules   Provide  clinical  prac.ce   Read  modules     Self-­‐assessment  exercises  in  modules  as  you  read   Prac.ce  in  clinic  and  record  cases  on  recording   forms  in  logbook   Hold  study  group  discussions   Maintain  contact  with  mentors  &  facilitators   Complete  assessment  exercises  in  logbook   Review  progress  &  issues  in  self-­‐study   Examine  cases  from  clinical  prac.ce   Review  content  from  all  modules   Provide  clinical  prac.ce   Individual  plans  for  con.nued  learning   Course  assessment  (skills  sta.ons  and  wriJen  exam)  

OBJECTIVES  

LOCATION  

  TBD      

   

DATE  

TBD           (3-­‐4  weeks)  

  Self-­‐study  period  1         Modules  1  &  2        

      Home  facili.es     TBD             Home  facili.es       TBD                

Review  &  prac>ce   2nd  face-­‐to-­‐face   mee.ng    

           

TBD            (8-­‐9  weeks)  

  Self-­‐study  period  2        Remaining   modules                 Final  synthesis          rd    3  face-­‐to-­‐face     mee.ng           Distance-­‐learning  IMCI  

TBD    

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Course  materials   1. 

STUDY  MODULES   LOGBOOK  

   Includes  overview  of  course  and  IMCI      Prac.ce  exercises  as  you  read  

2. 

   Complete  exercises  for  each  module  

   Complete  2  recording  forms  for  each  module  

You  will  submit  your  logbook  at  each  mee>ng;  the  exercises   and  recording  forms  count  for  up  to  33%  of  your  course  mark  

from  cases  that  you  prac.ce  in  your  clinic      Use  checklist  of  clinical  signs  

3. 

CHART  BOOKLET  

Distance-­‐learning  IMCI  

SELF-­‐STUDY  MODULES    

1   General  danger  signs      

 

 

2   Care  of  the  sick  young  infant   3   Cough  or  difficult  breathing   4   Diarrhoea   5   Fever   6   Malnutri.on  and  anaemia   AddiHonal,  opHonal  modules:   7   Ear  problems   8   HIV/AIDS   9   Well  child  care   Distance-­‐learning  IMCI  

Study  period  1  

 

Study  period  2  

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Involving  others  in  learning   →     Debrief  your  in-­‐charge  officer  about  the  course  materials  and  how   you  will  use  IMCI  in  your  clinical  prac.ce    

AT  YOUR  CLINIC  

→  •  • 

Mentors  should  be  willing  to  demonstrate  IMCI  skills  in  the  clinic   and  can  help  you  understand  and  apply  the  new  skills   Could  be  a  senior  provider  in  the  district  hospital  or  your  facility,   or  a  colleague  (nurse,  doctor)  who  trained  in  IMCI  

IDENTIFY  A  MENTOR    

 

→ 

 Develop  a  study  plan  

FORM  A  STUDY  GROUP  

Distance-­‐learning  IMCI  

Tips  for  study  groups   →  →  →  →  →  →  → 

Agree  on  date  and  >mes  for  regular  mee.ngs   Set  detailed  reading  goals  (page  numbers)   Read  material  in  advance  &  complete  exercises   Note  down  ideas  that  you  find  confusing   Bring  ques>ons  to  the  group   Talk  about  cases  you  have  seen   Prac>ce  together  in  the  clinic,  as  necessary  

Distance-­‐learning  IMCI  

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Planning  self-­‐study  period  1   SAMPLE  INDIVIDUAL  STUDY  PLAN   WEEK   2! 4! 3! 1! STUDY  PLAN   Read Module 2 (p. 1-21)! Module 1 + 2 recording forms + logbook exercises! GROUP   13 August! 20 August!

Read Module 2 (p. 48-76) + logbook exercises! SAMPLE  STUDY  GROUP  PLAN   DATE  &  TIME   20 Aug, 5-6pm! 27 Aug, 5-6pm! 13 Aug, 5-6pm! LOCATION   Bisho! Bisho! Bisho! MATERIAL   All Module 1 !

Read Module 2 (p. 21-48) + 2 recording forms!

27 August!

LEADER   L.M.! S.T.!

Module 2, assess & classify up to feeding (p.1-21)! Module 2, assess feeding & treat (p.21-48)!

M.T.!

Distance-­‐learning  IMCI  

Next  mee.ng   DATE            LOCATION            

WHAT  DO  I  BRING?     Study  modules       Logbook  (module  1  and  2  exercises  completed)     Recording  forms  from  your  clinical  prac.ce  (4  total  =   2  each  from  modules  1  and  2)     Your  ques.ons  (challenging  cases,  confusing  material)    

AT  THE  NEXT  MEETING  WE  WILL–       Review  self-­‐study  progress     Prac.ce  IMCI  in  clinic     Introduce  new  content  from  upcoming  modules   Distance-­‐learning  IMCI  

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A5.2 REVIEW & PRACTICE POWERPOINT SLIDES

DISTANCE   LEARNING   COURSE    

Integrated   Management  of   Childhood  Illness  

Review  &  PracCce  

2nd  of  three  face-­‐to-­‐face  mee/ngs  

Distance-­‐learning  IMCI  

SECTION  1   OVERVIEW  

Distance-­‐learning  IMCI  

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Course  objecCves   At  the  end  of  this  distance  learning  course,  you  will  be  able  to:    

Implement  integrated  case  management  for   common  health  problems  in  sick  young  infants   and  children     Use  the  IMCI  chart  booklet  and  recording  forms   in  your  clinical  prac/ce     Counsel  caretakers  on  home  treatment,   feeding,  well  child  care,  and  disease  preven/on    

Distance-­‐learning  IMCI  

dIMCI  course  structure   OrientaCon     1st  face-­‐to-­‐face     mee/ng     3-­‐4  weeks  

Review  &  pracCce     2nd  face-­‐to-­‐face     mee/ng     6-­‐8  weeks  

Final  synthesis     3rd  face-­‐to-­‐face     mee/ng      

(1  day)  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

PracCce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance-­‐learning  IMCI  

2  to  3  months  

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Review  &  prac;ce  objec/ves   At  the  end  of  today,  you  should  be  able  to:    Demonstrate  skills  from  Modules  1  and  2  in  a  clinical  

seOng  

 Explain  and  demonstrate  how  to  use  IMCI  chart  

instruc/ons  to  assess,  classify,  and  treat  main   symptoms  and  condi/ons  in  a  sick  child     clinical  prac/ce  for  remaining  modules  

 Plan  self-­‐study,  group  study,  work  with  mentors,  and  

 

Distance-­‐learning  IMCI  

SECTION  2   REVIEW  OF  SELF-­‐STUDY     What  was  your  experience  studying  module  1?     What  was  your  experience  studying  module  2?     What  was  your  experience  using  the  logbook?     How  did  you  prac/ce  IMCI  in  your  clinic?     What  challenges  did  you  have  in  prac/ce?     Any  cases  to  discuss?     How  did  you  study  with  others?     How  did  you  seek  help  for  ques/ons?   Distance-­‐learning  IMCI  

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SECTION  3   ASSESS  &  CLASSIFY  THE  SICK  CHILD  (PART  1)  

Distance-­‐learning  IMCI  

ASSESS   CLASSIFY   &  IDENTIFY   TREATMENT  

ASK,  LOOK,  LISTEN,  and  FEEL  for:   •  Signs  of  severe  illness   •  Main  symptoms  and  common  health  issues   BASED  ON  SEVERITY  OF  CLASSIFICATION:   •  RED:  severe,  urgent  referral  required   •  YELLOW:  treat  in  clinic   •  GREEN:  home  treatment  

TREAT   COUNSEL   FOLLOW-­‐UP   Distance-­‐learning  IMCI  

INTEGRATED  TREATMENT  FOR  ALL  CLASSIFICATIONS  

THE  CARETAKER  ON  HOME  TREATMENT  &  FOLLOW-­‐UP  

ON  CARE  AND  RE-­‐ASSESS  

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IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  ini/al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breas^eed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS           Even  if  present  

  Cough  or  difficult  breathing          Diarrhoea     Fever                              Ear  problems     Malnutri/on  &  anaemia                        HIV  status     Check  immuniza/ons                            Others  

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

   

 VIDEO  REVIEW      IMCI  DVD  “DemonstraIon:  cough  and  difficult  breathing”    

Disc  1,  12:00  minutes  

   

 VIDEO  REVIEW      IMCI  DVD  “DemonstraIon:  assess  and  classify  diarrhoea”      

Disc  1,  9:30  minutes  

InstrucCons  for  parCcipants:  follow  along  with  Chart  Booklet  and  recording  form  

Distance-­‐learning  IMCI  

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SECTION  4   CLINICAL  PRACTICE   Important  notes  for  clinical  pracCce:     Our  /me  is  limited  –  it  is  important  to  move  quickly,   pay  aeen/on,  and  ask  ques/ons!     Bring  your  IMCI  chart  booklets     Bring  IMCI  recording  forms     Bring  materials  for  notes  as  required     Our  plans  for  geOng  to  the  clinic  and  lunch   Distance-­‐learning  IMCI  

SECTION  5   ASSESS  &  CLASSIFY  THE  SICK  CHILD  (PART  2)  

Distance-­‐learning  IMCI  

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For  children  under  2  years  or  weak

Measuring  length  

 

Measuring  height   For  children  2  years  and  older  

Distance-­‐learning  IMCI  

Determining  Z  scores  

You  need:  weight  (kg),  height  or  length  (cm)   7iˆ}…̇vœÀ‡…iˆ}…ÌÊ "9ÓÊ̜ÊxÊÞi>ÀÃÊ­â‡ÃVœÀiî 7iˆ}…̇vœÀ‡iˆ}…ÌÊ, 

ÓÊ̜ÊxÊÞi>ÀÃÊ­â‡ÃVœÀiî

  



 



 

 

 

   

 



 

   



 

7iˆ}…ÌÊ­Ž}®









7iˆ}…ÌÊ­Ž}®



         



  

       





















 

  

 

 





 

 

 

 

  

Distance-­‐learning  IMCI  

iˆ}…ÌÊ­V“®  

iˆ}…ÌÊ­V“®

7"Ê …ˆ`ÊÀœÜ̅Ê-Ì>˜`>À`à 7"Ê …ˆ`ÊÀœÜ̅Ê-Ì>˜`>À`Ã

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PRACTICE:   1.  Girl,  105  cm,  13.5  kg   2.  Girl,  80  cm,  10  kg     3.  Boy,  118  cm,  16  kg   4.  Boy,  100  cm,  13  kg  

Distance-­‐learning  IMCI  

   

 VIDEO  REVIEW      IMCI  DVD  “Assess  and  classify  fever”    

   

Disc  1,  9:30  minutes  

   

 VIDEO  REVIEW      IMCI  DVD  “Assess  for  malnutriIon,  anaemia,  and  ear”      

Disc  2,  8:30  minutes  

InstrucCons  for  parCcipants:  follow  along  with  Chart  Booklet  and  recording  form  

Distance-­‐learning  IMCI  

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SLIDES  FOR  OPTIONAL  MODULES  

Distance-­‐learning  IMCI  

HIV/AIDS  

Distance-­‐learning  IMCI  

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Why  is  IMCI  an  approach  to  improve   paediatric  access  to  treatment  and  care?   BIG  ISSUES:     Coverage  of  child  tes/ng  is  low     Coverage  of  early  infant   diagnosis  is  low     Interna/onal  ART  coverage  is   low:  only  28%  of  children  who   should  be  receiving  ART  are     HIV  requires  quick  management,   especially  for  opportunis/c   infec/ons  and  nutri/on     Children  can  be  lost  in  follow-­‐up   Distance-­‐learning  IMCI  

IMCI  HELPS  HEALTH   WORKERS  TO:   IdenCfy  HIV-­‐exposed  and  infected   children  because  you  will  assess   every  child  you  see   Determine  when  children  should   be  iniCated  on  ART  at  primary  care   level   Provides  guidance  on  management   of  common  issues  for  HIV  infected   children   Provide  close  follow-­‐up  at  primary   care  level  

What  is  special  about  HIV/AIDS   care  in  children?   1. 

HIV  can  progress  very  quickly  in  children          

Early  iden/fica/on  is  cri/cal   Preventa/ve  prophylaxis  to  minimize  infec/on   Rapid  management  of  opportunis/c  infec/ons   Ini/a/ng  ART  when  required  

2.  3.  4. 

HIV  tesCng  methods  are  different  than  adults   ART  formulaCons  are  different  than  adults   Child  need  special  care  to  make  sure  they  are   growing  and  developing  opCmally  

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Types  of  HIV  tes/ng       SEROLOGICAL   TESTS   including  rapid   tests         VIROLOGICAL   TESTS   including  DNA   or  RNA  PCR        

    PRESENCE  OF  HIV   ANTIBODIES          

What  does  test  detect?  

      HIV  an/bodies  pass  from  mother  to  child     An/bodies  can  stay  with  child  up  to  18   months  of  age    

How  can  you  interpret  the  test?  

 

PRESENCE  OF  HIV   VIRUS        

POSITIVE  TEST  IN  CHILD  UNDER  18   MONTHS  IS  NOT  RELIABLE  TO  CONFIRM   INFECTION       Directly  tests  presence  of  virus     Must  be  conducted  aler  child  has   stopped  breas^eeding  for  at  least  6   weeks    

POSITIVE  TEST  ANY  ANY  AGE  CAN   CONFIRM  INFECTION  

HIV  tes/ng  and  breas^eeding   Is  child   breasTeeding?   NOT  BREASTFEEDING,  and   has  not  in  last  6  weeks  

POSITIVE  (+)  test   NEGATIVE  (-­‐)  test   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months.   HIV  EXPOSED  AND/OR  HIV   INFECTED—Manage  as  if   they  could  be  infected.   Repeat  test  at  18  months  or   once  breas^eeding  has  been   discon/nued  for  more  than  6   weeks.   HIV  NEGATIVE   Child  is  not  HIV  infected      

BREASTFEEDING  

Child  can  sCll  be  infected  by   breasjeeding.  Repeat  test   once  breas^eeding  has  been   discon/nued  for  more  than  6   weeks.  

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Early   infant   diagnosis  

HIV-­‐exposed  Infant  or  child  <18  months   Conduct  diagnosCc  viral  testa   Viral  test  available   PosiIve   NegaIve   Viral  test  not  available  

Infant/child  is  likely   infected     <24  months:  immediately   start  ARTb   And  repeat  viral  test   to  confirm  infecCon  

Never  breasjed  

Ever  breasjed  or  currently   breasjeeding   Infant  /child  remains  at  risk   for  acquiring  HIV  infecCon   unCl  complete  cessaCon  of   breasjeedingc   Regular  and  periodic   clinical  monitoring  

   

Infant/child  is   uninfected  

Infant/child  develops  signs  or  symptoms   suggesCve  of  HIV  

Infant  remains  well  and  reaches  9  months  of   age  

Viral  test  not  available  

Conduct  HIV  anCbody  test  at     approximately  9  months  of  age  

Viral  test  available       NegaIve   PosiIve  

PosiIve  

NegaIve  

Viral  test  not  available   assume  infected  if  sick   assume  uninfected  if  well   sick well

Infant/child  is  infected  

Start  ARTb   And  repeat  viral  test  to  confirm   infecCon    

HIV  unlikely  unless  sCll   breasjeedingc  

Distance-­‐learning  IMCI  

Repeat  anCbody  test  at  18  months  of  age   and/or  6  weeks  amer  cessaCon  of   breasjeeding    

When  will  HIV-­‐exposed  infants  receive   ART  prophylaxis?   !"#$%&'##()*+, !"#$$%&"'(")*(+*,"-.'-/01+2)&" #),/"'*3$45+)10"678" "

"#-.$/#0#*&,'##()*+, 9:!"#$$%&"'(")*(+*," -.'-/01+2)&"#),/"'*3$45+)10" 678";'.",#)3$45+)10"<=>?"

NOTE:  this  is  the  recommenda/on  for  both  Op;on  B   and  Op;on  B+  PMTCT  na/onal  policies   Distance-­‐learning  IMCI  

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When  will  infants  and  children  begin   cotrimoxazole  prophylaxis?   THESE  YOUNG  INFANTS…   SHOULD  START…   CONFIRMED  HIV  INFECTION   From  4-­‐6  weeks   HIV  EXPOSED   From  4-­‐6  weeks   THESE  CHILDREN…   SHOULD  START…   CONFIRMED  HIV  INFECTION     As  soon  as  possible   Less  than  12  months  old   1.  When  at  WHO  clinical   CONFIRMED  HIV  INFECTION     stages  2-­‐3-­‐4,  regardless  of   CD4%   12  months  up  to  5  years   2.  When  CD4%  less  than  25%   HIV  EXPOSED   As  soon  as  possible   WHY?   Infant  is  HIV  infected   Infant  is  born  to  HIV   infected  mother   WHY?   Child  is  HIV  infected   This  is  regardless  of   whether  the  child  is   on  ART  or  not.       Child  is  exposed  to   HIV  

Distance  learning  IMCI  

Using  IMCI  to  ini/ate  pediatric  ART        Who  is  eligible  to  ini/ate  ART?  

 

 All  children  who  are  classified  CONFIRMED    HIV  INFECTION      What  is  the  preferred  first  line  ART  regimen?  

Distance-­‐learning  IMCI  

 For  children  under  3  years:      ABC  or  AZT  +  3TC  +  LPV/r        For  children  3  years  and  older  (but  under  35  kg):      ABC  +  3TC  +  EFV       229

 

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INSTRUCTIONS  FOR  EXERCISE   ANTIRETROVIRAL  TREATMENT     Find  the  ART  dosing  tables  in  your  chart  booklet     Using  the  drugs  provided,  prepare  the  dose  for   each  drug  in  the  combina/on  therapy     Call  facilitator  to  check  your  drugs  when  you  are   done  

Distance  learning  IMCI  

WELL  CHILD  CARE  

Distance-­‐learning  IMCI  

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What  is  well  child  care?      Child  development      Child  growth      Preven/on  of  childhood  accidents  

(poison,  road  accident,  drowning,  fall,   burns)  

   Immuniza/ons        Regular  Vitamin  A  and  deworming      Feeding  recommenda/ons  by  age   Distance-­‐learning  IMCI  

What  is  child  growth?  

Physical  development,  changes  in  body   and  strength   Measured  and  monitored:   •  Regular  growth  monitoring  by  weight  and  height/length  

What  is  child  development?   Measured  and  monitored:   •  Development  milestones   •  Play  and  communica/on  

?  

Development  of  mental,  crea/ve,  social,   and  adap/ve  skills  

Distance-­‐learning  IMCI  

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+   Important  concepts  in  child   development      

   

 

Bonding  between  a  mother  and  child   InteracCons  between  a  child  and  caregivers   (where  caregivers  are  aware  and  sensi;ve  to   child,  and  respond  to  needs)   CommunicaCon  between  caregiver  and  child   Crea/ng  ways  for  the  child  to  play  and  develop   skills  (especially  with  homemade  or   inexpensive  items)   Observing  child’s  development  and  milestones  

Distance-­‐learning  IMCI  

Distance-­‐learning  IMCI  

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SECTION  6   INTEGRATED  TREATMENT  

Distance-­‐learning  IMCI  

IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  iniCal  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breasjeed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS       Even  if  present  

   

  Cough  or  difficult  breathing            Diarrhoea     Fever                              Ear  problems     MalnutriCon  &  anaemia                        HIV  status     Check  immunizaCons                            Others    

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance-­‐learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment         FOLLOW-­‐UP  CARE     FOLLOW-­‐UP  CARE  

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+   Giving  the  most  important  advice    

Determine:   1.  2.  3. 

How  much  can  this  caretaker  understand  &  remember?   Is  she  likely  to  come  back  for  follow-­‐up  treatment?    If   so,  some  advice  can  wait.   What  advice  is  most  important  to  get  the  child  well?  

 

Select  instrucCons  essenCal  to  child’s  survival  if   caretaker  confused  or  can’t  remember      

EssenCal:  an/bio/cs,  an/malarial,  fluids  with  diarrhoea   Can  delete  or  delay:  feeding  assessment,  feeding   counselling,  soothing  remedies,  iron  treatment,  etc.  

Distance-­‐learning  IMCI  

Providing  FOLLOW-­‐UP  care    

Follow-­‐up  on  condiCon.    Is  it:            Improving?    Worsening?        The  same?  

   

Re-­‐assess  child  for  any  new  symptoms  or   condiCons   Use  new  recording  form:        FOLLOW  UP  VISIT  

Distance-­‐learning  IMCI  

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SECTION  7   NEXT  STEPS  

Distance-­‐learning  IMCI  

NEXT  STEPS:  self-­‐study  phase  2   •   Read  modules  and  do  wrieen  exercises   3   Cough  or  difficult  breathing  

 

4   Diarrhoea   5   Fever   6   Malnutri/on  and  anaemia    

Study  period  2  

    •   Prac/ce  in  clinic  using  recording  forms   •   Stay  in  contact  with  mentors  and  facilitators   •   Meet  with  study  group   Distance-­‐learning  IMCI  

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SAMPLE  AGENDA:  self-­‐study  phase  2   SAMPLE  INDIVIDUAL  STUDY  PLAN   WEEK  

1!

2! 4! 3!

Module 3 (assess, classify, and treat) + 13 August! 1 form! Module 3 (remaining) + logbook + 1 form!

STUDY  PLAN  

GROUP  

20 August! 27 August!

5   ! 6! 7!

Module 5 (all) + logbook + 2 forms! Module 6 (all) + logbook + 2 forms! Module 7 (all) + logbook + 2 forms! Prepare for exam!

Module 4 (all) + logbook + 2 forms!

4 September! 11 September! 19 September! 24 September!

Distance-­‐learning  IMCI  

NEXT  MEETING:  Final  synthesis     DATE     LOCATION  

   

   

   

   

     

   

  TO  BRING  COMPLETED  –    

  Logbook  exercises:  20  for  each  module     Recording  forms  from  clinic:  2  from  each  module  

  AT  THE  NEXT  MEETING  WE  WILL  -­‐       Prac/ce  IMCI  in  clinical  seOng     Review  content  from  main  symptoms  and  condi/ons     Complete  examina/on  of  your  IMCI  skills     Complete  the  course     Distance-­‐learning  IMCI  

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A5.3 FINAL SYNTHESIS POWERPOINT SLIDES

DISTANCE   LEARNING   COURSE    

Integrated   Management  of   Childhood  Illness  

Final  Synthesis  

3rd  of  three  face-­‐to-­‐face  mee.ngs  

Distance  learning  IMCI  

SECTION  1   OVERVIEW  

Distance-­‐learning  IMCI  

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Course  objecFves   At  the  end  of  this  distance  learning  course,  you  will  be  able  to:    

Implement  integrated  case  management  for   common  health  problems  in  sick  young  infants   and  children     Use  the  IMCI  chart  booklet  and  recording  forms   in  your  clinical  prac.ce     Counsel  caretakers  on  home  treatment,   feeding,  well  child  care,  and  disease  preven.on    

Distance  learning  IMCI  

dIMCI  course  structure   1st  face-­‐to-­‐face     mee.ng     (today)   3-­‐4  weeks  

OrientaFon    

Review  &  pracFce     2nd  face-­‐to-­‐face     mee.ng  

Final  synthesis     3rd  face-­‐to-­‐face     mee.ng      

(1  day)   6-­‐8  weeks  

 

 

(1  day)  

Self-­‐study  period  1     (Modules  1  &  2)  

Self-­‐study  period  2     (Remaining  modules)  

PracFce  IMCI  in  clinic,  using  Chart  Booklets  and  recording  forms   Review  with  study  groups   Work  with  mentors  

Distance  learning  IMCI  

2  to  3  months  

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Final  Synthesis  objecFves   At  the  end  of  today,  you  should  be  able  to:       Explain  and  demonstrate  IMCI  clinical  process  with  sick  children  

and  young  infants   clinical  prac.ce  

  Demonstrate  good  use  of  IMCI  charts  and  recording  forms  in  

  Design  an  individual  ac.on  plan  for  using  IMCI  and  con.nuing  

 

to  improve  skills  

Distance  learning  IMCI  

SECTION  2   REVIEW  OF  SELF-­‐STUDY     What  was  your  experience  studying  the  modules?     Which  modules  gave  you  difficul.es,  and  why?     What  was  your  experience  using  the  logbook?     How  did  you  prac.ce  IMCI  in  your  clinic?     What  challenges  did  you  have  in  prac.ce?     Any  cases  to  discuss?     How  did  you  study  with  others?     How  did  you  seek  help  for  ques.ons?   Distance-­‐learning  IMCI  

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SECTION  3   REVIEWING  INTEGRATED  MANAGEMENT  

Distance-­‐learning  IMCI  

ASSESS   CLASSIFY   &  IDENTIFY   TREATMENT  

ASK,  LOOK,  LISTEN,  and  FEEL  for:   •  Signs  of  severe  illness   •  Main  symptoms  and  common  health  issues   BASED  ON  SEVERITY  OF  CLASSIFICATION:   •  RED:  severe,  urgent  referral  required   •  YELLOW:  treat  in  clinic   •  GREEN:  home  treatment  

TREAT   COUNSEL   FOLLOW-­‐UP   Distance  learning  IMCI  

INTEGRATED  TREATMENT  FOR  ALL  CLASSIFICATIONS  

THE  CARETAKER  ON  HOME  TREATMENT  &  FOLLOW-­‐UP  

ON  CARE  AND  RE-­‐ASSESS  

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IMCI  FOR  THE  SICK  CHILD  (2  months  up  to  5  years  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  child) ASK:  what  are  the  child’s  problems?  

GREET  THE  CARETAKER        

 ASK:  ini.al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

  Unable  to  drink  or  breas\eed   Vomits  everything     Convulsions     Lethargic  or  unconscious All  danger  signs   require  urgent   referral  

CHECK  GENERAL  DANGER  SIGNS           Even  if  present  

  Cough  or  difficult  breathing          Diarrhoea     Fever                              Ear  problems     Malnutri.on  &  anaemia                        HIV  status     Check  immuniza.ons                            Others  

ASSESS  MAIN  SYMPTOMS  

CLASSIFY     in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED     at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance  learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

IMCI  FOR  THE  SICK  YOUNG  INFANT  (up  to  2  months  of  age)   ASK:  child’s  age  (this  chart  is  for  sick  young  infant)     ASK:  what  are  the  infant's  problems?    

GREET  THE  CARETAKER  

 ASK:  ini.al  or  follow  up  visit  for  problems?    MEASURE:  weight  and  temperature  

ASSESS  for     GENERAL  DANGER  SIGNS    for  very  severe  disease   All  danger  signs   require  urgent   referral  

Even  if  present  

CLASSIFY  

  Jaundice       Diarrhoea     HIV  status  or  mother’s  HIV  status       Feeding  problem  and  growth     Check  immuniza.ons             Assess  other  problems  &  mother’s  health  

ASSESS  MAIN  SYMPTOMS  

  IDENTIFY  pre-­‐        referral  treatment     URGENTLY  REFER   Distance  learning  IMCI  

  URGENT  REFERRAL  REQUIRED  

Urgent   referral           (RED)

  IDENTIFY  TREATMENT         IDENTIFY  TREATMENT     TREAT       COUNSEL  caretaker       COUNSEL  caretaker            on  home  treatment       FOLLOW-­‐UP  CARE       FOLLOW-­‐UP  CARE  

  in   Treat     clinic     (YELLOW)     REFERRAL  NOT  REQUIRED  

  at   Treat     home     (GREEN)     REFERRAL  NOT  REQUIRED  

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Kali  case:  ASSESS  &  CLASSIFY    Seven  month  old  (7  kg)  Kali  was  brought  to  the  clinic  because     she  is  coughing  and  seems  very  sick.  Aeer  assessing  Kali,  the   health  worker  finds  that  she  has  no  general  danger  signs,  no   fever  and  no  ear  problem.      She  has  cough  with  fast  breathing,  but  no  chest  indrawing  and   no  stridor  or  wheeze.  She  has  never  had  a  chest  infec.on   before.        She  has  has  diarrhoea  for  5  days,  but  there  is  no  blood.    She   has  sunken  eyes  and  a  slow  skin  pinch.    She  has  no  pallor.        

QuesFon  1:  How  do  you  classify  Kali?    

Distance  learning  IMCI  

Kali  case:  TREAT   1.  What  is  the  appropriate     treatment   for  Kali?   2. 

What  are  the  drug  dosages  and   schedules  required?     What  are  the  major  steps  for   teaching  Kali’s  mother  to  give   oral  an.bio.cs?   How  will  you  label  the  drug   envelope?  

3. 

4. 

Distance  learning  IMCI  

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Kali  case:  COUNSEL     1.  What  are  3  checking  ques.ons  to  ask  Kali’s   2. 

mother  to  make  sure  she  understands  how  to   give  the  oral  drugs?  

When  should  the  mother  bring  Kali  back  to   the  clinic  for  a  follow-­‐up  visit?     When  should  the  mother  bring  Kali  back   immediately?  

3. 

Distance  learning  IMCI  

SECTION  4   CLINICAL  PRACTICE   Important  notes  for  clinical  pracFce:     This  is  our  last  .me  prac.cing  together—clarify  any   ques.ons  or  concerns!     Bring  your  IMCI  chart  booklets     Bring  IMCI  recording  forms     Bring  materials  for  notes  as  required     Our  plans  for  gemng  to  the  clinic  and  lunch   Distance-­‐learning  IMCI  

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SECTION  5   ASSESSMENT:  SKILLS  STATIONS  

SKILLS  STATIONS   Distance  learning  IMCI  

Skills  sta.on  1    

PHOTO  EXERCISE     PHOTOS  1-­‐10  

  Shows  clinical  signs  

  On  your  answer  sheet,  record  the   sign  that  you  iden.fy  in  each  photo  

PHOTOS  10-­‐15     Shows  infants  breas\eeding     On  your  answer  sheet,  record  your   observa.ons  about  aoachment   Distance  learning  IMCI  

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PHOTOGRAPH  1   8  months  old  with   diarrhoea,  restless,   irritable  

PHOTOGRAPH  2   6  weeks  old  with   diarrhoea,  irritable     Distance  learning  IMCI  

PHOTOGRAPH  3  

PHOTOGRAPH  4  

2  years  old,  presenPng   with  high  fever   Distance  learning  IMCI    

4  weeks  old,  not  feeding  well  

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PHOTOGRAPH  5  

PHOTOGRAPH  6  

3  years  old,  not  growing  well     Distance  learning  IMCI  

3  years  old,  history  of  measles    

PHOTOGRAPH  7   4  years  old,  history  of   repeated  malaria  

PHOTOGRAPH  8   40  days  old,  liTle   movement  

Distance  learning  IMCI  

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PHOTOGRAPH  9   30  months  old,  not   growing  well  

PHOTOGRAPH  10   of  5  day  old    Umbilicus   neonate  

Distance  learning  IMCI  

PHOTOGRAPH  11  

PHOTOGRAPH  12    

Distance  learning  IMCI  

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PHOTOGRAPH  13  

PHOTOGRAPH  14    

Distance  learning  IMCI  

PHOTOGRAPH  15  

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Skills  sta.on  2    

VIDEO  EXERCISE      You  will  watch  3  videos  about  3  

different  clinical  signs.     Does  each  child  in  the  video  have   the  sign?     Record  your  answers  on  the  answer   sheet:  YES  or  NO.    

Distance  learning  IMCI  

Skills  sta.on  3    

CASE  STUDY  ZINET   Read  the  case  and  answer  the  quesPons  on  your  answer  sheet:   Zinet  is  2  years  old.    Her  mother  brought  her  for  an  ini.al  visit  for   cough  and  bloody  diarrhoea.    She  has  had  the  diarrhoea  for  2  days.   Her  weight  is  9.0  kg.    She  has  a  temperature  of  38.6oC.           On  assessment  you  find  that  Zinet  breathes  54  breaths  per  minute.     You  do  not  observe  chest  indrawing,  wheeze,  stridor  or  general   danger  signs.  She  has  sunken  eyes,  and  she  is  restless  and  irritable.     She  has  palmar  pallor,  but  no  visible  was.ng.    She  never  received   any  immuniza.ons.    She  is  s.ll  breas\eeding,  but  eats  other  foods   as  well.    She  has  had  ear  discharge  for  the  last  3  weeks.   Distance  learning  IMCI  

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Skills  sta.on  4    

CASE  STUDY  MITU   Read  the  case  and  answer  the  quesPons  on  your  answer  sheet:  

Mitu  was  born  3  days  ago  aeer  prolonged  labour.  Her   mother  says  she  has  not  been  sucking  the  breast  at  all  in   the  past  24  hours.         Mitu  breathes  with  difficulty.    You  measure  her   breathing  twice.    She  breathes  86  and  90  breaths  per   minute  in  the  two  counts.    She  has  chest  indrawing.    She   does  not  move  at  all.    Her  palms  are  very  yellow.   Distance  learning  IMCI  

SECTION  6   ASSESSMENT:  WRITTEN  EXAMINATION   INSTRUCTIONS  FOR  WRITTEN  EXAMINATION:   You  have  30  minutes  to  complete  the  exam.       You  must  respect  silence  during  the  assessment.    If  you   have  ques.ons  for  the  facilitator,  do  not  disturb  others.           Read  the  examina.on  instruc.ons  carefully.    You  will   mark  your  answers  on  the  answer  sheet.    Please  do  not   mark  on  the  examina.on  papers.   Distance  learning  IMCI  

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SECTION  7   NEXT  STEPS  &  CLOSE  OF  COURSE  

Distance-­‐learning  IMCI  

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ISBN 978 92 4 150682 3

9 789241 506823



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 9 CARE OF THE WELL CHILD

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

n CONTENTS This module includes the following sections of information. It follows a different flow compared to the other IMCI modules and process. Acknowledgements 4 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 Module overview Introducing growth and care for child development Growth monitoring Caregiver–child interaction: bonding and attachment Interventions for child development Monitoring a child’s development Counselling about feeding problems Feeding recommendations Water, sanitation & hygiene 5 8 10 19 23 29 37 41 50 53 60 64 68 70

9.10 Immunization 9.11 9.12 9.13 9.14 Routine vitamin A and deworming Prevention of childhood accidents Review questions Answer key

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

9.1

MODULE OVERVIEW

In this course, you have learned how to assess, classify, and treat the sick child. You have learned about giving treatments, and counselling on treatment at home. You have learned about follow-up visits, and how to teach a caregiver about signs of illness. This module is a little different from your previous study of the sick child. In this module, you are going to learn how to care for a well child.

WHAT IS A WELL CHILD? This is a child coming to the health facility seeking preventive health services such as immunizations, feeding advice, growth and developmental monitoring.

HOW DOES IMCI FOR THE SICK CHILD RELATE TO WELL CHILD CARE? Throughout this course, you have learned how to care for a sick child coming to your health facility. You will use some of the same skills that you have already practiced when assessing and treating a sick child. Despite the fact that you may feel you have a lot of children to attend to, and that these are well children, it is important to take time to assess a well child properly. For example, when caring for a well child, you will use the IMCI counselling and communication skills you have learned. You will ask the mother questions to determine how she is caring for her child. You will then listen carefully to the mother’s answers so that you can make your advice relevant to her. You will praise the mother for appropriate practices such as bringing her child for important interventions such as immunizations, and advise her about any practices that need to be changed. You will use simple language that the mother understands. Finally, you will ask checking questions to ensure that the mother knows how to care for her well child.

WHAT IS CARE FOR CHILD DEVELOPMENT AND WHY IS IT SO IMPORTANT? There are over 200 million children under age 5 who are not developing to their full potential because they did not get simple and essential interventions to promote their development. Care that children receive has powerful effects on their survival, growth, and development. The key risk factors for development include issues like stunting, iron deficiency, iodine deficiency, frequent illness and difficulty learning new skills, understanding the world around them, solving problems and communicating with others. This module is a small introduction to care for child development. The WHO has a full course called Care for Child Development: improving the care for young children (2012) if you would like further information.

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ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

WHAT TYPES OF CARE ARE DESCRIBED IN THIS MODULE?

DOES THE CHILD HAVE care DIARRHOEA? feeding, for the child’s For how long? ___ Days Is there blood in the stool? measures.

You are going to learn about

Count the breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor several topics, including infant and young child Look and new listen for wheezing

healthy growth and development, and prevention Yes __ Look at the childs general condition. Is the child: Lethargic unconscious? for Restless In caring a well child, it isorimportant youand toirritable? learn on different Look for sunken eyes. preventive measures. These include preventing accidents, poisoning, abuse, and Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? neglect of children, in an effort to resolve this universal problem. Pinch the skin of the abdomen. Does it go back: Very slowly (longer then 2 seconds)? Slowly?

No __

Look are or feel for stiff neck for a child’s wellness and to realize Decide malaria risk: High ___ Low ___ No___ healthy growth and development essential Look for runny nose For how long? ___ Days Look for signs MEASLES: his or In addition, youof will learn about injuries and abuse. This is If more than 7 days, hasher feverfull been potential. present every day? Generalized rash and Has child had measles within the last 3 months? because injuries in children haveOne become acough, major problem worldwide, including in of these: runny nose, or red eyes Do a malaria test, if NO general danger sign in all cases in Look for any other cause of fever. high malaria risk or NO obvious cause of fever in low developing countries. There is also clear evidence that child abuse is a global problem, malaria risk: but that the patterns of child abuse are not very clear, so the issue requires individual Test POSITIVE? P. falciparum P. vivax NEGATIVE? Look for mouth ulcers. If yes,focus are they deep and extensive? . If the child has measles now or within the attention with families. This module has a special on prevention Look for pus draining from the eye. last 3 months:

Why these topics? As you have already learned, immunizations, good nutrition, and Yes __ No __ DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for clouding of the cornea.

MODULE LEARNING OBJECTIVES Look for pus draining from the ear

Yes __ No __

describe and allow to practice the following tasks: Lookyou for oedema of both feet. THEN CHECKThis FORmodule ACUTE will MALNUTRITION Determine WFH/L z-score:____ AND ANAEMIA Less than -3? ✔✔ Optimal infant and young child feeding

Feel for tender swelling behind the ear

Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. ✔✔ Care for child’s healthy growth and development Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or ✔✔ Immunization and related interventions Any severe classification? Pneumonia with chest indrawing? WFH/L less than -3 Z scores or oedema of Child 6 months or older: Offer RUTF to eat. Is the child: both feet: ✔✔ Prevention of childhood accidents Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem?

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2 Vitamin A Mebendazole

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Look at your IMCI recording form for the Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: module: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

YOUR RECORDING FORM

sick child. This section deals with this

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

Page 60 of 75 

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BEFORE YOU BEGIN What do you know about caring for a well child? Before you begin this module, quickly practice your knowledge with these questions. Circle the most correct answer for each question: 1. Sami is 8 months old, and his mother is not infected with HIV. What would you recommend for his feeding? a. Exclusive breastfeeding b. Four meals a day of porridge and vegetables, and no breastfeeding c. Breastfeeding as often as he will have, and three meals a day of cereals, mashed fruits and vegetables, and sources of protein 2. What is child development? a. Is an increase in physical size, composition and distribution of tissues b. Is the increase in the complexity of structures and of their functions (what a child can do) c. Is the same as child growth 3. Interaction of mother and child involve a. Bonding only b. Attachment only c. Bonding and attachment 4. What is the interval for administering Pneumococcal vaccine in children? a. 4 weeks b. 6 weeks c. 8 weeks 5. At what age do we begin giving Vitamin A to children? a. 12 months b. 9 months c. 6 months 6. Why is it important to deworm (giving antihelminths medicines) children? a. Soil-transmitted helminthes (intestinal worms) is a serious worldwide health problem b. Worm infestations are associated with a significant loss of micronutrients and contribute to anemia, growth failure and malnutrition c. Worm infestation is common in young infants 7. Regarding childhood injuries: a. Burns and falls are rare b. Are not a significant problem in developing countries c. Can be prevented through family and community sensitization and awareness raising After finishing the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

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9.2

INTRODUCING GROWTH AND CARE FOR CHILD DEVELOPMENT

In this section, you are going to learn about growth and development of a child. This will enable you to monitor children’s progress, to identify abnormalities in development, and to counsel parents.

WHAT IS CHILD GROWTH? Child growth is defined as an increase in physical size, composition, and distribution of tissues. It is associated with changes in a child’s proportions, shape, and function – and includes among other things like a child’s weight, height, and length. You will learn more about child growth later in this module. For now, we will focus on child development.

WHAT IS CHILD DEVELOPMENT? Child development is the gradual unfolding of capacities. Children become more and more capable, and learn to talk, walk, run, solve problems, receive affection and express emotions. Healthy child development is an interaction between biology and genes, a child’s experiences of the world around him/her and their environment. In other words, children need good physical and mental health and nutrition, opportunities to explore the world, and a safe and nurturing caregiving environment.

WHAT ARE THE SKILLS THAT A CHILD IS DEVELOPING? You have read that child development is defined as, in simple terms, what a child can do. Child development especially focuses on four areas of skills development. These areas are motor, cognitive, social, and affective skills. 1. MOTOR SKILLS Motor skills are particularly physical, like reaching and grabbing. The goal of motor skills is to organize planned eye and hand movement, and control and strengthen muscles. Cognitive skills focus on the ability to explore and learn, like seeing, hearing, moving, and touching. Cognitive skills help a child to recognize people, things, and sounds. They help to compare sizes and shapes. They also stimulate exploring and learning. Social skills help a child communicate interests and needs. Social skills develop to help someone express self through verbal and non-verbal skills. Affective skills help a child to receive and express appropriate emotions and affection. Good affective skills help a person have appropriate emotional reactions to his or her own efforts, and to other people.

2. COGNITIVE SKILLS

3. SOCIAL SKILLS

4. AFFECTIVE/EMOTIONAL SKILLS

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

WHY SHOULD CHILD GROWTH AND DEVELOPMENT BE A FOCUS FOR HEALTH WORKERS? Health care workers need to understand growth and development in order to monitor children’s progress, to identify delays or abnormalities in development, to counsel caregivers, and to prescribe treatment. There are evidence-based strategies to help health workers focus on improving growth and development. One strategy is growth promotion and monitoring (GPM), which you will learn about below. This strategy helps health workers identify and target risk factors for poor growth and development. It also requires health workers to think about the caregiver-child relationship and interactions within the family. A child’s growth and development may also reflect larger social or economic issues, like the issues of inequity that you discussed during the first face-to-face meeting. Some examples of these issues were poverty, poor education in the family, and access to nutritious diets, safe water, and health services. In the next section, you will learn about important interactions between a child and caregiver, and how this impacts a child’s development.

SELF-ASSESSMENT EXERCISE A Practice child development skills that you read about on the previous page: motor, cognitive, social, and affective skills. Which skill type is the activity describing? Tick the best answer for the skill type it is demonstrating. 1. Child sees ball rolling and tries to take and hold it 2. Child cries and reaches for the ball when it rolls away 3. Child examines ball’s shape and size 4. Child smiles at mother when she begins speaking to him about the ball Which skill type? M C S A

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

9.3

GROWTH MONITORING

You will remember that we started this module by defining child growth and development. Until this point you have been focusing on child development. You also learned how to monitor a child’s development. Similarly, now you will read more about growth and growth monitoring.

REFRESH: WHAT IS CHILD GROWTH? Let us begin by refreshing on the definition of child growth: Child growth is defined as an increase in physical size, composition, and distribution of tissues. It is associated with changes in a child’s proportions, shape, and function – and includes among other things both weight and height.

WHAT CAUSES POOR GROWTH? There are many reasons a child’s growth is poor. It is important to examine a child’s history and current living and nutrition situations to better understand how to address poor growth. Caretakers will need to be counselled on these issues as well. 1. ACUTE OR CHRONIC ILLNESS: you learned about these in the previous IMCI modules 2. ACUTE MALNUTRITION: you learned about this in MODULE 6 3. FEEDING PROBLEMS: which you will learn about in a later section

WHY IS IT IMPORTANT TO CONDUCT GROWTH MONITORING AND PROMOTION? As you read above, one strategy for children is growth and development monitoring and promotion (GMP). GMP is a strategy that helps health workers detect growth delays in a child early and in a timely way, in order to prevent further growth delays. GMP does not only focus on measuring a child’s physical growth, like weight and height. It also emphasizes using that information to counsel caregivers on how to take actions in the home that could improve growth and health status. Here are some important benefits of growth monitoring and promotion: ✔✔ It helps health workers to analyze the causes of a child’s poor growth. ✔✔ It uses a growth chart that helps demonstrate the child’s condition to the caregiver. ✔✔ It involves caregivers in thinking through what actions can be done in the home to address causes of poor growth. ✔✔ It involves caregivers in taking preventative or early corrective actions with a child. ✔✔ It can help a health worker connect families to important community and nutrition interventions. ✔✔ It can help keep a child or family in regular contact with your clinic, or with other community interventions. The actions that can be taken to improve a child’s status are broadly called ‘child care development’.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

HOW DO YOU MEASURE CHILD GROWTH? Measuring and monitoring child growth means comparing certain indicators of the child across the averages of many other children. There are three recommended indicators for growth monitoring children below the age of 5 years. 1. WEIGHT-FOR-AGE 2. LENGTH/HEIGHT-FOR-AGE 3. WEIGHT-FOR-LENGTH/HEIGHT Now let us explore each of these indicators a bit more. WEIGHT FOR AGE (WFH) LOW WFH = UNDERWEIGHT The relative change of weight for age is more rapid than height and is much more sensitive to any deterioration or improvement in the health of the child. Significant changes can be observed over period of few days making the measurements easy, so a high level of accuracy is possible. It is for these reasons that weight for age is the measurement employed in growth monitoring, particularly in infants and young children. HEIGHT FOR AGE LOW HFA = STUNTING Stunting refers to a child that is short for his/her age and is also known as chronic malnutrition. The levels are very high in many developing countries and it is a result of long-term poor nutrition. You will learn more about infant and young child feeding practices that have a great impact of stunting levels. WEIGHT FOR LENGTH/HEIGHT LOW WFH/L = WASTING By relating the weight of the child to its height or length, the child’s degree of thinness can be obtained. Wasting is a measurement of acute malnutrition. You have learned about this in module 6.

WHAT IS THE DIFFERENCE BETWEEN LENGTH AND HEIGHT? There is an important difference between height and length for you to remember. They are measured differently for certain age groups. ■■ LENGTH is measured when the child is lying down. Length is measured for children below 2 years of age. ■■ HEIGHT is measured when the child is standing upright. Children 2 years and older are measured in height.

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What happens if you do not use the recommend method for the child’s age? If you measure a child other than with the method recommended, you must make corrections to the measurement. The height of a child is 0.7 cm shorter than length. •• If you measure a child below 2 years in standing position (height), instead of the recommended length, you must add 0.7 cm to give you his/her correct length. •• If you measure a child 2 years and above while they are laying down (length), instead of height, you must subtract 0.7 cm to give you his/her correct height.

HOW FREQUENTLY SHOULD CHILDREN UNDER 5 BE MONITORED FOR GROWTH? The current international recommendations are the following for growth monitoring: BIRTH TO 2 YEARS MONTHLY MONITORING 2 TO 5 YEARS MONITORING EVERY 3 MONTHS

•  Weight: measured monthly Weight, length, height on every •  Length/height: every 3 months attendance

WHERE CAN GROWTH MONITORING OCCUR? Growth monitoring can occur both in the health facility and in the community during outreach services. There are different requirements for both settings. HEALTH FACILITY: The clinic should be spacious. ✔✔ There should be chairs or benches for caregivers and children to sit while waiting. ✔✔ There should be a strong table and a wall to hold the measuring board. COMMUNITY: Community leaders should be informed to prepare a strong table for growth monitoring. No matter the location, it is important for you to use the opportunity of growth monitoring to provide other services and interventions to a child. These can include child assessment, treatment, vaccination, Vitamin A supplementation, deworming and psychosocial support.

WHAT ARE TOOLS USED TO MONITOR GROWTH? These are several tools you require to effectively do growth monitoring. We will review these tools now. 1. CHILD GROWTH AND MONITORING BOOKLET ✔✔ Why is this tool useful? It provides growth charts to record child’s indicators at each visit. At the time of the visit, it helps you determine if the child is growing poorly. In the long-term, it also helps you chart the child’s growth. It also includes various service schedules, for example vaccinations, vitamin A, and deworming.

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✔✔ Important tips: this booklet is different for male child and female child . It should NOT be used interchangeably. •• Male child book is blue in colour, with picture of male child •• Female child book is pink in colour, with picture of a female child You will learn more about the importance of these books in the following pages. 2. WEIGHING SCALE ✔✔ What scale is best? There are two important qualities for the acceptable scale: •• It should be a solar scale. •• It should be a taring scale, which means the standing type with the ability to erase the mother/care taker’s weight. ✔✔ What if these scales are not immediately available? Salter scales can be used temporarily while a recommended scale is being procured. 3. LENGTH AND HEIGHT BOARD ✔✔ What kind of board should be used? A wooden length board is preferred. The board should have two or three pieces. If the child is tall, the pieces can be joined.

HOW WILL YOU MEASURE A CHILD’S LENGTH? Remember that length is used for children under 2 years, or those too weak to stand. One assistant should hold the child’s head over the ears and with straight arms. The measurer hold one hand on the child’s knees keeping the legs straight and the other on the foot-place to read the length. The child should lie flat on the board.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

Once you have measured the child’s length, you will use the weight and length to calculate a child’s Z-score

HOW WILL YOU MEASURE A CHILD’S HEIGHT? Remember that height is used for children 2 years and older. The assistant should hold the child’s knees to keep the legs straight with one hand, and the other hand on the shins to keep the heels against the back and base of the board. The measurer should hold one hand the child’s chin and the other on the head-piece to read the height. The child’s eyes should the in horizontal level and the body flat against the board.

Once you have measured the child’s height, you will use the weight and height to calculate a child’s Z-score

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HOW DO YOU CALCULATE A CHILD’S Z-SCORE? You should remember this calculation from the MALNUTRITION module. Let us quickly review how to plot weight and height on the chart, and find the Z-score. Once you have the child’s weight and height/length, you will calculate their Z-score. This is basically a score comparing the weight-for-height/length of children across the world. Children with low Z-scores have low weight-for-height/length. The Z-score does not require any math. You will use an easy chart, which you can refer to your IMCI Chart Booklet. 1. THERE ARE SEPARATE CHARTS FOR HEIGHT (2 to 5 years) and LENGTH (birth to 2 years) 2 DETERMINE WHICH CHART TO USE BASED ON THE CHILD’S SEX It is important to note that there are two separate charts for females and males. They cannot be used interchangeably.

3. MARK THE INTERSECTION OF THE CHILD’S WEIGHT AND HEIGHT Next you will find the intersection of the weight and height. The numbers for weight (kg) run up the chart, and guiding lines run across the chart. The numbers for height (cm) are along the bottom of the chart, and the guiding lines run up the chart. Let us review an example. Ben is 10.5 kg and 82 cm. See how we find the intersection:

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4. USE THE INTERSECTION POINT TO FIND THE Z-SCORE Think about the Z-scores like zones between two lines. Look at the figure below. You should be most worried about any weight-for-height intersection points that fall: ✔✔ Between the -2Z and -3Z lines, like the circle below. This is moderate malnutrition. ✔✔ Below the -3Z line, like the star below. This is severe malnutrition.

n  CASE STUDY – SAMSON Practice measuring length and height Samson is 6 months old boy. His mother has brought him to the clinic today for growth and development monitoring, and for vitamin A supplementation. His weight is 8 kg and his length is 64 cm. Review your chart – what is Samson’s Z score? Once you have your answer, read on. The growth-monitoring chart from the CHILD HEALTH BOOK for boys shows that he is between median and -2, Z-score. This indicates that Samson child is doing well.

SELF-ASSESSMENT EXERCISE B Practice measuring length and height

1. How often should children under 2 years be monitored for growth? 2. How often should children between 2 and 5 years be monitored?

3. What equipment is important for growth monitoring?

WHERE WILL YOU RECORD INFORMATION ABOUT THE CHILD’S GROWTH? You have just read about three important tools for growth monitoring: the growth monitoring chart in the child health book, a weighing scale, and a length board. Once you have measured a child’s growth, where you will record and track this information? You will use the child health book available in your country.

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Every child should receive a growth and monitoring book as soon as possible after birth. You should explain the book to the caregivers. Caregivers should be encouraged to bring the book with the child whenever coming to the health facility. It has important child records, including services given.

HOW SHOULD YOU INVOLVE CAREGIVERS IN GROWTH MONITORING? You have an important job in explaining to caregivers why regular growth monitoring is critical for their child’s health. Even if they think their child is healthy and growing (for example, as compared to other children in the house) it is important to track. Here are some helpful tips about what to explain to caregivers: ✔✔ Explain why child growth is important ✔✔ Explain what the child health book is used for monitoring growth ✔✔ Use the growth monitoring chart to show caregivers how the child is growing ✔✔ Use the chart to help caregivers understand the child’s growth pattern ✔✔ Show feeding recommendations (if available) from the book ✔✔ Show other schedules (if available) from the book, including vaccinations ✔✔ Remind caregivers about the different interventions expected during the visit ✔✔ Remind caregivers to always carry the child health book to the facility, because it has important child records

Remember! Health of the mother is an important factor in the health of the child. Assess the mother about pregnancy through post delivery history and record.

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SELF-ASSESSMENT EXERCISE C This is practice for what you have learned about monitoring growth and development.

1. Review the children below. Tick if their growth or development is normal, or not. If you decide that the growth or development is not normal, make a note with your reasons. If the child: a. Edward is 6 months. He does not have neck control b. Maria, girl, 24 months. She weighs 13 kg, height is 85 cm c. Asha is 30 months old. She says few words with meaning. She can hop on one foot and can walk backwards. d. Hamisi, 17 months, is only able to walk with support. e. Amiri is 4 years old. He is not able to say a single word f. Alice can dress herself and is toilet trained. She is 4½ years. g. Kemilembe is 3 years old. She is not able to tell a short story. She does not know her sex. h. Alex is 4 years, 10 months. He weighs 22 kg, and his height is 113 cm. He has started kindergarten/nursery school. Growth/development is: Normal Not normal

2. Jandika is 19 months old boy. His mother brought him to the clinic for growth monitoring. He weighs 8 kg and his length is 71 cm. What are you going to do for Jandika during this visit? What advice do you need to give Jandika’s mother? Write reasons for your answers.

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9.4

CAREGIVER-CHILD INTERACTION: BONDING AND ATTACHMENT

This section describes an important piece of child development, the bonding and attachment between a caregiver and child. We will begin by defining these concepts.

WHAT IS ‘BONDING’? Bonding is the process of a mother forming a relationship with her new infant. It begins during the first few hours after birth. The connection is mother-to-child.

WHAT IMPACTS BONDING? It is important to remember that bonding occurs early in the child’s life, and can have a lasting impact on his or her development. Bonding is a process that happens very quickly after birth. Therefore, some actions might affect the bonding between a mother and child. For example: ✔✔ Mother is separated from infant for a long period after birth, like many days or even weeks ✔✔ Mother has poor health ✔✔ Mother is depressed after delivery, which happens to many women. This depression often goes undetected and many mothers do not seek help. ✔✔ The mother or someone else is abusing or neglecting the child ✔✔ The infant is a low weight baby and therefore need even more attention and care ✔✔ The infant is ill

WHAT IS ‘ATTACHMENT’? Attaching is primarily a process of the infant forming a relationship with his or her mother or the primary caregiver, and reinforced by the responses. It occurs during the first two years of life, but especially between 2 and 7 months of age. During attachment, the child develops a personal communication system with the primary caregiver. The connection is child-to-caregiver.

WHAT ARE CONSEQUENCES OF POOR ATTACHMENT? Poor attachment between a child and caregiver can have very serious impact on development. Some of the known complications of poor attachment include: ✔✔ Child might have difficulty trusting others in their life. ✔✔ Child can experience increasing depression or rage. ✔✔ Child fails to thrive as a child that is physically and emotionally healthy, curious about the world around him/her, active, and happy. ✔✔ Child can have difficulty adapting to change. ✔✔ As child grows older, he or she will have more behavioral problems and worse peer relations compared to their peers. ✔✔ Older children may also have poor problem-solving abilities, and low self-esteem.

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WHAT IS IMPORTANT FOR STRONG INTERACTIONS BETWEEN A CAREGIVER AND CHILD? There are two important concepts to understand about strong interactions between a caregiver and a child. These concepts are sensitivity and responsiveness.

SENSITIVITY Is the ability of the caregiver to be aware of the infant. This includes the infant’s acts and vocalizations that communicate the infant’s needs and wants. If the caregiver is sensitive, this means the caregiver: ✔✔ Is aware of the infant’s signals, and interprets them accurately ✔✔ Accepts the child’s interests ✔✔ Regards the child as an individual, separate person ✔✔ Sees things from the child’s point of view What are some examples of sensitivity?

RESPONSIVENESS Is the ability of the caregiver to respond appropriately to the infant’s signals. The response is triggered by the child’s signal. It happens quickly after the signal, and is the appropriate level of response. A caregiver must be sensitive in order to be responsive. That means that the caregiver must be aware of the infant’s signals in order to appropriately respond to them. A caregiver would for example be able to see the child’s signs of discomfort, recognize that the child is hungry, and feed the child. What are some examples of responsiveness?

WHY IS IT IMPORTANT THAT A CAREGIVER BE SENSITIVE AND RESPONSIVE ? There are two primary reasons why it is critical for a caregiver to be sensitive and responsive. First, it helps a caregiver be more effective in giving care to a young child. Second, it creates attachment with the child, which helps development. Let us review these two in more detail: 1. To be effective in caring for a young child: —— Providing feeds on demand —— Protect a child from any potential harm —— Recognize when the child is sick, and seek care —— See cause and effect in the environment and in social relationships —— Learn to talk to the child to resolve problem 2. To develop a secure attachment with a young child. This is the basis for health growth, and a child’s intellectual, social, and emotional development.

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LET US REVIEW THE CONNECTIONS BETWEEN WHAT YOU HAVE LEARNED SO FAR

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SELF-ASSESSMENT EXERCISE D Practice concepts of bonding and attachment.

1. How would you describe bonding to a mother?

2. How would you describe attachment to a caregiver?

3. Are the following actions examples of a caregiver’s sensitivity or responsiveness? Tick your answer. A mother, Sara, takes the following actions with her son John: a. Sara hears John crying b. Sara picks up John to soothe his crying c. Sara is giving John a bath and notices a rash on his leg d. Sara sees John watching the tree’s branches blowing in the wind e. Sara asks John, “Do you see the wind blowing? The leaves are blowing!” f. Sara notices that John is not feeding as much as usual g. Sara offers John a food he likes to see if he will eat S R

4. Sara’s grandmother told her that it’s important John be left alone so he’ll become a strong and independent man, instead of emotional and weak. How would you address this concern of Sara’s? How should she discuss with her grandmother?

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9.5

INTERVENTIONS FOR CHILD DEVELOPMENT

WHAT ARE THE INTERVENTIONS THAT HELP CHILD CARE DEVELOPMENT? Care for child care development begins with improving the skills of health workers and others who work with families. Many people are not very trained in this area. This is why you are studying this module on well child care. Next, there are tools for health workers to use while counselling families on play and communication activities with their child. One such tool is the child care development chart on the next page. This chart includes recommended activities for children and caregivers for specific age groups.

WHAT DO THESE ACTIVITIES DO? These activities help to: ✔✔ Stimulate the child’s learning ✔✔ Improve routine care practices, including newborn and child feeding ✔✔ Improve a caregiver’s care-giving skills, especially to prevent and solve any problems in care ✔✔ Improve the interaction between caregivers and their children Review the chart on the next page to see examples of these activities. Watch “Care for Child Development” (on Care for Child Development CD) This video clip reviews all steps child development through case stories

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WHY ARE TOYS IMPORTANT? When you review the important play activities on the Care for Development chart, you see many involve toys. It is very important that caregivers understand that play materials can be made using simple, available materials at home. It is not necessary to buy toys from the store. Mothers might be discouraged by the price of toys. As a health worker, it is important to explain that homemade toy items help a child develop.

WHAT ARE GOOD TOYS TO MAKE AT HOME? Here is a list of great toys for children. It is recommended that you make these toys and have them at your clinic to show caregivers. You can demonstrate how easy it was to make, and also show how the child can play with it. SAMPLE TOY ITEMS Newborn Sponge (rough and smooth) 1 week up to 6 months Shaker rattle Rings on a string 6 to 9 months Containers with lids Metal objects to bang and drop 9 to 12 months Peek-a-boo cloths Homemade doll with face 12 months up to 2 years Stacking cups, plastic or metal with handles Empty boxes, bowls, other containers with small, safe objects like clothes clips Nesting objects (bowls, cups, boxes) 2 years and older Pictures Face puzzles Coloured circles, squares, triangles to sort by colour and shape Ball Chalk and flat stone for writing Book Magazine pictures or marker to draw on paper Magazine picture or drawn face, on cardboard, cut in 3-5 pieces Cardboard or magazine covers, glue, scissors, bowls or other containers for sorting shapes Small, soft ball Chalk and flat stone Pages with pictures and words, punched and tied together Stacking cups, plastic or metal with handles (different sizes and shapes, at least three to a set) Boxes, bowls, or other containers to put things in and take them out, clothes clips, stones Plastic or metal bowls and cups and other nesting objects to stack Clean cotton cloth to hide things and face Cloth, thread, needle, scissors Plastic containers with lids small enough for child to take on and off Metal pots, lids, bowls, plates, cups, and wooden spoons Small plastic jars with lids and small stones, strips of plastic, or other items to make noise inside Rings (e.g. rubber bands or spools) on a piece of colourful yarn Sponges MATERIALS NEEDED

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Other helpful supplies for making toys: ■■ Scissors ■■ Coloured paper or cardboard ■■ Box cardboard ■■ Marking pens ■■ Punch ■■ Glue ■■ Dish soap for cleaning toys ■■ Plastic boxes and bags to hold supplies and toys

SELF-ASSESSMENT EXERCISE E Check that a caregiver understands after you explain.

The following questions are not good checking questions, because they can be answered “yes” or “no”. Rewrite the questions as good checking questions. 1. Do you understand how to improve skills of other people at home who take care of the child?

2. Did the nurse explain to you how to stimulate play and communication to your child?

SELF-ASSESSMENT EXERCISE F Practice using the care for child development chart.

The following children are in your clinic for a well child visit. What activities would you recommend to their caregivers for play and communication? Take quick notes on the activities below. PLAY? 1.  Jyothi, 2 months 2.  Linus, 11 months 3.  Julie, 7 months 4.  Nathan, 4 days 5.  Frank, 17 months COMMUNICATION?

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HOW WILL YOU USE THIS CHART IN YOUR CLINICAL CARE? The figure below shows the important steps you will take when using the care development chart in your clinic. First, you will determine the child’s age and the age-appropriate activities. You will show these to the caregiver and explain how the chart works. You will use your 3 basic teaching steps to teach the caregiver how to use these activities. First, you will explain how to play and communicate with the child. Second, you will demonstrate. Third, you will watch as the caregiver practices and give feedback. Once the caregiver is practicing well, you will explain how to use the chart activities regularly at home. As you explain, remember to use checking questions to check her understanding.

Next, you will complete a self-assessment exercise.

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SELF-ASSESSMENT EXERCISE E Practice concepts of child development.

1. Rakim and his mother Beta have come for their immunizations, and you would like to do a well child assessment. How would you explain ‘child development’ to Beta?

2. Beta does not seem very interested. What would you explain to her about child development is important for Rakim’s health?

3. Describe to Beta how she can play and communicate with Rakim. He is 4 months old.

4. Beta insists that he is too little to understand how to communicate or play. How will you address this concern?

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9.6

MONITORING A CHILD’S DEVELOPMENT

In the previous sections, you have learned important information about child development. You have read about the importance of bonding and attachment between a child and a caregiver. You have also learned about counselling a caregiver on age-appropriate activities and interactions with a child. In this section, you will learn about how to assess a child’s development.

WHY SHOULD YOU MONITOR CHILD DEVELOPMENT? You should monitor growth and development of all children. A growing child passes through several stages of development. Each of these development stages has milestones. These milestones are important actions or skills that the child should develop at a particular stage.

REMINDER: what are the types of skills that children are developing? Quickly refresh yourself on the skill sets you have read about: ✔  Motor (physical) ✔  Social (communication) ✔  Adaptive (emotional) ✔  Cognitive (exploratory)

You will use these milestones to monitor a child’s development. Health workers should also educate caregivers on these simple milestones so that they can help you identify children early who might have developmental delays.

WHAT TOOLS ARE AVAILABLE TO MONITOR CHILD DEVELOPMENT? There are many different charts that explain milestone development for certain age groups. These milestones are usually described for particular skills, like motor or speech. Review the milestone chart on the next page.

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REVIEW THE MILESTONE DEVELOPMENT CHART FOR CHILDREN AGED 6 WEEKS TO 5 YEARS This chart can be used to identify children who are delayed in reaching their milestones. Children with delayed developmental milestones should be referred for further management. As a health worker, you can also use this chart to counsel the mother on ways to stimulate the child’s mental and motor development. AGE 6 weeks 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months GROSS MOTOR Prone-lifts chin intermittently Prone-arms extended forward Prone-raises head and chest, rolls rolls over front to back, no head lag Prone-weight on hands, tripod sit Pulls to stand Walks with support, “cruises” Walks without support Up steps with help Up 2 feet per step, runs, kicks ball Tricycle, up 1 foot per step, down 2 feet per step, stands on one foot, jumps Hops on 1 foot, down 1 foot per step Skips, rides bicycle Pulls at clothes Reach and grasp, objects to mouth Ulnar grasp Finger-thumb grasp Pincer grasp, throws Draws a line Tower of 3 cubes, scribbling Tower of 6 cubes, undresses Copies a circle and a cross, puts on shoes Copies a square, uses scissors Copies a triangle, prints name, ties shoelaces Coos Responds to voice Begins to babble, responds to name Mama, dada, imitates one word 2 words with meaning besides mama or dada Jargon 10 words, follows simple commands 2–3 word phrases, uses I, me, you, 25% intelligible Prepositions, plurals, 75% intelligible, knows sex, age Tells tory, normal dysfluency, speech intelligible Fluent speech, future tense, alphabet Stranger anxiety Plays games, separation anxiety Plays peek-a-boo, drinks with cup Points to needs Uses spoon, points to body parts Parallel play, helps to undress Dress and undress fully except buttons, counts to 10 Cooperative play, toilet trained, buttons clothes Knows four colours FINE MOTOR SPEECH AND LANGUAGE ADAPTIVE AND SOCIAL SKILLS

3 years

4 years 5 years

SELF-ASSESSMENT EXERCISE F Practice using the milestone development chart.

1. What type of fine motor skills should a child aged 2 years have? 2. Which sounds or words should a child at 9 months be able to speak? 3. What social and adaptive skills should a child aged 3 years have?

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HOW ARE YOU GOING TO ASSESS DEVELOPMENTAL MILESTONES IN CHILDREN? Using the development milestone chart on the previous page as a starting point, you will now learn how to assess milestones in children. 2 TO 4 MONTHS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? What actions will you take? If a child is not meeting these milestones, how will you advise the caregiver? Record your notes here:

A child holds the head erect and lifts his head. Turns head from side to front. A child is able to recognize faces and follows objects through a visual field. Becomes alert in response to voice, and can smile spontaneously. 5 TO 7 MONTHS

1. Lay the child down face up The child must be able to do (supine position). these things: 2. Hold both her hands and pull to a sitting position. 3. Play with an object like keys to make a noise. 4. Ask the caregiver to play with the child by making a joyful sound. ✔✔ Hold her head in erect ✔✔ Turn her head sideways ✔✔ Become responsive to voice ✔✔ Smile at the mother/ caregiver

What the child should be able How you will conduct your to do at this age: assessment:

Is the child meeting these development milestone criteria? The child must be able to do these things:

What actions will you take? How will you advise the caregiver if child is not meeting? Record notes:

A child can sit without using hands or being supported. The head is straight up for at least 10 seconds. Usually the lower limb is flexed at the knee joint. A child reaches for and brings objects to mouth.

1. Look and smile at the child.

2. Make the child sit on a safe ✔✔ The child must have a and flat surface. neck control. 3. Offer the child a toy to hold so as not to support the body with hands. 4. Place a clean safe object within a child’s reach. ✔✔ The child does not use hands to support the body while sitting. ✔✔ The child is able to maintain that posture for at least 10 seconds.

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8 TO 11 MONTHS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: What actions will you take? How will you advise the caregiver if child is not meeting? Record notes:

At this age group, a child starts standing up with support before being able to stand up alone by 11 months of age. This is an important stage for a child to be able to stand up before beginning to move forward. A child is able to withstand his/her weight by either being supported or supporting himself. In this stage a child also crawls by being able to moves to and fro using upper and lower limbs. The abdomen may or may not be in contact with the floor. Then, a child is able to stand still for a period of time. The lower limbs are straight without flexion at the knees. A child imitates “bye bye”, passes object from hand to hand in midline, and obeys simple command like “no, stop, shh”. A child also rolls from back to stomach.

1. Look at the child. Let the mother or caregiver stand the child upright.

✔✔ A child is able to stand 2. Observe closely if the up. lower limbs are able to ✔✔ A child holds on to a support the child’s weight. table or any other object Make sure the child’s body without leaning to it. is not in contact with the ✔✔ The child’s body is not in supporting object. contact with the object 3. Ensure that child’s weight he is holding on. is supported by his/ ✔✔ The lower limbs are able her lower limbs. The to support the weight of height of the table or the the child. supporting object should be parallel to the child’s ✔✔ The child is able to stand abdomen. with support for at least 10 seconds. 4. Put the child upright then leave him standing slowly ✔✔ Hands and knees move to and carefully. Observe if and fro in exchange the child is able to stand ✔✔ A child moves to and on his own for at least 10 fro at least three times seconds. consecutively. 5. Place a child in a prone position on a flat and safe ✔✔ A child is able to stand on his two feet and not surface. Stand in front of on his toes with his back the child at a distance of upright. at least 120 to 150cm. If the child does not crawl, ✔✔ The lower limbs are able encourage him/her by to support the child’s showing a toy or an weight. attractive object. Ask the ✔✔ A child is able to stand mother or caregiver to still without being help you to encourage the supported for at least 10 child to crawl. seconds.

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12 TO 18 MONTHS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: ✔✔ A child is able to stand up with the back upright. ✔✔ A child is able to move forwards or sideways with support of one or both hands. ✔✔ One lower limb moves while the other supports the weight of the child. ✔✔ A child is able to walk at least five steps consecutively. ✔✔ The child is able to stand with a straight back. ✔✔ The child is able to move one limb forward while the other being supports the child’s weight. ✔✔ While walking a child is not in contact with a person or being supported by an object. ✔✔ A child is able to move at least five steps. What actions will you take? How will you advise the caregiver if child is not meeting? Record notes:

At this age group, a child is 1. Place the child upright. able to stand up with the 2. The child should be at a back upright. A child is able distance but able to reach to move sideways or forwards for a supporting object with support of one or both with either one or both hands. hands. In this stage a child is able to 3. Encourage the child to walk on his own at least five move by showing him steps with confidence. The a toy or an attractive child is able to stand up on object. Ask the mother his own and moves forward or caregiver to help without being supported. you to encourage the One leg moves forwards child. Ensure that the while the other supports the supporting object is at the weight of the child without same height as the child’s being held or supported by abdomen. an object. This stage is more 4. Let the child stand in a than the early stages when a safe place. Stand in front child is learning how to walk by of the child at a distance moving one to two steps alone of around 120 to 150 cm. then waits for support. A child is able to climb stairs with help and throws a ball. Says 4-20 words with meaning. Drinks with cup. 5. Encourage the child to walk towards you by showing him a toy or an attractive object. Ask the mother or caregiver to help you encourage the child to walk towards you.

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19 TO 24 MONTHS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: ✔✔ A child is able to speak short sentences with meaning (in baby tongue/language) ✔✔ While standing, a child kicks a ball upon request ✔✔ The child names objects or pictures correctly ✔✔ A child indicates when wants to go toilet 30 TO 36 MONTHS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: ✔✔ From standing position, a child can walk backwards while facing front What actions will you take? How will you advise the caregiver if child is not meeting? Record notes: What actions will you take? How will you advise the caregiver if child is not meeting? Record notes:

A child speak short phrases, 2 words or more, kicks ball on request, dresses and undresses with help, and verbalizes toilet needs. A child is also able to jump off floor with both feet, and turns pages of book singly. Points to named objects or pictures.

1. Ask or ask the mother/ caregiver to ask the child simple question(s) requiring short answer. 2. Ask the child to stand and offer a ball to kick. 3. Give pictures or objects such as common toys and ask the child to name them.

The child is able to walk backwards, and hop on one foot. Refers to self as I, and gives first and last name. Child knows sex (gender). A child is able to put on shoes, and can dress/undress with supervision full except buttons.

1. Ask or ask the mother to ask the child to walk backwards, or to hop on one foot from a standing position.

2. Speak or ask the mother ✔✔ From standing position a to speak to the child to get child can hop on one foot the name of the child. at least 3 steps 3. Ask the child to remove ✔✔ While speaking, a child then put on shoes and refers himself as I, and remove a shirt if the child can give first and last is wearing one. name accurately when asked ✔✔ A child is able to put on clothes or remove them with supervision

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3 TO 4 YEARS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: ✔✔ From standing position, a child climbs stairs alone with alternating feet ✔✔ A child puts on or takes off shirt or jacket and is able to button and unbutton ✔✔ When asked, a child is able to tell if is a boy or a girl ✔✔ A child can tell a short story 4 TO 5 YEARS What the child should be able How you will conduct your to do at this age: assessment: Is the child meeting these development milestone criteria? ✔✔ The child must be able to do these things: ✔✔ While running, a child is able to turn without losing balance ✔✔ A child goes to toilet when wants to relieve him/herself ✔✔ A child is fluent in speech and use future tense ✔✔ Child recognizes at least 3 different types of primary colours What actions will you take? How will you advise the caregiver if child is not meeting? Record notes: What actions will you take? How will you advise the caregiver if child is not meeting? Record notes:

At this age group children can climb stairs with alternating feet. Begins to button and unbutton. Is able to feed himself/herself. Knows own sex and gives full name. A child can tell a short story, engage in cooperative play, and is toilet trained.

1. Ask child to button or unbutton his/her shirt. 2. Ask the child if s/he is a girl or a boy, or to tell a short story.

At this age, child runs and turns while maintaining balance. A child also can do self-care at toilet (although may need care with wiping). Child has fluent speech, knows future tense, and knows at least 3 colors. Child of this age also copies and in imitation.

1. Ask the child to run and then make a turn while run. 2. Show 3 different types of primary colours for a child to identify.

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SELF-ASSESSMENT EXERCISE G Practice using child development charts

1. Mariamu has brought her daughter Manka to your health facility. She says Manka was born 5 months ago at term with birth weight of 3.1 kg. Manka attained neck control at 5 months. Mariamu is worried that Manka is not able to sit without support. How are you going to advice Mariamu?

2. Ikupa is 36 months old. She has been brought to the clinic by her grandmother for growth and development monitoring. When you assess Ikupa, she can stand, move sideways or forwards with support of one or both hands of which she moves at least five steps in that state. Ikupa says about 10 words with meaning and drinks with cup. So far this is what Ikupa can do. What advice would you give to Ikupa’s grandmother and why?

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

9.7

COUNSELLING ABOUT FEEDING PROBLEMS

What are good practices in counselling about feeding? When you have identified the feeding problems, you will be able to give advice that is most relevant to the mother. ✔✔ BEFORE GIVING ADVICE, BUILD CONFIDENCE If the feeding recommendations are being followed, praise the mother for her good feeding practices. Encourage her to keep feeding the child the same way during illness and health. Avoid using words that are judgmental. ✔✔ COUNSEL ACCORDING TO THE CHILD’S AGE If the child is entering a new age group with different feeding recommendations, explain these new recommendations to the mother. For example, if the child is almost 6 months old, explain the value of good complementary foods and when to start them. ✔✔ EXPLAIN RECOMMENDATIONS IF THEY ARE NOT BEING FOLLOWED If the feeding recommendations for the child’s age are not being followed, explain those recommendations and make suggestions.

WHAT ARE COMMON FEEDING PROBLEMS THAT YOU MAY HAVE TO COUNSEL? There are many reasons that a child might have a feeding problem. You should refer to the counselling tools you have available in your country about counselling on feeding recommendations and issues. Below are some common problems that you might hear from caretakers about feeding.

Mother reports difficulty with breastfeeding Refer to MODULE 2 – SICK YOUNG INFANT. You learned to check and improve positioning and attachment. If the mother has a breast problem, such as engorgement, sore nipples, or a breast infection, she may need referral to a specially trained breastfeeding counselor. This could be a health worker who has taken Breastfeeding Counseling: A Training Course or someone experienced in managing breastfeeding problems.

Child under 6 months old is taking other milk or foods All children should be exclusively breastfed until the age of 6 months. If a child under 6 months old is receiving food or fluids other than breastmilk, the goal is to gradually change back to more or exclusive breastfeeding. Suggest giving more frequent, longer breastfeeds, day and night . As breastfeeding increases, the mother should gradually reduce other milk or food. Since this is an important change in the child’s feeding, be sure to ask the mother to return for follow-up in 5 days.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

If the mother has started to give complementary feeds under the age of 6 months, encourage her to try and reduce these feeds and give breastmilk (or other milk if she is not breastfeeding) 8 times a day before complementary feeds. All mothers should be strongly encouraged to breastfeed their children for 6 months. In some cases this might not be impossible. For example, if the mother passed away, if she must be away from her child for long periods, or if she will not breastfeed for personal reasons. Explain to her how to correctly prepare breastmilk substitutes and use the feed within one hour to avoid spoilage.

Mother is using a bottle to feed the child Recommend the use of a cup rather than a bottle, and show the mother how to use a cup to feed her child. A cup is easier to keep clean and does not interfere with breastfeeding.

If the child is not being actively fed (when older) The mother should sit with the child and encourage him to eat. He should have his own serving and not have to compete with siblings for food. If all the children are eating from the same plate, the younger children will often not eat enough.

If the child has a poor appetite or is not feeding well during illness Even though children may lose their appetite during illness, they should be encouraged to eat the types of food recommended for their age, as often as recommended. If possible, children should be breastfed more frequently and for longer. Soft, nutritious foods which the child likes should be offered. Offer small feeds frequently. After illness, good feeding helps make up for any weight loss and prevent malnutrition. Sometimes the poor appetite is due to snacks or juices that satisfy the appetite for a short time, but are not sufficiently nutritious. This practice needs to be discouraged. Also look at the recommendations for the child with a poor appetite in the Chart Booklet. How can families encourage a young child to eat? ✔✔ Offer small amounts at times when the child is alert and happy; ✔✔ Offer more food if the child shows interest; ✔✔ Give foods of a suitable consistency, not too thick or dry; ✔✔ Give physical assistance – a spoon of a suitable size, food within reach of the child, young child sitting on caregiver’s lap while eating; ✔✔ Offer verbal encouragement (e.g. “open for tasty beans”), smiles, songs, and other positive facial gestures. If a child receives more attention for refusing food than for eating it, the child may eat less in order to get the attention.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

Special feeding problems for HIV-infected children Careful attention needs to be given to the feeding of the HIV-infected child. Belonging to an HIV-affected family may affect a young child’s nutrition in a number of ways: •• As time goes on, the child’s mother may become sicker with HIV-related illnesses. •• Her illness may result in the child getting less care, increasing risk of malnutrition. •• The mother may soon be pregnant again, or have another young baby. This can also affect the feeding of the young child. •• Illness and death in a household can reduce the availability of food, through lack of money or inability to work the land fully, to go to the shop, or to prepare food. •• An older child may be responsible for caring for young children. •• The child may be at increased risk of illness, if not breastfeeding, or if infected with HIV, and need extra care. •• Active feeding is needed to help with catch-up growth after an illness – but less care may be available. These need to be addressed carefully as disease progression can be slowed down considerably if the nutritional state is optimal. You will learn more about feeding recommendations for HIV-exposed or infected children and infants in the HIV MODULE.

HOW WILL YOU PROVIDE FOLLOW-UP CARE FOR A FEEDING PROBLEM? Caregiver should be instructed to return with the child for follow-up in 5 days. When a caregiver and child return for a feeding problem: ✔✔ Reassess the child’s feeding by asking the questions in the top box on the COUNSEL THE MOTHER chart. Refer to the child’s chart or follow-up note for a description of any feeding problems found at the initial visit and previous recommendations. ✔✔ Ask the mother how she has been carrying out the recommendations. For example, if on the last visit more active feeding was recommended, ask the mother to describe how and by whom the child is fed at each meal. ✔✔ Counsel the mother about any new or continuing feeding problems. If she encountered problems when trying to feed the child, discuss ways to solve them. For example, if the mother is having difficulty changing to more active feeding because it requires more time with the child, discuss some ways to reorganize the meal time. ✔✔ If the child is very low weight for age, ask the mother to return 30 days after the initial visit. At that visit a health worker will measure the child’s weight gain to determine if the changes in feeding are helping the child.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

CONSIDER AN EXAMPLE SITUATION FOR FOLLOW-UP: On the initial visit the mother of a 3-month-old infant said that she was giving the infant 2 or 3 bottles of milk and breastfeeding several times each day. The health worker advised the mother to give more frequent, longer breastfeeds and gradually reduce other milk or foods. At the follow-up visit, the health worker asks the mother questions to find out how often she is giving the other feeds and how often and for how long she is breastfeeding. The mother says that she now gives the infant only 1 bottle of milk each day and breastfeeds 6 or more times in 24 hours. The health worker tells the mother that she is doing well. The health worker then asks the mother to completely stop the other milk and breastfeed 8 or more times in 24 hours. Since this is a significant change in feeding, the health worker also asks the mother to come back again. At that visit the health worker will check that the infant is feeding frequently enough and encourage the mother.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

9.8

FEEDING RECOMMENDATIONS

This section of the module will explain the feeding recommendations on the COUNSEL chart. The recommendations are listed in columns for different age groups.

HOW WILL YOU DETERMINE WHAT RECOMMENDATIONS ARE REQUIRED? You need to understand all of the feeding recommendations. However when you are counselling a caregiver, you will only need to explain the recommendations specific to the child’s age group. ✔✔ FIRST, ASK QUESTIONS to find out how her child is already being fed. ✔✔ SECOND, GIVE SPECIFIC ADVICE that is needed for the child’s age and situation. You may need to give different feeding advice if the mother is HIV positive.

WHEN WILL YOU USE THESE FEEDING RECOMMENDATIONS? These feeding recommendations are appropriate both when the child is sick and when the child is healthy. Sick children visits are a good opportunity to counsel the mother (or other caregiver) on how to feed the child both during illness and when the child is well. During illness, children may not want to eat much. However, they should be offered the types of food recommended for their age, as often as recommended, even though they may not take much at each feed. After a child has been ill, good nutrition helps make up for weight loss and helps to build up the resistance. In this way good feeding helps prevent future illness.

Children up to 6 months The best way to feed a child from birth to 6 months of age is to breastfeed exclusively. Breastfeeding advantages are described in the SICK YOUNG INFANT module. Exclusive breastfeeding means that the child takes only breastmilk and no additional food, water, or other fluids. The only exception is medicines and vitamins, if needed. How often should children breastfeed? Children at this age should be breastfed as often as they want, day and night. This will be at least 8 times in 24 hours.

REVIEW IMPORTANT RECOMMENDATIONS FOR THIS AGE GROUP •• Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours •• Do not give other foods or fluids

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

Children 6 months up to 12 months MILK IS STILL THE MOST IMPORTANT SOURCE OF FOOD. The mother should continue to breastfeed the baby during the day and night. However after 6 months of age, breastmilk cannot meet all of the baby’s energy needs, so you will read below about beginning complementary foods. If the baby is not breastfed, give formula or three cups of full cream cow’s milk (only from 9 months of age). If the baby gets no milk, give five nutritionally adequate complementary feeds per day. BEGIN GIVING NUTRITIOUS COMPLEMENTARY FOODS. If the child is breastfed, she should also take 3 meals a day plus snacks. If the child is not breastfeeding, she should take 5 meals a day. Always give breastmilk first before giving other foods. Start giving 2–3 teaspoons of soft porridge or mashed food, and begin to introduce vegetables and fruit. Gradually increase the amount and frequency of feeds. Children between 6 and 8 months of age should have two meals a day, by 12 months this should have increased to 5 meals per day. Give a variety of locally available food.

IMPORTANT TO INCLUDE ALL FOOD GROUPS •• Cereals, roots, and tubers: rice, wheat, maize, millet, sorghum, cassava, yams, potatoes •• Foods of animal original and legumes: meats, chicken, fishes, eggs, milk products (milk, cheese and yoghurt), chickpeas, lentils, beans, cowpeas •• Green leafy and orange-fleshed vegetables: carrots, pumpkins, avocados, leafy greens •• Fruits: mangoes, oranges, bananas, all locally available fruits, given mashed •• Oils, fats, sugar, and honey: Diets need adequate fat content, including oils (preferably seed oils like groundnuts, cashew, pumpkin, and sunflower), margarine, butter, or lard

Do not recommend pre-cooked, bottled complementary foods. Some mothers may be using them. These have the advantage of being quick and easy to prepare, and clean when first opened. They are not recommended because they are expensive, cost much more than other healthy foods, supply can be unreliable, and many products also lack important nutrients. Many mothers give them before 6 months, because of advertising and confusing instructions on the labels. Fruit juices, tea, and sugary drinks should be avoided. VEGETABLES AND FRUIT PROVIDE ESSENTIAL VITAMINS AND MICRO­ NUTRIENTS. The child should have 2 servings a day. For example, squeeze the juice of an orange and give it between meals. Mashed or grated can be given with meals. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed. CLEAN, SAFE PREPARATION AND FEEDING OF COMPLEMENTARY FOODS IS ESSENTIAL to reduce the risk of contamination. It is important to observe that hands, utensils, water and food are clean. Drinking water and milk should be boiled and kept in clean covered containers. Food should be well-cooked and kept in clean covered containers as well.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

REVIEW IMPORTANT RECOMMENDATIONS FOR THIS AGE GROUP ✔✔ Breastfeed as often as the child wants ✔✔ Give adequate servings of complementary foods a. If the child is breastfeeding, give 3 meals plus healthy snacks every day b. If the child is not breastfeeding, give 5 meals a day

Children 12 months up to 2 years During this period the mother should continue to breastfeed as often as the child wants and also give nutritious complementary foods. THE VARIETY AND QUANTITY OF FOOD SHOULD BE INCREASED. Give nutritious complementary foods or family foods five times a day. Give locally available protein at least once a day. Give food from all the food groups mentioned above. Give fresh fruit or vegetables twice every day. Family foods should become an important part of the child’s diet. Family foods should be chopped or mashed, so that they are easy for the child to eat. If the child is not getting breastmilk, she should receive full cream milk every day. THE CHILD SHOULD BE RECEIVING FOODS RICH IN VITAMINS. Important vitamins include iron, zinc, Vitamin A, and Vitamin C. As you have read in previously modules, iron and zinc are important to prevent anaemia and strengthen the immune system.

IMPORTANT VITAMINS AND RECOMMENDED FOODS IRON ZINC VITAMIN A VITAMIN C B VITAMINS: RIBOFLAVIN Green leafy vegetables, fish, meat, chicken, liver or kidney, eggs Fish, meat, chicken, liver or kidney, eggs Dark coloured fruits and vegetables, red palm oil Many fruits, vegetables, and potatoes Liver, egg, dairy products, green leafy vegetables, soybeans

B VITAMINS: VITAMIN B6 Meat, poultry, fish, banana, green leafy vegetables, potato and other tubers, peanuts B VITAMINS: FOLATE Legumes, green leafy vegetables, orange juice

IT IS IMPORTANT TO ACTIVELY FEED THE CHILD. Active feeding means encouraging the child to eat. The child should not have to compete with older brothers and sisters for food from a common plate. He should have his own serving. Feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues. Feed slowly and patiently, and encourage children to eat, but do not force them. If children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement. Minimize distractions during meals if the child loses interest easily.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

Remember that feeding times are periods of learning and love. They are times to talk to children, with eye-to-eye contact. An “adequate serving” means that the child does not want any more after active feeding.

REVIEW IMPORTANT RECOMMENDATIONS FOR THIS AGE GROUP ✔✔ Breastfeed as often as the child wants ✔✔ Give adequate servings of complementary foods, 3 to 4 times a day plus snacks ✔✔ Encourage active feeding

Children above 2 years GIVE A VARIETY OF FAMILY FOODS AS 3 MEALS PER DAY. The child should also be given 2 extra feedings per day. These may be family foods or other nutritious foods, which are convenient to give between meals. Examples are bread with peanut butter, fresh fruit or full cream milk. CONTINUE ACTIVE FEEDING. If a new food is refused, offer ‘tastes’ several times. Show that you like the food. Continue to ensure that the child receives foods rich in iron and vitamins.

REVIEW IMPORTANT RECOMMENDATIONS FOR THIS AGE GROUP ✔✔ Give 3 meals a day of family foods ✔✔ Give 2 snacks a day in between meals

Recommendations for children of HIV-positive mothers (above 2 years) Children whose mothers are known to be HIV positive may need special feeding. HIV can be passed from the mother to the baby through breastmilk. At the same time, breastmilk is very important for these infants to prevent other infections. The importance of breastmilk is discussed in the SICK YOUNG INFANT module. Feeding recommendations for HIV-exposed or infected children are in the HIV/AIDS module.

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If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM?

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes __ No __

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO YEARS Is there ear pain? Look for pus draining from the ear 5 OF IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE THE WELL CHILD Is there ear discharge? If Yes, for how long? ___ Days Name: THEN CHECK FOR ACUTE MALNUTRITION Ask: What are the child's problems?

Feel for tender swelling behind the ear Age: for oedema of both Weight (kg): Height/Length (cm): Temperature (°C): Look feet. Initial Visit? Follow-up Visit? Determine WFH/L z-score:____ AND ANAEMIA Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. ASSESS (Circle all signs present) Look for palmar pallor. CLASSIFY Severe palmar pallor? Some palmar pallor? CHECK FOR GENERAL DANGER SIGN General danger sign Is there any medical complication: in General sign? case studies. Answer feeding assessment thedanger following If child has MUAC less the thanquestions 115 mm or for each present? NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS Any severe classification? Pneumonia with chest indrawing? WFH/L less than -3 Z scores or oedema of VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ Child 6 months or older: Offer RUTF to eat. Is the child: In the cases below, identify correct and incorrect feeding practices. Write the feeding both feet: CONVULSIONS Remember to use Not able to finish? Able to finish? Danger sign when problem in the classification box. Identify possible reasons for the feeding problem. Child less than 6 months: Is there a breastfeeding problem? selecting CHECK FOR HIV INFECTION classifications Then write down your feeding advice. Note mother's and/or child's HIV status DOES THE CHILD COUGH OR DIFFICULT BREATHING? Yes __ No __ Mother's HIV test:HAVE NEGATIVE POSITIVE NOT DONE/KNOWN For Child's how long? ___ Days Count the breaths in one ___ breaths per minute. Fast breathing? 1. THULI is 3 months and weighs 5.5 kg minute: today. She is classified as cough or virological test: NEGATIVE POSITIVE old NOT DONE for chest indrawing Child's serological test: NEGATIVE POSITIVE NOT Look DONE cold and not underweight. Her mother stopped breastfeeding at 6 weeks because Look and listen for stridor If mother is HIV-positive and NO positive virological test in child: Look and listen for wheezing Is the child breastfeeding now?

SELF-ASSESSMENT EXERCISE J

Hep B1 Hep B2 Hep B3 Pinch the skin of the abdomen. Does it go back: a. Use the chart to note feeding problems: RTV-1 RTV-2 RTV-3 Very slowly (longer then 2 seconds)? Slowly? Pneumo-1 Pneumo-2 Pneumo-3 DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Look or has feel for stiff neck Decide malaria risk: High if ___ Low ___ No___ ASSESS FEEDING the child is less then 2 years old, MODERATE ACUTE MALNUTRITION, Look for runny nose For how long? ___ Days ANAEMIA, or is HIV exposed or infected Look for signs of MEASLES: If more 7 days, haschild? fever been present every day? Do you than breastfeed your Yes ___ No ___ Generalized rash and Has within the last 3 months? Ifchild yes, had how measles many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ One of these: cough, runny nose, or red eyes Does the child take otherdanger foods or fluids? ___ Do a malaria test, if NOany general sign in all Yes cases in No ___ Look for any other cause of fever. high malaria risk or food NO obvious cause of fever in low If Yes, what or fluids? malariaHow risk:many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Test POSITIVE? P. falciparum P. vivax NEGATIVE? Does the child receive his own serving? ___ Who feeds the child how? Look for and mouth ulcers. If yes, are they deep and extensive? If the child has measles now or within the During this illness, has the child's feeding changed? Yes ___Look No ___ for pus draining from the eye. last 3Ifmonths: Yes, how? Look for clouding of the cornea. Ask about mother's own health ASSESS OTHER PROBLEMS:

she had to go back to work. The grandmother looks after her during the day Yes __ No __ breastfeeding: Isand the mother child on comes ARV prophylaxis? For If how long? ___ Days Look at at the childs general Is makes the child: up three bottles of the and mother home night. Her condition. mother Is thereTHE bloodCHILD'S in the stool? Lethargic or unconscious? Restless and irritable? CHECK IMMUNIZATION STATUS (Circle immunizations needed today) Return for next 125 ml formula a day. Thuli drinks 2 bottles during the day, and 1 at night. Sheimmunization Look for sunken eyes. on: BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A Offer the child fluid. Is the child: ________________ also gets 1 bottle of thin porridge a day. OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole Not able to drink or drinking poorly? Drinking eagerly, thirsty? (Date) Was theCHILD child breastfeeding at the time of test or 6 weeks before it? DOES THE HAVE DIARRHOEA? Hep B0 Yes __ No __ FEEDING PROBLEMS

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for pus draining from the ear Feel for tender swelling behind the ear b. Possible reasons for feeding Look for problems: oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L z-score:____ AND ANAEMIA Page 60 of 75  Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or Feeding advice, of including praise for what is Pneumonia being done correctly: Any severe classification? with chest indrawing? WFH/L less than -3c. Z scores or oedema Child 6 months or older: Offer RUTF to eat. Is the child: both feet: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem?

Yes __ No __

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Bongi also gets water or tea with a cup and spoon on hot days. Due to her illness Return for next BCG OPV-0 Hep B0 DPT+HIB-1 during OPV-1 Hep B1 a. Use RTV-1 Pneumo-1

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN 2. BONGI is 5 months old. She weighs 6.8kg. She is classified as ACUTE EAR Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serologicalINFECTION. test: NEGATIVE POSITIVE NOT DONE WELL. She is breastfed on demand during the She is GROWING If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? night. She started formula and porridge with milk twice a day at 3 day and Was the child breastfeeding at the time of test or 6 weeks before it? months because the mother felt she did not have enough milk. Sometimes If breastfeeding: Is the mother of andage, child on ARV prophylaxis?

the last few days she has only wanted to breastfeed. OPV-2 OPV-3 the chart to note feeding problems: RTV-2 RTV-3 Pneumo-2 Pneumo-3 Hep B2 Hep B3

DPT+HIB-2

DPT+HIB-3

Measles1

Measles 2

Vitamin A Mebendazole

immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

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Page 60 of 75 

Decide malaria risk: High ___ Low ___ No___ Look for runny nose For how long? ___ Days Look for signs of MEASLES: If more than 7 days, has fever been present every day? Generalized rash and Has child had measles within the last 3 months? One of these: cough, runny nose, or red eyes Do a malaria test, if NO general danger sign in all cases in Look for any other cause of fever. high malaria risk or NO obvious cause of fever in low IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD malaria risk: Test POSITIVE? P. falciparum P. vivax NEGATIVE?

If the child has measles now or within the last 3 months:

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

b. Possible reasons for feeding problems:

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes __ No __

Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L z-score:____ AND ANAEMIA Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. c. Feeding advice, including praise for what is being done correctly: Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or Any severe classification? Pneumonia with chest indrawing? WFH/L less than -3 Z scores or oedema of Child 6 months or older: Offer RUTF to eat. Is the child: both feet: Not able to finish? Able to finish? Child less than7 6 months: Is is there a breastfeeding 3. PIET is 10 months old and weighs kg. He classified as problem? COUGH OR

COLD, WEIGHT FOR AGE (UNDERWEIGHT), and has been exposed to HIV. He Note mother's and/or LOW child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN lives with his grandmother, as his mother went to the city to look for work. He Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serologicaldoes test: NEGATIVE POSITIVE NOT DONE not get milk every day. He has porridge three times a day, occasionally If mother is HIV-positive and NO positive virological test in child: with now? yogurt for breakfast, usually plain porridge for lunch and porridge with Is the child breastfeeding Was the child breastfeeding at the time of test or 6 weeks before it? gravy for diner. Occasionally If breastfeeding: Is the mother and child on ARV prophylaxis? the grandmother adds meat and vegetables to the CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed with today) soup or stew at night. His feeding has not changed this illness. The only Return for next immunization on: BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A ________________ source of family income is the grandmother’s pension. OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole CHECK FOR HIV INFECTION Hep B0 Hep B1 a. Use RTV-1 Pneumo-1

the chart to note feeding problems: RTV-2 RTV-3 Pneumo-2 Pneumo-3 FEEDING PROBLEMS

Hep B2

Hep B3

(Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

b. Possible reasons for feeding problems: Page 60 of 75 

c. Feeding advice, including praise for what is being done correctly:

4. DUMISANI is 20 months old. He weighs 8 kg. He is classified as PNEUMONIA and LOW WEIGHT FOR AGE (UNDERWEIGHT). He is exposed to HIV. He is still breastfed a few times a day. He gets family foods three times a day. This is usually plain porridge for breakfast and lunch, and porridge with relish or vegetables once a day. The family has avocado, banana, and orange trees in the garden. The family sells the fruit on the road. If they cannot sell fruit the family consumes it. Dumisani does not have his own serving and is not actively fed. There are 6 older siblings at home. They have a few chickens and sometimes have eggs and meat.

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DOES THEvirological CHILD HAVE COUGH OR DIFFICULT BREATHING? Child's test: NEGATIVE POSITIVE NOT DONE

For Child's how long? ___ Days serological test: NEGATIVE POSITIVE NOT Count DONEthe breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing If mother is HIV-positive and NO positive virological test in child: Look and listen for stridor Is the child breastfeeding now? and Was the child breastfeeding at the time of test or 6 weeksLook before it?listen for wheezing If THE breastfeeding: the mother and child on ARV prophylaxis? DOES CHILDIs HAVE DIARRHOEA?

Yes __ No __

IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD CHECK THE CHILD'S needed today) For how long? ___ Days IMMUNIZATION STATUS (Circle Look at immunizations the childs general condition. Is the child: Is there blood in the stool? BCG DPT+HIB-1 OPV-0 OPV-1 Hep B0 Hep B1 a. Use RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 the chart to RTV-2 Pneumo-2

Look or feel for stiff neck Decide malariaor risk: Low ___ or No___ ANAEMIA, isHigh HIV___ exposed infected Look for runny nose Do you child? Yes ___ No ___ For howbreastfeed long? ___ your Days Look for signs ofthe MEASLES: If yes, how manyhas times in 24 hours? ___ every times.day? Do you breastfeed during night? Yes ___ No ___ If more than 7 days, fever been present Does the child take any within other foods or3 fluids? Yes ___ No ___ Generalized rash and Has child had measles the last months? One of these: cough, runny nose, or red eyes If Yes,test, what or fluids? Do a malaria iffood NO general danger sign in all cases in other cause of fever. How many times per day? ___ times. What do you use toLook feed for theany child? high malaria risk or NO obvious cause of fever in low MODERATE ACUTE MALNUTRITION: How large are servings? malariaIfrisk: Does the child receive his serving? ___ Who feeds the child and how? Test POSITIVE? P. falciparum P.own vivax NEGATIVE? During this illness, has the child's feeding changed? Yes ___ No ___ Look for mouth ulcers. If yes, are they deep and extensive? If the If child has measles now or within the Yes, how? Look for pus draining from the eye. last 3 months: Ask about mother's own health ASSESS OTHER PROBLEMS: Look for clouding of the cornea.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION,

Lethargic or unconscious? Restless DPT+HIB-3 Measles1 Measlesand 2 irritable? Vitamin A Look for sunken eyes. OPV-3 Mebendazole Offer the child fluid. Is the child: Hep B3 Not able to drink or drinking poorly? Drinking eagerly, thirsty? note feeding problems: RTV-3 Pinch the skin of the abdomen. Does it go back: Pneumo-3 Very slowly (longer then 2 seconds)? Slowly?

Yes __ No __ Return for next immunization on: ________________ (Date)

Yes __ No __ FEEDING PROBLEMS

DOES THE CHILD HAVE AN EAR PROBLEM? THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Is there ear pain? b. Possible reasons for Is there ear discharge? If Yes, for how long? ___ Days

Feel for tender swelling behind the ear Look for oedema of both feet. Page 60 of 75  Determine WFH/L z-score:____ Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. palmar Some palmar pallor? c. Feeding advice, includingSevere praise forpallor? what is being done correctly: Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or Any severe classification? Pneumonia with chest indrawing? WFH/L less than -3 Z scores or oedema of Child 6 months or older: Offer RUTF to eat. Is the child: both feet: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem?

Look for problems: pus draining from the ear feeding

Yes __ No __

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) has become worse with this illness. The mother buys her chips BCG OPV-0 Hep B0 DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 this is often all she will eat. Lefuno does not OPV-1 OPV-2 OPV-3 Hep B1 Hep B2 Hep B3 a. Use the chart to note feeding problems: RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

5. LEFUNO is 3 years old and weighs 12 kg. She has had diarrhoea for 3 days. She Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN is classified NO VISIBLE DEHYDRATION, NOT GROWING WELL and HIV Child's virological test: NEGATIVE as POSITIVE NOT DONE Child's serologicalINFECTION test: NEGATIVE POSITIVE NOTShe DONE UNLIKELY. is not breast-fed. She has milk with sugar and If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? for breakfast and eats some family food, but often leaves her bowl porridge Was the child breastfeeding at the time of test or 6 weeks before it? Her says Lefuno has a poor appetite and will not eat. This If breastfeeding: Isuntouched. the mother and child on mother ARV prophylaxis? like fruit or Measles 2 Vitamin A vegetables. Mebendazole Return for next and sweets, asimmunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

b. Possible reasons for feeding problems: Page 60 of 75 

c. Feeding advice, including praise for what is being done correctly:

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SELF-ASSESSMENT EXERCISE K Answer questions about counselling on feeding recommendations.

1. How could you restate the following advice in simpler words? Give foods that are high in energy and nutrient content in relation to volume. 2. The mother of an 8-month-old girl says that her child usually takes infant formula by cup about 5 times a day and plain cereal 3 times per day. The mother stopped breastfeeding about 1 month ago when she had to return to work, which requires that she be away from the child for 10 hours each work day. The child has taken the same amount of food during the illness. Which of the following comments are appropriate when counselling this mother? (Tick appropriate comments.)  a. You should still be breastfeeding this child.  b. It is good that your child is still eating as usual during the illness.  c. It is good that you are using a cup instead of a feeding bottle.  d. Your child needs food more often. Try to increase the number of times you give the cereal gruel to 5 times a day.  e. The cereal is good for your child. Add a little oil and some mashed vegetables or peas, or bits of meat to the cereal gruel. Then it will be even better for your child. 3. A health worker has just counselled the mother of a 5-month-old about starting complementary foods. The first and second columns below show the health worker’s first checking questions and the mother’s responses. In the third column, write another checking question to make sure that the mother knows how to feed the child correctly. First Checking Question What are some good foods to give when your baby is ready? When will you begin giving these foods? Mother’s Response Thick foods with nutrition When he is ready Second Checking Question

4. Greg is 10 months old and is still breastfed. He gets porridge once a day and mashed fruit or vegetables twice a day. Greg’s mother often uses baby food jars of fruit and vegetables for convenience. Greg eats a jar at each meal. a. Comment on his diet.

b. How would you increase the energy density of Greg’s diet?

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c. List alternate ways the mother could spend this money to feed the baby and the family.

5. Fatima is 14 months old. You have classified her as having PNEUMONIA and ANAEMIA. The mother says that he often gets chest infections. a. Which micronutrients are important for Fatima?

b. Which foods contain these micronutrients?

6. The mother of three month old Joyce is still exclusively breastfeeding her baby, but her mother-in-law says she does not have enough milk and must start giving the baby porridge. a. Why is it important to continue exclusive breastfeeding until 6 months?

b. The mother also gives Joyce water. What do you think of this?

7. Xoli is 15 months old. He still breastfeeds but also takes a variety of other foods including rice, bits of meat, vegetables, fruit and yoghurt. a. How many times should Xoli be given these foods?

b. How can the mother judge whether she is giving an adequate serving to Xoli?

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9.9

WATER, SANITATION, & HYGIENE

WHY IS WATER, SANITATION, AND HYGIENE IMPORTANT FOR CHILD HEALTH? Over 1.6 million children die every year from diarrhoeal diseases. About 9 out of 10 diarrhoeal disease cases is caused by unsafe water supply or poor sanitation and hygiene. Unsafe drinking water and poor sanitation and hygiene also lead to other infections like pneumonia or intestinal parasites that contribute to anaemia. These diseases are very serious risks to a child’s health and development. At the same time, there are important and inexpensive interventions that health workers can advise families on in order to prevent childhood illness from poor water, sanitation, and hygiene.

WHAT ARE IMPORTANT INTERVENTIONS TO PREVENT ILLNESS? Some of the most important interventions to discuss with families include: •• Access to safe drinking water •• Washing hands •• Improving sanitation in the home and community, including use of toilets

WHY IS HAND WASHING IMPORTANT? Hand washing is a simple practice that can make a significant difference in reducing diarrhoeal disease. Washing hands at important times can reduce the number of diarrhoeal cases by more than one-third. As a health worker, you have an opportunity to talk to caregivers about their own hand washing, which is important for their own health but also the contact they have with their children. You can also support families to teach their children how to wash their hands and prevent illness.

WHEN IS HAND WASHING IMPORTANT? There are important times for hand washing: ✔✔ Before preparing food ✔✔ Before eating ✔✔ Before feeding a child ✔✔ After using the toilet ✔✔ After cleaning up a child who has used the toilet ✔✔ After coughing, sneezing, or blowing your nose ✔✔ Before and after cleaning a child’s face, mouth, or nose ✔✔ After handling animals, animal waste, or garbage

WHAT ARE GOOD PRACTICES IN HAND WASHING? There are some important messages about good practice in hand washing. They are also demonstrated in the picture.

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✔✔ Use soap ✔✔ Rub hands together – including between fingers and under fingernails – for 20 seconds ✔✔ Pour water over the hands (instead of dipping hands into water, which then contaminates that water)

WHAT ARE THE STEPS FOR HAND WASHING? Washing your hands properly takes about as long as singing “Happy Birthday” twice, using these steps.

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HOW CAN YOU SUPPORT A FAMILY IN HAND WASHING? During a well child visit with a caregiver, ASK: ✔✔ Where do you wash your hands? ✔✔ Is there soap? ✔✔ When do you wash your hands? If necessary, help the caregiver identify how they can prepare a convenient place to wash their hands. This should include access to water and soap. Review when to wash hands. Demonstrate how to wash hands, using the steps above. Let the caregiver practice.

WHY SHOULD A FAMILY KEEP THE ENVIRONMENT CLEAN AND SAFE? Young babies explore their environment by taking objects to their mouth. Therefore, we have to make sure the environment is clean and safe with no harmful objects. It is important to discuss this with a caregiver. You can start by asking: •• Where does the child rest and play? •• How does your child explore the environment? Here are some key messages for the caregiver: •• Keep the environment clean and safe, with no harmful objects. This includes: —— Small objects that the child might put into his/her mouth —— Items that might be sharp, like glass or stones —— Sources of heat, like cooking/warming fires, outlets for electricity, heaters, or lamps •• One idea might be to lay a blanket or mat on the floor for the child to play on. Shake or clean this regularly to remove any harmful objects.

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9.10 IMMUNIZATION In this section, you will learn about the types of vaccines routinely given, and the schedule for each. You will also learn how to check a child’s vaccination status, and when it is necessary to provide a child with a vaccine on the same day of the visit. You should be aware that the terms ‘ immunization’ and ‘vaccination’ could be used interchangeably. You will see both terms used in this study session.

WHY IS IMMUNIZING CHILDREN IMPORTANT? Several diseases that affect children are vaccine-preventable. Given this, immunization is the single most cost-effective strategy to decrease childhood morbidity and mortality. The objective of immunization programmes is to reduce and control the illness, death, and disability caused by vaccine-preventable diseases. As you will remember from studying the IMCI process, ‘check immunizations’ is an important step after you have assessed and classified main symptoms, malnutrition, and anaemia.

WHY SHOULD YOU CHECK CHILDREN FOR IMMUNIZATIONS? Ideally, every child must complete vaccination before celebrating his/her first birthday. Therefore, you must assess every child at the health facility. You need to check whether they have been vaccinated up to the appropriate schedule, and if not, you should give any missed vaccinations on the day of the visit. The recommended vaccine should be given when the child reaches the appropriate age for each dose. If vaccination is administered too early, protection may not be adequate. If there is any delay in giving the appropriate vaccine, this will increase the risk of the child developing the disease.

WHAT DISEASES DO IMMUNIZATIONS PROTECT CHILDREN FROM? Currently, immunization programmes deliver twelve vaccine antigens to protect children against the following serious illnesses: tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, Hemophilus influenzae-B (Hib) infections, hepatitis-B, and measles. There are additional vaccinations to protect against pneumococcal infections, rotavirus diarrhea, and Human papilloma virus (HPV) infections.

WHAT IS THE RECOMMENDED SCHEDULE FOR IMMUNIZATIONS? Review the table below. This shows the recommended vaccination schedule, and how you will give the doses of each childhood vaccine. The immunization schedule is also available in your IMCI chart booklet, at the very end of the ASSESS and CLASSIFY charts. Most vaccines (except BCG and measles) require administration of repeated doses for about 3 times. For these vaccines: after the first dose, give the remaining doses at least 4 weeks apart.

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If you see a child who has not been immunized at the recommended age, you should give the necessary immunizations as soon as possible. AGE At birth VACCINATION BCG OPV-0 DPT1-HepB1-Hib1 6 weeks Pneumococcal 1 Rota 1 OPV-1 DPT2-HepB2-Hib2 10 weeks OPV-2 Pneumococcal 2 Rota 2 DPT3-HepB3-Hib3 14 weeks OPV-3 Pneumococcal 3 Rota 3 9 month MEASLES 0.5 ml 0.5 ml 2 drops 2 drops 0.5 ml 2 drops DOSE 0.1 ml 2 drops 0.5 ml HOW TO GIVE Upper arm of right intradermal Oral Front outer side of the left thigh muscle Deep IM to the right thigh Oral Oral Front outer side of the left thigh muscle Oral Deep IM to the right thigh Oral Front outer side of the left thigh muscle Oral Deep IM to the right thigh Oral Outer side of the right thigh

SPECIAL CASES FOR OPV You should not give OPV-0 (Oral Polio Vaccine-0) to an infant who is more than 14 days old. Therefore, if an infant has not received OPV-0 by the time s/he is 15 days old, you should wait until he is 6 weeks old to give him his first OPV (OPV-1), therefore the child should receive OPV-1 and DPT1-HepB1-Hib1 at this encounter. If child has diarrhoea: Children with diarrhoea who are due for OPV should still receive a dose of OPV during this visit. However, you should not count this dose as it may be passed through the body. You should tell the mother to return with the child in 4 weeks’ time so that you can give the child an extra dose of OPV.

HOW WILL YOU CHECK FOR VACCINATION STATUS AND DETERMINE WHAT NEEDS TO BE GIVEN? You must check the vaccination status of all the children who visit your health facility. You can use your IMCI Chart Booklet or a child health book, if available, to locate the recommended immunization schedule. ASK: the caregiver if she has the child health book, and if she brought it with her today:

YES

If the mother answers YES, ask her if she has brought the book with her today. If she has brought the book with her, ask to see it. 1. Compare the child’s vaccination record (and the dates) with the recommended schedule. 2. Decide if the child has had all vaccinations recommended for his/her age.

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3. Identify any vaccination the child needs today. These will be any vaccines the child should have already received but has not or if the child is due for vaccine today. 4. Unless the child is being referred, the mother needs to be advised that the child should receive vaccination(s) today. 5. Give the required immunizations and record the immunization and date on the child’s book. EXAMPLE: a 9 week old infant has not yet been vaccinated with DPT-HB-Hib1 and OPV-1, which she should have received at 6 weeks old. You should give the child these vaccines while she is at the clinic. On the immunization page of the child’s health book, record the date of vaccination.

NO

If the mother says that she does NOT have a CHILD HEALTH BOOK with her 1. Ask her to tell you what vaccinations the child has received. 2. Use your judgment to decide if the mother has given a reliable report. If you have any doubt, vaccinate the child. 3. Give the child vaccines according to the child’s age. 4. Give MOTHER the CHILD HEALTH BOOK and ask her to bring it with her each time she brings the child to the health facility.

WHERE WILL YOU RECORD THE CHILD’S IMMUNIZATION STATUS? To review what you read just above, after giving the correct dose of vaccines for the child’s age, you should record the date for when each specific vaccine was administered. This is recorded in the appropriate place in the child health book. If the child needs to return for vaccination, write the date when they should return. There is usually space for this on the immunization page of the health book.

SELF-ASSESSMENT EXERCISE L Practice what you have learned about immunizations.

1. Why is it important to check the vaccination status of all children under 12 months old?

2. How would you decide if a child needs vaccination today?

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3. What dose of OVP would you give to a 6 week old baby who did not receive OVP at birth? What are the reasons for your answer?

So far, you have gone through the twelve recommended vaccines and their schedule of administration. You also learned how to check immunization status of children. Now you will learn about adverse events following immunization and contraindications for vaccination.

WHAT IS AN ‘ADVERSE EVENT’ FOLLOWING IMMUNIZATION? After receiving immunization a child may develop an adverse event. Adverse event following immunization (AEFI) is an unwanted or unexpected event occurring following administration of vaccine(s). Such an event may be caused by the vaccine(s), or it might have occurred by chance (it would have occurred despite vaccination). The majority of vaccines cause minor adverse events, and therefore these should be explained to the caregivers. These minor events include low-grade fever, or pain or redness at the injection site. These common adverse events do not require any case from health providers. However, if the adverse events are significant, they should be reported to the health providers. Common adverse events also not contraindicate subsequent vaccination (you will read more about contraindication below).

WHAT ARE COMMON ADVERSE EVENTS? Please review some of the common adverse events below. Vaccine(s) DTP-HepB-Hib Common event, should not last long ✔✔ ✔✔ ✔✔ ✔✔ ✔✔ Swelling at injection site Redness, soreness at injection site Low-grade fever Crying and irritability (in infants) Injection site nodules are not as common, but do not require treatment Uncommon, return to facility Extensive swelling of limb, not just injection site

Oral rotavirus

✔✔ Mild fever ✔✔ Diarrhoea

HOW DO YOU MANAGE FEVER FOLLOWING VACCINATION? If a child develops fever of over 38.5 °C following vaccination , give oral paracetamol at a dose of 15 mg/kg/dose in 6 divided doses. This can be given for up to 2 days if child is still with high fever. DO NOT GIVE PARACETAMOL AT THE TIME OF VACCINATION, THIS IS NO LONGER RECOMMENDED.

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WHY COUNSEL CAREGIVERS ON COMMON ADVERSE EVENTS? During the consent process, advise caregivers on what common adverse events are to be expected, and what should be done. Common adverse events should be expected after vaccination. If parents/caregivers are not well counseled, the events can be upsetting. It is important to understand these events, because they may cause a mother not to bring the child for subsequent immunizations, or they may create fear in other mothers and might not to bring their children for immunization.

WHAT IS A CONTRAINDICATION TO VACCINE? A contraindication is a condition when the vaccine is not advised due to some potential and serious adverse effects. First, it is important to note that common illnesses are not a contraindication to vaccination. Therefore no sick child, including the malnourished child, should miss vaccination. A child should only miss the vaccination if there is a clear contraindication. There are only three situations that are contraindications to vaccination. These are important to remember: ✔✔ Do not give BCG to a child known to have AIDS. ✔✔ Do not give DTP-HepB-Hib2 and DTP-HepB-Hib3 to a child who has had convulsions or shock within 3 days of the last dose of the vaccine. ✔✔ Do not give DTP-HepB-Hib to a child with recurrent convulsions or another active neurological disease of the central nervous system.

HOW WILL YOU HANDLE IMMUNIZATIONS IN A SICK CHILD? There are two good rules to remember: 1. If a sick child is well enough to go home, there are no contraindications to vaccination. 2. If you are referring a child, you do not need to give him a vaccine before referral. The health care worker at the referral site should make the decision about vaccinating the child when the child is admitted. This will avoid delaying referral. Remember what you learned about managing a child with diarrhoea who is due for OPV. They receive their dose of OPV during this visit, but the dose should not be counted. You should tell the mother to return with the child in 4 weeks for an extra dose of OPV. IMPORTANT TIP: Also advise the mother to get other children in family vaccinated.

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SELF-ASSESSMENT EXERCISE M Complete the questions about this case study of Salma.

CASE STUDY: Salma is a 4 month year old girl. She has come for immunization, growth and development monitoring today on 20/4/2012. Her vaccination record on the CHILD HEALTH BOOK shows that she has received BCG and OPV0 on 02/1/2012 when she was 1 day old; OPV1, DTP-HepB-Hib1, Pneumococcal 1 and Rota 1 on 17/2/2012 and OPV2, DTP-HepB-Hib2, Pneumococcal 2 and Rota 2 on 18/3/2012. You can see this below on her immunization schedule. Age At birth 6 weeks Type of Vaccine BCG OPV0 OPV1 DTP-HepB-Hib1 Pneumococcal 1 Rota 1 10 weeks OPV2 DTP-HepB-Hib2 Pneumococcal 2 Rota 2 14 weeks OPV3 DTP-HepB-Hib3 Pneumococcal 3 Rota 3 At 9 months Measles Vaccine Date 02/1/2012 02/1/2012 17/2/2012 17/2/2012 17/2/2012 17/2/2012 18/3/2012 18/3/2012 18/3/2012 18/3/2012 Site of administration Right shoulder Oral Drops Oral Drops Left Thigh Right Thigh Oral Drops Oral Drops Left Thigh Right Thigh Oral Drops Oral Drops Left Thigh Right Thigh Oral Drops Right Thigh

1. Will you give any immunizations today? Which ones?

2. What date should Salma return to the clinic next? Which immunizations will be given?

3. What advice would you give Salma’s mother about Salma’s vaccinations?

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SELF-ASSESSMENT EXERCISE N Complete the questions about immunizations.

1. In the scenarios below, decide if a contraindication is present, and if you will vaccinate today or not. If you decide that the child should not be vaccinated, make a note giving your reasons. IF THE CHILD: a. Will be treated at home with antibiotics b. Has a local skin infection c. Had convulsion immediately after DPT1-HepB1-Hib1, Pneumococcal 1, Rota 1 and needs DPT2-HepB2Hib2, Pneumococcal 2 OPV 2 and Rota 2 today d. Has diarrhoea e. Older brother had convulsion last year f. Is VERY LOW WEIGHT g. Is known to have AIDS and has not received any immunizations at all h. Has NO PNEUMONIA: COUGH OR COLD Vaccinate today (if due) Do not vaccinate today Reasons:

2. Samuel is 6 months old boy. He has NO GENERAL DANGER SIGNS. He is classified as having NO PNEUMONIA: COUGH OR COLD and NO ANAEMIA AND NOT VERY LOW WEIGHT FOR his AGE. Vaccination history of Samuel: BCG, OPV 0 received at birth; OPV 1, OPV 2, DPT-HepB-Hib1, Pneumococcal 1 and Rota 1 given at 8 weeks. OPV 2, DPT-HepB-Hib2, Pneumococcal 2 and Rota 2 were given 6 weeks ago. What vaccinations, if any, does Samuel need today? Give reasons for your answer.

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9.11

ROUTINE VITAMIN A AND DEWORMING

This section focuses on two other important routine interventions: vitamin A and deworming. Vitamin A deficiency (VAD) and worm infestation are common in developing countries. Both have serious health effects for a growing child. Therefore, preventive therapy should be given routinely for both.

WHAT IS VITAMIN A AND VITAMIN A DEFICIENCY? Vitamin A helps maintain surface tissue of the eyes and respiratory, intestinal, and urinary tracts. It also helps the immune system to resist severe infections. Vitamin A deficiency (VAD) is a public health problem in many countries. It is the leading cause of preventable blindness in children. It also increases the risk of disease and death from severe infections particularly measles, diarrhea, and pneumonia. Improving vitamin A status of children aged 6–59 months can reduce measles mortality rates by 50%, and diarrhoea mortality rates by 33%. It can decrease overall under-five mortality by 23%. As you can see, vitamin A is a very important regular intervention for child health.

WHAT IS ROUTINE VITAMIN A DOSAGE? Routine supplementation of vitamin A every 6 months is recommended for all children aged 6–59 months. The first dose is usually given at 6 months of age and it should be given every 6 months up to 5 years. If a child in your clinic has not received a dose in the last 6 months, you should give one dose. These dosages are also included in your IMCI Chart Booklet in the TREAT charts. AGE 6 months up to 12 months 12 months up to 5 years 1 capsule VITAMIN A CAPSULES 200 000 IU 100 000 IU 1 capsule 2 capsules 50 000 IU 2 capsules 4 capsules

HOW WILL YOU GIVE VITAMIN A TO A CHILD? As you see in the dosage chart, Vitamin A is given in various capsule strengths. To give vitamin A, first cut across the nipple of the Vitamin A capsule with a clean instrument. This could be a surgical blade, razor blade, scissors or sharp knife). If the Vitamin A capsule does not have a nipple, pierce the capsule with a clean unused needle. Then pour contents into the child’s mouth.

HOW WILL YOU RECORD VITAMIN A? In the child’s health book, remember to record the date each time you give Vitamin A to a child. This is important. If you give repeated doses of Vitamin A in a period of less than 6 months, there is danger of an overdose and toxicity.

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WHY IS DEWORMING IMPORTANT? Intestinal worms (helminthes) that are transmitted through soil are a serious public health problem wherever the climate is tropical, and there are conditions of inadequate sanitation and hygiene. Worm infestations are associated with a significant loss of micronutrients in a child. Infestations negatively affect a child’s physical fitness and appetite. This contributes to anemia, poor growth, and malnutrition. Three types of worms are most prevalent and have the most damaging effect on the health of children. These are roundworms ( Ascaris lumbricoides), hookworms (Ancylostoma duodenale and Necator americanus), and whipworms (Trichuris trichiura).

WHAT DOSAGES ARE PROVIDED FOR ROUTINE DEWORMING? All children aged 12 months or older need to be given Mebendazole or Albendazole every 6 months to treat intestinal parasites, especially hookworm and whipworm infections. These dosages are also included in your IMCI Chart Booklet in the TREAT charts. Medicine Albendazole (400 mg tablets) Mebendazole (500 mg tablet) Give as a single dose every 6 months 0–1 year None None 1–2 years ½ tablet (200 mg) ½ tablet (250 mg) 2–5 years 1 tablet (400 mg) 1 tablet (500 mg)

For children under 5 years of age, it is preferable to give deworming tablets that are chewable and taste good. For children under 3 years of age, tablet(s) should be broken and crushed between two spoons, then water added to help give the tablet(s).

WHEN WILL YOU GIVE CHILDREN DOSES FOR DEWORMING? Every time you attend a child aged 12 months or older, you should check whether the child has been given a dose of Mebendazole or Albendazole in the previous 6 months. If not, give the child Mebendazole or Albendazole as indicated above.

A QUICK REVIEW OF IMMUNIZATIONS, VITAMIN A, AND DEWORMING These three interventions are important, time-sensitive measures that help reduce illness and mortality in children. Let us review what you have learned. ✔✔ You will provide 12 vaccines to protect children against: tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, Hemophilus influenzae-B (Hib) infections, hepatitis-B, measles, pneumococcal infections and rotavirus diarrhoea ✔✔ Most vaccines (except BCG and Measles) require repeated doses, usually 3 times. ✔✔ Ideally, every child must complete full vaccination before celebrating a first birthday. ✔✔ You must check the vaccination status of all the children who visit your health facility. ASK, does the child have a vaccination card? If the mother answers NO, ask her to tell you what vaccination has the child received, and use your

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judgment to decide if the mother has given a reliable report. If you have any doubt, immunize the child. ✔✔ Common illnesses are not contraindications for immunization. If the sick child is well enough to go home s/he should be vaccinated. ✔✔ Vitamin A deficiency and worm infections are common and both have serious health effects for a growing child and therefore preventive therapy should be given routinely for both conditions. ✔✔ Supplementation every 6 months is recommended for vitamin A (all children aged 6–59 months) and deworming (all children 12–59 months of age). The following tables demonstrates a schedule for both vitamin A supplementation and deworming: SCHEDULE FOR VITAMIN A SUPPLEMENTATION AND DEWORMING AGE Birth 6 months 1 year 1 ½ years 2 years 2 ½ years 3 years 3 ½ years 4 years 4 ½ years 5 years Begins at 6 months of age. Begins at 1 year of age. VITAMIN A DATE DEWORMING DATE

SELF-ASSESSMENT EXERCISE O Answer the questions about immunizations, vitamin A, and deworming for a well child.

1. Khadija is 3 months old. She has been brought to the clinic by her grandmother for vaccination. Her grandmother says Khadija is well and you see that the child looks healthy. Vaccination history: BCG, OPV 0, OPV 1, DPT-HepB-Hib1, Pneumococcal 1 and Rota 1 were given 5 weeks ago. a. What immunizations, if any, would you give Khadija today?

b. What advice would you give to Khadija’s grandmother and why?

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2. Thabit is 15 months old boy. He has completed his full immunization, and had received a dose of vitamin A at 6 months and mebendazole at 1 year of age. a. What are you going to do for Thabit during this visit?

b. What advice will you give to Thabit’s mother? Write reasons for your answers.

3. Sabrina, 8 months, has not received vitamin A or deworming. Circle your answers. CIRCLE: a. She requires Vitamin A today. b. She requires a Vitamin A dose (100 000 IU) of 2 capsules. c. She requires mebendazole today. TRUE FALSE TRUE FALSE TRUE FALSE IF FALSE, WHY?

4. Angie, 12 months, received Vitamin A six months ago. Circle your answers. CIRCLE: a. She requires mebendazole today. b. She requires mebendazole dose (200 mg). c. She requires Vitamin A in 6 months. TRUE FALSE TRUE FALSE TRUE FALSE IF FALSE, WHY?

5. Jot, 26 months, received Vitamin A four months ago. He received mebendazole 8 months ago during an outreach programme. Circle your answers. CIRCLE: a. He requires Vitamin A (1 capsule) today. b. He does not require mebendazole today. c. He requires 500 mg of mebendazole today. TRUE FALSE TRUE FALSE TRUE FALSE IF FALSE, WHY?

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9.12 PREVENTION OF CHILDHOOD ACCIDENTS In this section, you will learn about the problems of childhood accidents. The major causes include road accidents, burns, falls, poisoning, and drowning. Most importantly, you will learn about how you can help prevent them as a health worker.

HOW BIG IS THE PROBLEM OF CHILDHOOD INJURIES? Childhood injuries are a global concern. They are becoming a major health problem in developing countries. In 2002 WHO reported 14% of fatal injuries occur in children less than 15 years old. The report showed 712,000 children die every year due to injury worldwide. This accounts for 10% of the burden of disease in children. Nearly all of these injuries (93%) are unintentional injuries (accidents). Accidents are the leading cause of fatal injuries. Accidents include road traffic collisions, burns, falls, drowning, and poisoning. The morbidity due to unintentional injuries is also very high. For each death that occurs from an accident, there are several thousand children that survive but are left with permanent disabilities. Nearly all of the childhood unintentional injuries around the world (98%) occur in low and middle-income countries. The hardest hit areas are Africa, South East Asia, and Western Pacific. Together these areas account for 77% of all unintentional injuries. Now you will learn about some of the specific types of unintentional injuries.

HOW BIG IS THE PROBLEM OF ROAD TRAFFIC ACCIDENTS? The leading cause of death by injury is road traffic accidents. It is also the 10th leading cause of all deaths globally. An estimated 1.2 million people are killed in road crashes each year, and as many as 50 million are injured. Everyday 720 children die from road traffic injuries worldwide. Road traffic injuries are one of the primary causes of disability in children.

AS HEALTH WORKERS, HOW CAN WE PREVENT ROAD TRAFFIC INJURIES? You can counsel caregivers on several important prevention measures. You might begin by discussing where the house is located (like if it is near a busy road), and where the child frequently plays. You can also discuss how the child travels locally. The caregiver’s answers will help you give the appropriate counselling. Here are some actions to discuss with caregivers: ✔✔ Child should not play near the road; caregiver should watch where child plays to monitor this. ✔✔ If child rides on a motorcycle or on a bicycle, they should wear helmets all the time.

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✔✔ If child rides in a vehicle, child must always wear a seatbelt or sit in a child safety seat. ✔✔ Child should be under supervision; child-child caretaking should be discouraged for children that are preschool aged. Besides your interactions with caregivers, there are other measures that the larger community can take in preventing accidents. You and others can be involved in these efforts. ✔✔ Developing sidewalks away from the main traffic so people can walk safely. ✔✔ Establishing safe play grounds for children away from traffic. ✔✔ Establishing speed reduction zones particularly around residential areas, schools, and children playgrounds.

WHAT IS THE RISK OF CHILDREN DROWNING? In 2002 the WHO reported 40% of all drowning occur in children. Children less than 5 years of age have the highest risk of drowning. 480 children drown everyday worldwide. Most of the child drownings (98%) occurs in low and middle income countries. In these countries, drowning mostly occurs in open bodies of water. These include toilet pits, wells, ponds, streams, rivers, lakes, and oceans. However children even have a risk for drowning in small amounts of water, like buckets or drums used to store water.

AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION OF DROWNING? You can counsel caregivers on several important prevention measures. You might begin by speaking to caregivers about any open bodies of water in their living area, or some nearby that the child might visit. You might also speak to them about how they store water in the home, or how activities like baths are done in the home. Some topics to discuss with the caregivers can include: ✔✔ All hazardous water bodies in the residential areas should be removed or covered properly. This includes toilet pits, wells, and ponds. ✔✔ Everyone in the home should follow the safety instructions on water vessels like buckets or water drums. ✔✔ When children are around bodies of water, adults must supervise them closely. This includes even small amounts, like the bathtub. ✔✔ If children are in water, like for swimming, they should wear personal flotation devices at all times.

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WHY ARE BURNS SUCH A SERIOUS PROBLEM FOR CHILDREN? The WHO reports 260 fatal child burns occur every day worldwide. Infants have the greatest risk of fatal child burns. Low and middle-income countries have a death rate from burns 11 times higher than developed countries. Most non-fatal burns (75%) are scalds from hot liquids. Burns leave many children with disability or disfigurement for life.

AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION OF BURNS? Burn morbidity and mortality can be reduced if families and community are sensitized on preventive measures. It is very important to speak with the caregiver about these measures to be taken in the home. You can also make your counseling more specific if you ask about practices in the house like cooking, heating, and lighting. Prevention measures to discuss in the community include: ✔✔ Children should never be allowed to play with fire or around fireplaces. ✔✔ Cooking areas should be raised and protected. Children should not be allowed cooking areas. They might try to reach and grab onto surfaces or items like hot pots. Ensure that pot handles are out of reach. ✔✔ When cooking, do not hold the infant as you are near a fire source. ✔✔ Children sitting by the fire (during cold weather or in cold areas) must be supervised. ✔✔ Never leave children alone at home, especially at night. Never lock children inside the house. ✔✔ Never leave candles or kerosene lamps lit while sleeping.

WHAT IS THE RISK OF INJURY BY FALLING? Worldwide 130 children fall to their death every day. Falls commonly occur from trees, windows, beds, or rooftops. They can also occur during sport and play. Injury due to falls is among the leading cause of emergency attendance at outpatient clinics. Many children are left with permanent disability due to falls.

AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION OF FALLS? Several measures can be taken at the community level to reduce mortality and morbidity due to falls. These measures, among others, include: ✔✔ Building safety guards where children might flight and fall, like beds, stairs, windows, and rooftops. ✔✔ Community sensitization on closely supervising children at their playgrounds.

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WHAT IS THE RISK OF INJURY BY POISONING? Globally, poisoning is a significant public health concern. Children less than one year are at greatest risk of dying from poisoning than older children. Worldwide 125 children die from poisoning everyday. The rate of fatal poisoning is 4 times higher in low and middle-income countries than in high-income countries. In low and middle-income countries, most poisoning is the result of kerosene/paraffin or household products. Children consume these accidentally, or think they are something safe to eat or drink.

AS HEALTH WORKERS, HOW CAN YOU ADVISE ON PREVENTION OF POISONING? The first point is that poisonous agents should not be kept in the home. This advocacy should be done with caregivers and also the larger community. In case there are products in the home that could cause poisoning, the following measures can be used at home and at the community to reduce morbidity and mortality: ✔✔ Never leave a poisonous agent/material unattended, even for a second! ✔✔ All medicines or poisons in the home should be packaged in child-resistant packs/bottles. ✔✔ All medicines should be kept out of reach of children. Children should not be asked to fetch medicines for someone else’s use. Children should not be given medicines with instructions to give to another person in the household. ✔✔ All medicines should be packaged in small quantities so they are not lethal. ✔✔ If poisonous agents or petroleum distillates (such as kerosene) are in the house, they should never be stored in containers, tins, or bottles that were previously used to keep drinks or food. They should never be kept in soda or mineral water bottles. ✔✔ Keep products in their original labeled containers. ✔✔ Use poison stickers and teach your children to recognize them. ✔✔ Be careful of what you store in your bedside table and other cupboards that are lower than your shoulder height.

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9.13

REVIEW QUESTIONS

WHAT DO YOU KNOW NOW ABOUT WELL CHILD CARE? Now that you have finished the module, answer the same questions you tested before you started studying. This will help demonstrate what you have learned! Circle the most correct answer for each question: 1. Sami is 8 months old, and his mother is not infected with HIV. What would you recommend for his feeding? a. Exclusive breastfeeding b. Four meals a day of porridge and vegetables, and no breastfeeding c. Breastfeeding as often as he will have, and three meals a day of cereals, mashed fruits and vegetables, and sources of protein 2. What is child development? a. Is an increase in physical size, composition and distribution of tissues b. Is the increase in the complexity of structures and of their functions (what a child can do) c. Is the same as child growth 3. Interaction of mother and child involve a. Bonding only b. Attachment only c. Bonding and attachment 4. What is the interval for administering Pneumococcal vaccine in children? a. 4 weeks b. 6 weeks c. 8 weeks 5. At what age do we begin giving Vitamin A to children? a. 12 months b. 9 months c. 6 months 6. Why is it important to deworm (giving antihelminths medicines) children? a. Soil-transmitted helminthes (intestinal worms) is a serious worldwide health problem b. Worm infestations are associated with a significant loss of micronutrients and contribute to anemia, growth failure and malnutrition c. Worm infestation is common in young infants 7. Regarding childhood injuries: a. Burns and falls are rare b. Are not a significant problem in developing countries c. Can be prevented through family and community sensitization and awareness raising

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Check your answers on the next page. How did you do? ............... complete out of 7. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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9.14 ANSWER KEY REVIEW QUESTIONS QUESTION 1 2 3 4 5 6 7 ANSWER C B C A C B C GROWTH AND DEVELOPMENT CAREGIVER-CHILD INTERACTION IMMUNIZATION VITAMIN A SUPPLEMENTATION DEWORMING CHILDHOOD ACCIDENTS Did you miss the question? Return to this section to read and practice:

EXERCISE A (DESCRIBING ACTIVITY) Which skill type? M 1. Child sees ball rolling and tries to take and hold it 2. Child cries and reaches for the ball when it rolls away 3. Child examines ball’s shape and size 4. Child smiles at mother when she begins speaking to him about the ball X X X X C S A

EXERCISE B (MEASURING LENGTH AND HEIGHT) ✔✔ 1. Every month ✔✔ 2. Every 3 months ✔✔ 3. Weight, length and heightboards

EXERCISE C (GROWTH AND DEVELOPMENT) 1. Answers below: If the child: a. Edward is 6 months. He does not have neck control b. Maria, girl, 24 months. She weighs 13 kg, height is 85 cm c. Asha is 30 months old. She says few words with meaning. She can hop on one foot and can walk backwards. d. Hamisi, 17 months, is only able to walk with support. e. Amiri is 4 years old. He is not able to say a single word f. Alice can dress herself and is toilet trained. She is 4½ years. g. Kemilembe is 3 years old. She is not able to tell a short story. She does not know her sex. h. Alex is 4 years, 10 months. He weighs 22 kg, and his height is 113 cm. He has started kindergarten/nursery school. ✔ ✔ ✔ ✔ ✔ ✔ ✔ Growth/development is: Normal Not normal ✔

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2. In Jandika’s case, you should go back to your growth monitoring charts on boy’s CHILD HEALTH. First you assess Jandika on weight for length, which lies between 0 and -1 Z score, this is normal. However, when you assess Jandika on length for age, he falls below -3 Z score which is severe stunting. You should refer Jandika to hospital for further assessment regarding stunting. This is a non-urgent referral but advice Jandika’s mother not to delay going to hospital. This is important so as to identify risk factors and reasons for stunting inorder to treat and prevent it.

EXERCISE D (BONDING AND ATTACHMENT) 1. Bonding is a mother-to-child connection. Bonding is the process of a mother forming a relationship with her new infant. It begins during the first few hours after birth. Bonding is a process that happens very quickly after birth. It is important to remember that bonding occurs early in the child’s life, and can have a lasting impact on his or her development. Therefore, some actions might affect the bonding between a mother and child. These situations can include, for example: ✔✔ Mother is separated from infant for a long period after birth, sometimes many days or even weeks ✔✔ Mother has poor health ✔✔ Mother is depressed after delivery, which happens to many women. This depression often goes undetected and many mothers do not seek help. ✔✔ The mother or someone else is abusing or neglecting the child ✔✔ The infant is a low weight baby and therefore need even more attention and care ✔✔ The infant is ill 2. Attaching is primarily a process of the infant forming a relationship with his or her mother or the primary caregiver, and reinforced by the responses. It occurs during the first two years of life, but especially between 2 and 7 months of age. During attachment, the child develops a personal communication system with the primary caregiver. The connection is child-tocaregiver. Poor attachment between a child and caregiver can have very serious impact on a child’s development. Some of the known complications of poor attachment include: ✔✔ Child might have difficulty trusting others in their life ✔✔ Child can experience increasing depression or rage ✔✔ Child fails to thrive: Physically and emotionally healthy, curious about the world around them, active and happy. ✔✔ In situations of neglect, e.g. no primary caregiver or if there is poor institutional care a child attaches to things, environment, routines, etc. As a result, child has difficulty adapting to change. ✔✔ As child grows older, he or she will have more behavioral problems and worse peer relations compared to their peers. They may also have poor problem-solving abilities, and low self-esteem. 3. Answers below: A mother, Sara, takes the following actions with her son John: a. Sara hears John crying b. Sara picks up John to soothe his crying c. Sara is giving John a bath and notices a rash on his leg d. Sara sees John watching the tree’s branches blowing in the wind e. Sara asks John, “Do you see the wind blowing? The leaves are blowing!” f. Sara notices that John is not feeding as much as usual g. Sara offers John a food he likes to see if he will eat X X X X X S X X R

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4. You need to explain to Sara (and give her tips for speaking to her grandmother) the benefits of bonding and attachment during childhood, and the positive impacts this has on the child’s growth and development of skills. It is helpful to provide very clear examples of each concept that she can share with her grandmother.

EXERCISE E (CAREGIVER UNDERSTANDING) 1. Answers could vary, some examples: •• How will you work with your husband at home to improve his skills with the child? •• What skills can your husband improve upon? How will you suggest that he improve the way he interacts with the child to improve the child’s development? 2. Answers could vary: •• What activities can you do with your child to play? •• What are important things to keep in mind when communicating with your child?

EXERCISE F (CHILD DEVELOPMENT CONCEPTS) PLAY? 1.  Jyothi, 2 months • Allow child to see, hear, feel, move freely, and touch you • Move colourful things for your child to see and reach for. • Make toys like a shaker rattle or a big ring on a string. • Hide a child’s toy and see if they can find it • Play peek-a-boo • Make toys like a doll with a face • Give child household items to handle and bang, make sure they are clean and safe • Give toys like containers with lids, metal pot and spoon • Allow child to see, hear, feel, move arms and legs freely, and touch you • Skin to skin contact is very good • Gently soothe and stroke child • Hold your child • Give child things to stack up or put into containers • Give household objects like containers and small items COMMUNICATION? • Smile and laugh with child • Talk to child • Copy child’s gestures or sounds, like mimicking a conversation • Tell child the names of things and people • Teach gestures like waving ‘bye bye’ • Respond to child’s sounds and interests (e.g. if they look at something or repond) • Call name and see if child responds • Look into baby’s eyes • Talk to baby These activities are good during breastfeeding. • Ask child simple questions • Respond to child’s attempts to talk • Show child things around them (nature, pictures, people) and talk to them

2.  Linus, 11 months

3.  Julie, 7 months

4.  Nathan, 4 days

5.  Frank, 17 months

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EXERCISE G (CHILD DEVELOPMENT CONCEPTS) 1. Answers will vary, but should be in simple terms with clear Child development is the skills that a child gains as they grow, like the abilities to move, communicate, solve problems, and interact socially and with emotion. To develop well, children need good physical and mental health, nutrition, opportunities to explore and learn about the world, and be supported in a safe and nurturing environment. 2. Answers will vary, but should stress how development has strong impacts on a child’s long-term health and abilities. Child development has strong effects on a child’s physical development, interactions and connections to caregivers, and abilities to develop skills for solving problems, learning, interacting with others, communicating, etc. 3. Answers will vary, but should outline the play and communication activities for his age group. It should tailor the discussion to toys and products they have in their home. 4. Answers will vary, but should emphasize that child development begins at birth, and even in the earliest hours of a child’s life he is making connections with others around him, and his environment. Play and communication with a child is absolutely critical for development. You can demonstrate with Beta how Rakim is communicating and playing now (e.g. following voices, pointing, reaching).

EXERCISE H (MILESTONES) 1. Undresses him/herself, can tower 6 cubes 2. Basic (one or two syllable) words like ‘mama’ or ‘dada’, begins to mimic other words 3. Dress/undress fully except buttons, can count to 10

EXERCISE I (USING CHARTS) 1. This question was asking you to decide how you going to advice Mariamu regarding Manka. You should remember the normal developmental milestone for an infant. An infant aged 5–7 months is able to sit without support. Since Manka is only 5 months old which is the lower age limit of the normal for sitting without support, you should advice Mariamu that this is normal, and that Manka will be able to sit without support in a few months’ time. You should tell Mariamu that she needs to continue attending clinic for growth and development monitoring of her child, and for other interventions. 2. This question was asking on the advice you would give Ikupa’s grandmother, and to give reasons for your answers. You should remember normal developmental milestone for children. Ikupa can only walk with support and say 4–20 words with meaning even though she is 3 years old. This milestone is for children between 8–11 months old. Therefore Ikupa has delayed milestone development. At her age, Ikupa was supposed to be able to run backwards and forwards with confidence and hop on one foot. You should refer Ikupa for further assessment on why she has delayed milestone development. This is a non-urgent referral but advice the grandmother that it is important to go to hospital within few days so as to manage the problem inorder to optimizing growth and development.

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NOT DONE For how long? ___ Daysand NO positive virological test in child: Look at the childs general condition. Is the child: If mother is HIV-positive Is there blood the stool? now? Lethargic or unconscious? Restless and irritable? Is the childin breastfeeding forit? sunken eyes. Was the child breastfeeding at the time of test or 6 weeksLook before Offer the child fluid. Is the child: If breastfeeding: Is the mother and child on ARV prophylaxis? Not able to drink or drinking poorly?today) Drinking eagerly, thirsty? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed 1. THULI Pinch the skin of the abdomen. Does it go back: BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A Very slowly (longer then 2 seconds)? Slowly? OPV-0 OPV-1 OPV-2preparation OPV-3 Mebendazole a. Possibly correct of the feeds DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Hep B0 Hep B1 Hep B2 Hep B3 Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ b. Feeding Problems: RTV-1 RTV-2 RTV-3 Look for runny nose For how long? ___ Days Pneumo-1 Pneumo-2 Pneumo-3 Look for signs of MEASLES: If more than 7 days, has fever been present every day? Generalized rash and ASSESS FEEDING ifwithin the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, Has child had measles the last 3 months? One of these: cough, runny nose, or red eyes Do a malaria test, if NO general dangeror sign in all cases in ANAEMIA, or is HIV exposed infected Look for any other cause of fever. high malaria risk or NO obvious cause fever in low Do you breastfeed your child? Yes of ___ No ___ malariaIfrisk: yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Test POSITIVE? P. falciparum P. vivaxor fluids? NEGATIVE? Does the child take any other foods Yes ___ No ___ Yes, what food or fluids? Formula feeding Look for mouth ulcers. If yes, are they deep and extensive? If the If child has measles now or within the 3 times. What do you use toLook A bottle How many times per day? ___ feed for thepus child? draining from the eye. last 3Ifmonths: MODERATE ACUTE MALNUTRITION: How large are servings? Look for clouding of the cornea. Does the child receive his own serving? ___ Who feeds the child and how? DOES THE CHILD HAVE AN EAR PROBLEM? During this illness, has the child's feeding changed? Yes ___ No ___ Is there ear pain? Look for pus draining from the ear If Yes, how? Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear Ask about mother's own health ASSESS OTHER PROBLEMS: Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L z-score:____ AND ANAEMIA c. Possible reasons for feeding problems: Less than -3? Between -3 and -2? -2 or more ? •• Lack of appropriate information For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. •• Common belief that early introduction of semisolids is essential Page 60 of 75  Severe palmar pallor? Some palmar pallor? •• Mother returned to work Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or Any severe classification? Pneumonia with chest indrawing? WFH/L less than d. -3 Feeding Z scores or oedema of advice: Child 6 months or older: Offer RUTF to eat. Is the child: both feet: •• Try to reintroduce exclusive breastfeeding andAble find for this Not able to finish? tosolutions finish? Child less than 6 months: Is there a breastfeeding problem? •• Increase the number of feeds

Child 6 months or older: Offer RUTF to eat. Is the child: Not able to finish? Able to finish? DOES THE CHILD HAVE COUGH OR DIFFICULTChild BREATHING? less than 6 months: Is there a breastfeeding problem? For how long?HIV ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing? CHECK FOR INFECTION Look for chest indrawing Note mother's and/or child's HIV status Look and listen for stridor Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD Look and listen for wheezing Child's virological test: NEGATIVE POSITIVE NOT DONE

both feet:

classifications Yes __ No __

DOES THE serological CHILD HAVE DIARRHOEA? Child's test: NEGATIVE POSITIVE

Yes __ No __

EXERCISE J (FEEDING ASSESSMENT)

Return for next immunization on: ________________ Yes(Date) __ No __

FEEDING PROBLEMS

X

Not breastfed Not enough feeds per day Fed by bottle, not cup Early introduction Yes __ No __ of semi-solids

X

CHECK FOR HIV INFECTION •• Replace porridge feed with formula

a. Possibly correct preparation the feeds CHECK THE CHILD'S IMMUNIZATION STATUS of (Circle immunizations needed today) BCG OPV-0 Hep B0

Note mother's and/or child's HIV status that POSITIVE the preparation of formula is correct Mother's HIV test: •• Ensure NEGATIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE •• Change from bottle to cup Child's serological test: NEGATIVE POSITIVE NOT DONE ••and Follow-up in 5 days test in child: If mother is HIV-positive NO positive virological Is the child breastfeeding now? 2. breastfeeding BONGI at the time of test or 6 weeks before it? Was the child If breastfeeding: Is the mother and child on ARV prophylaxis?

•• Bongi is DPT+HIB-2 breastfed as often as she wants, day and night Measles as recommended. DPT+HIB-1 DPT+HIB-3 Measles1 2 Vitamin A OPV-1 OPV-3 Mebendazole •• Bongi is OPV-2 given other fluids or foods with a spoon and cup which. Hep B1 Hep B2 Hep B3 b. Feeding Problems: RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? Formula and porridge with milk 2 times. What do you use to feed the child? How many times per day? ___ If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Only breastfeeding Ask about mother's own health ASSESS OTHER PROBLEMS:

X

FEEDING PROBLEMS

Not only breastfed Early introduction of semi-solids and other fluids

X

X

c. Possible reasons for feeding problems: •• Lack of appropriate information •• Common belief that early introduction of semisolids and other fluids are essential d. Feeding advice: •• Congratulate mother for using a cup and spoon and not a bottle •• Breastfeed more frequently and for longer at each feed, day and night •• Ensure that Bongi is fed at least 8 times in 24 hours •• Possibly suggest to reduce other milk and fluids gradually until 6 months old •• Tea is not recommended for smaller children

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CONVULSIONS CHECK FOR HIV INFECTION

VOMITS EVERYTHING

CONVULSING Child less than 6 NOW months: Is there a breastfeeding problem?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) 3. PIET DOES THE CHILD HAVE DIARRHOEA?

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's test: NEGATIVE POSITIVE NOT DONE IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD DOES THEserological CHILD HAVE COUGH OR DIFFICULT BREATHING? If mother is HIV-positive and NO positive virological test in child: For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing? Is the child breastfeeding now? Look for chest indrawing Was the child breastfeeding at the time of test or 6 weeks before it? Look and listen for stridor If breastfeeding: Is the mother and child on ARV prophylaxis? Look and listen for wheezing

Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A For how long? ___ Days Look at the childs general condition. Is the child: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole a. Giving milk, yogurt, meat and vegetables are good practice Is there blood in the stool? Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Hep B0 Hep B1 Hep B2 Hep B3 Offer the child fluid. Is the child: b. Feeding Problems: RTV-1 RTV-2 RTV-3 Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pneumo-1 Pneumo-2 Pneumo-3 Pinch the skin of the abdomen. Does it go back: ASSESS FEEDING if the child is less then 2 years old, MODERATE ACUTE MALNUTRITION, Veryhas slowly (longer then 2 seconds)? Slowly?

Return for next Yes __ No __ immunization on: ________________ (Date)

ANAEMIA, or is HIV exposed or infected DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

for mouth ulcers. AskLook about mother's own health If yes, are they deep and extensive? If the child has measles now or within the ASSESS OTHER PROBLEMS: Look for pus draining from the eye. last 3 months: c. Possible reasons for feeding problems:

Do you breastfeed your child? No ___ Look or feel for stiff neck Decide malaria risk: High ___ LowYes ______ No___ If yes, how many times in 24 hours? ___ times. Do you breastfeed duringnose the night? Yes ___ No ___ Look for runny For how long? ___ Days Does the child take any other foods or fluids? Yes ___ No ___ Look for signs of MEASLES: If more than 7 days, has fever been present every day? If Yes, what food or fluids? Porridge Generalized rash and Has child had measles within the 3 months? 3 last How many times per day? ___ times. What do you use to feed theof child? One these: cough, runny nose, or red eyes Do a malaria test, if NO general danger sign in all cases in If MODERATE ACUTE MALNUTRITION: How large are servings? Look for any other cause of fever. high malaria risk or NO obvious cause of fever in low Does the child receive his own serving? ___ Who feeds the child and how? malaria risk: During this illness, has the child's feeding changed? Yes ___ No ___ Test POSITIVE? P. falciparum P. vivax NEGATIVE? If Yes, how?

X

X

X

Not breastfed Not getting milk Not getting 6 nutritious meals per day Not enough food available in the house

FEEDING PROBLEMS Yes __ No __

•• There inadequate food available in the house DOES THE CHILD HAVE AN is EAR PROBLEM?

Look for clouding of the cornea.

Is there ear pain? Look for draining from the ear how to meet these needs and •• Lack of appropriate information re:pus Piet’s dietary needs, Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear Page 60 of 75  how to obtain local supportLook for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L z-score:____ AND ANAEMIA d. Feeding advice: Less than -3? Between -3 and -2? -2 or more ? For children 6 months or olderfoods measure MUAC mm. •• Piet needs 3 servings of nutritious complementary per day.____ (6 servings if he does Look for palmar pallor. not get 3 cups of full cream milk per day) Severe palmar pallor? Some palmar pallor? •• Piet needs foodor from all 6 food groups. Is there any medical complication: General danger sign? If child has MUAC less than 115 mm severe classification? Pneumonia with chest indrawing? WFH/L less than -3 • Z orgrandmother oedema of local Any • scores Give the recipes for enriched (energy dense) porridge e.g. always mix Child 6 months or older: Offer RUTF to eat. Is the child: both feet: fat, oil, peanut butter etc with porridge Not able to finish? Able to finish? •• Each day he must have some protein e.g. eggs, Is beans, available protein etc Child less than 6 months: there alocally breastfeeding problem?

Yes __ No __

CHECK FOR HIV INFECTION •• Each day he must have mashed fruit and vegetables

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) 4. DUMISANI BCG OPV-0 Hep B0 DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 a. Still breastfed and receivesOPV-3 family foods OPV-1 OPV-2 Hep B1 Hep B2 Hep B3 b. Feeding Problems: RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status •• Advise the grandmother on how to go about obtaining local food support, including Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: government NEGATIVE POSITIVE NOT DONE schemes or local organizations Child's serological test: NEGATIVE POSITIVE NOT DONE •• If the clinic has a vegetable garden, give her vegetables from it. Teach her how to plant If mother is HIV-positive and NO positive virological test in child: her own Food Garden or put her in contact with someone who can Is the child breastfeeding now? Was the child breastfeeding at the time ofdays test or 6 weeks before it? •• Follow-up in 5 If breastfeeding: Is the mother and child on ARV prophylaxis? Vitamin A Mebendazole Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? Porridge 3 times. What do you use to feed the child? How many times per day? ___ If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

X

FEEDING PROBLEMS

X

Breastfeeds infrequently Only three meals per day – inadequate Not actively fed with own serving

X

c. Possible reasons for feeding problems: •• Family is struggling financially •• Mother too busy to feed and breastfeed Dumisani more frequently as there are at least 7 Page 60 of 75  children at home d. Feeding advice: •• Breastfeed as often as Dumisani wants •• Give at least 5 adequate nutritious meals per day of increased variety and quantity •• Mix fat, oil, peanut butter etc. with porridge •• Give fruit (from garden) and vegetables at least twice every day

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THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

Look for oedema of both feet. Determine WFH/L z-score:____ Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OFpallor? THE WELL CHILD Is there any medical complication: General danger sign? If child has MUAC less than 115 mm or Any severe classification? Pneumonia with chest indrawing? WFH/L less than -3 Z scores or oedema of Child 6 months or older: Offer RUTF to eat. Is the child: both feet: Not able to finish? Able to finish? •• Give some protein to Dumisani every day: e.g. eggs from their chickens, locally available Child less than 6 months: Is there a breastfeeding problem?

CHECK FOR HIV INFECTION protein etc

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) 5. LEFUNO BCG OPV-0 Hep B0 DPT+HIB-1 DPT+HIB-2 Given family food, given milk OPV-1 OPV-2 Hep B1 Hep B2 a. Feeding Problems: RTV-1 RTV-2 Pneumo-1 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status •• Feed actively with ownNOT serving Mother's HIV test: NEGATIVE POSITIVE DONE/KNOWN Child's virological test: NEGATIVE feeding POSITIVE NOTillness. DONE Suggest an extra meal a day for a week after getting •• Encourage during Child's serological test: NEGATIVE POSITIVE NOT DONE better If mother is HIV-positive and NO positive virological test in child: •• Follow-up in 5 days Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? •• Encourage family planning If breastfeeding: Is the mother and child on ARV prophylaxis? Vitamin A Mebendazole Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? Milk with sugar and porridge How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Reduced appetite Ask about mother's own health ASSESS OTHER PROBLEMS:

X

FEEDING PROBLEMS

X

Given non-nutritious foods Poor appetite Dislikes fruit and vegetables

X

b. Possible reasons for feeding problems: •• Lack of appropriate information regarding the nutritional needs of a 3 year old child •• Poor appetite (and possibly diarrhoea) due to eating too many sweet things and nonPage 60 of 75  nutritious foods •• Bad eating habits •• Manipulation by Lefuno as she knows that she will get sweet things etc. if she does not eat her food •• Not fed actively c. Feeding advice: •• Avoid sweet foods and drinks (this will help to stop the diarrhoea) •• Stop giving Lefuno sweets and chips as well as adding sugar to her milk etc. Only put 1 teaspoon of sugar (if you must) on her porridge and in her tea etc •• Educate the rest of the family and friends that they are NOT to give Lefuno sweets etc. as this is making her ill and causing her not to grow well. They must rather give her fresh fruit or vegetables, but first consult with her caregiver in this regard •• Educate that Lefuno is not to get “samples” of food or a drink (even water) before a meal as it will decrease her appetite •• Give Lefuno her own servings of family foods three times a day and feed her actively at the time when the family eats (if feasible). Educate the family regarding correct eating habits so that they are good examples for Lefuno to follow as children learn by imitating what the family does •• In addition, Lefuno is to be given 2 nutritious snacks such as bread with peanut butter, full cream milk or fresh fruit between meals •• Continue to feed Lefuno actively •• Follow-up in 5 days

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

EXERCISE K (FEEDING RECOMMENDATIONS) 1. ANSWERS WILL VARY: Give foods that are filled with energy and nutrients, some examples are…. 2. The mother of an 8-month-old girl X X b. It is good that your child is still eating as usual during the illness. c. It is good that you are using a cup instead of a feeding bottle.

X e. The cereal is good for your child. Add a little oil and some mashed vegetables or peas, or bits of meat to the cereal gruel. Then it will be even better for your child.

3. ANSWERS WILL VARY: First Checking Question What are some good foods to give when your baby is ready? When will you begin giving these foods? 4. Greg •• Greg should receive 4–5 servings of nutritious food per day. •• Add margarine, fat, oil, peanut butter or groundnuts to the porridge. •• She could buy eggs, fresh fruit and vegetables, peanut butter, etc. 5. Fatima •• Iron and Vitamin A. •• Iron: Liver, kidney, meat chicken, fish, legumes. Dark green leafy vegetables if eaten together with food rich in vitamin C (e.g. pumpkin, if not overcooked). Vitamin A: Vegetable oil, liver, mangoes, pawpaw, sweet potato, dark green leafy vegetables and legumes. 6. Joyce •• Breastmilk is the perfect food for infants: nutrients and micronutrients are well absorbed. Breastmilk prevents infections. •• There is no need to give water as the breastmilk provides all the fluids that the infant needs. 7. Xoli •• Xoli should be given these feeds 5 times a day. •• An ‘adequate serving’ means that Xoli does not want any more food after active feeding. Mother’s Response Thick foods with nutrition When he is ready Second Checking Question Which of these foods are in your home? When will you know that he is ready?

EXERCISE L (IMMUNIZATIONS) 1. Vaccination is the most effective strategy to decreasing childhood morbidity and mortality; it can reduce and control illness, disability or death caused by vaccine preventable diseases. 2. You are now going to look in more detail what you should do step by step. To decide if the child needs vaccination today, look at the child’s age on the clinical record. If you do not have the child’s age on the clinical record, ask about the child’s age. 3. You would give OVP1. OVP-0 should not be given to an infant who is more than 14 days old. You would also give the 6 weeks old infant her DPT1-HepB1-Hib1 vaccination.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

EXERCISE M (IMMUNIZATIONS) 1. Yes, 4 are required: OPV3, DTP-HepB-Hib3, Pneumococcal 3, and Rota 3. 2. At 9 months for measles, or before if the child has any issues with health or feeding. 3. There are several things you could talk to the mother about, for example the correct age to bring Salma for vaccination (i.e. at 9 months), and that she should bring the child’s health book with her each time she comes to the health facility. You would also need to tell the mother that she must return for her child to receive Measles vaccine when Salma reaches 9 months old, which will be on 01/9/2012. You should also tell her that it is important that all children in the family are vaccinated. Lastly, explain the potential side effects of the vaccines.

EXERCISE N (CONTRAINDICATIONS) 1. Answers in the table below: IF THE CHILD: a. Will be treated at home with antibiotics b. Has a local skin infection c. Had convulsion immediately after DPT1-HepB1-Hib1, Pneumococcal 1, Rota 1 and needs DPT2-HepB2Hib2, Pneumococcal 2 OPV 2 and Rota 2 today d. Has diarrhoea Immunize this child today X X Give OPV 2 but----> Do not give DPT2-HepB2Hib2 Do not immunize today

Give dose of OPV during, but the dose should not be counted. You should tell the mother to return with the child in 4 weeks for an extra dose of OPV X X Give OPV, DPT-HepBHib,Pneumococcal, Rota & measles but ---> X Do not give BCG

e. Older brother had convulsion last year f. Is VERY LOW WEIGHT g. Is known to have AIDS and has not received any immunizations at all h. Has NO PNEUMONIA: COUGH OR COLD

3. This question was asking you to decide whether Samuel needed any immediate immunizations or not, and to give reasons for your answers. From the information on the recording form you can see that Samuel’s vaccinations are not up-to-date. This means that he needs DPT-HepB-Hib3, Pneumococcal 3, Rota 3 and OPV 3 today. You should advise the mother that it is important that she ensures Samuel is brought for his future vaccinations at the right age. You should tell her that he needs to return to the health facility at 9 months of age for his measles vaccination.

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IMCI DISTANCE LEARNING COURSE | MODULE 9. CARE OF THE WELL CHILD

EXERCISE O (VITAMIN A AND DEWORMING) 1. Khadija case: a. What immunizations, if any, would you give Khadija today? This question was asking you to decide whether Khadija needed any immediate immunizations or not, and to give reasons for your answers. You should also have identified that her vaccinations are not up-to-date. This means that she needs OPV 2, DPT-HepB-Hib2, Pneumococcal 2 and Rota 2 today. However, do not record OPV 2 since today she has diarrhea, but the OPV 2 needs to be repeated during the next vaccination visit. b. What advice would you give to Khadija’s grandmother and why? You should advise the grandmother that it is important that she ensures Khadija is brought for her future vaccinations at the right age. You should tell her that she needs to return to the health facility after 4 weeks (at 4 months of age) to receive DPT-HepB-Hib3, Pneumococcal 3, Rota 3 and repeat OPV 2 immunizations. 2. Thabit case: a. What are you going to do for Thabit during this visit? In Thabit’s case, you should have identified that he has completed his vaccination schedule and does not need additional vaccines. However, he received a dose of vitamin A at 6 months and Mebendazole 1 year of age. You should give appropriate dose of Vitamin A because Thabit was supposed to receive the dose at 1 year together with mebendazole. Thabit does not need a dose of mebendazole today because he received the dose at 1 year (i.e. at 12 months of age). The interval for mebendazole is 6 months apart, of which Thabit has not fullfilled today because he got mebendazole only 3 months ago. b. What advice will you give to Thabit’s mother? You should advise the mother that it is important that she ensures Thabit is brought for his next doses of Vitamin A after 6 months and Mebendazole after 3 months. You should tell her that she needs to return to the health facility for Thabit to get these treatments till he is 5 years old. Remind the mother that the interval between specific doses is 6 months. 3. Sabrina, 8 months, has not received vitamin A or deworming. Circle your answers. a. TRUE b. FALSE: that is dose for child 12 months to 5 years. She needs 1 capsule of 100 000 IU. c. FALSE: deworming starts only after the child is 12 months 4. Angie, 12 months, received Vitamin A six months ago. Circle your answers. a. TRUE b. TRUE c. FALSE: it has been 6 months, so she requires another supplementation today 5. Jot, 26 months, received Vitamin A four months ago. He received mebendazole 8 months ago during an outreach programme. Circle your answers. a. FALSE: received last supplementation less than 6 months ago. Providing another dose within 6 months is dangerous. b. FALSE: it has been more than 6 months, so he requires today c. TRUE

79

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 8 HIV/AIDS

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

n CONTENTS Acknowledgements 4 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 Module overview Basic information about HIV HIV testing Assess & classify a sick child Assess & classify a sick young infant Prophylaxis and other preventative measures Counsel HIV-infected mothers about infant feeding Antiretroviral treatment Providing follow-up care Review questions Answer key 5 9 16 24 31 36 47 63 91 110 111

ANNEXES Annex 1 Clinical staging Annex 2 Treatment dosing tables 121 123

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.1

MODULE OVERVIEW

This module will teach you how IMCI can assist in providing critical HIV/AIDS care, treatment, support, and prevention. Worldwide, 3.4 million children were living with HIV in 2011

First, this module will explain basic information about HIV and how children are infected. This information will help you better manage children with suspected or confirmed infection. Next, you will learn how to assess and classify HIV in young infants and children. You will learn how to provide follow-up care for exposed and infected children. The module will also explain how to counsel HIV-positive mothers about safe feeding, and methods for further preventing illness in exposed and infected children. Lastly, you will learn how to provide antiretroviral treatment and provide follow-up.

MODULE OBJECTIVES After you study this module, you will know how to: ✔✔ Explain in basic terms how HIV affects the immune system ✔✔ Explain how children are infected with HIV ✔✔ Assess and classify a child for HIV ✔✔ Assess and classify a young infant for HIV ✔✔ Provide follow-up care to HIV exposed and infected children that are not on ART ✔✔ Counsel an HIV-infected mother about safe infant feeding, and preventing common illnesses in infants and young children exposed to, or infected with, HIV through cotrimoxazole prophylaxis, ARV prophylaxis, immunization, and Vitamin A supplementation ✔✔ Explain and provide the recommended ARV regimens for children ✔✔ Explain the criteria for initiating ART in children at first-level facilities ✔✔ Describe the WHO paediatric clinical staging process ✔✔ Identify the possible side effects of ARV drugs and explain the management of possible side effects ✔✔ Counsel the caregiver on giving ART and adherence ✔✔ Explain the principles of good follow-up care ✔✔ Provide chronic care for children with confirmed HIV infection and on ART

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

MODULE ORGANIZATION This module is divided into multiple sections: 1. BASIC INFORMATION ABOUT HIV 2. HIV TESTING 3. ASSESSING & CLASSIFYING A CHILD FOR HIV 4. ASSESSING & CLASSIFYING A YOUNG INFANT FOR HIV 5. PROPHYLAXIS AND PREVENTIVE MEASURES 6. COUNSELLING THE HIV-POSITIVE MOTHER ABOUT INFANT FEEDING 7. ANTIRETROVIRAL THERAPY (ART) 8. PROVIDING FOLLOW-UP CARE

WHY IS THE IMCI STRATEGY USED WITH HIV? Children with suspected or confirmed HIV infection have special needs. Therefore they need to be cared for differently from children who are not infected. As you have learned, the IMCI strategy is designed to help health workers identify common health problems in children. It also helps identify underlying issues, like malnutrition and HIV.

WHERE DOES HIV FIT IN THE IMCI PROCESS? You have learned that for every sick child or young infant, you check for signs of serious illness, assess and classify main symptoms, and check for malnutrition and feeding problems. Next, you will ASSESS and CLASSIFY for HIV using the same process.

CHECK for general danger signs or signs of serious illness 

ASSESS & CLASSIFY main symptoms 

CHECK for malnutrition of feeding problems 

CHECK for HIV infection

CHECK immunizations and for other problems

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT IMCI TOOLS WILL YOU USE? For this module, you will continue to use work aids provided earlier in the course: 1. IMCI Chart Booklet for HIV settings 2. IMCI recording forms for sick young infant and sick child You will also have additional work aids that are specific to HIV/AIDS care: 3. ART initiation form for the sick child (2 months up to 5 years) 4. ART follow-up form for the sick child (2 months up to 5 years) Open your chart booklets now to review each of these tools. Identify the recording forms you will use for each set of charts.

BEFORE YOU BEGIN What do you know now about managing HIV care? Before you begin studying this module, quickly practice your knowledge with these multiple-choice questions. Circle the best answer for each question. 1. A child is under 16 months old. What HIV test should be used for this child, and why? a. Serological tests, because it can detect if virus antibodies are present b. Virological (PCR) tests, because it can actually detect the virus c. Serological tests now, but after the child is 18 months, confirm with a PCR 2. What follow-up treatments are critical for HIV-exposed and infected infants and children? a. Cotrimoxazole prophylaxis b. Paracetamol c. Amoxicillin 3. What is the overall risk of a mother transmitting HIV to her child during pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used during prevention of mother-to-child transmission? a. 70% b. 10% c. 35% 4. A 2-month breastfeeding baby has a positive virological (PCR) test. Is the child HIV infected? a. Yes, HIV-infected b. No, HIV negative c. Possibly, he is HIV exposed 5. When is an HIV-positive child or infant eligible for ART? a. If a child has stage 2 HIV infection b. Any child under five with confirmed HIV infection c. Children over 5 years old with a count less than 350 cells per mm3

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

6. If a mother is HIV-positive, but the child is not confirmed with HIV infection, what is the recommended feeding practice? a. Exclusive breastfeeding as long as the child wants b. Breastfeeding and also formula, in order to provide additional nutrition c. Exclusive breastfeeding until 12 months After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.2

BASIC INFORMATION ABOUT HIV

What are the learning objectives for this section? After you study this section, you will know how to: •• Explain in basic terms how HIV affects the immune system •• Explain how HIV is transmitted to infants and children

WHAT IS THE IMMUNE SYSTEM? Every healthy person has a strong system to defend the body against diseases. This defence system is called the immune system. White blood cells are an important part of this defence system. They protect the body against all kinds of diseases. They can be thought of as the “soldiers” of the body.

HOW DO WHITE BLOOD CELLS ACT AS “SOLDIERS”? Lymphocytes are one type of white blood cell in the body. Some of these lymphocytes have a marker on their surface called CD4. Therefore they are called CD4 lymphocytes. These CD4 lymphocytes are responsible for warning your immune system that there are germs trying to invade the body. HIV (Human Immunodeficiency Virus) is a virus that infects and takes over cells of the immune system. Although HIV infects a variety of cells, its main target is the CD4 lymphocyte. CD4 lymphocytes warn your immune system that there are germs trying to invade the body. HIV infects cells of the immune system. Its main target is the CD4 lymphocyte.

HOW DO VIRUSES INFECT THESE CELLS? The human body is made of millions of different cells. Each body cell is able to make new cell parts, in order to stay alive and to reproduce. Viruses take advantage of this ability. They hide their own material in the centre of the cell, called the nucleus. When the cell tries to make its own new parts, it also makes new copies of the virus. When the HIV virus infects CD4 lymphocytes, HIV uses the CD4 cell to make new copies of the HIV virus. These copies go on to infect other cells.

WHAT DOES HIV DO TO CD4 LYMPHOCYTES? CD4 cells infected with HIV are not able to work very well. They die early. When the immune system loses these CD4 cells, the immune system becomes weaker. This makes children (and adults) much more likely to develop illness from the types of germs that would not normally cause them to be ill, or to be more sick with common germs. These infections are called opportunistic infections. They take the opportunity of the body’s defence system being weak to flourish.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

Figure 1 summarizes what happens to HIV after it enters a human cell. Figure 1. HIV entering the cell and making new copies

HIV attacks many CD4 cells. The infected CD4 cell will first produce many new copies of the virus, and then die. The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and then die. This goes on and on – more CD4 cells are destroyed, and more copies of HIV are made.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

HOW IS HIV MONITORED ONCE IT INFECTS THE BODY? When a person gets infected with the HIV, the virus will start to attack his/her immune system. Since HIV mostly attacks CD4 cells, there is a measurement of the number of CD4 cells in an HIVinfected person’s blood. This is a good way of checking how well their defence system is still working. This is called a CD4 count. CD4 counts tell you how healthy a person’s immune system is.

HOW DOES HIV AFFECT ADULTS? During the first years following infection, an adult’s immune system can still function quite well, even though the HIV virus is slowly damaging the immune system. The infected adult will have no symptoms, or only minor symptoms such as swollen lymph nodes or mild skin diseases. At this stage, most adults do not even know that are infected with HIV. Usually after several years, the adult’s immune system gets more and more damaged and weaker. The person becomes vulnerable to germs and diseases that they normally fight off. These infections are called ‘opportunistic infections’ because they take advantage of the weak immune system to cause disease. In adults it usually takes around 7–10 years after the initial infection with HIV before the person becomes ill and develops serious sickness from HIV. HIV is considered to have progressed to AIDS when these sicknesses occur and a CD4 count reaches below a certain number.

HOW DOES HIV AFFECT CHILDREN DIFFERENTLY THAN ADULTS? HIV infection progresses much more rapidly in children as compared to adults. The course of HIV infection is different in children than in adults because children’s immune systems are not yet well developed. HIV seems to damage the immune system more easily in children. This is especially true if the child is infected with HIV while in the mother’s womb, or at the time of delivery. Children are also more susceptible to common infections or unusual opportunistic infections. In the same way as adults, when the child’s immune system gets damaged it becomes weak. Children can get sick from germs that do not usually cause serious disease. For example, a child may normally have candida bacteria living in the mouth. However, when the immune system is damaged, the candida causes mouth ulcers or soreness. This is HIV can usually called oral thrush. As the damage to the immune system gets worse, children become highly vulnerable to life-threatening illnesses such as PCP pneumonia, unusual cancers (lymphoma), recurrent bacterial infections, and HIV brain damage (encephalopathy). These are considered AIDS-defining diseases because they are often seen once a child’s immune system is not performing well due to HIV infection. As the HIV disease progresses, a child’s CD4 percent or total count gets less. Figure 2 illustrates how HIV attacks our health.

weaken or destroy the immune system in children much more quickly. Children progress from HIV to AIDS more rapidly.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

Figure 2. How HIV attacks the body 1. The CD4 cell is a kind of white blood cell. The CD4 is the friend of our body. 2. Problems like cough try to attack our body, but the CD4 fights them to defend the body, his friend.

body

CD4

3. Problems like diarrhoea try to attack our body, but CD4 fights them to defend the body.

4. Now, HIV enters and starts to attack the CD4.

5. The CD4 notices he cannot defend himself against HIV!

6. Soon, CD4 loses his force against HIV.

7. CD4 loses the fight. The body remains without defence.

8. Now the body is alone without defence. All kinds of problems, like cough & diarrhoea, take advantage and start to attack the body.

9. In the end, the body is so weak that all the diseases can attack without difficulty.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

HOW ARE CHILDREN INFECTED WITH HIV? Mother-to-child transmission of HIV (MTCT) is the main way that young children are infected with HIV. This is also called vertical transmission. Other ways in which children can get HIV are sexual abuse, unsafe injections, or blood transfusion with blood products that are infected with HIV.

HOW DOES MOTHER-TO-CHILD TRANSMISSION OF HIV OCCUR? Mother-to-child transmission (MTCT) is when an HIV infected woman passes the virus to her baby. This can happen without the mother’s knowledge is she does not know her status. HIV can be transmitted from mother to child during several methods, and times: 1. Pregnancy (in utero) 2. Labour and delivery ( peri or intrapartum) 3. Breastfeeding ( postpartum) Not all HIV infected women will automatically transmit the virus to their child.

WHAT IS THE RISK OF MOTHER-TO-CHILD TRANSMISSION? Look at the diagram below. This will be an example. Consider 20 babies born to 20 HIV-infected women. If nothing is done to prevent HIV transmission in these 20 babies, then approximately 7 of the 20 women will transmit HIV to their infants during pregnancy, labour, delivery, or breastfeeding. This means that the overall risk of MTCT is about 35%. This is visualized in the picture below, where 7 of 20 of babies are shaded. Of these 7 babies, it is estimated that about 4 of them (or 20% of the total infection risk) would be infected during pregnancy, labour, or delivery. The remaining 3 babies (or about 15% of the total infection risk) would be infected during breastfeeding. This risk is decreased if the mother or child receives ART prophylaxis.

If  20  women   deliver   babies  without  any  intervenKon   4 (20%) 3 (15%) infected infected to  reduce   mother-­‐to-­‐child   HIV  transmission:     during during or on  a feeding How  labout m any   verage  will  be  infected?  7  out  of  20     delivery pregnancy, breast  

PREGNANCY   &  DELIVERY   4  out  of  20  

BREASTFEEDING   3  out  of  20  

13

NOT  INFECTED   13  out  of  20  

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

Why does transmission risk change during pregnancy, delivery, and breastfeeding? The risk of transmission during pregnancy is low, as the placenta protects the developing baby. During labour and delivery the risk is increased through sucking, absorbing, or aspirating blood or cervical fluid. Exclusive breastfeeding reduces the risk of HIV transmission.

Mixed feeding, compared to exclusive feeding, may increase the risk of HIV transmission. Studies have shown that exclusive breastfeeding carries a smaller risk of HIV transmission when compared with mixed feeding. This is due to potential damage to the lining of the infant’s gut by food particles or the introduction of an allergen or bacteria that causes inflammation. This can lead to easier access of the HIV virus from the mother’s breast milk into the infant’s blood.

IMPORTANT NOTE ABOUT MOTHER-TO-CHILD TRANSMISSION The term mother-to-child transmission is used in this document because the source of the child’s HIV infection is the mother. Use of the term mother-to-child transmission does not imply blame, whether or not a woman is aware of her own infection status. A woman can acquire HIV through unprotected sex with an infected partner, or by receiving contaminated blood through non-sterile instruments or medical procedures.

WHAT DOES IT MEAN TO BE ‘HIV EXPOSED’? For the purposes of this course, HIV-exposed infants are born to women who are known to be HIV-infected. HIV-exposed infants or children cannot be considered HIV-positive or HIV-negative until their status is confirmed with an appropriate HIV test.

WHAT HAPPENS IF HIV-INFECTED CHILDREN ARE UNTREATED? If untreated, three-quarters (75%) of children who are infected through MTCT will develop problems from HIV and will die before the age of five. For children who are infected through mother-to-child transmission and who do not receive any antiretroviral treatment or cotrimoxazole prophylactic therapy: about one-third will die by one year of age, and half will die by two years of age. Many of these infant deaths occur at home before presentation to health care facilities. Children with HIV infection can develop severe illness very quickly. They may not present with the classic picture of chronic wasting and decline that is commonly seen in adults with HIV or AIDS. HIV/AIDS is rapidly fatal in children – this is why early HIV diagnosis essential.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

HOW CAN DEATHS FROM HIV BE PREVENTED IN CHILDREN? Important interventions to reduce the risk of children dying from HIV includes: 1. Early diagnosis of HIV 2. Initiating Antiretroviral Therapy (ART) 3. Initiating other prophylaxis and treatments Infants are most at risk of developing serious complications and dying from HIV infection – therefore it is most important that these children are identified, and placed on treatment. You will now read more in the following sections about each of these points for preventing deaths: early diagnosis through HIV testing, prophylaxis, treatments, and ART.

SELF-ASSESSMENT EXERCISE A – HIV TERMS Define the following terms in a way that you would explain to a caretaker.

1. Immune system:

2. CD4:

3. Opportunistic infection:

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.3

HIV TESTING

What are the learning objectives for this section? After you study this section, you will know how to: •• Explain the types of HIV tests available in your country •• Interpret the tests based on a child’s age, breastfeeding status, and mother’s status

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

n  OPENING CASE STUDY – PETER Peter is 6 months old. His mother, Lungile, brought him to your clinic because he had cough for the last 3 days. Peter has no general danger signs. He breathes 54 per minute but he has no chest indrawing and no stridor or wheeze. He has no diarrhoea, fever, or ear problems. His weight is 7.2 kg. His temperature is 37.5 degrees. Lungile is worried. She was recently told she has HIV. She is receiving care at another clinic.

How will you assess and classify Peter? First, you know that you will use the sick child charts because Peter is between 2 months and 5 years of age. You record Peter’s important information at the top of the recording form. You assess his cough: he has fast breathing but no other signs. You classify as PNEUMONIA. You do not classify for diarrhoea, fever, or ear problems. He is not low weight for age. Lungile tells you she breastfed Peter until he was 4 months old.

How will you record this information on Peter’s recording form?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of Lungile has told you she is HIV-infected. Now you will learn about HIV tests used for sick children and both feet:

infants in your country.

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today)

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHY DOES HIV TESTING IMPORTANT FOR IMCI? In order to assess and classify a child for HIV, you need to know if he or she has already had an HIV test. Open your chart booklet and review the ASSESS and CLASSIFY table for HIV. You will see there are two sets of charts. These are based on whether or not the child has been tested for HIV. You will now learn about HIV tests, and then you will continue on to assessing and classifying.

WHEN IS IT NECESSARY TO TEST A CHILD FOR HIV? You will encourage HIV testing for: ■■ All children born to an HIV-infected mother ■■ All children that do not have a known test result, and you do not know the mother’s status ■■ In a high HIV setting, every child who is sick should be tested for HIV

WHAT ARE HIV TESTS? Different tests are available to diagnose HIV infection. It is first important to understand the different tests – some detect antibodies, and others detect the virus itself. The results from these two tests are understood differently. Review these two test types in the table: What does the test detect? SEROLOGICAL TESTS including rapid tests These tests detect antibodies made by immune cells in response to HIV. They do not detect the HIV virus itself. How can you interpret the test? HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not disappear until the child is 18 months of age. This means that a positive serological test in children under the age of 18 months is not a reliable way to check for infection of the child. Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old. If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected. Tests should be done six weeks or more after breastfeeding has completely stopped – only then do the tests reliably rule out infection.

VIROLOGICAL TESTS including DNA or RNA PCR

These tests directly detect the presence of the HIV virus or products of the virus in the blood.

Now you will read more about these tests and their relevance for different age groups: children under 18 months, and 18 months or older.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT TEST SHOULD BE USED IF THE CHILD IS 18 MONTHS OR OLDER? You will use a serological test to determine the HIV status of a child 18 months or older. If the serological test is positive it confirms the child’s status as HIVinfected.

WHAT TEST SHOULD BE USED IF THE CHILD IS UNDER 18 MONTHS OLD? A virological test (PCR) is the only reliable method to determine the child’s HIV status below 18 months of age. It detects the actual virus in the child’s blood. Remember that serological tests do not determine HIV status in this age group. This is because the test may detect antibodies that might have passed from the mother through the placenta. Therefore a positive serological test may only tell you that the child has been exposed to HIV, rather than that the child is HIVinfected.

THERE ARE TWO SCENARIOS FOR CHILDREN UNDER 18 MONTHS: This depends on the availability of PCR in your country: 1. IF PCR or other virological TEST IS AVAILABLE, TEST FROM 4–6 WEEKS OF AGE + A POSITIVE result means that the child is infected, as it detects the actual presence of HIV in the child – A NEGATIVE result means that child is not infected, but could become infected if they are still breastfeeding 2. IF PCR or other virological TEST IS NOT AVAILABLE, USE A SEROLOGICAL TEST + A POSITIVE result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected. All HIV-exposed infants should be tested using PCR or other virological test. – A NEGATIVE result usually means the child is not infected. A negative test is also useful because it usually excludes HIV infection from the mother, as long as the child has not breastfed for more than 6 weeks.

HOW WILL YOU INTERPRET A SEROLOGICAL TEST IN A CHILD UNDER 18 MONTHS? As you have read, the breast milk of an HIV-positive mother can transmit HIV. You see in the chart that this affects how you will interpret test results. Is child breastfeeding? NOT BREASTFEEDING, and has not in last 6 weeks BREASTFEEDING POSITIVE (+) test HIV exposed and/or HIV infected – Manage as if they could be infected. Repeat test at 18 months. HIV exposed and/or HIV infected – Manage as if they could be infected. Repeat test at 18 months or once breastfeeding has been discontinued for more than 6 weeks. NEGATIVE (-) test HIV negative Child is not HIV infected Child can still be infected by breastfeeding. Repeat test once breastfeeding has been discontinued for more than 6 weeks.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

  REVIEW THE EARLY INFANT DIAGNOSIS ALGORITHM BELOW:

flow charts help you make decisions about the testing course of action for Review  This the   early   infant   diagnosis   algorithm   below:  

children under 18 months. It provides some more c specifics in addition to the under   This  flow  c harts  help   you   make   decisions   about  t he  testing   ourse  of   action   for  c hildren   information you readm on the previousin   page. 18  months.   It  provides   some   ore   specifics   addition  to  the  information  you  read  on  the   previous  page.     HIV-­‐exposed  Infant  or  child  <18  months   Conduct  diagnostic  v iral  testa   Viral  test  available   Positive   Viral  test  not  available  

Negative  

Infant/child  is  likely  infected    

Never  breastfed  

Ever  breastfed  or  currently   breastfeeding   Infant  /child  remains   at  risk   for  acquiring  HIV  infection   until  complete  cessation  of   breastfeedingc   Regular  and  periodic   clinical  monitoring  

<24   months:  immediately   start  ARTb    

Infant/child  is   uninfected  

And  repeat  viral  test   to  confirm  infection  

Infant/child  develops  signs  or  symptoms   suggestive  of  HIV  

Infant  remains  well  and  reaches  9   months  of  age  

Viral  test  not  available  

Conduct  HIV  antibody  test  at     approximately  9  months  of  age  

Viral  test  available       Negative   Positive  

Positive  

Negative  

sick  

Infant/child  is  infected  

 

Viral  test  not  available   assume  infected  if  sick   assume  uninfected  if  well   well  

Start  ARTb   And  repeat  viral  test  to  confirm   infection    

HIV  unlikely  unless   still   breastfeedingc  

  a

Repeat  antibody   test  at  18  months  of  age   and/or  6  weeks  after  cessation  of   breastfeeding    

For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant diagnosis. b Start ART, if indicated, without delay. At the same time, retest to confirm infection. c The risk of HIV transmission remains as long as breastfeeding continues.

 

20 dIMCI  SELF-­‐STUDY  MODULES  |  World  Health  Organization  

 

 

 

 

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT MOTHERS NEED TO BE COUNSELLED FOR THEIR CHILD’S HIV TEST? Many mothers, and even health workers, are reluctant to discuss HIV. However, HIV is present in the community and the problem will not be solved as long as there is secrecy surrounding the topic. The mother of a child classified as HIV EXPOSED will need to be counselled about an HIV test for the child. These children all require HIV tests and re-classification based on these tests.

WHAT INFORMATION SHOULD BE PROVIDED TO THE MOTHER? When you have identified a young infant or child who is in need of HIV testing you should provide the mother with information: •• Explain why it is important to test the child (e.g. status is unknown). •• Help the mother to understand that the reason for HIV testing is so that the child can receive treatment that will improve his quality of life. He should have antibiotics to prevent infections, vitamin supplementation, regular growth monitoring, treatment of any illnesses, and antiretroviral therapy if needed. If the child is less than about 2 years, counsel on infant feeding.

HOW CAN YOU HELP ADDRESS A CAREGIVER’S CONCERNS? Once you have explained, allow the mother to ask questions and address her concerns. If she agrees to the test, arrange it in the normal way at your clinic. Since the most common route of HIV infection for a child is by mother-to-child transmission, you may need to discuss testing her and her partner as well perhaps even before testing the child. Mother-to-child transmission presents a number of barriers to testing of the child. HIV may provoke feelings of guilt on the part of the mother, as well as fears of rejection by and of the child and of revealing their own HIV status and how they were infected. All health workers must be equipped with the knowledge and ability to discuss HIV, ask questions and give appropriate counselling.

WHAT SHOULD A HEALTH WORKER DO IF A MOTHER REFUSES TESTING? If a mother does not agree to test the child, the health worker should listen to and address her concerns and reasons against testing. The health worker may be considered an advocate for the child and negotiate with the parent or carer in the child’s best interest. Reassurances should be made regarding treatment, care, support and/or preventive interventions that the child may benefit from once diagnosed. It may help for the parent/carer to express their concerns without the child’s presence.

WHAT STEPS SHOULD BE TAKEN AFTER TESTING? After testing, make an appointment for a review of the results and post-test counselling. If a serological test has been performed, do the post-test counselling immediately if this is agreeable to the mother. Maintain privacy and confidentiality so that the mother can discuss her concerns freely.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

After you explain information, allow the mother to ask questions. Address her concerns.

SELF-ASSESSMENT EXERCISE B – HIV TESTING Complete the following questions to practice what you have learned about HIV tests.

1. What is the difference between an HIV virological (PCR) test and an HIV serological test? 2. What test would you use to confirm HIV infection in a child under the age of 18 months? 3. A 20 month old baby has a positive virological (PCR) test. Is the child HIV infected? 4. A 2 month old breastfeeding baby has a positive HIV serological test. Is the child HIV infected? 5. A 2 month old baby has a positive virological (PCR) test. Is the child HIV infected? 6. A 21 month child has a negative serological test. Child has not breastfed since he was 6 months old. Is the child HIV infected? 7. An 18 month old breastfeeding child has a positive HIV serological test. Is the child HIV infected? 8. A 9 month old breastfeeding baby has a negative virological (PCR) test. Is the child HIV infected? 9. A 9 month old baby has a negative virological (PCR) test. The baby last breastfed 3 months ago. Is the child confirmed HIV negative? 10. A 16 month old child has a negative serological test. The child is not breastfeeding. Is the child confirmed HIV negative?

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SUMMARY: WHAT DID YOU LEARN IN THIS SECTION? Review the main points from this section. Reading this summary, and completing the self-assessment exercises in the module, are important for learning. 1. HIV testing is essential for assessing and classifying a child for HIV You will assess a child based on his HIV tests and clinical signs. 2. A positive serological HIV test cannot confirm HIV infection for children below 18 months. This is because the test shows the presence of antibodies – and children under 18 months can still have antibodies from their mothers. However, a negative test is useful because it usually excludes HIV infection from the mother, so long as the child has not been breastfed for more than 6 weeks. 3. A positive serological HIV test cannot confirm HIV infection for children below 18 months. This is because the test shows the presence of antibodies, and children under 18 months may have antibodies present from their mothers. 4. Breastfeeding matters A child can be infected with HIV through breast milk. An HIV test can only be confirmed once a child has stopped breastfeeding for at least 6 weeks.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.4

ASSESS & CLASSIFY A SICK CHILD

What are the learning objectives for this section? After you study this section, you will know how to: •• Assess a sick child for HIV by using their test results or clinical signs of HIV •• Classify a sick child for HIV

IN SUMMARY, HOW DO YOU KNOW WHEN A CHILD IS HIV INFECTED? In the last section you learned about HIV testing, and how to interpret results by age group and by breastfeeding status. These test results will determine how you assess and classify the child or sick young infant.

SUMMARY: how do you know when a child is HIV infected? n POSITIVE VIROLOGICAL (PCR) TEST at any age with a confirmatory test n POSITIVE SEROLOGICAL TEST at 18 months or older with a confirmatory test Remember that test results are not confirmed unless child has not been breastfeeding for at least 6 weeks. Children can still be infected by breastfeeding.

HOW WILL YOU USE TEST RESULTS TO ASSESS? To ASSESS a child for HIV, you will use: (a) test results, if available, and (b) clinical signs. The first step in assessing is to determine whether or not there are test results available for the child or mother. This will help determine your steps for ASSESSING.

For ALL sick children – ask the caretaker about the child’s problems, check for general danger signs, assess for cough or difficult breathing, assess for diarrhoea, assess for ear problem, check for malnutrition and anaemia, and then: ASK: HAS THE CHILD or MOTHER BEEN TESTED FOR HIV INFECTION?

YES, test results available Assess for HIV infection

NO test results available Check for features of HIV

CLASSIFY the child using the colour-coded charts Check immunization status, assess feeding, other problems and mother’s health

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

HOW WILL YOU ASSESS FOR HIV INFECTION?

THEN CHECK FOR HIV INFECTION Open to your ASSESS chart for HIV. It contains these instructions, starting with Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step an ASK: ASK Has the mother and/or IF YES: Then note child had an HIV test? mother's and/or child's HIV status:Mother's HIV status: POSITIVE or NEGATIVE Child's HIV status: Virological test POSITIVE or NEGATIVE Serological test POSITIVE or NEGATIVE IF NO: Mother and child status unknown, then TEST mother. If positive, then test the child. 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?

Classify HIV status

Positive viro child OR

Positive ser a child 18 m

Mother HIV negative vir child breast only stoppe weeks ago

O

Mother HIV not yet test

O

Positive ser a child less old

Negative HI or child*

* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical s

** pages, If virological islearn negative, repeat testof 6 weeks the breatfeeding has stopped; if serological test is positiv On the following you test will about each theseafter instructions.

ASK: HAS THE MOTHER AND/OR THE CHILD HAD AN HIV TEST? Remember that this is sensitive information, and that it is important to ensure confidentiality. All mothers should have been offered testing during their pregnancy. Ask the mother if she has had an HIV test. If the mother has had a test, ask her what the result was. YES the mother or child has had an HIV test. Record the test results: 1. Mother’s HIV status: POSITIVE or NEGATIVE Remember that a mother may have tested negative in the past, and could now be HIV infected. The more recent the test, the more likely it is to be accurate. 2. Child’s HIV status: a. Virological test POSITIVE or NEGATIVE b. Serological test POSITIVE or NEGATIVE

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

NO test result is available for mother or child. Conduct an HIV test: If there is no test available, you will test the mother. If the test is POSITIVE, then test the child. You learned in Section 3 of this module about the types of HIV tests available in your country. Remember tests are different depending on the child’s age: •• child 18 months or older: you will use a serological test. If the test is positive it confirms the child’s status as HIV-infected. •• child under 18 months: a virological test (PCR) is the only reliable method to determine the child’s HIV status. It detects the actual virus in the child’s blood.

IF MOTHER IS HIV POSITIVE AND CHILD IS NEGATIVE OR UNKNOWN In this situation, you must ask more about the child’s feeding status. You remember that breast milk can transmit HIV. As a result, a child who has initially tested negative may still develop HIV infection. It is therefore important to know if the child was breastfeeding or had been breastfed in the six weeks before the test was done. Six weeks is considered the “window period” or time during which a patient may test negative even though they are infected. In order to better understand the child’s feeding status, you will ask the following questions and record responses: 1. If a previous test was done, was the child breastfeeding at the time or the test? Was the child breastfeeding in the 6 weeks before the test? 2. Is the child breastfeeding now? 3. If the child is breastfeeding, ASK: is the mother and child on ARV prophylaxis? You will learn more about ARV prophylaxis in section 9.6. REMEMBER! Child must not have breastfed within six weeks of a test in order for it to be confirmed negative.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WITH HIV RESULTS AVAILABLE, CLASSIFY THE CHILD: Once you have the child or mother’s test results, you can classify according to the result. Open to the classification table. There are three classifications: 1. CONFIRMED HIV INFECTION 2. HIV EXPOSED 3. HIV INFECTION UNLIKELY Positive virological test in child OR Positive serological test in a child 18 months or older

already enrolled in HIV care, go to the next step and assess for mouth and gum condition. Yellow: CONFIRMED HIV INFECTION Give cotrimoxazole prophylaxis* Give HIV care and initiate ART treatment Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care Refer for TB assessment and INH preventive therapy Follow-up regularly as per national guidelines Mother HIV-positive AND negative virological test in child breastfeeding or if 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 old Negative HIV test in mother or child* Green: HIV INFECTION UNLIKELY Treat, counsel and follow-up existing infections Yellow: HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended Do virological test to confirm HIV status** 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

Classify HIV status

* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available, offer HIV testing for child.

CONFIRMED HIV INFECTION (YELLOW) eatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.

old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%

A child with a positive HIV test should be classified as CONFIRMED HIV INFECTION. This means a positive serological test for a child 18 months or older. Virological tests confirm HIV in all children. These children should be provided cotrimoxazole prophylaxis (you will learn about eligibility in 9.6), HIV care and ART, and other counselling.

HIV EXPOSED (YELLOW) Children born to HIV-positive women are HIV EXPOSED and could possibly have HIV. This classification is used for three different scenarios: 1. Mother is HIV-positive and the child has a negative virological test, but the child is still breastfeeding or stopped less than 6 weeks ago. Due to the breastfeeding, the child still risks exposure, or the negative status cannot yet be confirmed. 2. Mother is HIV-positive and child has not yet tested. 3. The child is less than 18 months old and has a positive serological test. Remember that this child’s status can only be confirmed with a virological test. Page 11 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

These children require cotrimoxazole prophylaxis and ARV prophylaxis (as recommended). The child should receive a virological test to confirm status. If this test is negative, it must be repeated after breastfeeding has stopped for 6 weeks in order to be confirmed.

HIV INFECTION UNLIKELY (GREEN) If mother or child has a negative test, the child is classified HIV NEGATIVE. You will treat, counsel, and follow-up existing conditions according to your IMCI assessment.

SELF-ASSESSMENT EXERCISE C – ASSESS & CLASSIFY SICK CHILD Are these statements about assessing and classifying true or false?

a. A 10-month old has a positive virological test. She stopped breastfeeding 30 days ago. She should be classified as CONFIRMED HIV INFECTION. b. A 9 month old child is still breastfeeding has tested negative with a PCR test. He should be classified as HIV INFECTION UNLIKELY. c. A 9 week old child is clinically well. His mother is HIVinfected. The child has not been tested yet, so you conduct a serological test. The result is positive. He should be classified as CONFIRMED HIV INFECTION. d. You send for a PCR test for a 16 month old. The results are positive. He stopped breastfeeding when he was 12 months old. He should be classified as CONFIRMED HIV INFECTION. e. A 4 month old was born to an HIV-infected mother. He is breastfeeding. You provide a serological test, and the result is positive. He should be classified as HIV EXPOSED. f. An 8 month old child born to an HIV-infected mother comes to the clinic. Her mother says she was tested 2 months ago. You see the PCR results, and they are negative. The child is still breastfeeding. She should be classified as HIV INFECTION UNLIKELY. g. A 36 month old child has a positive serological HIV test. She should be classified as CONFIRMED HIV INFECTION.

TRUE

FALSE

TRUE

FALSE

TRUE

FALSE

TRUE

FALSE

TRUE

FALSE

TRUE

FALSE

TRUE

FALSE

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

n  How will you assess Peter for HIV? First, you review the ASSESS table in the sick child charts. You ask Lungile is Peter is breastfeeding. She says yes. She has also already told you that she has been tested for HIV and is infected. She did not receive any ART prophylaxis for PMTCT. importance of identifying children who are exposed or infected with HIV. You provide a serological test. The Yellow: Positive virological test in Give cotrimoxazole prophylaxis* result is positive. child

You ask has been tested, and she says no. You counsel Lungile on testing Peter for HIV, and the already enrolled in HIV care, goif toPeter the next step and assess for mouth and gum condition. CONFIRMED HIV INFECTION Give HIV care and initiate ART treatment Assess the child’s feeding and provide appropriate counselling to the mother Advise the mother on home care

Classify HIV status

n  How willPositive you classify Peter? serological test in

OR

a child 18 months or older Lungile is HIV positive, and Peter has a negative serologicalRefer test.for He is 6 months old. You classify him as HIV TB assessment and INH preventive EXPOSED. therapy Follow-up regularly as per national guidelines Mother HIV-positive AND negative virological test in child breastfeeding or if 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 old or child* HIV INFECTION Remember that you cannot confirm Peter’s HIV status until he has stopped breastfeeding for at least UNLIKELY 6 weeks. His status must be confirmed with a virological test as long as he is under 18 months of age. Negative HIV test in mother Green: Treat, counsel and follow-up existing infections Yellow: HIV EXPOSED Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended Do virological test to confirm HIV status** 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

In section 6 you will learn how to give prophylaxis to Peter. In section 7 you will learn about feeding recommendations for Peter. In section 8 and subsequent sections you will learn about follow-up care, ART initiation if the confirmed positive. Withor the classification HIVCD4 EXPOSED, old and to children 1- including 4 years old at WHO clinical stages 2,child 3 and is 4 regardless of CD4 percentage at any WHO stage and <25% Peter will follow-up with you monthly. eatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.

SUMMARY: WHAT DID YOU LEARN IN THIS SECTION? 1. You will use HIV test results from a child and mother to assess and classify a child’s HIV status. You will use test results from a mother and/ or child to classify the child’s HIV status. The first course of action is to test the mother if you do not have her test results. If she is positive, then you will test the child. It is important to maintain confidentiality of the test results of mothers and children. If the HIV status of the mother or child is unknown, the care provider should offer HIV testing especially if the child has malnutrition, pneumonia, diarrhoea, chronic cough or other symptoms that may suggest HIV/ AIDS. This is referred as provider-initiated testing and counseling. Page 11 of 75  2. Children can be infected with HIV while breastfeeding. Test results cannot be confirmed unless the child has not breastfed for 6 weeks or more. This is an important window.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

3. Virological tests must be used to confirm the status of a child under 18 months. Children under 18 months require confirmation by PCR (virological) testing. Remember it is different for children older than 18 months: these children can be confirmed with a serological test. The second important point is that test results cannot be confirmed unless the child has not breastfed for 6 weeks or more.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.5

ASSESS & CLASSIFY A SICK YOUNG INFANT

What are the learning objectives for this section? •• Explain how assessing and classifying for HIV is different for a young infant •• Assess and classify a young infant using the chart booklet

WHEN WILL YOU ASSESS AND CLASSIFY A YOUNG INFANT FOR HIV? Review what you have learned so far about assessing and classifying the sick young infant.

For ALL sick young infants – ask the caretaker about the infant’s problems, check for signs of possible bacterial infection and jaundice, assess for diarrhoea, then: ASK: HAS INFANT BEEN TESTED FOR HIV?

YES Assess for HIV infection

NO Assess based on mother’s status

CLASSIFY the young infant’s HIV status using the colour-coded charts NEXT: assess for feeding problems or low weight, check immunizations, consider special risk factors, and assess mother’s health and other problems

HOW IS ASSESSING AND CLASSIFYING A YOUNG INFANT DIFFERENT THAN A CHILD? Assessing and classifying the sick young infant for HIV differs from the classification for an older child. It is not possible to classify the sick young infant for SYMPTOMATIC HIV INFECTION because infants usually do not show signs and symptoms of HIV like children. Young infants with HIV infection usually do not have any signs and symptoms directly related to HIV infection – this does not mean that they may not become ill, but rather that they will develop signs and symptoms of common childhood illnesses such as pneumonia or diarrhoea. As a result, the assessment and classification of HIV infection in young infants is based on HIV test results. Young infants usually do not have signs directly related to HIV. As a result, classifications use HIV test results.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHY IS EARLY IDENTIFICATION SO IMPORTANT WITH YOUNG INFANTS? It is very important that young infants with HIV are identified early. These infants may look well, but can become ill and die very quickly. PCR virological testing is now available in many regions – this helps to identify HIV-infected children early. All children born to HIV-infected mothers should be tested for HIV infection using a virological test. We have to ensure that all exposed babies are identified and tested, and that test results come back to the clinic and are communicated to the caregiver. Counselling of the mother or caregiver before and after the test is a key part of this process. Early identification allows the infant to benefit from ART and other treatments.

HOW WILL YOU ASSESS THE YOUNG INFANT FOR HIV? Review the ASSESS chart. What instructions do you see?

ASSESS  YOUNG  INFANT  FOR  HIV  

ASK: HAS THE MOTHER AND/OR YOUNG INFANT HAD AN HIV TEST? YES test available: note the mother’s and/or young infant’s HIV status 1. Mother’s HIV status: serological test POSITIVE or NEGATIVE Remember that a mother may have tested negative in the past, and could now be HIV infected. The more recent the test, the more likely it is to be accurate. 2. Young infant’s HIV status: a. Virological test POSITIVE or NEGATIVE b. Serological test POSITIVE or NEGATIVE

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

If mother is positive and no positive virological test in child, ASK about feeding status: As you know, the child’s status cannot be confirmed until breastfeeding has stopped for at least 6 weeks. Therefore you should ask the mother this important information: •• Is the young infant breastfeeding now? •• Was the young infant breastfeeding at the time of the test or before it? •• Are the mother and young infant on ARV prophylaxis? NO test available, so mother and young infant status unknown: If the mother and young infant test results are not known, you will perform an HIV test for the mother. If it is positive, perform a virological test for the young infant.

HOW WILL YOU CLASSIFY THE YOUNG INFANT FOR HIV? After you ASSESS for rest results, you will classify. There are three classifications: 1. CONFIRMED HIV INFECTION 2. HIV EXPOSED 3. HIV INFECTION UNLIKELY Positive virological test in child OR Positive serological test in a child 18 months or older Yellow: CONFIRMED HIV INFECTION Give cotrimoxazole prophylaxis* Give HIV care and initiate ART treatment 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

already enrolled in HIV care, go to the next step and assess for mouth and gum condition.

Classify HIV status

Mother HIV-positive AND negative virological test in child breastfeeding or if 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 old Negative HIV test in mother or child*

Yellow: HIV EXPOSED

Give cotrimoxazole prophylaxis Start or continue ARV prophylaxis as recommended Do virological test to confirm HIV status** 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

Green: HIV INFECTION UNLIKELY

Treat, counsel and follow-up existing infections

* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available, offer HIV testing for child.

eatfeeding has stopped; if serological test is positive, do a virological test as soon as possible. CONFIRMED HIV INFECTION (YELLOW)

old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%

If the young infant has a positive virological (PCR) test, she is classified as CONFIRMED HIV INFECTION. Remember that a virological test must be used because a serological test does not confirm HIV infection in children less than 18 months of age. Children with this classification should receive cotrimoxazole prophylaxis from age 4–6 weeks. All young infants with CONFIRMED HIV

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

INFECTION are eligible to receive ART and HIV care. You will learn about this in the upcoming sections of this module.

HIV EXPOSED (YELLOW) The young infant is classified as HIV EXPOSED if one of the following scenarios is true: •• If the mother is HIV-infected and the young infant’s virological is negative, but he is still breastfeeding or stopped breastfeeding less than 6 weeks ago. The infant is still exposed to HIV during breastfeeding. •• If the mother is HIV infected and no test result is available for the infant. •• If the infant has a positive serological test. The HIV EXPOSED child should receive cotrimoxazole prophylaxis from age 4–6 weeks. ARV prophylaxis should be given per national recommendations. Remember that the child’s status must be confirmed after he has stopped breastfeeding for at least 6 weeks.

HIV INFECTION UNLIKELY (GREEN) The child is classified HIV INFECTION UNLIKELY if the mother has a negative HIV test, or the young infant has a negative test and was not breastfed for six weeks before the test was done. These infants can be followed up routinely. Cotrimoxazole prophylaxis can be stopped, if it had been previously started.

SELF-ASSESSMENT EXERCISE D – CLASSIFY Classify the following sick young infants and children for HIV status. 1. 7 week old child. Mother HIV-positive. 2. 8 week old girl. Abandoned at birth, now formula feeding. PCR done at six weeks was negative. 3. 6 week old with positive PCR test. 4. 7 week old, status unknown. Mother tested negative. 5. 12 month old, status unknown. Grandmother brings child to clinic. Child has positive serological test.

SUMMARY: WHAT DID YOU LEARN IN THIS SECTION? 1. If the mother and young infant do not have test results, you will begin by testing the mother. If the mother is HIV positive, this means the young infant has been exposed. You will then test the young infant. If the mother is HIV negative, HIV infection in the young infant is unlikely. 2. Young infants can be infected with HIV while breastfeeding. Test results cannot be confirmed unless the young infant has not breastfed for 6 weeks or more. This is an important window.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

3. Virological tests must be used to confirm the status of young infant. Young infants are under two months of age. You remember that children under 18 months require confirmation by PCR (virological) testing. 4. Any child or young infant with symptoms suggestive of HIV infection, offer HIV testing.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.6

PROPHYLAXIS AND OTHER PREVENTIVE MEASURES

What are the learning objectives for this section? After you study this section, you will know how to prevent HIV infection and other common illnesses in infants and young children classified for HIV by: •• Providing prophylactic ARVs •• Providing cotrimoxazole prophylaxis •• Providing isoniazid preventive therapy to address TB and HIV co-infection •• Ensuring complete immunizations •• Providing Vitamin A supplementation and regular deworming •• Monitor HIV-infected children to ensure timely ART initiation

WHY IS THIS CARE IMPORTANT FOR HIV-EXPOSED AND INFECTED CHILDREN? You learned in the introduction of this module that HIV attacks a child’s immune system. Because of this, children and infants become very vulnerable to infections that may not usually make them so sick. There are many important treatments for preventing and managing these opportunistic infections. Several types of prophylaxis and other preventive measures seek to keep a child’s immune system strong.

WHAT TYPES OF PROPHYLAXIS ARE GIVEN? There are a number of prophylaxis and preventive measures for children and infants who are HIV exposed and infected. In this section you will read about the following measures: •• PROPHYLACTIC ARVs •• COTRIMOXAZOLE PROPHYLAXIS •• ISONIAZID PREVENTIVE THERAPY These important prophylactic measures are discussed in the well child care module: •• IMMUNIZATIONS •• VITAMIN A SUPPLEMENTATION

WHY ARE THESE TYPES OF PROPHYLAXIS IMPORTANT? Prophylactic ARVs (nevirapine and zidovudine prophylaxis) can help in preventing HIV infection in young infants. The other types of prophylaxis in this list prevent and manage common opportunistic infections like tuberculosis, pneumonia, and other bacterial infections. Routine care like immunizations, Vitamin A, and deworming are important measures for HIV-exposed and HIV-infected children to prevent illness.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

How will you give ARV prophylaxis? Nevirapine (NVP) or zidovudine (AZT) are provided to HIV-exposed infants to minimize mother-to-child transmission of HIV (PMTCT) until 4 to 6 weeks of age. Open your chart booklet to the ‘TREAT’ charts to find instructions for PMTCT prophylaxis: BREASTFEEDING 6 weeks of infant prophylaxis with once-daily NVP REPLACEMENT FEEDING 4–6 weeks of infant prophylaxis with once-daily NVP (or twice-daily AZT)

It is important to note that if a mother is found to be positive very late in pregnancy, during labour, or during breastfeeding, and begins ART at this time, the ARV prophylaxis for the child might need to be extended to 12 weeks. The recommendations above are for both Option B+ and Option B PMTCT national policies. The Option B+ policy says that every HIV-infected pregnant or breastfeeding woman in high HIV settings should receive triple ART during this period, and then continue on lifelong ART. The Option B policy says that HIV-infected women receiving ART will stop at the end of breastfeeding transmission risk.

WHAT IS THE DRUG DOSAGE FOR PMTCT PROPHYLAXIS IN YOUNG INFANTS? The same ‘TREAT’ chart for PMTCT prophylaxis includes dosing information for NVP and AZT. There are very important points about prophylaxis: ✔✔ Consider the infant’s birth weight if under 6 weeks old ✔✔ Monitor the infant’s age and change dosing as they age

What is cotrimoxazole prophylaxis? Regular prophylaxis with Trimethoprim-sulfamethoxazole (TMP/SMX), also known as cotrimoxazole, provides a simple, inexpensive, and effective strategy to prevent illness. Cotrimoxazole prophylaxis provided to children with suspected or confirmed HIV infection will decrease sickness and death due to PCP, other common bacterial infections, and malaria.

WHY IS COTRIMOXAZOLE PROPHYLAXIS IMPORTANT? Cotrimoxazole prophylaxis can reduce the mortality of HIV-infected children by up to 40%. Infants and children with suspected or confirmed HIV infection may acquire severe pneumonia and other serious infections at an early age. Often this occurs before their HIV status has been confirmed. Cotrimoxazole prophylaxis is given to HIV-exposed and infected children to reduce the risk of infection, and lower mortality.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

One serious life-threatening form of pneumonia is caused by an organism called pneumocystis jirovecii (previously carinii). This is commonly called PCP. This is a common cause of death in HIV-infected children, in particular young infants. The risk of PCP is decreased if the child takes regular daily cotrimoxazole prophylaxis.

WHO SHOULD RECEIVE COTRIMOXAZOLE PROPHYLAXIS? The table below reviews when certain classifications of infants and children should begin cotrimoxazole. THESE YOUNG INFANTS… CONFIRMED HIV INFECTION HIV EXPOSED THESE CHILDREN… CONFIRMED HIV INFECTION Less than 12 months old SHOULD START… From 4–6 weeks From 4–6 weeks SHOULD START… As soon as possible These children are eligible: 1. When at WHO clinical stages 2-3-4, regardless of CD4% 2. When CD4% less than 25%, no matter what stage Refer to Annex 1 to learn about staging. As soon as possible Follow adult guidelines WHY? Infant is HIV infected Infant is born to HIV infected mother and exposed to HIV WHY? Child is HIV infected

CONFIRMED HIV INFECTION 12 months up to 5 years

This is regardless of whether the child is on ART or not.

HIV EXPOSED Over 5 years of age

Child is exposed to HIV Children in this age category use adult prophylaxis guidelines.

WHAT DOSE OF COTRIMOXAZOLE WILL YOU GIVE FOR PROPHYLAXIS? The details for cotrimoxazole prophylaxis in HIV-exposed and infected children and infants are summarized below.1 You can also review in your TREAT charts, TREAT WITH ORAL ANTIBIOTIC. See Annex 2 for a more information on dosing. NOTE that if the HIV-infected child qualifies for cotrimoxazole and ART simultaneously, start cotrimoxazole first. COTRIMOXAZOLE DOSAGE – SINGLE DOSE PER DAY Drug: Cotrimoxazole (Trimethoprim-sulfamethoxazole or TMP/SMX) Age Syrup 40 mg TMP/200 mg SMX per 5 ml Adult Tablet Single Strength 80 mg TMP/400 mg SMX Paediatric Tablet Single Strength 20 mg TMP/100 mg SMX

Less than 6 months 6 months up to 5 years 5 to 14 years Over 15 years 1

2.5ml 5 ml 10 ml NIL

– 1/2 tablet 1 tablet 2 tablets

1 tablet 2 tablets 4 tablets –

Revised WHO guidelines for cotrimoxazole prophylaxis in HIV-exposed and HIV-infected children in resourcelimited countries, Geneva, May 10–12, 2005.

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HOW LONG DO CHILDREN RECEIVE COTRIMOXAZOLE PROPHYLAXIS? Cotrimoxazole prophylaxis is one of the medications an exposed or infected child will need to take for a long time. Even with increasing access to ART, cotrimoxazole prophylaxis is very important. NOTE that it is recommended that infants with confirmed HIV infection in resource-limited settings should continue cotrimoxazole indefinitely.

WHEN SHOULD COTRIMOXAZOLE PROPHYLAXIS BE STOPPED? •• HIV IS RULED OUT When children and infants classified as HIV EXPOSED are confirmed HIVnegative, and the mother is no longer breastfeeding •• SEVERE DRUG REACTIONS Severe toxicity can include Steven Johnson syndrome or severe pallor. This child should be referred to second level for assessment and for an alternate drug. If you are unsure about whether to stop cotrimoxazole, refer the child to second level for assessment and advice.

HOW CAN A HEALTH WORKER SUPPORT ADHERENCE TO COTRIMOXAZOLE? To make sure the caretaker and/or child are able to adhere to cotrimoxazole, they will need counselling and support. Several counselling sessions will be required in order to ensure that the issue of prophylaxis has been discussed with the caretaker and that they have fully understood and agreed to adhere to the treatment. You will learn more about chronic follow-up care for HIV-infected children in Section 11 of this module.

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SELF-ASSESSMENT EXERCISE E – COTRIMOXAZOLE Answer the following questions about cotrimoxazole prophylaxis.

1. What children should receive cotrimoxazole prophylaxis?

2. At what age should cotrimoxazole prophylaxis be started? 3. What are possible serious side effects of cotrimoxazole prophylaxis?

4. Should the following infants be receiving cotrimoxazole? If they should be receiving it, write down the correct dose in the last column. Should child receive cotrimoxazole? If YES, what is the daily dose?

a. 6 week HIV-exposed girl, PCR not available yet b. 6 month old HIV-exposed girl. PCR positive, not yet on ART. c. 7 month old HIV-exposed girl. PCR negative at 6 months of age. Stopped breastfeeding at 3 months. d. 4 month old boy who started on ART today e. 2 week old boy, HIV exposed, PCR test not sent yet f. 8 month old HIV-exposed boy, breastfeeding. PCR negative when tested at six weeks. g. 3 year old girl, clinical stage 3 h. 2 month old girl with SEVERE PNEUMONIA, and has tested PCR positive.

 YES   NO  YES   NO

....................... .......................

 YES   NO  YES   NO  YES   NO

....................... ....................... .......................

 YES   NO  YES   NO

....................... .......................

 YES   NO

....................... ....................... .......................

i. 9 month old boy classified as HIV EXPOSED. His caregiver declines testing.  YES   NO j. 4 year old boy with HIV infection, CD4% is 45%  YES   NO

5. When should cotrimoxazole prophylaxis be stopped?

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WHAT IS ISONIAZID PREVENTIVE THERAPY (IPT)? IPT is an important intervention for preventing and reducing active tuberculosis (TB) in children living with HIV. IPT is an important part of a comprehensive package of care for children and infants living with HIV. IMPORTANT NOTE: You will initiate IPT in your facility only if your facility can do investigations to identify tuberculosis cases.

WHY IS IPT FOR HIV-INFECTED CHILDREN AND INFANTS IMPORTANT? TB is a major cause of illness and death in children living with HIV. This is even true in children who are on ART. Increasing levels of co-infection with TB and HIV in children have been reported from resource-limited countries. Of children infected with TB living in resource-limited countries, 10% to 60% are also infected with HIV. HIV infection has an impact on the entire cycle of TB infection and disease. HIV increases a child’s susceptibility to tuberculosis infection, it increases the risk of rapid progression to TB disease, and it increases the risk of TB reactivation in older children with latent TB.

WHO SHOULD RECEIVE ISONIAZID PREVENTIVE THERAPY? You will only consider isoniazid preventive therapy for children and infants who are confirmed with HIV infection. IPT is also identified in your HIV classification tables in the TREATMENT column. IF THE HIV-INFECTED INFANT or CHILD IS: EXPOSED TO TB This means the child has been exposed to TB through household contacts, but has no evidence of active disease. NOT EXPOSED TO TB This includes children over 12 months living with HIV, including those previously treated for TB, who are not likely to have active TB and are not known to be exposed to TB. DIAGNOSED WITH TB This includes any child with active TB disease ACTIONS TO TAKE: Begin IPT for 6 months. See next page for dosage of isoniazid (INH) for preventive therapy in HIV co-infections. Begin IPT for 6 months. This is part of a comprehensive package of HIV care. See next page for dosage. 1. Begin TB treatment immediately 2. Start ART as soon as tolerated within the first 8 weeks of TB therapy, no matter the CD4 count and clinical stage

WHAT IS THE DOSAGE FOR ISONIAZID PREVENTIVE THERAPY? The recommended dose of isoniazid (INH) for preventive therapy in HIV coinfections is a daily dose of 10 mg per kg, with a maximum daily dose of 300 mg/ day. This dosage is given for 6 months. See Annex 2 for a more information on dosing.

DOSE: 10 mg/kg (maximum daily dose 300 mg)  for 6 months

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How will you give immunizations to HIV-exposed and infected infants? You have learned about giving immunizations in MODULES 2 and 7. You should also always follow the national guidelines for immunizations. However, there are important differences specific for infants who are HIV-exposed or infected. GIVE ROUTINE EPI VACCINES ACCORDING TO NATIONAL SCHEDULES All HIV-exposed infants and children should receive all EPI vaccines, including Hib and pneumococcal vaccine, as early in life as possible, according to the recommended national schedule. POSSIBLE ADDITIONAL DOSE OF HIB Haemophilus influenza type b (Hib) has been shown to be an important cause of childhood meningitis and a major cause of bacterial pneumonia in children. HIV appears to be a risk factor for developing invasive disease due to H. influenzae type B, especially bacteremic pneumonia. Hib vaccine is recommended for use in national childhood immunization programmes in all countries, including in HIVinfected children. The vaccine is generally administered along with DTP vaccines during infancy. The need and timing for an additional dose in the second year of life in children in developing countries is not well-defined. However, an additional dose may be particularly useful in HIV-infected children even in developing countries. BCG VACCINATION New findings indicate a high risk of disseminated BCG disease developing in HIVinfected infants. However, it is difficult to identify infants infected with HIV at birth. Therefore, the BCG vaccination may need to be given at birth to all infants regardless of HIV exposure, in areas with high endemicity of tuberculosis and populations with high HIV prevalence. YELLOW FEVER Infants with symptomatic HIV infection should NOT receive yellow fever vaccines. DO NOT VACCINATE SEVERELY ILL CHILDREN As for any severely ill child at the time of immunization, severely ill HIV-infected children should NOT be vaccinated.

How will you provide Vitamin A supplementation? Young infants and children infected with HIV should follow the same Vitamin A supplementation protocol as for uninfected young infants and children. It is best that the Vitamin A doses are synchronised with immunization visits or campaigns. Remember to make sure that children with HIV infection also receive routine deworming treatments. This is further described in the module on well child care.

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SELF-ASSESSMENT EXERCISE F – INTEGRATED TREATMENT You will again practice integrated treatment, a skill you have learned throughout your modules. In the cases below, the child also has an HIV-related classification. How will you treat or follow-up?

1. How would you treat a child with the classifications: HIV EXPOSED and PNEUMONIA?

2. When should you follow-up a child with the classifications: PERSISTENT DIARRHOEA and HIV EXPOSED?

3. How would you treat a child with the classifications: PNEUMONIA (wheeze present) and HIV EXPOSED?

4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA and CONFIRMED HIV INFECTION? The child’s father has active TB and has just begun treatment.

5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC EAR INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and CONFIRMED HIV INFECTION?

43

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

n  Now you will return to Peter. What will you do during your first visit? During your first visit with Peter, you classified him with PNEUMONIA and HIV EXPOSED. These are both yellow. You identify treatments in your chart booklet: PNEUMONIA Yellow • Give oral amoxicillin for 5 days • If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days** • Soothe the throat and relieve the cough with a safe remedy • If coughing for more than 2 weeks or if having recurrent wheezing, refer for assessment for TB or asthma • Consider HIV infection • Advise mother when to return immediately • Follow-up in 3 days HIV EXPOSED Yellow • Give cotrimoxazole prophylaxis • Start or continue ARV as recommended • Do virological test to confirm HIV status** • Assess the child’s feeding and provide appropriate counseling to the mother • Advise the mother on home care • Follow-up regularly

EPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

You know that Peter requires an oral antibiotic for pneumonia, and cotrimoxazole for HIV exposure. Your first step is to manage these two treatments.

1. Amoxycillin: Peter requires an appropriate oral antibiotic for 5 days for PNEUMONIA. He will receive OME for 5Appropriate days at the appropriate dosage for a six month old. This is indicated by the arrow. You Give an Oral Antibiotic be given at amoxycillin TEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART will assess Peter’s cough again during the follow-up visit in 3 days. FOR PNEUMONIA, ACUTE EAR INFECTION: FIRST-LINE ANTIBIOTIC: Oral Amoxicillin AMOXICILLIN* WEIGHT Give AGE anorAppropriate Oral Antibiotic TABLET FOR PNEUMONIA, ACUTE EAR INFECTION: 2 months up to 12 months (4 - <10 kg) FIRST-LINE ANTIBIOTIC: Oral Amoxicillin 12 months up to 3 years (10 - <14 kg) 250 mg 1 2 Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION SYRUP 250mg/5 ml 5 ml 10 ml

dosage table. HOME or weight. to be given at

g's dosage table.

he ge drug. or weight. ach drug

nish the course of

AMOXICILLIN* 3 years up to 5 years (14-19 kg) 3 15 ml Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION * Amoxicillin is now the first-line drug of choice in the treatment of pneumonia due to its efficacy and increasing high resistance AGE or WEIGHT TABLET SYRUP to cotrimoxazole . 250 mg 250mg/5 ml FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED CHILD: ANTIBIOTIC FOR PROPHYLAXIS: Cotrimoxazole 2 months up to 12 monthsOral (4 - <10 kg) 1 5 ml

e the drug. e each drug

o finish the course of

2. Cotrimoxazole prophylaxis: After Peter completes 5 days of oral antibiotics for pneumonia, you 12 months up to 3 years (10 - <14 kg) 2COTRIMOXAZOLE 10 ml determine he needs further antibiotic treatment for cause. If he does not, (trimethoprim + sulfamethoxazole) 3 years up to 5 years (14-19 kg) 3 another 15 ml he can begin Give once a day starting at 4-6 weeks of to: a 6 cotrimoxazole prophylaxis for HIV exposure. The appropriate daily for month old isresistance indicated * Amoxicillin is now the first-line drug of choice in the treatment of pneumonia duedose to age its efficacy and increasing high All infants HIV exposed untill definitly ruled out to cotrimoxazole . with the arrow: AGE All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED CHILD: ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole All infants or children with CD4 < 25% Syrup (40/200 mg/5ml) Paediatric COTRIMOXAZOLE tablet Adult tablet (Single strength 20/100 + mg) (Single strength 80/400 mg) (trimethoprim sulfamethoxazole)

c.

Less than 6 months 2.5 ml Give once a1 day starting at 4-6 weeks of age to: 6 months up to 5 years 5 ml 2 exposed untill definitly ruled out 1/2 All infants HIV AGE give Ciprofloxacine FOR DYSENTERY All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine All infants or children with CD4 < 25% CIPROFLOXACINE Syrup Paediatric tablet Adult tablet AGE Give 15mg/kg two times daily for 3 days (40/200 mg/5ml) (Single strength (Single strength 250 mg tablet 20/100 mg) 500 mg tablet 80/400 mg) Less than 6 months Less than 6 months 6 months up to 5up years 6 months to 5 years 2.5 ml 5 ml 1/2 1 1 2 1/4 1/2 1/2

3.

FOR DYSENTERY give Ciprofloxacine FOR CHOLERA: FIRST-LINEANTIBIOTIC ANTIBIOTIC: Oral Ciprofloxacine FIRST-LINE FOR CHOLERA: ____________________________________________________ SECOND-LINE ANTIBIOTIC FOR ____________________________________________________ CIPROFLOXACINE You will advise Lungile on: aCHOLERA: throat remedy, feeding advice, to follow-up for the PNEUMONIA AGE Give 15mg/kg two times daily for 3 days ERYTHROMYCIN TETRACYCLINE in 3 days, when to return for HIV test results, and when to return immediately. You will check 250 mg tablet 500 mg tablet Give four times daily for 3 days Give four times daily for 3 days Less than 6 months 1/2 1/4 AGE or WEIGHT immunizations, vitamin A, and deworming. 6 months up to 5 years 1/2 TABLET 1 TABLET 250 mg 250 mg FOR CHOLERA: FIRST-LINE ANTIBIOTIC ____________________________________________________ 2 years up to 5 years (10FOR - 19 CHOLERA: kg) 1 1 SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________ ERYTHROMYCIN AGE or WEIGHT Give four times daily for 3 days TABLET 250 mg 1

44

TETRACYCLINE Give four times daily for 3 days TABLET 250 mg 1

↺

Page 15 of 75 

2 years up to 5 years (10 - 19 kg)

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

*,9( )2//2: 83 &$5( ¾

n  What care will you provide when Peter returns for follow-up? ¾ ,I WKH FKLOG KDV DQ\ QHZ SUREOHPV DVVHVV FODVVLI\ DQG WUHDW WKH QHZ SUREOHP DV RQ WKH $66(66 $1 Your classification of PNEUMONIA requires follow-up in 3 days. $IWHU GD\V

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¾ 31(8021,$ n  Lungile brings Peter in 3 days for PNEUMONIA follow-up: You re-assess Peter’s PNEUMONIA and do another full IMCI assessment. &KHFN WKH FKLOG IRU JHQHUDO GDQJHU VLJQV $VVHVV WKH FKLOG IRU FRXJK RU GLIILFXOW EUHDWKLQJ $VN ,V WKH FKLOG EUHDWKLQJ VORZHU" ,V WKHUH OHVV IHYHU" ,V WKH FKLOG HDWLQJ EHWWHU"

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Peter’s breathing has slowed to 45 breaths per minute. His pneumonia is improving. You ask Lungile to *LYH LW IRU GD\V VHFRQG OLQH DQWLE continue giving the cotrimoxazole until it is complete. You remind her to provide additional food. You ¾ 3(56,67(17 ',$55+2($ complete a full IMCI assessment and there are no new problems. You as happy to see that Peter is improving, ([FHSWLRQV LI WK GD\V and Lungile$IWHU is relieved. +DV WKH GLDUUKRHD n  What other care does PeterVWRSSHG" require? $VN ILUVW YLVLW RU LI KH +RZ PDQ\ ORRVH VWRROV LV WKH FKLOG KDYLQJ SHU GD\"

&KDQJH WR VHFRQ

You will remember that you have classified Peter as HIV EXPOSED. As Lungile is HIV-infected, you must counsel her on feeding Peter. You will learn about this in the next section. 7UHDWPHQW ¾ ,I WKH GLDUUKRHD KDV QRW VWRSSHG FKLOG LV VWLOO KDYLQJ RU PRUH ORRVH VWRROV SHU GD\ GR D IXOO DVVHVVPHQW RI WKH FKLOG 7UHDW IRU GHK\GUDWLRQ LI SUHVHQW 7KHQ UHIHU WR KRVSLWDO ¾

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45

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SUMMARY: WHAT DID YOU LEARN IN THIS SECTION? Review the main points from this section. Reading this summary, and completing the self-assessment exercises in the module, are important for learning. 1. Cotrimoxazole prophylaxis is very important to reducing mortality in HIV-exposed and infected children and infants n All young infants with confirmed HIV infection, from 4–6 weeks of age n All young infants who are HIV-exposed, from 4–6 weeks of age n All children who are HIV-infected and under 12 months old n All children who are HIV-infected, from 12 months and up to 5 years of age, who are at clinical stages 2, 3, or 4, or have a CD4% of under 25%. n All children classified as HIV EXPOSED 2. Antiretroviral prophylaxis is an important measure in preventing mother-to-child transmission in young exposed infants The intervention depends on whether or not the child is breastfeeding. If the child is breastfeeding, 6 weeks of once-daily NVP is recommended. If the child is receiving replacement feeding, 4–6 weeks of once-daily NVP is recommended (or twice-daily AZT).

3. Isoniazid preventive therapy is an important measure to protect children and young infants who are HIV-infected children from tuberculosis. Therapy lasts for 6 months. If a child has active TB they require TB treatment. 4. Routine care is critical for keeping HIV-exposed and infected infants and children healthy This includes timely immunizations, deworming, and Vitamin A.

46

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.7

COUNSEL HIV-INFECTED MOTHERS ABOUT INFANT FEEDING

What are the learning objectives for this section? After you study this section, you will know how to: •• Explain your national guidelines on infant feeding, depending on if countries recommend: (a) HIV-infected mothers receive ARVs while breastfeeding their infants or (b) HIV-infected mothers should avoid all breastfeeding and use infant milk formulas. •• Describe feeding options for HIV exposed and infected children, including the advantages and disadvantages of each option •• Explain the nutritional needs of infants at different ages, and recommendations to meet those needs: 0 to 6 months, 6 to 12 months, 12 to 24 months

WHAT FEEDING TOPICS ARE COVERED IN THIS SECTION? This section includes a number of important discussions when considering safe infant feeding for HIV-exposed and infected children. 1. Feeding options and considerations for HIV-infected mothers 2. Feeding recommendations for HIV-exposed children up to 24 months a. If national recommendations are breastfeeding with ARV interventions b. If national recommendations are no breastfeeding 3. Counselling on feeding problems that you might see in HIV-infected children 4. Counselling the mother on stopping breastfeeding 5. Counselling the mother on her own health

WHY DO HIV-INFECTED MOTHERS NEED SPECIAL COUNSELLING AND SUPPORT? Infant feeding counselling and support are critical for preventing mother-to-child HIV transmission. You have learned about the risks of mother-to-child transmission during pregnancy, labour, delivery, and through breastfeeding. HIV-infected mothers need special counselling and support around infant feeding and their own health. Remember that counselling on infant feeding options requires skill and practice. This section provides you with the knowledge you will need to give HIV-infected mothers basic information about safer infant feeding.1

1

This section assumes that you have completed the Counsel the Mother module of the IMCI case management course. It does not provide you with all the skills you need to counsel pregnant or newly-delivered HIV-positive women on infant feeding options. If you regularly need to counsel pregnant women on infant feeding options, you should participate in one of the courses that include HIV and infant feeding counselling, for example the WHO/UNICEF Infant and Young Child Feeding Counselling: An Integrated Course.

47

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT ARE IMPORTANT DEFINITIONS FOR FEEDING PRACTICES? There are two key feeding practices to understand: exclusive breastfeeding, and mixed feeding.

EXCLUSIVE BREASTFEEDING: giving the child breast milk and nothing more until 6 months MIXED FEEDING: is giving the child breast milk and other foods or fluids

WHAT ARE THE FEEDING RECOMMENDATIONS FOR WOMEN WHO DO NOT KNOW THEIR STATUS? Women who do not know their HIV status should be encouraged to have an HIV test.

WHAT ARE THE FEEDING RECOMMENDATIONS FOR HIV-UNINFECTED WOMEN? All women who are HIV-negative or who do not know their HIV status should be counselled to exclusively breastfeed their babies for the first six months of life, then introducing complementary feeds and continuing with breastfeeding for up to two years or beyond.

WHAT ARE THE FEEDING RECOMMENDATIONS FOR HIV-INFECTED WOMEN? All HIV-infected women should be informed on national recommendations for HIV and infant feeding as part of antenatal and postnatal care. Informing mothers about feeding recommendations can help improve HIV-free survival of HIV-exposed infants. WHO guidelines state that national health authorities should decide if health services will principally counsel and support HIV-infected mothers in one of two strategies that will most likely give infants the greatest chance of HIV-free survival: 1. BREASTFEED AND RECEIVE ARV INTERVENTIONS, OR 2. AVOID ALL BREASTFEEDING This decision should be based on international recommendations and should consider: ✔✔ Socio-economic and cultural contexts of the populations served by maternal and child health services ✔✔ Availability and quality of health services ✔✔ Local epidemiology including HIV prevalence among pregnant women ✔✔ Main causes of maternal and child undernutrition, and infant and child mortality

48

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND RECEIVE ART: what are important considerations when discussing feeding options? There are advantages and disadvantages associated with the respective infant feeding practices available to the HIV-infected mother. These are described in the table on the next page.

WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND RECEIVE ART: What happens if the mother will not breastfeed? In exceptional circumstances when the mother cannot breastfeed or is unwilling to breastfeed, refer to feeding counsellors.

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THE MAIN FEEDING OPTIONS AVAILABLE TO HIV-INFECTED MOTHERS? The table below summarizes the major advantages and disadvantages of two feeding practices: exclusive breastfeeding, and using commercial formula. Please read this table to further your understanding of these feeding options. You can also discuss these advantages and disadvantages while you counsel mothers about feeding their child. PRACTICE ADVANTAGES DISADVANTAGES What are the disadvantages of exclusive breastfeeding? ✔✔ As long as a mother is breastfeeding, her baby is exposed to HIV ✔✔ People may pressure her to give water, other liquids, or food to the baby while she is breastfeeding. This practice, known as mixed feeding, increases the risk of HIV transmission, diarrhoea, and other infections ✔✔ The mother will need support to exclusively breastfeed until it is possible for the mother to use another feeding option ✔✔ It may be difficult if the mother works outside the home and cannot take the baby with her

Exclusive What are the advantages of breast milk? breastfeeding ✔✔ Is the perfect food for babies ✔✔ Protects babies from many serious diseases ✔✔ Gives babies all of the nutrition and water they need ✔✔ Is free, always available, and does not need any special preparation What are the advantages of exclusive breastfeeding? ✔✔ Exclusive breastfeeding for the first few months lowers the risk of passing HIV, compared to mixed feeding ✔✔ People will not ask why the mother is breastfeeding ✔✔ Exclusive breastfeeding protects the mother from getting pregnant again too soon Commercial infant formula What are the advantages of formula? ✔✔ Giving only formula carries no risk of transmitting HIV to the baby ✔✔ Most of the nutrients a baby needs have already been added to the formula ✔✔ Others can help feed the baby

What are the disadvantages of formula? ✔✔ Formula does not contain antibodies. These are substances that protect the baby from serious infections ✔✔ A formula-fed baby is more likely to get seriously sick from diarrhoea, chest infections and malnutrition ✔✔ To prepare formula there is a need for a sustainable supplies of fuel and clean water (brought to a rolling boil) ✔✔ People may wonder why the mother is not breastfeeding ✔✔ Formula takes time to prepare – bottle feeds should be made up fresh each time ✔✔ Formula is expensive ✔✔ The mother will need support to exclusively and safely formula feed ✔✔ Need to learn how to feed by cup ✔✔ The mother may get pregnant again too soon

49

WHAT ARE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN IF GUIDELINES ARE BREASTFEEDING AND ARVS?

This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12 months, and 12–24 months. It also reviews safe transition from exclusive breastfeeding to replacement feeding.

CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES RECOMMEND BREASTFEEDING AND ARVS 12 MONTHS UP TO 2 YEARS •• COMPLEMENTARY FOODS. Give adequate servings of the following foods, or family foods, 5 times a day: STOPPING BREASTFEEDING STOPPING BREASTFEEDING means changing from all breast milk to none. This should happen gradually over one month. Plan in advance for a safe transition. 1. HELP MOTHER PREPARE: Mother should discuss and plan in advance with her family, if possible •• IF BREASTFEEDING give adequate servings of complementary foods 3 times per day, plus snacks. •• Express milk and give by cup •• Find a regular supply or formula or other milk (e.g. full cream cow’s milk) •• Learn how to prepare a store milk safely at home 2. HELP MOTHER MAKE TRANSITION: •• Teach mother to cup feed •• Clean all utensils with soap and water •• Start giving only formula or cow’s milk once baby takes all feeds by cup 3. STOP BREASTFEEDING COMPLETELY: Express and discard enough breast milk to keep comfortable until lactation stops.

UP TO 6 MONTHS OF AGE

6 UP TO 12 MONTHS

•• BREASTFEED EXCLUSIVELY as often as the infant wants, day and night. Feed at least 8 times in 24 hours.

•• BREASTFEED as often as the infant wants

•• COMPLEMENTARY FOODS. Give 3 adequate servings of nutritious complementary foods, plus one snack, per day. Each meal should be ¾ cup. 1 cup = 250 ml.

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

50

•• DO NOT GIVE OTHER FOODS OR FLUIDS. Mixed feeding increases the risk of mother-tochild HIV transmission when compared to exclusive breastfeeding

•• This should include protein, and mashed fruits and vegetables. If possible, give an additional animal-source food, such as liver or meat. •• IF NOT BREASTFEEDING also give about 500 ml (1–2 cups) or full cream milk or infant formula per day. Give milk with a cup. Do not use a bottle. If no milk is available, give 4–5 feeds per day.

Foods can include:

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

REVIEWING FEEDING RECOMMENDATIONS CHART Breastfeeding and ARVs WHAT ARE THE KEY RECOMMENDATIONS FOR MOTHERS? In settings where national authorities recommend breastfeeding and ARV interventions for HIV-infected mothers, there are two scenarios: either the infants have been confirmed with HIV infection, or they are not infected or their status is unknown. IF INFANTS ARE CONFIRMED HIV INFECTED: These mothers should follow standard feeding recommendations, like any other child. Important points in these recommendations include: ✔✔ Exclusively breastfeed infants for the first 6 months of life ✔✔ Introduce appropriate complementary foods at 6 months, and ✔✔ Continue breastfeeding up to two years or beyond – that is, as per the recommendations for the general population IF INFANTS ARE HIV EXPOSED: These mothers should: ✔✔ Exclusively breastfeed infants for the first 6 months of life ✔✔ Introduce appropriate complementary foods at 6 months ✔✔ Continue breastfeeding for the first 12 months of life ✔✔ Breastfeeding should then only stop once a nutritionally adequate and safe diet without breastmilk can be provided.

WHAT IF ARVS ARE NOT IMMEDIATELY AVAILABLE TO THESE WOMEN? Mothers known to be HIV-infected should be provided with lifelong antiretroviral therapy or antiretroviral prophylaxis interventions to reduce HIV transmission through breastfeeding according to WHO recommendations. When antiretroviral drugs are not immediately available to HIV-infected mothers, breastfeeding may still provide their infants with a greater chance of HIV-free survival. In circumstances where ARVs are unlikely to be available, such as acute emergencies, breastfeeding of HIV-exposed infants is also recommended to increase survival.

51

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT ARE IMPORTANT FOR COUNSELLING HIV-INFECTED WOMEN WHO BREASTFEED? There are some important issues for HIV-infected women to be counselled on, and for you to remember as a health worker. ✔✔ When HIV-positive mothers decide to stop breastfeeding at any time, infants must be provided with safe and adequate replacement feeds to enable normal growth and develop­ ment ✔✔ Skilled counselling and support in appropriate infant feeding practices ✔✔ ARV interventions to promote HIV-free survival of infants should be available to all pregnant women and mothers. Refer to your section on prophylaxis. Later in this section you will review more information on counselling a mother as she stops breastfeeding. Refer to MODULE 2 on the sick young infant to review what you have learned about counselling a mother on breastfeeding. When you follow-up with a mother, here are some important items to counsel on, or check: ✔✔ Check that she breastfeeds exclusively and gives no other milk, water, or food ✔✔ Help her with any feeding problem she may report, such as “not enough milk”, “baby crying a lot”, or sore nipples. ✔✔ Check if she breastfeeds as often as the baby wants and for as long as the baby wants ✔✔ Observe a breastfeed and check the mother’s breasts, as required ✔✔ Check that the mother is receiving ART or ARV prophylaxis. Check drug adherence. ✔✔ Check the health of the mother and that she has had a CD4 count in the last 6 months.

52

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT ARE THE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN, IF NATIONAL GUIDELINES ARE INFANT FORMULA? This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12 months, and 12–24 months.

CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES RECOMMEND INFANT FORMULA ONLY UP TO 6 MONTHS OF AGE FORMULA FEED EXCLUSIVELY. Do not give any breast milk. Other foods or fluids are not necessary. Prepare correct strength and amount just before use. Use milk within two hours. Discard any left over – a fridge can store formula for 24 hours. Cup feeding is safer than bottle feeding. Clean the cup and utensils with hot soapy water. Give the following amounts of formula up to 6 times per day: AGE (months) AMOUNT x TIMES PER DAY

6 UP TO 12 MONTHS GIVE MILK. Give about 1–2 cups (250–500 ml) of infant formula or boiled (then cooled) full cream milk. Give milk with a cup, not a bottle. COMPLEMENTARY FOODS. Start by giving 2–3 tablespoons of food 2–3 times a day. Gradually increase to ½ cup (1 cup = 250 ml) at each meal, and to 3–4 meals a day. SNACKS. Offer 1–2 snacks each day when the child seems hungry. For snacks give small chewable items that the child can hold. Let your child try to eat the snack. This should include protein, and mashed fruits and vegetables. If possible, give an additional animal-source food, such as liver or meat. These foods can include:

12 MONTHS UP TO 2 YEARS COMPLEMENTARY FOODS. Give adequate servings of the following foods, or family foods, 5 times a day:

GIVE MILK. Give about 500 ml (1–2 cups) or full cream milk or infant formula per day. Give milk with a cup. Do not use a bottle.

0 up to 1 1 up to 2 2 up to 3 3 up to 4 4 up to 5 5 up to 6

60 ml x 8 90 ml x 7 120 ml x 6 120 ml x 6 150 ml x 6 150 ml x 6

* EXCEPTION: heat-treated breast milk can be given

53

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

REVIEWING FEEDING RECOMMENDATIONS CHART Infant formula WHAT ARE IMPORTANT REMINDERS ABOUT REPLACEMENT FEEDING? When you counsel and caretaker on formula feeding, and provide follow-up care in subsequent visits, there are important practices to check. You can ask checking questions about how feeds are being measured, prepared, and given. Based on what the caregiver explains, you might also ask him/her to demonstrate for you. Give appropriate feedback. If there are any problems, demonstrate how to prepare safely and give the feed to the baby. This is important to check the following: ✔✔ Only replacement feeding is being given, never breastmilk or unsafe fluids ✔✔ Appropriate volume and number of feeds ✔✔ Correct measurement of milk and other ingredients ✔✔ Feeds prepared cleanly and safely (e.g. boiling and cooling milk) ✔✔ Fresh feeds given each time ✔✔ Cup feeds are given for safety ✔✔ Use of hot soapy water for cleaning utensils and cup

REVIEWING FEEDING RECOMMENDATIONS CHART All HIV-infected or exposed children WHAT ARE IMPORTANT POINTS ABOUT GIVING CHILDREN FAMILY FOODS AND SNACKS? When children begin taking family foods, meals should contain foods that provide energy such as a staple, but should be combined with other foods to provide enough of the other essential nutrients such as protein, vitamins and iron. Good snacks provide both energy and nutrients. Examples of good snacks are: yoghurt and other milk products; bread or biscuits spread with butter, margarine, nut paste or honey; fruit; bean cakes; cooked potatoes. Poor value snacks are ones that are high in sugar but low in nutrients. Examples of these are fizzy drinks (sodas), sweet fruit drinks, sweets, salty items, and sweet biscuits.

HOW SHOULD FEEDING CHANGE DURING ILLNESS? Parents and caregivers should increase the amount of fluids they give to children during illnesses and encourage the child to eat soft, varied, appetizing favourite foods. After illness, parents and caregivers should give food more often than usual and encourage the child to eat more. Remember that PERSISTENT DIARRHOEA has specific feeding recommendations.

54

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

WHAT ARE SPECIAL FEEDING PROBLEMS HIV-INFECTED CHILDREN MIGHT HAVE? HIV-infected children may experience special feeding problems. These may require further interventions for nutrition or care. In addition to special feeding problems, HIV-related illnesses like tuberculosis and diarrhoea occur in malnourished children. They have severe consequences because they can cause appetite loss, weight loss, and acute malnutrition. CHILD HAS CLINICAL CONDITIONS THAT AFFECT THEIR NUTRITION Some clinical conditions may affect the HIV-infected child’s nutrition status. It is important to identify local nutrient-rich foods that are available and affordable and to advise the mother on how to increase the energy content of foods. Always advise the mother to continue feeding and continue giving fluids during any illness. CLINICAL SITUATION Recurrent or chronic infection CONSEQUENCE ✔ Increased metabolic needs ✔ Significantly higher caloric demands WHAT ACTION SHOULD YOU TAKE? Offer feeds more frequently than before: 1. The chronic infection should be treated. 2. If the child is breastfeeding breastfeed at least 8 times in 24 hours 3. If the child is on complementary foods, offer small meals at least 5 times a day. Increase the energy value of these feeds by adding oil or nuts. 4. Follow the recommendations in IMCI chart booklet 1. These infections should be treated appropriately. 2. Follow the same feeding recommendations for the child with recurrent or chronic infection 3. Treat for worms if the child has not been treated during the previous 6 months 4. Give Vitamin A if the child has not been treated during the past 6 months 1. Make sure child receives treatment for thrush 2. Offer foods that have been mashed up or pureed 3. Avoid spicy foods 4. Paracetamol half an hour before feeds may be helpful in extreme cases 1. Follow the feeding recommendations for the child with recurrent or chronic infection (above); the child with intestinal infections (above) and the child with persistent diarrhoea (in the chart booklet) 1. These are infrequent but may occur. 2. For ritonavir containing medication coat tongue with peanut butter before dose is given. 3. Encourage small frequent sips of fluids and give food that the child likes 4. Let the child eat before medication

Intestinal infections

✔ Increased nutrient requirements ✔ Impaired absorption and loss of appetite may decrease food intake ✔ Diarrhoea ✔ Potential pain with swallowing may result in decreased oral intake primarily for solids, but also for liquids ✔ Impaired absorption of nutrients

Oral or oesophageal thrush

Persistent diarrhoea caused by cryptosporidia or other parasites Nausea and vomiting as a result of ARV drugs

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

CHILD HAS A POOR APPETITE This is especially common with HIV infection, and may be made worse if the child has mouth lesions such as ulcers or oral thrush. ✔✔ Treat the oral lesions urgently and appropriately. Paracetamol may be used in addition for pain relief before each meal. ✔✔ Use soft, varied favourite foods to encourage the child to eat as much as possible ✔✔ Keep up fluid intake ✔✔ Give foods that are not too thick or dry ✔✔ Offer small, frequent feeds. Feed the child when he is alert and happy. Give more food if he shows interest. ✔✔ If the child has mouth lesions, offer foods that do not burn the mouth – such as eggs, mashed potatoes, sweet potato, pumpkin or avocado. Do not give spicy or salty foods. ✔✔ Ensure that the spoon is the right size, that food is within the reach of the child and that he is actively fed. For example, he sits on the mother’s lap while eating.

WHAT ARE THE RECOMMENDATIONS FOR SAFELY STOPPING BREASTFEEDING? Mothers known to be HIV-infected who decide to stop breastfeeding at any time should stop gradually within one month. The mother’s reason for stopping should be discussed and the health worker should assess if there are specific difficulties that can be overcome. Health workers should discuss with the mother what food she will give to her infant after stopping breastfeeding and if these will be sufficient for the child’s growth and development.

HOW SHOULD A MOTHER BE COUNSELLED ABOUT STOPPING BREASTFEEDING? It is advised to stop breastfeeding gradually over one month. Below are important counselling notes. n Planning ahead: Mothers should think and plan ahead about how she will provide supplementary foods and alternative sources of milk. n Comfort is an important part of breastfeeding: babies want to breastfeed not only because it gives them nutrition but also because they want the comfort and security of being with their mothers. Stopping breastfeeding means that mothers need to plan how they will feed their infant and also how they will comfort them when crying when they are tired or upset. Babies cry when they are hungry. However, they can also cry when they are tired or want their mother’s attention. Babies also have growth spurt when they want more milk and therefore they will want to breastfeed for longer. Mothers sometime interpret crying as meaning that their baby is always hungry and that they do not have enough milk. This is not true and the mother should not decide to stop breastfeeding based on this thinking.

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n Preparing the baby before breastfeeding is stopped: if a mother plans to stop breastfeeding then she can help to prepare her baby. — While breastfeeding, mothers can teach their babies to drink expressed breast milk from a cup — If the mother or baby are not receiving ARVs to prevent HIV transmission, then this milk may be boiled to destroy HIV — Once the baby is drinking comfortably from a cup, replace one breastfeed with one cup-feed using expressed breast milk — Increase the frequency of cup-feeding every few days and reduce the frequency of breastfeeding. Ask an adult member of the family to help with cup feeding — Stop putting your baby to your breast completely as soon as your baby is accustomed to frequent cupfeeding — If a baby needs to suck, give the child one of your clean fingers instead of the breast n Once a mother begins to stop breastfeeding: — To avoid breast engorgement (swelling) mothers should express a little milk whenever her breasts feel full. This will help mothers feel more comfortable. Use cold compresses to reduce inflammation. — Mothers should not begin breastfeeding again once they have stopped. If a mother does start again, this may increase the risk of passing HIV to her baby. If a mother’s breasts become engorged then it is better for her to express breast milk by hand. — Mothers should begin using a family planning method of her choice even before the end of breastfeeding and certainly as soon as she starts reducing breastfeeds. — Check with the mother that she has had a blood sample taken for a CD4 count in the past 6 months and that she knows this result. Remind her that this should be done every 6 months to assess if she needs lifelong ART for herself.

WHEN SHOULD ARV PROPHYLAXIS BE STOPPED AFTER BREASTFEEDING STOPS? Mothers or infants who have been receiving ARV prophylaxis should continue prophylaxis for one week after breastfeeding is fully stopped. Mothers should also know to continue the ARV prophylaxis for the child for one week following the complete cessation of breastfeeding: this means from the date that the child has absolutely no breastmilk. Health workers must ensure she has enough supplies of ARVs.

WHAT IF A MOTHER IS TOO SICK TO BREASTFEED? If the HIV-infected mother who has chosen to breastfeed develops symptomatic AIDS, she may no longer be able to manage the physical requirements of breastfeeding. Help the mother to make a safe and complete transition to replacement feeds. For women without adequate financial resources or any family support, you may have to arrange for a secure supply of formula milk (under six months) or plain milk (older children). The mother should be assessed and referred for ART and she should be placed on cotrimoxazole.

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WHAT ARE THE FEEDING RECOMMENDATIONS FOR ORPHANS? Abandoned children or maternal orphans require special consideration. Their feeding options are as follows: 0 TO 6 MONTHS Three options for feeding orphans are discussed below: 1. Receive a safe and appropriate breast milk substitute If the child receives formula milk, make sure that the milk given is appropriate. Follow the feeding recommendations for a child on formula milk in the Counsel the mother section of the chart booklet. 2. Receive breast milk from confirmed HIV negative women If the child receives breast milk from a wet nurse it will be crucial to determine that this wet nurse is confirmed HIV negative, is not in the window period where she might still become HIV-infected, and is not at risk of becoming HIV-infected. 3. Receive breast milk from a breast milk bank If the child receives breast milk from a milk bank, the milk bank should pasteurize the milk according to standard procedures. 6 to 24 MONTHS Infants from six months to 2 years who are not breastfed should be given safe family foods and milk or some other animal-source food every day.

HOW DO YOU COUNSEL A MOTHER ABOUT HER OWN HEALTH? During a sick child visit, listen for any problems that the mother (or caregiver) herself may have. The mother may need treatment or referral for her own health problems. Do not force mothers to queue twice or attend different places for simple problems. Write down her health concerns at the bottom of the recording form. This will remind you to help the mother after attending to her child.

WHAT COUNSELLING IS GIVEN TO MOTHERS WHO ARE HIV-INFECTED? Mothers known to be HIV-infected should be provided with lifelong antiretroviral therapy (ART) or antiretroviral prophylaxis interventions to reduce HIV transmission through breastfeeding according to WHO recommendations. Mothers should also have blood samples tested every 6 months to measure her CD4 count and assess if she needs ART.

WHAT ARE IMPORTANT COUNSELLING TOPICS? ✔✔ FAMILY PLANNING – Ask her about family planning and if she is happy with the method she has chosen. Discuss the alternatives with her and prescribe contraception as you have been taught in family planning. Offer barrier contraception as well, and ensure that the mother has enough contraception for at least 3 months.

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✔✔ SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STI) – Assess and treat these according to the National STI protocols. ✔✔ SOCIAL PROBLEMS – Encourage the mother to discuss any social problems. These can include her partner, family, support networks, housing, childcare, workload, and other issues. Provide ongoing counselling and care if she is HIVinfected. If necessary, refer her.

n  Counsel the mother about her own health ✔✔ IF SICK: If the mother is sick provide care for her, or refer her for ART. ✔✔ BREAST PROBLEMS: If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care or refer her for help. ✔✔ NUTRITION: Advise her to eat well to keep up her own strength and health. ✔✔ TT SHOTS: Check her immunization status and give tetanus toxoid if needed. ✔✔ ACCESS TO HEALTHCARE: Make sure she has access to: ✔✔ Regular testing for CD4 count ✔✔ Contraception and sexual health services ✔✔ Counselling on STI and AIDS prevention ✔✔ STIs: Counsel about safe sex and early treatment of STIs

n  Give additional counselling if the mother is HIV-infected •• FOLLOW UP: Reassure her that with regular follow-up, much can be done to prevent serious illness, and maintain her and the child’s health •• HYGIENE & CARE: Emphasize good hygiene, and early treatment of illnesses •• PAIN: See guidelines for palliative care in chart booklet

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SELF-ASSESSMENT EXERCISE G – INFANT FEEDING In this exercise you will answer questions about the feeding recommendations that you have read about in this module.

1. Are the following statements true or false? These questions are about a country that recommends breastfeeding and ARV interventions for HIV-infected mothers. a. It is advisable to give children fewer feeds during illness. b. It is best for a 3-month-old HIV-infected child to be exclusively breastfed. c. It is recommended that a 2-week-old child of unknown HIV status born to an HIV negative mother is never breastfed. d. It is advisable that a breastfeeding child born to an HIV-infected woman continues breastfeeding for as long as the mother wants to breastfeed up to 12 months of age. e. It is recommended that a 5-month-old child whose mother is HIV negative breastfeeds as often as he wants, day and night. f. A 9-month-old child who is HIV-infected on virological (PCR) tests can continue breastfeeding. g. All breastfeeding HIV-infected women transmit HIV to their infants. h. It is advisable that a child born to a mother with unknown HIV status is given formula i. ARVs to an HIV-infected mother or to her exposed infant very significantly reduces the risk of transmission through breastfeeding TRUE FALSE TRUE FALSE

TRUE

FALSE

TRUE

FALSE

TRUE TRUE TRUE TRUE

FALSE FALSE FALSE FALSE

TRUE

FALSE

2. Traci is born to an HIV-positive mother. When should she begin receiving family foods? What foods should be added, and in what quantity?

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n  How will you advise Lungile about infant feeding? Lungile is HIV-infected and you have classified Peter as HIV EXPOSED. You must advise Lungile about feeding options for Peter. From your IMCI assessment, you know that Peter’s weight is not low for age. You know that Peter is breastfeeding.

n  Peter is 6 months old – what will you recommend his mother? You will advise Lungile according to the feeding recommendations in your feeding chart: ✔✔ BREASTFEED as often as the infant wants ✔✔ COMPLEMENTARY FOODS. Give 3 adequate servings of nutritious complementary foods, plus one snack, per day. Each meal should be ¾ cup. 1 cup = 250 ml. This should include protein, and mashed fruits and vegetables. If possible, give an additional animal-source food, such as liver or meat. You emphasize that: •• She should provide safe family foods like porridge and mashed vegetables or fruit. She should give him 3 meals a day, plus one snack. You ask Lungile about what foods she has available in the home and what she can afford to give Peter. She tells you that she sometimes has eggs, potatoes, squash, and some chicken. You tell her how to prepare porridge, and show her how to feed Peter with a spoon. You ask her checking questions to make sure she understands what you have explained. •• She should not give Peter sugary drinks or unhealthy snacks. You will re-evaluate this feeding advice during follow-up visits. You will also discuss breastfeeding transitions with Lungile at the appropriate time. Remember that once Peter has stopped breastfeeding for at least 6 weeks, you will test again to confirm his HIV status.

n  How will you counsel Lungile about her own health? You ask more about Lungile’s situation. She tells you that she just found out that she is HIV-infected. Lungile lives in a tin shack in the centre of the city. She gets water from the tap in the street 200 metres from her home. She lives alone. Her partner works in another city and comes home at weekends. Her mother lives on the farm. Lungile visits her mother during Christmas. Previously she was working temporary jobs. Since Peter was born, she has struggled trying to find work during the days. She thinks that she might take Peter to the farm for some time. When she returns to the city her mother will look after her baby. Neither her mother nor her partner knows that she is HIV infected. She wants to tell her partner but she is scared. Maybe he will get angry with her and he will not give her any money for Peter’s care.

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n  What are important topics to discuss with Lungile? Lungile has a complicated social situation. Today you want to discuss the most important care topics, and encourage Lungile to continue seeking counseling and HIV care. Lungile might already be receiving counseling on these topics at her clinic. Today you can ask her more about the care she is receiving. If you notice areas that should be discussed more, you can address these with her. Lungile will need to be counseled on: ✔✔ HEALTH: is she ill? ✔✔ ACCESS TO CARE and FOLLOW UP: how frequently is she going for visits at the clinic where she was tested for HIV and is receiving care? ✔✔ FEEDING PROBLEMS: including breast problems? ✔✔ IMMUNIZATIONS: does she have her TT shots? ✔✔ NUTRITION: what advise has she been given about eating well? She must keep up her own health and strength, this is critical. ✔✔ SEXUALLY TRANSMITTED INFECTIONS: does she have any signs? ✔✔ FAMILY PLANNING: what method is she using, and is she happy with it? ✔✔ HYGIENE: discuss handwashing and other important hygiene practices, especially keeping Peter in mind Lungile does not feel ill today, but has many questions for you about her own nutrition. She is also worried that she is not making enough milk for Peter, so you discuss this issue. Her other clinic has provided her immunizations, screening for sexually transmitted infections, and a family planning method (condoms), so you only briefly discuss these topics. Now you will return to Peter’s care. This counseling with Lungile has given you a better sense for Peter’s environment and how the two of them will seek care. This information will be useful for approaching treatment. You will now learn about treatment for Peter.

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8.8

ANTIRETROVIRAL TREATMENT

What are the learning objectives for this section? After you study this section, you will know how to: •• Describe the common antiretroviral drugs •• Decide which children are eligible to receive ART •• Stage children using the clinical staging criteria in the IMCI chart booklet •• Understand which children should be started on ART by nurses at primary level •• Refer certain children to a doctor for initiation of ART •• Undertake a baseline assessment, including sending of laboratory results •• Counsel the mother/care giver for adherence to ART •• Describe the recommended ARV regimens for children •• Prescribe ARVs in the correct dosages •• Explain the possible side effects of ARV drugs and know how to manage them

SECTION OUTLINE This section is separated into three parts. These are described below: 1. WHAT IS ANTIRETROVIRAL TREATMENT? 2. THE FIVE STEPS OF INITIATING ART IN CHILDREN 1st . Decide if child has confirmed HIV infection 2nd. Decide if caretaker is able to give ART 3rd. Decide if ART can be initiated in your first level facility 4th. Record baseline information on the child’s HIV treatment card 5th. Start on ART and cotrimoxazole prophylaxis 3. SIDE EFFECTS OF ARVS

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PART 1: What is antiretroviral treatment? HIV is a special kind of virus called a retrovirus. So the drugs against HIV are called antiretroviral drugs:

Anti Retro Viral drugs In the first part of this module, you learned about how the HIV virus replicates by turning CD4 cells into HIV ‘factories’. Antiretroviral drugs interfere with the life cycle of the HIV virus, thus preventing it from replicating. Giving ARVs in the correct way, with adherence support, is called ARV Therapy. This is shortened to ART. ART does NOT cure HIV, but through preventing replication of the virus it prevents immune system damage and can improve the quality of life and life expectancy of the patient.

shortened to ARV drugs, or simply ARVs

HOW IS ART DIFFERENT FOR CHILDREN AND ADULTS? Antiretroviral (ARV) drugs are handled differently in children’s bodies, affecting the doses that are needed. Dosages in children need to be adjusted to weight as the child grows.

WHICH CHILDREN ARE GIVEN ANTIRETROVIRAL DRUGS? All children under five who are CONFIRMED HIV INFECTION are eligible to receive ART.

WHY ARE SEVERAL ARVS GIVEN AS ONE TREATMENT? For ART to be effective it is important that a combination of three drugs is used, rather than using one or two drugs. Combination therapy for HIV is like combination therapy for TB, and makes sense for lots of reasons. Here are the most important ones: n IT TAKES A LOT OF FORCE TO STOP HIV HIV makes new copies of itself very rapidly. Every day, many new copies of HIV are made. Every day, many infected cells die. One drug, by itself, can slow down this fast rate of infection of cells. Two drugs can slow it down more, and three drugs together have a very powerful effect.

n ARVs from different drug groups attack the virus in different ways Different ARV drugs attack HIV at different steps of the process of making copies of itself: first when entering the cell, second when making new copies and third when the new copies want to leave the cell. Targeting at least two of these steps increases the chance of stopping HIV from making new copies of itself and preventing new immune cells from infection.

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n Combinations of anti-HIV drugs may overcome or delay resistance Resistance is the ability of HIV to change its structure in ways that make drugs less effective. HIV has to make only a single, small change to resist the effects of some drugs such as nevirapine. For other drugs, such as zidovudine, HIV has to make several changes. When one drug is given by itself, sooner or later HIV makes the necessary changes to resist that drug. But if two drugs are given together, it takes longer for HIV to make the changes necessary for resistance. When three drugs are given together, it takes even longer.

WHAT ARE COMMONLY USED ANTIRETROVIRAL DRUGS? ARV classes and examples of ARVs are shown in the table below. You will learn much more about these ARVs later in this module. Recommended first-line regimens usually include 2 NsRTI with 1 NNRTI. STAVUDINE: You should note that stavudine was previously used as a first-line agent, and many children are still on this drug. However it is no longer a preferred first-line treatment. Nucleoside reverse transcriptase inhibitors (NsRTI) lamivudine (3TC) stavudine (d4T) zidovudine (AZT) didanosine (ddI) abacavir (ABC) Nucleotide reverse transcriptase inhibitors (NtRTI) tenofovir disoproxil fumarate (TDF) Non-nucleoside reverse transcriptase inhibitors (NNRTI) nevirapine (NVP) efavirenz (EFV) Protease inhibitors (PI)

lopinavir (LPV) indinavir (IDV) retonavir (RTV)* atazanavir (ATV) darunavir

* ritonavir is used as a ‘helper’ for one PI to make the effect of a second PI stronger

WHEN IS IT POSSIBLE TO INITIATE ART? Before starting antiretroviral therapy, a child must first be stabilised. This means any acute common illnesses and opportunistic infections must be treated and the general condition of the child improved. The following pages discuss the 6 steps for initiating ART in children.

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PART 2: HOW DO YOU INITIATE ART IN CHILDREN?1 There are 5 steps to initiating ART in children. These are also in your chart booklet. You will read more about each step in the following pages. Remember that if a child has any general danger sign or a severe classification, they need URGENT REFERRAL. ART initiation is not urgent, but should be initiated as soon as the 5 steps are completed. STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION Child is under 18 months: n HIV infection is confirmed if virological (PCR) is positive n Check that child has not breastfed for at least 6 weeks Child is over 18 months: n Two different serological tests are positive n Send any further confirmatory tests required n If results are discordant, refer ➜ If HIV infection confirmed, and child is stable, move to STEP 2 STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART Check that the caregiver is willing and able to give ART. The caregiver should ideally have disclosed the child’s HIV status to another adult who can assist with providing ART, or be part of a support group. ➜ If caregiver able to give ART: move to STEP 3 ➜ If caregiver not able: classify as CONFIRMED HIV INFECTION not on ART. Follow-up regularly. Support caregiver and move forward once she is willing and able to give ART. STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FIRST LEVEL FACILITY ➜ If child weighs less than 3 kg or has TB, refer for ART initiation. ➜ If child weighs 3 kg or more and does not have TB, move to STEP 4

STEP 4: RECORD BASELINE INFORMATION ON THE CHILD’S HIV TREATMENT CARD Record the following information: n Weight and height n If pallor is present n If child has feeding problem n Laboratory results (if available): Hb, viral load, CD4 count and percentage ➜ Send any laboratory tests that are required. If the child is confirmed HIV infection, do not wait for results. ➜ Move to STEP 5

STEP 5: START ON ART TREATMENT AND COTRIMOXAZOLE PROPHYLAXIS n Child is up to 3 years old: initiate preferred ART treatment: ABC or AZT +3TC+ LPV/R or other recommended first-line regimen n Child is 3 years or older but less than 35 kg: initiate preferred ART treatment: ABC + 3TC + EFV, or other recommended first-line regimen n Give cotrimoxazole prophylaxis n Give other routine treatments, including Vitamin A and immunizations n Follow-up regularly as per national guidelines

1

These steps were modified from South Africa’s IMCI Chart Booklet (2011).

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RECORDING THE FIVE STEPS:

In addition to the IMCI recording form, you will use a supplementary form to record the five steps and your assessments. It includes critical instructions for each step, and is a very useful job tool when determining HIV/AIDS care using IMCI. Review the form below: Age: ...................... Weight: ............ kg Temperature: ............... °C Date: ....................

STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2

ASSESS

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

•

Child 18 months and over:

 YES  NO  Virological test positive Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks • • • • If any present: REFER NON-URGENTLY If none present: GO TO STEP 4 If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group  YES  NO

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

67 • • Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5 • RECORD OTHER TREATMENTS HERE: • • Follow-up after one week If child is stable, follow-up regularly

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. .............................................................................................................

PROVIDE FOLLOW-UP CARE

NEXT FOLLOW-UP DATE: ..................................................

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

STEP 1. CONFIRM HIV INFECTION The first step in initiating ART is to confirm the diagnosis of HIV infection. In many cases, all the necessary tests will have been done, and you must correctly document the results. In other cases it may be necessary to do some of the tests, and to record the results.

HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN LESS THAN 18 MONTHS? A positive virological (PCR) test is required to confirm HIV infection in children less than 18 months of age.

HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN 18 MONTHS OR OLDER? HIV infection in children older than 18 months of age is diagnosed using a serological test. If the first serological test is positive, it requires a confirmatory test. If the child is 18 months or older, repeat a serological test.

WHAT ARE YOUR NEXT STEPS AFTER A CHILD IS CONFIRMED INFECTED? Before starting antiretroviral therapy, a child must first be stabilised. This means any acute common illnesses and opportunistic infections must be treated and the general condition of the child improved. If the child is stable, you will then move on to STEP 2.

REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR STEP 1? STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. recorded: ASSESS STEP 1: CONFIRM HIV INFECTION • Child under 18 months:  YES  NO  Virological test positive Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks

Review this section of the recording form to become familiar with the information Age: ...................... TREAT • •

Weight: ............ kg

Temperature: ..

Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2

RECORD ACTIO ALWAYS REMEM PROVIDE ROUTI

•

Child 18 months and over:

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO  YES  NO

• • • •

If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3 If any present: REFER NON-URGENTLY If none present: GO TO STEP 4

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

• •

Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5

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•

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen

RECORD ARVS & DOSAGES HERE: 1. .............................................................................................................

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SELF-ASSESSMENT EXERCISE H – CONFIRMING HIV INFECTION 1. Why is it important to use 3 drugs in ART for children?

2. Decide whether or not these children have confirmed HIV infection. The answer may be: YES, NO, or TO BE CONFIRMED. If the answer is TO BE CONFIRMED, write down in the final column what needs to done to confirm whether or not the child has HIV infection. Does the child have HIV infection? What should be done to confirm the diagnosis?

a. 2 month old child has a positive PCR test. b. 12 month old child with positive PCR test. c. A 2 month old breastfeeding child has a positive HIV serological test. d. An 18 month old breastfeeding child has a positive HIV serological test. A second test is also positive. e. 9 month old breastfeeding child has a negative PCR test. Mother is HIV infected. f. An 19 month old has a positive serological test. The second test is negative. g. 9 month old child has a negative PCR test. The child last breastfeed 3 months ago. h. An 18 months old child has a negative serological test. The child last breastfed one week ago.

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SELF-ASSESSMENT EXERCISE I – ART ELIGIBILITY Decide whether or not the following children are eligible to receive ART. AGE a.  4 years b.  6 months c.  9 months d.  3 years e.  9 years DETAILS Child is CONFIRMED HIV INFECTION but appears healthy Child is HIV exposed, and mother is very sick Child had a positive serological test Child had a positive serological test Child is CONFIRMED HIV INFECTION ANSWER

STEP 2. MAKE SURE THAT THE CARETAKER IS READY TO GIVE ART Adherence is the cornerstone of successful ART. For a good response at least 95% of the ARVs need to be taken.

WHAT MAKES ADHERENCE COMPLICATED FOR CHILDREN? Adherence is therefore the key to successful therapy, but may be difficult to achieve in children due to a number of reasons: ■■ Young children are heavily reliant on their parents/caregivers to ensure adherence. There may be a poor understanding of the need to take the medication both for parent and the child. ■■ Many parents may not wish to disclose the HIV status to the child or to others involved in care. ■■ Lack of suitable easy to use paediatric fixed dose combinations means complicated mixtures of pills/syrups need to be taken. ■■ Often the medicines are often not palatable to children, resulting in difficulty in their administration.

WHAT SOCIAL ENVIRONMENTS ARE IMPORTANT FOR ADHERENCE? The social criteria attempt to ensure good adherence. They aim to ensure that adherence is at least probable. They are: ■■ Availability of at least one identifiable caregiver who is able to supervise the child for administering medication (all efforts should be made to ensure that the social circumstances of vulnerable children, e.g. orphans, are addressed so that they too can receive treatment) ■■ Disclosure to another adult living in the same house is encouraged so that there is someone else who can assist with the child’s ART

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WHY SHOULD THESE CRITERIA BE MET BEFORE INITIATING ART? The social criteria highlight the fact that starting ART is not just a medical issue, but has implications for the child and his/her caregiver. These criteria should not be used as a barrier to giving a child ART, but should rather be thought of as part of the process for preparing a child to start ART. Some caregivers may be ready to commit themselves to giving their child ART immediately, while others may need more time to get used to the idea. In some instances there may be practical problems or issues that need to be addressed.

HOW CAN HEALTH WORKERS PREPARE CARETAKERS AND CHILDREN FOR ADHERENCE? Health care providers should use the ‘5 As’ to prepare children and their caregivers for ART adherence. These are helpful to use during each clinic or follow-up visit.

‘5 As’ for adherence counselling 1. ASSESS  2. ADVISE  3. AGREE  4. ASSIST  5. ARRANGE

1. ASSESS Try to ensure that a treatment supporter is identified. Make sure that the caregiver understands that ART is lifelong therapy, and that she understands the side effects of the medication. Though one cannot force another to disclose, the primary caregiver should be supported to identify an additional person who can assist treatment supervision. This will also provide insight into potential family supports and challenges to successful chronic care adherence. 2. ADVISE As you have learned in the previous counselling lessons in IMCI, it is very important when advising caretakers to approach them in an open, non-judgmental, and patient way. You might introduce the topic like this: “I have some information about HIV and AIDS and ART. Would you like to hear it? ” Do not overwhelm the caregiver with too much information at once. She will need time to think about and digest some information before being able to concentrate on further information. That is why it is good to split the advice over several visits, and indicate on the education side of the child’s treatment card the information that has been given already.

WHAT TOPICS SHOULD HEALTH WORKERS ADVISE CARETAKERS ON? HIV ILLNESS AND EXPECTED PROGRESSION: Explain that in children the progression of disease is often rapid. Children may be asymptomatic, but will become vulnerable to opportunistic infections that gradually become more serious.

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ARV THERAPY (ART): Advise the caregiver that ARVs are life-saving drugs. Her child’s life depends on taking the correct dose twice daily and at the right time. ADVISE ON WHAT ADDITIONAL STEPS SHOULD BE TAKEN TO IMPROVE ADHERENCE •• Involve all caregivers, both parents, and child (depending on age and maturity) in counselling sessions. Careful disclosure to the child can help them understand why adherence is important. In many cases the child will be too young to understand. It is important to gradually disclose to the child. This is the caregiver’s responsibility, but the health worker or counsellor needs to support and facilitate the process of disclosure. •• Involve school nurses or orphanage staff, if and where applicable •• Consider referral to support groups if available 3. AGREE It is important to establish that the caregiver (and the child in older children) is willing and motivated, and agrees to treatment, before initiating ART. The caregiver must be willing to take responsibility for regular supervision of treatment and make any life adjustments this may require. As children get older it is important they know about ART and understand the importance of 100% adherence. Start by asking: “After hearing all the explanation and advice, how do you think your child will be able to take this kind of treatment? ”

HOW CAN YOU CHECK THE MOTIVATION OF THE CAREGIVER? In addition to considering the response to this question, use some other measures to check the motivation of the caregiver (since in practice the health care provider’s impression does not always correspond with the real situation). You can check, for example: •• Has the caregiver demonstrated ability to keep appointments for her child and to adhere to other medications? •• Does the caregiver want treatment for her child and understand what treatment is for? •• Is the caregiver willing to bring the child to the clinic for the required follow-up? •• Is the caregiver taking her treatment or does she need it?

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4. ASSIST Explore what is needed to assist the caregiver with ART for her child: “What problems might arise when you follow this plan? ” “What questions do you have about this treatment or how to follow this plan? ”

WHAT KINDS OF ASSISTANCE WILL A CAREGIVER NEED FOR PROVIDING ART? Help the caregiver develop the resources/support/arrangements needed for adherence. These include: •• Ability to bring the child for required schedule of follow-up – plans for time off work and transport need to be in place. •• Home and work situation of caregiver that permits her giving medications regularly to the child without stigma •• Supportive family or friends •• Disclosure to child and or family •• ART adherence support group 5. ASSIST Note that it is often not be possible to prepare the caregiver and child for adherence on the same visit that you decide the child is medically eligible for ART. It usually takes at least 2 to 3 visits and the involvement of others on the clinical team and a treatment supporter. The adoption of ART requires long-term commitment on the side of both the clinical team and the caregiver (and child, depending on his/her age). Both will need support and help from treatment supporters and others in the community. If the caregiver needs another adherence preparation session, arrange a follow-up to reinforce key messages. Arrange an appointment with the ART support group if the caregiver wishes so. Remember that it is important to provide ongoing support and counselling to an HIV-infected caregiver. Refer to a support group with other caregivers It often takes 2 to 3 visits to prepare a caregiver and child for adherence, involve others on the clinical team, and arrange treatment supporters.

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STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS ASSESS TREAT

Age: ......................

Weight: ..

 YES  NO • Send any test required, including confirmation  Virological test positive • If HIV infection confirmed, and child is in st Ensure child has not breastfed for condition, GO TO STEP 2 at least 6 weeks • Child 18 months and over: form to  become Serological familiar test positivewith the information Review this section of the recording  Second serological test positive being recorded. Ensure child has not breastfed for at least 6 weeks

REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR STEP 2?

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO •  YES  NO

• • • •

If NO: classify as CONFIRMED HIV INFECTION N If none present: GO TO STEP 3 If any present: REFER NON-URGENTLY If none present: GO TO STEP 4

• Send tests that are required  SEVERE ACUTE MALNUTRITION  MODERATE ACUTE • REFER IF: Once a taken, it needs to MALNUTRITION be decided WHERE and  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRIT WHO will initiate the ART. This can be a nurse or a doctor. Your national guidelines • Pallor is present  YES  NO — SEVERE OR SOME ANAEMIA will specify WHERE and WHO can initiate ART. • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • If none present: GO TO STEP 5 • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................ Record weight and height, assess & classify malnutrition decision to start ART has been

STEP 3. DECIDE IF ART CAN BE INITIATED AT YOUR FIRST-LEVEL FACILITY STEP 4: ASSESS AND RECORD BASELINE INFORMATION

WHEN CAN ART BE INITIATED IN A FIRST-LEVEL FACILITY?

STEP doctors 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS RECORD In the past, only initiated ART, but it is anticipated that nurses will play ARVS an & DOSAGES HERE: • Child is under 3 years old: Initiate preferred first-line regimen 1. ...................................................................................... increasing role. In general, nurses should initiate ART in children who are stable. • Child is 3 years or older: Initiate preferred first-line regimen 2. ...................................................................................... This means they are not ill and do not have signs of advanced HIV infection. • Cotrimoxazole 3. ...................................................................................... • Give other routine treatments, including Vitamin A and immunizations RECORD OTHER TREATMENTS HERE:

WHEN DO CHILDREN REQUIRE REFERRAL FOR ART?

In general, the following children should be referred to a doctor for initiation of • Follow-up after one week PROVIDE FOLLOW-UP CARE ART, or a nurse should start ART in consultation with a doctor. • If child is stable, follow-up regularly 1. Children who weigh less than 3 kg Initiating ART is difficult in very small children due to the small doses that are required. These children should be referred to the next level of care for initiation of ART. 2. Children with TB or children in whom TB is suspected It can be difficult to diagnose TB in children with HIV infection, and investigations such as Chest X-rays and sputum microscopy, are required. ART doses also need to be adjusted. These children require referral.

WHAT DOES NON-URGENT REFERRAL MEAN IN THIS CONTEXT? Non-urgent referral will mean different things in different settings. Children should be referred as soon as possible, but it does not need to be the same day. The children should be referred to an on-site doctor if available, or to the local hospital or community health centre. Many children who should be started on treatment by doctors, can be referred to nurses for follow-up and ongoing care. Remember that if the child has a general danger sign or a severe classification, they must be referred urgently.

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STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. ASSESS TREAT

Age: ......................

Weight: ............ kg

Tempe

STEP 1: CONFIRM HIV INFECTION  YES  NO • Send any test required, including confirmation test IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS • Child under 18 months:  Virological test positive • If HIV infection confirmed, and child is in stable Ensure child has not breastfed for condition, GO TO STEP 2 at least 6 weeks • Child 18 months and over:  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks

RECOR ALWAY PROVID

REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR STEP 3? • •

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO being recorded.  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO  YES

Review this section of the recording form to become familiar with the information

If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

 NO

• •

If any present: REFER NON-URGENTLY If none present: GO TO STEP 4

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Send tests that are required • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION • REFER IF:  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION • Pallor is present  YES  NO — SEVERE OR SOME ANAEMIA • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • If none present: GO TO STEP 5 Children who are started on ART should begin to thrive. It is important that baseline 3 CD4 percentage ......................... % • CD4 count: ......................... cells/mm • WHO clinical stage today: ................................................................................................ information is recorded before they begin ART. This same baseline information will

STEP 4. RECORD BASELINE INFORMATION

WHY IS BASELINE INFORMATION IMPORTANT?

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS be monitored during the course of their ART. This • Child is under 3 years old: Initiate preferred first-line regimen be monitored. • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

ARVS & DOSAGES HERE: way, RECORD their response to ART can

WHAT BASELINE INFORMATION IS DOCUMENTED? • •

1. ............................................................................................................. 2. ............................................................................................................. 3. ............................................................................................................. RECORD OTHER TREATMENTS HERE:

The following information should be clearly documented: PROVIDE FOLLOW-UP CARE IMCI NUTRITIONAL

CLASSIFICATION

Follow-up after one week If child is stable, follow-up regularly

NEXT F

Assess and classify the child’s nutritional status using the relevant chart in the IMCI chart booklet. If the child has a severe classification they must be referred. All other children should be managed according to IMCI TREAT charts. ART should not be delayed. FEEDING ASSESSMENT Use the guidance in your chart booklet to assess the feeding of: •• All children under 2 years of age •• Children classified with acute malnutrition •• Check for feeding problems of all young infants Counsel the mother regarding feeding recommendations and any feeding problems. CLINICAL STAGING If the child has not already been staged, do this now as described above. Make sure that you record the child’s stage from 1 to 4. Information about staging is located in Annex 1. CD4 COUNT AND PERCENTAGE CD4 should be measured at the time of diagnosing HIV infection, prior to starting ART (as possible, and preferably with increasing frequency as the CD4 count approaches the threshold for starting ART), and every 6 months once the child has initiated ART. Send these tests if they have been done or were done more than three months ago. Record them accurately.

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ASSESS STEP 1: CONFIRM HIV INFECTION • Child under 18 months:  YES  NO

TREAT • Send any test required, including confirmation test condition, GO TO STEP 2

•

Ensure child has not breastfed for at least 6 weeks Child 18 months and over:  Serological test positive  Second serological test positive VIRAL LOAD MONITORING Ensure child has not breastfed for at least 6 weeks Viral load testing is desirable, but not essential.

Virological test positive • If HIV infection confirmed, and child is in stable IMCI  DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

RECORD AC ALWAYS REM PROVIDE RO

It is not always available. • • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group

REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR STEP 4? STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR  YES  NO • If any present: REFER NON-URGENTLY

FIRST LEVEL FACILITYthis section of the recording form to become •familiar If none present: GO information. TO STEP 4 Review with the • Weight under 3 kg  YES  NO • Child has TB  YES  NO STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................ STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations • • Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5

•

STEP 5. START ART AND COTRIMOXAZOLE PROPHYLAXIS

RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. .............................................................................................................

RECORD OTHER TREATMENTS HERE: WHEN SHOULD CHILD CONFIRMED WITH HIV INFECTION BEGIN ART? PROVIDE FOLLOW-UP CARE All children

under 5 years of age with confirmed infection should begin • HIV If child is stable, follow-up regularly ART. This is a new and important recommendation for paediatric HIV. If children are 5 years and older, there are two criteria used to determine eligibility for ART: ✔✔ CD4 count less than 500 cells/mm3 (give priority to those with CD4 less than 350), or ✔✔ Clinical stage 3 or 4 All HIV-infected children under 5 should begin ART

•

Follow-up after one week

NEXT FOLLO

WHAT FORMS ARE ARVS AVAILABLE IN? Most ARVs are currently available separately. However it is anticipated that fixed dose combinations and co-packaged formulations will become available. This will facilitate dispensing of ARVs, and promote adherence by reducing the number of medicines that patients have to take.

HOW WILL YOU DETERMINE ARV DOSING? Doses are based on the child’s weight. It is important to regularly check that children receive the correct dose based on their weight as they grow. Switch to tablets or capsules from syrups or solutions as soon as possible. Ensure the caregiver demonstrates ability to properly use a dosing syringe when prescribing liquid preparations. In older children or adolescents ensure that maximum doses are not exceeded.

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WHAT ARE FIRST-LINE ARV RECOMMENDATIONS FOR AGE BELOW 3 YEARS? The following regimens are recommended by WHO as first line ART for children age below 3 years. The choice of ART regimen at country level will be determined by national guidelines. AGE Birth up to 3 years PREFERRED ABCa or AZT + 3TC + LPV/rb ALTERNATIVE ABC or AZT + 3TC + NVP CHILDREN WITH TB/HIV INFECTION ABC or AZT + 3TC + NVP AZT + 3TC + ABC

Special notes: a Based on the general principle of using non-thymidine analogues in first-line and thymidine analogues in second-line regimens, ABC should be considered as the preferred NRTI whenever possible. This recommendation was developed by the CHAIN working group. Availability and cost should be carefully considered. b As recommended by the Food and Drug Administration (FDA), the use of LPV/r oral liquid should be avoided in premature babies (born one month or more before expected date of delivery) until 14 days after their due date, or in full-term babies younger than 14 days of age. Dosing in children younger than 6 weeks should be calculated based on body surface area (see Annex 3).

WHAT ARE FIRST-LINE ARV RECOMMENDATIONS FOR AGE 3 YEARS AND ABOVE? The following regimens are recommended by WHO as first line ART for children 3 years and above. The choice of ART regimen at country level will be determined by national guidelines. After the age of 3 years the child could be switched to an EFV-based regimen. AGE 3 years and older PREFERRED ABC + 3TC + EFV ALTERNATIVE ABC or AZT + 3TC + EFV or NVP CHILDREN WITH TB/HIV INFECTION ABC or AZT + 3TC + EFV AZT + 3TC + ABC

WHAT ARE THE ARV DRUG PREPARATIONS FOR CHILDREN? The range of commercially available paediatric ARV formulations is narrow and most drugs do not have solid formulations in doses appropriate for paediatric use. Lopinavir/ritonavir needs to be kept cool (<25 °C), and should be refrigerated prior to dispensing. It can be kept out of the fridge for up to 42 days. If the caregiver has a fridge at home, encourage them to store the lopinavir/ritonavir in the fridge. Do not dispense more than one month’s supply if there is no fridge at home.

WHAT IS THE DOSING FOR ART? Refer now to Annex 2. This explains the appropriate doses for antiretroviral therapies. ART DOSING IS LOCATED IN ANNEX 2

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Ensure child has not breastfed for at least 6 weeks STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO • • If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

IMCI  DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS YES  NO • If any present: REFER NON-URGENTLY • If none present: GO TO STEP 4

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................ STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

REVIEW: WHAT PART OF THE ART INITIATION FORM • REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION IS USED FOR STEP 5? — SEVERE OR SOME ANAEMIA • If none present: GO TO STEP 5

•

Send tests that are required

Review this section of the recording form to become familiar with the information. RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. ............................................................................................................. RECORD OTHER TREATMENTS HERE:

PROVIDE FOLLOW-UP CARE

• •

Follow-up after one week If child is stable, follow-up regularly

NEXT FOLLOW-UP DATE: ..................................................

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SELF-ASSESSMENT EXERCISE J – DOSING Practice writing the drugs and the dosages for all first-line ARVs for the following children. Refer to Annex 2 for dosing information.

Since accurate calculation of dosage based upon weight is the preferred method, use the following example to practice calculating the dosage needed to treat children of different weights. Refer to the ART drug dosage tables in your chart booklet, or in the ANNEX of this module. In this clinic the preferred regimen are the following: •• Birth up to 3: ABC (20 mg/ml liquid) + 3TC (10 mg/ml liquid) + LPV/r (80/20 mg liquid) •• 3 years and older: ABC (20 mg or 300 mg tablet) + 3TC (30 mg tablet) + EFV (200 mg tablet) 1. 12 month old 10 kg child

2. 4 year old 20 kg child

3. 4 month old 5 kg child

4. 13 month old 12 kg child

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SELF-ASSESSMENT EXERCISE K – ART INITIATION Bhengu works in a small clinic in a rural area. A doctor visits once a week. She sees the following children. Decide whether each child requires: URGENT REFERRAL, non-urgent referral to the doctor or whether Bhengu should initiate ART at the clinic. Tick your answer. URGENT REFERRAL NON-URGENT REFERRAL FOR ART ART AT CLINIC

1. LEATILE: Leatile is four years old. He shows signs of severe acute malnutrition, and has CHRONIC EAR INFECTION, but has no other problems. His CD4 count is 200 cells/mm3. 2. OFENTSE: Ofentse is three years old. She has been diagnosed with TB and on routine testing was found to be HIV-infected. 3. LUKE: Luke is two months old. When he was six weeks old he was admitted to hospital with severe pneumonia. In the hospital he was confirmed HIV infected. He is well now and is gaining weight – his weight today is 4.5 kg. His CD4 count and percentage have been sent, but the result is not back yet. 4. LENTSWE: Lentswe is four years old. He was seen a week ago and you classified PNEUMONIA. Despite receiving an antibiotic for five days he still has fast breathing (50 breaths per minute). At the previous visit he was found to be HIVinfected, and his CD4 count is 150 mm3. 5. LEAH: Leah is 18 months old. Her CD4 count is not yet available. Her Z-score is -3 but she has no other health concerns. 6. OWETHU: Owethu is eleven months old. She was recently confirmed HIV infection. Her mother wanted some time to discuss starting Owethu on ART with her family, but had agreed to come today to start treatment. Owethu’s mother says that Owethu has been feverish since the previous day. When you examine Owethu she finds that she is lethargic and does not respond when her mother or Sister Bhengu speaks to her or claps their hands.

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



 

 

 



















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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

PART 3: SIDE EFFECTS OF ARVs WHAT ARE THE SIDE EFFECTS OF ARVS? Most drugs have side effects of some sorts, although in the majority of cases they are mild, and not all people taking drugs will experience the same effects and to the same extent. Less than 5% of patients taking ART will have serious clinical side effects. Many more will have non-serious, self-limiting side effects, especially at the beginning of their therapy. If children and their caregivers know about possible side effects it is easier to deal with them. Caregivers and children must be aware of side effects, so that they do not stop the drug in reaction to the side effect. This is important for adherence.

WHY IS IT IMPORTANT TO UNDERSTAND AND EXPLAIN THESE SIDE EFFECTS? Many mothers and children are worried about possible side effects when they start ART for the first time. It is important that you warn mothers about the very common side effects, and suggest ways in which the mother can manage these side effects. If mothers or children do complain about side effects, you should take their complaints seriously. Mothers of children with side effects may be concerned and may stop giving the child the drug correctly because of this. Similarly children who have side effects may refuse to take the medication. We have already discussed the need to take all the doses to make sure the therapy works properly, and this should be emphasized at each visit.

WHAT KINDS OF ARV SIDE EFFECTS ARE REPORTED? ARV side effects can be divided into three categories.

1. Very common side effects Warn patients and suggest ways patients can manage; also be prepared to manage when patients seek care.

2. Potentially serious side effects Warn patients and tell them to seek care if they experience these side effects. These side effects are the ART Danger Signs which you will learn about in the next section. If these signs are present, stop ART and REFER URGENTLY.

3. Side effects occurring later during treatment You will need to look out for these during follow-up visits. The table below describes commonly experienced side effects of ARV drugs.

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WHAT ARE IMPORTANT SIDE EFFECTS FOR ARVS? VERY COMMON: Inform patients and suggest ways to manage; manage when patients seek care Stavudine (d4T) •• Nausea •• Diarrhoea POTENTIALLY SERIOUS: Warn patients and tell them to seek care •• Seek care urgently: Severe abdominal pain AND difficulty breathing •• Seek advice soon: Tingling, numb or painful feet or legs or hands. •• Seek care urgently: fever, vomiting, rash – this may indicate hypersensitivity to abacavir OCCURRING LATER DURING TREATMENT: Discuss with patients •• Changes in fat distribution: •• Arms, legs, buttocks, cheeks become THIN •• Breasts, tummy, back of neck become FAT

Abacavir (ABC)

Lamivudine •• Nausea (3TC) •• Diarrhoea Lopinavir/ ritonavir •• Nausea •• Vomiting •• Diarrhoea •• Elevated blood cholesterol and glucose •• Changes in fat distribution: —— Arms, legs, buttocks, cheeks become THIN —— Breasts, tummy, back of neck become FAT Seek care urgently: •• Yellow eyes •• Severe skin rash •• Fatigue AND shortness of breath •• Fever Seek care urgently: •• Pallor (anaemia)

Nevirapine (NVP)

•• Nausea •• Diarrhoea

Zidovudine (ZDV or AZT)

•• •• •• •• •• •• •• •• •• •• •• ••

Nausea Diarrhoea Headache Fatigue Muscle pain Nausea Diarrhoea Strange dreams Difficulty sleeping Memory problems Headache Dizziness

Efavirenz (EFV)

Seek care urgently: •• Yellow eyes •• Psychosis or confusion •• Severe skin rash

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WHY IS IT IMPORTANT TO EXPLAIN SIDE EFFECTS FOR ALL DRUGS IN A COMBINATION? For all combination treatments, it is important to advise the mother about the regimen as a whole and not on each specific drug. The mother should never stop giving the child just one drug or giving him a lower dose. If the mother thinks that the child has a side effect from one drug, which is so bad that she wants to stop or change the treatment, she should go with the child as soon as possible to the clinic. Consult with the clinician or, if not available, STOP ALL THREE DRUGS. Never just stop one or two drugs.

HOW DO YOU MANAGE SIDE EFFECTS? Good management of side effects should include the following: INTRODUCE: Discuss common possible side effects before the child starts the medication MANAGEMENT ADVICE: Give advice on how to manage these side effects. NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and children about potentially serious side effects and tell them to seek care urgently if they occur. PROVIDE IMMEDIATE ATTENTION: Give immediate attention to side effects, including access to the clinic or by phone QUESTION DURING FOLLOW-UP: Initiate a discussion about side effects, even if the mother or child does not mention them spontaneously REFER FOR SUPPORT: Refer the patient to peer-educators.

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WHAT ARE APPROPRIATE CARE RESPONSES TO ART SIDE EFFECTS? The table below outlines side effects experienced in patients on ART and appropriate responses or advice for the caregiver. Only gastrointestinal upsets and fatigue are fairly common in the small child treatment. Sleep disturbances, headaches and memory problems are fairly common in Efavirenz containing regimens.

SIGNS or SYMPTOMS Yellow eyes (jaundice) or abdominal pain Rash

RESPONSE Stop drugs and REFER URGENTLY If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is associated with fever or vomiting: stop drugs and REFER URGENTLY. Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer. Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being given. If vomiting persists, the caregiver should bring the child to clinic for evaluation. If vomiting everything, or vomiting associated with severe abdominal pain or difficult breathing, REFER URGENTLY.

Nausea Vomiting

Diarrhoea

Assess, classify, and treat using diarrhoea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If not improved after two weeks, call for advice or refer. Assess, classify, and treat using fever charts. Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or refer. This may be due to efavirenz . Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for advice or refer. If new or worse on treatment, call for advice or refer. Consider switching from Stavudine to Abacavir. Refer if needed.

Fever Headache

Sleep disturbances, nightmares, anxiety Tingling, numb or painful feet or legs Changes in fat distribution

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SELF-ASSESSMENT EXERCISE L – SIDE EFFECTS The table below lists common or potentially serious side effects to common ARV drugs. For each side effect listed, fill in the name of the drug (or drugs – there may be more than one) that cause the described side effect: Side effect * requires urgent care Severe abdominal pain * potentially serious, because could be pancreatitis Drug/s which causes the side effect

Tingling or numbness in feet or hands * this is neuropathy, should seek advice soon

Yellow eyes * needs urgent referral as it may indicate liver toxicity

Skin rash * It could be a severe reaction to the drug and may require urgent referral. Nausea, vomiting, diarrhoea Common -patients will need to be prepared to cope with these side effects

Changes in fat distribution Important side effect occurring with long term treatment

Fever, vomiting, skin rash * may indicate hypersensitivity

Difficulty sleeping and nightmares

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n  How will you initiate ART for Peter? Peter does not require any stabilization today for acute illness or opportunistic infections. As he is stable, you will walk through the six steps for ART initiation today.

STEP 1: CONFIRM HIV INFECTION Peter’s HIV infection has been confirmed through a positive virological test.

STEP 2: MAKE SURE LUNGILE IS READY TO GIVE ART You will use the ‘5As’ to determine if Lungile is ready to give Peter ART: 1. ASSESS: Ask Lungile more about her social situation, as you have previously discussed. Ask her about her understanding of HIV/AIDS. Ask what questions she has about HIV/AIDS and treatment. Ask her how she feels about starting Peter on treatment now – can she handle this responsibility? Use small, specific questions. 2. ADVISE: You will want to discuss key topics with Lungile. As she has already tested positive for HIV and is receiving care, she might know this information already. Ask her questions about topics so that you can try to understand what topics she might need more information about. These include: how HIV affects the body, ART, and adherence. Ask Lungile checking questions to see if she understands. 3. AGREE: After you explain this information, ask Lungile how she feels about the treatment, and how Peter will handle it. Ask her if she will be willing and able to come to appointments and give the medications everyday at home. 4. ASSIST: Discuss what support Lungile has, and will need, for providing ART. This includes her ability to bring Peter, for example transportation and time off work. It also includes stigma about giving medications in the home, support from friends and family, and her choice to disclose to her partner, mother, or friends. 5. ARRANGE: arrange another session with Lungile to continue discussing adherence.

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FACILITY Peter does not require referral for ART. This is because he does not have TB or fast breathing, and he weighs more than 3 kg. You will be able to initiate ART in your clinic.

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ART: FOLLOW THE FIVE STEPS Name: ............................................................................. n STARTING How will you complete Peter’s recording form thus far? ASSESS STEP 1: CONFIRM HIV INFECTION • Child under 18 months:  YES  NO  Virological test positive Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks

Age: ......................

Weight: ............ kg

Temperature: ..............

TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2

RECORD ACTIONS AN ALWAYS REMEMBER TO PROVIDE ROUTINE CAR

•

Child 18 months and over:

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO  YES  NO

• • • •

If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3 If any present: REFER NON-URGENTLY If none present: GO TO STEP 4

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Send tests that are required • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION • REFER IF: STEP 4: ASSESS AND RECORD BASELINE INFORMATION  NO ACUTE MALNUTRITION — COMPLICATED SEVERE ACUTE MALNUTRITION • Pallor is present  YES SEVERE OR SOME ANAEMIA Peter is not low weight for age and he  isNO not anaemic. You review — the clinical staging. You know that Peter • Child has feeding problem  YES  NO has had pneumonia, persistent diarrhoea, and ear infections within the past couple of months. When you • Hb: ............................. g/dl Viral load: .................................................... • If none present: GO TO STEP 5 assess him today you see that herpes zoster is beginning to develop. You will send for the CD4 and viral load • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % STARTING ART: FOLLOW FIVE STEPS Name: ............................................................................. Age: ...................... Weight: ............ kg Temperature: ............... tests today, and will fillTHE in results once they return. • WHO clinical stage today: ................................................................................................

STEP 5: START ARTold AND COTRIMOXAZOLE • Child is under 3 years : Initiate preferred first-line regimen STEP 1: CONFIRM HIV INFECTION • •

ASSESS STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS  YES  NO

• Child is 3 years or older: Initiate preferred first-line regimen You the first-line regimen for Peter. • will Childdetermine under 18 months:  Virological test positive

Cotrimoxazole Ensure child not breastfed for Give other routine treatments, including Vitamin Ahas and immunizations at least 6 weeks • Child 18 months and over:  Serological test positive Remember that Peter is 7.2 kg and 6.5 months old.  Second serological test positive Ensure child has not breastfed for PROVIDE FOLLOW-UP CARE •• ABC (20 mg/ml): 4 ml AM, 4 ml PM6 weeks at least

n  What ART doses will Peter require?

TREAT ARVS & DOSAGES HERE: RECORD 1. ............................................................................................................. • any test required, including confirmation test 2. Send ............................................................................................................. • HIV infection confirmed, and child is in stable 3. If ............................................................................................................. condition, GO TO STEP 2 RECORD OTHER TREATMENTS HERE:

RECORD ACTIONS AN ALWAYS REMEMBER TO PROVIDE ROUTINE CAR

• • • • • •

Follow-up after one week If child is stable, follow-up regularly If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3 If any present: REFER NON-URGENTLY If none present: GO TO STEP 4

NEXT FOLLOW-UP DAT

2: CAREGIVER ABLE TO GIVE ART •• STEP 3TC: (10 mg/ml): 4 ml AM, 4 ml PM

••

 YES  NO  YES: caregiver available and willing to give medication LPV/r: YES: caregiver has disclosed another adult, or PM is part of a support group (80/20 mg): 1.5 to ml AM, 1.5 ml STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO  YES  NO

n  How will you finish Peter’s ART initiation form? STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................ STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations • •

Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5

•

RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. ............................................................................................................. RECORD OTHER TREATMENTS HERE:

PROVIDE FOLLOW-UP CARE

• •

Follow-up after one week If child is stable, follow-up regularly

NEXT FOLLOW-UP DAT

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n  How will you counsel Lungile on side effects? Today you will inform Lungile about the possibility of side effects:

INTRODUCE: Discuss common possible side effects before the child starts the medication MANAGEMENT ADVICE: Give advice on how to manage these side effects. NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and children about potentially serious side effects and tell them to seek care urgently if they occur. PROVIDE IMMEDIATE ATTENTION: Give immediate attention to side effects, including access to the clinic or by phone QUESTION DURING FOLLOW-UP: Initiate a discussion about side effects, even if the mother or child does not mention them spontaneously REFER FOR SUPPORT: Refer the patient to peer-educators. When Peter visits your clinic for follow-up, you will need to: (a) question Lungile to see if any side effects have been occuring, (b) address any side effects, and (c) refer if necessary.

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SELF-ASSESSMENT EXERCISE M – STEPS OF INITIATING ART

CASE 1: AKSHAY

Akshay is a boy aged 30 months. He has been classified as HIV EXPOSED. He has severe oral thrush. His temperature is 36.7 °C and his weight now is 10 kg. His height is 75 cm. For the past 3 months his weight has remained the same. He has not received any treatment for poor weight gain. He has SOME ANAEMIA and his Hb is 8g/dL. A serological test was done which shows that he is HIV-infected. The diagnosis is confirmed with a second test which is also positive. His blood was sent to the laboratory for a CD4 count. The absolute count was 250 cells/mm3, which was 12%. Akshay’s mother has been on ART for the past year. She has been taking her medication every day and is very motivated to take care of herself and of Akshay. She is supported by her mother who know that she is HIV-infected and on treatment. She now asks that Akshay should also receive ART. Akshay lives with his mother. She runs a shop from home and looks after Akshay as well. Is Akshay is eligible for ART? If you decide that he is eligible complete the ART initiation form. Age: ...................... Weight: ............ kg Temperature: ............... °C Date: ....................

STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2

ASSESS

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

•

Child 18 months and over:

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89 • • • • If any present: REFER NON-URGENTLY If none present: GO TO STEP 4 If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3  YES  NO • • Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5 • RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. ............................................................................................................. RECORD OTHER TREATMENTS HERE: • • Follow-up after one week If child is stable, follow-up regularly

 YES  NO  Virological test positive Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

PROVIDE FOLLOW-UP CARE

NEXT FOLLOW-UP DATE: ..................................................

CASE 2: NANCY

Nancy is 6 months old and weighs 3.3 kg. Her mother was found to be HIV-infected during pregnancy. Nancy was tested at six weeks and was found to be PCR positive. Nancy’s CD4 count was 800 cells/ mm3 (30%). A full blood count done at the same time, showed that her Hb is 11g/dL. She is breastfeeding and is generally well. Her length is 60 cm. Her temperature was recorded as 36.5 °C. She lifts her head when her mother carries her with support, responds to sounds and follows close objects with both eyes. Her mother has not disclosed her own or Nancy’s HIV status to anyone at home, but is a regular member of the clinic support group. She has been counselled regarding adherence, and is available and committed to ensuring that Nancy receives her ARVs twice a day.

1. Is Nancy eligible for ART? 2. If you decide that she is eligible for ART complete the ART initiation form. You might need to know that Nancy is well, and there is no close TB contact. Age: ...................... Weight: ............ kg Temperature: ............... °C Date: ....................

STARTING ART: FOLLOW THE FIVE STEPS Name: ............................................................................. TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2

ASSESS

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

•

Child 18 months and over:

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90 • • • • If any present: REFER NON-URGENTLY If none present: GO TO STEP 4 If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3  YES  NO • • Send tests that are required REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5 • RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. ............................................................................................................. RECORD OTHER TREATMENTS HERE: • • Follow-up after one week If child is stable, follow-up regularly

 YES  NO  Virological test positive Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO  YES: caregiver available and willing to give medication  YES: caregiver has disclosed to another adult, or is part of a support group

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY • Weight under 3 kg  YES  NO • Child has TB  YES  NO

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

PROVIDE FOLLOW-UP CARE

NEXT FOLLOW-UP DATE: ..................................................

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

8.9

PROVIDING FOLLOW-UP CARE

What are the learning objectives for this section? After you study this section, you will know how to: •• Provide follow-up care to children and young infants exposed to HIV •• Explain the principles of good chronic care and how they can be used in your clinic •• Use the six steps for follow-up with children on ART •• Know when to refer children on ART, both for urgent and non-urgent reasons

WHY IS FOLLOW-UP SO IMPORTANT FOR HIV EXPOSED INFANTS? All children born to an HIV-infected mother are at risk of HIV infection. Effective prevention of mother-to-child transmission (PMTCT) can reduce the risk of infection. ARV prophylaxis is an important intervention to prevent HIV transmission from mother to child. Please turn back to Section 8.6 to re-read this information. It is also important that all children born to HIV-infected mothers are provided follow-up care to ensure safe feeding, optimal growth and development, HIV testing, and other care. In high HIV settings, an important part of follow-up care for exposed infants is an HIV test. Children classified as HIV EXPOSED will be reclassified once you can confirm their HIV test results. You will provide care according to their new classification.

WHAT ARE WAYS TO ENSURE THAT HIV-EXPOSED INFANTS ARE TESTED? All infants born to HIV-infected mothers should be offered PCR virological testing at 4–6 weeks of age. This can be done when the child comes for immunizations. It is very important that there is a system in every clinic for identifying infants and offering testing. The infant should also initiate cotrimoxazole. The caregiver should be counselled to return for HIV test results.

How can you work with your facility to better identify HIV-exposed infants? Sometimes a clinic needs to be structured in a certain way to help identify more infants. For example, integrated RCH clinics in health facilities and hospitals provide pregnant women and their children care together. This helps a health worker respond to both the mothers’ and children’s needs. Another example is a family-based care model. Here, all members of a family are linked for care. For example, if a mother or father comes to the clinic, you ask about the health and HIV status of their children or partner, and keep their health records together.

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AFTER CHILD HAS CONFIRMED HIV INFECTION, WHAT FOLLOW-UP IS PROVIDED? When managing children with HIV, it is important to be able to provide both good acute care and good chronic care at health facilities. There should be continuity between services.

WHAT IS ACUTE CARE FOR CHILDREN INFECTED WITH HIV? You learned about acute care in the IMCI case management course. Acute care includes the management of common childhood illnesses, such as bacterial infections, malaria, pneumonia, ear infections and skin conditions. In countries with a high prevalence of HIV infection, more and more of these acute problems are due to opportunistic infections that occur because of immunodeficiency caused by HIV infection.

WHAT IS CHRONIC CARE FOR CHILDREN INFECTED WITH HIV? HIV infection causes a chronic disease and this requires special health care. If we only care for the patient during episodes of acute illness, then we are not yet providing good chronic care. Good chronic care for children under the age of 5 years recognises that the mother (or other primary caregiver) must understand and learn to help with managing the child’s condition. The mother of an HIV-infected child has a double burden: she must firstly cope with her own illness, and second learn to manage and cope with her child’s illness.

HOW IS PROVIDING CHRONIC CARE DIFFERENT THAN ACUTE CARE? Providing chronic care is different from providing acute care. When we provide chronic care for an infant or child we have to take note of and follow several principles. These principles are important and are listed below:

General Principles of Good Chronic Care for HIV-infected children 1. Develop a treatment partnership with the mother and child 2. Focus on the mother or child’s concerns and priorities 3. Use the IMCI counselling skills as well as the ‘5 As’ that you learned in this module 4. Support the mother and child’s self-management 5. Organize proactive follow-up 6. Involve “expert patients”, peer educators and support staff in your health facility 7. Link the mother and child to community-based resources and support 8. Use written information to document, monitor and remind. 9. Work as a clinical multidisciplinary team (i.e. nurses, social workers, counsellors, rehab therapists, doctors, pharmacists and health promoters) 10. Assure continuity of care

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Research has shown that when patients receive this kind of health care, they do better. Five of these principles are explained in detail below:

1 HOW DO YOU DEVELOP A TREATMENT PARTNERSHIP? What is a partnership? A partnership is an agreement between two or more people to work together in an agreed way toward an agreed goal. For good chronic care, the partnership is between the health worker (or clinical team) and the mother and child. In a partnership both parties share responsibility for the agreement. Each partner knows what role he or she plays in the partnership. Partners treat each other with respect. One partner does not have all the power.

2 HOW DO YOU FOCUS ON THE MOTHER’S OR CHILD’S CONCERNS AND PRIORITIES? Often we focus only on the obvious signs or symptoms of illness and may miss the real reason that the mother came to the clinic. It is important to find out why the mother has come: Is the child sick? Does he have a cough or diarrhoea or mouth sores or all three? Is the mother afraid or is she having some difficulty or a psychosocial need? If the child is sick you will need to Assess, Classify, Treat, Counsel and Follow-up this child for all the common childhood illnesses. In addition, ask about or observe any psychosocial needs and make sure that these are addressed.

3 HOW DO YOU USE COUNSELLING SKILLS YOU LEARNED IN PREVIOUS MODULES? The counselling skills that you learned in the INTRODUCTION (PART 2) and previous modules will help you develop a good relationship with the mother and will ensure that good long-term care is provided. For long-term care, the mother and the child (depending on age and maturity) will need to agree to the treatment plan. The health worker should assist the caretaker to overcome barriers to ensure long term care. There need to be arrangements for definite follow-up dates and scheduling and arranging for the mother to pick up medication such as cotrimoxazole prophylaxis or ART.

4 HOW WILL YOU SUPPORT THE MOTHER AND CHILD SELFMANAGEMENT? Whenever you think and speak about how an HIV-infected mother and her HIVinfected child should be managed, you need to realize that the mother should be left as much in charge of her and her child’s care as is practically possible and feasible. This self-help approach will give the mother a better sense of control and make her feel better about her situation. It has been shown that this approach makes people more successful in caring for themselves. Self-management recognizes that the mother takes responsibility for the daily treatment of the child’s condition.

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9 HOW WILL YOU WORK AS A CLINICAL TEAM? Providing good chronic care (and also good acute care) requires teamwork. To be able to deliver ART, this requires long-term commitment from a clinical team that includes a nurse, clinical officer, an ART aid (for education, psychosocial support and adherence counselling) and a medical officer or doctor. The team may work together differently depending on where they are located.

SELF-ASSESSMENT EXERCISE N – FOLLOW-UP CARE Complete this exercise about follow-up care for exposed and infected infants or children

1. Children are classified during their first visit with you, and you will continue to provide follow-up care according to this classification 2. Children under 24 months are started on ART. 3. All children born to HIV-positive women should be identified and provided HIV testing by PCR at 4–6 weeks of age. 4. Sami is 8 months old, and had a negative PCR test while he was still breastfeeding. He needs to be re-tested after breastfeeding has been stopped for 4 weeks. 5. Cotrimoxazole is an important element of follow-up care for HIV-exposed and infected children. 6. Jyothi was classified as HIV EXPOSED. You will provide follow-up and test for HIV as soon as possible.

TRUE TRUE

FALSE FALSE

TRUE

FALSE

TRUE TRUE TRUE

FALSE FALSE FALSE

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WHAT ARE THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN ON ART? Follow the steps outlined below whenever you follow-up a child on ART. This followup lets you assess if ART drugs are working (child will be well and growing well with few intercurrent infections), or causing any harm like side effects. You will read details in the following pages.

STEP 1: ASSESS AND CLASSIFY ➞ ASK: Does the child have any problems? Has the child received care at another health facility since the last visit? ➞ CHECK: for general danger signs ➞ ASSESS, CLASSIFY, TREAT: for main symptoms using IMCI ➞ CHECK: for ART severe side effects • Severe skin rash • Difficulty breathing and severe abdominal pain • Yellow eyes • Severe anaemia • Fever, vomiting, rash (only if on Abacavir)

STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE ➞ Assess and classify for malnutrition and anaemia Record child’s height and weight ➞ Assess adherence Ask about adherence: how often, if ever, does the child miss a dose? Record your assessment. ➞ Assess clinical stage Assess clinical stage. Compare with the child’s stage at previous visits. IF ANY OF FOLLOWING PRESENT, REFER NON-URGENTLY: n Not gaining weight for 3 months n Poor adherence n Stage worse than before n CD4 count lower than before n LDL higher than 3.5 mmol/L n TG higher than 5.6 mmol/L n Manage side effects n Send tests that are due

If present, REFER URGENTLY

➞ Monitor laboratory results Record results of tests that have been sent.

STEP 3: CONTINUE ART AND OTHER MEDICATIONS ➞ If child is stable: continue with ART and cotrimoxazole doses. Remember these will need to increase as the child grows ➞ If the child has developed lipodystrophya on Stavudine, substitute with Abacavir or Zidovudine.

STEP 4: COUNSEL THE MOTHER OR CAREGIVER Use every visit to educate and provide support to the mother or caregiver ➞ Key issues to discuss include: How the child is progressing, feeding, adherence, side effects and correct management, disclosure (to others and the child), support for the caregiver ➞ Remember to check that the mother and other family members are receiving the care that they need ➞ Set a follow-up visit: if well, follow-up in one month. If problems, follow-up as indicated.

a

  Lipodystrophy will be explained later in this section.

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RECORDING THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN ON ART

This follow-up form is in addition to the IMCI recording form. It provides critical instructions for the four steps of ART follow-up. The ART Follow-up Recording Form provides an easy tool to remind you of the steps. Record the information on the form. All HIV-infected children should have a clinic file where these forms, growth charts and laboratory results are filed. Height: ............ cm Temperature: ............... °C Date: ....................

ART FOLLOW UP

Name: .......................................................................................................... Age: ...................... Weight: ............ kg

STEP 1: ASSESS AND CLASSIFY ASK: does the child have any problems? If yes, record here: ............................................................................................................................................................................................................................................................................................................... ASK: has the child received care at another health facility since the last visit?  YES  NO Provide pre-referral treatment and REFER URGENTLY. RECORD ACTIONS TAKEN:

Check for general danger signs:  NOT ABLE TO DRINK OR BREASTFEED  VOMITS EVERYTHING Check for ART danger signs:  Severe skin rash  Yellow eyes Assess, classify, treat, and follow-up according to IMCI guidelines. Refer if necessary.  Other problems

 CONVULSIONS DURING THIS ILLNESS  LETHARGIC OR UNCONSCIOUS

 Difficulty breathing and severe abdominal pain  Fever, vomiting, rash (only if on Abacavir)

Check for main symptoms:  Cough or difficult breathing  Fever

 Diarrhoea  Ear problem

STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE Assess and classify for malnutrition:

RECORD ACTIONS TAKEN:

Weight: ............................... kg

Height: ............................... cm

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96 2  Lamivudine (3TC) RECORD ART DOSAGE: 3  Lopinavir/Ritonavir (LPV/r)  Nevirapine (NVP)  Abacavir (ABC)  Efavirenz (EFV)  Nevirapine (NVP)  Abacavir (ABC)  Other medications RECORD ISSUES DISCUSSED:  Lamivudine (3TC) OTHER:  Mebendazole

 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION  MODERATE ACUTE MALNUTRITION  NO MALNUTRITION Assess development:  Developing well  Some delay  Losing milestones Assess adherence:  Takes all doses  Frequently misses doses  Occasionally misses a dose  Not taking medication Assess clinical condition:  Progressed to higher stage Stage when ART initiated:  1  2  3  4  unknown

Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:

DATE: ...............................

 CD4 COUNT: ............................... cells/mm3

1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ✔ Not gaining weight for 3 months ✔ Loss of milestones ✔ Poor adherence despite adherence counselling ✔ Significant side effects despite appropriate management ✔ Higher clinical stage than before ✔ CD4 count significantly lower than before ✔ LDL higher than 3.5 mmol/L ✔ TGs higher than 5.6 mmol/L 2. MANAGE MILD SIDE EFFECTS 3. SEND TESTS THAT ARE DUE  CD4 count  LDL cholesterol and Triglycerides OTHERWISE, GO TO STEP 3

If on LPV/r:  LDL Cholesterol: ...............................

STEP 3: CONTINUE ART AND OTHER MEDICATIONS

1  Abacavir (ABC), or  zidovudine (AZT)

1. ...................................................................................................................................................................................... 2. ...................................................................................................................................................................................... 3. ......................................................................................................................................................................................

OVER 3 YEARS:

 Abacavir (ABC), or  zidovudine (AZT)

OTHER MEDICATIONS:  Cotrimoxazole

DATE OF NEXT VISIT: .......................................................................

STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include:  How is child progressing  Adherence  Support to caregiver  Disclosure (to others & child)  Side effects and correct management

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

Step 1. ASSESS AND CLASSIFY The first step when providing follow-up for a child on ART is to identify and manage any serious problems or intercurrent illnesses.

HOW DO YOU IDENTIFY PROBLEMS FOR THE CHILD ON ART? In order to identify problems so you can address them in follow-up care, you need to: ✔✔ Ask if the child has experienced any problems since the last visit It is important to know how the child has been since the last visit, and whether the mother has any concerns. Make sure that you address any concerns at some point during the visit. ✔✔ Find out if the child has received care at another health facility since the last visit It is also important to know whether the child has received care at another facility –intercurrent illnesses may suggest that ART is not working adequately, or that the child is experiencing side effects. You will need to find out details of any admissions to hospital including what treatment the child received, and whether any changes were made to the child’s ARV medication. ✔✔ Check for general danger signs (IMCI charts) ✔✔ Check for ART Danger Signs ✔✔ Check for main symptoms (IMCI charts)

WHAT ARE ART SEVERE SIGNS? As you learned about in the previous section, children on ART can develop side effects. A very small number of children can develop serious life-threatening side effects. Although these are very rare, they require immediate action, so it is important to always ask about them. ART SEVERE Signs are: ■■ Severe skin rash ■■ Difficulty breathing and severe abdominal pain ■■ Yellow eyes ■■ Two of the following: •• Fever •• Vomiting •• Rash in a child on abacavir If any of these danger signs are present, the child requires URGENT REFERRAL. It is not necessary to complete the ART follow-up assessment, but remember to provide relevant pre-referral treatment.

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Step 2. MONITOR ARV TREATMENT Most children who are put on ART will start to thrive. Their weight will increase, and they will experience fewer infections and other HIV-related problems. Many children will not experience any side effects. Where side effects are present, these are usually mild and will respond to simple measures. Each follow-up visit provides the opportunity to assess whether the child is adhering to ART and whether ART is working well. It is also important to find out whether the child is experiencing any side effects. The steps can be outlined as follows: 1. Assess growth and nutritional status 2. Assess development 3. Assess adherence 4. Assess side effects 5. Assess stage 6. Monitor laboratory results

1. ASSESS THE CHILD’S GROWTH AND NUTRITIONAL STATUS Children on ART should grow well and gain weight. It is important to monitor the child’s height and weight on a regular basis. Follow the guidelines in the well child module.

2. ASSESS DEVELOPMENT It is important to assess the child’s development. Children on ART should develop normally. Any child who is stalling in milestones should be referred. Review your well child module.

3. ASSESS ADHERENCE Adherence is key to successful ART. In order to be fully effective at least 95% of doses should be taken. Decide which of the four adherence categories the child fits into: 1. Takes all doses 2. Occasionally misses a dose (one or two doses missed per week) 3. Frequently misses doses (more than two doses missed per week) 4. Not taking medication TIPS TO ASSESS: It is not always easy to assess, as caregivers may not want to tell the health care worker that doses have been missed. Use a welcoming approach that acknowledges that chronic medications can be difficult to take. Ask about the last time the child missed a dose of ART and how often that occurs. This opens the door to explore possible reasons for missed doses, such as multiple caregivers, travel or simply forgetting. You may also be able to do a pill count to monitor adherence. Once you categorize the child by one of the above 4 categories, document this on your recording form. If poor adherence persists despite adherence counselling, consider referral. Remember to praise and encourage good adherence at all visits. Poor adherence = missing more than two doses per week

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4. ASSESS SIDE EFFECTS Ask about any side effects, and manage as described in previous section. You must refer if the child has any ART severe signs, or if side effects persist despite appropriate management.

5. ASSESS CLINICAL STAGE Assess the child’s stage at each visit. You can learn more about clinical staging in Annex 1. Any new clinical stage 3 or 4 illness may be an indication that the ART is no longer working well and the child must be referred.

6. MONITOR BLOOD RESULTS Several clinical and laboratory assessments should be performed to help health workers track a child’s progress on ART. These are in three stages: ■■ BASELINE: when children are identified as HIV-infected and enter into HIV care, but are not yet eligible for ART ■■ ART INITIATION: when children initiate ART ■■ WHILE ON ART: ongoing to monitor response to ART In resource-limited settings, the WHO recommends that clinical presentations should also be used to monitor children on ART, in addition to laboratory results. If laboratory monitoring is not available, for example CD4 counts or viral loads, it should not prevent children from receiving ART. Other regular blood tests might be included as per availability in the country. These may include viral load, and if a child is on lopinavir/ritonavir, LDL cholesterol and triglyceride tests. How will you monitor CD4 results? CD4 counts and percentage should be monitored routinely. These tests should be repeated after six months, after one year and thereafter annually. Normal CD4 counts are higher in young children than in adults and decrease with age to reach adult levels around the age of 6 years. The absolute CD4 count depends on age and so cannot be used in the same way as for adults to determine progression of HIV infection. What do the viral load (VL) test results mean? ✔✔ VL of less than 400 copies/mL: Suggests that ART is working well. The child should receive routine follow-up and support, and the VL should be repeated after a year. ✔✔ VL of between 400 and 1000 copies/mL: suggests that improvements are required. Step-up adherence counselling, and repeat the test after six months. ✔✔ VL of above 1000 copies/mL : suggests that the ARVs are not working adequately. This may be because of poor adherence, but may also be because resistance is developing. Adherence counselling should be stepped-up, and the VL should be checked after three months. If the VL is still above 1000 copies/ mL the child should be referred to the next level of care.

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HOW WILL YOU DETERMINE IF THERE IS TREATMENT FAILURE? The detection of new or recurrent clinical events classified within the WHO clinical staging (Annex 1) may also reflect progression of disease when a child is on ART. Treatment failure should be considered when either new or recurrent clinical stage 3 or 4 events develop in a child adherent to therapy. Using WHO paediatric clinical staging of events to guide decision-making on switching to second-line therapy for treatment failure: New or recurrent event develops after at least 24 weeks on ARTa,b No new events or Stage 1 events Stage 2 events Management optionsc,d Do not switch to new regimen Maintain regular follow-up Treat and manage staging event Do not switch to new regimen Assess and offer adherence support Assess nutritional status and offer support Schedule earlier visit for clinical review and CD4 or viral load measurement where available Stage 3 events Treat and manage staging event and monitor patient Check if on treatment 24 weeks or more Assess and offer adherence support Assess nutritional status and offer support Check CD4f or viral load where available Institute early follow-up Stage 4 events Treat and manage staging event Check if on treatment 24 weeks or more Assess and offer adherence support Assess nutritional status and offer support Check CD4f or viral load where available Consider switching regimen or refer to higher levels A clinical event refers to a new or recurrent condition as classified in the WHO clinical staging at the time of evaluating the infant or child on ART. Annexes C and D provides more details about clinical events. b It needs to be ensured that the child has had at least 24 weeks of treatment and that adherence to therapy has been assessed and considered adequate before considering switching to a second-line regimen. c Differentiating OIs from IRIS is important. d In considering change of treatment because of growth failure, it should be ensured that the child has adequate nutrition and that any intercurrent infections have been treated and resolved. e Pulmonary or lymph node TB, which are clinical stage 3 conditions, may not be an indication of treatment failure, and thus may not require consideration of second-line therapy. The response to TB therapy should be used to evaluate the need for switching therapy. f CD4 measurement is best performed once the acute phase of the presenting illness has resolved. a

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WHEN SHOULD A CHILD BE REFERRED? However, some children will not thrive. This may be due to a number of reasons, including: •• Poor adherence – if the child is not taking the ARVs they cannot be expected to have any effect. It may be helpful to enlist help from a treatment supporter. If the problem persists, then refer the child to the doctor. •• Untreated opportunistic infections e.g. TB. •• Immune reconstitution – as the child’s immune function improves, symptoms and signs can develop or worsen as the body begins to fight pre-existing unrecognized or partially treated infections. •• Inadequate nutrition •• Resistance – the HI virus may have developed resistance to the ARVs that the child is taking. The only option is to change the child to another (second-line) regimen but this can only be done under expert supervision for which the child should be referred – and only once adherence problems are excluded or attended to.

WHEN SHOULD A CHILD BE REFERRED? The following criteria can be used in deciding whether to refer a child. •• Not gaining weight for 3 months •• Loss of development milestones •• Poor adherence despite adherence counselling •• Significant side effects despite appropriate management •• Higher clinical stage than before •• CD4 count significantly lower than before •• Viral load > 400 copies despite adherence counselling

Step 3. CONTINUE ART AND OTHER MEDICATIONS If the child is stable, then ARVs should be prescribed and dispensed. Remember to check that the child is receiving the correct dose at each visit.

IF THE CHILD IS STABLE, WHAT ACTIONS SHOULD BE TAKEN ON ART? Continue the child on the same regimen that they are currently on. This means that most children will be on a first-line regimen. In general, children should only receive first-line regimens at primary level. Decisions to change the regime should only be taken by experienced clinicians who are usually based at treatment centres or hospitals. Some children on second-line regimens may be referred back to primary level for ongoing care. However, caring for children on these regimens is not covered in IMCI.

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n  Substituting Abacavir for Stavudine: Nurses working at primary level should only prescribe first-line regimens, and should not substitute or change any ARVs without consultation with an expert. The one exception is as follows. Stavudine is being phased out as it has a number of side effects, including peripheral neuropathy and lipodystrophy. •• Peripheral neuropathy causes tingling sensations in the hands and feet. •• Lipodystrophy is used to describe the development of an abnormal distribution of fat. It usually only develops when the child has been on Stavudine for some time. The child’s arms, legs, buttocks and cheeks become THIN, while the breasts, tummy, and back of neck become FAT. Lipodystrophy can be very unsightly and may not resolve when treatment is stopped. It is therefore important to identify it early and to switch to Abacavir in these children. However children who were previously started on Stavudine, and are doing well on Stavudine should remain on it.

Step 4. COUNSEL Counselling is an ongoing process. Key issues that need to be discussed include: ✔✔ How the child is progressing ✔✔ Adherence ✔✔ Side effects and correct management ✔✔ Disclosure (to others and to the child) ✔✔ Support for the caregiver ✔✔ Access to local or government child and family support programmes Counselling children for disclosure of their HIV status, to discuss antiretroviral therapy (ART), and to support adherence to ART requires special effort and skills in communication.

WHO IS RESPONSIBLE FOR DISCLOSING HIV STATUS TO A CHILD? It remains the role of the caregiver to disclose HIV status to a child. Caregivers should be counselled by a knowledgeable health care worker regarding disclosure. Health care workers play an important role in helping to meet multiple client needs, including gaining access to social support pre- and post-disclosure and improving mental health. Many health care workers express anxiety around disclosing HIV-status to children. Several key principles and recommendations can help guide health care workers. HIV disclosure should be viewed in a process-oriented approach. Disclosure is not an “event”, instead it is an ongoing conversation with the child that gradually involves more and more detail about his or her status and need for medical treatments.

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WHY DISCLOSE TO A CHILD? Increased knowledge and understanding about HIV helps to: •• Facilitate children’s adjustment within the family and broader society •• Boost self-esteem •• Increase adherence to treatment •• Decrease risky behaviours such as unprotected sex and multiple partners •• Build stronger family ties to tackle more challenging issues in the future.

HOW DO YOU DISCLOSE HIV STATUS TO A CHILD? Disclosure should be individualized to include the child’s level of understanding, developmental stage, clinical status and social circumstances. As mentioned, it is a process which can begin with partial disclosure where the child is presented with information that avoids specific mention of HIV and AIDS. This is then followed over time with full disclosure where detailed HIV and AIDS terminology is used. The “Soldier Story” is one of many strategies commonly used to discuss concepts about HIV, the body’s defences and the role of medication in a developmentally appropriate way.

WHEN SHOULD HIV STATUS BE DISCLOSED TO A CHILD? Several studies and developmental specialists advocate the need to consider each child individually, and as such, a definite age for disclosure should not be outlined. A general rule is that if a child is asking questions about their need to go to clinic, take treatments or demonstrates oppositional behaviour related to treatment, this is a sign they want more information and disclosure should be furthered. Caregivers may oppose disclosure out of a natural response to “protect” the child from negative information. This is an opportunity to explore further some of the negative outcomes that have been observed should one fail timely disclosure: ✔✔ Impaired understanding of HIV increases ignorance of HIV ✔✔ Less participation in treatment ✔✔ Increased psychological and behavioural problems ✔✔ Decreased desire to access support services ✔✔ More complicated bereavement, difficulty dealing emotionally with illness, dying and death ✔✔ Continuation of risky behaviours associated with adolescents ✔✔ Children can think about inaccurate and hurtful fantasies about their illness if not properly informed ✔✔ Silence about their illness isolates the child

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✔✔ Increases the risk of accidental disclosure, where children find out by overhearing conversations with other individuals. Self-discovery can undermine the child’s sense of trust in adults Adolescents, however, should know their HIV status. They should be fully informed to appreciate consequences for many aspects of their health, including sexual behaviour. They also require the information to make appropriate decisions about their treatment plan.

SELF-ASSESSMENT EXERCISE O – FOLLOW-UP The following children have come in for follow-up visits. They are all on ART. Using the 4 steps, describe what you will do for each child.

1. Mandla is a 4 year old boy who has been on ART for 3 years. He is currently on Stavudine, Lamivudine and Liponavir/ritonavir. His mother has noticed that his face and arms are looking very thin, but that his body is looking fatter than before.

2. Ross is a 9 month old boy has been on ART for two weeks. His mother complains that he has not wanted to eat and has had diarrhoea. On examination he has sunken eyes, but no other signs of dehydration.

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n  What follow-up care will you provide to Peter? You have classified Peter as HIV EXPOSED. He has been instructed to follow up monthly for care. When he returns to the clinic, what follow-up care will you provide during visits? ✔✔ Provide routine child health care: Vitamin A, immunization, growth monitoring, and feeding assessment and counselling ✔✔ Continue cotrimoxazole prophylaxis ✔✔ Assess, classify, and treat any new problems ✔✔ Ask about the mother’s health. Provide HIV counselling and testing and referral if necessary

n  When will you retest Peter to confirm his HIV status? Lungile decides to stop breastfeeding after Peter is 9 months old. She is out of the house working during the days and is not able to breastfeed any more. Peter and Lungile return to the clinic 7 weeks after he stopped breastfeeding. You will now re-test and classify Peter because he has not breastfed for at least 6 weeks.

n  How will you retest Peter? Peter is now almost 11 months old. He will require a virological test to confirm his status. First, it is important than you provide counselling to Lungile about re-testing Peter and confirming his status. You also discuss disclosure with her. Then, you draw specimen for a PCR test. Lungile needs to return for the results in 2 weeks. You schedule Peter for a follow-up visit to return for his test results.

n  What happens when Peter and Lungile return for the results? Lungile returns about two and a half weeks later for Peter’s PCR results. Peter’s results are positive. You counsel Lungile on this news. She is very upset and says she feels very guilty that she made Peter sick. You counsel her about this reaction, emphasizing that treatment will be very important for Peter and can keep him healthy. You also discuss how Lungile will disclose Peter’s status.

n  How will you re-classify Peter with these test results? You first classified Peter as HIV EXPOSED because you didn’t have a test result. Now that a virological test is positive, and Peter has not breastfed in over 6 weeks, you will reclassify as CONFIRMED HIV INFECTION.

n  With Peter’s new classification, how will you provide follow-up care? You have learned that all children under 5 years who are classified as CONFIRMED HIV INFECTION should receive ART.

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n  How will you provide follow-up care for Peter? Peter has come for his first monthly follow-up visit. You will complete the following seven steps.

n  STEP 1: ASSESS AND CLASSIFY 1. Conduct a full IMCI assessment: check for general danger signs and main symptoms 2. Ask Lungile if Peter has had any new problems since the last visit. Ask if he has received care from anywhere else since the last visit. 3. Check for ART danger signs 4. Screen for TB Lungile says there are no new problems. Peter does not have any general danger signs. You check for main symptoms, and Peter has none. You check him for severe skin rash, difficult breathing, yellow eyes, fever, and vomiting. He has none.

n  STEP 2: MONITOR ART Peter has gained a little weight to 7.4 kg. You talk to Lungile about adherence, and she says that she has given all of the pills. She has brought the containers to show you. You praise her and encourage and she continue such good adherence. You check for side effects and clinical staging, and there is no difference. You will monitor the CD4 count and viral load tests that have come back. His CD4 count is 600 cells/mm3.

n  STEP 3: PROVIDE ART So far, Peter is stable. He will remain on this ART. You will continue to monitor him.

n  STEP 4: COUNSEL PETER’S MOTHER Counselling is an ongoing process. Key issues that need to be discussed include: ✔✔ How the child is progressing ✔✔ Adherence – especially in light of his detected viral load even though it is not very high. ✔✔ Side effects and correct management ✔✔ Disclosure (to others and to the child) ✔✔ Support for the caregiver, including local support services, government schemes, etc.

n  FINALLY, ARRANGE NEXT VISIT You are relieved to see Peter responding well to treatment. You praise his mother for good drug adherence. You counsel when to come for the next visit.

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SELF-ASSESSMENT EXERCISE P – FOLLOW-UP You will return to the cases of Akshay and Nancy. Read the cases below and complete the ART follow-up recording forms on the following two pages.

CASE 1: NANCY Nancy is now 12 months old. She has been doing very well. After six months of treatment her CD4 count had risen to 1,200 cells/mm3, and her VL was 340 copies/ mm3. She has come for a routine follow-up visit. She was well until the previous day, when she started vomiting. She has been able to drink fluids, but vomits after every meal. Her mother noticed that her eyes are yellow. How will you provide follow-up care today?

CASE 2: AKSHAY Akshay has come for a follow-up visit. He has been on ART for three months and has been doing well – he has been completely well in the last month and is developing well. His weight is 12.5 kg, his height is 86 cm. He has no General Danger Signs, ART Danger Signs or main symptoms. He is screened for TB, but does not require further assessment for TB. His mother is proud that he never misses a dose of ARVs. She tells the nurse that she has recently discovered that she is pregnant again. Akshay has no symptoms or signs of HIV infection. He does not require any routine treatments. Complete the ART follow-up form.

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ART FOLLOW UP

Name: .......................................................................................................... Age: ...................... Weight: ............ kg

Height: ............ cm

Temperature: ............... °C

Date: ....................

STEP 1: ASSESS AND CLASSIFY ASK: does the child have any problems? If yes, record here: ............................................................................................................................................................................................................................................................................................................... ASK: has the child received care at another health facility since the last visit?  YES  NO Provide pre-referral treatment and REFER URGENTLY. RECORD ACTIONS TAKEN:

Check for general danger signs:  NOT ABLE TO DRINK OR BREASTFEED  VOMITS EVERYTHING Check for ART danger signs:  Severe skin rash  Yellow eyes Assess, classify, treat, and follow-up according to IMCI guidelines. Refer if necessary.  Other problems

 CONVULSIONS DURING THIS ILLNESS  LETHARGIC OR UNCONSCIOUS

 Difficulty breathing and severe abdominal pain  Fever, vomiting, rash (only if on Abacavir)

Check for main symptoms:  Cough or difficult breathing  Fever

 Diarrhoea  Ear problem

STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE Assess and classify for malnutrition:

RECORD ACTIONS TAKEN:

Weight: ............................... kg

Height: ............................... cm

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

108 2  Lamivudine (3TC) RECORD ART DOSAGE: 3  Lopinavir/Ritonavir (LPV/r)  Nevirapine (NVP)  Abacavir (ABC)  Efavirenz (EFV)  Nevirapine (NVP)  Abacavir (ABC)  Other medications RECORD ISSUES DISCUSSED:  Lamivudine (3TC) OTHER:  Mebendazole

 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION  MODERATE ACUTE MALNUTRITION  NO MALNUTRITION Assess development:  Developing well  Some delay  Losing milestones Assess adherence:  Takes all doses  Frequently misses doses  Occasionally misses a dose  Not taking medication Assess clinical condition:  Progressed to higher stage Stage when ART initiated:  1  2  3  4  unknown

Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:

DATE: ...............................

 CD4 COUNT: ............................... cells/mm3

1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ✔ Not gaining weight for 3 months ✔ Loss of milestones ✔ Poor adherence despite adherence counselling ✔ Significant side effects despite appropriate management ✔ Higher clinical stage than before ✔ CD4 count significantly lower than before ✔ LDL higher than 3.5 mmol/L ✔ TGs higher than 5.6 mmol/L 2. MANAGE MILD SIDE EFFECTS 3. SEND TESTS THAT ARE DUE  CD4 count  LDL cholesterol and Triglycerides OTHERWISE, GO TO STEP 3

If on LPV/r:  LDL Cholesterol: ...............................

STEP 3: CONTINUE ART AND OTHER MEDICATIONS

1  Abacavir (ABC), or  zidovudine (AZT)

1. ...................................................................................................................................................................................... 2. ...................................................................................................................................................................................... 3. ......................................................................................................................................................................................

OVER 3 YEARS:

 Abacavir (ABC), or  zidovudine (AZT)

OTHER MEDICATIONS:  Cotrimoxazole

DATE OF NEXT VISIT: .......................................................................

STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include:  How is child progressing  Adherence  Support to caregiver  Disclosure (to others & child)  Side effects and correct management

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SUMMARY: WHAT DID YOU LEARN IN THIS SECTION? 1. Follow-up for young infants exposed to HIV is critical for preventing mother-to-child transmission. Mothers should be told about the important need for follow-up during antenatal care. Exposed infants should be offered PCR virological testing at 4-6 weeks of age.

2. Regular follow-up care for exposed and infected children (who are not receiving ART) includes: •• Testing and counselling for HIV, both for the child and mother •• Routine care like immunizations, feeding assessments and counselling, Vitamin A •• Cotrimoxazole prophylaxis, to reduce the risk of illness by bacterial infections 3. Infants and children need to be reclassified based on new test results. Follow-up care should change according to the new classifications.

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8.10 REVIEW QUESTIONS AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING HIV CARE FOR SICK CHILDREN AND INFANTS? Now that you have finished the module, answer the same questions you tested before you started studying. This will help demonstrate what you have learned! 1. A child is under 16 months old. What HIV test should be used for this child, and why? a. Serological tests, because it can detect if virus antibodies are present b. Virological (PCR) tests, because it can actually detect the virus c. Serological tests now, but after the child is 18 months, confirm with a PCR 2. What follow-up treatments are critical for HIV-exposed and infected infants and children? a. Cotrimoxazole prophylaxis b. Paracetamol c. Amoxicillin 3. What is the overall risk of a mother transmitting HIV to her child during pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used in prevention of mother-to-child transmission? a. 70% b. 10% c. 35% 4. A 2 month breastfeeding baby has a positive virological (PCR) test. Is the child HIV infected? a. Yes, HIV-infected b. No, HIV negative c. Possibly, he is HIV exposed 5. When is an HIV-positive child or infant eligible for ART? a. If a child has stage 2 HIV infection b. Any child under five with confirmed HIV infection c. Children over 5 years old with a count less than 350 cells per mm3 6. If a mother is HIV-positive, but the child is not confirmed with HIV infection, what is the recommended feeding practice? a. Exclusive breastfeeding as long as the child wants b. Breastfeeding and also formula, in order to provide additional nutrition c. Exclusive breastfeeding until 12 months Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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8.11 ANSWER KEY REVIEW QUESTIONS QUESTION 1 2 3 4 5 6 ANSWER B A C A B C Did you miss the question? Return to this section to read and practice: HIV TESTING PROPHYLAXIS & OTHER PREVENTIVE MEASURES BASIC INFORMATION ABOUT HIV HIV TESTING ANTIRETROVIRAL TREATMENT COUNSEL HIV-POSITIVE MOTHERS ABOUT FEEDING

EXERCISE A – HIV TERMS a. Immune system: The immune system protects the body against infections. b. CD4: Lymphocytes are one of the types of white blood cell in the body and some of these have a marker on their surface called CD4, and so are called CD4 lymphocytes. These CD4 lymphocytes are responsible for warning your immune system that there are germs trying to invade the body. c. Opportunistic infection: An opportunistic infection is an infection which is not able to attack a healthy body. When the body’s immune system is weak, the infection is able to infect the body. Examples of opportunistic infections include thrush and herpes zoster.

EXERCISE B – HIV TESTING 11. An HIV virological (PCR) test detects the actual HIV virus or virus products in the blood. An HIV serological test detects the presence of antibodies made in response to the presence of HIV – however these antibodies can be from the mother and do not disappear until the child is 18 months. 12. Virological (PCR) 13. Confirmed HIV infection 14. EXPOSED, not confirmed infection, as antibodies present can be from mother and from breastfeeding. To confirm, child needs positive virological test at least 6 weeks after stopping breastfeeding. 15. Confirmed HIV infection 16. Confirmed HIV negative 17. EXPOSED, breastfeeding should be done for 6 weeks and serological test completed again 18. EXPOSED, because the child can still be infected through breastfeeding. Virological (PCR) tests should be done 6 weeks after breastfeeding has stopped to confirm that the child is HIV-negative. 19. YES, confirmed HIV negative 20. Yes, confirmed HIV negative

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EXERCISE C – ASSESS & CLASSIFY SICK CHILD a. TRUE: virological test is positive b. FALSE: he should be classified HIV EXPOSED. Status must be confirmed after breastfeeding has stopped for 6 weeks. c. FALSE: she should be classified HIV EXPOSED. The status must be confirmed with a virological test because the child is under 18 months old. The result can only be confirmed 6 weeks after stopping breastfeeding. d. TRUE: positive virological test in a child, and has not been breastfeeding for 4 months, so is out of 6 week ‘window’. e. TRUE: status must be confirmed after breastfeeding has stopped for 6 weeks. f. FALSE: she should be classified as HIV EXPOSED. The result can only be confirmed 6 weeks after stopping breastfeeding. g. TRUE

EXERCISE D – CLASSIFY YOUNG INFANT 1. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped, and with virological test 2. HIV INFECTION UNLIKELY 3. CONFIRMED HIV INFECTION 4. HIV INFECTION UNLIKELY 5. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped, and with virological test

EXERCISE E – COTRIMOXAZOLE The following children should receive cotrimoxazole prophylaxis: 1. All young infants classified as CONFIRMED HIV INFECTION. Should start immediately. • Children (under 12 months of age) classified as CONFIRMED HIV INFECTION • Children (between 12 months and under 5 years of age) classified as CONFIRMED HIV INFECTION when they are clinically staged at 2, 3, or 4. Their CD4% does not matter. Should start immediately. • Children (between 12 months and under 5 years of age) classified as CONFIRMED HIV INFECTION who have a CD4% less than 25%. Their clinical stage does not matter. Should start immediately. • All children classified as HIV EXPOSED. Should start immediately. • All young infants who are HIV EXPOSED. Should start from 4-6 weeks of age 2. All HIV-infected or -exposed infants should begin from 4-6 weeks of age. Otherwise, children and young infants classified as HIV EXPOSED should start as soon as possible. All HIV-infected children under 12 months should start immediately. All HIV-infected children aged 12 months up to 5 years with WHO stage 2-3-4 or CD4% under 25%. If children are HIV-infected and over 5 years of age, they follow adult guidelines for cotrimoxazole. 3. Severe toxicity can include Steven Johnson syndrome or severe pallor

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4. Answers are below: a. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength b. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets single strength c. NO d. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength e. NO f. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets g. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets h. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength; requires referral today for SEVERE PNEUMONIA i. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets j. NO 5. Cotrimoxazole prophylaxis should be stopped if: (a) children classified as EXPOSED are confirmed HIV negative, and the child is not breastfeeding and has not for at least 6 weeks, or (b) child develops severe drug reactions.

EXERCISE F – INTEGRATED TREATMENT 1. How would you treat a child with the classifications: HIV EXPOSED and PNEUMONIA? • • • • • • Oral antibiotic for 5 days Provide HIV test appropriate for age and breastfeeding status If mother is HIV-positive, give nevirapine if indicated Initiate cotrimoxazole Provide Vitamin A and immunizations as required Follow-up in 3 days for PNEUMONIA

2. When should you follow-up a child with the classifications: PERSISTENT DIARRHOEA and HIV EXPOSED? • Follow-up in 5 days on persistent diarrhoea, see if zinc and multivitamin treatment is lessening diarrhoea and no other issues have developed • Repeat HIV testing after breastfeeding has stopped for 6 weeks 3. How would you treat a child with the classifications: PNEUMONIA (wheeze present) and HIV EXPOSED? • • • • • • • • Oral antibiotic for 5 days Give inhaled bronchodilator for 5 days Advise on throat remedy Provide HIV test appropriate for age and breastfeeding status If mother is HIV-positive, give nevirapine if indicated Initiate cotrimoxazole Provide Vitamin A and immunizations as required Follow-up in 3 days for PNEUMONIA

4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA, CONFIRMED HIV INFECTION, and exposure to TB? • Zinc and multivitamins for 2 weeks • Provide Vitamin A and immunizations as required • Initiate cotrimoxazole prophylaxis

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• Initiate ART if fulfills 5 steps for initiating in your clinic • Initiate izoniazid preventive therapy (IPT) for 6 months • Follow-up in 5 days for PERSISTENT DIARRHOEA 5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC EAR INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and CONFIRMED HIV INFECTION? • • • • Test for low blood sugar, then treat and prevent Give first dose of antibiotic Give ciprofloxacin REFER URGENTLY (COMPLICATED SEVERE ACUTE MALNUTRITION is a severe classification)

EXERCISE G – INFANT FEEDING 1. TRUE/FALSE a. F – children need more feeds and fluids during illness b. T c. F – the child should be exclusively breastfed, especially as there is no risk of HIV infection from the mother d. T – the mother should breastfeed exclusively until 6 months of age, and then begin adding safe complementary foods at 6 months in addition e. T f. T g. F – according to studies, the risk of infection during breastfeeding is 15% h. F – it is recommended for all women, regardless of HIV status, to breastfeed exclusively at least for the first 6 months i. T 2. Traci’s mother should begin adding family foods at 6 months of age. Foods should include porridge and a mix of locally available foods, like eggs, mashed vegetables, beans, and meat livers. If the child is not growing well, oil, margarine, or peanut paste should be mixed with porridge. Traci should receive 2 meals a day from 6-8 months, and then increase to 5 meals a day.

EXERCISE H – CONFIRMING HIV INFECTION 1. Antiretrovirals are best used in combination to act against HIV and prevent rapid drug resistance 2. Answers are below: a. Yes b. Yes c. Possibly; Send a PCR test d. Yes e. Possibly; Repeat the child’s HIV test 6 weeks after breastfeeding stops. The test will depend on the child’s age when the test is done. f. Possibly; Send a confirmatory test as per national procedures g. No h. Possibly; Repeat the child’s HIV test after 5 weeks i.e. 6 weeks after breastfeeding stopped. Use a serological test because the child is older than 18 months.

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EXERCISE I – ART ELIGIBILITY AGE f. 4 years g. 6 months h. 9 months i. 3 years j. 9 years DETAILS Child is CONFIRMED HIV INFECTION but appears healthy Child is HIV exposed, and mother is very sick Child had a positive serological test Child had a positive serological test Child is CONFIRMED HIV INFECTION ANSWER YES NO; need to confirm infection NO; need to confirm infection YES HANDLED BY ADULT GUIDELINES

EXERCISE J – DOSING 1. 12 month old 10 kg child a. ABC: 2 tablets (20 mg), twice a day b. 3TC: 2 tablets (30 mg), twice a day c. EFV: 1 tablet (200 mg) in evening 2. 4 year old 20 kg child a. ABC: 3 tablets (60 mg), twice a day b. 3TC: 3 tablets (30 mg), twice a day c. EFV: 1.5 tablet (200 mg) in evening 3. 4 month old 5 kg child a. ABC: 3ml, twice a day b. 3TC: 1 tablet (30 mg), twice a day c. LPV/r: 1ml, twice a day 4. 13 month old 12 kg child a. ABC: 2 tablets (20 mg), twice a day b. 3TC: 2 tablets (30 mg), twice a day c. EFV: 1 tablet (200 mg) in evening

EXERCISE K – ART INITIATION 1. LEATILE: Start ART at clinic 2. OFENTSE: Non-urgent referral for ART because of her TB 3. LUKE: Start ART 4. LENTSWE: Urgent referral; his PNEUMONIA is not improving 5. LEAH: Non-urgent referral for ART because of SEVERE UNCOMPLICATED ACUTE MALNUTRITION 6. OWETHU: URGENT REFERRAL

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EXERCISE L – SIDE EFFECTS Severe abdominal pain *potentially serious, because could be pancreatitis Tingling or numbness in feet or hands * this is neuropathy, should seek advice soon Yellow eyes * needs urgent referral as it may indicate liver toxicity Skin rash * It could be a severe reaction to the drug and may require urgent referral. Nausea, vomiting, diarrhoea Common -patients will need to be prepared to cope with these side effects Changes in fat distribution Important side effect occurring with long term treatment Fever, vomiting, skin rash * may indicate hypersensitivity Difficulty sleeping and nightmares Stavudine Stavudine Efavirenz Abacavir Stavudine, Efavirenz Lopinavir/ritonavir Lamivudine Stavudine Lopinavir/ritonavir Abacavir Efavirenz

EXERCISE M – BASELINE ASSESSMENT CASE 1: AKSHAY 1. Akshay is eligible to receive ART. Criteria considered: • He has confirmed HIV infection and is under 5 years of age. • His mother has disclosed her HIV status to her mother and is willing to give ART to Akshay. 2. Recording form follows. CASE 2: NANCY 1. Nancy is eligible to receive ART. Criteria considered: • She has confirmed HIV infection and is under 5 years of age. • Her mother is willing to give her treatment. She has not disclosed to anyone at home, but is a regular member of a support group. 2. Recording form follows.

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 STARTING ART: FOLLOW THE FIVE STEPS Date: .................... TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2 RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

Akshay Name: .............................................................................

30 mo Age: ......................

9.1 kg Weight: ............

36.7 °C Temperature: ...............

ASSESS

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

•

Child 18 months and over:

✔YES  NO   Virological test positive Ensure child has not breastfed for at least 6 weeks ✔Serological test positive  ✔Second serological test positive  Ensure child has not breastfed for at least 6 weeks • • • • If any present: REFER NON-URGENTLY If none present: GO TO STEP 4 If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO ✔ YES: caregiver available and willing to give medication  ✔ YES: caregiver has disclosed to another adult, or is part of a support group  ✔YES   NO

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY ✘ NO • Weight under 3 kg  YES  ✘ NO • Child has TB  YES  • • Send tests that are required

− TST negative − Viral load sent − ARVs given − Cotrimoxazole given − Vitamin A 200 00IU − Mebendazole 500 mg stat − Mother counselled re: adherence and side effects − Follow-up in one week to check progress

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

117 REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5

250 kg, 145 cm •

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

8

250

3

12

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. .............................................................................................................

ABC (20 mg/ml) 6ml AM, 6ml PM 3TC (10mg/ml) 6ml AM, 6ml PM EFV (200mg tablet) 1 in PM

RECORD OTHER TREATMENTS HERE:

Treat thrush, ferrous gluconate 2.5ml tds • • Follow-up after one week If child is stable, follow-up regularly NEXT FOLLOW-UP DATE: ..................................................

PROVIDE FOLLOW-UP CARE

 STARTING ART: FOLLOW THE FIVE STEPS Date: .................... TREAT • • Send any test required, including confirmation test If HIV infection confirmed, and child is in stable condition, GO TO STEP 2 RECORD ACTIONS AND TREATMENTS HERE: ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE

Nancy Name: .............................................................................

6 mo Age: ......................

3.3 kg Weight: ............

36.5 °C Temperature: ...............

ASSESS

STEP 1: CONFIRM HIV INFECTION • Child under 18 months:

•

Child 18 months and over:

✔YES  NO  ✔Virological test positive  Ensure child has not breastfed for at least 6 weeks  Serological test positive  Second serological test positive Ensure child has not breastfed for at least 6 weeks • • • • If any present: REFER NON-URGENTLY If none present: GO TO STEP 4 If NO: classify as CONFIRMED HIV INFECTION NOT ON ART If none present: GO TO STEP 3

STEP 2: CAREGIVER ABLE TO GIVE ART  YES  NO ✔ YES: caregiver available and willing to give medication  ✔ YES: caregiver has disclosed to another adult, or is part of a support group  ✔YES   NO

− ARVs given − Cotrimoxazole given − 10 week immunization given − Mother counselled re: adherence and side effects − Follow-up in one week to check progress

STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FIRST LEVEL FACILITY ✘ NO • Weight under 3 kg  YES  ✘ NO • Child has TB  YES  • • Send tests that are required

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

118 REFER IF: — COMPLICATED SEVERE ACUTE MALNUTRITION — SEVERE OR SOME ANAEMIA If none present: GO TO STEP 5

6 kg, 61 cm •

STEP 4: ASSESS AND RECORD BASELINE INFORMATION • Record weight and height,  SEVERE ACUTE MALNUTRITION assess & classify malnutrition  MODERATE ACUTE MALNUTRITION  NO ACUTE MALNUTRITION • Pallor is present  YES  NO • Child has feeding problem  YES  NO • Hb: ............................. g/dl Viral load: .................................................... • CD4 count: ......................... cells/mm3 CD4 percentage ......................... % • WHO clinical stage today: ................................................................................................

11

800

31

550 copies/mm 30

STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS • Child is under 3 years old: Initiate preferred first-line regimen • Child is 3 years or older: Initiate preferred first-line regimen • Cotrimoxazole • Give other routine treatments, including Vitamin A and immunizations

RECORD ARVS & DOSAGES HERE: 1. ............................................................................................................. 2. ............................................................................................................. 3. .............................................................................................................

ABC (20mg/ml): 3ml AM, 3 ml PM 3TC: (10mg/ml): 3ml AM, 3 ml PM LPV/r: (80/20mg): 1 ml AM, 1 ml PM

RECORD OTHER TREATMENTS HERE:

Cotrimoxazole 5ml daily

PROVIDE FOLLOW-UP CARE

• •

Follow-up after one week If child is stable, follow-up regularly

NEXT FOLLOW-UP DATE: ..................................................

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

EXERCISE N – FOLLOW-UP CARE 1. False – children are reclassified according to test results, and follow-up care must follow these new classifications 2. False – all children under 5 years should begin ART. 3. True 4. False – he should be re-tested after breastfeeding has been stopped for 6 weeks 5. True 6. True

EXERCISE O – ART AND DOSING 1. Mandla a. Check his VL. b. If VL is less than 400 copies/mL, stop Stavudine and replace it with Abacavir. c. If VL is greater than 400 copies/mL, refer non-urgently. 1. Ross a. Explain to his mother that the diarrhoea may be due to the ARVs, but that it is likely to get better in a few weeks. b. Stress the importance of adherence. c. Advise mother to continue feeding and give SSS after each loose stool. d. Follow-up in 5 days.

EXERCISE P – FOLLOW-UP 1. NANCY: Nancy’s ARVs must be stopped immediately. She must be referred urgently. 2. AKSHAY: see form below FORM DATA: • Akshay • 33 months • 86 cm • 12.5 kg • FOLLOW-UP VISIT • STEP 1: NO problems, NO other visits. Nothing further to check. • STEP 2: Check NO MALNUTRITION, DEVELOPING WELL, TAKES ALL DOSES • BLOOD • STEP 3: 1. ABC (20 mg/ml) 6 ml AM, 6 ml PM 2. 3TC (10 mg/ml) 6 ml AM, 6 ml PM 3. EFV (200 mg tablet) 1 in PM

• STEP 4: Discuss upcoming pregnancy, PMTCT, nutrition, family planning, ART adherence…

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ANNEXES CONTENTS Annex 1 Clinical staging Annex 2 Treatment dosing tables 121 123

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ANNEX 1 – CLINICAL STAGING WHAT IS CLINICAL STAGING? Once a child is confirmed to be HIV infected it is important to perform a task called CLINICAL STAGING when you ASSESS the infant or child. If the child does not have confirmed HIV infection but you suspect they have severe HIV disease, they will need referral to assess whether ART is indicated. Please turn to the WHO Clinical Staging chart on the next page to read more about severe HIV disease. Clinical staging will help you estimate the degree of immune deficiency the infant or child has. Staging uses a combination of signs and symptoms to determine the degree of immune deficiency. When you STAGE an HIV-infected infant or child you will need to LOOK, LISTEN, FEEL, and also conduct laboratory tests if possible. You should be aware of some of the staging criteria so that you can identify when a child is in need of referral. According to the WHO REVISED PAEDIATRIC CLINICAL STAGING developed in 2005, a child with confirmed HIV infection can fall into one of four stages: ■■ STAGES 1 and 2 clinical statuses indicate that the immune system is not yet seriously affected. Most conditions can be managed at first level facility. ■■ STAGES 3 and 4 indicate advanced immune deficiency. Most conditions need URGENT REFERRAL.

HOW IS CLINICAL STAGING USED TO INDICATE ART? Review the clinical stages on the following page. Carefully review the final row, which discusses when ART is indicated for a child ■■ All children under 24 months of age with HIV INFECTION should be started on ART irrespective of staging. However these children still need to be staged, as changes in stage are used to monitor response to ART. ■■ In children 24 months and older, staging is used to decide whether or not the child should receive ART. Once the child is on ART it is used to monitor the child’s response.

SELF-ASSESSMENT EXERCISE – CLINICAL STAGING Using the WHO paediatric clinical staging, where will you stage these HIV-infected children? STAGE a. 4 years old with many lymph nodes more than 0.5 cm in diameter in the axilla, groin and neck without underlying cause. b. 6 months old and severe wasting which has not responded to treatment. c. 9 months old with PERSISTENT DIARRHOEA (no response to treatment) and herpes zoster. d. 3 years old with persistent lymphadenopathy and recurrent SEVERE PNEUMONIA e. 9 years old with Kaposi’s sarcoma, otherwise well.

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WHO PAEDIATRIC CLINICAL STAGING FOR HIV

This is only used for confirmed HIV infected children. Determine the clinical stage by assessing the child’s signs and symptoms. Look at the classification for each stage. Decide what is the highest stage applicable to the child where one or more of the child’s symptoms are represented. STAGE 2 Mild Disease — Moderate unexplained malnutrition not responding to standard therapy ➞ Oral thrush (outside neonatal period) ➞ Oral hairy leukoplakia ➞ Unexplained and unresponsive to standard therapy: ➞ Oesophageal thrush ➞ More than one month of herpes simplex ulcerations ➞ Severe multiple or recurrent bacterial infections ≥ 2 episodes in a year (not including pneumonia) ➞ Pneumocystis pneumonia (PCP)a ➞ Kaposi’s sarcoma ➞ Extrapulmonary tuberculosis ➞ Toxoplasma brain abscessa ➞ Cryptococcal meningitisa Severe unexplained wasting/ stunting/Severe malnutrition not responding to standard therapy Stage 3 Moderate Disease Stage 4 Severe Disease (AIDS)

STAGE 1 Asymptomatic

Growth

—

Symptoms & signs ➞ Enlarged liver and/or spleen ➞ Enlarged parotid ➞ Skin conditions (prurigo, seborrhoeic dermatitis, extensive molluscum contagiosum or warts, fungal nail infections, herpes zoster) ➞ Mouth conditions (recurrent mouth ulcerations, angular cheilitis, lineal gingival Erythema) ➞ Recurrent or chronic RTI (sinusitis, ear infections, otorrhoea) ➞ Lymph node TB ➞ Symptomatic LIPa ➞ Acute necrotizing ulcerative gingivitis/ periodontitis ➞ Chronic HIV associated lung disease including bronchiectasisa • Diarrhoea for over 14 days • Fever for over 1 month • Thrombocytopeniaa (under 50,000/mm3 for more than 1 month) • Neutropeniaa (under 500/mm3 for 1 month) • Anaemia for over 1 month (haemoglobin under 8 gm)a

No symptoms, or only:

Persistent generalized lymphadenopathy

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

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➞ Recurrent severe bacterial pneumonia ➞ Acquired HIV-associated rectal fistula ➞ Pulmonary TB ➞ HIV encephalopathya b

for presumptive diagnosis of severe HIV disease, see definition below.

a

b

Conditions requiring diagnosis by a doctor or medical officer – should be referred for appropriate diagnosis and treatment. In a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated.

IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

ANNEX 2 – TREATMENT DOSING TABLES WEIGHT (Kg) AZT/3TC 60/30 mg tablet 300/150 mg tablet

AZT/3TC/NVP 60/30/50 mg tablet 300/150/200 mg tablet

ABC/AZT/3TC 60/60/30 mg tablet 300/300/150 mg tablet

ABC/3TC 60/30 mg tablet 600/300 mg tablet

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

3–5.9 6–9.9 10–13.9 14–19.9 20–24.9 25–34.9

1 1.5 2 2.5 3

1 1.5 2 2.5 3 1 1

1 1.5 2 2.5 3

1 1.5 2 2.5 3 1 1

1 1.5 2 2.5 3

1 1.5 2 2.5 3 1 1

1 1.5 2 2.5 3

1 1.5 2 2.5 3 0.5 0.5

LOPINAVIR / RITONAVIR (LPV/R), NEVIRAPINE (NVP) & EFAVIRENZ (EFV) LOPINAVIR / RITONAVIR (LPV/r) WEIGHT (KG) Target dose 230–350 mg/m² twice daily 80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet

NEVIRAPINE (NVP)

EFAVIRENZ (EFV) Target dose 15 mg/kg once daily 200 mg tablet

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

pm.

3–5.9 6–9.9 10–13.9 14–19.9 20–24.9 25–34.9

1 ml 1.5 ml 2 ml 2.5 ml 3 ml

1 ml 1.5 ml 2 ml 2.5 ml 3 ml 2 2 2 3 1 2 2 3

5 ml 8 ml 10 ml

5 ml 8 ml 10 ml

1 1.5 2 2.5 3

1 1.5 2 2.5 3 1 1 1 1.5 1.5 2

ABACAVIR (ABC), ZIDOVUDINE (AZT OR ZDV) & LAMIVUDINE (3TC) WEIGHT (KG) ABACAVIR (ABC) Target dose: 8mg/kg/dose twice daily 20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet

ZIDOVUDINE (AZT or ZDV) Target dose 180–240mg/m² twice daily 10 mg/ml liquid 60 mg tablet 300 mg tablet

LAMIVUDINE (3TC) 10 mg/ml liquid 30 mg tablet 150 mg tablet

a.m.

p.m. 3 ml 4 ml 6 ml

a.m. 1 1.5 2 2.5 3

p.m. 1 1.5 2 2.5 3

a.m.

p.m.

a.m. 6 ml 9 ml

p.m. 6 ml 9 ml

a.m. 1 1.5 2 2.5 3

p.m. 1 1.5 2 2.5 3

a.m.

p.m.

a.m. 3 ml 4 ml 6 ml

p.m. 3 ml 4 ml 6 ml

a.m. 1 1.5 2 2.5 3

p.m. 1 1.5 2 2.5 3

a.m.

p.m.

3–5.9 6–9.9 10–13.9 14–19.9 20–24.9 25–34.9

3 ml 4 ml 6 ml

12 ml 12 ml

1

1

1

1

1

1

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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS

SIMPLIFIED HARMONIZED DOSING FOR CURRENTLY AVAILABLE TDF FORMULATIONS FOR CHILDREN Drug Size of powder scoop (mg) or strength of tablet (mg) Number of scoops or tablets by weight band once daily 3–5.9 kg 6–9.9 kg 10– 13.9 kg 14–19.9 kg 20–24.9 kg Strength of adult tablet (mg) Number of tablets by weight band 25–34.9 kg

TDFa

Oral powder scoops 40 mg/scoop

– –

– –

3 –

– 1 (150 mg)

– 300 mg 1 (200 mg)

Tablets 150 mg or 200 mg a

1 (200 mg)b or 1 (300 mg)

Target dose: 8 mg/kg or 200 mg/m2 (maximum 300 mg). The Paediatric Antiretroviral Working Group developed this guidance to harmonize TDF dosing with WHO weight bands and to reduce the numbers of strengths to be made available. The WHO generic tool was used based on the target dose provided by the manufacturer’s package insert. In accordance with the standard Paediatric Antiretroviral Working Group approach, dosing was developed ensuring that a child would not receive more than 25% above the maximum target dose or more than 5% below the minimum target dose. b 200-mg tablets should be used for weight 25–29.9 kg and 300-mg tablets for 30–34.9 kg.

SIMPLIFIED DOSING OF ISONIAZID (INH) AND COTRIMOXAZOLE (CTX, SULFAMETHOXAZOLE (SMX) + TRIMETHOPRIM (TMP)) PROPHYLAXIS Drug Strength of tablet or oral liquid (mg or mg/5 ml) Number of tablets or ml by weight band once daily 3–5.9 kg 6–9.9 kg 10– 13.9 kg 14–19.9 kg 20–24.9 kg Strength of adult tab (mg) Number of tablets by weight band 25–34.9 kg

INH CTX (SMX + TMP)

100 mg Suspension 200/40 per 5 ml Tablets (dispersible) 100 + 20 mg Tablets (scored) 400 + 80 mg Tablets (scored) 800 + 160 mg

0.5 2.5 ml 1 – – –

1 5 ml 2 one half – –

1.5 5 ml 2 one half – –

2 10 ml 4 1 one half one half

2.5 10 ml 4 1 one half one half

300 mg – – 400 + 80 mg 800 + 160 mg 960 mg + 300 mg + 25 mg

1 – – 2 1 1

INH + CTX + B6a a

Tablets (scored) 960 mg + 300 mg +  25 mg

This formulation is currently awaiting regulatory approval, and a scored junior tablet (480 mg + 150 mg + 12.5 mg ) is also under development.

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PRACTICE USING THE DOSING TABLES! List the ARVs with doses that the following children should receive based on drug recommendations for their age and weight.

1. 3 year old boy. Weighs 14.5 kg.

2. 5 year old girl. Weighs 18.5 kg.

3. 2 month old boy. Weighs 6 kg.

4. 4 year old boy. Weighs 17 kg.

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ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 7 Ear problems

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

n CONTENTS Acknowledgements 4 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 Module overview Introduction to ear problems Assess an ear problem Classify an ear problem Treat an ear problem Counsel a caregiver about an ear problem Provide follow-up care Using this module in your clinic Review questions 5 7 10 12 17 19 27 29 30 31

7.10 Answer key

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

7.1

MODULE OVERVIEW

Ear problems are a common presentation at health clinics. You will check all children for ear problems.

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, assess and classify for main symptoms, then ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

NO

YES ASSESS & CLASSIFY the child using (kg): Temperature (°C): theWeight colour-coded classification Initial Visit? Follow-up Visit? chart for ear problems.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age:

CLASSIFY

CHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS CONTINUE ASSESSMENT:

check for malnutrition and anaemia, check status, HIV status, and other problems

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ immunization Remember to use Danger sign when selecting classifications Yes __ No __

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

MODULE LEARNING OBJECTIVES

After you study this module, For how long? ___ Days Is there blood in the stool?

DOES THE CHILD HAVE DIARRHOEA? Explain why it is necessary to check all children for ear problems. Look at the childs general condition. Is the child: Lethargic or unconscious? Explain why ear problems can cause long-term ear damage and Restless and irritable? Look for sunken eyes. the child fluid. Is the child: Recognize tender swelling, theOffer clinical sign of mastoiditis. Not able to drink or drinking poorly? Drinking eagerly, thirsty? Determine if an ear infection is chronic or acute. Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Classify ear problems using IMCISlowly? charts.

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Lookwill and listen for stridor you be able to: Look and listen for wheezing

Yes __ No __

deafness.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Counsel on wicking Look an ear dry. or feel for stiff neck Decide malaria risk: High ___ caregivers Low ___ No___ Look for runny nose For how long? ___ Days Look for signs of according MEASLES: If more than 7 days, has fever been present every Follow-up with a child with ear problems to IMCI guidelines. Generalized rash and day? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious of fever Lookcause at your IMCI recording form for the sick child. This section deals Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Yes __ No __

YOUR RECORDING FORM

with this

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

module:

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

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CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE Child's virological test: NEGATIVE POSITIVE Child's serological test: NEGATIVE POSITIVE

NOT DONE/KNOWN NOT DONE NOT DONE

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

MODULE ORGANIZATION This module follows the major steps of the IMCI process: ✔✔ Assess all children for ear problems ✔✔ Classify ear problems ✔✔ Treat ear problems ✔✔ Counsel caregiver on home treatment for ear problems ✔✔ Follow-up care for ear problems ✔✔ Module contents

BEFORE YOU BEGIN What do you know now about managing ear problems? Before you begin studying this module, quickly practice your knowledge with these multiple-choice questions. Select the best answer for each question: 1. What is mastoiditis? a. Infection of the ear drum, which can cause deafness b. Infection that has spread from the ear to the brain c. Infection of the bone behind the ear 2. What is a clinical sign of mastoiditis? a. A lot of pus is seen draining from the ear b. Tender swelling behind the ear c. The ear has a very terrible smell 3. Why are ear problems important in IMCI? a. Ear problems are a common health issue in children, and can cause deafness and serious infection b. Ear problems are a major killer of children c. Ear problems are sign of serious brain or bone infections 4. What is an acute ear infection? a. When one point of the ear (like the ear lobe) has a local infection b. When the child is experiencing ear pain, and pus is draining from the ear c. When the child has had pus draining from the ear for over a month 5. What is an important care measure for ear infections? a. Regularly wicking the ear to keep it dry b. Rinsing out the ear with saline water c. Antiseptic ointment After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

7.2

INTRODUCTION TO EAR PROBLEMS

Consider a typical case that you might see in your practice. Imagine the situation. This will help you start thinking about the problem of a child with an ear problem.

n  OPENING CASE STUDY – TELISA Sara has brought in her daughter Telisa to your clinic. Telisa and Sara live some distance from the clinic. They travelled this morning by taxi and walking. Telisa is a small girl, and she looks very tired. Her mother, Sara, sits down and puts Telisa on her lap. She takes a strip of cloth out of her bag, pours some water into it, and holds the rag on Telisa’s neck. She says Telisa has been feeling hot.

WHY DO YOU CHECK EVERY CHILD FOR EAR PROBLEMS? Ear problems are a common complaint when children and caregivers come to the clinic. Ear infections rarely cause death. However, they cause many days of illness in children. Ear infections are the main cause of deafness in developing countries, and deafness causes learning problems in school. It is very important to assess, classify, and treat an ear problem to prevent pain in the short term, and more serious consequences in the long-term.

WHAT IS AN EAR INFECTION? A child with an ear problem may have an ear infection. When a child has an ear infection, pus collects behind the eardrum and causes pain and often fever. If the infection is not treated, the eardrum may burst. The pus discharges, and the child feels less pain. The fever and other symptoms may stop, but the child suffers from poor hearing because the eardrum has a hole in it. Usually the eardrum heals by itself. At other times the discharge continues, the eardrum does not heal and the child becomes deaf in that ear. Eardrums can burst if ear infections are not treated. This causes long-term ear and hearing damage.

WHEN DOES AN EAR PROBLEM CAUSE SEVERE DISEASES? Sometimes the infection can spread from the ear to the bone behind the ear (the mastoid) causing mastoiditis. Infection can also spread from the ear to the brain causing meningitis. These are severe diseases. They need urgent attention and referral.

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

n  How will you begin to assess Telisa? First, you gather important information in the greeting. Sara tells you that Telisa is 3 years old. Telisa was weighed in triage, and she weighs 13 kg. You take her temperature. It is 37.5 °C. You ask Sara what Telisa’s problem is. Sara says that she came to the clinic today because Telisa has felt hot for the last 3 days. Telisa also woke the past 2 nights complaining of ear pain. You praise Sara for bringing Telisa into the clinic.

n  Next, you check for general danger signs. You ask Sara “is Telisa is able to drink?” She says yes, with no trouble. Telisa is not vomiting. Telisa has not had convulsions. You look at Telisa’s condition. She is sitting on Sara’s lap and looking around the room. She is holding onto her mother’s arm. Does Telisa have any general danger signs?

n  Next, you will assess Telisa for main symptoms. You ask if Telisa has a cough or any difficult breathing. Sara says no. Telisa does not have diarrhoea. Sara has already said that Telisa has been feeling hot. Her temperature is also 37.5 °C, which is fever. You will assess and classify Telisa for fever.

n  Then you will assess Telisa’s fever. You assess Telisa for fever because she has a temperature, and Sara says she feels hot. You ask how long Telisa Pink: Any general danger or says Give risk first dose of artesunate orif quinine for has been feeling hot. Hersign mother 3 days. There is no malaria for this area. You ask Sara they have severe malaria Stiff neck. VERY SEVERE travelled to another area in the last month. She says no. You look to see if Telisa has signs of meningitis. You watch Telisa to seechild if she to moves her head and neck. She Treat the prevent low blood sugar is sitting quietly. You ask her to look down at her mother’s shoes. over easily to look down atfor the Give She one bends dose of paracetamol in clinic shoes. high fever (38.5°C or above) FEBRILE DISEASE Give first dose of an appropriate antibiotic

or Low ria Risk

Refer URGENTLY to hospital You check for runny nose, generalized rash, and red eyes. You ask Telisa’s mother if she has had measles in Yellow: Malaria test POSITIVE.*** Give recommended line the last 3 months, and she says no. Given that there is no clear source of fever, you first quickly dooral a malaria test to antimalarial MALARIA rule out malaria. The result is negative. Give one dose of paracetamol in clinic for high fever (38.5°C or above) n  How will you classify Telisa’s fever? Advise mother when to return immediately Telisa is not in an area of malaria risk. She does not have anyFollow-up signs of measles. She does not have a general in 3 days if fever persists danger sign, or stiff neck. If fever is present every day for more than 7 days, refer for assessment Malaria test NEGATIVE and/or Other cause of fever PRESENT. Green: FEVER: NO MALARIA

Give one dose of paracetamol in clinic for high fever (38.5°C or above) Give appropriate treatment for any other cause of fever Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment Give Vitamin A treatment Give first dose of an appropriate antibiotic If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment Refer URGENTLY to hospital Give Vitamin A treatment If pus draining from the eye, treat eye infection with tetracycline eye ointment If mouth ulcers, treat with gentian violet Follow-up in 3 days

ow or within Classify

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

Pink: SEVERE COMPLICATED MEASLES****

Pus draining from the eye or Mouth ulcers.

Yellow: 8 MEASLES WITH EYE OR MOUTH COMPLICATIONS****

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

n  How will you record your assessment thus far?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Telisa Age: 3 years Weight (kg): 13 kg Temperature (°C): 37.5 °C Initial Visit? X Follow-up Visit? Ask: What are the child's problems? Feels hot, complaining of ear pain ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

Yes __ No __

X

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

3

X

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

Fever, no malaria

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM?

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Yes __ No __

Is there ear pain? Is there ear discharge? YouIfhave assessed Telisa Yes, for how long? ___ Days

for the symptoms we have learned about so far. Now you will learn how to check Look for oedema of bothevery feet. THEN CHECK FOR main ACUTE MALNUTRITION Telisa for the next symptom: ear problems. You check child for an ear problem. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

7.3

ASSESS AN EAR PROBLEM

ASK: DOES THE CHILD HAVE AN EAR PROBLEM? Be sure to ask this question for all sick children who come to your clinic for care. NO If the caregiver says NO, continue your assessment to malnutrition and anaemia. YES If the caregiver answers YES to your question about her child’s ear problem, continue:

HOW DO YOU ASSESS FOR AN EAR PROBLEM? To determine if a child has an ear problem, you should ask, look, and feel. Open your ASSESS chart for ear problems. It has these instructions, which you will now read about: Does the child have an ear problem? If yes, ask: Is there ear pain? Is there ear discharge? If yes, for how long? Look and feel: Look for pus draining from the ear. Feel for tender swelling behind the ear.

Classify EAR PROBLEM

Tender swel ear. Pus is seen the ear and reported for days, or Ear pain. Pus is seen the ear and reported for more.

ASK: DOES THE CHILD HAVE EAR PAIN? Ear pain can mean that the child has an ear infection. If the caregiver is not sure that the child has ear pain, ask if the child has been irritable and rubbing his ear.

ASK: IS THERE DISCHARGE FROM THE EAR? Use words the caregiver understands. If the caregiver answers “yes,” ask how long the child has had the discharge. Give her time to answer the question. She may need to remember when the discharge started. You will classify and treat the ear problem depending on how long the ear discharge has been present. n Ear discharge reported for 2 weeks or more (with pus seen draining from the ear) is treated as a chronic ear infection. n Ear discharge reported for less than 2 weeks (with pus seen draining from the ear) is treated as an acute ear infection.

No ear pain a No pus seen the ear.

LOOK: IS THERE PUS DRAINING FROM THE EAR? Look inside the child’s ear to see if pus is draining. That is a sign of infection, even if the child is not feeling any pain. Draining pus is a sign of infection.

FEEL: IS THERE TENDER SWELLING BEHIND THE EAR? If both tenderness and swelling are present, the child may have mastoiditis, a deep infection in the mastoid bone. Feel behind both ears. Compare them and decide if there is tender swelling of the mastoid bone. In infants, the swelling may be above the ear. Do not confuse this swelling of the bone with swollen lymph nodes.

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

SELF-ASSESSMENT EXERCISE A Answer the following questions about assessing an ear problem.

1. Ear problems can be the result of: a. Acute or chronic ear infections b. Mastoiditis c. Fever 2. What is mastoiditis? What signs you will look for to see if the child has mastoiditis?

3. What is an acute ear infection?

4. What is a chronic ear infection?

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

7.4

CLASSIFY AN EAR PROBLEM

HOW DO YOU CLASSIFY AN EAR PROBLEM? There are four classifications for an ear problem. In order of seriousness, they are: 1. MASTOIDITIS 2. ACUTE EAR INFECTION 3. CHRONIC EAR INFECTION 4. NO EAR INFECTION Open to your classification chart for ear problems. What do you see? Tender swelling behind the ear. Pus is seen draining from the ear and discharge is reported for less than 14 days, or Ear pain. Pus is seen draining from the ear and discharge is reported for 14 days or more. No ear pain and No pus seen draining from the ear. Pink: MASTOIDITIS Yellow: ACUTE EAR INFECTION Give first dose of an appropriate antibiotic Give first dose of paracetamol for pain Refer URGENTLY to hospital Give an antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Follow-up in 5 days Dry the ear by wicking Treat with topical quinolone eardrops for 14 days Follow-up in 5 days No treatment

Classify EAR PROBLEM

Yellow: CHRONIC EAR INFECTION Green: NO EAR INFECTION

Now you will read more about each of these classifications.

MASTOIDITIS (RED) If a child has tender swelling behind the ear, classify the child as having MASTOIDITIS. What actions will you take? Refer to hospital urgently. This child needs treatment with injectable antibiotics (ceftriaxone). He may also need surgery. Before the child leaves for hospital, give the first dose of the antibiotic and give one dose of paracetamol if the child is in pain.

ACUTE EAR INFECTION (YELLOW) If you see pus draining from the ear and discharge has been present for less than two weeks, classify the child’s illness as ACUTE EAR INFECTION. If the caregiver says that the child has ear pain, ask whether the pain wakes the child at night. If the child is able to tell you that the ear is hurting or if the child is distressed with pain or the caregiver tells you the child has been distressed with pain earlier, classify as ACUTE EAR INFECTION. However if the only history is that the child seems to have been scratching or pulling the ear but otherwise does not appear to be in pain, do not classify. Explain to the caregiver that children often rub their ears and it is not always a sign of ear pain. Page 8 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

What actions will you take? Give a child with an ACUTE EAR INFECTION amoxycillin for 5 days. Antibiotics for treating pneumonia are also effective against the bacteria that cause most ear infections. Give paracetamol to relieve the ear pain (or high fever). If pus is draining from the ear, dry the ear by wicking. The child should be seen again after 5 days if there is still pain or if the ear is still discharging. A follow-up visit after 14 days must be scheduled for all children with ACUTE EAR INFECTION.

CHRONIC EAR INFECTION (YELLOW) If you see pus draining from the ear and discharge has been present for two weeks or more, classify the child’s illness as CHRONIC EAR INFECTION. What actions will you take? Most bacteria that cause CHRONIC EAR INFECTION are different from those causing acute ear infections. Do not give antibiotics to a child with a chronic ear infection. Appropriate drops (usually acetic acid) if available, are instilled into the ear after drying the ear by wicking whenever pus can be seen. The most important and effective treatment for CHRONIC EAR INFECTION is to keep the ear dry by wicking. You will learn to teach the caregiver how to do this in the COUNSEL section.

NO EAR INFECTION (GREEN) If there is no ear pain (or pain that does not wake the child at night) and no pus is seen draining from the ear, the child’s illness is classified as NO EAR INFECTION. What actions will you take? The child needs no additional treatment. An infant or small child that is irritable and slightly feverish – but does not have ear pain – may have an ear infection, but is unable to locate the pain. This child will have a fever for which no cause is obvious, so you will ask the caregiver to bring the child back after two days if there is no improvement. One reason for doing this is because by then there may be pus draining from the ear.

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ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

n  How will you assess and classify Telisa for ear problems? You have assessed and classified Telisa for general danger signs, cough or difficult breathing, diarrhoea, DOES THE CHILD HAVE DIARRHOEA? Yes __ No and __ For how long? ___ Days Look at the childs general condition. Is the child: fever. Next you will ask about the next main symptom, ear problems. Telisa’s mother has already mentioned Is there blood in the stool? Lethargic or unconscious? Restless and irritable? that an ear problem is part of the reason they came to the clinic today.

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

n  How will you assess Telisa’s ear problem?

Sara said she hurt. You ask DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ about a year. You look but you do not see any pus draining from the child’s ear. You feel behind Telisa’s ears. Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ Look for runny nose YouFor feel tender swelling behind one ear. how long? ___ Days Look for signs of MEASLES: If more than 7 days, has fever been present every Generalized rash and day? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Look for any other cause of fever. Do malaria test if NO general danger sign Highhave risk: allidentified fever cases one clinical signs from your assessment: tender swelling behind You Low risk: if NO obvious cause of fever says there has been discharge in the past, but you do not see any. Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: came to the clinic because Telisa Very has slowsly ear pain. The cried most of the night because her ear (longer then child 2 seconds)? if there is discharge coming from Slowly? Telisa’s ear. Sara says there has been discharge on and off for

n  How will you classify Telisa’s ear problem?

the ear. Telisa’s mother

If yes, they deep and extensive? n   How will you complete this section ofare Telisa’s recording form? last 3 months:

If the child has measles now or within the

Look for mouth ulcers.

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for pus draining from the eye. Look for clouding of the cornea.

Look for pus draining from the ear Feel for tender swelling behind the ear

Yes __ No __

PROBLEM

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is thereyou any medical complication? If child has MUAC less than 115 You classify as MASTOIDITIS. Inmm theor next section will learn about identified treatments. General danger sign? WFH/L less than -3 Z scores or oedema of Any severe classification? both feet: Pneumonia with chest indrawing? Tender swelling behind the Pink: For a child 6 months or older Give first dose of appropriate antibiotic offer RUTF to eat. Is thean child: Not able to finish or able to finish? ear. Give first dose of paracetamol for pain MASTOIDITIS For a child less than 6 months is there a breastfeeding problem?

n  With these signs, how will you classify?

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

CHECK FOR HIV INFECTION

Refer URGENTLY to hospital

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Yellow: DPT+HIB-2 BCG DPT+HIB-1 the ear and discharge is OPV-2 OPV-0 OPV-1 Hep B1 days orHep B2 Hep reported B0 for 14 RTV-2 RTV-1 more. Pneumo-2 Pneumo-1

Note mother's and/or child's HIV status Yellow: Pus is seen draining from POSITIVE Mother's HIV test: NEGATIVE NOT DONE/KNOWN Child's virological test: NEGATIVE NOT DONE the ear and discharge is POSITIVE ACUTE EAR Child's serological test: NEGATIVE POSITIVE NOT DONE for less than 14 virologicalINFECTION If reported mother is HIV-positive and NO positive test in child: Is the child days, or breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? Ear pain. If breastfeeding: Is the mother and child on ARV prophylaxis?

Give an antibiotic for 5 days Give paracetamol for pain Dry the ear by wicking Follow-up in 5 days Return for next Dry the Measles ear by wicking immunization on: 2 Vitamin A ________________ Mebendazole Treat with topical quinolone eardrops for 14 days (Date) Follow-up in 5 days

Pus is seen draining from

DPT+HIB-3 CHRONIC OPV-3 EAR Hep B3 INFECTION RTV-3 Pneumo-3

Measles1

No ear pain and No pus seen draining from the ear.

Green: NO EAR INFECTION

No treatment

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SELF-ASSESSMENT EXERCISE B How will you classify the following children?

1. You can see pus draining from Ben’s ear. His grandmother tells you it has been happening for about 3 months. 2. Leboheng is not able to sleep because he says his ears hurt. There has been discharge for less than 1 week. 3. Akiiki has a fever. You feel swelling behind her ear, and she cries when you touch this area. 4. Khotso wakes up at night crying because his right ear hurts. 5. Jamie says that his ears hurt. He does not wake up at night from pain. You do not see discharge. You ask the mother if there is pus draining from the ear. She says no.

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SELF-ASSESSMENT EXERCISE C Record Dana’s signs of ear problem and classify them on the Recording Form.

Dana is 18 months old. She weighs 9 kg. Her temperature is 37 °C. Her mother said that Dana had discharge coming from her ear for the last 3 days. Dana does not have any general danger signs. She does not have cough or difficult breathing. She does not have diarrhoea and she does not have fever. The health worker asked about Dana’s ear problem. The mother said that Dana does not have ear pain, but the discharge has been coming from the ear for 3 or 4 days. The health worker saw pus draining from the child’s right ear. She did not feel any tender swelling behind either ear.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

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Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child:

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

7.5

TREAT AN EAR PROBLEM

HOW WILL YOU TREAT AN EAR PROBLEM? Open to your ear problem classification table. What treatments are identified in the TREATMENT column?

➞ Give ceftriaxone IM – you learned about this in Module 3 ➞ Give paracetamol – you learned about in Module 5 ➞ Give amoxicillin – you learned about giving oral drugs in Module 3 ➞ Teach the to wick the ear ➞ Give recommended ear drops You will read more about counselling on wicking the ear in the next section. Now let us return to Telisa’s case to determine what treatment she requires.

n  What treatment does Telisa require? You have classified Telisa’s ear problem as MASTOIDITIS. This is a red classification. It requires urgent referral.

n  What urgent treatments are required for Telisa? Tender swelling pre-referral behind the Pink: Give first dose of an appropriate antibiotic MASTOIDITIS Review what you have classified Telisa with today: ear.

PROBLEM

•• FEVER and

Give first dose of paracetamol for pain Refer URGENTLY to hospital

PROBLEM

Give an antibiotic for 5 days Give paracetamol for pain reported for less than 14 Dry the ear by wicking What pre-referral treatments are identified in bold in these classification tables? days, or Follow-up in 5 days Ear pain. Tender swelling behind the Pink: Give first of an appropriate antibiotic Yellow: Pus is seen draining from Dry the eardose by wicking ear. Give first dose paracetamol forfor pain MASTOIDITIS the ear and discharge is Treat with topicalof quinolone eardrops 14 days CHRONIC EAR Refer URGENTLY reported for 14 days or INFECTION Follow-up in 5 daysto hospital more. Yellow: Pus is seen draining from Give an antibiotic for 5 days the ear and discharge is •• MASTOIDITIS Pus is seen draining from the ear pain and and discharge is No ear reported for less than from 14 No pus seen draining days, or the ear. Ear pain. Green: ACUTE EAR INFECTION NO EAR INFECTION Give paracetamol for pain No treatment Dry the ear by wicking Follow-up in 5 days

Yellow: ACUTE EAR INFECTION

Yellow: Pus is seen draining from the ear and discharge is CHRONIC EAR reported for 14 days or 1. Give an appropriate antibiotic INFECTION more.

These are the required pre-referral treatments before you send Telisa to the hospital:

Dry the ear by wicking Treat with topical quinolone eardrops for 14 days Follow-up in 5 days No treatment

2. Give first dose of paracetamol No ear pain and No pus seen draining from the ear.

Green: NO EAR INFECTION

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n  How will you prepare Telisa and Sara for referral? You will prepare a referral note for Sara to carry with her to the hospital. You will also counsel Sara on why Telisa must be referred. Sara is confused when you tell her Telisa must go to the hospital. She says that all children have fevers and ear problems. She did not think that this was so serious. She is worried that her husband will not want her to go to the hospital today. He already did not think that it was necessary to come today. He said that all children have pain in their ears and it goes away. It is a small issue. She says that Telisa is moving around fine, besides the ear pain.

n  How will you address Sara’s concerns? You explain to Sara that yes, ear problems are often common with children. You explain that Telisa has a problem in her ear that is now outside of her ear, in the bone. You explain that this is serious and must be treated. Sara still seems unsure. You explain more. If the ear problem is not treated, it could cause more damage. It could cause damage to her ears, and damage her ability to hear properly. It could also spread to other parts of her body, like her brain. You tell Sara that this is why Telisa has a fever and is feeling hot. Her body is trying to fight the infection. Sara now looks panicked and afraid. You tell her not to be afraid, but that you are telling her these things so she understands what is causing Telisa’s ear problem. You are firm and tell Sara that if she goes immediately to the hospital, they can provide more care for Telisa. They will treat the infection.

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7.6

COUNSEL A CAREGIVER ABOUT AN EAR PROBLEM

WHAT ARE GOOD COMMUNICATION SKILLS FOR HOME TREATMENT? Good communication is critical when teaching a caregiver about home treatment. It is also important to never be judgemental when speaking to the caregiver. Remember the APAC process when you are counselling: ASK questions to find out what the caregiver is already doing for the child. PRAISE the caregiver for what she has done well. ADVISE her how to treat the child at home. Use the teaching steps below. CHECK the caregiver’s understanding

WHAT ARE THE IMPORTANT STEPS WHEN TEACHING A CAREGIVER? 1. GIVE INFORMATION – about a home treatment. Ask checking questions to make sure she understood the information. She needs to know: a. How to give the treatment b. Hot much to give c. For how long to give the treatment d. Why the treatment is important, and what the drugs will be doing. 2. Show an example 3. Let caregiver practise 1. Give information

2. SHOW AN EXAMPLE – for example, how to hold the child still and wick the ear. It may be enough to ask the caregiver to describe how she will do the task at home. 3. LET HER PRACTICE – ask the caregiver to do the task while you watch. For example, have the caregiver wick the child’s ear. Letting a caregiver practice is the most important part of teaching a task.

HOW WILL YOU COUNSEL THE CAREGIVER TO WICK THE EAR? To teach a caregiver how to dry the ear by wicking, first tell her it is important to keep an infected ear dry to allow it to heal. Then show her how to dry wick her child’s ear. As you wick the child’s ear dry, tell the caregiver to: •• Use clean, absorbent cotton cloth or soft strong tissue paper for making a wick. Paper towels used in some clinics are also suitable. Do not use a cotton-tipped applicator, a stick or flimsy paper that will fall apart in the ear. •• Clean the child’s ear with the wick and then place a clean wick in the child’s ear until the wick is wet.

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•• Replace the wet wick with a clean one. •• Repeat these steps until the wick stays dry. Then the ear is dry. Observe the caregiver as she practises Give feedback. When she is finished, give her the following information.

What is important information for wicking the ear? •• Wick the ear dry 3 times daily. •• Use this treatment for as many days as it takes until the wick no longer gets wet when put in the ear, and no pus drains from the ear. •• Do not place anything (oil, fluid, or other substance) in the ear between dry wicking treatments. Recommended ear drops (1% acetic acid) can be used if these are available. If these ear drops are not available, then none should be used. Do not plug the ear – it needs air to dry out. Do not allow the child to go swimming. No water should get in the ear.

HOW WILL YOU CHECK TO BE SURE THE CAREGIVER UNDERSTANDS? If the caregiver thinks she will have problems wicking the ear dry, help her solve them. Ask checking questions, such as: •• “What materials will you use to make the wick at home?” •• “How many times per day will you dry the ear with a wick?” •• “What else will you put in your child’s ear?”

COUNSEL ON WHEN TO RETURN For an ACUTE or CHRONIC EAR INFECTION, the child should follow-up in 14 days. Any sick child should return immediately if they: ✔✔ Not able to drink or breastfeed ✔✔ Become sicker ✔✔ Vomiting everything ✔✔ Convulsions

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SELF-ASSESSMENT EXERCISE D Answer the following questions about treatment.

1. Paracetemol is given when a child’s temperature is what degrees? 2. How often should a caregiver wick the ear dry? 3. What is important information to tell a caregiver about wicking an ear? 4. When should a child with an ear infection return for follow-up?

SELF-ASSESSMENT EXERCISE E INTRODUCTION TO EXERCISE: You are going to read about four important skills when counselling a caretaker. These skills focus on building a caregiver’s confidence. This is important for a caregiver to feel confident, informed, and supported when caring for a child and providing treatment and good feeding. In the following pages, there will be a section explaining each skill. It will be followed by a set of exercises about the skill you just read about. You will begin with skill 1 below.

Skill 1: Acknowledge how the caregiver thinks and feels. What is this skill? It is important not to disagree with a caregiver; it is also important not to agree with a mistaken idea. You may want to suggest something quite different. That may be quite difficult if you have already agreed with her. Instead you just accept how she thinks or feels. This means responding in a neutral way, and not agreeing or disagreeing. Example: Many caregivers have the idea that ‘My milk is weak and thin.’ What are the possible ways you can respond to this? Inappropriate response: ‘Oh no milk is never weak and thin’ Agreeing: Accept: ‘Yes, thin and weak milk can be a problem’ ‘I see, you are worried about your milk’ or ‘Ah-ha’

Reflecting back and giving simple responses are useful ways to show acceptance. These are also good listening and learning skills. Example: It is important to accept how the caregiver feels. You let her know that you understand the emotions she is feeling about her child’s health. For example, a caregiver might say ‘My baby has a cold and blocked nose and just cries all the time.’ Which response accepts how the caregiver feels? •• Don’t worry, your baby is doing very well. •• You are upset about him, aren’t you? •• Don’t cry, it’s not serious. He will soon be better.

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The second response here recognizes how the caregiver feels: she is upset and worried. On the other hand, the first and third responses do not accept how she feels. Instead they seem to argue against her.

SKILL 1 EXERCISE: For each of the following scenarios write another response that shows you accept what the caregiver thinks or feels. CAREGIVER SAYS: 1. ‘It is so hot that I am giving him water.’ 2. ‘I am so worried because he refuses to take any porridge, he just wants to breastfeed.’ 3. ‘I am giving him some porridge in a bottle, and he really likes it.’ 4. Mother is HIV positive: ‘He cries so much at night I have to breastfeed him or else he will wake the whole family.’ 5. Caregiver of an 11-month old baby: ‘I never give him egg or meat, he will get an allergy’ 6. ‘My child does not want to eat. I have to close his nose and put food into his mouth.’ HEALTH WORKER RESPONSE:

Skill 2: Recognize and praise what a caregiver and baby are doing right. What is this skill? We are trained to look for problems. This means that we see only what we think people are doing wrong, and try to correct them. If you tell a caregiver she is doing something wrong, you make her feel bad, and that reduces her confidence. As counsellors we must look for what caregivers and babies are doing right. We must recognize what they do right and then we should praise or show approval of the good practices. Praising good practices has these benefits: •• It builds a caregiver’s confidence, •• Encourages her to continue those good practices and •• Makes it easier for her to accept suggestions later. Example: You are weighing a baby together with his caregiver. He is exclusively breastfed. He has gained some weight in the last month, however his growth line shows that he is growing too slowly. Which of these remarks will help build the caregivers confidence? •• ‘Your baby’s growth line is going up too slowly’ •• ‘I don’t think your baby is gaining enough weight’ •• ‘Your baby gained weight last month just on your breastmilk’

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SKILL 2 EXERCISE In the scenarios bellows, there are three responses that are good things to say to the caregiver. Tick the response that best praises the caregiver.

1. A mother has started bottle-feeding her baby by day while she is at work. She breastfeeds as soon as she gets home, but the baby does not want to suckle as much as he did before.  You are very wise to breastfeed whenever you are at home.  It would be better if you gave him artificial feeds by cup and not by bottle  Babies often do stop wanting breastfeeds when you start giving bottles. 2. A 15 month old child is breastfeeding and having thin porridge and sometimes tea and bread. He has not gained weight for 6 months and is thin and miserable.  He needs to eat a more balanced diet.  It is good that you are continuing to breastfeed him at this age, as well as giving him other food.  You should be giving him more than breastmilk and thin porridge at this age. In the scenarios below, write your own response to the caregiver. 3. A 3 month old is completely bottle fed, and has diarrhoea. The growth chart shows that he weighed 3.5 kg at birth. He has gained only 200 grams in the last two months. The bottle smells very sour.

4. Neera comes to the clinic to learn how to take her 3 month old baby off the breast. She is HIV positive and is going back to work soon. She is breastfeeding and giving him bottles, which Neera is refusing, so she asks you to advise her. Neera is alert and active.

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Skill 3: Give a little relevant information Caregivers often need information about feeding, but it is important to give information that is relevant to her situation now. Try to give her only one or two pieces of information at a time, especially if the caregiver is tired and has already received a lot of advice. Give information in a positive way, so that it does not sound critical, or make the caregiver feel she is doing something wrong. This is especially important if you want to correct a mistaken idea. Wait until you have built the caregiver’s confidence by accepting what she says, and praising what she does well.

SKILL 3 EXERCISE Read each scenario below. Which response gives information that is more relevant? Tick your answer.

1. Lerato is 2 months old, breastfeeding exclusively, and gaining weight happily. Now she suddenly seems hungry, and she wants to feed more often. Her caregiver thinks that she does not have enough milk.  Oh, Lerato is growing well. Don’t worry about your breastmilk supply. It is best to breastfeed exclusively for 6 months, and then you can start complementary feeds.  Lerato is growing fast. Healthy babies have these hungry times when they grow fast. Lerato’s growth chart shows she is getting all the breastmilk she needs. She will settle in a few days. 2. Joseph is 3 months old. His mother recently started giving him some bottle feeds in addition to breastfeeding. The baby has started having diarrhoea. She asks you if she should stop breastfeeding.  It is good that you asked before deciding. Diarrhoea usually stops sooner if you continue breastfeeding.  Oh no, don’t stop breastfeeding. He may get worse if you do that. 3. You are talking with the mother of a 15 month old child who is no longer breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feeds of cow’s milk and 1 meal of family foods each day. His diet has not changed since the diarrhoea started.  Your child needs more food each day. Try to give him 3 family meals plus 2 feedings between meals.  Give your child amasi or yoghurt instead of milk (until the follow-up visit in 5 days). Or give only half the usual milk and increase the amount of family foods to make up for this

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Skill 4: Use simple language Health workers often use technical terms when they talk to caregivers, and caregivers do not understand them. It is important to use simple familiar terms to explain things to caregivers.

SKILL 4 EXERCISE: Restate the following advice in simpler words:

1. Give foods that are high in energy and nutrient content in relation to volume

2. Consider starting a ‘safe transition’

3. When your baby suckles, prolactin is released which makes breasts secrete more milk.

Skill 5: Make one or two suggestions, not commands When you counsel a caregiver, you suggest what she could do. Then she can decide if she will try it or not. This leaves her feeling in control, and helps her to feel confident. You must be careful not to tell or command her to do something. This does not help her feel confident. Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should be avoided. Suggestions include: •• Have you considered…? •• Would it be possible…? •• What about trying…to see if it works for you? •• Would you be able to? •• Have you thought about…? Instead of …? •• You could choose between… and …. •• Usually… sometimes… often..

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SKILL 5 EXERCISE Rewrite the following as suggestions, not commands

1. Use a cup to feed your baby.

2. Do not give cereal or juice as a substitute for milk if your baby is under 6 months old.

3. Give your child 5 meals a day and add a teaspoon of oil to each feed.

4. Never give your baby water; he does not need it if he is breastfeeding.

5. Always remember to give the child his own serving.

6. You must wash your hands before preparing the formula.

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7.7

PROVIDE FOLLOW-UP CARE

WHEN WILL CHILDREN FOLLOW-UP FOR ACUTE EAR INFECTIONS? If the child has an ACUTE EAR INFECTION:

➞ Follow-up in 5 days: If discharge persists ➞ Follow up in 14 days: If discharge does not persist If the child has a CHRONIC EAR INFECTION, they will follow-up in 14 days. During a follow-up visit, follow the instructions in the follow-up box of the Chart Booklet. Reassess the child for ear problem and check for fever. Then select treatment based on the child’s signs. REMEMBER! If you feel tender swelling behind the ear: The child may have developed mastoiditis. If there is a high fever (axillary temperature of 38.5 °C or above), the child may have a serious infection. A child with tender swelling behind the ear or high fever has become worse, and thus needs URGENT REFERRAL.

ACUTE EAR INFECTION (follow-up 5 days if persists)  NO EAR PAIN OR DISCHARGE Praise the caregiver. Advise her to come back to the clinic immediately if the ear becomes painful or starts to discharge again.

 EAR PAIN OR DISCHARGE PERSISTS If ear pain or discharge persists after 5 days of antibiotics treat with 5 additional days of the same antibiotic. Continue wicking if ear discharge is still present. Ensure the caregiver is properly wicking. Ask the following, and correct if necessary: •• To describe or show you how she wicks the ear •• How frequently the ear is wicked •• What problems are faced when wicking, and discuss how to overcome them Discuss with her the importance of keeping the ear dry so that it will heal. Encourage her to continue wicking the ear. Show her how to give ear drops, if available. Explain that drying is the only effective therapy for a draining ear. Hearing loss could occur if the ear is not wicked. Ask the caregiver to return in 5 days so that you can check whether the ear infection is improving. It is important that the child has a follow-up visit to ensure that mastoiditis has not developed and to ensure that the ear is being wicked (if ear discharge). After 2 weeks of adequate wicking, refer if discharge persists. REFER if no improvement after 14 days despite ear drops and adequate wicking.

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CHRONIC EAR INFECTION (follow-up 14 days)  NO EAR PAIN OR DISCHARGE Praise the caregiver. Advise her to come back to the clinic immediately if the ear becomes painful or starts to discharge again.

 EAR PAIN OR DISCHARGE PERSISTS Check that the caregiver is wicking the ear correctly, using the steps above. Explain the importance of properly wicking the ear. Review in 14 days. If no improvement (persistent pain or offensive discharge or reduced hearing), refer.

 NO IMPROVEMENT DESPITE EAR DROPS AND ADEQUATE WICKING If there is no improvement despite proper care, refer the child.

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7.8

USING THIS MODULE IN YOUR CLINIC

HOW WILL YOU BEGIN TO PRACTICE THIS MODULE IN YOUR CLINIC? In the coming days, you should focus on these key clinical skills. Practicing these skills and using your job aids will help you to better understand how to use IMCI for ear problems. ASSESS ✔✔ Check every child for malnutrition and anaemia. ✔✔ Look for draining pus. ✔✔ Feel for tender swelling behind the ear. ✔✔ Ask how long the ear has been draining, in order to determine if the infection is acute or chronic. CLASSIFY ✔✔ Use your chart booklet to classify ear problems. ✔✔ Identify any pre-referral treatments if required. TREAT & COUNSEL ✔✔ Give paracetamol for high fever. ✔✔ Give amoxicillin for infection. ✔✔ Give ceftriaxone IM if required before an urgent referral. ✔✔ Teach a caregiver to wick the ear dry. Demonstrate and let her practice. Give feedback. FOLLOW-UP ✔✔ Follow the IMCI instructions for follow-up with children who were classified with ear problems.

Remember to use your logbook for MODULE 7: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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7.9

REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING EAR PROBLEMS? Before you began studying this module, you practiced your knowledge on with several multiple-choice questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. What is mastoiditis? a. Infection of the ear drum, which can cause deafness b. Infection that has spread from the ear to the brain c. Infection of the bone behind the ear 2. What is a clinical sign of mastoiditis? a. A lot of pus is seen draining from the ear b. Tender swelling behind the ear c. The ear has a very terrible smell 3. Why are ear problems important in IMCI? a. Ear problems are a common health issue in children, and can cause deafness and serious infection b. Ear problems are a major killer of children c. Ear problems are sign of serious brain or bone infections 4. What is an acute ear infection? a. When one point of the ear (like the ear lobe) has a local infection b. When the child is experiencing ear pain, and pus is draining from the ear c. When the child has had pus draining from the ear for over a month 5. What is an important care measure for ear infections? a. Regularly wicking the ear to keep it dry b. Rinsing out the ear with saline water c. Antiseptic ointment

Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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7.10

ANSWER KEY ANSWER C B A B A Did you miss the question? Return to this section to read and practice: INTRODUCTION, ASSESS ASSESS INTRODUCTION CLASSIFY CLASSIFY, TREAT, COUNSEL

REVIEW QUESTIONS QUESTION 1 2 3 4 5

EXERCISE A 1. A and B 2. Mastoiditis is a deep infection in the mastoid bone, which is behind the ear. You will look for tenderness and swelling behind the ear at the mastoid bone. This might be a sign of mastoiditis. It is important not to confuse this swelling of the bone with swollen lymph nodes. 3. A chronic infection is when there has been discharge from the ear for longer than 2 weeks. 4. An acute ear infection has had discharge for less than 2 weeks.

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EXERCISE B

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Dana Name: Age: 18 months Weight (kg): 9 kg Temperature (°C): 37 °C Ask: Initial Visit? X Follow-up Visit? What are the child's problems? Discharge from ear for three days ASSESS (Circle all signs present)

CLASSIFY

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

Yes __ No __

X

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear

Yes

Yes __ No __

X

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

3-4

EXERCISE C If child has MUAC less thanEAR 115 INECTION mm or 1. CHRONIC WFH/L less than -3 Z scores or oedema of 2. ACUTE EAR INECTION both feet:

3. MASTOIDITIS CHECK FOR HIV INFECTION

4. ACUTE EAR INECTION

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

Acute ear infection

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 32 Measles 2

Note mother's and/or child's HIV status 5. NO EAR INFECTION Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

EXERCISE D 1. 38.5 degrees C or more 2. They should wick the ear 3 times a day, for as many days as necessary until the ear is dry and no pus drains from the ear. 3. Some important information is: a. Use clean, absorbent cotton cloth or soft strong tissue paper for making a wick. Paper towels used in some clinics are also suitable. Do not use a cotton-tipped applicator, a stick or flimsy paper that will fall apart in the ear. b. Clean the child’s ear with the wick and then place a clean wick in the child’s ear until the wick is wet. c. Replace the wet wick with a clean one. d. Repeat these steps until the wick stays dry. Then the ear is dry. 4. In 14 days

EXERCISE E Skill 1: Acknowledge how the caregiver thinks and feels TO ANSWER: For each case, write a response that acknowledges or accepts how the caregiver thinks or feels. 1. Caregiver: Health worker: 2. Caregiver: Health worker: “It is so hot that I am giving him water” I can understand that you want to give him water when it is so hot. “I am so worried – he refuses to take any porridge, he just wants to breastfeed.” I can see that you are worried that he does not want to eat porridge.

3. Caregiver: “I am giving him some porridge in a bottle, and he really likes it.” Health worker: He certainly seems to like porridge in the bottle, or Many caregivers put porridge into the babies’ bottles. 4. HIV positive mother: Health worker: “He cries so much at night, I have to breastfeed him or else he will wake the whole family.” It is very considerate of you not to want to wake the family when you get up to prepare a feed.

5. Caregiver of an 11 month old: “I never give him egg or meat, he will get an allergy.” Health worker: Yes, it is a common belief that giving infants meat or eggs cause an allergy. 6. Caregiver: Health worker: “My child does not want to eat. I have to close his nose and put food into his mouth.” It can be very frustrating when a child does not want to eat.

33

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

Skill 2: Recognize and praise what a mother and baby are doing right TO ANSWER: In stories 1 and 2, there are three responses. They are all things you might want to say. Tick the response that praises what the mother is doing right. For stories 3 and 4, write a praising response of your own. 1. A mother has started bottle-feeding her baby by day while she is at work. She breastfeeds as soon as she gets home, but the baby does not want to suckle as much as he did before. — You are very wise to breastfeed whenever you are at home — It would be better if you gave him artificial feeds by cup and not by bottle — Babies often do stop wanting breastfeeds when you start giving bottles 2. A 15 month old child is breastfeeding, having thin porridge and sometimes tea and bread. He has not gained weight for 6 months and is thin and miserable. — He needs to eat a more balanced diet — It is good that you are continuing to breastfeed him at this age, as well as giving him other food — You should be giving him more than breastmilk and thin porridge at this age 3. A 3 month old is completely bottle fed, and has diarrhoea. The growth chart shows he weighed 3.5 kg at birth, and he has only gained 200 grams in the last two months. The bottle smells very sour. It is good that you brought the Growth Chart today, so that we can see how he is growing. 4. Neera comes to the clinic to learn how to take her 3 month old off the breast. She is HIV positive and going back to work soon. She is breastfeeding and giving him bottles, which he is refusing, so she asks you to advise. The baby is alert and active. It is good of you to bring your bright baby boy to get advice on the feeding difficulty. Skill 3: Give a little relevant information 1. Lerato is growing fast. Health babies have these hungry times when they grow fast. Lerato’s Growth Chart shows that she is getting all the breastmilk she needs. She will settle in a few days. 2. It is good that you asked before deciding. Diarrhoea usually stops sooner if you continue breastfeeding. 3. Your child needs more food each day. Try to give him 3 family meals plus 2 feedings between meals.

34

IMCI DISTANCE LEARNING COURSE | MODULE 7. EAR PROBLEMS

Skill 4: Use simple language TO ANSWER: Restate the following advice in simpler words: •• Give foods that are high in energy and nutrient content in relation to volume. NEW: It is important to give him food which helps him to grow without making him feel too full. NEW: It is time for us to think about getting him used to other milk as you stop breastfeeding. NEW: Every time your baby suckles your breast makes more milk.

•• Consider starting a “safe transition”.

•• When your baby suckles, prolactin is released which makes breasts secrete more milk.

Skill 5: Make one or two suggestions, not commands TO ANSWER: Rewrite as suggestions rather than commands (you can use your own language): •• Use a cup to feed your baby. NEW: You may wish to try feeding him with a cup. NEW: Once your baby is 6 months old you could think about giving him some cereal and a little juice. NEW: As your child is growing he needs more food. Five meals a day with a little oil added to each meal should be just right for him. NEW: Babies don’t need extra water as long as they are fully breastfed. NEW: By always giving your child his own serving you can see exactly how much he is eating. NEW: It is advisable for you to wash your hands before preparing the formula. •• Do not give cereal or juice as a substitute for milk if your baby is under 6 months old.

•• Give your child 5 meals a day and add a teaspoon of oil to each feed.

•• Never give your baby water; he does not need it if he is breastfeeding. •• Always remember to give the child his own serving.

•• You must wash your hands before preparing the formula.

35

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 6 Malnutrition and anaemia

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n CONTENTS Acknowledgements 4 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Module overview Opening case study Introduction to malnutrition Assess malnutrition Classify malnutrition Treat malnutrition Assess & classify anaemia Treat anaemia Provide follow-up care for nutrition 5 8 10 13 27 31 36 40 44 47 48 49

6.10 Using this module in your clinic 6.11 Review questions 6.12 Answer key

3

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

4

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.1

MODULE OVERVIEW

As malnutrition is an underlying cause of much illness, this is a very important assessment. Review the chart below to refresh on when this assessment comes in the IMCI process:

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, assess and classify for main symptoms, then CHECK ALL CHILDREN FOR MALNUTRITION AND ANAEMIA

ASSESS & CLASSIFY nutrition status for all children.

CHECK immunization status and other problems. Assess caregiver’s health.

MODULE LEARNING OBJECTIVES After you study this module, you will be able to: ✔✔ Explain why it is necessary to check all children for malnutrition and anaemia ✔✔ Determine weight for height/length ✔✔ Measure a child’s mid-upper arm circumference (MUAC) ✔✔ Recognize clinical signs of severe acute malnutrition ✔✔ Conduct an appetite test for child with acute malnutrition ✔✔ Recognize clinical signs of anaemia ✔✔ Classify malnutrition and anaemia using IMCI charts ✔✔ Provide ready-to-use therapeutic foods (RUTF) and counsel the caregiver on giving ✔✔ Distribute iron and mebendazole ✔✔ Counsel caregivers on home treatments ✔✔ Follow-up a child with malnutrition or anaemia according to IMCI guidelines

5

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? IMCI DISTANCE LEARNING Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes COURSE | MODULE 6. MALNUTRITION AND ANAEMIA Look for any other cause of fever.

Yes __ No __

YOUR RECORDING Look for mouth ulcers. If the child has measles now or within FORM the If yes, are they deep and extensive? last 3 months: Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days Look for pus draining from the ear Feel for tender swelling behind the ear

Look at your IMCI recording form for sick child. Look for pus the draining from the eye. This section deals with this Look for clouding of the cornea. module: DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

No __

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-3 DPT+HIB-2 ✔DPT+HIB-1 ✔ CLASSIFY MALNUTRITION OPV-1 Hep B1 ✔RTV-1 ✔ TREAT Pneumo-1 OPV-3 OPV-2 Hep B3 Hep B2 MALNUTRITION RTV-3 RTV-2 Pneumo-3 Pneumo-2 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: This module follows the IMCI process. It will first discuss IMCI for malnutrition: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother andCHILDREN child on ARV prophylaxis? ✔✔ CHECK ALL FOR MALNUTRITION AND ASSESS

MODULE ORGANIZATION

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

Then it will discuss IMCI for anaemia: ✔✔ CHECK ALL CHILDREN FOR ANAEMIA ✔✔ CLASSIFY ANAEMIA ✔✔ TREAT ANAEMIA ✔✔ FOLLOW-UP CARE FOR NUTRITION Page 65 of 75 

And finally you will learn how to provide follow-up care for nutrition concerns:

6

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

BEFORE YOU BEGIN What do you know now about managing malnutrition and anaemia? Before you begin studying this module, quickly practice your knowledge with these multiple-choice questions. Circle the best answer: 1. When is it necessary to check a child for malnutrition and anaemia? a. Check if the child appears low weight for age b. Check every child for malnutrition and anaemia, as sometimes problems go unnoticed c. Check if the caregiver tells you about a feeding problem 2. Sami has a MUAC measurement of 112 mm. What does this tell you? a. Sami is healthy b. 112 mm is low weight, so you will advise on feeding recommendations c. Sami is showing a sign of severe acute malnutrition 3. A child with anaemia needs: a. Vitamin A b. Iron c. Glucose 4. Traci shows oedema in her feet. What are your actions? a. Sit Traci and elevate her legs, to drain the swelling b. Advise Traci’s mother to cut down the salts and fats in her child’s diet c. Urgently refer, as this is a sign of severe malnutrition 5. What is palmar pallor? a. A sign of anaemia b. A sign of local infection c. A sign of severe wasting 6. What is marasmus? a. A common skin infection in malnourished children b. A type of malnutrition where the child is very thin and lacks fat c. A type of malnutrition where the child has a puffy moon face and thin hair 7. Which of the following in an important measurement of wasting? a. Weight-for-age b. Percentage weight gain since last visit c. Weight-for-height (or length) After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

7

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.2

OPENING CASE STUDY

Consider a typical case that you might see in your practice. Imagine the situation. This will help you start thinking about the problem of a child with malnutrition or anaemia.

n  OPENING CASE STUDY – NOAH A young mother, Rachel, brings in her child Noah on a quiet morning in your clinic. You invite them into your clinic room. Rachel sits Noah on her lap. Rachel looks tired, and you ask how she came to the clinic this morning. She said she had to wait for a bus to come. It took a long time. The trip to the clinic is on a rough road and it is hot, so she does not feel very well. She said she was worried about Noah getting sicker during the long trip. Then, you examine Noah for possible signs of malnutrition or anaemia. You notice that his skin is very pale. You look at the skin of his palm and see that it is very pale. You tell Rachel that you are concerned that her son may have a nutritional deficiency. He can be treated, but she will have to learn about home care.

n  First, you gather important information in the greeting. You praise Rachel for bringing Noah in, especially because the trip is difficult and costs her money. You tell her that you were good to bring him in, and he is in an important age of growth and development, so it is good that we make sure he is healthy. You ask how old Noah is, and Rachel tells you he is 2 years old and 4 months. You ask what his problem is, and she tells you that he has had a cough for 3 days. You ask about the initial visit, and she says that this is their first time to the clinic for the cough. Noah weighs 12.7 kg and his temperature is 37 degrees Celsius.

n  Next, you check for general danger signs. You ask Rachel if Noah is able to drink, and she says yes, with no trouble. He is not vomiting. He has not had convulsions. You look at Noah’s condition, and he is sitting on Rachel’s lap and kicking his legs against her skirt. He coughs and looks around the room. Does Noah have any general danger signs?

n  Then you will assess Noah for main symptoms. You will first check for cough or difficult breathing. Rachel already identified Noah’s problem as a cough that has lasted for 3 days. You count Noah’s breaths in one minute. You count 35 breaths. You check for chest indrawing and stridor. Noah’s chest wall and abdomen move out when he breathes IN, and you hear no harsh noises. How will you assess Noah’s cough? Noah shows no signs of pneumonia. You tell Rachel that you think Noah’s cough is a cold, and can be treated at home with a safe remedy to soothe the throat and cough. You tell her that you will teach her about this later.

8

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

Then you ask Rachel if Noah has had diarrhoea, and she says no. You move to the next symptom, fever. Noah’s temperature is below the 37.5 degree point for fever. You ask if Noah has felt hot, or if he has had a fever recently. Rachel says no. You have assessed Noah for the symptoms we have learned about so far.

n  How will you complete Noah’s recording form thus far?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Noah Age: 26 mo Weight (kg): 12.7 kg Temperature (°C): 37 °C Initial Visit? X Follow-up Visit? Ask: What are the child's problems? Cough ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

3

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Yes __ No __

X

35

No

Cough or cold Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Now you will learn how to check Noah Has child had measels within the last 3 months? conditions. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

X

for

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and malnutrition and anaemia. You check One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

every child for these

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

9

Measles 2

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.3

INTRODUCTION TO MALNUTRITION

WHY DO YOU CHECK EVERY CHILD FOR MALNUTRITION? You have previously learned that malnutrition is a major underlying cause of death and illness in children . Even children with mild and moderate malnutrition have an increased risk of death. You will check all sick children for signs suggesting malnutrition. This is a very important part of the clinic visit. A caregiver may bring her child to clinic because the child has an acute illness. The child may not have specific complaints that point to malnutrition or anaemia. However, a child can be malnourished, but you or the child’s family may not notice the problem.

WHY IS IT SO IMPORTANT TO IDENTIFY CHILDREN WITH MALNUTRITION? A child with malnutrition has a higher risk of many types of disease and death. Even children with mild and moderate malnutrition have an increased risk of death. More than one out of three child deaths are linked to malnutrition. Identifying children with malnutrition and treating them can help prevent many severe diseases and death. Some malnutrition cases can be treated at home. Severe cases need referral to hospital for special feeding, blood transfusion for severe anaemia, or specific treatment of a disease contributing to malnutrition. You have a chance to make a real difference in a child’s health by assessing, classifying, and treating malnutrition and anaemia.

WHAT CAUSES MALNUTRITION? There are several causes of malnutrition. They may vary from country to country. A child whose diet lacks recommended amounts of essential vitamins, minerals, or other nutrients can develop malnutrition. The child may not be breastfeeding efficiently or eating enough of the recommended amounts of nutrients, like proteins and calories. They might not get enough specific vitamins, such as vitamin A, or minerals, such as iron. A child who has had frequent illnesses, HIV infection, or tuberculosis can also develop acute malnutrition. The child’s appetite decreases, and the food that the child eats is not used efficiently. Now you will read more about severe acute malnutrition. Malnutrition develops when a child’s diet lacks amounts of essential vitamins, minerals and other nutrients. Illness and disease can often cause malnutrition.

10

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

WHAT IS SEVERE ACUTE MALNUTRITION (SAM)? One type of malnutrition is severe acute malnutrition (SAM). Severe acute malnutrition develops when the child is not getting enough energy or protein and other nutrients from his food to meet his nutritional needs. You will learn to assess a child for severe acute malnutrition in the next section. It is also helpful to be aware of common clinical signs of SAM. Some clinical signs of a child with severe acute malnutrition can include: •• The child may become severely wasted (a sign of marasmus) •• The child may develop oedema (a sign of kwashiorkor)

This child is showing clinical signs of malnutrition like: •• Very thin body with reduced subcutaneous fat, especially on the arms, legs, and buttocks •• The belly may be distended •• The face may appear the same

This child is showing clinical signs of malnutrition like: •• Thin, sparse and pale (yellowish or reddish) hair that easily falls out •• Dry, scaly skin especially on the arms and legs •• A puffy or “moon” face •• Swelling of ankles and/or feet

In the next section you will learn how to assess for severe acute malnutrition using IMCI.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SELF-ASSESSMENT EXERCISE A Answer these questions about what you have read about malnutrition and anaemia.

1. What is malnutrition? 2. Why do you check every child for malnutrition and anaemia? 3. Are the following signs common presentations of severe acute malnutrition? Answer true or false. 1. Puffy face 2. Distended abdomen 3. Extremely thin body 4. Oedema of the feet 5. Scaly skin on legs 6. Rash on belly 7. Lack of fat on buttocks and arms 8. Child is crying from hunger 9. Thin hair that may fall out TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE

12

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.4

ASSESS MALNUTRITION

HOW DO YOU CHECK FOR MALNUTRITION? The assessment for malnutrition includes many important steps. This section is structured to help you learn each step in order. Open your ASSESS chart for malnutrition. What instructions do you observe? THEN CHECK FOR ACUTE MALNUTRITION CHECK FOR ACUTE MALNUTRITION LOOK AND FEEL: Look for signs of acute malnutrition FOR ALL CHILDREN: Look for oedema of both feet. FOR ALL CHILDREN: Determine WFH/L** ___ z-score. FOR CHILDREN 6 MONTHS AND OLDER: Measure MUAC*____ mm. If MUAC less than 115 mm, or WFH/L less than -3 zscore, or oedema of both feet: FOR ALL CHILDREN check if there is a medical complication: Any general danger sign Any severe classification Pneumonia with chest indrawing ADDITIONALLY FOR CHILDREN UP TO 6 MONTHS: Does the child have a breastfeeding problem?*** ADDITIONALLY FOR CHILDREN UP TO 6 MONTHS: Offer the child RUTF**** to finish within 30 minutes Does the child finish all the RUTF or not? Classify NUTRITIONAL STATUS

Oed OR WF sco MU (6 m

AND a follow

Med pre Bre (up Not note (6 m

MU mm WF sco AND

WHY ARE THERE SOME AGE DIFFERENCES IN THE ASSESS CHART? Severely malnourished infants under 6 months of age need special care. They should always be treated in inpatient care until full recovery. Remember that children under 6 months are assessed differently than children 6 months and older. For example, MUAC cannot be used for children less than 6 months.

No No pro mon Abl amo mon

NOW YOU WILL LEARN HOW TO ASSESS: You will now learn more about these instructions. We will think about the malnutrition assessment in two parts. First, you will assess for severe acute malnutrition (SAM): n PART 1: ASSESS FOR SAM Second, if there is SAM, you will assess for complications: n PART 2: WHEN SAM, ASSESS FOR COMPLICATIONS * MUAC is Mid-Upper Arm Circumference is measured using MUAC tape in a child 6 months or older. **WFH/L is Weight-for- height / Weight-for- Length is determined using the WHO growth standards charts. ***Refer to the FEEDING PROBLEM classification (yellow) for the sick young infant.

MU to 1 WF -2 oed

MU WF or m of b

****RUTF is Ready-to-Use Therapeutic Food for therapeutic feeding and conducting the appetite test for children

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

PART 1: ASSESS FOR SAM STEP 1: LOOK AND FEEL FOR OEDEMA OF BOTH FEET The first step when assessing for SAM is looking and feeling for oedema of both feet.

WHAT IS OEDEMA? Oedema is when an unusually large amount of fluid gathers in the child’s tissues. The tissues become filled with the fluid and look swollen or puffed up. If a child has oedema of both feet they should be referred to inpatient care.

HOW WILL YOU ASSESS FOR OEDEMA? LOOK and FEEL to determine if the child has oedema of both feet. Using your thumbs, press the topside of both feet simultaneously for 3 seconds on the top side of each foot. The child has oedema if a dent remains in the child’s foot when you lift your thumb. See the photo below as an example:

REMEMBER! Oedema of both feet means severe acute malnutrition. ALL CHILDREN WITH OEDEMA OF BOTH FEET SHOULD BE REFERRED TO A HOSPITAL.

14

PHOTO: UNICEF

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

STEP 2: MEASURE WEIGHT-FOR-HEIGHT OR LENGTH By comparing a child’s weight to his/her height or length, you can measure how thin the child is. If the weight-for height or length is low, the child is wasted. This is an important measurement of acute malnutrition. You have also learned wasting is an important sign of marasmus.

WHY USE WEIGHT-FOR-HEIGHT? You might be familiar with other ways to measure a child’s growth, like weight-forage, or height-for-age. These measurements do not indicate acute malnutrition in the same way that weight-for-height does. You will learn about these other ways to measure growth in the WELL CHILD CARE module.

WHAT IS THE DIFFERENCE BETWEEN LENGTH AND HEIGHT? There is an important difference between height and length for you to remember. They are measured differently for certain age groups. n LENGTH is measured when the child is lying down. This is used for children below 2 years of age or if the child is too weak to stand. n HEIGHT is measured when the child is standing upright. This is used for all other children. NOTE: the height of a child is 0.7 cm shorter than length. Therefore in case you measure a child 2 years or older using length instead of height, subtract 0.7 cm from the measurement.

HOW WILL YOU MEASURE A CHILD’S LENGTH? Remember that length is used for children under 2 years, or those too weak to stand. One assistant should hold the child’s head over the ears and with straight arms. The measurer hold one hand on the child’s knees keeping the legs straight and the other on the foot-place to read the length. The child should lie flat on the board.

Once you have measured the child’s length, you will use the weight and length to calculate a child’s Z-score

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

HOW WILL YOU MEASURE A CHILD’S HEIGHT? Remember that height is used for children 2 years and older. The assistant should hold the child’s knees to keep the legs straight with one hand, and the other hand on the shins to keep the heels against the back and base of the board. The measurer should hold one hand the child’s chin and the other on the head-piece to read the height. The child’s eyes should the in horizontal level and the body flat against the board.

Once you have measured the child’s height, you will use the weight and height to calculate a child’s Z-score

HOW DO YOU CALCULATE A CHILD’S Z-SCORE? Once you have the child’s weight and height/length, you will calculate their Z-score. This is basically a score comparing the weight-for-height/length of children across the world. Children with low Z-scores have low weight-for-height/length. The Z-score does not require any math. You will use an easy chart, which you can refer to your IMCI Chart Booklet. 1. THERE ARE SEPARATE CHARTS FOR HEIGHT (2 to 5 years) and LENGTH (birth to 2 years)

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

2. DETERMINE WHICH CHART TO USE BASED ON THE CHILD’S SEX It is important to note that there are two separate charts for females and males. They cannot be used interchangeably.

3. MARK THE INTERSECTION OF THE CHILD’S WEIGHT AND HEIGHT Next you will find the intersection of the weight and height. The numbers for weight (kg) run up the chart, and guiding lines run across the chart. The numbers for height (cm) are along the bottom of the chart, and the guiding lines run up the chart. Let us review an example. Ben is 10.5 kg and 82 cm. See how we find the intersection:

1. Locate the child’s weight: 10.5 kg

2. Locate child’s height: 82 cm

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

4. USE THE INTERSECTION POINT TO FIND THE Z-SCORE Think about the Z-scores like zones between two lines. Look at the figure below. You should be most worried about any weight-for-height intersection points that fall: ✔ Between the -2Z and -3Z lines, like the circle below. This is moderate malnutrition. ✔ Below the -3Z line, like the star below. This is severe malnutrition.

Between -2Z and -3Z is moderate malnutrition

Below -3Z is severe malnutrition

WHAT DO YOU DO AFTER CALCULATING A CHILD’S Z-SCORE? Children above the -2Z score are not malnourished. However you should routinely check children because their nutrition status can change rapidly. If children are between -2Z and -3Z, or below -3Z, you will use this information to classify their acute malnutrition. You will learn this in the next section. REMEMBER! WFH/L below -3Z means severe acute malnutrition

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SELF-ASSESSMENT EXERCISE B Plot weight and height on the chart. Use a dot that is very clear. Determine the Z score.

1. 76 cm, 9 kg 2. 80 cm, 7.5 kg 3. 90 cm, 11.2 kg 4. 93 cm, 11 kg 5. 85 cm, 12 kg

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

STEP 3: MEASURE MUAC (only for children 6–59 months) WHAT IS MUAC? The measurement around the middle of a child’s upper arm is an important indicator of acute malnutrition in a child. This is called mid-upper arm circumference (MUAC). The MUAC strip is a flexible measuring tape that measures in millimetres (mm). MUAC can only be used for children 6–59 months.

HOW DO YOU READ THE MUAC STRIP? Examine your own MUAC strip, and refer to the picture below. The first thing you should note about your MUAC strip is that there are three different colours: green, yellow, and red to note danger of child’s MUAC.

There are two important pieces of the MUAC strip you should note in the picture above. The first is the slit where you will insert the MUAC strip. The next is the window where you will read the child’s MUAC in mm. Children with a MUAC less than 115 mm have severe acute malnutrition. This measurement is red on the MUAC strip. These children need special treatment.

HOW DO YOU MEASURE THE CHILD’S MUAC? The steps and the figure below explain how to measure the child’s MUAC. •• •• •• •• Find the mid-point of the child’s upper arm between the shoulder and elbow. Use MUAC tape to mark the midpoint on the child’s arm. Hold the large end of the strap against the arm at the midpoint of the arm. Put the other end of the strap around the child’s arm. Thread the end up through the second small slit in the strap. The end will come from behind. •• Pull both ends until the strap fits closely. It should not be so tight that it makes folds in the skin. It should also not be too loose. •• Gently press the window. At the marks note the measurement and colour.

REMEMBER! MUAC below 115 mm (RED) means severe acute malnutrition

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SIGNS OF SEVERE ACUTE MALNUTRITION: A REVIEW BELOW ARE THE SIGNS OF A CHILD LESS THAN 6 MONTHS WITH SAM: •• Infant has oedema of both feet •• Weight-for-length is less than 3 z-score

BELOW ARE THE SIGNS OF A CHILD 6 MONTHS AND OLDER WITH SAM: •• Child has oedema of both feet •• Weight-for-height/length is less than 3 z-score •• MUAC is 115 mm or below

WHAT DO YOU DO IF ANY OF THESE SIGNS ARE PRESENT? If any signs are present, you will look for other clinical complications. You will learn about these next.

WHAT IF NO SIGNS OF SAM ARE PRESENT? If none of the three signs above are present, you will move to CLASSIFY the child’s nutrition status using your IMCI charts.

REMEMBER! IF ANY OF THE SIGNS OF SEVERE ACUTE MALNUTRITION ARE PRESENT, YOU WILL LOOK FOR OTHER CLINICAL COMPLICATIONS.

SELF-ASSESSMENT EXERCISE C Exercises on signs of severe acute malnutrition.

1. What is the child’s Z-score? Tick the correct box. Child is: a. Boy, 18 months, length 75 cm, weight 8.5 kg b. Boy, 30 months, height 118 cm, weight 22 kg c. Girl, 11 months, length 70 cm, weight 6 kg d. Girl, 27 months, weight 11 kg, height 95 cm e. Boy, 7 months, length 60 cm, weight 5 kg f. Girl 32 months, length 111 cm, weight 14.5 kg g. Boy, 26 months, weight 14.5 kg, height 113 cm h. Girl, 32 months, height 111 cm, weight 16.5 kg i. Girl, 20 months, length 100 cm, weight 14.5 kg Below -3 Between -3 and -2 Between -2 and -1 Between -1 and 0 Between 0 and 3

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

2. Which of the children above are moderately malnourished based on their Z-scores?

3. Which of the children above have severe acute malnutrition based on their Z-scores?

4. Do the children below have signs of severe acute malnutrition? Tick YES or NO. If NO, answer why not. TICK: Child is: a. Child’s MUAC is 112 mm b. Child has Z-score between -2 and -3 c. Child has a swollen right foot and is very skinny d. Child is too weak to stand e. Child’s MUAC is 113.5 f. Child has oedema of both feet g. MUAC is 120 mm and child is irritable Signs of SAM No signs of SAM

WRITE: If no, why not?

5. What clinical sign does this picture show?

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

PART 2: WHEN SAM, ASSESS FOR COMPLICATIONS IF CHILD IS UNDER 6 MONTHS: If the child is under 6 months, you will do two steps: 1. Check the child for medical complications. These are discussed below. 2. Check the child for a breastfeeding or feeding problem. Refer to the sick young infant assessment chart for FEEDING PROBLEM.

WHEN WILL YOU CHECK A CHILD FOR CLINICAL COMPLICATIONS? If the child has the following complications, it must be noted for their assessment: •• General danger sign or sign of severe illness, done at the beginning of ASSESS •• Any severe (red) classification •• Pneumonia with chest indrawing

IF CHILD IS 6 MONTHS AND OLDER: If the child is 6 months and older, you will do two steps: 1. Check the child for medical complications, as was described above. 2. Conduct an appetite test with RUTF.

WHEN WILL YOU CONDUCT AN APPETITE TEST? Review your ASSESS chart again. You just learned how to check children with signs of SAM for other clinical complications. Additionally, if these children are 6 months or older, you will also need to conduct an appetite test. If a child is 6 months or older, and shows signs of severe acute malnutrition, you should conduct an appetite test. You will assess appetite by giving the child some Ready-to-use Therapeutic Food (RUTF) to try at the site.

HOW WILL YOU PREPARE TO GIVE A CHILD AN APPETITE TEST? A child may refuse to eat RUTF because it is unfamiliar and because the child is in a strange environment. In this case, the caregiver should move to a quiet, private area and slowly encourage the child to take the RUTF. The health worker will also need to move to this area, because you must observe the child eating the RUTF before classifying.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

HOW WILL YOU CONDUCT AN APPETITE TEST? To carry out the appetite test, it is important to follow the steps listed below: 1. The appetite test should be conducted in a separate quiet area. 2. Explain to the caregiver the purpose of the appetite test. Explain how it will be carried out. 3. The caregiver should wash her hands. 4. The caregiver should sit comfortably with the child on his lap. She should offer the RUTF from the packet, or put a small amount on her finger and give it to the child. 5. The caregiver should offer the child the RUTF gently, encouraging all the time. If the child refuses, then the caregiver should continue to quietly encourage the child. She can take time for the test. The child must not be forced to take the RUTF. 6. The child needs to be given plenty of water from a cup as he/she is taking the RUTF.

HOW DOES A CHILD ‘PASS’ THE APPETITE TEST? To pass the test, the child must eat the RUTF quantities in table below within 30 minutes. Minimum RUTF amount child should eat within 30 minutes to pass the appetite test Number of sachets the child should consume willingly during the test (sachets = 500 Kcal, or 92 g)a Weight of the child Minimum Maximum

< 4 kg 4 up to 6.9 kg 7 up to 9.9 kg 10 up to 14.9 kg 15 kg and above a

1/8 1/4 1/3 1/2 3/4

1/4 1/3 1/2 3/4 1 or above

Note: quantities should be adjusted if RUTF is available in containers or in packaging with different weights.

ARE THERE ANY TIMES WHEN AN APPETITE TEST SHOULD NOT BE CONDUCTED? There are some scenarios where the child is showing signs of severe malnutrition but does not need an appetite test. If a child has any general danger signs, the appetite test is not done. The appetite test is also not done in children who have pneumonia, persistent diarrhoea, dysentery, measles, or malaria. If RUTF is not available for an appetite test, refer.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SELF-ASSESSMENT EXERCISE D Complete the exercises below on steps you will take with children who have signs of SAM.

1. What are the three signs of severe acute malnutrition? 1. 2. 3. 2. When evaluating a SAM child for hypothermia, how will you evaluate if the child has a low body temperature?

3. Are the following true or false statements? Circle your answer. If false, write the correct statement. a. Aram is 5 months old, and has a z-score of less than -3. You will immediately begin an appetite test. b. A child must consume the RUTF within 30 minutes for an appetite test, so the caregiver should rush the child to finish quickly. c. Masha’s blood sugar level is 52.5 mg/dL. She is hypoglycaemic. d. Shock is an important clinical complication of SAM to evaluate for. TRUE  FALSE

TRUE  FALSE TRUE  FALSE TRUE  FALSE

4. Boniface weighs 9.9 kg. What is the minimum amount of the RUTF sachet he should consume to pass an appetite test?

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n  How will you assess Noah for acute malnutrition? You have completed Noah’s IMCI assessment up to malnutrition. You know that you need to check all children for these conditions. First you will check Noah for the three signs of severe acute malnutrition. You check Noah for oedema of both feet. You see no swelling. Noah’s weight is 12.7 kg, which you measured at the beginning of the visit using a solar scale. He was able to stand on this himself for measurement. Noah’s height is 104 cm. What is Noah’s Z-score? You measure his MUAC, which is 116 cm. While you measure his MUAC, you encourage Rachel to keep him calm on her lap. Then you explain to Rachel that you need to measure his height. You ask for her help in doing so, and she agrees. You explain each step as you go.

n  Does Noah have any signs of severe acute malnutrition? Let us review the results of checking Noah for signs of severe acute malnutrition: 1. There is no oedema of both feet 2. WFH z-score is -3Z: this qualifies as SAM 3. MUAC is 116 cm: this is above the 115 cm required for SAM Noah is showing at least one sign of SAM because he has a WFH Z-score under -3Z. Now you will need to evaluate him for medical complications. As he is over 6 months of age, you will also conduct an appetite test.

n  How will you check Noah for other medical complications? You check Noah for common medical complications in children with malnutrition, including shock, hypothermia, hypoglycemia, and infections. Earlier in your assessment you classified Noah’s cough as COUGH OR COLD, and not an acute respiratory infection like pneumonia. You do not see any medical complications.

n  How will you conduct an appetite test for Noah? Noah weighs 12.7 kg, so here is the amount of minimum RUTF he must eat during the appetite test. You will give him about 30 minutes. Minimum RUTF amount child should eat within 30 minutes to pass the appetite test Number of sachets the child should consume willingly during the test (sachets = 500 Kcal, or 92 g)a Weight of the child Minimum Maximum

10 up to 14.9 kg

1/2

3/4

You explain to Rachel that you want to see how strong Noah’s appetite is. Your clinical space is quiet, so you have Rachel and Noah sit on the side. Rachel washes her hands. You explain to Rachel how to give the RUTF directly from the packet, and how to encourage Noah. You emphasize that she should not force Noah. You also provide a cup of water for her to give Noah. He slowly takes the RUTF and about 20 minutes into the test, he has eaten over ½ of the sachet. You tell Rachel that he has done a good job eating, and he does not need to anymore. Now you will learn how to classify Noah based on his signs.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.5

CLASSIFY MALNUTRITION

HOW DO YOU CLASSIFY SIGNS OF MALNUTRITION? After you complete the assessment for malnutrition, you will classify. There are FOUR classifications for malnutrition: 1. COMPLICATED SEVERE ACUTE MALNUTRITION 2. UNCOMPLICATED SEVERE ACUTE MALNUTRITION 3. MODERATE ACUTE MALNUTRITION 4. NO MALNUTRITION Oedema of both feet, OR WFH/L less than -3 Z score, OR MUAC less than 115 mm (6 months or older) AND any one of the following: Medical complication present, OR Breastfeeding problem (up to 6 months), OR Not able to finish the noted amount of RUTF (6 months and older) MUAC less than 115 mm, OR WFH/L less than-3 Z score AND No medical complication No breastfeeding problem (under 6 months) Able to finish the noted amount of RUTF (6 months and older) MUAC between 115 up to 125 mm, OR WFH/L between -3 and - 2 Z scores and no oedema of both feet MUAC over 125 mm, OR WFH/L Z scores are -2 or more and no oedema of both feet Yellow: MODERATE ACUTE MALNUTRITION Yellow: UNCOMPLICATED SEVERE ACUTE MALNUTRITION Give oral antibiotics for 5 days. Give ready-to-use therapeutic food for a child aged 6 months or more Re-establish effective breast feeding for a child aged less than 6 months 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 Pink: COMPLICATED SEVERE ACUTE MALNUTRITION Give first dose appropriate antibiotic Treat the child to prevent low blood sugar Keep the child warm Refer URGENTLY to hospital

ONAL

Assess the child's feeding and counsel the mother on the feeding recommendations. If feeding problem, follow up in 7 days Assess for possible TB infection. Advise mother when to return immediately Follow-up in 30 days If child is less than 2 years old, assess the child's feeding and counsel the mother on feeding according to the feeding recommendations If feeding problem, follow-up in 7 days

Green: NO ACUTE MALNUTRITION

in a child 6 months or older.

he WHO growth standards charts.

Now you will read about each of these classifications.

ung infant.

conducting the appetite test for children with severe acute malnutrition.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

COMPLICATED ACUTE SEVERE MALNUTRITION (RED) Remember that signs of severe acute malnutrition that you have assessed for include MUAC less than 115 mm, weight-for-height lower than -3 Z, or include oedema of both feet. The child is classified as COMPLICATED SEVERE ACUTE MALNUTRITION when they have severe acute malnutrition and one of the following complications: •• At least one medical complication, including any general danger sign, any severe classification, or pneumonia with chest indrawing •• No appetite, determined failed appetite test in a child 6 months or older •• A feeding problem in children under 6 months according to the FEEDING PROBLEM classification for the young infant What are your actions? Children classified as having SEVERE COMPLICATED MALNUTRITION are at high risk of death from pneumonia, diarrhoea, measles, and other severe diseases. These children need urgent referral to hospital where their treatment can be carefully monitored. They may need special feeding, antibiotics or blood transfusions. Before the child leaves for hospital you should give: •• The first dose of amoxicillin •• 50 ml of 10% glucose or sucrose solution; if you do not have solution this is one rounded teaspoon of sugar in three tablespoons of water •• Keep the child warm

UNCOMPLICATED SEVERE ACUTE MALNUTRITION (YELLOW) If the child has at least one sign of severe acute malnutrition, but passed the appetite test or does not other signs of complication, they are classified as UNCOMPLICATED SEVERE ACUTE MALNUTRITION. What are your actions? These children need urgent treatment-based RUTF, deworming, and oral antibiotics. These children are at risk of death from serious diseases. Check if the child is at high risk of HIV infection, whether s/he has been vaccinated for measles, and test for malaria. You will learn how to provide treatment-based RUTF later in this module. You will also learn how to counsel the caregiver on giving RUTF. A child with SEVERE UNCOMPLICATED MALNUTRITION should return for follow-up after 1 week.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

MODERATE ACUTE MALNUTRITION (YELLOW) If the child’s weight-for-age is between -3 and -2 Z-score or MUAC between 115 and 125, classify as MODERATE ACUTE MALNUTRITION. What are your actions? A child classified as having MODERATE ACUTE MALNUTRITION has a higher risk of severe disease. Assess the child’s feeding and counsel the caregiver about feeding her child according to the recommendations in the FOOD box on the COUNSEL chart and in the WELL CHILD CARE module. You should also consider screening the child for HIV and TB and same medications as above. If the child has a feeding problem, they should follow-up in 5 days. If there is no feeding problem, the child should follow-up in 30 days.

NO ACUTE MALNUTRITION (GREEN) If the child has a weight-for-age over -2 Z-scores, and has no other signs of malnutrition, classify as NO ACUTE MALNUTRITION. If the child is less than 2 years of age, assess the child’s feeding. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children. Counsel the caregiver about feeding her child according to the recommendations in the FOOD box on the COUNSEL chart and in the WELL CHILD CARE module.

n  How will you classify Noah’s malnutrition? Noah shows one sign of SAM, a WFH Z score under -3Z. He does not have oedema or any clear medical complications. He passed his appetite test. You classify him as UNCOMPLICATED SEVERE ACUTE MALNUTRITION (yellow).

n  What treatments are identified for Noah? Noah needs immediate treatment, as he is at risk of death from serious diseases given his nutrition status. You identify his treatments for this classification as: ✔✔ Treatment-based RUTF ✔✔ Oral antibiotics ✔✔ Deworming Now you will learn how to provide these treatments to Noah.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SELF-ASSESSMENT EXERCISE E Practice classifying malnutrition.

1. How will you classify the following children? Tick the appropriate box. Complicated severe acute malnutrition Uncomplicated severe acute malnutrition Moderate acute malnutrition No acute malnutrition

a. Child has MUAC of 112 mm and no complications b. Child has WFH z-score less than -3 and failed the appetite test c. Child has MUAC of 112 mm d. Child has MUAC of 117 mm and no oedema e. Child’s WFH z-score is between -1 and -2 f. Child has WFH z-score between -3 and -2 g. Child has MUAC of 113 mm and is showing signs of shock h. Child is less than 6 months, has lost weight and not breastfeeding effectively

2. You classify a child as UNCOMPLICATED SEVERE ACUTE MALNUTRITION. What are the primary treatments you have identified for this classification?

3. When will you advise this child to return for follow-up?

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.6

TREAT MALNUTRITION

WHAT TREATMENTS ARE IDENTIFIED FOR MALNUTRITION? Review your classification table for malnutrition. It identifies the following treatments:

Oedema of both feet, OR WFH/L less than -3 Z score, OR MUAC less than 115 mm (6 months or older) AND any one of the following: Medical complication present, OR Breastfeeding problem (up to 6 months), OR Not able to finish the noted amount of RUTF (6 months and older) MUAC less than 115 mm, OR WFH/L less than-3 Z score AND No medical complication No breastfeeding problem (under 6 months) Able to finish the noted amount of RUTF (6 months and older) MUAC between 115 up to 125 mm, OR WFH/L between -3 and - 2 Z scores and no oedema of both feet MUAC over 125 mm, OR WFH/L Z scores are -2 or more and no oedema of both feet

Pink: COMPLICATED SEVERE ACUTE MALNUTRITION

Give first dose appropriate antibiotic Treat the child to prevent low blood sugar Keep the child warm Refer URGENTLY to hospital

Yellow: UNCOMPLICATED SEVERE ACUTE MALNUTRITION

Give oral antibiotics for 5 days. Give ready-to-use therapeutic food for a child aged 6 months or more Re-establish effective breast feeding for a child aged less than 6 months 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

Yellow: MODERATE ACUTE MALNUTRITION

Assess the child's feeding and counsel the mother on the feeding recommendations. If feeding problem, follow up in 7 days Assess for possible TB infection. Advise mother when to return immediately Follow-up in 30 days If child is less than 2 years old, assess the child's feeding and counsel the mother on feeding according to the feeding recommendations If feeding problem, follow-up in 7 days

Green: NO ACUTE MALNUTRITION

arts.

or children with severe acute malnutrition.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

You have already learned about several of the treatments listed in this chart:

➞ Give all children oral antibiotics for 5 days (Module 3) ➞ Treat for low blood sugar if child is being referred (Module 1) The treatments that you will read about now include:

➞ Give RUTF to children with UNCOMPLICATED SEVERE ACUTE MALNUTRITION (yellow)

➞ How to manage children with severe acute malnutrition AND dehydration, as dehydration should be managed differently when the child has malnutrition (also refer to Module 4) Counselling on feeding problems is discussed in module 8, care of the well child

HOW WILL YOU GIVE RUTF? A child classified as UNCOMPLICATED SEVERE ACUTE MALNUTRITION must receive RUTF. The caregivers will provide RUTF. RUTF is the only food that thin children need for their recovery. If the child is young and still breastfeeding, this should continue. It is important to remember that RUTF is a therapeutic treatment and must be given in correct quantity. Quantities of RUTF are given according to the child’s weight, in the table: Weight of the child (kg) RUTF paste grams per day grams per week RUTF Sachetsa (500 Kcal sachets, or 92 g) sachets per day sachets per week

4.0–4.9 5.0–6.9 7.0–8.4 8.5–9.4 9.5–10.4 10.5–14.9 15.0–19.9 20.0–29.9 a

190 230 280 320 370 400 450 550

1300 1600 1900 2300 2600 2800 3200 3900

2 2½ 3 3½ 4 4½ 5 6

14 18 21 25 28 32 35 40

Note: quantities should be adjusted if available in containers or in packaging with different weights.

HOW WILL YOU COUNSEL THE CAREGIVER ABOUT GIVING RUTF? You will start a child immediately on RUTF, and the caregivers will continue the treatment. There are several key messages for the caregiver about RUTF: •• Wash hands before giving RUTF •• Sit with child on the lap and gently offer the RUTF •• Encourage the child to eat the RUTF without forced feeding

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

•• Give small, regular meals of RUTF, and encourage child to eat often (5-6 meals per day) •• If still breastfeeding, should continue by offering breast milk first before every RUTF feed •• Offer plenty of clean water, to drink from a cup, when the child is eating the RUTF

WHEN SHOULD THE CHILD RECEIVING RUTF RETURN FOR FOLLOW-UP? A child with UNCOMPLICATED SEVERE MALNUTRITION should return for follow-up after 1 week. Advise the caregiver to return immediately if the child does not eat RUTF.

WHEN SHOULD THE CHILD STOP RUTF? RUTF should be given until the weight-for-height is above -2 z scores for 2 consecutive visits OR there is 15% weight gain. The child should be well and alert. If the child presents with oedema, he will lose weight as the swelling goes down and he begins to improve. RUTF should not be stopped until the child has achieved weight gain as described above, AND the oedema has disappeared and been gone for at least two weeks. RUTF is stopped after the child gains appropriate weight, AND there have been no signs of oedema for at least 2 weeks.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

SELF-ASSESSMENT EXERCISE F Answer the following questions about RUTF treatment.

1. How much RUTF should the following children be given for a week’s supply? a. 3.7 kg, paste available b. 16.7 kg, sachets available c. 7.8 kg, sachets available d. 11.6 kg, paste available 2. When should the child receiving RUTF follow-up?

3. List three important counselling messages about providing RUTF at home: 1. 2. 3. 4. List three checking questions to see if the caregiver understands how to provide home treatments: 1. 2. 3. 5. Should the following children stop RUTF? Tick your answer. a. Tsepi (boy) now weighs 13.5 kg, and is 96 cm in height. Last visit he weighed 13 kg. CONTINUE RUTF STOP RUTF

    

    

b. Rakim’s weight has changed from 20.5 kg to 23 kg. c. Angie (girl) weighs 15.5 kg and is 109 cm in height. Last visit she weighed 14.5. d. Sheena’s weight has changed from 32.5 kg to 38.0 kg. e. Maria (girl) now weighs 17.2 kg and is 116 cm in height. Last visit she weighed 17.3 kg.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

HOW YOU MANAGE CHILDREN WITH SAM AND DEHYDRATION? In Module 4 you have learned to assess for dehydration. If a child has severe acute malnutrition and signs of dehydration, they must be managed differently. There are two classifications for dehydration. Let us revisit these and the actions to be taken.

SEVERE DEHYDRATION All children with severe dehydration should be urgently referred.

SOME DEHYDRATION If the child has some dehydration they can be treated in the health facility. Children with SAM and some dehydration should not be treated with normal ORS. This is because normal ORS has high sodium and low potassium content, which is not suitable for severely malnourished children.

n  Treating dehydration in children with SAM PREFERRED: ReSoMal If available, give ReSoMal 5 ml/kg every 30 minutes the first 2 hours, and 5-10 ml/kg per hour for the next 4-10 hours on alternate hours with RUTF. IF ReSoMal NOT AVAILABLE: ½ STRENGTH ORS If ReSoMal is not available prepare half strength ORS with concentrated electrolyte/mineral solution in same doses as ReSoMal. NEITHER AVAILABLE: REFER If ReSoMal is not available and half strength ORS cannot be prepared, urgently refer to the nearest hospital.

HOW LONG WILL YOU GIVE RESOMAL OR HALF STRENGTH ORS? A child with SAM and some dehydration cannot be sent home before improvement is seen. The child should be assessed every 30 minutes for the first 2 hours and every hour for the next 4–10 hours. If the child improves the caregiver can be sent home with ReSoMal/half strength ORS for two days. She should give 50–100 ml after each loose stool. Tell the caregiver to return urgently if the child is not improving and to come back for follow-up after the two days. If the child is deteriorating or not improving she/he should urgently be referred. You have completed assessing, classifying, and treating malnutrition. Now you will learn about the IMCI process for anemia.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.7

ASSESS & CLASSIFY ANAEMIA

WHAT IS ANAEMIA? Anaemia is a reduced number of red cells or a reduced amount of haemoglobin in each red cell. Iron deficiency anaemia is considered to be the most common cause of anaemia, but other causes include deficiencies in folate, Vitamin B12, and Vitamin A. Besides iron deficiency, a child can also develop anaemia as a result of: ✔✔ Infections ✔✔ Parasites, such as hookworm or whipworm, that can cause blood loss from the gut ✔✔ Malaria, which can destroy red cells rapidly. Children can develop anaemia if they have repeated episodes of malaria or if malaria was inadequately treated. The anaemia may develop slowly. Often, anaemia in these children is due to both malnutrition and malaria.

HOW DO YOU CHECK FOR ANAEMIA? Open your ASSESS chart for anaemia. What instructions do you observe? THEN CHECK FOR ANEAMIA Check for aneamia Decide Malaria Risk: High or Low Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? Do a malaria test If high malaria risk and some pallor present

Severe Classify ANEAMIA Classification arrow

Some

HOW WILL YOU DETERMINE MALARIA RISK? Before you begin, determine is the malaria risk is high or low. Remember that you learned about high and low risk malaria areas in the beginning of Module 5 on Fever. It is also important to remember that a child can live in a low risk area, but you need to check if the child has travelled to a high risk area. You will do a malaria test if the child has high malaria risk and shows sign of some pallor. * If malaria test not available in malaria high risk, give oral antimalarial. ** If child has severe acute malnutrition, DO NOT give iron.

No pal

HOW WILL YOU LOOK FOR PALMAR PALLOR?

Pallor is unusual paleness of the skin, and is a sign of anaemia. Palmar pallor means it is identified in the palm of the hand. LOOK at the skin of the child’s palm. Hold the child’s palm open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause pallor by blocking the blood supply. Compare the colour of the child’s palm with your own palm and with the palms of other children. The child has some palmar pallor if the skin of the child’s palm is pale. The child has severe palmar pallor if the skin of the palm is very pale or so pale that it looks white. A good example of severe palmar pallor is in the picture to the right.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

HOW DO YOU CLASSIFY SIGNS OF ANAEMIA? What do you observe about the classification chart for anaemia? You will see how palmar pallor is the important sign. There are 3 classifications for anaemia. These are: 1. SEVERE ANAEMIA 2. ANAEMIA 3. NO ANAEMIA

Severe palmar pallor

assify NEAMIA Classification arrow

Pink: SEVERE ANAEMIA Yellow: ANAEMIA

Refer URGENTLY to hospital

Some pallor

Give iron** Give oral antimalarial if malaria test postive* 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 Follow-up in 14 days If child is less than 2 years old, assess the child's feeding and counsel the mother according to the feeding recommendations If feeding problem, follow-up in 5 days

No palmar pallor

Green: NO ANAEMIA

ial.

SEVERE ANAEMIA (RED) A child with severe palmar pallor has severe anaemia and should be referred urgently.

ANAEMIA (YELLOW) A child with some palmar pallor should be classified as having ANAEMIA. The child should be given iron. Asses for malaria with in all children with some palmar pallor. In addition, the anaemia may be due to malaria, hookworm, or whipworm. If the child’s malaria test is positive, you should give oral antimalarials. Hookworm and whipworm infections contribute to anaemia because the loss of blood from the gut results in iron deficiency. Give the child mebendazole only if there is hookworm or whipworm in the area. Only give mebendazole if the child with anaemia is 1 year or older and has not had a dose of mebendazole in the previous 6 months. You can review the dosage in your TREAT charts. You will also learn more about deworming in in the WELL CHILD CARE module.

NO ANAEMIA (GREEN) If the child has no palmar pallor, classify the child as having no anaemia and not very low weight. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children do. If the child is less than 2 years of age, assess the child’s feeding. Page 10 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

Watch “Assess for malnutrition, anaemia, & ear problems” (disc 2) This video clip reviews all steps of assessing for malnutrition and anaemia. You will return to watch the ‘ear problems’ portion. NOTE: video also covers feeding problems, which you will learn about in the WELL CHILD CARE module.

SELF-ASSESSMENT EXERCISE G Answer the following questions about malnutrition and anaemia.

1. Match the following key terms with their definitions. These are important concepts for nutrition. MATCH THIS TERM … … WITH A DEFINITION

Anaemia Oedema Pallor

A food product that is used for the safe therapeutic feeding of SAM children. A sign that is identified by looking at a child’s palm. A reduced number of red cells or a reduced amount of haemoglobin in each red cell, caused by not eating foods rich in iron, folate, Vitamin 12 and A; parasites, malaria; or other infections. Unusual paleness of the skin, and a sign of anaemia. When an unusually large amount of fluid gathers in the child’s tissues. The tissues become filled with the fluid and look swollen or puffed up.

RUTF Palmar pallor

2. Ned has severe palmar pallor – his hands are nearly white. How will you classify him?

3. You classify a child as SOME PALMAR PALLOR. What treatments are identified for this classification?

4. Lisa has been classified as SOME DEHYDRATION and SEVERE ACUTE MALNUTRITION. How will you take action now? a. Give ORS and zinc as per the diarrhoea charts b. Give ReSoMal in the clinic c. Advise the caregiver on how to give half strength ORS and RUTF at home

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MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present)

IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA Age: Weight (kg): Initial Visit?

Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting you want to classifications

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

n  How will you check Noah for anemia?

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

You take Noah’s hands and survey his palms. You fold his fingers back and tell Rachel that compare the colorHAVE of their palms. Rachel also BREATHING? puts her hand out. Noah’s palms are quite a bit paler his DOES THE CHILD COUGH OR DIFFICULT Yes than __ No __ For how long? ___ Days Count the breaths in one minute mother’s. They are pale, but not white. ___ breaths per minute. Fast breathing? How will you classify Noah? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Noah did show some palmar pallor, a sign of anemia. You review your classification chart for anemia and DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: classify Noah with SOME ANAEMIA (YELLOW). If his palmar pallor was severe--that is, his hands were white-Is there blood in the stool? Lethargic or unconscious? Restless and irritable? you would have classified him with SEVERE ANAEMIA.

n  How does Noah’s recording form look now?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Look or feel for stiff neck Decide Noah malaria risk: High ___ Low ___ No___ Name: Age: 26 mo Weight (kg): 12.7 kg Temperature (°C): 37 °C Look for runny nose how long? Days What are the ___ child's problems? Initial Visit? X Follow-up Visit? Ask:For Cough Look for signs of MEASLES: If more than 7 days, has fever been present every ASSESS (Circle all signs present) CLASSIFY Generalized rash and day? CHECK FOR DANGER SIGNS Has child hadGENERAL measels within the last 3 months? NOT ABLE DRINK OR BREASTFEED Do malaria test TO if NO general danger sign VOMITS EVERYTHING High risk: all fever cases CONVULSIONS Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? One of these: cough, runny nose, or red eyes Look for any other cause of fever. LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

X

Look for mouth ulcers. If the child has measles now or within the If yes, are they deep and extensive? last 3 months: DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE AN EAR PROBLEM? DOES THE CHILD HAVE DIARRHOEA? THEN CHECK FOR ACUTE MALNUTRITION For how long? ___ Days AND ANAEMIA Is there blood in the stool? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

14

Look for pus draining from the eye. Count the breathsof inthe one minute Look for clouding cornea. ___ breaths per minute. Fast breathing? Look for chest indrawing Look pus draining from the ear Look for and listen for stridor Feel tender behind the ear Lookfor and listenswelling for wheezing

Yes __ No __

X

35

No

Yes __ No __ Cough or cold Yes __ No __

Look for oedema of both feet. Look at the childs general condition. Is the child: Determine WFH/L _____ Z score. Lethargic or unconscious? For children 6 months or older measure MUAC ____ mm. Restless and irritable? Look for palmar pallor. Look for sunken eyes. Severe palmar pallor? Some palmar pallor? Offer the child fluid. Is the child: Is there any medical complication? If child has MUAC less than 115 mm or Not able to drink or drinking poorly? General danger sign? WFH/L less than -3 Z scores or oedema of Drinking eagerly, thirsty? Any severe classification? Pinch the skin of the abdomen. Does it go back: both feet: Pneumonia with chest indrawing? Very slowsly (longer then 2 seconds)? For a child 6 months or older offer RUTF to eat. Is the child: Slowly? Not able to finish or able to finish? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) For a child less than 6 months is there a breastfeeding problem? Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ CHECK FOR HIV INFECTION Look for runny nose For how long? and/or ___ Days Note mother's child's HIV status Look for signs of MEASLES: If more than 7 days, has fever been present every Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Generalized rash and day? Child's virological test: NEGATIVE POSITIVE NOT DONE One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Child's serological test: NEGATIVE POSITIVE NOT DONE Look for any other cause of fever. Do malaria test if NO general danger sign virological test in child: If mother is HIV-positive and NO positive Is the child breastfeeding now? High risk: all fever cases Was theobvious child breastfeeding at the time of test or 6 weeks before it? Low risk: if NO cause of fever If breastfeeding: Is the mother and child on ARV prophylaxis? Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

<-3z

116

Uncomplicated severe acute malnutrition Some anaemia Yes __ No __

CHECK THE CHILD'S IMMUNIZATION STATUS Look (Circle immunizations needed today) for mouth ulcers. If the child has measles now or within the Measles1 Measles 2 DPT+HIB-3 DPT+HIB-2 BCG DPT+HIB-1 If yes, are they deep and extensive? last 3 months: OPV-1 OPV-3 OPV-2 OPV-0 Hep B1 RTV-1 DOES THE CHILD HAVE Pneumo-1 Is there ear pain? Hep B0

AN

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

Is there ear discharge? If Yes, for how long? ___ Days

Look for pus draining from the eye. Hep Look B3 for clouding of the cornea. Hep B2 RTV-3 RTV-2 EAR PROBLEM? Pneumo-3 Pneumo-2 Look for pus draining from the ear

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date) Yes __ No __

Feel for tender swelling behind the ear

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Page 65 of 75  Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.8

TREAT ANAEMIA

WHAT TREATMENTS ARE IDENTIFIED FOR ANAEMIA? Review your classification table for anaemia. What treatments do you identify?

Severe palmar pallor

sification w

Pink: SEVERE ANAEMIA Yellow: ANAEMIA

Refer URGENTLY to hospital

Some pallor

Give iron** Give oral antimalarial if malaria test postive* 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 Follow-up in 14 days If child is less than 2 years old, assess the child's feeding and counsel the mother according to the feeding recommendations If feeding problem, follow-up in 5 days

No palmar pallor

Green: NO ANAEMIA

The identified treatments you have already learned about include:

➞ Give oral antimalarials – you learned steps in Module 5 Some new important treatments are identified here. You will learn more about these in Module 9 (well child care):

➞ Give iron ➞ Give mebendazole if child is over one year: a dose of 500 mg is given to children age 12–59 months, every 6 months. As you read about these treatments, follow along in your TREAT THE CHILD section of your chart booklet. Counselling on feeding problems is discussed in module 9 on well child care.

Page 10 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

HOW WILL YOU GIVE IRON? A child with SOME PALMAR PALLOR may have anaemia. A child with anaemia needs iron. Give syrup to the child under 12 months of age. If the child is 12 months or older, give iron tablets. Iron should not be given if the child is also receiving RUTF for severe acute malnutrition, since there is adequate iron and folic acid in RUTF to treat mild anaemia and folate deficiency. Remember to test all children for malaria. It is important you counsel the caregiver on continuing regular iron treatments at home. Give the caregiver enough iron for 14 days. Tell her to give her child one dose daily for the next 14 days. Ask her to return for more iron in 14 days. You should also tell her that the iron may make the child’s stools black. Sometimes this scares caregivers and they might stop the treatment if they do not expect it. It is also important to tell the caregiver to keep the iron out of reach of the child. An overdose of iron can be fatal or make the child very ill.

Iron/folate tablet grams per day Age or weight 2– 4 mths or 4–6 kg 4 –12 mths or 6–10 kg 12 mths–3 yrs or 10–14 kg 3–5 years or 14–19 kg ½ tablet ½ tablet Ferrous sulfate 200 mg + 250 µg folate (60 mg elemental iron)

Iron syrup sachets per day Ferrous fumarate 100 mg per 5 ml (20 mg elemental iron per ml) 1 ml (< ¼ tsp.) 1.25 ml (¼ tsp.) 2 ml (< ½ tsp.) 2.5 ml (½ tsp.)

Note: Children with Severe Acute Malnutrition and on RUTF should not be given iron

HOW WILL YOU GIVE MEBENDAZOLE? If the child is 1 years of age or older and has not had a dose of mebendazole in the past 6 months, the child should also be given a dose of mebendazole for possible hookworm or whipworm infection. These infections contribute to anaemia because of iron loss through intestinal bleeding. If hookworm or whipworm is a problem in your area: an anaemic child 2 years of age or older needs mebendazole. Give 500 mg mebendazole as a single dose in the clinic. Give either one 500 mg tablet or five 100 mg tablets. Refer to the dosage chart below, and to your TREAT charts.

HOW WILL YOU GIVE ORAL ANTIMALARIALS? If a child with pallor has a positive malaria test, the child should also be given an oral antimalarial. This is done even if the child does not have a fever. Refer to Module 5 on Fever to refresh your skills on giving oral antimalarials.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n  What treatments do you identify for Noah? You have 3 classifications for Noah: COUGH OR COLD (green), UNCOMPLICATED SEVERE ACUTE MALNUTRITION (yellow), and SOME ANAEMIA (yellow). Using your classification tables, you have identified the following treatments: ✔✔ Home remedy for cough ✔✔ Oral antibiotics ✔✔ RUTF home treatment ✔✔ Mebendazole: if Noah hasn’t had within 6 months You will not give iron because Noah is taking RUTF

n  What treatments will you provide Noah today? Of the treatments you have identified for Noah, you will give him the following today: ✔✔ Oral antibiotics: initiate today for 5 days following guidelines in TREAT charts ✔✔ RUTF home treatment: Noah weighs 12.7 kg, and you have sachets of RUTF available, so he requires 32 sachets for the week’s supply. He needs to consume 4 ½ sachets a day. ✔✔ Mebendazole: Noah hasn’t had within 6 months, so you will give him a dose of 500 mg today according to your TREAT charts. First, you explain to Rachel your concerns with Noah. You explain that you think his cough is not showing signs of severe infection, but that she will need to keep an eye on it. You also tell her that Noah’s weight is low and that getting him to a higher weight is very important to improve his nutrition and protect his body from other serious diseases. Malnutrition seriously weakens children’s bodies. Rachel looks very frightened by this but you reassure her that the RUTF treatment, and making some changes to his regular diet, should help this.

n  How will you counsel Rachel? There are five key topics that you need to counsel Rachel on today: 1. Home care for cough, including a safe local remedy for cough 2. Providing oral antibiotics for 5 days, including the dosage and schedule 3. Providing RUTF at home, including the dosage, schedule, and how to give. You will also explain the special tips below: •• Wash hands before giving RUTF •• Sit with child on the lap and gently offer the RUTF •• Encourage the child to eat the RUTF without forced feeding •• Give small, regular meals of RUTF •• Encourage child to eat 5–6 meals per day •• Offer plenty of clean water from a cup when the child is eating the RUTF 4. Feeding recommendations for his age, which you will learn about in module 8 5. When to return to the clinic

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n  How will you help teach Rachel? Here you remember your 3 basic teaching steps: give information, demonstrate, and allow Rachel to practice. You do this now to show her how to give the RUTF safely from the sachet, and providing water in a cup to drink.

n  When should Rachel and Noah return to the clinic? You explain to Rachel the signs that she should look for that would require Noah to come back to the clinic immediately. This includes the signs you normally discuss in your Chart Booklet, but in Noah’s case this also includes if he does not eat RUTF. You also tell her to return to the clinic in 7 days or sooner in 5 days if Noah’s cough does not improve. In 7 days you need to check Noah’s weight and nutrition status.

n  You check Rachel’s understanding with checking questions ✔✔ How will you prepare a safe cough remedy at home? ✔✔ How will you provide the RUTF to Noah? ✔✔ What are important things to remember about giving RUTF while at home? ✔✔ What kinds of foods and servings can you provide to Noah, can you give me an example of one day’s feeding schedule? ✔✔ When will you come back to the clinic with Noah? Rachel seems a little confused when she tries to explain how to provide RUTF. However, she remembers the tips well, especially about not giving the RUTF to others in the house. You again explain RUTF to Rachel, demonstrate how to feed from the sachet, and let her practice. When you ask checking questions again, you are satisfied with her responses.

n  Reassuring Rachel Rachel says she is worried she will forget to do something for Noah, because he has many treatments. You help her by providing a dosage schedule for her to reference. You reassure Rachel that she is a good mother for noticing Noah’s illness and bringing him to the clinic, and that they treatments should help him quickly. Rachel collects her things and leaves the clinic with Noah.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.9

PROVIDE FOLLOW-UP CARE FOR NUTRITION

WHEN WILL CHILDREN FOLLOW-UP FOR PROBLEMS RELATED TO NUTRITION? Notice that there are several different follow-up times related to nutrition. You will read about each of these follow-up visits in this section.

➞ Follow-up in 1 week: the child classified as UNCOMPLICATED SEVERE ACUTE MALNUTRITION that is receiving RUTF

➞ Follow-up in 5 days: See module 8 for more information on feeding problems. If a child has a feeding problem and you have recommended changes in feeding, to see if the caregiver has made the changes. You will counsel more if needed.

➞ Follow up in 14 days: •• If a child is classified as MODERATE ACUTE MALNUTRITION •• If a child has pallor, to give more iron.

PALLOR (follow-up 14 days) During this visit, follow these instructions: ✔✔ Give the caregiver iron for the child. Advise her to return in 14 days for more iron. ✔✔ Continue to give the caregiver iron when she returns every 14 days for 2 months. ✔✔ If the child still has palmar pallor after 2 months, refer the child for assessment.

UNCOMPLICATED SEVERE ACUTE MALNUTRITION (follow-up 1 week) The child should return to the facility every week to have a health check-up and to receive their supply of RUTF. During each follow-up visit, the health worker at the clinic should assess the following: 1. Measure weight and MUAC at each visit. Measure height every four weeks. Determine WFH z-score at every visit. 2. Check for oedema of both feed 3. Vital signs (temperature, pulse, respiration rate) and medical check 4. Appetite test with RUTF 5. Provide RUTF ration and review counselling messages with caregiver

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

 NO LONGER SEVERELY MALNOURISHED The child has improvements in MUAC and/or weight-for-height/length. Praise the caregiver. Continue with RUTF until the weight for length/height is above -2Z or the child has gained 15 % weight.  STILL SEVERELY ACUTE MALNOURISHED This child still has very low weight for height. Children who fail to respond to the treatment could be followed-up at home to determine the family circumstances and if there are concerns with the care or sharing of food. Ask the caregiver to come back after one week. After one month of non-response to treatment , these children should be referred for further medical review and laboratory tests as required to diagnose underlying illnesses. Some of the potential problems are: COMMON PROBLEMS IN MANAGEMENT OF MALNUTRITION Problems related to the quality of treatment ✔ Inappropriate evaluation of health condition, or missed medical complication ✔ Poorly conducted appetite test ✔ Inadequate instructions given to parent/caregiver on home care ✔ Inaccurate quantity of RUTF is given to child ✔ Protocol for routine medicines is not followed ✔ Health facility is a long distance from the patient’s home Problems related to the home environment or child ✔ Low frequency of visits to the health facility ✔ Insufficient RUTF given to child, or RUTF sharing with family members ✔ Inadequate intake of routine medicines ✔ Sharing of the family food ✔ Micronutrient deficiency ✔ Malabsorption ✔ Psychological trauma ✔ Infection/underlying disease ✔ Unwilling parent/caregiver

 IF CHILD CONTINUES TO LOSE WEIGHT Refer the child to hospital or to a feeding programme.

REMEMBER! A child can be discharged from outpatient malnutrition treatment if: •• No signs of oedema for at least two weeks •• He/she has gained 15 % •• He/she is above -2 Z score for two consecutive visits

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n  How will you provide follow-up care for Noah? Rachel returns with Noah in 7 days, as you discussed during the initial visit. You are happy to see her. During this visit you will do an IMCI assessment and check for: ✔✔ If any new symptoms or signs are present ✔✔ If his cough is improving, the same, or worse ✔✔ If his weight is improving, the same, or worse ✔✔ If his palmar pallor has improved ✔✔ You will also discuss any issues Rachel has had with the treatments. You will check to be sure she’s provided all of the medications according to schedules.

n  How will you re-assess Noah? In your IMCI re-assessment, you find the following: 1. Noah has no new symptoms. 2. Noah’s cough has cleared. 3. Noah’s weight is now 13 kg. He is still 104 cm tall. His MUAC is 117 cm. His new z-score is slightly between -2 and -3, which is positive news. Although he has improved you will continue the treatment with RUTF. In order to stop RUTF, Noah needs to have a z-score higher than -2Z for 2 consecutive visits. He will need to continue taking RUTF in the same amounts, 4 ½ sachets a day. 4. Noah’s palms look improved. You reclassify as NO ANAEMIA.

n  How will you treat Noah and counsel Rachel? Rachel needs to continue providing RUTF treatment to Noah. You give her new supplies, and ask her to explain how she has been providing the RUTF. You also ask her to demonstrate for you. You are pleased. Rachel also needs to continue recommended feeding practices for Noah. You discuss the average day of food she has provided to Noah in the past week. You ask her about any foods that you recommended in the last visit, but that she was not able to give. You discuss if they are too expensive, or not available, and reasonable other options. You praise Rachel for the progress so far. You counsel her on continuing this important nutrition for Noah. She seems a little worried that he needs to continue the RUTF. She was hoping he would be all better by now. You explain that gaining weight needs time, and a lot of nutrition. You encourage her to continue giving as she has.

n  When should Rachel and Noah return to the clinic? You also counsel on when to return to the clinic next: either immediately, or in 1 week.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.10 USING THIS MODULE IN YOUR CLINIC HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU HAVE GAINED FROM THIS MODULE IN MANAGING CHILDREN WITH MALNUTRITION AND ANAEMIA? In the coming days, you should focus on these key clinical skills. Practicing these skills and using your job aids will help you to better understand how to use IMCI for malnutrition and anaemia. ASSESS & CLASSIFY ✔✔ What commonly causes malnutrition in your country? ✔✔ Does malnutrition change by season? By region? ✔✔ Check every child for malnutrition. ✔✔ Look for oedema of both feet. ✔✔ Determine children’s weight for height or length. ✔✔ Determine a child’s z-score using growth charts. ✔✔ Measure the child’s MUAC and determine if less than 115mm ✔✔ If child has severe acute malnutrition, check for medical complications. ✔✔ Conduct appetite test for children over 6 months. ✔✔ Check every child for anaemia by looking for palmar pallor. ✔✔ Use your chart booklet to classify malnutrition. ✔✔ Use your chart booklet to classify anaemia. TREAT ✔✔ Treat children with severe malnutrition for low blood sugar. ✔✔ Give RUTF to children with severe malnutrition. ✔✔ Give iron to children with anaemia. ✔✔ Give mebendazole. ✔✔ Determine feeding recommendations for your area (also refer to Module 8) ✔✔ Determine the nutritional resources in your area. Is there nutrition counselling at your clinic or in an organization nearby? Where can you refer families for food support? What services in your area work on issues related to food and nutrition? COUNSEL ✔✔ Counsel a caregiver on providing RUTF safely at home. ✔✔ Counsel a caregiver on feeding recommendations. ✔✔ Use clinic resources to teach a caregiver about nutrition and food. Also refer to module 8. FOLLOW-UP ✔✔ Use IMCI instructions for follow-up of classifications of malnutrition and/or anaemia.

Remember to use your logbook for MODULE 6: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.11 REVIEW QUESTIONS AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING MALNUTRITION AND ANAEMIA? Now that you have finished the module, you will answer the same questions from the beginning of the module. This will help demonstrate what you have learned. Circle the best answer. 1. When is it necessary to check a child for malnutrition and anaemia? a. Check if the child appears low weight for age b. Check every child for malnutrition and anaemia, as sometimes problems go unnoticed c. Check if the caregiver tells you about a feeding problem 2. Sami has a MUAC measurement of 112 mm. What does this tell you? a. Sami is healthy b. 112 mm is low weight, so you will advise on feeding recommendations c. Sami is showing a sign of severe acute malnutrition 3. A child with anaemia needs: a. Vitamin A b. Iron c. Glucose 4. Traci shows oedema in her feet. What are your actions? a. Sit Traci and elevate her legs, to drain the swelling b. Advise Tracy’s mother to cut down the salts and fats in her child’s diet c. Urgently refer, as this is a sign of severe malnutrition 5. What is pallor palmar? a. A sign of anaemia b. A sign of local infection c. A sign of severe wasting 6. What is marasmus? a. A common skin infection in malnourished children b. A type of malnutrition where the child is very thin and lacks fat c. A type of malnutrition where the child has a puffy moon face and thin hair 7. Which of the following in an important measurement of wasting? a. Weight-for-age b. Percentage weight gain since last visit c. Weight-for-height (or length) Check your answers on the next page. How did you do? ............... complete out of 7. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

6.12 ANSWER KEY REVIEW QUESTIONS QUESTION 1 2 3 4 5 6 7 ANSWER B C B C A B C Did you miss the question? Return to this section to read and practice: INTRODUCTION ASSESS MALNUTRITION TREAT ANAEMIA ASSESS MALNUTRITION, TREAT MALNUTRITION ASSESS ANAEMIA INTRODUCTION TO MALNUTRITION ASSESS MALNUTRITION

EXERCISE A (INTRODUCTION) 1. Malnutrition develops when a child’s diet is missing amounts of essential vitamins, minerals and other nutrients. There are many types of malnutrition. The causes vary by country. 2. Malnutrition is an underlying cause in up to 35% of childhood deaths around the world. However, children might not present with specific complaints that suggest malnutrition or anaemia. It is possible that you or the child’s family might not even notice or know that the child is malnourished or anaemic. This is why it is important to check every child. 3. Answers below: a. Puffy face b. Distended abdomen c. Extremely thin body d. Oedema of the feet e. Scaly skin on legs g. Lack of fat on buttocks and arms i. Thin hair that may fall out TRUE TRUE TRUE TRUE TRUE FALSE FALSE TRUE TRUE

f. Rash on belly h. Child is crying from hunger

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

EXERCISE B (PLOT WEIGHT FOR HEIGHT) 1. 76 cm, 9 kg: Between 0 and -1 2. 80 cm, 7.5 kg: Below -3 3. 90 cm, 11.2 kg: Between -1 and -2 4. 93 cm, 11 kg: Between -2 and -3 5. 85 cm, 12 kg: Between 0 and 1

EXERCISE C (ASSESS) 1. Answers below Child is: a. Boy, 18 months, length 75 cm, weight 8.5 kg b. Boy, 30 months, height 118 cm, weight 22 kg c. Girl, 11 months, length 70 cm, weight 6 kg d. Girl, 27 months, weight 11 kg, height 95 cm e. Boy, 7 months, length 60 cm, weight 5 kg f. Girl 32 months, length 111 cm, weight 14.5 kg Below -3 Between -3 and -2 Between -2 and -1 Between -1 and 0 Between 0 and 3

X X X X X X This one is a trick! She is 32 months but you are given length (presumably because she was too weak to stand), so you need to subtract 0.7 cm for her height.

g. Boy, 26 months, weight 14.5 kg, height 113 cm h. Girl, 32 months, height 111 cm, weight 16.5 kg i. Girl, 20 months, length 100 cm, weight 14.5 kg

X X X

2. Which of the children above are moderately malnourished based on their Z-scores? D, E, F 3. Which of the children above have severe acute malnutrition based on their Z-scores? C, G

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

4. Answers below: TICK: Child is: a. Child’s MUAC is 112 mm b. Child has Z-score between -2 and -3 c. Child has a swollen right foot and is very skinny d. Child is too weak to stand Signs of SAM No signs of SAM

WRITE: If no, why not?

X X X X Must be below -3 for SAM SAM sign is oedema of both feet Child could be weak for many other reasons, this is not alone a sign of SAM

e. Child’s MUAC is 113.5 f. Child has oedema of both feet g. MUAC is 120 mm and child is irritable

X X X MUAC must be under 115

mm

5. Oedema of both feet. This is a sign of SAM, and especially, kwashiorkor.

EXERCISE D (ASSESS) 1. Signs: 1. MUAC at or less than 115 mm 2. Weight-for-height/length z-score less than -3 3. Oedema of both feet 2. Low body temperature is under 35 °C under-arm, or rectal under 35.5 ° or very cold hands and feet 3. Are the following true or false statements? a. FALSE: cannot give appetite test to child under 6 months old b. FALSE: child should be encouraged, but not forced to consume c. TRUE d. TRUE 4. The minimum is 1/3 of a 92 g sachet of RUTF, to be eaten within 30 minutes.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

EXERCISE E (CLASSIFY) 1. Answers below: Complicated severe acute malnutrition Uncomplicated severe acute malnutrition Moderate acute malnutrition No acute malnutrition

a. Child has MUAC of 112 mm and no complications b. Child has WFH z-score less than -3 and failed the appetite test c. Child has MUAC of 112 mm d. Child has MUAC of 117 mm and no oedema e. Child’s WFH z-score is between -1 and -2 f. Child has WFH z-score between -3 and -2 g. Child has MUAC of 113 mm and is showing signs of shock h. Child is less than 6 months, has lost weight and not breastfeeding effectively

X X X X X X X

X

2. These children need urgent treatment-based RUTF, deworming, Vitamin A, and second line oral antibiotics. These children are at risk of death from serious diseases. Check if the child is at high risk of HIV infection, whether s/he has been vaccinated for measles, and test for malaria. 3. A child with SEVERE UNCOMPLICATED MALNUTRITION should return for follow-up after 1 week.

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

EXERCISE F (TREAT) 1. RUTF amounts below: a. 3.7 kg, paste available – 900 grams paste b. 16.7 kg, sachets available – 35 sachets (92 g each) c. 7.8 kg, sachets available – 21 sachets (92 g each) d. 11.6 kg, paste available – 2800 grams paste 2. Should follow-up in 1 week 3. Could include the following messages: ✔✔ RUTF is a special therapeutic food for thin children only. It should not be shared. ✔✔ RUTF is the only food that thin children need for their recovery. ✔✔ For young children who are breastfeeding, continue breastfeeding. ✔✔ Always give plenty of clean water to the child to drink when giving RUTF. ✔✔ Wash hands before feeding the child. 4. Focus on counselling messages above, (b) start with who, what, why, when, where, or how. 5. Answers below: CONTINUE STOP WHY?

a. Tsepi (boy) now weighs 13.5 kg, and is 96 cm in height. Last visit he weighed 13 kg. b. Rakim’s weight has changed from 20.5 kg to 23 kg. c. Angie (girl) weighs 15.5 kg and is 109 cm in height. Last visit she weighed 14.5. d. Sheena’s weight has changed from 32.5 kg to 38.0 kg. e. Maria (girl) now weighs 17.2 kg and is 116 cm in height. Last visit she weighed 17.3 kg. X X X

X

Has been above -2 z-score for two consecutive visits Has not achieved 15% weight gain Is not above -2 z-score

X

Has achieved 15% weight gain Has not been above -2 z-score for two consecutive visits

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IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

EXERCISE G (ASSESS) 1. TERMS ARE MATCHED WITH CORRECT DEFINITION BELOW: Anaemia A reduced number of red cells or a reduced amount of haemoglobin in each red cell, caused by not eating foods rich in iron, parasites, malaria, or other infections. When an unusually large amount of fluid gathers in the child’s tissues. The tissues become filled with the fluid and look swollen or puffed up. Unusual paleness of the skin, and a sign of anaemia. A food product that is used for the safe therapeutic feeding of SAM children.

Oedema

Pallor RUTF

Palmar pallor A sign that is identified by looking at a child’s palm. 2. SEVERE PALMAR PALLOR. Requires referral. 3. Treatments for SOME PALMAR PALLOR include: ✔✔ Give Iron ✔✔ Oral antimalarials (if test positive) ✔✔ Mebedenazole or other deworming treatment (if child older than one year)

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ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 5 Fever

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

n CONTENTS Acknowledgements 4 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Module overview Introduction to fever Assess a child for fever Classify fever Treat the child with fever Counsel the caregiver Provide follow-up care Using this module in your clinic Review questions 5 8 13 21 29 35 40 45 47 48

5.10 Answer key

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

5.1

MODULE OVERVIEW

A fever can have many causes. Fever can be the only sign of a sick child, or it may be combined with other problems. It is important to keep the big picture in mind as you manage the child with fever. You will have to do a careful assessment to determine how serious the problem is. This module will teach you how to do this assessment.

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, assess for cough or difficult breathing, assess diarrhoea and dehydration, then DETERMINE: DOES THE CHILD HAVE A FEVER?

NO

YES ASSESS & CLASSIFY the child using the colour-coded classification charts for fever.

CONTINUE ASSESSMENT: check for malnutrition & anaemia, check immunization status, HIV status, and other problems

MODULE LEARNING OBJECTIVES After you study this module, you will be able to: ✔✔ Determine if a child has fever by measuring temperature, history, or feeling ✔✔ Determine a child’s malaria risk ✔✔ Recognize the clinical signs of severe febrile disease ✔✔ Identify clinical signs of measles and complications from measles ✔✔ Classify fever using IMCI charts ✔✔ Classify measles and measles with complications ✔✔ Give oral antimalarials ✔✔ Give appropriate treatments for measles ✔✔ Counsel on home treatment and follow-up care for children with fever ✔✔ Provide follow-up to children with fever

5

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listenCOURSE for stridor| MODULE 5. FEVER IMCI DISTANCE LEARNING Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: form for the sick child. This section Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

Yes __ No __

YOUR RECORDING FORM

Look at your IMCI recording module:

deals with this

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Yes __ No __

Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L _____ Z score. AND ANAEMIA This module follows the major steps of the IMCI process:

MODULE ORGANIZATION

For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. ✔✔ Assess fever Severe palmar pallor? Some palmar pallor? Is there any medical complication? If child has MUAC less than 115 mm or General danger sign? ✔✔ Classify fever WFH/L less than -3 Z scores or oedema of Any severe classification? both feet: Pneumonia with chest indrawing? ✔✔ Treat fever For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? ✔✔ Counsel caregiver on home care

CHECK FOR HIV INFECTION

do you know now about managing fever? needed today) CHECK THE What CHILD'S IMMUNIZATION STATUS (Circle immunizations BCG OPV-0 Hep B0

Note mother's and/or child's HIV status ✔ ✔ Follow-up care for fever Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE ✔ ✔ Module contents Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

BEFORE YOU BEGIN

Return for next immunization on: Measles1 Measles 2 Vitamin A DPT+HIB-3 DPT+HIB-2 DPT+HIB-1 Before studying this module, quickly practice your knowledge with these ________________ Mebendazole OPV-3 OPV-2 OPV-1 you begin (Date) Hep B3 Hep B2 Hep B1 multiple-choice questions. RTV-3 RTV-2 RTV-1 Pneumo-3 Pneumo-2 Pneumo-1

Circle the best answer for each question.

1. Which of the following children has a fever that requires further investigation? a. Imrana has an axillary temperature of 37 °C b. Joy’s mother says she has been feeling very hot for the pastPage 65 of 75  three days c. Samuel’s face is very flushed and red 2. What are common causes of fever that often kill children? a. Local infection and malaria b. Meningitis and influenza c. Measles and malaria

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

3. What would you give to children with high fever? a. Paracetamol b. Amoxicillin or another antibiotic c. Fluids 4. What is recommended treatment for malaria? a. Chloroquine b. Artemisinin-based combination therapies c. Paracetamol 5. Traci has a fever, generalized rash, runny nose, and mouth ulcers. How you would you classify? a. She shows signs local infections of the skin b. She shows clinical signs of AIDS c. Measles with mouth complications After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

5.2

INTRODUCTION TO FEVER

Now you will consider a typical case that you might see in your practice – imagine the situation. This will help you start thinking about the problem of a child with a fever.

n  OPENING CASE STUDY – SAMI It is a hot day in your clinic, and the waiting room is crowded with mothers. Miriam comes into your clinic with her son, Sami. He has been complaining of being “hot” for a few days, she says. Sami sits next to Miriam but does not look very energetic. He is a quiet boy, and when you ask him how he is feeling, he puts his head into his mother’s skirt. He continues to lie on her lap and looks unwell. You are not yet sure if he is feeling unwell because of the heat, or if he has a fever. You know there are several causes for fever.

WHEN DOES A CHILD HAVE THE MAIN SYMPTOM FEVER? The child has a history of fever n The child feels hot n The child has an axillary (underarm) temperature of 37.5 °C (38 °C rectal) or above

WHAT CAUSES FEVER IN CHILDREN? A child with fever may have malaria, measles or another severe disease – like meningitis, septicaemia and very severe pneumonia. Signs of some very severe diseases may be general and non-specific. For a health worker it is very important to identify key symptoms and signs of the diseases that may cause the child’s death very quickly. Therefore all sick children with those signs should be referred to the hospital for further assessment and treatment. Other bacterial infections causing fever include pneumonia, acute ear infection, streptococcal sore throat, dysentery, local bacterial infection, typhoid, and urinary tract infection. Or, a child with fever may have a simple cough or cold or other viral infection. All health workers should know how to assess a child for common childhood causes of fever: malaria and measles. These are two major killers of children under five in the world. In malaria risk areas, malaria is still a major cause of fever and death in children although measles has been on the decline due to successful measles immunization. 

Malaria and measles are common causes of fever, and two major killers of children.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

WHAT CAUSES MALARIA? Malaria is caused by parasites in the blood called plasmodia. These parasites are transmitted when an infected female anopheline mosquitoes bite humans. Four species of plasmodia can cause malaria. The most dangerous type is Plasmodium falciparum. Signs of falciparum malaria include shivering, sweating and vomiting. Another parasite species that commonly causes malaria is called Plasmodium vivax. This rarely causes very severe illness or death, but Plasmodium vivax contributes to malaria morbidity in some countries. Malaria may occur throughout the year or during the rainy season in some countries. It is important to know which species of Plasmodium is in your country and area of work. It is also important to know when during the year it occurs.

HOW CAN MALARIA CAUSE ILLNESS AND DEATH IN CHILDREN? In areas with very high malaria transmission, malaria is a major cause of death in children. A case of uncomplicated malaria can develop into severe malaria as soon as 24 hours after the fever first appears. Severe malaria is malaria with complications such as cerebral malaria, severe anaemia, or presence of any other general danger sign. The child can die if he or she does not receive urgent treatment.

WHAT ARE SIGNS OF MALARIA? Fever is the main symptom of malaria. It can be present all of the time, or it can go away and return at regular intervals. Signs of malaria can overlap with signs of other illnesses. For example: ✔✔ A child may have malaria and a cough with fast breathing, a sign of pneumonia. This child needs treatment for both malaria and pneumonia. ✔✔ Children with malaria may also have diarrhoea. They need an antimalarial and treatment for the diarrhoea. ✔✔ A child with malaria may have chronic anaemia (with no fever) as the only sign of illness. You will read more about anaemia in MODULE 6.

HOW DO YOU CONFIRM MALARIA? If a child has a fever due to malaria, malaria parasites or malaria antigens should be present in the blood when it is tested to confirm malaria infection. If the child does not have malaria parasites present, then it is unlikely that the fever is due to malaria. The child should be assessed for other possible causes of fever. How do you determine fever? •• History of fever •• Feels hot •• Axillary temperature 37.5 °C or above

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

BESIDES MALARIA, WHAT ARE OTHER CAUSES OF FEVER? If a child with fever does not show signs of malaria parasites, it is unlikely that the fever is not due to malaria. The child should be assessed for other possible cause of fever. There are three major categories of children with fever: 1. FEVER WITH LOCALISING SIGNS A child might have an apparent bacterial cause of fever such as pneumonia, dysentery, acute ear infection, sore throat, meningitis, and local infection that has localising signs. Signs of local infection may be refusal to use a limb, hot tender swelling, tenderness, or red tender skin. 2. FEVER WITHOUT LOCALISING SIGNS A child might also have fever due to bacterial infection with no localising signs like septicaemia, typhoid fever, urinary tract infection, HIV infection and miliary tuberculosis. These infections are difficult to diagnose without use of laboratory tests and therefore children suspected of having these conditions should be referred to hospital for assessment. 3. FEVER WITH A RASH Fever with a rash is commonly caused by measles. It can also be other simple viral infections, or infections like meningococcal meningitis and dengue haemorrhagic fever.

WHAT CAUSES MEASLES? Measles is caused by a virus that infects the skin and layer of cells that line the lung, gut, eye, mouth, and throat. Measles is highly infectious. Most cases occur in children between 6 months and 2 years of age. The measles virus damages the immune system for many weeks after the onset of measles. This leaves the child at risk for other infections. Complications of measles occur in about 30% of all cases.

WHAT ARE SIGNS OF MEASLES? Fever and a generalized rash are the main signs of measles. Sometimes measles presents with eye and mouth complications.

WHY DOES MEASLES CONTRIBUTE TO MALNUTRITION? Measles contributes to malnutrition because it causes diarrhoea, high fever, and mouth ulcers. These problems interfere with feeding. Malnourished children are more likely to have severe complications due to measles. This is especially true for children who don’t have enough vitamin A. One in ten severely malnourished children with measles may die. For this reason, it is very important to help the caregiver to continue to feed her child during measles.

10

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

n  How will you greet Miriam and begin the assessment? You praise Miriam for bringing Sami to the clinic. You tell her that she has been attentive to listen to her son’s complaints and to bring him in. She tells you Sami is 3 years old, so you know you will be using the sick child charts. You ask her to tell you more about Sami’s problem, “feeling hot,” and what she has done for the problem so far. Miriam tells you that he handles the heat well, so you do not think that he is only talking about the heat outside. She says his body feels warm. She has tried to put cool, wet rags on his chest and head, she says, but they have not helped him. You ask if this is the first time she is coming to the clinic for this, and she says yes. You take Sami’s temperature under his armpit, and it is 38.6 degrees. He does has a fever, because his temperature is over 37.5 degrees. He weighs 12 kg.

n  Next, you will check for general danger signs: You ask Miriam if Sami is able to eat and drink, and she says yes. She says he is not vomiting, and has not had convulsions. You watch Sami. He acts very tired – he continues to lay his head on his mother’s lap – but he watches you as you talk. He holds the material of Miriam’s skirt and plays with it. Does Sami have any general danger signs?

n  Next, you assess for cough or difficult breathing and diarrhoea: You will now assess Sami for the first two main symptoms, cough or difficult breathing and diarrhoea. You ask Miriam if Sami has had a cough. She says no. You ask if he has diarrhoea, and she says that he has been having loose stools. She says this has been a problem for the last week. You ask if there is blood in the stool and she says no. Then you assess Sami’s dehydration. Sami does not look restless or irritable. You look for sunken eyes, but Sami’s look normal. You pour Sami a glass of water from a pitcher on the counter, and offer it to him. He is shy to take it, but Miriam asks him to take it and drink. He drinks eagerly. You ask Miriam to set Sami on the examination table and lay down with his hands to his sides. You tell them that you will pinch Sami’s skin, but it will not hurt. The skin returns immediately.

n  How will you classify Sami’s diarrhoea and dehydration? You classify that Sami does not have persistent diarrhoea (lasting longer than 14 days) or dysentery (blood in the stools). Sami has diarrhoea, but not enough signs to classify any dehydration. You determine that you will counsel Miriam on Plan A for home treatment of diarrhoea.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

n  How will you complete Sami’s recording form thus far?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Sami Age: 3 years Weight (kg): 12 kg Temperature (°C): 38.6 °C Initial Visit? X Follow-up Visit? Ask: What are the child's problems? Feels hot ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

7

Yes __ No __

X

Diarrhoea, no dehydration (Plan A) Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? ThisHas was also complaint, and you have child had his measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

n  Now you will learn to assess Sami for the next main symptom, fever. that he has a fever.

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes already determined by taking his temperature Look for any other cause of fever.

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

5.3

ASSESS A CHILD FOR FEVER

First, determine if the child has a fever.

A child has the symptom of fever if: •• Has a history of fever •• Feels hot •• Has an axillary (underarm) temperature of 37.5 °C (38 °C rectal) or above If you do not have a thermometer, feel the child’s stomach or axilla (underarm) and determine whether the child feels hot. Ask the caregiver: “Does the child have fever?” The child has a history of fever if the child has had any fever with this illness. History of fever is enough to assess the child. If the child has a history of fever, you will assess even if his current temperature is not 37.5 °C or above, or he does not feel hot now. If the child has no fever, ask about the next main symptom, ear problem.

HOW WILL YOU ASSESS? NO fever, ask about the next main symptom using the IMCI process. YES fever is present, you will assess in three parts: 1. Determine if malaria risk is high or low 2. Assess for causes of fever 3. Assess for complications from measles, if child shows signs of measles or has had measles Open your chart booklet to the ASSESS chart for fever. The top part of the box describes how to assess for causes of fever. These include signs of malaria, measles, meningitis and other causes. The bottom part of the box describes how to assess the child for signs of measles complications, if the child has measles now or within the last 3 months.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

HOW WILL YOU ASSESS FOR CAUSES OF FEVER? You will now read about assessing forfever? causes of fever, the top part of the ASSESS Does the child have chart: (by history or feels hot or temperature 37.5°C* or above) If yes: Decide Malaria Risk: high or low Then ask: Look and feel: For how long? Look or feel for stiff neck. If more than 7 days, has Look for runny nose. fever been present every Look for any other cause day? of fever**. Has the child had measles Look for signs of within the last 3 months? MEASLES. Generalized rash and One of these: cough, runny nose, or red eyes. Do a malaria test: If NO general danger sign or stiff neck In all fever cases if High malaria risk. In Low malaria risk if no obvious cause of fever present.

Classify High or Low FEVER Malaria Risk

Any genera Stiff neck.

Malaria test

Malaria test and/or

Other caus PRESENT.

MALARIA RISK HOW WILL YOU DECIDE MALARIA RISK? To classify and treat children with fever, you must know the malaria risk in your area. If the child has measles Look for mouth ulcers. Most national malaria control programmes define areas of malaria risk as follows: now or within the last 3 Are they deep and If MEASLES now or within last 3 months, Classify extensive? •• HIGH MALARIA RISK: in area where more than 5% of fever cases in children Look for pus draining from 2 to 59 months are attributable to malaria. the eye. months:

Any genera or Clouding of Deep or ext ulcers.

•• LOW MALARIA RISK: in area where fewer than 5% of fever cases in children cornea. 2 to 59 months are attributable to malaria, but where the risk is not negligible. •• NO MALARIA RISK: malaria transmission does not normally occur in the area, and imported malaria is uncommon.

Look for clouding of the

Pus drainin or Mouth ulcer

HOW IS MALARIA RISK DETERMINED? Malaria risk depends on: n How prevalent malaria is in your area – this is called malaria endemicity Risk also varies by:

Measles no the last 3 m

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C hig

**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower ab

*** If no malariain test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause o n Extent of malaria control the country

**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - a

n Region, because malaria risk can change across a local area or across a country n Season, because the breeding conditions for mosquitoes are limited or absent during the dry season, and as a result, malaria risk is usually low during dry season

Page 7 of 

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

WHAT IS THE MALARIA RISK IN YOUR AREA? Find out the risk of malaria for your area. If the risk changes according to season, be sure you know when the malaria risk is high and when the risk is low. If you do not have information telling you that the malaria risk is low in your area, always assume that children under 5 years of age who have fever are at high risk for malaria. ASK the caregiver: “Has the child travelled during the past two weeks and, if so, where?” Some families in low risk areas may have travelled to areas where there is a malaria risk. If a caregiver in a low malaria risk area tells you she has travelled with the child to an area where you know there is a high malaria risk, you will assess the child according to a high risk area. WHAT IS THE MALARIA RISK IN YOUR AREA? Does it change by season? Are there other nearby regions that people travel to that have a higher malaria risk?

WHY DOES MALARIA RISK MATTER FOR IMCI? Depending on the local malaria risk, you may do a malaria test for the child. It is not possible to clinically distinguish fever caused by malaria from other causes of fever because there are many causes of fever. To be sure that a child with a fever or history fever has a malaria infection, you need to do a malaria test. To avoid a large number of children being treated for malaria when in fact they have another febrile illness, children should first be tested for malaria to determine treatment. Testing for malaria will also help to distinguish malaria caused by P.  falciparum or P. vivax. As you learned earlier, P. falciparum is more dangerous.

WHEN WILL YOU DO A MALARIA TEST: HIGH MALARIA RISK? Here the chance of the child’s fever attributable to malaria is very high. A malaria test should be done in all children with a fever or history of fever with no general danger sign or stiff neck. Do not do a malaria test if a child has a danger to avoid delay in referral but give pre-referral antimalarial and antibiotic treatment, and refer urgently.

WHEN WILL YOU DO A MALARIA TEST: LOW MALARIA RISK? The chance of malaria causing the child’s fever is low. There is an even lower chance of malaria if the child has signs of another infection that can cause fever. A malaria test should be done if the child with fever has no general danger signs and no apparent cause of fever.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

HOW WILL DETERMINE WHICH MALARIA TEST TO USE? There are two ways of doing a malaria test: 1. Examining a blood slide for malaria parasites using a microscope 2. Using a Rapid Diagnostic Test (RDT) to check blood for malaria antigens

HOW WILL YOU RECORD A MALARIA TEST RESULT? To do a malaria test, take a blood smear if you have a microscope in the clinic, or check the blood by using an RDT. The malaria test result will determine whether a child has malaria parasites requiring treatment or not. Always check the quality of your blood slides if using microscopy or RDTs to ensure that the test results are reliable. Circle the results of the test on the recording form: n POSITIVE – if there are malaria parasites or RDT is positive. Note if it is P.  falciparum or P. vivax if able to do so especially when using microscopy. n NEGATIVE – If there are no parasites seen by microscopy, or RDT is negative

CAUSES OF FEVER ASK: HOW LONG HAS THE CHILD HAD FEVER? Most fevers due to viral illnesses go away within a few days. If the fever has been present for more than 7 days, ask if the fever has been present every day. A fever that has been present every day for more than 7 days can mean that the child has a more severe disease such as typhoid fever. Refer this child for further assessment.

ASK: HAS THE CHILD HAD MEASLES WITHIN THE LAST 3 MONTHS? Measles damages the child’s immune system and leaves the child at risk for other infections for many weeks. A child with fever and a history of measles within the last 3 months may have an infection, such as an eye infection, due to complications of measles.

LOOK OR FEEL FOR STIFF NECK A stiff neck may be a sign of meningitis, cerebral malaria or another very severe febrile disease. It requires urgent treatment with injectable antibiotics and referral to a hospital. WATCH THE CHILD: While you talk with the caregiver during the assessment, look to see if the child moves and bends his or her neck easily when looking around. If the child is moving and bending his or her neck, the child does not have a stiff neck. TEST THE CHILD: If you did not see any movement, or if you are not sure, draw the child’s attention to his or her umbilicus or toes. For example, you can shine a flashlight on the toes or umbilicus or tickle the toes to encourage the child to look down. Look to see if the child can bend his or her neck when looking down at his or her umbilicus or toes.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

FEEL FOR STIFF NECK: If you still have not seen the child bend his or her neck himself, ask the caregiver to help you lay the child on his or her back. Lean over the child, gently support the child’s back and shoulders with one hand. With the other hand, hold the child’s head. Then carefully bend the head forward towards the child’s chest. If the neck bends easily, the child does not have stiff neck. If the neck feels stiff and there is resistance to bending, the child has a stiff neck. Often a child with a stiff neck will cry when you try to bend the neck.

DVD EXERCISE – NECK STIFFNESS Watch “Assess neck stiffness” (disc 2). It is very useful to practice with a video. Record your answers as you watch, and the video will review them. Do these children have stiff necks?

CHILD 1   YES   NO CHILD 2   YES   NO

CHILD 3   YES   NO CHILD 4   YES   NO

LOOK FOR RUNNY NOSE When malaria risk is low, a child with fever and an obvious cause of fever like a runny nose (common cold), pneumonia or ear infection does not need a malaria test. This child’s fever is probably caused by a common cold or pneumonia or ear infection.

LOOK FOR OTHER SIGNS OF FEVER Assess the child for signs of other non-apparent bacterial infection. Look for local tenderness, oral sores, refusal to use a limb, hot tender swelling, red tender skin or boils, lower abdominal pain, or pain on passing urine in older children.

LOOK FOR SIGNS SUGGESTING MEASLES There are two categories of signs suggesting measles. First, the child should have a generalized rash. They should also show one of the following: cough, runny nose, or red eyes. Generalized rash In measles, a red rash begins behind the ears and on the neck. It spreads to the face. During the next day, the rash spreads to the rest of the body, arms and legs. After 4 to 5 days, the rash starts to fade and the skin may peel. Some children with severe infection may have more rash spread over more of the body. The rash becomes more discoloured (dark brown or blackish), and there is more peeling of the skin. A measles rash does not have vesicles (blisters) or pustules. The rash does not itch. Do not confuse measles with other common childhood rashes such as chicken pox, scabies, or heat rash. Chicken pox rash is a generalized rash with vesicles. Scabies occurs on the hands, feet, ankles, elbows, buttocks and axilla (underarm). It also

17

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

itches. Heat rash can be a generalized rash with small bumps and vesicles, which itch. A child with heat rash is not sick. Does the child have fever? (by history or feels hot or temperature 37.5°C* or above) Cough, runny nose, or red eyes

To classify a child as having measles, the child with fever must have a generalized If yes: Malaria Risk: high or low runny nose, or red eyes. rash AND one ofDecide the following signs: cough, High or Low The child has “red eyes” if there the white part of the eye. In a healthy FEVER For how long? is redness inLook or feel for stiff neck. Malaria Risk If more has white Look runny nose. eye, the white part of the than eye 7 isdays, clearly andfor not discoloured. fever been present every Look for any other cause day? of fever**. Has the child had measles Look for signs of Watch “Assess and classify fever” (disc 2) within the last 3 months? MEASLES. This video reviews all steps of assessing fever. IMPORTANT: note that Generalized rash and this video does not include a malaria test. Doing a malaria test with One of these: cough, microscopy or RDT is a recent technical update. runny nose, or red eyes. Then ask: Look and feel: Classify

Any genera Stiff neck.

Malaria test P

Do a malaria test: If NO general danger sign or stiff neck In all fever cases if High malaria risk. COMPLICATIONS FROM MEASLES In Low malaria risk if no obvious cause of fever present.

Malaria test and/or

WHEN WILL YOU ASSESS FOR COMPLICATIONS FROM MEASLES? If the child has measles now or has had measles within the last 3 months, you will assess if the child has mouth or eye complications. This assessment follows instructions on the lower portion of the fever ASSESS chart: If the child has measles now or within the last 3 months: Look for mouth ulcers. Are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea.

Other cause PRESENT.

If MEASLES now or within last 3 months, Classify

Any genera or Clouding of Deep or ext ulcers.

Pus draining or Mouth ulcer

WHAT ARE MEASLES WITH COMPLICATIONS? Children with measles may have other serious complications of measles. Measles complications can lead to severe disease and death. Classifying complications will allow you to better treat the child with measles.

Measles no the last 3 mo

* These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C high Complications include stridor in a calm child, severe pneumonia, severe dehydration, **Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abd or severe malnutrition. Some complications of measles are due to bacterial infections. *** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause o Others are due to the measles virus, which causes damage to the respiratory and **** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and malnutrition - a intestinal tracts. Vitamin A deficiency contributes to some of the complications such as corneal ulcer. Any vitamin A deficiency is made worse by the measles infection.

Now you will learn about assessing for these clinical signs.

Page 7 of 7

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

LOOK FOR MOUTH ULCERS Look inside the child’s mouth for mouth ulcers. Ulcers are painful open sores on the inside of the mouth and lips or the tongue. They may be red or have white coating. In severe cases, they are deep and extensive. A child with measles who has mouth ulcers will find it difficult to drink or eat. Mouth ulcers are different than the small spots called Koplik spots. Koplik spots occur in the mouth inside the cheek during early stages of the measles infection. Koplik spots are small, irregular, bright red spots with a white spot in the centre. They do not interfere with drinking or eating. They do not need treatment.

LOOK FOR CLOUDING OF THE CORNEA The cornea is usually clear. When clouding of the cornea is present, the cornea may appear clouded or hazy. The cornea may look the way a glass of water looks when you add a small amount of milk. The clouding may occur in one or both eyes. Corneal clouding is a dangerous condition. It may be the result of vitamin A deficiency that has been made worse by measles. If the corneal clouding is not treated, the cornea can ulcerate and cause blindness. A child with clouding of the cornea needs urgent treatment with vitamin A. A child with corneal clouding may keep his or her eyes tightly shut when exposed to light. The light may cause irritation and pain to the child’s eyes. To check the child’s eye, wait for the child to open his or her eye. Or gently pull down the lower eyelid to look for clouding. If there is clouding of the cornea, ask the caregiver how long the clouding has been present. If the caregiver is certain that clouding has been there for some time, ask if the clouding has already been assessed and treated at the hospital. If it has, you do not need to refer this child again for corneal clouding.

LOOK FOR PUS DRAINING FROM THE EYE Pus draining from the eye is a sign of conjunctivitis. Conjunctivitis is an infection of the conjunctiva, the inside surface of the eyelid and the white part of the eye. If you do not see pus draining from the eye, look for pus on the conjunctiva or on the eyelids. Often the pus forms a crust when the child is sleeping and seals the eye shut. You can gently open the eye, making sure that your hands are clean. Wash your hands after examining the eye of any child with pus draining from the eye.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

n  How will you assess Sami for fever? When you took Sami’s temperature, you saw that he does have a temperature higher than normal, 38.6 °C. A fever is anything higher than 37.5 degrees. You ask Miriam about his symptoms. She tells you that Sami has been “hot”. He does not have a history of fever.

Sami has the symptom fever, so you will now assess for its causes. First, you determine that Sami and his family live in a high risk malaria area. You ask how long Sami has been feeling hot, and Miriam says 2 SICK days. This is underAGED the 7 day2 threshold that may a more serious MANAGEMENT OF THE CHILD MONTHS UPindicate TO 5 YEARS disease, and would require referral. Name: Ask: What are the child's problems? You continue to watch Sami ASSESS (Circle all signs present) Age: Weight (kg):

as he rests on his mother’s lap. He is able to move his neck you tap Sami’s feet andDANGER ask him SIGNS to look down. He bends his neck well to look down. Sami does not have CHECK FOR GENERAL General dangera sign present? NOT ABLE TO DRINK LETHARGIC OR UNCONSCIOUS runny nose. You ask OR to BREASTFEED examine him and survey his body for any signs of bacterial infection, like tenderness, VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ swelling, or red skin. He has none. CONVULSIONS Remember to use selecting Now you will do a malaria test. You remember that all children in a high malaria risk area with a fever, without classifications a general danger sign or stiff neck, should take a malaria test. You have RDT available at the clinic. Sami’s test is DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ positive for P. falciparum . This is the more dangerous parasite. You mark this on his recording form. For how long? ___ Days Count the breaths in one minute Look for chest indrawing You ask Miriam if Sami has had measles within the past three months. She does not understand when you ask Look and listen for stridor about measles, so you explain some of the symptoms – awheezing rash, runny nose, or red eyes, for example. She has Look and listen for DOES THE CHILD HAVE DIARRHOEA? Yes __ If No __ already mentioned that Sami has not had a cough. She says no, he has not shown any of these signs. Sami For how long? ___ Days Look at the childs general condition. Is the child: did show signs of stool? measles today, or Miriam reported he has had measles within the past three months, Is there blood in the Lethargicthat or unconscious? Restless and irritable? you would have assessed for complications affecting his eyes or mouth. You would have assessed for mouth Look for sunken eyes. Offer the child ulcers, clouded cornea, and pus draining from the eye.fluid. Is the child: ___ breaths per minute. Fast breathing? Danger sign when

Initial Visit?

Temperature (°C): Follow-up Visit? well. Just CLASSIFY to check,

n  How will you record your assessment on Sami’s form? Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

2

X

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

Malaria RDT positive (P. falciparum)

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM?

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Yes __ No __

Is there ear pain? there ear discharge? You Is will learn how to If Yes,now for how long? ___ Days

classify Sami’s fever.

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 20 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

5.4

CLASSIFY FEVER

If the child has fever and no signs of measles, classify the child for fever only. If the child has signs of both fever and measles, classify the child for fever and for measles.

CAUSES OF FEVER HOW DO YOU CLASSIFY FEVER? You will classify based on the signs you have assessed, and the results of the malaria test if you conducted. There are three classifications for fever. These are: 1. VERY SERIOUS FEBRILE DISEASE 2. MALARIA 3. FEVER: NO MALARIA Any general danger sign or Pink: Stiff neck. VERY SEVERE FEBRILE DISEASE Give first dose of artesunate or quinine for severe malaria Give first dose of an appropriate antibiotic Treat the child to prevent low blood sugar Give one dose of paracetamol in clinic for high fever (38.5°C or above) Refer URGENTLY to hospital Give recommended first line oral antimalarial Give one dose of paracetamol in clinic for high fever (38.5°C or above) Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment Give one dose of paracetamol in clinic for high fever (38.5°C or above) Give appropriate treatment for any other cause of fever Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment

Classify High or Low FEVER Malaria Risk

Malaria test POSITIVE.***

Yellow: MALARIA

Malaria test NEGATIVE and/or Other cause of fever PRESENT.

Green: FEVER: NO MALARIA

If MEASLES now or within last 3 months, Classify

Pink: Any general danger sign Give Vitamin A treatment or Give first dose of an appropriate SEVERE VERY SEVERE FEBRILE DISEASE (RED) Clouding of cornea or antibiotic COMPLICATED MEASLES**** Deep or extensive If clouding of neck the cornea or pus draining A child with fever mouth and any general danger sign or a stiff should be classified ulcers. from the eye, apply tetracycline eye as having very severe febrile disease. A childointment with fever and any general danger Refer URGENTLY to hospital sign or stiff neck may have meningitis, sepsis, or severe malaria (including cerebral Yellow: Pus draining from the Give Vitamin A treatmentbetween these malaria) if there is eye malaria risk. It is not possible to distinguish or If pus draining from the eye, treat eye MEASLES WITH EYE severe diseases tests. Mouth ulcers. without laboratory infection with tetracycline eye ointment OR MOUTH COMPLICATIONS**** Green:

What are your actions? Measles now or within

If mouth ulcers, treat with gentian violet Follow-up in 3 days Give Vitamin A treatment

A child classified severe febrile disease needs urgent pre-referral the last 3 months. as having very MEASLES treatment and referral. You will learn about pre-referral treatment in the next section.  temperature readings are approximately 0.5°C higher.

t tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.

ALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.

ridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

MALARIA (YELLOW) A child with a fever, a positive malaria test, and NO general danger sign or stiff neck is classified as having MALARIA. This is the same for both high and low risk malaria areas. What are your actions? It is critical to provide antimalarial treatment for the child. You will also give paracetamol for high fever. This child should be followed up in 3 days. Remember that if the fever has been present for longer than 7 days, the child should be referred.

FEVER: NO MALARIA (GREEN) In a low malaria risk area, a child with a malaria test negative or no other clinical signs of other possible infection is classified as having FEVER: NO MALARIA. What are your actions? If the child’s fever is 38.5 °C, give paracetamol. You will also treat for any other causes of fever. If the fever has been present every day for more than 7 days, refer for assessment. If the fever persists for 2 days, the caregiver should return.

SELF-ASSESSMENT EXERCISE A Answer the questions below about assessing and classifying fever.

1. Should all children with a fever be classified for fever?

2. When will you conduct a malaria test? 3. Which signs indicate that a child has VERY SEVERE FEBRILE DISEASE?

4. Reba has a positive P. vivax test and no general danger signs or stiff neck. She has a temperature of 38 degrees Celsius. a. How will you classify? b. Reba requires oral antimalarials and paracetamol. TRUE or FALSE

5. TRUE or FALSE: a child lives in a low malaria risk area. You will never need to conduct a malaria test for this child.

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high fever (38.5°C or above) Refer URGENTLY to hospital Malaria test POSITIVE.*** Yellow: Give recommended first line oral antimalarial MALARIA IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER Give one dose of paracetamol in clinic for high fever (38.5°C or above) Advise mother when to return immediately Follow-up in 3 days if fever persists If fever is present every day for more than 7 days, refer for assessment Green:

MEASLES & COMPLICATIONS Malaria test NEGATIVE

Give one dose of paracetamol in clinic for high fever (38.5°C or above) Give appropriate treatment for any other cause Other cause of fever NO MALARIA You previously learned that a child who has aof fever fever and measles now or within the PRESENT. Advise mother when to return immediately last 3 months is classified both for fever and measles. Open your classification Follow-up in 3 days if fever persists chart for measles: If fever is present every day for more than 7 days, refer for assessment and/or HOW DO YOU CLASSIFY MEASLES? FEVER: Any general danger sign or Clouding of cornea or Deep or extensive mouth ulcers. Pink: SEVERE COMPLICATED MEASLES**** Give Vitamin A treatment Give first dose of an appropriate antibiotic If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment Refer URGENTLY to hospital Give Vitamin A treatment If pus draining from the eye, treat eye infection with tetracycline eye ointment If mouth ulcers, treat with gentian violet Follow-up in 3 days Give Vitamin A treatment

If MEASLES now or within last 3 months, Classify

Pus draining from the eye or Mouth ulcers.

Yellow: MEASLES WITH EYE OR MOUTH COMPLICATIONS**** Green: MEASLES

Measles now or within the last 3 months.

 temperature readings are approximately 0.5°C higher.

SEVERE MEASLES t tender swelling; red tender skin or boils; lower COMPLICATED abdominal pain or pain on passing urine (RED) in older children. ulcers should be classified as having SEVERE COMPLICATED MEASLES. WhatPage 7 of 75  are your actions? This child needs urgent treatment and referral to hospital. Before referral, the child requires Vitamin A treatment and the first dose of an appropriate oral antibiotic. If there is clouding of the cornea, or pus draining from the eye, apply tetracycline ointment. If it is not treated, corneal clouding can result in blindness. Ask the caregiver if the clouding has been present for some time, and if it was assessed and treated at the hospital. If it was, you do not need to refer the child again for this eye sign.

ALARIA; Low malaria risk AND NOA obvious fever - classify as MALARIA. childcause withof any general danger sign, clouding of cornea, or deep or extensive mouth

ridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.

MEASLES WITH EYE OR MOUTH COMPLICATIONS (YELLOW) If the child has pus draining from the eye, or mouth ulcers that are not deep or extensive, classify the child as having MEASLES WITH EYE OR MOUTH COMPLICATIONS. What are your actions? A child with this classification does not need referral. However, early identification and treatment of measles complications can prevent many deaths. Treat the child with vitamin A. It will help correct any vitamin A deficiency and decrease the severity of the complications. Teach the caregiver to treat the child’s eye infection or mouth ulcers at home. Treating mouth ulcers helps the child resume normal feeding more quickly.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

MEASLES (GREEN) A child with measles now or within the last 3 months and with none of the complications listed in the top or middle row of the table is classified as MEASLES. Give the child vitamin A to help prevent measles complications. All children with measles should receive vitamin A.

n  How will you classify Sami’s fever? You assessed that Sami had a fever by taking his temperature, which was 38.6 degrees. You know his family lives in a high risk area, so you will use the high malaria risk charts. Sami did not show signs of a stiff neck. He did not show any general danger signs when you checked him earlier. Sami had a positive malaria test with the RDT. He did not have a runny nose. He did not have any signs of other causes of fever. Miriam said that he has not had measles.

n  How will you classify Sami? You classify Sami as having MALARIA. This classification identifies the appropriate treatments, which we will discuss in the next section. You will not need to classify Sami for measles. This is because Miriam reported that Sami did not have measles within the past three months, and he did not show any signs of measles today. Now you will practice assessing and classifying two case studies for fever and measles. You will be given an example case to review before you do the two exercises. Then you will learn about appropriate treatments for febrile disease, malaria, fever, complicated measles, and measles.

SELF-ASSESSMENT EXERCISE B Answer the questions below about assessing and classifying measles.

1. When should a child be classified for measles?

2. When you assess a child with fever for measles, what signs will you look for?

3. Allan has a fever and deep, extensive ulcers. How will you classify?

4. Which signs indicate that a child has MEASLES WITH COMPLICATIONS?

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

SELF-ASSESSMENT EXAMPLE This example will show you how to assess and classify illness in a child with fever. After this example, you will have two self-assessment exercises to complete yourself.

Paulo is 10 months old. He weighs 8.2 kg. His temperature is 37.5 °C. His mother says he has a rash and cough. The health worker checked Paulo for general danger signs. Paulo was able to drink, was not vomiting, did not have convulsions and was not lethargic or unconscious. The health worker next asked about Paulo’s cough. The mother said Paulo had been coughing for 5 days. He counted 43 breaths per minute. He did not see chest indrawing. He did not hear stridor when Paulo was calm. Paulo did not have diarrhoea. Next the health worker asked about Paulo’s fever. The malaria risk is high. The mother said Paulo has felt hot for 2 days. Paulo did not have a stiff neck. He has had a runny nose with this illness, his mother said. Paulo had a positive RDT test for P. falciparum malaria parasites. Paulo has a rash covering his whole body. Paulo’s eyes were red. The health worker checked the child for complications of measles. There were no mouth ulcers. There was no pus draining from the eye and no clouding of the cornea. 1. To classify Paulo’s fever, the health worker looked at the table for classifying fever: — He checked to see if Paulo had any of the signs in the pink row. He thought, “Does Paulo have any general danger signs? No, he does not. Does Paulo have a stiff neck? No, he does not. Paulo does not have any signs of VERY SEVERE FEBRILE DISEASE.” — Next, the health worker looked at the yellow row. He thought, “Paulo has a fever. His temperature measures 37.5 °C. He also has a history of fever because his mother says Paulo felt hot for 2 days. He classified Paulo as having MALARIA. 2. Because Paulo had a generalized rash and red eyes, Paulo has signs suggesting measles. To classify Paulo’s measles, the health worker looked at the classification table for classifying measles: — He checked to see if Paulo had any of the signs in the pink row. He thought, “Paulo does not have any general danger signs. The child does not have clouding of the cornea. There are no deep or extensive mouth ulcers. Paulo does not have SEVERE COMPLICATED MEASLES.” — Next the health worker looked at the yellow row. He thought, “Does Paulo have any signs in the yellow row? He does not have pus draining from the eye. There are no mouth ulcers. Paulo does not have MEASLES WITH EYE OR MOUTH COMPLICATIONS.” — Finally the health worker looked at the green row. Paulo has measles, but he has no signs in the pink or yellow row. The health worker classified Paulo as having MEASLES.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

3. Here is how the health worker recorded Paulo’s case information and signs of illness.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Paulo Name: Age: 10 mo Weight (kg): 8.2 kg Temperature (°C): 37.5 °C Ask: Initial Visit? X Follow-up Visit? What are the child's problems? Rash, cough ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

4 Days For how long? ___

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute 43 breaths per minute. Fast breathing? ___ Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

cough or cold Yes __ No __

X

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ 2 Days For how long? ___ If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

X

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

Malaria

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? Are ___ there If Yes, for how long? Daysany

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear

Measles Yes __ No __

parts of this form that are confusing to you?

for oedema of both feet. THEN CHECK Revisit FOR ACUTE MALNUTRITION the ASSESS section toLook review clinical signs. You learned that the first step Determine WFH/L _____ Z score. AND ANAEMIA

For children 6 months or older measure MUAC ____ mm. is to determine the malaria risk. Then you will assess for causes of fever. If the Look for palmar pallor. child shows signs of measles, orSevere has palmar had measles within the past 3 months, you pallor? Some palmar pallor? Is there any medical complication? If child has MUAC than 115 mm or will less assess for complications. General danger sign? WFH/L less than -3 Z scores or oedema of Any severe classification? Revisit the CLASSIFY section to see how you will classify both feet: Pneumonia with chest indrawing?

with different tables,

For a child 6 months or older offer RUTF to eat. Is the child: depending on the malaria risk.

CHECK FOR HIV INFECTION

Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

26 Measles1

Measles 2

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

SELF-ASSESSMENT EXERCISE C Record Kareem’s signs and classify all signs assessed on the recording form. Kareem’s case is from an area of high malaria risk.

Kareem is 5 months old. He weighs 5.2 kg. His axillary temperature is 37.5 °C. His mother said he is not eating well. She said he feels hot, and she wants a health worker to help him. Kareem is able to drink, has not vomited, does not have convulsions, and is not lethargic or unconscious. Kareem does not have a cough, said his mother. He does not have diarrhoea. Because Kareem’s temperature is 37.5 °C and he feels hot, the health worker assessed Kareem further for signs related to fever. It is the rainy season, and the risk of malaria is high. The mother said Kareem’s fever began 2 days ago. He has not had measles within the last 3 months. He does not have stiff neck, his nose is not runny, and there are no signs suggesting measles. He had a positive RDT test for P. falciparum.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Yes __ No __

27

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor?

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

SELF-ASSESSMENT EXERCISE D Record Dolma’s signs and classify all signs assessed on the recording form. Dolma’s case is from an area of low malaria risk.

Dolma is 12 months old. She weighs 7.2 kg. Her axillary temperature is 36.5 °C. Her mother brought Dolma to the health centre today because she feels hot. Dolma has no general danger signs. She does not have cough or difficult breathing. When asked about diarrhoea, the mother said, “Yes, Dolma has had diarrhoea for 2 to 3 days.” She has not seen any blood in the stool. Dolma has not been lethargic or unconscious. Her eyes are not sunken. She drinks normally. Her skin pinch returns immediately. The health worker said, “You brought Dolma today because she feels hot. I will check her for fever.” The risk of malaria is low. Her mother said that Dolma has felt hot for 2 days. She has not had measles within the last 3 months. There is no stiff neck and no runny nose. Dolma has a dry, generalized rash. She also has red eyes. She has a negative malaria test.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Yes __ No __

28

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor?

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

5.5

TREAT THE CHILD WITH FEVER

HOW WILL YOU TREAT FEVER? Return to your classification charts for fever and measles. What treatments do you see in the IDENTIFY TREATMENT columns? You will review several treatments for fever and malaria in this section: As you read more about each, follow along with your TREAT THE CHILD charts. ✔✔ Give quinine or artesunate for severe malaria ✔✔ Give paracetamol ✔✔ Give first-line oral antimalarials ✔✔ Give Vitamin A treatment Some treatments are require counselling the caregiver, so you’ll read in the next section: ✔✔ Apply eye ointment ✔✔ Treat with gentian violet You will see that some identified treatments that have been previously discussed: ✔✔ Give antibiotics ✔✔ Treat for low blood sugar

MALARIA HOW WILL YOU GIVE QUININE OR ARTESUNATE FOR SEVERE MALARIA? A child with VERY SEVERE FEBRILE DISEASE may have severe malaria. To kill malaria parasites as quickly as possible, give a quinine injection before referral. Artesunate suppositories are the preferred antimalarials because they are effective in most areas of the world and they act rapidly. Possible side effects of a quinine injection are a sudden drop in blood pressure, dizziness, ringing of the ears, and a sterile abscess. If a child’s blood pressure drops suddenly, the effect stops after 15–20 minutes. Dizziness, ringing of the ears and abscess are of minor importance in the treatment of a very severe disease. Use the table in TREAT chart to determine the dose. Use the child’s weight, if the child can be weighed.

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

HOW WILL YOU GIVE FIRST-LINE ORAL ANTIMALARIALS FOR MALARIA? ACT (artemisinin-based combination therapies) are recommended for treating malaria

WHO now recommends the use of artemisinin-based combination therapies (ACT), which have been shown to improve treatment efficacy. The advantages of ACT are that it can very quickly reduce the number of malarial parasites and improve the symptoms.

WHAT ACTS ARE RECOMMENDED? The antimalarials to be used for treatment of malaria will depend on the national policy guidelines. There are several ACT options available. Based on available data on safety, efficacy, and cost, the following therapies are recommended in prioritized order: 1. artemether-lumefantrine (CoartemTM) 2. artesunate (3 days) plus amodiaquine 3. artesunate (3 days) plus SP in areas where SP efficacy remains high 4. SP plus amodiaquine in areas where efficacy of both amodiaquine and SP remain high (this is mainly limited to countries in West Africa). You will now read the instructions and dosing for two common treatments – numbers 1 and 2 from above. This information is also in your Chart Booklet. ORAL ARTESUNATE – LUMEFANTRINE (AL) 1. First dose in clinic: Give the first dose of Artesunate – lumefantrine (AL) in the clinic and observe for one hour. If child vomits within an hour repeat the dose. 2. Continued doses at home: The second dose is given at home after 8 hours. Artesunate – lumefantrine (AL) should be taken with food. Then twice daily for further two days as shown below: AL TABLETS (20 mg artemether and 120 mg lumefantrine) WEIGHT (age) 5–15 kg (2 mo under 3 years) 15–24 kg (4–8 years) 25–34 kg (9–14 years) Over 34 kg (over 14 years) 0h 1 2 3 4 8h 1 2 3 4 24h 1 2 3 4 36h 1 2 3 4 48h 1 2 3 4 60h 1 2 3 4

30

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

ORAL ARTESUNATE PLUS AMODIAQUINE (AS+AQ) This is currently available as a fixed-dose formulation with tablets containing 25/67.5 mg, 50/135 mg or 100/270 mg of artesunate and amodiaquine. Blister packs of separate scored tablets containing 50 mg of artesunate and 153 mg base of amodiaquine, respectively, are also available. 1. First dose in clinic: Give first dose in the clinic and observe for an hour, if a child vomits within an hour repeat dose. 2. Continued doses at home: The child will then require a dose every day for the following two days as per the table below using the fixed dose combination: AS+AQ (Fixed Dose formulation tablets) WEIGHT (age) 5 up to 10 kg (2 mo up to 1 year) 10 up to 18 (1–5 years) 18 up to 36 kg (6–13 years) 36 kg or more (14 years or older) DAY 1 1 tablet (25 mg AS/67.5 mg AQ) 1 tablet (50 mg AS/135 mg AQ) 1 tablet (100 mg AS/270 mg AQ) 2 tablets (100 mg AS/270 mg AQ) DAY 2 1 tablet (25 mg AS/67.5 mg AQ) 1 tablet (50 mg AS/135 mg AQ) 1 tablet (100 mg AS/270 mg AQ) 2 tablets (100 mg AS/270 mg AQ) DAY 3 1 tablet (25 mg AS/67.5 mg AQ) 1 tablet (50 mg AS/135 mg AQ) 1 tablet (100 mg AS/270 mg AQ) 2 tablets (100 mg AS/270 mg AQ)

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

SELF-ASSESSMENT EXERCISE E Answer the following questions about oral antimalarials treatment.

1. Why are chloroquine and Sulfadoxine-pyrimethamine (SP) no longer the first-line and second-line antimalarial medicines recommended in the IMCI guidelines of many countries?

2. What does the WHO recommend for oral antimalarial treatment?

3. Explain how the following children should receive treatment: a. 10 kg child, 6 months old, AL (20 mg/120 mg):

b. 12 kg child, AS+AQ:

c. 33 kg child, 12 years old, AL (20 mg/120 mg):

4. What special instructions are given with AL?

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IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

FEVER HOW WILL YOU GIVE PARACETAMOL FOR HIGH FEVER (OVER 38.5 DEGREES OR ABOVE)? Paracetamol lowers a fever and reduces pain. If a child has high fever, regardless of the classification, give one dose of paracetamol in clinic. See the TREAT THE CHILD charts for doses.

MEASLES HOW WILL YOU GIVE VITAMIN A TREATMENT? Vitamin A is given to a child with MEASLES or SEVERE MALNUTRITION. Vitamin A is available in capsule and syrup. Use the child’s age to determine the dose. Give 2 doses. Vitamin A helps resist the measles virus infection in the eye as well as in the layer of cells that line the lung, gut, mouth and throat. It may also help the immune system to prevent other infections. Corneal clouding, a sign of vitamin A deficiency can progress to blindness if vitamin A is not given. Give the first dose to the child in the clinic. Give the second dose to the mother to give her child the next day at home. If the vitamin A in your clinic is in capsule form, make sure the child swallows it whole. If the child is not able to swallow a whole capsule or needs only part of the capsule, open the capsule. Tear off or cut across the nipple with a clean tool. If the vitamin A capsule does not have a nipple, pierce the capsule with a needle. Record the date each time you give vitamin A to a child. This is important. If you give repeated doses of vitamin A in a short period of time, there is danger of an overdose.

HOW WILL YOU TREAT LOCAL INFECTIONS? Local infections include the eye infection and mouth ulcers that measles might cause. You will learn more in the next section about teaching a caregiver to treat eye infection with tetracycline eye ointment and treat mouth ulcers with gentian violet. Some treatments for local infections cause discomfort. Children often resist having their eyes, ears or mouth treated. Therefore, it is important to hold the child still. This will prevent the child from interfering with the treatment. However, do not attempt to hold the child still until immediately before treatment. If the child is not being referred, and if the child has eye infection, ear infection, mouth ulcers, cough or sore throat, teach the child’s mother or caregiver to treat the infection at home. If the child will be referred, and the child needs pre-referral treatment with tetracycline eye ointment, clean the eye gently. Pull down the lower lid. Squirt the first dose of tetracycline eye ointment onto the lower eyelid. The dose is about the size of a grain of rice.

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n  How will you treat Sami? You have classified Sami’s fever as MALARIA. The classification table identifies the following treatments for Sami: ✔✔ Antimalarials ✔✔ One dose paracetamol in clinic for high fever – Sami will need this, because his fever is 38.6 degrees. Paracetamol is recommended for 38.5 degrees and above. ✔✔ You will advise Miriam when to return immediately and when to follow-up You explain to Miriam that you think Sami has malaria, but that he can easily be treated with an oral medication. You also tell her that you will also give him some medicine to bring down his high fever. This should help him start to feel better.

n  How will you give Sami paracetamol? You will refer to your TREAT THE CHILD chart about pain relief medications to determine the dosage of paracetamol. Sami is 3 years old and 12 kg. What dosage will you give? WEIGHT 12 up to 14 kg AGE 2 up to 3 years PARACETAMOL (120 mg/5 mls) 7.5 ml

You decide that Sami needs 7.5 ml of 120 mg/5 mls paracetamol. You give this to him now. Miriam looks very relieved and holds Sami’s hands. She asks how she will be able to give the antimalarials. She says she is nervous to do this and will need instructions, and she is worried about harming Sami with medication because he is grown. You tell her that you will walk her through this all.

n  How will you give Sami antimalarials? You stress that it will be very important for her to give him the medication properly at home. You have Artesunate-lumefantrine (AL) in the clinic so you will explain how to give this medication. What dosage of AL tablets (20 mg artemether and 120 mg lumefantrine) will you give him? AL tablets (20 mg artemether and 120 mg lumefantrine) WEIGHT (age) 5–15 kg (2 mo under 3 years) 0h 1 8h 1 24h 1 36h 1 48h 1 60h 1

You will give the first dose of AL in the clinic and observe for one hour. You show Miriam how to measure the dosage, and give Sami the medication. You ask her to practice, and then you ask her to give the first dose in the clinic. You explain that you will watch him for 1 hour to make sure he does not vomit the medication up. Sami does not vomit, so you do not need to repeat the dose. You instruct Miriam to give the second dose at home in 8 hours. You tell her to give the same dose twice each day for the next two days. AL should be given with food. Sami will then require additional tablets for the next two days. This is shown in the table above. You will learn in the next section how to counsel further Miriam about Sami’s care and when to return to the clinic, and you will check her understanding.

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5.6

COUNSEL THE CAREGIVER

DO YOU REMEMBER THE IMPORTANT STEPS WHEN COUNSELLING A CAREGIVER? Review the topics that you will always discuss with a caregiver: In this section, you will learn about home treatments for fever and measles, and when a child should return to the clinic. The good communication skills you have learned previously are very important for the teaching you will be doing.

HOME TREATMENTS Giving oral medicines, treating local infections FEEDING & FLUIDS Feeding problems, during illness, breastfeeding FOLLOW-UP WHEN TO RETURN IMMEDIATELY CAREGIVER’S HEALTH and OTHER CARE

HOW WILL YOU COUNSEL ON GIVING ORAL ANTIMALARIALS? Antimalarials will be given with the same steps that we reviewed for oral medicines in Module 4 on cough or difficult breathing. Let us review the steps for counseling a caregiver about giving oral medicines at home: 1. DETERMINE APPROPRIATE MEDICINES & DOSAGE – for child’s weight and age. You will determine this based on oral antimalarials in your country. 2. EXPLAIN TREATMENT – tell caregiver what the drug is, and why you are giving it. Explain the treatment steps as described in the appropriate TREAT THE CHILD box. 3. DEMONSTRATE how to measure a dose 4. LET HER PRACTICE – watch the caregiver practice measuring a dose by herself 5. ASK CAREGIVER TO GIVE FIRST DOSE to the child 6. EXPLAIN DRUG CAREFULLY, THEN LABEL AND PACKAGE – you would also give the caregiver a tube of tetracycline ointment for the eyes or a small bottle of gentian violet for mouth ulcers. 7. CHECK UNDERSTANDING

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HOW WILL YOU TREAT EYE INFECTIONS WITH TETRACYCLINE EYE OINTMENT? If the child will be URGENTLY referred, clean the eye gently. Pull down the lower lid. Squirt the first dose of tetracycline eye ointment onto the lower eyelid. If the child is not being referred, teach the caregiver to apply the tetracycline eye ointment. Refer to the TREAT THE CHILD chart and give the caregiver the following information. The dose is about the size of a grain of rice. GIVE INFORMATION. Tell the caregiver: ✔✔ Treat both eyes to prevent damage to the eyes ✔✔ Wash her hands before and after treating the eye. ✔✔ Clean the child’s eyes immediately before applying the tetracycline eye ointment. Use a clean cloth to wipe the eye. ✔✔ The ointment will slightly sting the child’s eye ✔✔ Repeat the process (cleaning the eye and applying ointment) 3 times per day – in the morning, at mid-day and in the evening. DEMONSTRATE how to treat the eye. ✔✔ Wash your hands ✔✔ Hold down the lower lid of your eye. Point to the lower lid. Tell the caregiver that this is where she should apply the ointment. Tell her to be careful that the tube does not touch the eye or lid. ✔✔ Have someone hold the child still. ✔✔ Wipe one of the child’s eyes with the cloth. Squirt the ointment onto the lower lid. Make sure the caregiver sees where to apply the ointment and the correct dose (rice grain). ASK CAREGIVER TO PRACTICE cleaning and applying the eye ointment into the child’s other eye. Observe and give feedback as she practices. When she is finished, give her the following additional information. •• Treat both eyes until the redness is gone from the infected eye. The infected eye is improving if there is less pus in the eye or the eyes are not stuck shut in the morning. •• Do not put any other eye ointments, drops or alternative treatments in the child’s eyes. They may be harmful and damage the child’s eyes. Putting harmful substances in the eye may cause blindness. •• After 2 days, if there is still pus in the eye, bring the child back to the clinic. 1. Give information

Dose size = grain of rice

2. Show an example 3. Let caregiver practise

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Then give the caregiver the tube of ointment to take home. Give her the same tube you used to treat the child in the clinic. Before the caregiver leaves, ask checking questions about treating the eye. For example, ask: “Will you treat one or both eyes? ” or “How much ointment you will put in the eye? ”

HOW WILL YOU TREAT MOUTH ULCERS WITH GENTIAN VIOLET? Treating mouth ulcers controls infection and helps the child to eat. Teach the caregiver to treat mouth ulcers with half-strength gentian violet (.25%), which should be used in the mouth, not full-strength (0.5%). 1. GIVE INFORMATION. Tell the caregiver: ✔✔ A child will start eating normally sooner if she paints the mouth ulcers in her child’s mouth. It is important that the child eats. ✔✔ Clean the child’s mouth. Wrap a clean soft cloth around her finger. Dip it in salt water. Wipe the mouth. ✔✔ Use a clean cloth or a cotton-tipped stick to paint gentian violet on the mouth ulcers. The gentian violet will kill germs that cause the ulcers. Put a small amount of gentian violet on the cloth or stick. Do not let the child drink the gentian violet. ✔✔ Treat the mouth ulcers 2 times per day, in the morning and evening. ✔✔ Treat the mouth ulcers for 5 days and then stop. 2. SHOW how to wrap a clean cloth around your finger, dip it into salt water, and wipe the child’s mouth clean. Then paint half of the child’s mouth with halfstrength gentian violet. As you have read, some treatments for local infections cause discomfort. The drawing on the right shows a good position for holding a child. Tilt the child’s head back when applying eye ointment or treating mouth ulcers. Do not attempt to hold the child still until immediately before treatment.

3. ASK CAREGIVER TO PRACTICE. Watch her wipe the child’s mouth clean and paint the rest of the ulcers with gentian violet. Comment on the steps she did well and those that need to be improved. Give the caregiver a bottle of half-strength gentian violet to take home. Tell her to return in 2 days for follow-up. Also tell her that she should return to the clinic earlier if the mouth ulcers get worse or if the child is not able to drink or eat.

Before the caregiver leaves, ask checking questions. If she anticipates any problems providing the treatment, help her to solve them. For example, ask: “What will you use to clean the child’s mouth? ” “When will you wash your hands? ” “How often will you treat the child’s mouth? ” “For how many days? ”

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WHEN SHOULD A CHILD WITH FEVER RETURN TO THE CLINIC? MALARIA FEVER: NO MALARIA MEASLES Any sick child … in 3 days if the fever persists … in 2 days if the fever persists … in 2 days Should return immediately if they: ✔ are not able to drink or breastfeed ✔ become sicker

SELF-ASSESSMENT EXERCISE F Answer the following questions about counselling a caregiver about fever.

1. What are the 3 basic teaching steps?

2. What are important instructions for the caregiver about treating the eye with ointment? List 5 that you can think of from the information you provide the caregiver, and when you would demonstrate how to put the ointment on.

3. When should children with FEVER: NO MALARIA return for follow-up? Pick the best answer below. a. The next day b. 3 days, after antimalarials are finished c. 2 days, if the fever persists 4. When should children with measles and eye or mouth complications return for follow-up? Pick the best answer below. a. The next day b. 4 days, if signs of measles (rash, runny nose, red eyes) persist c. 3 days

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n  How will you counsel Miriam? Now you will review how to counsel Miriam about home care to treat Sami’s malaria. Sami will need oral antimalarials for his malaria. You will give AL. Let us review the treatment guidelines for AL now: AL is given twice daily for 3 day.

He weighs 12 kg, so give Sami tablets of AL for 3 days. He should get 1 tablet (Artemether-lumefantrine) at the clinic, another dose after 8 hours on the first day, then 1 tablet twice daily on the second and third day.

n  What important information does Miriam require? You tell Miriam that Sami will need to take the medication for 3 days, and explain how she will give 1 tablet 8 hours after the first dose given at the clinic, and then 1 tablet twice daily for the next two days. Demonstrate how to give Sami the medication, and ask her to practice measuring the dosage. You tell Miriam to watch Sami carefully for 30 minutes after she gives the AL. If he vomits within 30 minutes, she should repeat the dose. She will need to return to the clinic for extra doses. You will also need to counsel Miriam on Plan A for home treatment of diarrhoea.

n  How will you check that Miriam understands? You finish by asking checking questions about the home treatment. You ask, “How will you give the tablets? What is the schedule?” You ask, “What should you do after giving the tablets to Sami?” You ask, “How will you mix the ORS?” You ask, “How will you give the zinc?”

Miriam answers the questions well.

n  When should Sami return? You tell Miriam that she should bring Sami back in 3 days if his fever continues, or in 5 days if his diarrhoea is continuing. You take Miriam’s Mother’s Card and review when she should bring Sami back immediately if danger signs develop. Miriam takes the AL tablets, zinc supplements, and two packets of ORS. She thanks you for your help.

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5.7

PROVIDE FOLLOW-UP CARE

Open your Chart Booklet and review the boxes on follow-up care. What do you observe? You will use these instructions when a child returns for a follow-up visit for a persistent fever, measles, or other cause of fever. The follow-up boxes also describe treatment. REMEMBER! If a fever has been present for 7 days or longer, refer the child for assessment. This child may have typhoid fever or another serious infection requiring additional diagnostic testing and special treatment.

FEVER: NO MALARIA HOW DO YOU FOLLOW UP ON FEVER IF PERSISTS AFTER 3 DAYS? If this child returns for follow-up after 3 days because the fever persists, follow the instructions below. 1. Do a full reassessment of the child, assessing for other causes of fever 2. Do a malaria test with RDT or microscopy  MALARIA TEST IS POSITIVE Treat with recommended first-line oral antimalarial. Advise the caregiver to return again in 3 days if the fever persists.  CHILD HAS ANOTHER CAUSE OF FEVER, BESIDES MALARIA If the child has any cause of fever other than malaria, provide treatment for that cause.  CHILD HAS GENERAL DANGER SIGN(S) OR STIFF NECK If the child has any general danger signs or stiff neck, treat as described on the chart for VERY SEVERE FEBRILE DISEASE. Refer to the previous page to review this treatment.

MALARIA HOW WILL YOU FOLLOW-UP MALARIA (IF FEVER PERSISTS 3 DAYS)? Any child classified as having MALARIA should return for follow-up if the fever persists for 3 days. If a child classified with MALARIA returns with a fever within 14 days of receiving treatment, you will provide the same follow-up care.

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If a child returns because the fever persists after 3 days, or within 14 days: ✔✔ Do a full reassessment of the child, assessing for other causes of fever If the child also had measles or any other cause of fever at the initial visit, the fever may be due to the measles or another cause. This will require further assessment and possible laboratory investigations. It is very common for the fever from measles to continue for several days. Therefore, the persistent fever may be due to the measles rather than to resistant malaria.  CHILD HAS GENERAL DANGER SIGN(S) OR STIFF NECK If the child has any general danger signs or stiff neck, treat as described on the chart for VERY SEVERE FEBRILE DISEASE. Refer urgently to hospital. If the child has already been on an antibiotic, the illness worsening to very severe febrile disease might mean there is a bacterial infection that is not responsive to this antibiotic. Give a first dose of the second-line antibiotic or intramuscular chloramphenicol. If the child cannot take an oral antibiotic because he has repeated vomiting, is lethargic or unconscious, or is not able to drink, give intramuscular chloramphenicol. Also give intramuscular chloramphenicol if he has a stiff neck. ✔✔ Do a malaria test with RDT or microscopy It is very unusual for the fever due to malaria to persist for 3 days after the initial visit or fever to return within 14 days of receiving ACT treatment. Therefore, a blood test using microscopy should be done to confirm that malaria parasites are resistant to the first-line ACT antimalarial before giving an effective second-line ACT treatment.  MALARIA TEST POSITIVE Treat with second-line oral antimalarial. Ask the caregiver to return again in 3 days if the fever persists. If second line oral antimalarial is not available, refer the child to hospital. Note: If a child had a positive malaria test on the initial visit, the commonly used HRP-2-based RDT tests will remain positive for even up to 3 weeks after effective treatment. Therefore only microscopy should be used to identify malaria parasites on follow up after initial treatment malaria. HRP-2 based RDT tests should not be repeated if fever persists or returns within 14 days. Check on the type of RDT you use in your clinic and how long the test remains positive.  CHILD HAS ANOTHER CAUSE OF FEVER, BESIDES MALARIA If the child has any cause of fever other than malaria, provide treatment for that cause. For example, give treatment for the ear infection or refer for other problems such as urinary tract infection or abscess.

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SELF-ASSESSMENT EXERCISE F Read about Lin, who is returning for follow-up for MALARIA. Answer the questions.

In this clinic, Artemether-lumefantrine (AL) is the first-line oral antimalarial (20 mg artemether and 120 mg lumefantrine). Artesunate plus Amodiaquine is the second-line oral antimalarial. Lin’s mother has brought him back to the clinic because he still has fever. The risk of malaria is high. Two days ago he was given AL for MALARIA. He was also given a dose of paracetamol. His mother says that he has no new problems, just the fever. He is 3 years old and weighs 14 kg. His axillary temperature is 38.5 °C. 1. How would you reassess Lin?

When you reassess Lin, he has no general danger signs. He has no cough and no diarrhoea. He has now had fever for 4 days. He does not have stiff neck. There is no runny nose or generalized rash. Microscopy slide for malaria parasites is positive. He has no ear problem. He is classified as having NO ANAEMIA AND NOT VERY LOW WEIGHT. There is no other apparent cause of fever. 2. How would you treat Lin? If you would give a drug, specify the dose and schedule.

SELF-ASSESSMENT EXERCISE G Read about Sindi, who is returning for follow-up for MALARIA. Answer the questions.

Sindi’s mother has come back to the clinic because Sindi still has a fever. Three days ago she had a positive rapid malaria test and was given treatment for MALARIA. Her mother says that she is sicker now, vomiting and very hot. Sindi is 18 months old and weighs 11 kg. Her axillary temperature is 39 °C today. When you assess Sindi, her mother says that yesterday she could drink, but she vomited after eating. She did not always vomit after drinking a small amount. She has not had convulsions. She will not wake up when her mother tries to wake her. She is unconscious. Her mother says that she does not have a cough or diarrhoea. She has now had fever for 5 days. She does not have stiff neck, runny nose or generalized rash. 3. How will you manage Sindi?

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MEASLES HOW WILL YOU FOLLOW-UP ON MEASLES WITH COMPLICATIONS (IN 2 DAYS)? When a child who was classified as having MEASLES WITH EYE OR MOUTH COMPLICATIONS returns for follow-up in 2 days, you will check the eyes and mouth. You will select treatment based on the signs. Follow these instructions: 1. Look for red eyes and pus draining from the eyes 2. Look at mouth ulcers 3. Smell the mouth

EYE INFECTIONS  NO PUS OR REDNESS Stop the treatment. Praise the caregiver for treating the eye well. Tell her the infection is gone.  PUS IS GONE, BUT REDNESS REMAINS Continue the treatment. Tell the caregiver that the treatments are helping. Encourage her to continue giving the correct treatment until the redness is gone.  PUS IS STILL DRAINING FROM EYE Ask the caregiver to describe or show you how she has been treating the eye infection. If she has brought the tube of ointment with her, you can see whether it has been used. There may have been problems so that the caregiver did not do the treatment correctly. For example, she may not have treated the eye three times a day, or she may not have cleaned the eye before applying the ointment, or the child may have struggled so that she could not put the ointment in the eye. If the caregiver has not correctly treated the eye, ask her what problems she had in trying to give the treatment. Teach her any parts of the treatment that she does not seem to know. Discuss with her how to overcome difficulties she is having. Finally, explain to her the importance of the treatment. Ask her to return again if the eye does not improve. However, if you think that the caregiver still will not be able to treat the eye correctly, arrange to treat the eye each day in clinic or refer the child to a hospital. If the caregiver has correctly treated the eye infection for 2 days and there is still pus draining from the eye, refer the child to a hospital.

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MOUTH ULCERS  ULCERS ARE WORSE, OR VERY FOUL SMELL FROM MOUTH Refer to hospital. The mouth problem may prevent the child from eating or drinking and may become severe. A very foul smell may mean a serious infection. Mouth problems could be complicated by thrush or herpes, which is the virus which causes cold sores.   ULCERS ARE SAME or BETTER Ask the caregiver to continue treating the mouth with half-strength gentian violet for a total of 5 days. She should continue to feed the child appropriately to make up for weight lost during the acute illness and to prevent malnutrition. Review with the caregiver when to seek care and how to feed her child as described on the COUNSEL THE MOTHER chart. Tell her that attention to feeding is especially important for children who have measles because they are at risk of developing malnutrition. The child with measles continues to have increased risk of illness for months, it is important that the caregiver know the signs to bring the child back for care. Children who have measles are at increased risk of developing complications or a new problem. This is due to immune suppression that occurs during, and following, measles.

n  How will you provide follow-up for Sami? You classified Sami’s fever as MALARIA, and gave Miriam AL tablets to give to Sami for 3 days. You counselled her on how to safely give this treatment at home, and instructions on when to return to the clinic if the fever continued. Fortunately, you did not see Miriam or Sami in the days following their visit, which hopefully means the medication worked well and Sami’s fever reduced within 3 days. As you instructed Miriam how to give the medication, and how to monitor Sami closely, this would have wellequipped her to deliver the medication and not return to the clinic with concern over these common issues.

n  What if Sami had come to the clinic for follow-up? However, in the case that Sami’s fever had continued for 3 days, and Miriam had returned to the clinic, you would have needed to do a full re-assessment. As you reassess a child in this situation, look for the cause of the fever, possibly pneumonia, meningitis, measles, ear infection, or dysentery. Also consider whether the child has any other problem that could cause the fever, such as tuberculosis, urinary tract infection, osteomyelitis or abscess.

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5.8

USING THIS MODULE IN YOUR CLINIC

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU HAVE GAINED FROM THIS MODULE IN MANAGING CHILDREN WITH FEVER? In the coming days, you should focus on these key clinical skills. Practicing these skills will help you to better understand how to use IMCI for fever and measles. MALARIA & MEASLES ✔✔ Determine if your area is high or low malaria risk. Does this change by season? Are there nearby areas that are of a different risk setting – in case any of your patients travel from there, or recently travelled? ✔✔ Determine what capacity you have to do malaria tests in your facility (e.g. microscopy or Rapid Diagnostic Tests). What tests are available, and what is the procedure? ✔✔ If you have a case of measles, what are the national reporting procedures for measles outbreaks (if any)? ASSESS ✔✔ Determine if children have fever by taking their temperature, feeling if they are hot, or examining their history of fever. ✔✔ Look and feel children for stiff neck ✔✔ Look for runny nose ✔✔ Look for signs of measles – generalized rash, cough, runny nose, or red eyes ✔✔ Look for signs of complications from measles – mouth ulcers, pus draining from eye, and clouded cornea CLASSIFY ✔✔ Use your chart booklet to classify fever in high and low malaria risk areas ✔✔ Use your chart booklet to classify any complications if children have measles, or have had measles within the past 3 months TREAT ✔✔ Determine how to give urgent treatment for very severe febrile disease ✔✔ Determine what antimalarials you have available to you. Determine what dosages you have, and which are appropriate for certain weight/age groups ✔✔ Practice giving oral antimalarials ✔✔ Practice giving paracetamol for high fever ✔✔ Practice giving Vitamin A treatment COUNSEL ✔✔ Teach a caregiver how to give antimalarials, eye ointment, and violet gentian ✔✔ Counsel a caregiver about when to return for follow-up for fever or complications ✔✔ Counsel a caregiver about when to return immediately

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Remember to use your logbook for MODULE 5: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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5.9

REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING FEVER? Before you began studying this module, you practiced your knowledge on with several multiple-choice questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. Which of the following children has a fever that requires further investigation? a. Imrana has an axillary temperature of 37 °C b. Joy’s mother says she has been feeling very hot for the past three days c. Samuel’s face is very flushed and red 2. What are common causes of fever that often kill children? a. Local infection and malaria b. Meningitis and influenza c. Measles and malaria 3. What is a critical treatment for reducing high fever in children? a. Paracetamol b. Amoxicillin or another antibiotic c. Fluids 4. What is recommended treatment for malaria? a. Chloroquine b. Artemisinin-based combination therapies c. Paracetamol 5. Traci has a fever, generalized rash, runny nose, and mouth ulcers. How you would you classify? a. She shows signs local infections of the skin b. She shows clinical signs of AIDS c. Measles with mouth complications Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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5.10 ANSWER KEY REVIEW QUESTIONS QUESTION 1 2 3 4 5 ANSWER B C A B C Did you miss the question? Return to this section to read and practice: INTRODUCTION, ASSESS INTRODUCTION CLASSIFY, TREAT TREAT ASSESS, CLASSIFY

EXERCISE A (ASSESS & CLASSIFY) 1. YES. Children who have a fever AND signs of measles will also be assessed for measles. 2. In high risk areas, all children with fever; in low risk areas, any child without another clear cause of fever 3. Fever and any general danger sign OR stiff neck 4. Reba answers: a. MALARIA b. FALSE: she requires oral antimalarials, but not paracetamol because her fever is not high fever (38.5 degrees C) 5. FALSE. The child may require a malaria test in two scenarios: (a) the child has no other clear cause of fever, or (b) if the child travelled to a high risk malaria area within 2 weeks.

EXERCISE B (ASSESS & CLASSIFY) 1. If the child has a fever and shows signs of measles now, or has had measles in the last 3 months. 2. First you look for a generalized rash. If this is present, the child should also have one of the following signs: cough, runny nose, or red eyes. 3. SEVERE COMPLICATED MEASLES 4. Signs of measles, and also pus draining from eye or mouth ulcers

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EXERCISE C (KAREEM)

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Kareem Name: Age: 5 mo Weight (kg): 5.2 kg Temperature (°C): 37.5 °C Ask: Initial Visit? X Follow-up Visit? What are the child's problems? Not eating well, feels hot ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

Yes __ No __

X

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ 2 Days For how long? ___ If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

X

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

Malaria positive P. falciparum

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

49

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

EXERCISE D (DOLMA) MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Dolma Name: Age: 12 mo Weight (kg): 7.2 kg Temperature (°C): 36.5 °C Ask: Initial Visit? X Follow-up Visit? What are the child's problems? Feels hot ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

4 Days For how long? ___

DOES THE CHILD HAVE DIARRHOEA?

Count the breaths in one minute 43 breaths per minute. Fast breathing? ___ Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

X

2-3 Days For how long? ___ Is there blood in the stool?

Yes __ No __

X

Diarrhoea, no dehydration

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ 2 Days For how long? ___ If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

X

Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

X

Measles

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

50

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 5. FEVER

EXERCISE E (TREAT) 1. Resistance to chloroquine is emerging and growing, and now resistance to SP is growing as well. 2. WHO now recommends the use of artemisinin-based combination therapies (ACT), which have been shown to improve treatment efficacy. The advantages of ACT are that it can very quickly reduce the number of malarial parasites and improve the symptoms. 3. Explain how the following children should receive treatment: a. 10 kg child, 6 months old, AL (20 mg/120 mg): 1 tablet given twice a day for next two days (at 0 hours, 12, 24, 36, 48, and 60) b. 12 kg child, AS+AQ: 1 tablet (50 mg AS/135 mg AQ) each day for 3 days c. 33 kg child, 12 years old, AL (20 mg/120 mg): 4 tablets given twice a day for next two days (at 0 hours, 12, 24, 36, 48, and 60) 4. First dose in clinic, and observe for 1 hour. If child vomits within the hour, repeat the dose. Give second dose at home 8 hours later. Must be taken with food.

EXERCISE F (COUNSEL) 1. Give information, 2. demonstrate, 3. ask caregiver to practice 2. Answers can include any of the following tips: ✔✔ Dose of tetracycline eye ointment is the size of a grain of rice ✔✔ Treat both eyes ✔✔ Wash hands before and after treating eye ✔✔ Clean child’s eyes before applying ointment – use a clean cloth to wipe the eye ✔✔ Do not touch the tube to the eye or lid when applying the ointment ✔✔ Put the ointment in the lower lid of the eye. Hold the lid down. ✔✔ Apply dose of ointment 3 times per day – in the morning, afternoon, and evening ✔✔ Treat until redness is gone from eyes ✔✔ If pus remains after 2 days, return to clinic ✔✔ Do not put other drops, ointments, or treatments in the eye. They might harm the child’s eyes. 3. B: 3 days if fever persists 4. C: 3 days

EXERCISE G (FOLLOW-UP) 1. Today you will test Lin again for malaria, and assess for other causes of fever using the instructions in your charts. 2. Lin has tested positive for malaria again. You will need to give him the second-line treatment, which is Artesunate plus Amodiaquine. You will give him the first dose in the clinic: 1 tablet (50 mg AS/135 mg AQ). He will require the same dose, once daily, for the next two days. 3. Do a full reassessment as on the ASSESS & CLASSIFY chart. You classify as VERY SEVERE FEBRILE DISEASE. Sindi must be referred urgently because she has a general danger sign. You will give the first doses of an antimalarial, the first dose of an appropriate antibiotic, and one dose of paracetamol. You also need to treat for low blood sugar, but Sindi is unconscious. If you can provide by NG tube you will. Refer urgently.

51

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 4 Diarrhoea

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

n CONTENTS Acknowledgements 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Module overview Introduction to diarrhoea Classify diarrhoea & dehydration Treat the child with diarrhoea Counsel the caregiver Provide follow-up care for diarrhoea Using this module in your clinic Review questions 5 8 17 23 37 42 45 46 47

Assess a sick young infant & child for diarrhoea 10

4.10 Answer key

3

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

4

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.1

MODULE OVERVIEW

Diarrhoea is likely a very common problem in the children you see at your clinic. Diarrhoea can be serious – and even lead to death.

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, assess for cough or difficult breathing, then ASK: DOES THE CHILD HAVE DIARRHOEA?

NO

YES ASSESS & CLASSIFY the child using the colour-coded classification charts for dehydration & diarrhoea.

CONTINUE ASSESSMENT: assess for main symptoms (next is fever), check for malnutrition & anaemia, check immunization status, HIV status, other problems

NOTE ON DIARHOEA IN SICK YOUNG INFANT: In Module 2, you were told to refer to this module to assess and classify diarrhoea in sick young infants. The IMCI process is similar for the two. There are some important distinctions, which you will learn about in the module.

MODULE LEARNING OBJECTIVES After you study this module, you will be able to: ✔✔ Define the types of diarrhoea and levels of dehydration ✔✔ Recognize clinical signs of dehydration ✔✔ Assess diarrhoea in sick children ✔✔ Assess dehydration in young infants and sick children ✔✔ Classify diarrhoea and severity of dehydration using IMCI charts ✔✔ Provide Plans A, B, and C for dehydration ✔✔ Counsel the caregiver about home treatment for diarrhoea and dehydration

5

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW

Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications No __

YOUR RECORDING FORM DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Look at your IMCI recording form for the sick child. This section deals with this Yes __ For how long? ___ Days Count the breaths in one minute module:

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ Look for runny nose For how long? ___ Days Look for signs of MEASLES: If more than 7 days, has fever been present every Generalized rash and day? of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? This module follows the major stepsOne of the IMCI process: Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases ✔ ✔ ASSESS DIARRHOEA and DEHYDRATION IN SICK CHILD Low risk: if NO obvious cause of fever Test POSITIVE?✔ P.✔falciparum P.DEHYDRATION vivaxNEGATIVE? ASSESS IN SICK YOUNG INFANT

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

Yes __ No __

MODULE ORGANIZATION

Look for mouth ulcers. If the child has measles now or within the If yes, are they deep and extensive? ✔✔ CLASSIFY DIARRHOEA and DEHYDRATION last 3 months: Look for pus draining from the eye. Look for clouding of the cornea.

✔✔ CLASSIFY DEHYDRATION IN SICK YOUNG INFANT DOES THE CHILD HAVE AN EAR PROBLEM? for oedema of both feet. TREATMENT THEN CHECK ACUTE MALNUTRITION ✔FOR ✔ COUNSEL CAREGIVER ONLook 4 RULES OF HOME Determine WFH/L _____ Z score. AND ANAEMIA Is there ear pain? ✔✔ TREAT DIARRHOEA Is there ear discharge? If Yes, for how long? ___ Days Look for pus draining from the ear Feel for tender swelling behind the ear

Yes __ No __

For children 6 months or older measure MUAC ____ mm. ✔✔ FOLLOW-UP CARE FOR DIARRHOEA Look for palmar pallor.

If child has MUAC less than 115 mm or BEFORE YOU WFH/L less than -3 Z scores orBEGIN oedema of both feet:

CHECK FORmultiple-choice HIV INFECTION questions.

Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia withdiarrhoea? chest indrawing? What do you know now about managing For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? your knowledge with these Before you begin studying this module, quickly practice For a child less than 6 months is there a breastfeeding problem?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0

Note mother's and/or child's HIV status Mother's HIV test: the NEGATIVE POSITIVE NOT DONE/KNOWN Circle best answer for each question. Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE 1. How can diarrhoea kill children? If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Children lose fluids, salts, Was the child a. breastfeeding at the timevaluable of test or 6 weeks before it? and sugars, which can cause shock to vital If breastfeeding: Is the mother and child on ARV prophylaxis?

organs Measles1 they cannot Measles 2 eat b. ChildrenDPT+HIB-2 lose valuable nutrients because DPT+HIB-3 DPT+HIB-1 OPV-3 OPV-2 OPV-1 c. B1 Diarrhoea causes liver failure Hep B3 Hep B2 Hep RTV-1 RTV-2 RTV-3

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

2. Pneumo-1 What are critical treatments for children with diarrhoea and dehydration? Pneumo-3 Pneumo-2 a. Oral antibiotics b. Oral rehydration therapy and zinc c. Paracetamol for discomfort Page 65 of 75 

6

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

3. What is persistent diarrhoea? a. When a child frequently has diarrhoea over a period of 1 month, and is ill as a result b. When a child has several episodes of diarrhoea a day c. When a child has an episode of diarrhoea lasting 14 days or more, which is particularly dangerous for dehydration and malnutrition 4. Critical messages for caregivers about diarrhoea and dehydration include: a. The child must receive increased fluids, ORS, zinc, and regular feeding b. The child requires ORS, but should receive less food in order to reduce the diarrhoea c. The child should immediately receive antibiotics to stop the diarrhoea 5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She has diarrhoea. You observe a significant loss of skin elasticity. How will you manage Nidhi? a. Nidhi requires ORS immediately, as she is dehydrated. b. These are common signs of diarrhoea, as the child’s body is exhausted. c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV or nasogastric tube. After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

7

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.2

INTRODUCTION TO DIARRHOEA

n  OPENING CASE STUDY – MARY It is a busy afternoon in your clinic. A young mother comes into your clinic room, carrying a small girl. She says her daughter, Mary, has diarrhoea. You ask the mother’s name, and she says Ana. Ana says that Mary usually eats porridge and milk, but that she has had bad diarrhoea in the past few days. Ana tried giving more porridge but Mary is still sick. Ana thought it was a bad stomach from spoiled milk, and that it would pass. However, the diarrhoea has remained for several days now, and now Mary looks unwell. Ana fears that Mary is getting worse, and is feeling guilty that she did not come to the clinic sooner. Ana works in the mornings, and lives some distance from the clinic. By the time she commutes into the city for her work duties, she does not have very much time in the day to bring Mary in. She says she is worried that her family will blame her for working at the job and letting Mary get more and more sick.

WHAT IS DIARRHOEA? Diarrhoea occurs when stools contain more water than normal, and are loose or watery. In many regions diarrhoea is defined as three or more loose or watery stools in a 24-hour period. Children between the ages of 6 months and 2 years often have diarrhoea. It is more common in settings of poor sanitation and hygiene, including a lack of safe drinking water.

WHAT ARE THE TYPES OF DIARRHOEA IN CHILDREN? Most diarrhoea that causes dehydration is loose or watery. Cholera is one example, though only a small proportion of all loose or watery diarrhoeas are due to cholera. n ACUTE DIARRHOEA is an episode of diarrhoea that lasts less than 14 days. Acute watery diarrhoea causes dehydration and contributes to malnutrition. The death of a child with acute diarrhoea is usually due to dehydration. n PERSISTENT DIARRHOEA lasts 14 days or more. Up to 20% of episodes of diarrhoea become persistent, and this often causes nutritional problems and contributes to death in children. n DYSENTERY is diarrhoea with blood in the stool, with or without mucus. The most common cause of dysentery is Shigella bacteria. Amoebic dysentery is not common in young children. A child may have both watery diarrhoea and dysentery.

WHAT ARE THE TYPES OF DIARRHOEA IN YOUNG INFANTS? A young infant has diarrhoea if the stools have changed from the usual pattern, and are many and watery. This means more water than faecal matter. The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

8

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

n  How do you greet Ana and begin the assessment? You praise Ana for bringing in her daughter. You tell her that diarrhoea can be a serious problem for young children, but that there are ways to help her daughter get better. You explain that you will check her condition and decide the best treatment. Ana seems relieved. You ask Mary’s age. Ana tells you that she is 9 months old. You ask Ana if there are other problems besides the diarrhoea. She says no. This is their first time coming to the clinic for this diarrhoea. You take Mary’s weight, 8.2 kg, and temperature, 37 degrees Celsius.

n  You will check Mary for general danger signs. First, you check Mary for general danger signs. Ana tells you that Mary is able to drink milk and take porridge. She does not vomit. She has not had convulsions. You watch Mary. She looks very tired in Ana’s arms, but she watches you as you speak. When you reach out to her to take her hand, she grabs your finger. Does Mary have any general danger signs?

n  Next, you will assess Mary for cough or difficult breathing. Now you check Mary for cough or difficult breathing. You ask Ana if Mary has had a cough, or any fast or noisy breathing. Ana says that Mary had a cough about 2 months ago, but it has cleared up. This is how you will complete Mary’s recording form thus far:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Mary Age: 9 mo Weight (kg): 8.2 kg Temperature (°C): 37 °C Initial Visit? X Follow-up Visit? Ask: What are the child's problems? Diarrhoea for several days ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

For how long? ___ Days Now willin assess Is you there blood the stool?Mary

DOES THE CHILD HAVE DIARRHOEA?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Yes __ No __

X

for the next mother brought her to the clinic for.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Look at the childs general condition. Is the child: main Lethargic symptom, diarrhoea. This is or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

also the problem that her

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

9

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.3

ASSESS A SICK YOUNG INFANT & CHILD FOR DIARRHOEA

You have a very important job to do in helping a child with diarrhoea. This module will guide you through the process of assessing, classifying, and treating by the type of diarrhoea and the severity of dehydration.

HOW WILL YOU ASSESS? First, you will ASK all caregivers if the child has diarrhoea. You might need to explain diarrhoea as loose, watery stools if the caregiver needs clarification. Be sure to use words for diarrhoea that the mother understands. NO diarrhoea, ask about the next main symptom, fever. You do not need to further assess. YES or reported earlier that diarrhoea was the reason for coming to the clinic, record her answer. You will then assess in two parts: 1. Type of diarrhoea: especially if it is persistent, or dysentery 2. Signs of dehydration Open to your ASSESS chart for diarrhoea, which includes the assessment for both diarrhoea and dehydration. It contains the following instructions, which you will now learn about. Does the child have diarrhoea? If yes, ask: Look and feel: For how long? Look at the child's general condition. Is the child: Is there blood in the stool? Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

for DEHYDRATION Classify DIARRHOEA

Two of the Letharg Sunken Not able drinking Skin pin very slo

Two of the Restless Sunken Drinks e Skin pin slowly.

The ASSESS chart for the sick young infant is slightly different. There is some additional detail to examine about the infant’s movements. It also does not test how well the child drinks. Review the ASSESS chart for the sick young infant as well.

Not enough as some or dehydration

Dehydra and if diarrhoea 14 days or more

10

No dehy

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

DIARRHOEA: SICK CHILD ASK: FOR HOW LONG? Diarrhoea which lasts 14 days or more is persistent diarrhoea. Give the mother time to answer the question. She may need time to recall the exact number of days.

ASK: IS THERE BLOOD IN THE STOOL? Ask the mother if she has seen blood in the stools at any time during this episode of diarrhoea. As we previously reviewed, dysentery is diarrhoea with blood in the stool, with or without mucus. The most common cause of dysentery is Shigella bacteria. Dysentery will require specific treatments.

DEHYDRATION: SICK CHILD & YOUNG INFANT WHAT IS DEHYDRATION? Diarrhoea can be a serious problem – and even lead to death – if child becomes dehydrated. Dehydration is when the child loses too much water and salt from the body. This causes a disturbance of electrolytes, which can affect vital organs. A child who is dehydrated must be treated to help restore the balance of water and salt. Many cases of diarrhoea can be treated with Oral Rehydration Salts (ORS), a mixture of glucose and several salts. ORS and extra fluids can be used as home treatment to prevent dehydration. Low osmolarity ORS should be used to treat dehydration.

HOW WILL YOU ASSESS DEHYDRATION? There are several signs that help you decide the severity of dehydration. When a child becomes dehydrated, he is at first restless or irritable. As the body loses fluids, the eyes may look sunken, and skin loses elasticity. If dehydration continues, the child becomes lethargic or unconscious.

LOOK: AT THE CHILD’S GENERAL CONDITION When you checked for general danger signs, you checked to see if the child was lethargic or unconscious. If the child is lethargic or unconscious, he has a general danger sign. Remember to use this general danger sign when you classify the child’s diarrhoea. A child is classified as restless and irritable if s/he is restless and irritable all the time or every time s/he is touched and handled. If an infant or child is calm when breastfeeding but again restless and irritable when he stops breastfeeding, s/he has the sign restless and irritable. Many children are upset just because they are in the clinic. Usually these children can be consoled and calmed, and do not have this sign. FOR THE YOUNG INFANT: watch the infant’s movement. Does he move on his own? Does the infant only move when stimulated, but then stops? Is the infant restless and irritable?

11

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

LOOK FOR SUNKEN EYES The eyes of a child who is dehydrated may look sunken. Decide if you think the eyes are sunken. Then ask the mother if she thinks her child’s eyes look unusual. Her opinion can help you confirm. NOTE: In a severely malnourished child (see Module 6) who is wasted, the eyes may always look sunken, even if the child is not dehydrated. Still use the sign to classify dehydration.

DVD EXERCISE – SUNKEN EYES Watch “Assess sunken eyes” (disc 1). It is very useful to practice with a video. Record your answers as you watch, and the video will review them. Do these children have sunken eyes?

CHILD 1   YES   NO CHILD 2   YES   NO

CHILD 3   YES   NO CHILD 4   YES   NO

CHILD 5   YES   NO CHILD 6   YES   NO

LOOK: TO SEE HOW THE CHILD DRINKS Ask the mother to offer the child some water in a cup or spoon. Watch the child drink. A child is not able to drink if he is not able to suck or swallow when offered a drink. A child may not be able to drink because he is lethargic or unconscious. A child is drinking poorly if the child is weak and cannot drink without help. He may be able to swallow only if fluid is put in his mouth. A child has the sign drinking eagerly and acts thirsty if it is clear that the child wants to drink. Look to see if the child reaches out for the cup or spoon when you offer him water. When the water is taken away, see if the child is unhappy because he wants to drink more. If the child takes a drink only with encouragement and does not want to drink more, he does not have the sign drinking eagerly, thirsty.

FEEL: BY PINCHING THE SKIN OF THE ABDOMEN This skin pinch tests is an important tool for testing dehydration. When a child is dehydrated, the skin loses elasticity. To assess dehydration using the skin pinch: 1. ASK the mother to place the child on the examining table so that the child is flat on his back with his arms at his sides (not over his head) and his legs straight. Or, ask the mother to hold the child so he is lying flat on her lap. 2. USE YOUR THUMB AND FIRST FINGER to locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen. Do not use your fingertips because this will cause pain. The fold of the skin should be in a line up and down the child’s body. 3. PICK UP all the layers of skin and the tissue underneath them. 4. HOLD the pinch for one second. Then release it.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

5. LOOK to see if the skin pinch goes back very slowly (more than 2 seconds), slowly, (less than 2 seconds, but not immediately), or immediately. If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back slowly. The photographs below show you how to do the skin pinch test and what the skin looks like when the pinch does not go back immediately.

Skin pinch

Skin pinch going back very slowly

NOTE: The skin pinch test is not always an accurate sign. In a child with severe malnutrition, the skin may go back slowly even if the child is not dehydrated. In a child is overweight or has oedema, the skin may go back immediately even if the child is dehydrated. However you should still use it to classify the child’s dehydration.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

DVD EXERCISE – SKIN PINCH Watch “Assess skin pinch” (disc 1) to see how skin pinches look. How do you assess the 5 children in the video? Record your answers, and the video will review answers with you. 1 VERY SLOWLY SLOWLY IMMEDIATELY 2 3 4 5

Watch “Demonstration: assess and classify diarrhoea” (disc 1) This video reviews all steps in assessing diarrhoea. It is useful to see in a clinical setting.

n  How will you assess Mary’s diarrhoea? Name: Age:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Weight (kg): Temperature (°C):

Ana has already reported she has had diarrhoea, and Ask: What are the child's problems?that Mary has diarrhoea. You ask Ana how many days Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) she tells you 3 days. You ask Ana if there is blood in her daughter’s stool, and she tells you no. CLASSIFY CHECK FOR DANGER SIGNS She seems restless and irritable, especially when you touch General danger sign Now you willGENERAL examine Mary’s condition. her. You present? NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS begin to examine Mary for signs of dehydration. You check that VOMITS EVERYTHING CONVULSING NOW to see if she has sunken eyes, and it appears Yes ___ No ___ sheCONVULSIONS does. Ana agrees that her daughter’s eyes look unusual. You offer her some water to drink and notice Remember to use Danger sign when how she responds. She drinks the water eagerly.

Next, you give Mary a pinch test to determine how dehydrated she is. You ask Ana to place Mary classifications on the DOES THE table CHILD HAVE ORon DIFFICULT Yes __ pinch No __ examining so thatCOUGH she is flat her backBREATHING? with her arms at her sides, and her legs straight. You do how long? ___ Days Count the breaths in one minute theFor skin of Mary’s abdomen, and it goes back in 1 second. ___ breaths per minute. Fast breathing? Look and listen for stridor form? How will you record these signs on Mary’s recording Look for chest indrawing Look and listen for wheezing

selecting

DOES THE CHILD HAVE DIARRHOEA?

3 Days For how long? ___ Is there blood in the stool?

Look or feel for stiff neck Decidein malaria High ___ Low you ___ No___ Then the risk: next section, will learn how to assess Mary’s diarrhoea using the signs you have assessed. Look for runny nose Look for signs of MEASLES: more than 7 days, has fever been present every On If the next page you will have the opportunity to practice assessing signs in two case studies. Generalized rash and day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? One of these: cough, runny nose, or red eyes Look for any other cause of fever. For how long? ___ Days

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

X No __ Yes __

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear 14 Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE A Read the case study below. Assess and classify the child’s diarrhoea and dehydration.

Maya is at the clinic today because she has had diarrhoea for 4 days. She is 25 months old. She weighs 9 kg. Her temperature is 37.0 °C. Maya has no general danger signs. She does not have cough or difficult breathing. The health worker said to the mother, “When Maya has diarrhoea, is there any blood in the stool?” The mother said, “No.” The health worker checked for signs of dehydration. Maya is not lethargic or unconscious. She is not restless or irritable. Her eyes are not sunken. Maya drinks eagerly when offered some water. Her skin pinch goes back immediately. Record Maya’s signs and classify them.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

15

CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE B Read the case study below. Assess and classify the child’s diarrhoea and dehydration.

Rana is 14 months old. She weighs 12 kg. Her temperature is 37.5 °C. Rana’s mother said the child has had diarrhoea for 3 weeks. Rana does not have any general danger signs. She does not have cough or difficult breathing. The health worker assessed her diarrhoea. He noted she has had diarrhoea for 21 days. He asked if there has been blood in the child’s stool. The mother said, “No.” The health worker checked Rana for signs of dehydration. The child is irritable throughout the visit. Her eyes are not sunken. She drinks eagerly. The skin pinch goes back immediately. Record Rana’s signs and classify.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

16

CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.4

CLASSIFY DIARRHOEA & DEHYDRATION

HOW WILL YOU CLASSIFY FOR MAIN SYMPTOM DIARRHOEA? This main symptom has more than one classification table in the ASSESS AND CLASSIFY charts. You will now classify both diarrhoea and dehydration. When classifying: ✔✔ All children with diarrhoea are classified for dehydration ✔✔ If the child has had diarrhoea for 14 days or more, classify for persistent diarrhoea ✔✔ If the child has blood in the stool, classify the child for dysentery

DEHYDRATION: SICK CHILD & YOUNG INFANT HOW DO YOU CLASSIFY DEHYDRATION? There are three possible classifications for the type of diarrhoea. These are: 1. SEVERE DEHYDRATION 2. SOME DEHYDRATION 3. NO DEHYDRATION Open your Chart Booklet to the dehydration classification table. What do you observe? You will now read about these classifications and identified treatments. Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If child has no other severe classification: Give fluid for severe dehydration (Plan C) OR If child also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way 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, zinc supplements, and food for some 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 not improving 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 not improving Treat dehydration before referral unless the child has another severe classification Refer to hospital Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

for DEHYDRATION

sify DIARRHOEA

Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

Dehydration present. and if diarrhoea 14 days or more No dehydration.

Pink: SEVERE PERSISTENT DIARRHOEA Yellow: PERSISTENT DIARRHOEA

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SEVERE DEHYDRATION (RED) Classify as SEVERE DEHYDRATION if the child has two or more of the following signs: lethargic or unconscious, not able to drink or drinking poorly, sunken eyes, or very slow skin pinch. What are your actions? Any child with dehydration needs extra fluids. A child classified with SEVERE DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids. The box “Plan C: Treat Severe Dehydration Quickly” on the TREAT chart describes how to give fluids to severely dehydrated children. You will learn more about Plan C in the next section.

SOME DEHYDRATION (YELLOW) If the child does not have signs of SEVERE DEHYDRATION, look at the next row. Does the child have signs of SOME DEHYDRATION? If the child has two or more of the following signs – restless, irritable; drinks eagerly, thirsty; sunken eyes; skin pinch goes back slowly – classify as SOME DEHYDRATION. What are your actions? If a child has one sign in the red (top) row and one sign in the yellow (middle) row, classify the child in the yellow row (SOME DEHYDRATION). A child who has SOME DEHYDRATION needs fluid, foods, and zinc supplements. Treat the child with ORS solution. In addition to fluid, the child with SOME DEHYDRATION needs food. Breastfed children should continue breastfeeding. Other children should receive their usual milk or some nutritious food after 4 hours of treatment with ORS. The treatment is described in the box “Plan B: Treat Some Dehydration with ORS”. You will learn more about ORS and zinc supplements in the next section.

NO DEHYDRATION (GREEN) A child who does not have two or more signs in the red or yellow row is classified as having NO DEHYDRATION. This child needs extra fluid and foods to prevent dehydration. The four rules of home treatment are: 1. Give extra fluid 2. Give zinc supplements 3. Continue feeding 4. Return immediately if the child develops danger signs, drinks poorly, or has blood in stool What are your actions? The treatment box called “Plan A: Treat Diarrhoea At Home” describes what fluids to teach the mother to give and how much she should give. A child with NO DEHYDRATION also needs food and zinc supplements. You will learn more about Plan A and zinc in the next section.

18

breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat COURSE | MODULE 4. DIARRHOEA as some or severe IMCI DISTANCE LEARNING diarrhoea at home (Plan A) NO dehydration. DEHYDRATION Advise mother when to return immediately Follow-up in 5 days if not improving

and if diarrhoea 14 days or more

After you classify dehydration, classify the child for persistent diarrhoea if the child Pink: Dehydration present. Treat dehydration before referral unless the has had diarrhoea for 14 daysSEVERE or more. Then child you has classify for dysentery. another severe classification

DIARRHOEA: SICK Yellow: CHILD Two ofdehydration. the following signs: Pink: No for DEHYDRATION Sunken eyes

PERSISTENT DIARRHOEA

Refer to hospital

PERSISTENT Lethargic or unconscious Give fluid DIARRHOEA for severe dehydration (Plan C) PERSISTENT SEVERE HOW DO YOU CLASSIFY DYSENTERY IN A CHILD? DIARRHOEA DEHYDRATION Give multivitamins and OR

Advise the mother on feeding a child who has If child has no other severe classification:

sify DIARRHOEA

If childyou also hasclassify another severe (including zinc) for as 14 days If the child has diarrhoea and any blood in the minerals stool, will DYSENTERY. Not able to drink or classification: Follow-up in 5 days drinking poorly Review the classification table in your Chart Booklet. Refer URGENTLY to hospital with Skin pinch goes back very slowly. Blood in the stool.

and if blood in stool

Yellow: DYSENTERY

A child with dysentery should be treated an antibiotic recommended for Shigella in your area. Finding the actual cause of the Yellow: Two of the following signs: Give fluid, zinc supplements, and food for dysentery requires for which it can dehydration take at least 2B) days to obtain the Restless, irritable a stool culture some (Plan SOME laboratory results. You willDEHYDRATION assume Shigella is cause because: Sunken eyes Ifthe child also has a severe classification: ✔Page 6 of 75  ✔ Shigella causes about 60% of dysentery casesmother seen in clinics. giving frequent sips of ORS Skin pinch goes back ✔✔ Shigella causes nearly all cases of life-threatening dysentery. Advise the mother to continue slowly. on the way breastfeeding Advise mother when to return immediately PERSISTENT Follow-up DIARRHOEA IN A CHILD? in 5 days if not improving Drinks eagerly, thirsty Refer URGENTLY to hospital with

mother giving frequent sips of ORS on the way Give ciprofloxacin for 3 days Advise mother to continue Follow-up inthe 2 days breastfeeding If child is 2 years or older and there is in your area, give antibiotic for for cholera dehydration. You should also give cholera

HOW DO YOU CLASSIFY

Not enough to classify Green: Give fluid, zinc supplements, and food to treat If the childsigns has had diarrhoea for 14 days or more , you will classify for persistent as some or severe diarrhoea at home (Plan A) NO diarrhoea. often mismanage persistent diarrhoea, so these dehydration. Health workers DEHYDRATION Advise mother when to return immediately Follow-up in 5 days if not improving instructions are important: Dehydration present. and if diarrhoea 14 days or more No dehydration. Pink: SEVERE PERSISTENT DIARRHOEA Yellow: PERSISTENT DIARRHOEA Treat dehydration before referral unless the child has another severe classification Refer to hospital Advise the mother on feeding a child who has PERSISTENT DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

and if blood in stool

SEVERE PERSISTENT

Blood in the stool.

Yellow: DYSENTERY DIARRHOEA

Give ciprofloxacin for 3 days Follow-up in 2 days (RED)

If a child has had diarrhoea for 14 days or more and also has some or severe dehydration, is classified SEVERE PERSISTENT DIARRHOEA. Children who are classified with SEVERE PERSISTENT DIARRHOEA should be referred to hospital. What are your actions? Treat the child’s dehydration before referral unless the child has another severe Page 6 of 75  classification. Treating dehydration in children with another severe disease can be difficult. These children should be treated in a hospital. These children need special attention to help prevent loss of fluid. They may need a change in diet. They may also need laboratory tests to identify the cause of the diarrhoea.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

PERSISTENT DIARRHOEA (YELLOW) A child who has had diarrhoea for 14 days or more and who has no signs of dehydration is classified as having PERSISTENT DIARRHOEA. What are your actions? Special feeding is the most important treatment for persistent diarrhoea.

DVD EXERCISE – JOSH CASE STUDY Watch “Case study Josh” (disc 1). This is a great way to practice assessing and classifying a child for general danger signs, respiratory problems, and diarrhoea. As you watch the video, complete the recording form below as you would a normal case. Assess and classify using this form and your Chart Booklet.

Does Josh present with any general danger signs? How do you classify Josh for respiratory illness? How do you classify Josh’s diarrhoea?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Yes __ No __ Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ Look for runny nose For how long? ___ Days Look for signs of MEASLES: If more than 7 days, has fever been present every Generalized rash and day? One of these: cough, runny nose, or red eyes Has child had Answer measels within the questions last 3 months? below about the assessing and classifying diarrhoea and Look for any other cause of fever. Do malaria test if NO general danger sign dehydration. High risk: all fever cases Low risk: if NO obvious cause of fever 1. How many signs are needed to classify a child with SOME DEHYDRATION? Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

SELF-ASSESSMENT EXERCISE C

If the child has measles now or within the last 3 months:

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

2. Give two signs that may

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. indicate that aof child has SEVERE Look for clouding the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear

DEHYDRATION. Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child:

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

3. What type of ORS should be used to treat dehydration? 4. Which children need zinc supplements? 5. What are the 4 rules of home treatment of diarrhoea?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? Assess and classify dehydration in these children. Be sure to circle the signs you ASSESS (Circle all signs present) CLASSIFY

SELF-ASSESSMENT EXERCISE D use to classify.

CHECK FOR GENERAL DANGER SIGNS

General danger sign present? NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS 1. PANO has had diarrhoea forCONVULSING five days. He has no blood in the stool. He is irritable. VOMITS EVERYTHING NOW Yes ___ No ___ CONVULSIONS Remember to use His eyes are sunken. His father and mother also think that Pano’s eyes are sunken. Danger sign when The health worker offers Pano some water, and the child drinks eagerly. When selecting classifications

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

the health worker pinches the skin on the child’s abdomen, it goes back slowly.

Count the breaths in one minute Record the child’s signs and classification for dehydration on the Recording ___ breaths per minute. Fast breathing? Look for chest indrawing Form. Look and listen for stridor Look and listen for wheezing

Yes __ No __

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present)

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Look or feel for stiff neck CHECK FOR GENERAL DANGER SIGNS Decide malaria risk: High ___ Low ___ No___

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Age: Weight (kg): Very slowsly (longer then 2 seconds)? Initial Visit? Slowly?

Yes __ No __

Low risk:THE if NO CHILD obvious cause of COUGH fever DOES HAVE OR DIFFICULT BREATHING? For how long? ___ Days Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

General danger sign present? Look for runny nose NOT ABLE TO___ DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS For how long? Days 2. JANE has had diarrhoea for 3 days. There was no blood in the stool. The child Look for signs of MEASLES: VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ If more than 7 days, has fever been present every Generalized rash and CONVULSIONS day? Remember to use was not lethargic or unconscious. She was not irritable Her eyes were One of these: cough, runny nose, or or red restless. eyes Has child had measels within the last 3 months? Danger sign when Lookbut for any other cause of fever. sunken. She was able to drink, she was not thirsty. The skin pinch went back selecting Do malaria test if NO general danger sign classifications High risk: all fever cases

Temperature (°C): Follow-up Visit? CLASSIFY Yes __ No __

immediately.

Count the breaths in one minute Record the child’s signs and classification forbreathing? dehydration on the Recording ___ breaths perulcers. minute. Fast Look for mouth If the child has measles now or within the Look for chest indrawing If yes, are they deep and extensive? last 3 months: Form. Look and listen for stridor

Yes __ No __

DOES DOES THE THE CHILD CHILD HAVE HAVE DIARRHOEA? AN EAR PROBLEM? For howear long? ___ Days Is there pain? Is in the stool? Is there there blood ear discharge?

Look for pus draining from the eye. Look listen for wheezing Look and for clouding of the cornea.

Look childs general Look at forthe pus draining fromcondition. the ear Is the child: Lethargic orswelling unconscious? Feel for tender behind the ear Restless and irritable? If Yes, for how long? ___ Days Look for sunken eyes. Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Offer the child fluid. Is the child: Determine WFH/L _____ Z score. AND ANAEMIA Not able to drink or drinking poorly? For children 6 months or older measure MUAC ____ mm. Drinking eagerly, thirsty? Look for palmar pallor. Pinch the skin of the abdomen. Does it go back: Severe palmar pallor? Some palmar pallor? Very slowsly (longer then 2 seconds)? Is there any medical complication? If child has MUAC less than 115 mm or Slowly? General danger sign? WFH/L less than -3 Z scores or oedema of DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Any severe classification? both Look or feel for stiff Decidefeet: malaria risk: High ___ Low ___ No___ Pneumonia withneck chest indrawing? Look for runny noseor older offer RUTF to eat. Is the child: For a child 6 months For how long? ___ Days Look for signs of MEASLES: Not able to finish or able to finish? If more than 7 days, has fever been present every rash For aGeneralized child less than 6 and months is there a breastfeeding problem? day? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? CHECK FOR HIV INFECTION Look for any other cause of fever. Do malaria test if NO general danger sign Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN High risk: all fever cases Child's test: of NEGATIVE POSITIVE NOT DONE Low risk: if NOvirological obvious cause fever

Yes Yes __ __ No No __ __

Yes __ No __

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

Pink: jaundice if age less n  How Any will you classify Mary’s diarrhoea? JAUNDICE

Y

Treat to prevent low blood sugar than 24 hours or Refer URGENTLY to hospital SEVERE Mary has had diarrhoea for 3 days, is an acute episode of diarrhoea. She does not persistent Yellow palms and soles at which JAUNDICE Advise mother how to keep thehave infant diarrhoea, which dysentery, as there no blood in the stool. any age lasts 14 days or more. She does not havewarm on the way to is the hospital Yellow:for dehydration. Jaundice appearing Advise the mother to give home care for the Every child with diarrhoea isafter also classified 24 hours of age and young infant JAUNDICE Palms and soles not mother to return immediately if palms n  How yellow will you classify Mary’s dehydration? Advise and soles appear yellow. If the young infant is older than 14 days, refer When you assessed Mary, you observed the following signs: to a hospital for assessment — She has sunken eyes Follow-up in 1 day No — She is jaundice eager to drink Green: NO JAUNDICE Advise the mother to give home care for the young infant

— Her skin pinch goes back slowly

With these signs, you classify Mary with SOME DEHYDRATION. Look at your classification table. What do you observe about the identified treatments for this classification? Two of the following signs: Movement only when stimulated or no movement at all Sunken eyes Skin pinch goes back very slowly. Pink: SEVERE DEHYDRATION If infant has no other severe classification: Give fluid for severe dehydration (Plan C) OR If infant also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Give fluid and breast milk for some dehydration (Plan B) If infant has any 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 2 days if not improving Give fluids to treat diarrhoea at home and continue breastfeeding (Plan A) Advise mother when to return immediately Follow-up in 2 days if not improving

EA for DEHYDRATION

Two of the following signs: Restless and irritable Sunken eyes Skin pinch goes back slowly.

Yellow: SOME DEHYDRATION

Not enough signs to classify as some or severe dehydration.

Green: NO DEHYDRATION

rhoea.

n and are many and watery (more water fecal matter). begin treatment at than the clinic, and she can continue treatment at home. Ana looks relieved.

You tell Ana that Mary has some dehydration. It is not serious enough to send her to the hospital. You can You will now learn more about treatment in the next section. Page 44 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.5

TREAT THE CHILD WITH DIARRHOEA

Children with diarrhoea are treated for dehydration. They are also treated for their diarrhoea, if they have persistent diarrhoea or dysentery.

WHAT TREATMENTS ARE IDENTIFIED FOR DIARRHOEA AND DEHYDRATION? Open your classification tables for dehydration, persistent diarrhoea, and dysentery and review the “IDENTIFY TREATMENT” columns. The colour-coded classifications also indicate where the treatment can be delivered – by urgent referral, at the clinic, or at home. Identified treatments are listed below. These are all new treatments, so you will learn about all of them in this section: ✔✔ Plans A, B, and C for giving fluids and food ✔✔ Giving ORS for dehydration ✔✔ Zinc supplementation ✔✔ Ciproflaxacin for dysentery

DEHYDRATION: SICK CHILD & YOUNG INFANT HOW DO YOU TREAT DEHYDRATION? When you classified the severity of dehydration, you identified the appropriate treatment to replenish fluids or prevent dehydration. There are three plans to provide fluid and replace water and salts lost in diarrhoea: n PLAN A – treat diarrhoea at home n PLAN B – treat SOME DEHYDRATION with low osmolarity oral rehydration salts (ORS) n PLAN C – treat SEVERE DEHYDRATION quickly with intravenous (IV) fluids In the following pages, you will now learn how to give Plans A, B, and C. PLAN C (SEVERE DEHYDRATION) Urgent treatment

PLAN B (SOME DEHYDRATION) Treat at clinic

PLAN A (NO DEHYDRATION) Treat at home

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

PLAN C (SEVERE DEHYDRATION) Urgent treatment HOW IS PLAN C GIVEN? Severely dehydrated children and young infants need to have water and salts quickly replaced. Plan C requires rapid hydration using IV fluids or a nasogastric (NG) tube. It is important to note that rehydration therapy using IV fluids or using a nasogastric (NG) tube is recommended only for children who have SEVERE DEHYDRATION.

WHERE IS PLAN C GIVEN? Open to Plan C in your Chart Booklet. There is a flow chart determining where is the safest place to treat the severely dehydrated child. You will observe that the treatment of the severely dehydrated child depends on: n Type of available equipment at your clinic or at a nearby clinic or hospital, n Training you have received n If the child can drink

IN YOUR CLINIC, WHERE IS THE SAFEST PLACE TO GIVE PLAN C? This is important for you to determine based on available equipment and your training. If you cannot give IV or NG fluid and the child cannot drink, refer the child urgently to the nearest hospital that can give IV or NG treatment. If IV (intravenous) treatment is available within a 30-minute drive, refer urgently to hospital for treatment with IV fluids. On the way to hospital, have the mother offer frequent sips of ORS to her sick child. Are you able to provide Plan C in your clinic? If not, where will you refer?

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

PLAN B (SOME DEHYDRATION) Treat at clinic A child or young infant with some dehydration needs fluid, zinc supplementation, and food. You will give zinc just as you will for Plan A.

HOW IS PLAN B GIVEN? Plan B begins with a 4-hour treatment period at the clinic. During the 4 hours, the mother slowly gives a recommended amount of ORS solution. If a child who has SOME DEHYDRATION needs treatment for other problems, you should start treating the dehydration first. Then provide the other treatments. After the 4 hours, you will reassess and classify the child’s dehydration. If the signs are gone, put the child on Plan A for home treatment. If there is still some dehydration, the child repeats Plan B. If the child now has SEVERE DEHYDRATION, put the child on Plan C.

WHAT HAPPENS IF A CHILD HAS A SEVERE CLASSIFICATION AND NEEDS PLAN B? A child who has a severe classification and SOME DEHYDRATION needs urgent referral to hospital.1 Do not try to rehydrate the child before he leaves. Quickly give the mother some ORS solution. Show her how to give frequent sips to child on the way to the hospital.

HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS IN THE CLINIC? Now study Plan B in your TREAT THE CHILD section. It contains the following instructions: 1. DETERMINE AMOUNT of ORS to give during first 4 hours. Use the chart in Plan B to determine how much ORS to give. To find the recommended amount, look below the child’s weight (or age only if the weight is not known). The child will usually want to drink as much as he needs. If the child wants more or less than the estimated amount, give him what he wants. The mother should also breastfeed whenever the baby wants to, then resume the ORS solution. 2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. Find a comfortable place in the clinic for the mother to sit with her child. Tell her how much ORS solution to give over the next 4 hours. Show her the amount in units that are used in your area. If the child is less than 2 years, show her how to give a spoonful frequently. If the child is older, show her how to give frequent sips from a cup. Sit with her while she gives the child the first few sips from a cup or spoon. Ask her if she has any questions. 1

The exception is a child with the severe classification, SEVERE PERSISTENT DIARRHOEA. This child should be rehydrated then referred.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

REFRESH: how do you decide amount of ORS to give? 1. Use chart in Plan B with child’s weight 2. If no chart, multiple child’s weight (kg) by 75 (Example: 8 kg child x 75 ml = 600 ml)

WHAT WILL YOU DO WHILE THE MOTHER GIVES ORS FOR 4 HOURS? n Show the caregiver where to wash her hands, and where she can change the child’s nappy or where the child can use a toilet. n Check with the mother from time to time to see if she has problems. If the child is not drinking the ORS solution well, try another method of giving the solution. You may try using a dropper or a syringe without the needle. n This also provides valuable time to teach the mother about care for her child. The first concern is to rehydrate the child. When the child is obviously improving, the mother can turn her attention to learning. Teach her about mixing and giving ORS solution (Plan A). n It is a good idea to have printed information that the mother can study while she is sitting with her child. Posters on the wall can also reinforce this information.

TIPS FOR THE YOUNG INFANT During the first 4 hours of rehydration, encourage the mother to pause to breastfeed the infant whenever the infant wants, then resume giving ORS. Give a young infant who does not breastfeed an additional 100–200 ml clean water during this period.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

HOW WILL YOU REASSESS THE CHILD AFTER 4 HOURS? After four hours you will reassess the child using the ASSESS AND CLASSIFY chart. Classify the dehydration. Choose the appropriate plan to continue treatment. If the child is not taking the ORS solution, or seems to be getting worse, reassess before four hours. Depending on your classifications, you will take further action: n If the child has NO DEHYDRATION, move to Plan A. Counsel on home care. n If the child has SOME DEHYDRATION, choose Plan B again. Begin feeding the child in clinic. Offer food, milk, or juice. Continue to breastfeed frequently if child is breastfed. n If the child is worse and now has SEVERE DEHYDRATION, begin Plan C. If the child’s eyes are puffy, it is a sign of overhydration. It is not a danger sign or a sign of hypernatraemia. It is simply a sign that the child has been rehydrated and does not need any more ORS solution at this time. The child should be given clean water or breastmilk, and ORS according to Plan A when the puffiness is gone.

WHAT HAPPENS IF A CAREGIVER MUST LEAVE BEFORE FINISHING 4 HOURS OF ORS? 1. Show the caregiver how to prepare ORS solution and have her practice. 2. Show her how much ORS to give to complete the 4-hour treatment at home. 3. Give her packets to complete rehydration PLUS 2 more packets as recommended in Plan A. 4. Explain 4 rules of home treatment

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE E Answer the following questions about PLAN B for dehydrated children.

1. The following children are classified SOME DEHYDRATION. Write the range of amounts of ORS solution each child is likely to need in the first 4 hours of treatment: Name a. c. Andras Nirveli b. Gul d. Sami Age or Weight 3 years 10 kg 7.5 kg 11 months Range of Amounts of ORS Solution

2. Vinita is 5 months old and has diarrhoea. She is classified as SOME DEHYDRATION. There is no scale for weighing Vinita at the small clinic. Vinita’s mother died during childbirth, so Vinita has been taking infant formula. The grandmother has recently started giving cooked cereal as well. a. Vinita should be given    ml of         during the first   hours of treatment. She should also be given    ml of               during this period. b. What should the grandmother do if Vinita vomits during the treatment? c. When should the health worker reassess Vinita? d. When Vinita is reassessed, she has NO DEHYDRATION. What treatment plan should Vinita be put on? 3. Yasmin is 9 months old and weighs 8 kg. Her mother brought her to the clinic with diarrhoea. The health worker assesses Yasmin as SOME DEHYDRATION. The health worker chooses Plan B. He asks if Yasmin still breastfeeds. Her mother says that she breastfeeds several times each day. She also eats 3 meals each day of rice along with vegetables, pulses, and sometimes bits of meat. a. Approximately how much ORS solution should Yasmin’s mother give her during the first 4 hours? b. During the first 4 hours of treatment, should Yasmin eat or drink anything in addition to the ORS solution? If so, what? c. After 4 hours of treatment, the health worker reassesses Yasmin. She is still classified as SOME DEHYDRATION. What is the appropriate plan to continue her treatment?

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

PLAN A (NO DEHYDRATION) Treat at home A child with diarrhoea but no dehydration requires fluid, zinc, and food to prevent dehydration. This child can be treated at home with Plan A.

WHAT IS PLAN A? Plan A is based on the four rules of home treatment. These are critical for you to remember. Plan A requires you to counsel the child’s mother about the 4 rules of home treatment. As such, your teaching and advising skills are an important part of Plan A. Plan A is also an important treatment plan because eventually, all children with diarrhoea will require Plan A . Children with diarrhoea who come to a health worker with NO DEHYDRATION are put on Plan A right away. Child with more serious dehydration will first be treated with Plan B or C, and then they will be put on Plan A.

WHAT ARE THE 4 RULES OF HOME TREATMENT? The four rules of home treatment are very important to remember: 1. Give extra fluid – as much as the child will take 2. Give zinc 3. Continue feeding 4. When to return (for a follow-up visit, or immediately if danger signs develop) Now you will learn more about the four rules of home treatment. Open to Plan A in your Chart Booklet to read along with the instructions.

RULE 1: GIVE EXTRA FLUID Tell the caregiver to give as much fluid as the child will take. It is very important for the child to have extra fluid – as much as the child will take. The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to prevent dehydration. The critical action is to give more fluid than usual, as soon as the diarrhoea starts.

HOW SHOULD THE CAREGIVER GIVE EXTRA FLUID? Tell the mother that breastfeeding should continue, with the addition of ORS and clean water. If the child is exclusively breastfed, it is important for this child to be breastfed more frequently than usual. Breastfed children under 4 months should first be offered a breastfeed then given ORS. If the child is not being breastfed, the child should receive ORS solution, foodbased fluids (soup, rice water, yoghurt drinks), and clean water. In your country, the national programme for diarrhoeal disease control may have specified several food-based fluids to use at home.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

TIPS FOR THE YOUNG INFANT n If infant is exclusively breastfed, it is important not to introduce a food-based fluid. n If infant will be given ORS solution at home, you will show how much ORS to give the infant after each loose stool. Mother should first offer a breastfeed, then give ORS.

HOW WILL YOU TEACH THE CAREGIVER TO MIX ORS? Teach the caregiver how to mix and give ORS. Ask the caregiver to practice doing it as you observe. The steps for making ORS are (follow along in drawings below): ✔✔ Wash your hands with soap and water ✔✔ Pour all the powder from one packet into a clean container. Use any available container, such as a jar, bowl or bottle. ✔✔ Measure 1 litre of clean water (or correct amount for packet used). It is best to boil and cool the water, but if this is not possible, use the cleanest drinking water available. ✔✔ Pour the water into the container. Mix well until the powder is completely dissolved. ✔✔ Taste the solution so you know how it tastes. The caregiver should mix fresh ORS every day, in a clean container. She should keep the container covered. She should throw away any solution remaining from the day before.

1 litre bottle

HOW WILL THE CAREGIVER GET ORS TO USE IN THE HOME? Give the caregiver 2 packets of ORS to use at home. Show her how much fluid should be given in addition to the usual fluid intake: n Up to 2 years: 50–100 ml after each loose stool n 2 years or older: 100–200 ml after each loose stool

HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS? Finally, give the caregiver instructions for giving ORS: 1. Give frequent small sips from a cup 2. If child vomits, wait 10 minutes. Then continue, but more slowly. 3. Continue giving extra fluid until the diarrhoea stops

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

WHEN IS ORS ESPECIALLY IMPORTANT? It is especially important to give ORS at home when: ✔✔ Child was treated with Plan B or C during this visit – in other words, the child has just been rehydrated and needs ORS to prevent dehydration from coming back ✔✔ Child cannot return to the clinic if the diarrhoea gets worse – for example, if the family lives far away or the mother has a job that she cannot leave

RULE 2: GIVE ZINC SUPPLEMENTS Zinc treatment can considerably reduce the duration and severity of a child’s diarrhoeal episode. It is also shown to decrease stool output and decrease the need to hospitalize a child with diarrhoea. Zinc is only given to children 2 months up to 5 years. This box describes how much zinc to give a child with diarrhoea. Review this information in Plan A in your Chart Booklet.

GIVE ZINC SUPPLEMENTS (one tablet is 20 mg zinc) Remind the caregiver to give zinc supplements for the full 14 days Tell the caregiver how much zinc to give Up to 6 months: ½ tablet per day, for 14 days 6 months or older: 1 tablet per day, for 14 days Show the caregiver how to give zinc supplements Infants: dissolve the tablet in a small amount of breast milk, ORS, or clean water in a small cup or spoon Older children: tablets can be chewed or dissolved in small amount of clean water in a cup or spoon

RULE 3: CONTINUE FEEDING You will learn more about special feeding recommendations if the child has persistent diarrhoea.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

RULE 4: WHEN TO RETURN You have learned the signs when a caregiver should return immediately to a health worker. Tell the mother of any sick child that the signs to return are: •• Not able to drink or breastfeed •• Becomes sicker •• Develops a fever If the child has diarrhoea, also tell the mother to return if the child has: •• Blood in stool •• Drinking poorly – also includes not able to drink or breastfeed

SELF-ASSESSMENT EXERCISE F Answer the following questions about PLAN A for children with diarrhoea.

1. At your clinic, what are the recommended fluids for children with diarrhoea with NO DEHYDRATION?

2. Somi is a 4-year-old boy who has diarrhoea. He has no general danger signs. He was classified as having diarrhoea with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. He will be treated according to Plan A. a. What are the 4 rules of home treatment of diarrhoea?

b. What fluids should the health worker tell his mother to give?

3. Kasit is a 3-month-old boy who has diarrhoea. He has no general danger signs. He was classified as NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. He is exclusively breastfed. What should the health worker tell his mother about giving him extra fluids?

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4. For which children with NO DEHYDRATION is it especially important to give ORS at home?

5. The following children came to the clinic because of diarrhoea. They were assessed and found to have no general danger signs. They were classified as NO DEHYDRATION. Write the amount of extra fluid that the mother should give after each stool. Name a. c. Kala Kara b. Sam d. Lalita Age 6 months 2 years 15 months 4 years Amount of extra fluid to give after each loose stool

DIARRHOEA: SICK CHILD Treatment is required for children who have persistent diarrhoea or dysentery.

HOW WILL YOU TREAT SEVERE PERSISTENT DIARRHOEA? Children with this classification have persistent diarrhoea (14 days or longer) and signs of dehydration. These children should be referred to hospital. They need special attention to prevent fluid loss. You should treat dehydration before referral, unless child has another severe classification.

HOW WILL YOU TREAT PERSISTENT DIARRHOEA? Children with this classification have persistent diarrhoea (14 days or longer) and no signs of dehydration. Special feeding is the most important treatment for persistent diarrhoea with no signs of dehydration. Children with persistent diarrhoea may have difficulty digesting milk other than breastmilk. They need to temporarily reduce the amount of other milk in their diet. Special feeding advice for a child with PERSISTENT DIARRHOEA includes: ✔✔ If still breastfeeding, give more frequent, longer breastfeeds, day and night. ✔✔ If taking other milk: — Replace with increased breastfeeding, OR — Replace with fermented milk products, such as yogurt, OR — Replace half the milk with nutrient-rich semi-solid food. ✔✔ For other foods, follow feeding recommendations for the child’s age: give small, frequent meals (at least 6 times a day), and avoid very sweet foods or drinks. The child also should receive zinc for 14 days. The child should follow up in 5 days.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

HOW WILL YOU TREAT DYSENTERY? Children with dysentery should receive ciprofloxacin for 3 days (or another oral antibiotic recommended for Shigella in your area). The box “Give an Appropriate Oral Antibiotic” on the TREAT THE CHILD chart tells the recommended antibiotics. Refer to Module 3 to review counselling the caregiver on oral medicines. They should also receive zinc supplements. Zinc should be given in the same way that you learned previously in Plans A and B. Treat dehydration as classified. Children should follow-up for the dysentery in 2 days.

WHEN SHOULD ANTIBIOTICS BE USED FOR DIARRHOEA? Antibiotics are not effective in treating most diarrhoea. They rarely help and make some children sicker. Unnecessary use of antibiotics may increase the resistance of some pathogens. In addition, antibiotics are costly. Money is often wasted on ineffective treatment. Therefore, do not give antibiotics routinely. The only types of diarrhoea that should be treated with antibiotics are DYSENTERY and diarrhoea with SEVERE DEHYDRATION with cholera in the area.

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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE G Answer the questions below about treatment for diarrhoea and dehydration.

1. How will you give zinc supplements to a 4 month old infant, weight 7.3 kg, with SOME DEHYDRATION?

2. How will you give zinc supplements to a 37 month old infant, weight 12 kg, with NO DEHYDRATION?

3. How would you treat a 9 month old, weighing 8.3 kg, with a classification of DYSENTERY?

4. How would you treat a 36 month old, weighing 15 kg, with a classification of DYSENTERY?

5. How would you treat a 7 month old with SEVERE PERSISTENT DIARRHOEA?

6. You are talking with the mother of a 15-month-old child who is no longer breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feedings of cow’s milk and 1 meal of family foods each day. His diet has not changed during the diarrhoea. Which of the following are appropriate to say when counselling this mother? Tick appropriate comments.   a. You were right to keep feeding your child during the diarrhoea. He needs food to stay strong.   b. Your child needs more food each day. Try to give him 3 family meals plus 2 feedings between meals.   c. Cow’s milk is very bad for your child.   d. Your child may be having trouble digesting the cow’s milk, and that may be the reason that the diarrhoea has lasted so long.   e. Give your child yoghurt instead of milk (until follow-up visit in 5 days). Or give only half the usual milk and increase the amount of family foods to make up for this.

35

RATION

EA

Two of the following signs: Pink: If child has no other severe classification: Lethargic or unconscious Give 4. fluid for severe dehydration (Plan C) IMCI DISTANCE LEARNING COURSE | MODULE DIARRHOEA SEVERE OR Sunken eyes DEHYDRATION If child also has another severe Not able to drink or classification: drinking poorly Refer URGENTLY to hospital with Skin pinch goes back mother giving frequent sips of ORS n  What treatment will Mary require? very slowly. on the way Mary has an acute episode of diarrhoea lasting for 3 days, and there is no blood in the stool, so you did not Advise the mother to continue classify her for persistent diarrhoea or dysentery. breastfeeding If child is 2treatments years or older and there You classified Mary’s dehydration as SOME DEHYDRATION. Review what were identified foris SOME cholera in your area, give antibiotic for DEHYDRATION. cholera Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly. Yellow: SOME DEHYDRATION Give fluid, zinc supplements, and food for some 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 not improving

Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat as some or severe diarrhoea at Plan home (Plan A) foods, and zinc. Plan NO DEHYDRATION You will remember from this section that SOME requires B for fluids, DEHYDRATION Advise mother to return immediately Bdehydration. will require Ana to give ORS to Mary for 4 hours in the clinic, then you will when re-assess Mary’s dehydration. Follow-up in 5 days if not improving Open your Chart Booklet to review Plan B.

rhoea 14 more

od in stool

The steps of Plan B are: Pink: Dehydration present. Treat dehydration before referral unless the 1. Determine the amount of ORS to give for the first 4 hours in the clinic. Mary is 8 kg and 9 months old. child has another severe classification SEVERE We review the chart in Plan B and decide that she should receive between 450 and 800 ml of ORS. If we Refer to hospital PERSISTENT had calculated with the second method, multiplying her weight 8 kg by 75 ml, we would have calculated DIARRHOEA 560 ml, which is within the chart range. Yellow: No dehydration. Advise the mother on feeding a child who has 2. Teach Ana how to give the ORS solution. You explain to Ana that Mary has diarrhoea with some PERSISTENT DIARRHOEA PERSISTENT dehydration. She needs fluids and food. You ask Ana to stay at the clinic to give Mary ORS solution. Show Give multivitamins and DIARRHOEA Ana how much ORS to give from a cup. minerals (including zinc) for 14 days You take Ana to a corner where she can sit with Mary and give the ORS. show her where you can wash Follow-up in 5 You days her hands, and where she can change Mary or use the toilets. You make sure she is comfortable. She does not have any questions for you, but it worried about staying too late at the clinic because her husband Yellow: will worry. Youstool. assure her that she can give all of the ORSGive now, ciprofloxacin and then you will work with her to decide Blood in the for 3 days about treatment later tonight at home. Ana props Mary on her lap. She slowly begins to give her ORS Follow-up in 2 days DYSENTERY from a cup. You also encourage Ana to breastfeed if Mary wants to. 3. After 4 hours, you reassess Mary. She had NO DEHYDRATION. Her diarrhoea continued, but you think that she is ready to go home on Plan A. Plan A will also include giving zinc and food.

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4.6

COUNSEL THE CAREGIVER

Good teaching and advising skills are particularly important when treating dehydration and diarrhoea. As you read in the previous section on treatment, the caregiver gives many of the treatments in the clinic or at home. This requires you to teach them how to give the treatment.

WHAT ARE THE 4 RULES OF HOME TREATMENT? It is very important to counsel caregivers on the 4 rules of home treatment. This is required for Plan A. Child classified with NO DEHYDRATION need Plan A. After children who required Plan B or C have completed this plan, they will also require Plan A at home. 1. Give extra fluid – as much as the child will take 2. Give zinc 3. Continue feeding 4. When to return (for a follow-up visit, or immediately if danger signs develop)

RULE 1. How will you counsel a caregiver to give extra fluid? You will tell a caregiver that during illness, a child loses fluid due to fever, fast breathing, or diarrhoea. The child will feel better and stay stronger if he drinks extra fluid to prevent dehydration. Extra fluid is especially important for children with diarrhoea. FIRST, TELL THE CAREGIVER TO GIVE AS MUCH FLUID AS THE CHILD WILL TAKE. The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to prevent dehydration. The critical action is to give more fluid than usual as soon as the diarrhoea starts. More fluid can be given by: •• Breastfeeding more frequently, and for longer feeds. If the child is exclusively breastfed, also give ORS or clean water in addition. •• If child is not breastfed, increase fluid with food-based fluids (soup, rice water, yoghurt drinks), or ORS •• ORS is especially important at home if the child was treated on Plan B or C, or if the child cannot return to the clinic if the diarrhoea gets worse SECOND, teach the caregiver how to mix and give ORS. Review these teaching steps in the previous TREAT section. Ask the caregiver to practice doing it as you observe. You will review these steps, which are also discussed in Plan B in the previous section: 1. Wash hands with soap and water 2. Pour the ORS powder into a clean container

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3. Measure 1 litre of water (or specified amount). It is best to boil and cool water. 4. Pour the water into the container with the powder. Mix and taste. 5. Give solution to the child slowly, by cup. If the child vomits, wait for 10 minutes and then continue more slowly. 6. Always make fresh ORS solution each day. Keep the solution covered.

RULE 2. How will you counsel a caregiver to give zinc? Your TREAT chart and the previous section describe how much zinc to give a child with diarrhoea. Zinc is only given to children 2 months up to 5 years. Show the mother how to give the zinc to her baby with diarrhoea. For example, infants can be given the tablet dissolved in a small amount of expressed breast milk ORS, or clean water in a cup. Older children can chew the tablet or take it in a small amount of clean water. The mother should give her child the first zinc supplement. If a child is 2 months up to 6 months, he can have half a 20 mg tablet daily for 14 days. A child 6 months or older can take a whole 20 mg tablet. Explain how she will continue to give this treatment for 14 days. Check her understanding with checking questions, and answer any problems she has.

RULE 3. How will you counsel a caregiver to continue feeding? The caregiver should continue feeding, as explained in the previous TREAT section. You will also remember that children with persistent diarrhoea have special feeding needs. If may be difficult for these children to digest milk other than breast milk. Caregivers need to temporarily reduce the amount of other milk in the child’s diet. To make up for this reduction, the child must take more breast milk or other foods. Continue other foods appropriate for the child’s age. The child with persistent diarrhoea should be seen again in 5 days for follow-up, and will be given further feeding instructions during this visit.

RULE 4. How will you counsel a caregiver to return to clinic? You will advise on follow-up care as you would with all other conditions. Remember that if the child is required to follow up for more than one illness, they should return for follow-up at the earliest definite date. The child should follow up: Immediately if  The child is not able to breastfeed or drink  Becomes sicker  Develops a fever  Has blood in the stool The child has dysentery The child has persistent diarrhoea

In 3 days if In 5 days if

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SELF-ASSESSMENT EXERCISE H Complete this case study.

CASE STUDY: Health worker Basaka must teach a mother to prepare ORS solution for her child with diarrhoea. First he explains how to mix the ORS, then he shows her how to do it. He asks the mother, “Do you understand?” The mother answers “yes”. So Basaka gives her 2 ORS packets and says good-bye. 1. What are the four rules of home treatment that must be explained to the mother?

2. What information did Basaka give the mother about the task?

3. Did he show her an example? 4. Did he ask her to practice? 5. How did Basaka check the mother’s understanding?

6. Did Basaka check the mother’s understanding correctly? 7. How would you have checked the mother’s understanding?

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SELF-ASSESSMENT EXERCISE I Answer these questions about counselling a caregiver.

1. A 4-year-old boy has diarrhoea. He has no general danger signs. He was classified with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. The health worker has taught his mother Plan A and given her 2 packets of ORS to use at home. Tick all the fluids that the mother should encourage her son to drink as long as the diarrhoea continues.  Tea that the child usually drinks with meals  Fruit juice that the child usually drinks each day  Water from the water jug. The child can get water whenever he is thirsty.  ORS after each loose stool  Yoghurt drink when the mother makes some for the family 2. A mother brought her 11-month-old daughter, Aviva, to the clinic because she has diarrhoea. Aviva usually eats cereal and bits of meat, vegetables and fruit. Her mother has continued to breastfeed her as well. The mother says she lives far from the clinic and might not be able to come back for several days, even if the child gets worse. The health worker assesses Aviva and finds she has no general danger signs and no other disease classifications. He classifies her as NO DEHYDRATION. He decides Aviva needs treatment according to Plan A. a. Should the health worker give this mother ORS packets to take home? If so, how many one-litre packets should he give? b. What should the mother do if the child vomits while being fed the solution? c. How long should Aviva’s mother continue giving extra fluid? d. The health worker will tell the mother to continue feeding Aviva. He will also teach her the signs to return immediately. What signs should the health worker teach Aviva’s mother?

3. Which of the following is the best checking question after advice about increasing fluids during diarrhoea? (Tick one.) a.  Do you remember some good fluids to give your child? b.  Will you be sure to give your child extra fluid? c.  How much fluid will you give your child

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n  What do you advise Ana about home treatment? You classified Mary with SOME DEHYDRATION and gave her Plan B in the clinic. You re-assessed after Ana had been giving her ORS for 4 hours, and Mary showed signs of NO DEHYDRATION. You will now counsel Ana on home treatment of diarrhoea with Plan A. You give Ana a Mothers’ Card to take home. This card reminds her of important information like what fluids and food to give her child.

n  What are the 4 rules of home treatment you will teach Ana? 1. You tell Ana to give extra fluid, as much as Mary will take. This will include breast milk, clean water, ORS, or food-based fluids such as soup, rice water, yogurt drinks. You ask Ana which of these options she will use to give Mary more fluid. Ana says that Mary takes rice water well, and she will still breastfeed. She will also try to get some yogurt from a neighbour who makes some. You remind Ana to breastfeed as often as Mary will. You previously taught Ana how to make the ORS when you were preparing it in the clinic. You ask her checking questions to make sure she remembers how to make it. — You ask, “How much clean water do you need for 1 packet of ORS? ” Ana says, “1 litre.” — You ask, “How will you give the ORS? ” Ana says, “With a cup, as she sits in my lap.” — You also ask Ana, “How often will you give ORS? ” “What will you do if Mary vomits? ” You remind Ana that if Mary vomits, she should wait 10 minutes, then continue again, but more slowly. You give Ana 2 packets of ORS to take home.

2. You advise Ana how to give Mary zinc tablets. Mary is 9 months old, so she will take 1 full tablet a day for 14 days. You show Ana how to dissolve the tablet in a spoon with breast milk or clean water. You explain why you are giving zinc to Ana, that it is a good nutrient for the body that will help with Mary’s diarrhoea.

3. You advise Ana to continue feeding, and that Mary should get between 50–100 ml of solution after each loose bowel movement. 4. You advise Ana to return to the clinic immediately if Mary develops the following: she is not able to breastfeed or drink, she becomes sicker, she develops a fever, she has blood in the stool. You use Ana’s Mother’s Card to demonstrate these signs. Mary does not have other illnesses that require specific followup, or else you would have given them a specific date to return. Your conversation with Ana also gives her a chance to ask questions. Your checking questions gave you an idea of how much she understands home treatment. After you talk with Ana, you feel confident that she understands home treatment, and you say goodbye to her and Mary.

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4.7

PROVIDE FOLLOW-UP CARE FOR DIARRHOEA

DO YOU REMEMBER THE STEPS FOR PROVIDING FOLLOW-UP CARE? First, you will re-assess your earlier classifications. Is the child:  Improving?  The same?  Worsening? Second, you will reassess the child using IMCI to see if there are any new issues. You will use a second recording form for this visit.

DIARRHOEA IN SICK YOUNG INFANT (FOLLOW-UP 2 DAYS) When an infant with diarrhoea follows-up in 2 DAYS, you will: ✔✔ ASK – Has the diarrhoea stopped?  DIARRHOEA HAS STOPPED Tell the mother to continue exclusive breastfeeding. If the infant’s signs are improving, tell the mother to continue giving the infant the fluids and breastfeeding according to plan A.   DIARRHOEA HAS NOT STOPPED If the diarrhoea has not stopped, reassess the young infant for diarrhoea. Classify the dehydration and select a fluid plan. If the signs are the same or worse, refer the infant to hospital. If the young infant has developed fever, give intramuscular antibiotics before referral, as for VERY SEVERE DISEASE.

PERSISTENT DIARRHOEA (FOLLOW-UP 5 DAYS) First you will ASK: ✔✔ Has the diarrhoea stopped? ✔✔ How many loose stools is the child having per day?  DIARRHOEA HAS STOPPED (less than 3 stools/day) Tell the mother to follow the usual feeding recommendations for the child’s age. If the child is not normally fed in this way, you need to teach her the feeding recommendations on the COUNSEL chart.  DIARRHOEA HAS NOT STOPPED (more than 3 stools/day) Do a full reassessment of the child. Identify and manage any problems that require immediate attention such as dehydration. Then refer the child to hospital.

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DYSENTERY (FOLLOW-UP 3 DAYS) First you will ASK: ✔✔ Are there fewer stools? ✔✔ Is there less blood in the stool? ✔✔ Is there less fever? ✔✔ Is there less abdominal pain? ✔✔ Is the child eating better?  FEWER STOOLS, LESS BLOOD IN STOOLS, LESS FEVER, LESS ABDOMINAL PAIN, AND EATING BETTER The child is improving on the antibiotic ciprofloxacin. Usually all of these signs will diminish if the antibiotic is working. If only some signs have diminished, use your judgment to decide if the child is improving. Tell the mother to finish the 3 days of the ciprofloxacin prescribed. Review with the mother the importance of finishing the antibiotic.  CHILD IS DEHYDRATED Use the classification table to classify the child’s dehydration. Select the appropriate fluid plan and treat the dehydration.  MORE STOOLS, BLOOD IN STOOLS, FEVER, ABDOMINAL PAIN, AND EATING IS SAME OR WORSE The child is not improving on the antibiotic. Stop the first antibiotic and give the second-line antibiotic recommended for Shigella for 5 days. Refer to TREAT chart. Antibiotic resistance of Shigella may be causing the lack of improvement. Advise the caretaker to return in 2 days. What actions will you take? ✔✔ Give the first dose of the new antibiotic in the clinic. ✔✔ Teach the caregiver how and when to give the antibiotic and help her plan how to give it. ✔✔ Advise the caregiver to bring the child back again after two more days. What actions will you take on the follow-up visit in 2 days? If the child has received the second-line antibiotic for two days, and has not improved, the child may have amoebiasis. This child may be treated with metronidazole if it is available or can be obtained by the family, or referred for treatment. Amoebiasis can only be diagnosed with certainty when trophozoites of E. histolytica containing red blood cells are seen in a fresh stool sample.

REFER if the non-improving child has any of these 3 high-risk factors: 1. Less than 12 months old, or 2. Was dehydrated on the first visit, or 3. Had measles within the last 3 months,

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n  How do you provide Mary with follow-up care? You classified Mary with SOME DEHYDRATION, and she received Plan B in the clinic. Then you re-assess her, and classified with NO DEHYDRATION. You counselled her mother Ana on Plan A home treatment, and sent them home. Ana and Mary were only supposed to return for follow-up if Mary’s dehydration and diarrhoea did not improve. You are pleased that Mary does not return to the clinic for follow-up. You hope this means that the fluid plan worked, and Mary was no longer dehydrated and acting unwell.

SELF-ASSESSMENT EXERCISE J Answer questions for this case about follow-up of DYSENTERY or PERSISTENT DIARRHOEA.

Details about this clinic: This clinic refers children with severe dehydration because health workers cannot give IV or NG therapy. A hospital nearby can give IV therapy. Evaristo was brought for follow-up of PERSISTENT DIARRHOEA after 5 days. He is 9 months old and weighs 6.5 kg. His temperature is 36.5 °C today. He is no longer breastfed. His mother feeds him cereal twice a day and gives him a milk formula 4 times each day. When you saw him last week, you advised his mother to give him only half his usual amount of milk. You also advised the mother to replace half the milk by giving extra servings of cereal with oil and vegetables or meat or fish added. 1. What is your first step for reassessing Evaristo? 2. Evaristo’s mother says the diarrhoea has not stopped. What do you do next? You do a complete reassessment of Evaristo, as on the ASSESS & CLASSIFY chart. You find that Evaristo has no general danger signs. He has no cough. When you reassess his diarrhoea, his mother says that now he has had diarrhoea for about 3 weeks. There is no blood in the stool. Evaristo is restless and irritable. His eyes are not sunken. When you offer him some water, he takes a sip but does not seem thirsty. A skin pinch goes back immediately. Evaristo’s mother tells you that he has no other problems. 3. Is Evaristo dehydrated? 4. How will you treat Evaristo? 5. If your reassessment found that Evaristo had some dehydration, what would you have done before referral?

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4.8

USING THIS MODULE IN YOUR CLINIC

How will you begin to apply the knowledge you have gained from this module in managing children with diarrhoea? In the coming days, you should focus on these key clinical skills. Practicing these skills in your clinic, and using your IMCI job aids, will allow you to observe and better understand the signs needed to assess and classify a child with dehydration and diarrhoea. ASSESS ✔✔ Assess children for diarrhoea – how long has the diarrhoea lasted? Is there blood in the stool? ✔✔ Assess children for signs of dehydration, including sunken eyes, skin pinches, the child’s condition, and the child’s willingness and ability to drink. ✔✔ Practice giving children skin pinches and assessing if it returns very slowly, slowly, or immediately. ✔✔ Practice observing children’s conditions (restless, irritable, unconscious, lethargic) and willingness to drink. CLASSIFY ✔✔ Use your chart booklet to classify the signs of dehydration ✔✔ Classify if a child has persistent diarrhoea or dysentery TREAT ✔✔ Determine if children need Plans A, B, or C. ✔✔ Determine how you will give Plan C in your facility – what equipment do you have for intravenous fluid? Is there a facility within a 30 minute drive that can give this fluid? Are you trained to use Naso-Gastric tubes for rehydration? ✔✔ Advise a caregiver on giving Plan B in your facility. Determine correct amount of ORS. ✔✔ Advise a caregiver about giving Plan A. Focus on the 4 rules of home treatment. COUNSEL ✔✔ Teach a caregiver how to make and give ORS. Determine the amounts required. ✔✔ Advise a caregiver on giving extra fluid and continue breast feeding in the home. ✔✔ Advise a caregiver on giving zinc, and show them how to give tablets. Advise on how often zinc should be given. ✔✔ Advise a caregiver on continued feeding, especially for children with persistent diarrhoea. ✔✔ Counsel a caregiver about when to return for follow-up for diarrhoea or dehydration. ✔✔ Counsel a caregiver about when to return immediately.

Remember to use your logbook for MODULE 4: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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4.9

REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING DIARRHOEA AND DEHYDRATION? Before you began studying this module, you practiced your knowledge on with several questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. How can diarrhoea kill children? a. Children lose valuable fluids, salts, and sugars, which can cause shock to vital organs b. Children lose valuable nutrients because they cannot eat c. Diarrhoea causes liver failure 2. What are critical treatments for children with diarrhoea and dehydration? a. Oral antibiotics b. Oral rehydration therapy and zinc c. Paracetamol for discomfort 3. What is persistent diarrhoea? a. When a child frequently has diarrhoea over a period of 1 month, and is ill as a result b. When a child has several episodes of diarrhoea a day c. When a child has an episode of diarrhoea lasting 14 days or more, which is particularly dangerous for dehydration and malnutrition 4. Critical messages for caregivers about diarrhoea and dehydration include: a. The child must receive increased fluids, ORS, zinc, and regular feeding b. The child requires ORS, but should receive less food in order to reduce the diarrhoea c. The child should immediately receive antibiotics to stop the diarrhoea 5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She has diarrhoea. You observe a significant loss of skin elasticity. How will you manage Nidhi? a. Nidhi requires ORS immediately, as she is dehydrated. b. These are common signs of diarrhoea, as the child’s body is exhausted. c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV or nasogastric tube. Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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4.10 ANSWER KEY REVIEW QUESTIONS QUESTION 1 2 3 4 5 ANSWER A B C A C Did you miss the question? Return to this section to read and practice: INTRODUCTION CLASSIFY, TREAT CLASSIFY TREAT, COUNSEL THE CAREGIVER CLASSIFY, TREAT

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: EXERCISE A (MAYA) Ask: What are the child's problems? Age: Weight (kg): ASSESS (Circle all signs present) MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS CHECK FOR GENERAL DANGER SIGNS General danger sign present? ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS NOT Maya 37 °C Name: Age: 25 mo Weight (kg): 9 kg Temperature (°C): EVERYTHING CONVULSING NOW Yes ___ No ___ Ask: What are the child's problems? Initial Visit? X Follow-up Visit? VOMITS Diarrhoea CONVULSIONS ASSESS (Circle all signs present) Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY

NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS VOMITS EVERYTHING CONVULSING NOW DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? CONVULSIONS For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ Look and listen for wheezing For how long? ___ Days Count the breaths in one minute DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ ___ breaths per minute. Fast breathing? For how long? ___ Days Look at the childs general condition. Is the child: Look for chest indrawing Is there blood in the stool? Lethargic or unconscious? Look and listen for stridor Restless and irritable? Look and listen for wheezing Look for sunken eyes. DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ Offer the child fluid. Is the child: For how long? ___ Days Look at able the childs general condition. Is the child: Not to drink or drinking poorly? Is there blood in the stool? Lethargic or unconscious? Drinking eagerly, thirsty? Restless and irritable? Pinch the skin of the abdomen. Does it go back: Look for sunken eyes. Very slowsly (longer then 2 seconds)? Offer the child fluid. Is the child: Slowly? Not able to drink or drinking poorly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Drinking eagerly, thirsty? Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ Pinch the skin of the abdomen. Does it go back: Look for runny nose For how long? ___ Days Very slowsly (longer then 2 seconds)? Name: Age: Weight (kg): Temperature (°C): Look for signs of MEASLES: EXERCISE B If What more are than 7(RANA) days, has fever been present every Slowly? Ask: the child's problems? Initial Visit? Follow-up Visit? Generalized rash and day? (Circle all signs present) ASSESS DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ CLASSIFY One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Look for or feel stiffcause neck of fever. Decide malaria risk: High ___ Low ___ No___ Look anyfor other CHECK DANGER General danger sign Do malariaFOR test if GENERAL NO general danger sign SIGNS Look for runny nose For how long? Days present? NOT TO___ DRINK OR BREASTFEED LETHARGIC UNCONSCIOUS Name: Age: for signsOR Weight (kg): Temperature (°C): High risk:ABLE all fever cases Look of MEASLES: If more than 7 days, has fever been present every VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ Ask: What are the child's problems? Initial Visit? Follow-up Visit? Low risk: if NO obvious cause of fever Generalized rash and day? CONVULSIONS ASSESS (Circle all signs present) Remember to use CLASSIFY One of these: cough, runny nose, or red eyes Test POSITIVE? falciparum P.the vivaxNEGATIVE? Has child hadP. measels within last 3 months? Danger sign when Look for any other cause of fever. CHECK FOR GENERAL DANGER SIGNS General danger sign Look for mouth ulcers. Dothe malaria testhas if NOmeasles general danger sign If child now or within the selecting present? NOT ABLE TOcases DRINK OR BREASTFEED LETHARGIC UNCONSCIOUS If yes, are OR they deep and extensive? High risk: all fever classifications last 3 months: VOMITS EVERYTHING CONVULSING NOW from the eye. Yes ___ No ___ Look for pus draining Low risk: if NO obvious cause of fever DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ CONVULSIONS Look for clouding of the cornea. Remember to use Test POSITIVE? P. falciparum P. vivaxNEGATIVE? For how long? ___ Days Danger sign DOES THE CHILD HAVE AN EAR PROBLEM? Count the breaths in one minute Yes __ No when __ Look for mouth ___ breaths perulcers. minute. Fast breathing? If the child selecting Is there ear has pain?measles now or within the Look for pus draining from the ear If yes, are they deep and extensive? Look for chest indrawing classifications last months: Is 3 there ear discharge? Feel for tender swelling behind the ear Look for pus draining from the eye. and listen for stridor If Yes, for how long? HAVE ___ Days DOES THE CHILD COUGH OR DIFFICULT BREATHING? Yes __ No __ Look for clouding of the cornea. and listen for wheezing Look for oedema of both THEN CHECK FOR ACUTE MALNUTRITION For how long? ___ Days Count the breaths in one feet. minute DOES THE CHILD HAVE AN EAR PROBLEM? Determine Yes __ No __ DIARRHOEA? WFH/L _____ Z score. ___ breaths per minute. Fast breathing? AND ANAEMIA Is there pain? Look for pus draining from the ear For howear long? ___ Days at the childs general condition. Is the child:____ mm. For children 6 months or older measure MUAC Look for chest indrawing Is there ear discharge? Feel for tender swelling behind the ear blood in the stool? Lethargic or unconscious? Look palmar pallor. Look for and listen for stridor If Yes, for how long? ___ Days Restless and irritable? Severe palmar Some palmar pallor? Look and listen for pallor? wheezing Look for sunken eyes. oedema of complication? both feet. THEN CHECK FOR ACUTE MALNUTRITION Is there any medical If childTHE has CHILD MUAC HAVE less than 115 mm or DOES DIARRHOEA? Yes __ No __ Offer the child fluid. Is the Z child: Determine WFH/L _____ score. General danger sign? AND WFH/L less than Z scores or oedema of ForANAEMIA how long? ___ -3 Days Look at able the childs general condition. Is the child:____ mm. Not tomonths drink oror drinking poorly? For children 6 older measure MUAC Any severe classification? Is there blood in the stool? Lethargic or pallor. unconscious? both feet: Drinking eagerly, thirsty? Look for palmar Pneumonia with chest indrawing? Restless and irritable? Pinch the skin of the abdomen. Does it go back: Severe palmar pallor? Some palmar pallor? For a child 6 months or older offer RUTF to eat. Is the child: Look for sunken eyes. Very slowsly (longer then 2finish? seconds)? Is there any medical complication? If child has MUAC less than 115 mm or Not able to finish or able to Offer the child fluid. Is the child: Slowly? danger sign? For aGeneral child less than 6 months is there a breastfeeding problem? WFH/L less than -3 Z scores or oedema of Not able to drink or drinking poorly? Any severe classification? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ CHECK FOR HIV INFECTION both feet: Drinking eagerly, thirsty? Pneumonia chest indrawing? Look or feel for with stiff neck Decide malaria risk: High child's ___ Low No___ Note mother's and/or HIV___ status Pinch the skin of the abdomen. Does it go back: For a child 6 months Look for runny noseor older offer RUTF to eat. Is the child: ForMother's how long? ___ Days NEGATIVE POSITIVE HIV test: NOT DONE/KNOWN Very slowsly (longer then 2finish? seconds)? Not able to of finish or able to Look for signs MEASLES: If more than 7 days, has fever been present every Child's virological test: NEGATIVE POSITIVE NOT DONE Slowly? For aGeneralized child less than 6 months is there a breastfeeding problem? rash and day? Child's serological test: NEGATIVE POSITIVE NOT DONE DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ One of these: cough, runny nose, or red eyes CHECK FOR HIV INFECTION Has child had measels within the last 3 months? If mother is HIV-positive and NO positive virological test in child: Look or feel stiffcause neck of fever. Decide malaria risk: High child's ___ Low ___ No___ Look for anyfor other Note mother's and/or HIV status Is the child breastfeeding now? Do malaria test if NO general danger sign Look for runny nose ForMother's how the long? ___ Days NEGATIVE HIV test: POSITIVE NOT DONE/KNOWN Was child breastfeeding at the time of test or 6 weeks before it? High risk: all fever cases Look for signs of MEASLES: If more than 7 days, has fever been present every Child's virological test: NEGATIVE POSITIVE NOT DONE If breastfeeding: Is the mother and child on ARV prophylaxis? Low risk: if NO obvious cause of fever Generalized rash and

CHECK FOR GENERAL DANGER SIGNS

Remember to use CLASSIFY Danger sign when General danger sign selecting present? classifications Yes ___ No ___ Yes __ No __ Remember to use Danger sign when selecting classifications

X

4

X

X

No

No

No

Yes

No visible dehydration

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Rana 14 mo 12 kg 37.5 °C X Diarrhoea

X

21

X

X

No

No Yes

Yes

Some dehydration

47

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE C (CLASSIFY) 1. 2 SIGNS from any of the following – sunken eyes, restless/irritable, drinks eagerly/ thirsty, and slow skin pinch (faster than 2 seconds, but not immediate). 2. 2 SIGNS from any of the following – lethargic/unconscious, sunken eyes, not able to drink/drinking poorly, very slow skin pinch (over 2 seconds) 3. Low osmolarity ORS.

MANAGEMENT OF SICK CHILD AGED 2 MONTHS UP TO 5with YEARS 4. Children withTHE diarrhoea that do not require immediate referral – that is, children diarrhoea and some or no dehydration. Children with persistent diarrhoea receive Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? zinc for 14 days. Zinc supplements are a very important part of treating diarrhoea. ASSESS (Circle all signs present) CLASSIFY 5. 4 rules DANGER of home SIGNS treatment of diarrhoea: CHECK FOR GENERAL NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING 1. Give extra fluid CONVULSIONS

– as

LETHARGIC OR UNCONSCIOUS CONVULSING NOW much as the child will take

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

2. Give zinc 3. Continue feeding 4. When to return (for a follow-up visit, or immediately if danger signs develop) Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look Age: and listen for wheezing Weight (kg):

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

3. PANO

EXERCISE D (CLASSIFY) MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? DOES THE CHILD HAVE DIARRHOEA? ASSESS (Circle all signs present) For how long? ___ Days

Look at the childs general condition. Is the child: Is thereFOR blood GENERAL in the stool? DANGER SIGNS Lethargic or unconscious? CHECK Restless and NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR irritable? UNCONSCIOUS Look for sunken eyes. VOMITS EVERYTHING CONVULSING NOW Offer the child fluid. Is the child: CONVULSIONS Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days Count the breaths in one minute DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) ___ breaths perstiff minute. Look or feel for neckFast breathing? Decide malaria risk: High ___ Low ___ No___ Look for for runny chest indrawing Look nose For how long? ___ Days Look for and listen for stridor Look signs of MEASLES: 4. JANE If more than 7 days, has fever been present every Look and listen for wheezing Generalized rash and day? One of these: cough, runny nose, or red eyes DOES THE CHILD HAVE Has child had measels within DIARRHOEA? the last 3 months? Look for any othergeneral cause of fever. Is the child: For howtest long? ___ Days danger sign at the childs condition. Do malaria if NO general Is there blood in the stool? Lethargic or unconscious? High risk: all fever cases Restless and irritable? Low risk: if NO obvious cause of fever Look for sunken eyes. Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Offer the child fluid. Is the child: Not to drink or drinking poorly? Look forable mouth ulcers. If the child has measles now or within the Drinking eagerly, thirsty? If yes, are they deep and extensive? last 3 months: Pinchfor the skin of the abdomen. Does it go back: Look pus draining from the eye. Very slowsly (longer then 2 seconds)? Look for clouding of the cornea. Slowly? DOES THE CHILD HAVE AN EAR PROBLEM?

5

Initial Visit?

No

No Yes

Temperature (°C): Follow-up Visit? Yes __ No __ CLASSIFY

X

Yes

Yes

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

Some dehydration Yes __ No __ Yes __ No __

3

Yes __ No __

X

No

No No

No dehydration

Lookfor or tender feel forswelling stiff neck Is there ear discharge? Feel behind the ear Decide malaria risk: High ___ Low ___ No___ Look for runny nose If Yes, for how long? ___ Days For how long? ___ Days EXERCISE E (PLAN B) Look for for oedema signs of MEASLES: Look of both feet. If more than 7 days, has fever been present every THEN CHECK FOR ACUTE MALNUTRITION Generalized rash and Z score. Determine WFH/L _____ day? AND ANAEMIA 1. Answers below: of these: cough, runnymeasure nose, or MUAC red eyes For One children 6 months or older ____ mm. Has child had measels within the last 3 months? Look for for palmar any other cause of fever. Look pallor. Do malaria test if NO general danger sign palmar Some of palmar pallor? Name Age or Weight Severe Range ofpallor? Amounts ORS Solution High risk: all fever cases Is there any medical complication? If child has MUACcause less of than 115 mm or Low risk: if NO obvious fever a. Andras 3 years 900–1400 ml General danger sign? WFH/L less than -3 Z scores or oedema of Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Any severe classification?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Is there ear pain? Look for pus draining from the ear

Yes __ No __ Yes __ No __

b. Gul 10 kg both If the feet: child has measles now or within the 7.5 kg last 3 months: c. Nirveli d. Sami

11 months

DOES THE CHILD HAVE AN EAR PROBLEM? CHECK FOR HIV INFECTION

Look for mouth with ulcers. Pneumonia chest indrawing? yes, are they deep andoffer extensive? For aIfchild 6 months or 400–700 older RUTF 562.5 ml or ml to eat. Is the child: Look for pusto draining from the Not able finish or able to eye. finish? 400–700 ml Look for clouding of cornea. For a child less than 6the months is there a breastfeeding problem? Yes __ No __

750 ml or 700–900 ml

Is there ear pain? Look for pus draining from the ear Note mother's and/or child's HIV status Is there ear discharge? Feel for tender swelling behind the ear Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN If Yes, for how long? ___ Child's virological test:Days NEGATIVE POSITIVE NOT DONE Look for oedema of both feet. Child's serological NEGATIVE POSITIVE NOT DONE THEN CHECK FOR test: ACUTE MALNUTRITION Determine WFH/L _____ Z score. If mother is HIV-positive and NO positive virological test in child: AND ANAEMIA For children 6 months or older measure MUAC ____ mm. Is the child breastfeeding now? Look for palmar pallor. Was the child breastfeeding at the time of test or 6 weeks before it? Severe palmar pallor? Some palmar pallor? If breastfeeding: Is the mother and child on ARV prophylaxis? Is(Circle there any medical complication? If child has MUAC less than 115 mm or CHECK THE CHILD'S IMMUNIZATION STATUS immunizations needed today) General danger sign? Measles1 Measles 2 Vitamin A WFH/L less than -3 Z scores or oedema of DPT+HIB-3 DPT+HIB-2 BCG DPT+HIB-1 Any severe classification? Mebendazole OPV-3 OPV-2 OPV-0feet: OPV-1 both Hep B3 Pneumonia with chest indrawing? Hep B2 Hep B1 Hep B0 For a child 6 months or older offer RUTF to eat. Is the child:

48

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

2. Answers below: a. Vinita should be given 400–700ml of low osmolarity ORS solution during the first 4 hours of treatment. She should also be given 100–200 ml of clean water during this period. b. She should wait 10 minutes before giving more ORS solution. Then she should give Vinita the ORS solution more slowly. c. After Vinita is given ORS solution for 4 hours on Plan B d. Because Vinita has been reassessed as NO DEHYDRATION, she should be put on Plan A. e. 2 one-litre packets f. To continue treatment at home, the grandmother should give Vinita 50–100 ml of ORS solution after each loose stool. 3. Answers below: a. 400–700 ml of ORS solution b. Yes, Yasmin should breastfeed whenever and as much as she wants. c. Because Yasmin is still classified as SOME DEHYDRATION, she should continue on Plan B.

EXERCISE F (PLAN A) 1. Answers will vary 2. Somi answers: a. Give extra fluid, Give zinc, Continue feeding, Advise when to return b. ORS solution, food-based fluids (such as soup, rice water, yoghurt drinks), clean water 3. The health worker should tell Kasit’s mother to breastfeed him more frequently than usual. The health worker should also tell the mother that after breastfeeding, she should give Kasit ORS solution or clean water. 4. Children who have been treated with Plan B or Plan C during the visit, or children who cannot return to a clinic if the diarrhoea gets worse. 5. Answers below: Name Age Name a. c. Kala Kara b. Sam d. Lalita

Amount of extra fluid to give after each loose stool Age 6 months 2 years 15 months 4 years Amount of extra fluid to give after each loose stool 500–100 ml 100–200 ml 50–100 ml 100–200 ml

49

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE G (TREAT) 1. 10 mg (1/2 of a 20 mg tablet) once each day for 14 days. Tablet should be crushed and dissolved in breast milk, ORS, or clean water. It is important to give zinc for all 14 days. 2. 20 mg tablet given once each day for 14 days. Tablets can be chewed or dissolved in fluid. It is important to give zinc for all 14 days. 3. Give 1ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days 4. Give 3ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days 5. Start treatment for dehydration, give Vitamin A dose, teach mother to give frequent sips of ORS on the way, give other urgent pre-referral treatment as other classifications require, and refer URGENTLY. 6. Correct answers are A, B, D, E

EXERCISE H (CASE STUDY COUNSEL) 1. Rules are: a. GIVE EXTRA FLUID: Explain what extra fluids to give. Since the child is being treated with Plan B during this visit, the mother should give ORS at home. Explain how much ORS solution to give after each loose stool. b. CONTINUE FEEDING: Instruct her how to continue feeding during and after diarrhoea. c. GIVE ZINC: explain dosing and schedule for 14 days of zinc, how to give, why it is given d. WHEN TO RETURN: Teach her the signs to bring a child back immediately. 2. How to mix ORS into water. He did not include what containers to use, what ratio of packets and water, how to give the ORS to her child, or instructions for frequency of treatment. 3. YES 4. NO 5. WITH A YES/NO QUESTION (“DO YOU UNDERSTAND?”). THIS IS NOT A CHECKING QUESTION. 6. NO. THE QUESTION DOES NOT SHOW IF THE CAREGIVER LEARNED. 7. CHECKING QUESTION –for example “How will you prepare the ORS for your child?”

EXERCISE I (CASE STUDY COUNSEL) 1. All five answers should be checked. 2. Aviva answers: a. YES, 2 PACKETS b. The mother should wait 10 minutes before giving more fluid. Then she should give the solution more slowly. c. Aviva’s mother should continue giving extra fluid until the diarrhoea stops d. Drinking poorly or not able to drink or breastfeed, Becomes sicker, Develops a fever, Blood in stool 3. Only C “How much fluid will you give your child?” is a good checking question

50

IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE J (EVARISTO FOLLOW-UP) 1. Ask: Has Evaristo’s diarrhoea stopped? How many loose stools is he having per day? 2. Reassess Evaristo completely as described on the ASSESS & CLASSIFY chart. Treat any problems that require immediate attention. Then refer him to hospital. 3. NO 4. Refer him to a hospital. He does not need any treatments before he leaves. 5. Rehydrate him according to Plan B before referral.

51

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 3 Cough or difficult breathing

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

n CONTENTS Acknowledgements 4 3.1 3.2 3.3 3.4 Module overview Introduction to cough or difficult breathing Assess a child for cough or difficult breathing Classify cough or difficult breathing 5 7 9 15 21 28 35 38 39 40

3.5 Treat the child with cough or difficult breathing 3.6 3.7 3.8 3.9 Counsel the caregiver Provide follow-up care for cough or difficult breathing Using this module in your clinical practice Review questions

3.10 Answer key

3

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

4

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.1

MODULE OVERVIEW

A cough or difficult breathing is a common reason why a mother will bring a child to your clinic. The problem may be a mild cold, or it may be a serious problem like pneumonia. How can you tell the difference? How should you treat the child? How should you counsel the mother? The choices may seem confusing, but this selflearning module will help you make the correct decisions.

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, and then ASK: DOES THE CHILD HAVE A COUGH OR DIFFICULT BREATHING?

NO

YES ASSESS & CLASSIFY the child using the colour-coded classification charts for cough or difficult breathing.

CONTINUE ASSESSMENT: assess for main symptoms (next is diarrhoea), check for malnutrition & anaemia, check immunization status, HIV status, and other problems

MODULE LEARNING OBJECTIVES After you study this module, you will be able to: ✔✔ Assess cough or difficult breathing using the IMCI Chart Booklet ✔✔ Recognize main clinical signs of cough or difficult breathing ✔✔ Classify cough or difficult breathing ✔✔ Treat a child with cough or difficult breathing according to IMCI guidelines ✔✔ Counsel caregiver on home care Age:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present)

✔✔ Give appropriate follow‐up care for a child with cough or difficult breathing Weight (kg): Initial Visit?

CHECK FOR GENERAL DANGER SIGNS

YOUR RECORDING FORM

Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS Look at your IMCI recording form for the sick child. This VOMITS EVERYTHING CONVULSING NOW module: CONVULSIONS

section deals with this

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

5

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Yes __ No __

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

MODULE ORGANIZATION This module follows the major steps of the IMCI process: ✔✔ Assess cough or difficult breathing ✔✔ Classify cough or difficult breathing ✔✔ Treatment for cough or difficult breathing ✔✔ Counsel caregiver on home care (oral antibiotics, safe remedies) ✔✔ Follow-up care for cough or difficult breathing

BEFORE YOU BEGIN What do you know now about managing cough or difficult breathing? Before you begin studying this module, quickly practice your knowledge with these multiple-choice questions. Circle the best answer for each question. 1. What clinical signs can help you identify if a child has pneumonia? a. Wet cough b. Fast breathing c. Chest indrawing 2. If a child has pneumonia, how will you treat? a. Oral antibiotics b. Honey c. Paracetamol 3. Why is it important to correctly identify and manage pneumonia? a. Pneumonia is very common, but it is not so serious for children b. Pneumonia is a major killer of children under 5 around the world, and it requires early management c. Children with pneumonia need to be isolated from all other family members 4. Chest indrawing is when: a. The lower ribs move in when the child breathes out b. The lower ribs move in when the child breathes in c. The lower ribs are always pushed in, no matter if the child is breathing in or out 5. Children who have a cough, but do not show signs of pneumonia, should immediately receive an antibiotic: a. TRUE b. FALSE 6. The following is a good checking question: “how will you prepare a safe home remedy for cough?” a. TRUE b. FALSE After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the module!

6

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.2

INTRODUCTION TO COUGH OR DIFFICULT BREATHING

Consider a typical case that you might see in your practice. Imagine the situation. This will help you start thinking about the problem of a child with a cough or difficult breathing.

n  OPENING CASE STUDY – JACOB Amira lives in a village two hours walk away from the regional health centre. She arrives at your clinic and carefully takes Jacob off her back. She presents him to you with a look of panic on her face. She tells you that Jacob is not feeling well and she is worried about him. Amira watches her children carefully. She has been noticing for the last 3 days that Jacob does not seem to be himself. He is 6 months of age and has been started on some solids, but is now refusing to take these solids. He is also not breastfeeding as much as he was. Amira is quite worried and scared to tell her husband. She decides to walk the two hours to the local health clinic carrying Jacob on her back. Amira had three other children. However, one died at three weeks of age from an illness she is not sure about. Her husband is often away. When he is home he sometimes is violent towards the children, especially if they are crying and seem to be unwell. Amira thinks he may be frightened that another child will die. She is unsure about whether she should attend the clinic. She decides that this is the best thing. She just hopes that Jacob gets well and her husband does not find out.

n  Greet Amira at the clinic First, you praise Amira for bringing Jacob to the clinic. You tell her that you know it is a long walk and she must be tired. Compliment her on the wisdom of her decision and her effort in bringing Jacob to the clinic. Reassure her that she did the right thing to help her child. This conversation with Amira will establish good communications between you and the mother. That is important, because she will have a lot of responsibility for Jacob’s care. You want her to trust you and understand your directions. You have learned from Amira that the child’s name is Jacob, and he is 6 months old. She is concerned because he is not feeding well. When you ask more about this, Amira tells you that she has noticed that Jacob starts to breastfeed and then pulls off the breast and seems to pant for air before going back for a further suckle. She has noticed that his stomach seems to be going in and out quite quickly. This is her initial visit to the clinic for this problem. Jacob weighs 5kg and his temperature is 37 degrees.

7

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

n  Next, check Jacob for general danger signs Amira has told you that Jacob is not eating solids well, and he is taking the breast less than he used to. You ask her if he is still able to drink or breastfeed. She says yes, he will take the breast, but he does not drink well. He does not vomit. He has had no convulsions. You look at Jacob’s condition. He appears very tired, but lifts his hand to Amira. His eyes look up to Amira and follow you when you snap your fingers. Here is how you would complete Jacob’s recording form thus far:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Jacob Age: 6 mo Weight (kg): 5 kg Temperature (°C): 37 °C Follow-up Visit? Ask: What are the child's problems? Not feeding well (not taking other foods, not taking Initial Visit? X CLASSIFY ASSESS (Circle all signs present) breast well), rapid breathing CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

Jacob shows no general danger signs. You DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

For how long? ___ Days

Count the breaths in one minute ___ breaths per minute. Fast breathing? will now assess for cough or difficult Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

breathing. Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

8

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.3

ASSESS A CHILD FOR COUGH OR DIFFICULT BREATHING

WHY ARE WE CONCERNED ABOUT COUGH OR DIFFICULT BREATHING? Jacob reminds us that many problems can occur at any site in the respiratory system. Here is a simple illustration to remind you of the different parts of the respiratory system. You will go step-by-step through the process of assessing, classifying, and treating respiratory infections. You will use the story of Jacob and his mother Amira as an example. nose throat ribs lungs epigottis larynx trachea bronchi

The respiratory tract

WHAT CAUSES COUGH OR DIFFICULT BREATHING? Many children who come to your clinic with a cough or difficult breathing may have mild respiratory infections. They may have a cold or bronchitis. These children are not seriously ill and do not need antibiotics, they can be treated at home. However, some children with cough or difficult breathing may have pneumonia or another serious respiratory infection. You have learned that pneumonia is one of the greatest causes of child mortality in the world. Children can die from bacterial pneumonia because they can’t get enough oxygen ( hypoxia) or they get a generalized infection (sepsis). Most pneumonia in developing countries is caused by bacteria and can be treated with antibiotics.

HOW CAN YOU IDENTIFY PNEUMONIA? Pneumonia is a serious respiratory infection. You can identify children with pneumonia by checking for two clinical signs. When children develop pneumonia, their lungs become stiff. These two signs help show how stiff the lungs have become. 1. FAST BREATHING: is one of the body’s responses to stuff lungs and hypoxia. 2. CHEST INDRAWING: develops when the lungs become even stiffer as the pneumonia becomes more severe.

HOW WILL YOU ASSESS A CHILD FOR COUGH OR DIFFICULT BREATHING? This assessment will examine how quickly the child is breathing, the noises he is making as he breaths, and how much difficult he appears to have while breathing.

9

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

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A cough or difficult breathing that lasts for more than 14 days may indicate tuberculosis, asthma, whooping cough, or some other problem.

LOOK: DOES THE CHILD HAVE FAST BREATHING? As you have learned, fast breathing is one sign of pneumonia in a child. How do you determine if a child is breathing faster than he or she normally should be? You count the number of breaths the child takes per minute to determine if fast breathing is present. To count the breaths per minute, use a watch with a second hand or a digital watch. Look for the breathing movement anywhere on the child’s chest or abdomen. The number of breaths for ‘fast breathing’ depends on the child’s age. Younger children normally have higher rates of breathing than older children.

10

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

It is very important that the child is calm and still. If the child is moving or crying, you will not be able to get an accurate count of breaths. Ask the mother to help keep her child calm.

FAST BREATHING 2 months up to 12 months = 50 or more breaths per minute

DVD EXERCISE – FAST BREATHING Watch “Count respiratory rate” (disc 1) to practise identifying fast breathing. It is very useful to practice counting with a video. The video will review answers with you.

What did you find? CHILD 1: CHILD 2: breaths/minute. Is this fast? breaths/minute. Is this fast?  YES   NO  YES   NO

SELF-ASSESSMENT EXERCISE A Remember that all self-assessment exercise answers at in a key at the end of this module.

Let us practise what we have learned about cough or difficult breathing thus far. 1. What are two clinical signs that help you identify children with pneumonia? 2. Do the following children have fast breathing? Tick your answers.

a. 3 years, 36 breaths per minute b. 12 months, 50 breaths per minute c. 6 months, 45 breaths per minute d. 3 months, 57 breaths per minute

 YES   NO  YES   NO  YES   NO  YES   NO

3. Julie arrives at your clinic with her mother. You begin by gathering important information about the child. You check Julie for danger signs, and she has none. What do you do next? a. ASK: b. LOOK: 4. When you ask Julie’s mother, she says Julie has no cough or difficult breathing. You watch Julie, and she seems to be breathing regularly. What do you do next?

11

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

LOOK: FOR CHEST INDRAWING Chest indrawing occurs when the child needs to make a greater effort than normal to breathe in. You will look for chest indrawing when the child breathes IN. In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. The child has chest indrawing if the lower chest wall (lower ribs) goes IN when the child breathes IN. Review the photo below.

For chest indrawing to be present, it must be visible and present all the time you are observing the child. If you still do not see the lower chest wall go IN when the child breathes IN, the child does not have chest indrawing. Here are some helpful tips to look for chest indrawing: ✔✔ Ask the caregiver to lift the child’s shirt, if you did not when you counted breaths. ✔✔ If the child’s body is bent at the waist, it is hard to see the lower chest wall move. Ask the caregiver to change the child’s position so he is lying flat in her lap.

REMEMBER! When do you look for chest indrawing? When the child breathes IN NORMAL: when child breathes IN, chest wall moves OUT CHEST INDRAWING: when child breathes IN, chest wall moves IN

12

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

DVD EXERCISE – CHEST INDRAWING Watch “Assessing indrawing” (disc 1). It is very useful to practise with a video. Record your answers as you watch. It will review the answers at the end. Do these children have chest indrawing?

CHILD 1   YES   NO CHILD 4   YES   NO CHILD 2   YES   NO CHILD 5   YES   NO CHILD 3   YES   NO

LOOK AND LISTEN FOR STRIDOR Stridor is a harsh noise made when a child breathes IN. It occurs when the larynx, trachea, or epiglottis is swollen. These conditions are often called croup. This swelling interferes with air entering the lungs. If the swelling blocks the child’s airway, it can be life threatening. Stridor is present when the child breathes IN It is a harsh noise caused when swelling interferes with air entering the lungs.

To look and listen for stridor, look to see when the child breathes IN. Then listen for stridor. Put your ear near the child’s mouth because stridor can be difficult to hear. Sometimes you will hear a wet noise if the child’s nose is blocked. Clear the nose, and listen again.

Be sure to look and listen for stridor when the child is calm. A child who is not very ill may have stridor only when he is crying or upset. However, a child who is calm and also has stridor has a dangerous situation. You may only hear a wheezing noise when the child breathes OUT – this is not stridor.

DVD EXERCISE – STRIDOR Watch “Assessing stridor” (disc 1) to practise identifying stridor. It is very useful to practice with a video. The video will review answers with you. Do you hear stridor in these children?

CHILD 1   YES   NO CHILD 4   YES   NO CHILD 2   YES   NO CHILD 5   YES   NO CHILD 3   YES   NO

LOOK AND LISTEN FOR WHEEZING Wheeze is a high-pitched whistling or musical sound heard at the end of the breathing OUT. The child’s small air passages narrow to cause wheezing. To hear wheezing, put your ear near to the child’s mouth when the child is calm. Look at the child’s breathing while you listen to check that the sound mainly occurs when the child breathes out. If the child has wheezing and either fast breathing or chest indrawing: you need to perform an additional assessment. Give a trial of rapid acting inhaled bronchodilator for up to three times 15–20 minutes apart. Count the breaths and look for chest indrawing again. Then classify the problem.

13

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

Watch “Demonstration: cough or difficult breathing” (disc 1) This video will review all steps in assessing for cough or difficult breathing. It is very useful to see these signs in the clinical setting.

n  Now you will return to Jacob’s case. How will you assess him for cough or difficult breathing? You have already assessed Jacob for general danger signs, and found that he did not have any. Next, you will assess Jacob for cough or difficult breathing. You ask Amira if Jacob has a cough or difficult breathing. She is confused when you say “difficult breathing,” so you explain it as breathing that is fast, noisy, or interrupted. Amira says yes, she thinks Jacob has been breathing fast. He also moves away from the breast to take breaths. She says he did not do this in the past. You ask Amira how long this issue has been present. She says 1 week. You remember that a cough or difficult breathing that lasts for more than 14 days may indicate tuberculosis, asthma, whooping cough, or some other problem. Based on Amira’s answers, you will need to assess Jacob for a cough or difficult breathing. You think there may be a respiratory problem. You hold up Jacob’s shirt and count his breaths in one minute. When he is calm, he is breathing 70 breaths per minute. He coughs frequently. MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Then When Jacob breathes wall and Name:you look at his lower chest wall for indrawing. Age: Weight (kg):in, his lower chest Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? You abdomen move out. You listen for stridor when Jacob breathes in, and you do not hear any harsh noise. ASSESS (Circle all signs present) CLASSIFY also do not hear wheezing when he breathes out. General danger sign present? VOMITS EVERYTHING Yes ___ No ___ Does he have indrawing or stridor? CONVULSIONS Remember to use Danger sign when Here is how you would complete Jacob’s recording form for cough or difficult breathing: selecting classifications

Does Jacob have fast breathing? NOT ABLE TO DRINK OR BREASTFEED

CHECK FOR GENERAL DANGER SIGNS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ 7 Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days

Count the breaths in one minute breathing? 70 breaths per minute. Fast ___ Look for chest indrawing No Look and listen for stridor No Look and listen for wheezing No

Yes __ X No __

Yes

You Is will now learn how to classify the signs you checked Jacob for. there blood in the stool? Lethargic or unconscious?

Look at the childs general condition. Is the child: Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM?

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Yes __ No __

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.4

CLASSIFY COUGH OR DIFFICULT BREATHING

Now you will learn how to classify using the signs you assessed for. There are three possible classifications for a child with cough or difficult breathing: 1. SEVERE PNEUMONIA OR VERY SEVERE DISEASE 2. PNEUMONIA 3. COUGH OR COLD Open your chart booklet: what does the classification table look like? Any general danger sign or Stridor in calm child. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA Give first dose of an appropriate antibiotic Refer URGENTLY to hospital**

ify GH or CULT ATHING

Chest indrawing or Fast breathing.

Give oral Amoxicillin for 5 days*** If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** If chest indrawing in HIVexposed or infected child, give first dose of amoxicillin and refer to hospital. If coughing for more than 2 weeks or if having recurrent wheezing, refer for further assessment or consider TB or asthma Advise mother when to return immediately Follow-up in 3 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 5 days if not improving

No signs of pneumonia or very severe disease.

Green: COUGH OR COLD

* **

If pulse oximeter is available, determine oxygen saturation and refer if < 90%. If referral is not possible, manage the child as described in Integrated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient care.

*** Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings. **** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried.

REMEMBER! Classifications are colour-coded, and identify treatments: RED = refer urgently ated Management of Childhood Illness, Treat the Child, Annex: Where Referral is Not Possible, and WHO guidelines for inpatient

r if < 90%.

YELLOW = treat in clinic

GREEN = home treatment

athing but no chest indrawing in low HIV settings.

butamol may be tried.

Page 5 of 75 

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

VERY SEVERE PNEUMONIA OR VERY SEVERE DISEASE (RED) A child with cough or difficult breathing and any general danger sign or stridor (in a calm child) is classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE. The child may have another serious acute lower respiratory infection such as bronchiolitis, pertussis, or a wheezing problem. What actions will you take? A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is seriously ill. He or she needs urgent referral to a hospital for treatments such as oxygen, a bronchodilator, or injectable antibiotics. Before the child leaves, give the first dose of an appropriate antibiotic. The antibiotic helps prevent severe pneumonia from becoming worse. It also helps treat other serious bacterial infections such as sepsis or meningitis.

PNEUMONIA (YELLOW) A child with cough or difficult breathing who has fast breathing and or chest indrawing is classified as having PNEUMONIA. This child should not have a general danger sign, or stridor. What actions will you take? A child with PNEUMONIA needs treatment with oral amoxicillin for 5 days. You will begin this treatment in the clinic, and it will continue at home. Later in this section, you will read about how to identify and give an antibiotic. You will also learn how to teach caregivers to give treatments at home. If the child has wheezing, this will require treatment with an inhaled bronchodilator. If the child is HIV exposed or infected and chest indrawing, she needs give the first dose of amoxicillin and refer to the hospital.

COUGH OR COLD (GREEN) A child with cough or difficult breathing but none of the signs already discussed – general danger signs, chest indrawing, stridor when calm, or fast breathing – is classified as COUGH OR COLD. What actions will you take? A child with COUGH OR COLD does not need an antibiotic. The antibiotic will not relieve the child’s symptoms. It will not prevent the cold from developing into pneumonia. Instead, give the mother advice about good home care, like safe remedies. A child with a cold normally improves in one to two weeks. However, a child who has a chronic cough lasting more than 2 weeks, he/she may have tuberculosis, asthma, whooping cough or another problem. A child with a chronic cough needs to be referred to hospital for further assessment.

16

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: n   How will you classify Jacob? Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? ASSESS (Circle allone signs sign present) You observed in Jacob – fast breathing. You counted 70 breaths per minute. For his age, 50 breaths CLASSIFY

or more is considered Fast breathing is a sign used to classify pneumonia (yellow). He didGeneral not show CHECK FOR GENERALfast. DANGER SIGNS danger sign ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS any NOT signs from the SEVERE PNEUMONIA or VERY SEVERE DISEASE (red) classification, like stridor orpresent? a general VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ danger sign. CONVULSIONS You will write your classification on the recording form: DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ 7 Days Remember to use Danger sign when selecting classifications Yes __ X No __

Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood the stool? Lethargic or unconscious? n  What doin you do after classifying Jacob’s cough? Restless and irritable? In a normal scenario, you will then begin to ASSESS Jacob for the next main symptom, diarrhoea, until you Look for sunken eyes. Offer the child fluid. Is the child: are done with the full assessment. Not able to drink or drinking poorly? Drinking eagerly, thirsty? Then you will review all of the treatments you have identified for his various classifications, and decide on his Pinch the skin of the abdomen. Does it go back: integrated treatment. You will learn more about giving treatment, counselling Amira, and providing Very slowsly (longer then 2 seconds)? follow-up care in the following sections. Slowly? Look or feel for stiff neck Decide risk: High ___ Low ___ No___ n   Asmalaria a practice exercise, consider a second scenario with Jacob: Look for runny nose For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA?

Count the breaths in one minute breathing? 70 breaths per minute. Fast ___ Look for chest indrawing No Look and listen for stridor No Look and listen for wheezing No

Yes

Pneumonia

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

Yes __ No __

Look for signs of MEASLES: If more thanyou 7 days, has fever been present every How would have classified differently if you had heard a harsh noise while Jacob sat with Amira? Jacob’s Generalized rash and day? first Has sign, fast breathing , is a sign used to classify PNEUMONIA (yellow The second sign, One of these: cough, runny nose, or classification). red eyes child had measels within the last 3 months? Look for any other DISEASE cause of fever. stridor , is a sign of SEVERE PNEUMONIA or VERY SEVERE (red classification). Do malaria test if NO general danger sign

There are often Low risk: if NO obviouscases cause ofwhen fever you will find signs from several classifications. In these situations, you always classify with the most severe classification. So in a scenario where you assess one sign from a yellow Test POSITIVE? P. falciparum P. vivaxNEGATIVE? classification, and another sign from a red classification, you would use the red classification. This signifies Look for mouth ulcers. If the child has measles now or within the yes, are they deep and extensive? last 3 months: SEVERE illness and requires urgent pre-referralIftreatment, and then referral. DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

High risk: all fever cases

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

17

Return for next immunization on: ________________ (Date)

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

SELF-ASSESSMENT EXERCISE B Open your Chart Booklet. Review the classification table for cough or difficult breathing.

1. Match the boxes below. Each “signs” box should be matched with one classification. SIGNS Sal is 9 months old and has a cough. You count 45 breaths per minute. No chest indrawing or stridor. Linus is 3 months old, and you could 65 breaths in one minute. When he breathes in, has had convulsions during current illness. Jojo is 3 years old. You count 56 breaths in one minute. No indrawing or stridor. CLASSIFICATION SEVERE PNEUMONIA or VERY SEVERE DISEASE PNEUMONIA

COUGH OR COLD

2. Are these statements true or false? If false, write the statement as correct. a. You should look for chest indrawing when the child breathes OUT. b. Fast breathing in a child 12 months and older is 40 or more a minute. c. Chest indrawing is a sign of pneumonia. d. If a child has a cough but no other signs, they probably have pneumonia. e. A child with chest indrawing will always also have fast breathing. f. Chest indrawing is when the lower ribs move IN when the child breathes IN g. A child 2 up to 12 months has fast breathing if more than 45 breaths a minute. h. A child with chest indrawing has a higher risk of death from pneumonia than a child with fast breathing and no chest indrawing. i. Difficult breathing can also be described as noisy, interrupted, or fast. j. If a child has cough, fast breathing, and vomits everything, he is classified as PNEUMONIA (YELLOW) TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

EXAMPLE EXERCISE: CLASSIFYING Read this case study and see how the health worker classified this child’s illness.

Aziz is 18 months old. He weighs 11.5 kg. His temperature is 37.5 °C. His mother brought him to the clinic because he has a cough. She says he is having trouble breathing. This is his first visit for this illness. The health worker checked Aziz for general danger signs. Aziz is able to drink. He has not been vomiting. He has not had convulsions. He is not lethargic or unconscious. The health worker asked “How long has Aziz had this cough?” His mother said he had been coughing for 6 or 7 days. Aziz sat quietly on his mother’s lap. The health worker counted the number of breaths the child took in a minute. He counted 41 breaths per minute. He thought, “Since Aziz is over 12 months of age, the cut-off for determining fast breathing is 40. He has fast breathing.” The health worker did not see any chest indrawing. He did not hear stridor. Here is how the health worker recorded Aziz’s case information and signs of illness:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Age: 18 mo Aziz Ask: What are the child's problems? ASSESS (Circle all signs present) Weight (kg):

11.5 kg

Initial Visit?

X

Temperature (°C): 37.5 °C Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

X

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

Yes __ No __ Look at the childs general condition. Is the child: Lethargic or unconscious? To classify Aziz’s illness, the health worker Restless and irritable? looked at the classification. Look for sunken eyes. Offerhad the child fluid. the child: 1. First, he checked to see if Aziz any ofIs the signs in the pink row. He thought, Not able to drink or drinking poorly? “Does Aziz have any general danger signs? No, Drinking eagerly, thirsty? he does not. Does Aziz have any HEN ASK ABOUT MAIN SYMPTOMS: Pinch the skin of the abdomen. Doesdoes it go back: the other signs in this row? No, he does not.” Aziz not have any signs for oes the child have cough or of difficult breathing? Very slowsly (longer then 2 seconds)? severe classification. Slowly? For how long? ___ Days Is there blood in the stool?

DOES THE CHILD HAVE DIARRHOEA?

Count the breaths in one minute 41 breaths per minute. Fast breathing? ___ Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Yes __ No __

X

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) yes, ask: Look, listen, feel: Any general danger sign 2. Next, the health at for the Look or feel stiffyellow neck High ___ Low ___ No___ worker looked For how long? Decide malaria risk: or Count the Look for runny nose Classify For how long? ___ row. Days Aziz have signs in the Stridor in calm child. breaths inHe thought, “Does Look for signs of MEASLES: COUGH or If more than 7 days, has fever been present every oneyellow minute*.row? He has DIFFICULT Generalized rash and fast breathing.” day? One of these: cough, runny nose, or red eyes Look for BREATHING Has child had measels within the last 3 months? Look for any other cause of fever. chest 3. The health worker classified Aziz as having Do malaria test if NO general danger sign Chest indrawing or indrawing. High risk: all fever cases PNEUMONIA. He wrote PNEUMONIA on the Fast breathing. Lookcause and of fever Low risk: if NO obvious Recording Form. listen for P. vivaxNEGATIVE? Test POSITIVE? P. falciparum stridor. Look for mouth ulcers. If the child has measles now or within the Look and If yes, are they deep and extensive? last 3 months: Look for pus draining from the eye. listen for Look for clouding of the cornea. wheezing. DOES THE CHILD HAVE AN EAR PROBLEM? CHILD Is there ear pain? Look for pus draining from the ear MUST BE Is there ear discharge? Feel for tender swelling behind the ear CALM THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA If Yes, for how long? ___ Days

Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA

Yes __ No __

Give first d antibiotic Refer URGE

Yes __ No __

Look for oedema of both feet. Determine WFH/L _____ Z score. No signs of pneumonia or For children 6 months or older measure MUAC ____ mm. very severe disease. Look for palmar pallor. Severe palmar pallor? Some palmar pallor?

19

Give oral A If wheezing rapidly actin bronchodila If chest indr child, give fi hospital. If coughing having recu assessment Advise moth Follow-up in

Green: COUGH OR COLD

If wheezing rapidly actin bronchodila

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

SELF-ASSESSMENT EXERCISE C Read the following case study and answer the questions.

Gyatsu is 6 months old and weighs 5.5 kg. His temperature is 38 °C. His mother said he has had cough for 2 days. The health worker checked for general danger signs. The mother said that Gyatsu is able to breastfeed. He has not vomited during this illness. He has not had convulsions. Gyatsu is not lethargic or unconscious. The health worker said to the mother, “I want to check Gyatsu’s cough. You said he has had cough for 2 days now. I am going to count his breaths. He will need to remain calm while I do this.” The health worker counted 58 breaths per minute. He did not see chest indrawing or hear stridor. 1. Record Gyatsu’s signs on the Recording Form below.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

2.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) c. Will you classify SEVERE PNEUMONIA OR

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and classification irritable? To classify Gyatsu’s illness, look at the table for cough or difficult Look for sunken eyes. breathing in your chart booklet. Look the top row (is pink in the Chart Booklet). Offer the childat fluid. Is the child: Not able to drink or drinking poorly? a. Does Gyatsu have a general danger sign?  YES   NO Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer when then 2 seconds)? b. Does he have chest indrawing or stridor calm?  YES   NO Slowly?

Yes __ No __

If the child has measles now or within the last 3 months:

Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ VERY SEVERE DISEASE?  YES   NO Look for runny nose For how long? ___ Days Look for signs of MEASLES: If more than 7 days, has fever been present every 3. If he does not have the severeGeneralized classification, rash and look at the middle row (yellow on day? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Chart). Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases a. Does Gyatsu have fast breathing?  YES   NO Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? b. How would you classify Gyatsu’s illness? Write on the Recording Form. Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. 20 Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing?

Yes __ No __

DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.5

TREAT THE CHILD WITH COUGH OR DIFFICULT BREATHING

REFRESH: WHAT DOES THE ‘IDENTIFY TREATMENT’ COLUMN IN THE CLASSIFICATION TABLE EXPLAIN? The classification table identifies three pieces of critical information: 1. Appropriate treatment for each classification 2. Where treatment is given: either in a second-level facility (RED), at the clinic (YELLOW), or at home (GREEN) 3. Pre-referral treatments: are identified clearly (in bold), and are required if child needs urgent referral

WHAT TREATMENTS ARE IDENTIFIED FOR COUGH OR DIFFICULT BREATHING? Open your classification chart. What treatments are listed in the “IDENTIFY TREATMENT” column for cough or difficult breathing? There are three treatments that you will learn about in this section: ✔✔ Oral antibiotics (amoxicillin) ✔✔ Remedy for soothing sore throats ✔✔ Inhaler treatment if wheezing Any general danger sign or Stridor in calm child.

CLASSIFY Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE Yellow: PNEUMONIA

IDENTIFY TREATMENT Give first dose of an appropriate antibiotic Refer URGENTLY to hospital**

Chest indrawing or Fast breathing.

Give oral Amoxicillin for 5 days*** If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** If chest indrawing in HIVexposed or infected child, give first dose of amoxicillin and refer to hospital. If coughing for more than 2 weeks or if having recurrent wheezing, refer for further assessment or consider TB or asthma Advise mother when to return immediately Follow-up in 3 days If wheezing (even if it disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days**** Soothe the throat and relieve the cough with a safe remedy If coughing for more than 2 weeks or if having recurrent wheezing, refer for assessment for TB or asthma Advise mother when to return immediately Follow-up in 5 days if not improving

No signs of pneumonia or very severe disease.

Green: COUGH OR COLD

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Follow along with your Chart Booklet TREAT THE CHILD section. This section of charts provides detailed instructions for providing each of these listed treatments.

HOW WILL YOU GIVE ORAL ANTIBIOTICS? It is important to review some general instructions on giving antibiotics with integrated management, as this is the first time you are learning about antibiotic use within IMCI. You will refer back to this information when later Modules discuss antibiotic treatment. You will see in your TREAT THE CHILD section that there are instructions for giving antibiotics for various classifications that require antibiotics. These are listed below. In this section you will learn about antibiotics for PNEUMONIA . n SEVERE PNEUMONIA OR VERY SEVERE DISEASE n PNEUMONIA n SEVERE DEHYDRATION with cholera in the area n DYSENTERY n VERY SEVERE FEBRILE DISEASE n SEVERE COMPLICATED MEASLES n MASTOIDITIS n ACUTE EAR INFECTION

HOW DO YOU SELECT THE APPROPRIATE ANTIBIOTIC? Many health facilities have more than one type of antibiotic. You must learn to select the most appropriate antibiotic for the child’s illness. Some important instructions for giving antibiotics include: n GIVING FIRST LINE: Give the “first-line” oral antibiotic if it is available. It has been chosen because it is effective, easy to give and inexpensive. n GIVING SECOND LINE: You should give the “second-line” antibiotic only if the first-line antibiotic is not available, or if the child’s illness does not respond to the first-line antibiotic. n ORAL ANTIBIOTICS: If the child is able to drink, give an oral antibiotic. The appropriate oral antibiotic for each illness varies by country. The antibiotics recommended in your country are on your TREAT THE CHILD chart.

INTEGRATED MANAGEMENT: GIVING ANTIBIOTICS n GIVE FIRST LINE antibiotics n GIVE SECOND LINE only if first line not available, or if child does not respond to first. n WHERE CHILD HAS TWO+ CLASSIFICATIONS REQUIRING ANTIBIOTICS treat with one antibiotic for both classifications if possible

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WHAT IF THE CHART IDENTIFIES MORE THAN ONE ILLNESS REQUIRING ANTIBIOTICS? MULTIPLE ILLNESSES, ONE ANTIBIOTIC: Sometimes one antibiotic can be given to treat more than one illness. For example, a child with DYSENTERY and ACUTE EAR INFECTION can be treated with a single antibiotic, co-trimoxazole, if the first-line antibiotic for an ACUTE EAR INFECTION (co-trimoxazole) is also a first- or second-line antibiotic for DYSENTERY. NOTE: when treating a child with more than one illness requiring the same antibiotic, do not double the size of each dose or give the antibiotic for a longer period of time. MULTIPLE ILLNESSES, MULTIPLE ANTIBIOTICS: Sometimes more than one antibiotic must be given to treat multiple health problems. For example, the antibiotics used to treat PNEUMONIA may not be effective against DYSENTERY in your country. Here, a child who needs treatment for DYSENTERY and PNEUMONIA must be treated with two antibiotics. How do you decide on the appropriate dosage? The TREAT THE CHILD chart has the schedule and dose for giving antibiotics. SCHEDULE tells you how many days and how many times each day to give the antibiotic. Most antibiotics should be given for 5 days. Only cholera cases receive antibiotics for 3 days. The number of times to give the antibiotic each day varies depending on the type of antibiotic. CORRECT DOSAGE of the antibiotic is determined by: 1. Identify the column of the type of tablets or syrup available in your clinic. 2. Choose the row for the child’s weight or age. Use weight over age. 3. The correct dose is listed at the intersection of the column and row.

AMOXICILLIN * AGE OR WEIGHT Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION

TABLET (250 mg) 1 2 3

SYRUP 250 mg/5 ml 5 ml 10 ml 15 ml

2 months up to 12 months (4 – <10 kg) 12 months up to 3 years (10 – <14 kg) 3 years up to 5 years (14 – 19 kg)

* Amoxicillin is now the first-line drug of choice i the treatment of pneumonia due to its efficacy and increasing high resistance to cotrimoxazole.

CRUSHING OR BREAKING TABLETS: If a tablet has to be crushed before it is given to a child, add a few drops of clean water and wait a minute or so. This softens the tablet to make it easier to crush.

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HOW ARE ANTIBIOTICS GIVEN FOR PNEUMONIA? If the child is classified as SEVERE PNEUMONIA , the first dose of the antibiotic should be given before urgent referral. If the classification is PNEUMONIA , you will give the first dose of oral amoxicillin in the clinic and teach the caregiver how to give the remaining 5 days of treatment at home. Amoxicillin is now the recommended first-line antibiotic to treat pneumonia due to its efficacy, and the increasing resistance to cotrimoxazole. Now that you have learned how to give oral antibiotics, you will examine other treatments required for cough or difficult breathing classifications.

HOW WILL YOU GIVE AN INHALER FOR WHEEZING? If the child has wheezing and will require an inhaler treatment in the clinic or at home, review the TREAT THE CHILD chart for inhaled salbutamol for wheezing. •• From salbutamol metered dose inhaler (100 μg/puff) give 2 puffs. •• Repeat up to 3 times every 15–20 minutes before classifying pneumonia. A spacer is a way of delivering the bronchodilator medicines effectively into the lungs. A spacer works as well as a nebuliser if correctly used. No child under 5 should be given an inhaler without a spacer. If commercial spacers are not available, spacers can be easily made with a drink bottle (500 ml) or something similar. Using a sharp knife, cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. Cut the bottle between the upper quarter and the lower ¾. Disregard the upper quarter of the bottle. Cut a small V in the border of the large open part of the bottle to fit to the child’s nose and be used as a mask. Flame the edge of the cut bottle with a candle or a lighter to soften it. In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. To use an inhaler with a spacer: ✔✔ Remove the inhaler cap. Shake the inhaler well. ✔✔ Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. ✔✔ The child should put the opening of the bottle into his mouth and breath in and out through the mouth. ✔✔ A carer then presses down the inhaler and sprays into the bottle while the child continues to breath normally. ✔✔ Wait for three to four breaths and repeat. ✔✔ For younger children place the cup over the child’s mouth and use as a spacer in the same way. ✔✔ If a spacer is being used for the first time, prime with 4-5 extra puffs from the inhaler.

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WHAT IS A SOOTHING REMEDY FOR THE THROAT? Find this chart in your TREAT charts. To soothe the throat or relieve a cough, use a safe remedy. Such remedies can be homemade, given at the clinic, or bought at a pharmacy. It is important that they are safe. Homemade remedies are as effective as those bought in a store. Your TREAT THE CHILD chart recommends safe, soothing remedies for children with a sore throat or cough. If the child is exclusively breastfed, do not give other drinks or remedies. Breastmilk is the best soothing remedy for an exclusively breastfed child. Harmful remedies may be used in your area. If so, they should be recorded in the box. Never use remedies that contain harmful ingredients, such as atropine, codeine or codeine derivatives, or alcohol. These items may sedate the child. They may interfere with the child’s feeding. They may also interfere with the child’s ability to cough up secretions from the lungs. Medicated nose drops (that is, nose drops that SOOTHING REMEDIES contain anything other than salt) should also SAFE HARMFUL not be used. When explaining how to give the safe remedy, it is not necessary to watch the mother practice giving the remedy to the child. Exact dosing is not important with this treatment. ✔ Breastmilk ✔ ✔ ✔ ✔ Atropine or codeine ✔ Alcohol ✔ ✔

DVD EXERCISE – CASE STUDY ‘BEN’ Watch ‘Case study Ben’ (disc 1). Watching this case is a great way to practice.

As you watch the video, complete the recording form below as you would a normal case. Does Ben present with any general danger signs? How do you classify? AN IMPORTANT NOTE: videos are used to show signs. The classification discussed at the end of the video may not be accurate due to recent technical updates.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)?

Yes __ No __

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

SELF-ASSESSMENT EXERCISE D Answer the following questions about the treatments you have read about.

1. Are these statements true or false? Circle your answer. a. You should give a child the first-line antibiotic, unless it is unavailable or the child has not responded to it. b. If a child has more than one illness that requires antibiotics, if possible, give one antibiotic for more than one illness. c. If a child can drink, it is preferable to give syrup antibiotics. d. If a child has two illnesses that require the same antibiotic, you should, just double the dosage or put the child on the treatment for 10 days instead of 5. 2. How often should you give amoxicillin for pneumonia? 3. What is the correct dosage for the following oral treatments? Refer to your dosage chart for pneumonia. Write out the medicine and concentration, and its dosage and schedule. a. Child is 3 months old, weighs 5 kg, and can drink. You have amoxicillin syrup in your clinic. b. Child is 9 months old, and you have amoxicillin tablets. c. Child is 13 months old, and 8 kg. She can drink. You have amoxicillin syrup in your clinic. d. Child is 4 years. You have amoxicillin tablets in the clinic. 4. What is meant by a “safe” remedy? Give an example. 5. Give at least 2 examples of remedies that are not safe. TRUE  FALSE

TRUE  FALSE TRUE FALSE

TRUE   FALSE

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n  Now you will return to Jacob. What treatments are identified? Review your classification table in your Chart Booklet. The TREATMENT column instructs on the appropriate treatment for each classification. You have classified Jacob’s problem as PNEUMONIA: The classification chart instructed that the correct treatments are: •• An oral antibiotic •• Soothe the throat and relieve the cough with a safe remedy •• Advise Amira when to return: 3 days for PNEUMONIA, or immediately if he worsens

n  How will you give Jacob the oral antibiotics? First, you prescribe amoxicillin in syrup form. Jacob is able to drink, so an oral antibiotic is given. Amoxicillin is an appropriate first-line in your clinic. Second, you must determine Jacob’s dosage. Jacob is 6 months old, and weighs 5 kg. What is the correct dosage? The chart determines that the correct dosage for Jacob is 5 ml of syrup (250 mg/5 ml), given twice a day for 5 days. AMOXICILLIN * Give two times daily for 5 days AGE OR WEIGHT 2 months up to 12 months (4 up to 10 kg) 12 months up to 5 years (10–19 kg) TABLET (250 mg) 1 2 SYRUP 250 mg/5ml 5 ml 10 ml

You also designate a safe remedy for cough in your area. Breast milk will be an important remedy for Jacob because he is breastfed. In the next section, you will learn more about how you will counsel Amira on why the antibiotic is important to treat Jacob’s pneumonia. You will counsel her on how she will give it in the home. You will also counsel her on giving the throat remedy. You will explain to Amira why the antibiotic is important to treat Jacob’s pneumonia.

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.6

COUNSEL THE CAREGIVER

WHY MUST YOU COUNSEL THE CAREGIVER? As you will remember from previous lessons, this is an important opportunity to counsel home treatment, feeding, care in the home, and when to return to the clinic. You will counsel the caregiver on all relevant treatment and health conditions after you have assessed, classified, and decided on treatment for all conditions.

AS A REVIEW, WHAT ARE GOOD COMMUNICATION SKILLS DURING COUNSELLING? For the full discussion on communication skills when using IMCI, refer back to your section on “Good communication and counselling skills” in INTRODUCTION PART 1. Quickly review these good skills that you have learned about. APAC PROCESS Used as you assess, classify, treat, and counsel:  ASK and LISTEN to find out what the child’s problems are and what the caregiver is already doing for the child.  PRAISE the caregiver for what she has done well.  ADVISE her how to care for her child at home.  CHECK the caregiver’s understanding, using checking questions THREE BASIC TEACHING STEPS For example, Jacob’s pneumonia requires oral antibiotic given at home. What should you remember as you teach Amira how to give this treatment? 1. GIVE INFORMATION – use words the caregiver understands, and focus on the most important messages 2. SHOW AN EXAMPLE – using familiar objects as teaching aids 3. LET HER PRACTICE – affirm, give feedback, and allow for more practice as needed

HOW WILL YOU COUNSEL A CAREGIVER ABOUT COUGH OR DIFFICULT BREATHING? There are several topics relevant to cough or difficult breathing. You will read more about these topics below. They include:  Giving oral antibiotics in the home  Giving soothing remedies in the home  How to use an inhaler if necessary for wheezing  When to return immediately  When to follow-up

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

GIVING ORAL MEDICINES AT HOME: Your TREAT THE CHILD charts include instructions for counselling a caregiver on giving oral medicines at home. The oral medicines listed on the chart are given for different reasons, in different doses and on different schedules. However, the way to give each drug is similar. Pneumonia requires antibiotics given at home. However, as this is the first time we are dealing with giving an oral drug, we will review the basic steps of teaching caregivers to give oral medicines. If a caregiver learns how to give a drug correctly, then the child will be treated properly. The important points to remember are:  DETERMINE APPROPRIATE MEDICINES & DOSAGE – for child’s weight and age  EXPLAIN TREATMENT – tell caregiver why you are giving the drug to the child  DEMONSTRATE how to measure a dose  LET HER PRACTICE- watch the caregiver practice measuring a dose by herself. Tell her what she has done correctly when she measures the dose, or crushes a tablet. If she measured the dose incorrectly, show her again how to measure it.  ASK CAREGIVER TO GIVE FIRST DOSE to the child  EXPLAIN DRUG CAREFULLY, THEN LABEL AND PACKAGE – Tell the mother how much of the drug to give her child. Tell her how many times per day to give the dose. Tell her when to give it (such as early morning, lunch, dinner, before going to bed) and for how many days. Write the information on a drug label. This is an example:

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

HOW DO YOU LABEL AND PACKAGE A DRUG? To write information on a drug label, be sure to write the instructions clearly so that a literate person is able to read and understand them: 1. Write the full name of the drug. 2. Write the total amount of tablets, capsules, or syrup to complete the course of treatment. 3. Write the daily dose and schedule. For example: ½ tablet twice daily for 5 days.  Write the correct dose for the patient to take. For example, the number of tablets, capsules, drops, or spoonfuls.  Write when to give the dose. For example, early morning, lunch, dinner, before going to bed. EXAMPLES OF DRUG LABELS:

Li, Jung Iron Syrup 1 / 4 tsp.

17-02-96 14 ml

Agar, MAnu Vitamin A

17-02-96 1 capsule

1 Give vitamin A capsule tomorrow

1 Give / 4 teaspoon one time per day

4. To package the drug, put the total amount of each drug into its own labelled drug container. Use clean containers. This could be an envelope, paper, tube, or bottle. It is important to keep medicines clean. After you have labelled and packaged the drug, give it to the mother.

TIPS FOR DRUG LABELS  REPEAT IF MORE THAN ONE DRUG – give, collect, count, and package each drug separately  EMPHASIZE COURSE OF TREATMENT – explain that all the tablets or syrup must be used to finish the course of treatment, even if the child gets better.

 CHECK CAREGIVER’S UNDERSTANDING – ask checking questions to make sure she understands how to treat her child. In some clinics, a drug dispenser has the task of teaching the caregiver to give treatment and checking the caregiver’s understanding. If this is your situation, teach the skills you are learning here to that dispenser.

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WHEN TO RETURN FOR FOLLOW-UP CARE: The TREATMENT column in your chart booklet designates how soon the child should return for follow-up. A child with PNEUMONIA Follow-up in 3 days

A child with COUGH OR COLD Follow-up in 5 days if not improving

WHEN TO RETURN IMMEDIATELY: You should always counsel the caregiver on looking for signs that they should bring the child immediately to the clinic. Turn to INTRODUCTION PART 2 to review these signs.

WHEN TO RETURN IMMEDIATELY Advise the caregiver to return immediately if the child has any of these signs: Any sick child If child has COUGH OR COLD ✔ Not able to drink or breastfeed ✔ Becomes sicker ✔ Develops a fever ✔ Fast breathing ✔ Difficult breathing

SELF-ASSESSMENT EXERCISE E Rewrite the following questions as good checking questions.

1. Do you remember when to give the amoxicillin?

2. Do you understand how much amoxicillin syrup to give your child?

3. Did the nurse explain to you how to use an inhaler?

4. Do you know how to make a remedy for the throat?

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SELF-ASSESSMENT EXERCISE F Review the case below on treating with antibiotics.

Nurse Aluka gives some oral antibiotics to a mother for her child, Maria Balana. Before he explains how to give them, Aluka asks the mother if she knows how to give her child the medicine. The mother nods her head yes. So Aluka gives her the antibiotics and says good-bye. 1. If a mother tells you that she already knows how to give a treatment, what should you do?

2. How would you fill out this drug label? You have classified the child’s respiratory condition as PNEUMONIA. Maria Balana is 4 months old. You have adult cotrimoxazole tablets (80/400 mg) in your clinic.

3. When should a child classified as COUGH OR COLD return immediately to the clinic?

4. When should they follow-up on the cough or cold?

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n  How will you counsel Amira about Jacob’s pneumonia? Amira hovers over you and asks what you have found. You explain to her what you have observed and what you think it means. You explain to Amira that Jacob is breathing faster than he normally should, and that you think he has pneumonia. Amira becomes very panicked and says that Jacob is going to die. She says that she must run home with him in case he dies away from home and her husband will be furious with her. You ask Amira to sit down and you try to calm her. You ask her why she is so afraid. She says it is because her other child died so young. You explain that pneumonia is an infection, but there is treatment for him to take. You will be able to give this treatment at home. You will teach her steps to care for the pneumonia at home.

n  How you will begin to explain treatment? You emphasize that it is really important that Jacob receives appropriate treatment for his pneumonia. Without treatment, he could become very ill. You reassure her that you will tell her all of the steps for the treatment Jacob needs. This will help ensure that Jacob will get better. Amira starts to settle and her face relaxes a little. However, she is still worried about Jacob and worried about her husband’s response. You explain to her that this infection can be treated but that it will take some time. She will need to give Jacob antibiotics on a regular basis. You also encourage Amira to bring Jacob’s father to the clinic if he wishes to have further questions answered. You encourage Amira to discuss these things with Jacob’s father and ask him to help with Jacob’s treatment.

n  As a reminder, you want to counsel Amira on these topics relevant to Jacob’s pneumonia:  Giving oral antibiotics in the home  Giving soothing remedies in the home  When to return immediately  When to return for follow-up

n  How will you teach Amira about home treatment? You have already identified that Jacob needs an oral antibiotic for 5 days. He will receive it twice a day. You will also teach Amira how to make and give a safe remedy for sore throat. You also explain to her that the medicine you are giving needs to be taken regularly. Explain that it will take a few days for Jacob to improve. Remind her that you must see Jacob again to watch his progress.

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

n  How will you explain antibiotic treatment? Jacob will get his first dose of antibiotic in the clinic. This provides a good teaching opportunity for you to instruct Amira on the correct way to give her son the antibiotic at home. You show Amira how to measure the correct dose of the syrup. You ask her to practice measuring it while you watch. Then, you ask her to give the first dose to Jacob in the clinic. You praise her for doing a good job. You give her a bottle of the syrup and remind her that she must give it to Jacob twice a day for the full 5 days. Even if Jacob gets better before the 5 days are up, she must continue the treatment. You label the syrup and give her the package.

n  What will you tell Amina about follow-up? You again praise her for being such a good mother and bringing in her sick child for treatment. You encourage her to continue breastfeeding, as that is the best way to soothe her son if his throat is sore. Then, you ask Amira to bring Jacob back in 3 days to check on his condition. You record this date on Jacob’s recording form. Then you will take Amira’s Mothers Card and review the signs that she should be aware of for immediate return to the clinic. Amira still seems fearful, but very reluctantly agrees with the plan that you have discussed together. She puts Jacob onto her back and walks off back to her village. You watch her go and wonder what will happen.

n  Now you will learn how to provide follow-up care for respiratory illnesses: A few days later you are sitting in your busy clinic room when you see Amira coming to the door. As she unbundles Jacob, you notice that this time her face is less fearful. You also see that her husband is with her, as he has decided to come to the clinic to talk with you. How will you provide care to Jacob? You will learn about follow-up for cough or difficult breathing in the next section.

34

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.7

PROVIDE FOLLOW-UP CARE FOR COUGH OR DIFFICULT BREATHING

REFRESH: WHAT ARE THE STEPS TO PROVIDING FOLLOW-UP CARE? During a follow-up visit, you will do two things.

FIRST, YOU ASSESS PREVIOUS CLASSIFICATIONS ✔ You will check the child for general danger signs. ✔ You will assess for cough or difficult breathing. You will ASK: 1. Is the child breathing slower than on his first visit? 2. Is there less fever? 3. Is the child eating better? ✔ You will assess if the child’s respiratory condition is:  IMPROVING  THE SAME  WORSENING

SECOND, YOU WILL USE IMCI TO FULLY RE-ASSESS THE CHILD Second, you will use IMCI to reassess the child using IMCI to see if there are any new issues. You will use a second recording form for this visit.

WHEN SHOULD A CHILD WITH COUGH OR DIFFICULT BREATHING RETURN FOR FOLLOW-UP? A child with PNEUMONIA should follow-up in 3 days. A child with COUGH OR COLD should follow-up in 5 days if not improving. You have read in the box above about what signs you will ask in the follow-up visit. You will use these to decide if the child is improving, worsening, or the same.  CHILD HAS A GENERAL DANGER SIGN The child is getting worse. This child needs urgent referral to a hospital.  CHEST INDRAWING OR BREATHING RATE, FEVER, AND EATING ARE SAME The signs may not be exactly the same as 3 days before – but the child is not worse, and not improving. This child needs urgent referral to a hospital.  CHILD IS BREATHING SLOWER AND WITHOUT CHEST INDRAWING, EATING BETTER, AND LESS FEVER The child is improving. The child may cough, but most children who are improving will no longer have fast breathing. The fever is lower or completely gone. What actions will you take? Tell the mother that the child should finish taking the 5 days of the antibiotic. Review with her the importance of finishing the entire 5 days.

35

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

n  How will you provide follow-up care for Jacob? Amira has returned to the clinic with her husband. Amira looks more relaxed. You welcome Amira and her husband and praise them for bringing Jacob back for a follow-up visit. Amira tells you that she has been giving her son his antibiotic regularly, as you discussed. Amira says that Jacob seems to be better. You check Jacob over and ask the appropriate questions for a pneumonia followup visit: •• Is Jacob breathing slower than on his first visit? •• Is there less fever? •• Is he eating better? You notice that Jacob is coughing much less. His breathing rate is now 40 breaths per minute. Amira says that he is eating better. He will take solid foods and is breastfeeding better now.

 THE CHILD IS BREATHING SLOWER AND EATING BETTER Jacob is improving. You tell his parents that he is much better. They are relieved and thank you for the help.

n  What actions will you take? You remind Amira that Jacob should finish taking 5 days of the antibiotic. Review with her the importance of finishing the entire 5 days. And again, praise the parents for their good care of Jacob.

REMEMBER! If child needs follow-up for more than one condition, they should come at the earliest definite follow-up.

36

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

SELF-ASSESSMENT EXERCISE G Read the following case study. Answer the questions about how you would manage the case. Refer to any of the case management charts as needed.

Pandit’s mother has brought him back for follow-up. He is one year old. Three days ago he was classified as having PNEUMONIA and you gave him amoxicillin. You ask how he is doing and if he has developed any new problems. His mother says that he is much better. 1. How would you reassess Pandit today? List all the signs you would look at and write the questions you would ask his mother.

When you assess Pandit, you find that he has no general danger signs. He is still coughing and he has now been coughing for about 10 days. He is breathing 38 breaths per minute and has no chest indrawing and no stridor. His mother said that he does not have fever. He is breastfeeding well and eating some food. He was refusing all food before. He was playing with his brother this morning. 2. Based on Pandit’s signs today, what actions will you take?

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.8

USING THIS MODULE IN YOUR CLINICAL PRACTICE

How will you begin to apply the knowledge you have gained from this module in managing children with cough or difficult breathing? In the coming days, you should focus on these key clinical skills and using your Chart Booklet and recording form. Practicing will help you better understand the clinical signs needed to assess and classify these children. ASSESS ✔✔ Ask caregivers if their children have a cough or difficult breathing, and for how long. Explain difficult breathing if they do not understand. ✔✔ Look at the children’s chests to identify difficult breathing. ✔✔ Count the number of breaths in one minute. Decide if it is fast breathing. ✔✔ Watch children’s chest walls. See how in normal children the chest wall and abdomen move out when the child breathes in. ✔✔ Identify chest indrawing – the lower chest wall moves in when child breathes in. ✔✔ Listen for the different noises of breathing – do you hear stridor or wheezing? CLASSIFY ✔✔ Use your chart booklet to classify the signs you identify in children ✔✔ Record your classifications and appropriate treatment on your recording form. TREAT ✔✔ Determine the appropriate treatment for a respiratory classification. ✔✔ Determine the correct type and dosage of antibiotic. ✔✔ Determine safe remedies in your area. COUNSEL ✔✔ Use the key communication skills (APAC, 3 teaching steps) as you counsel caregivers. ✔✔ Teach a caregiver how to give the antibiotic at home. ✔✔ Teach a caregiver about making or buying and giving a safe remedy for sore throat or cough. ✔✔ Counsel about when to return for follow-up on this respiratory condition. ✔✔ Counsel about when to return immediately. FOLLOW-UP ✔✔ Re-assess the child’s previous classification ✔✔ Determine how you will manage

Remember to use your logbook for MODULE 3: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.9

REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING COUGH OR DIFFICULT BREATHING? Before you began studying this module, you practiced your knowledge on with several questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. What clinical signs can help you identify if a child has pneumonia? a. Wet cough b. Fast breathing c. Runny nose 2. If a child has pneumonia, how will you treat? a. Oral antibiotics b. Honey c. Paracetamol 3. Why is it important to correctly identify and manage pneumonia? a. Pneumonia is very common, but it is not so serious for children b. Pneumonia is a major killer of children under 5 around the world, and it requires early management c. Children with pneumonia need to be isolated from all other family members 4. Chest indrawing is when: a. The lower ribs move in when the child breathes out b. The lower ribs move in when the child breathes in c. The lower ribs are always pushed in, no matter if the child is breathing in or out 5. Children who have a cough, but do not show signs of pneumonia, should immediately receive an antibiotic: a. TRUE b. FALSE 6. The following is a good checking question: “how will you prepare a safe home remedy for cough?” a. TRUE b. FALSE Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

3.10 ANSWER KEY NOTE: All video exercises discuss answers in the video.

REVIEW QUESTIONS QUESTION 1 2 3 4 5 6 ANSWER B A B B B A Did you miss the question? Return to this section to read and practice: INTRODUCTION, ASSESS TREAT INTRODUCTION ASSESS CLASSIFY, TREAT COUNSEL

EXERCISE A (ASSESS) 1. Fast breathing, chest indrawing. 2. Answers below a. b. c. d. 3 years, 36 breaths per minute 12 months, 50 breaths per minute 6 months, 45 breaths per minute 3 months, 57 breaths per minute NO YES NO YES

3. Answers below: a. ASK: does the child have cough or difficult breathing? b. LOOK: do you notice any issues with breathing? 4. Continue to the next assessment, for diarrhoea.

EXERCISE B (CLASSIFY) 1. Signs below are matched with the appropriate classification. SIGNS Sal is 9 months old and has a cough. You count 45 breaths per minute. No chest indrawing or stridor. Linus is 3 months old, and you could 65 breaths in one minute. When he breathes in, has had convulsions during current illness. Jojo is 3 years old. You count 56 breaths in one minute. No indrawing or stridor. CLASSIFICATION COUGH OR COLD SEVERE PNEUMONIA or VERY SEVERE DISEASE PNEUMONIA

2. Answers below. If the statement is false, a correct statement is provided. a. FALSE: You look for chest indrawing when the child breathes IN. b. TRUE c. TRUE d. FALSE: If a child shows no signs, they are classified as COUGH OR COLD. e. FALSE: A child with chest indrawing may not have fast breathing. f. TRUE

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

g. FALSE: Fast breathing in this age group 50 or more breaths per minute. h. TRUE i. TRUE j. FALSE: Classify as SEVERE PNEUMONIA OR VERY SERIOUS DISEASE. This child shows signs from two classifications. Fast breathing is a sign of PNEUMONIA (yellow). He also has a general danger sign (red classification). When a child presents with signs from different boxes, you always classify with the more severe.

EXERCISE C (GYATSU) 1. Form below:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Gyatsu Name: Age: 6 months Weight (kg): 5.5 kg Temperature (°C): 38 °C Ask: What are the child's problems? Cough ASSESS (Circle all signs present)

for 2 days

Initial Visit? ✓

Follow-up Visit? CLASSIFY General danger sign present? ✓ Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes ✓ __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

2 Days For how long? ___

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days 2. To classify Is there blood in the stool?

Count the breaths in one minute 58 breaths per minute. Fast breathing? ___ Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Pneumonia Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Look or feel for stiff neck Decide malaria risk: High ___ Low ___ No___ a. NO Look for runny nose For how long? ___ Days b. PNEUMONIA Look for signs of MEASLES: If more than 7 days, has fever been present every Generalized rash and day? One of these: cough, runny nose, or red eyes Has child had measels within the last 3 months? Look for any other cause of fever. EXERCISES D (TREATMENT) Do malaria test if NO general danger sign High risk: all fever1. cases Answers below: Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? a. TRUE Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea.

3. If he does not have the severe classification, look at the yellow (or middle) row.

Look at the childs general condition. Is the child: Gyatsu’s illness, look at the classification table for Lethargic or unconscious? Restless and breathing in your chart booklet. Look at irritable? the pink (or top) row. Look for sunken eyes. Offer the child fluid. Is the child: a. NO Not able to drink or drinking poorly? b. NO Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: c. NO Very slowsly (longer then 2 seconds)? Slowly?

cough or difficult

Yes __ No __

If the child has measles now or within the b. TRUE last 3 months: c. TRUE

DOES THE CHILD HAVE AN EAR PROBLEM?

d. FALSE

Is there ear pain? Look for pus draining from the ear 2. 5 days, 2 times a day Is there ear discharge? Feel for tender swelling behind the ear If Yes, for how3. long? ___ Days What is the correct dosage for the following oral treatments? Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Determine WFH/L _____ Zdays score. a day, for five AND ANAEMIA a. 5 ml (250 mg/5 ml), two times For children 6 months or older measure MUAC ____ mm. b. 1 tablet (250 mg), two times day, for five days Look a for palmar pallor. Severe pallor? Some palmar pallor? c. 10 ml (250 mg/5 ml), two times a palmar day, for five days Is there any medical complication? If child has MUAC less than 115 mm or d. 3 tablets (250 mg), two times a day, for sign? five days General danger WFH/L less than -3 Z scores or oedema of Any severe classification? both feet: Pneumonia with chest indrawing? 41 or older offer RUTF to eat. Is the child: For a child 6 months Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

Yes __ No __

CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE

NOT DONE/KNOWN

IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

4. Many safe remedies are locally specific and recorded in your chart booklet. Remedies can be homemade, given at clinic, or bought at pharmacy. Breast milk is best remedy for exclusively breastfed child – do not give other drinks or remedies. 5. Many unsafe remedies are locally specific and recorded in your chart booklet. Other harmful remedies contain atropine, codeine or codeine derivatives, or alcohol. These items may sedate the child. They may interfere with the child’s feeding. They may also interfere with the child’s ability to cough up secretions from the lungs. Medicated nose drops (that is, nose drops that contain anything other than salt) should also not be used.

EXERCISE E (COUNSEL) ANSWERS: questions should now be open-ended, and begin with how, what, why, when, where, or how. You should not be able to answer them ‘yes’ or ‘no’. Some examples are below, but you will have your own questions. 1. Do you remember when to give the amoxicillin? When will you give the amoxicillin? 2. Do you understand how much syrup to give your child? How much syrup will you give your child? 3. Did the nurse explain to you how to give an inhaler? How will you give the inhaler? 4. Do you know how to make a remedy for the throat? How will you make a remedy for the throat at home?

EXERCISE F (COUNSEL) 1. Ask the mother to show you how to measure the dosage, and tell you the schedule for the antibiotic. If she is incorrect, give her information, and demonstrate for her. If she does indeed know the information and measures the dosage correctly, ask her to give the first dose so you can observe.

Maria 05/02/03 Amoxicillin 10 tablets 1

Give 1 tablet, two times a day, for 5 days 2. They must return immediately if breathing becomes fast or difficult. 3. They should return for a follow-up visit in 5 days, only if the cough is not improving.

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IMCI DISTANCE LEARNING COURSE | MODULE 3. COUGH OR DIFFICULT BREATHING

EXERCISE G (PANDIT) 1. List all the signs you would look at and write the questions you would ask his mother: 1. Is he able to drink or breastfeed? 2. Does he vomit everything? 3. Has he had convulsions? 4. See if he is lethargic or unconscious. 5. Is he still coughing? How long has he been coughing? 6. Count the breaths in one minute. 7. Look for chest indrawing. 8. Look and listen for stridor. 9. Is he breathing slower? 10. Is there less fever? 11. Is he eating better? 2. Tell his mother that he is improving nicely. She should continue giving him the pills as she has been until they are all gone. You should ask her checking questions about how she has been giving the treatment. If you notice any issues, or she has any concerns and questions, address this.

43

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 2 The sick young infant

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n CONTENTS Acknowledgements 4 2.1 Module Overview 5 9 10 12 22 27 30 35 39 42 43 54 56 65 68 70 71 PART I. Assess, classify, and treat the sick young infant 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Introduction to sick young infant Assess a sick young infant for signs of serious disease Assess & classify jaundice Assess & classify diarrhoea in young infant Treat the young infant requiring urgent referral Treat the young infant not requiring urgent referral Provide follow-up care for the sick young infant

PART II. Feeding problems and counselling the caregiver 2.9 2.10 2.11 2.12 2.13 2.14 2.15 Assess feeding problems or low weight Check immunizations Counsel the caregiver on feeding Counsel the caregiver on infant care Using this module in your clinic Review questions Answer key

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2. 1

MODULE OVERVIEW

As you learned in your first face-to-face meeting, young infants up to 2 months of age have special characteristics that must be considered when classifying their health conditions.

MODULE LEARNING OBJECTIVES After you study this module, you will know how to: ✔✔ Assess a young infant for very severe disease and local bacterial infection ✔✔ Recognize the clinical signs for assessing jaundice ✔✔ Check for a feeding problem or low weight ✔✔ Assess breastfeeding ✔✔ Classify a young infant for very severe disease and local bacterial infection using IMCI charts ✔✔ Classify for jaundice and diarrhoea using IMCI charts ✔✔ Provide pre-referral treatment to a young infant with very severe disease ✔✔ Treat a young infant with oral or intramuscular antibiotics ✔✔ Teach correct positioning and attachment for breastfeeding ✔✔ Teach the mother how to express breast milk and feed the infant by a cup ✔✔ Teach the caregiver to treat local bacterial infections and thrush at home ✔✔ Give follow-up care for the sick young infant

MODULE ORGANIZATION: WHY IS THIS MODULE SPLIT INTO PARTS? Module 2 is a very large module because there is a lot to learn about care for the sick young infant. As such, the module is split into two parts. Each contains the following sections: PART I This part focuses on how to assess, classify, treat, and provide follow-up care for the young infant’s common symptoms. n SPECIAL CARE FOR YOUNG INFANTS n IMCI TOOLS FOR THE SICK YOUNG INFANT n ASSESS & CLASSIFY THE SICK YOUNG INFANT n TREAT THE SICK YOUNG INFANT n FOLLOW-UP PART II As infant feeding is such an important part of care, this part focuses on feeding and how to counsel the caregiver. n ASSESS & CLASSIFY FEEDING PROBLEMS OR LOW WEIGHT n COUNSEL THE CAREGIVER ON INFANT FEEDING n COUNSEL THE CAREGIVER ON INFANT CARE

5

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

WHAT DOES THE IMCI PROCESS LOOK LIKE FOR THE SICK YOUNG INFANT? You learned in your 1st face-to-face meeting that IMCI for the sick young infant follows the same major steps of the IMCI process for the sick child. However, IMCI for the sick young infant has some different signs and symptoms to assess. Some treatments are also age-appropriate. A flow chart for using IMCI for the sick young infant is below:

IMCI FOR THE SICK YOUNG INFANT (up to 2 months of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick young infant) ASK: what are the infant’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

ASSESS MAIN SYMPTOMS ASSESS FOR GENERAL DANGER SIGNS for very severe disease Even if present

•• •• •• •• •• ••

Jaundice Diarrhoea HIV status or mother’s HIV status Feeding problem and growth Check immunizations Assess other problems and mother’s health

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

WHAT JOB AIDS WILL YOU USE DURING THIS MODULE? You have two aids for using IMCI with the sick young infant: n IMCI CHART BOOKLET – YOUNG INFANT SECTION is an excellent reference tool. It provides instructions for assessing, classifying, and treating the sick young infant. It also includes instructions for counselling the caregiver and providing follow-up care.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n RECORDING FORM FOR SICK YOUNG INFANT follows the charts for the sick young infant. This form is below. It can also be found in your logbook.

WHAT RECORDING FORM IS USED FOR THIS MODULE? MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

7

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

BEFORE YOU BEGIN What do you know now about managing sick young infants? Before you begin studying this module, quickly practice your knowledge with the questions below. Do not look up the answers. This is for your own exercise. After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module! Circle one answer for each question. 1. Why do young infants require different care than sick children? a. Young infants are much quicker to recover from illness because they are young. b. Young infants show signs of illness differently. They can also become ill and die from an infection very quickly. c. Young infants very rarely get sick. 2. Which of the following is important care for a young infant? a. Keeping the infant loosely bundled so he can begin to move his arms and legs b. Keeping the umbilical cord moist so that it falls off quickly c. Keeping the infant warm through skin-to-skin care 3. What are the feeding recommendations for sick young infants? a. Exclusive, on-demand breastfeeding for at least 6 months b. Breastfeeding and additional sources of fluid, like water, to hydrate c. Soft complementary foods as soon as the child is ready 4. What are signs that a young infant is seriously ill and needs urgent referral and care? a. Breathing more than 60 breaths per minute b. Skin pustules c. Some jaundice, where the eyes are yellow but not the palms or soles 5. A young infant presents at your clinic, and his caregiver says the infant has been feeding well, but in the past 2 days is unable to breastfeed at all. What actions will you take? a. Counsel the caregiver on positioning and attachment so that the infant can breastfeed better. b. The infant is seriously ill if they are unable to feed. You must urgently refer. c. Recommend that the caregiver give other safe fluids by cup.

8

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

Assess, classify, and treat the sick young infant

PART I

9

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.2

INTRODUCTION TO SICK YOUNG INFANT

WHY ARE YOUNG INFANTS SPECIAL? Young infants differ from older infants and children in the ways they show signs of infection: n They become ill and die very quickly from serious bacterial infections. Severe infections are the most common serious illness during first 2 months of life. A young infant is a child up to 2 months of age.

If 2 months old or above, n Special risk for low birth weight infants: Infants she or he is considered under 2.5 kilograms at birth are low weight. Infections a sick child. are particularly dangerous in low birth weight infants. This means the infant had low weight at birth, due either to poor growth in the womb or to prematurity (being born early). n Infants often show only general signs when seriously ill, such as difficulty in feeding, reduced movements, fever or low body temperature. n Newborn infants are often sick from conditions related to labour and delivery. Newborns with any of these conditions require immediate attention. Some infants are premature, or born before 37 weeks of pregnancy. They may have trouble in breathing due to immature lungs. These conditions include birth asphyxia, birth trauma, preterm birth, and early-onset infections such as sepsis from premature ruptured membranes.

IMPORTANT! Young infants can become sick and die very quickly.

WHAT ARE YOUNG INFANTS’ SPECIAL CARE REQUIREMENTS? Young infants have important care requirements to protect them from infection during the first months of life. This care includes: •• EXCLUSIVE, ON-DEMAND BREASTFEEDING, which provides young infants with the nutrients and antibodies they require for healthy growth, development, and immune function •• KEEPING INFANTS WARM, particularly through methods like skin-to-skin contact •• MAINTAINING GOOD HYGIENE by washing hands every time before holding an infant, and keeping the umbilical cord area clean, which is vulnerable to infection •• IMMUNIZING a young infant on schedule •• SEEKING IMMEDIATE CARE IF THERE ARE SIGNS OF SEVERE DISEASE As you have learned, the IMCI process (ASSESS, CLASSIFY, TREAT) is the same for young infants and children. However, as infants have some special care requirements, they are assessed for specific symptoms and signs.

10

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

IMPORTANT CARE FOR YOUNG INFANTS n Exclusive breastfeeding n Keep warm n Keep umbilical cord clean n Wash hands before holding n Immunize on schedule

SELF-ASSESSMENT EXERCISE A Complete this exercise, and try not to look back at the material. Remember that you can check your answers to all of the self-assessment exercises at the end of the module.

1. Are these statements true or false? If they are false, write out the correct statement. a. Young infants are up to 2 months of age TRUE  FALSE b. Young infants have a different section of charts because they have a separate IMCI process that is entirely different from the process for the sick child. TRUE FALSE c. Severe infections are the most serious illness in the first two months of life d. Young infants and children are very similar in how they show signs of illness. TRUE  FALSE TRUE  FALSE

e. Sami is 2 months old. He is considered a sick young infant. TRUE  FALSE 2. You have learned that there is special care that is particularly important for young infants. Tick (✔ ) the measures below that are important care for infants.  Skin-to-skin contact (kangaroo care) to keep the infant warm  Give water regularly to keep infant hydrated  Seek care immediately if infant develops signs of serious illness  Change gowns before holding young infant  Exclusive, on-demand breastfeeding  Give all immunizations at birth, and never again  Give immunizations on schedule  Wash hands before handling the young infant  Rub the young infant with oils, lotion, or vasoline to keep skin moist

11

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.3

ASSESS A SICK YOUNG INFANT FOR SIGNS OF SERIOUS DISEASE

n  OPENING CASE – MIMI A young caregiver, Biya, comes into your clinic on Tuesday morning with her small young infant, a little girl named Mimi. Biya is very concerned because Mimi is her first child, and is very precious to the family. Mimi was born 6 weeks ago. Biya tells you that during the weekend she noticed Mimi was not taking the breast as often as she normally did. She got worried and wanted to take Mimi to the nearby health centre on Monday. Biya herself had an appointment scheduled for Tuesday for follow-up care on the pregnancy. Biya’s husband and caregiver told her to wait and take Mimi on Tuesday to the schedule appointment so that they do not have to pay for the transport twice. Biya is now very worried because she thinks Mimi is getting worse with the feeding.

HOW WILL YOU GREET BIYA WHEN SHE ENTERS THE CLINIC? Greeting the caregiver is an important first step in obtaining appropriate information about the sick infant, and why they are coming to the clinic. You will greet the caregiver and obtain the same information as you would with the sick child. First, this greeting helps to create a welcoming environment, and build trust with caregivers. You can review communication skills in INTRODUCTION PART 2: Introduction to IMCI. Second, it allows you to gather important information about the infant: ✔✔ ASK: what is the child’s name? ✔✔ ASK: how old is Mimi? This determines the charts to use. ✔✔ ASK: what is Mimi’s problem? Is this the first time you are coming to the clinic for this problem? ✔✔ MEASURE: Mimi’s weight and temperature, which will be used during the assessment. Next, you will assess Mimi for signs of severe disease or local infection. You will check every sick young infant for these signs. This is similar to checking every sick child for the general danger signs, which was discussed in Module 1.

12

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

WHEN DO YOU CHECK EVERY SICK YOUNG INFANT FOR SIGNS OF SEVERE DISEASE? The first part of your assessment is checking for signs of severe illness. Every sick young infant is checked for signs of very severe disease, especially a serious infection.

For ALL sick young infants – ask the caregiver about the infant’s problems, then ASSESS EVERY YOUNG INFANT FOR SIGNS OF SEVERE DISEASE AND LOCAL INFECTION

NO signs present

YES, one or more signs present Young infant requires urgent referral. Continue assessment quickly so referral is not delayed.

CONTINUE ASSESSMENT: assess for jaundice, diarrhoea, check HIV status, check feeding problems and low weight, check immunization status, and other problems

WHY DO YOU CHECK EVERY SICK YOUNG INFANT FOR SIGNS OF SEVERE DISEASE? Young infants can become sick and die very quickly from serious bacterial infections such as pneumonia, sepsis, and meningitis. The signs of very severe disease also identify young infants who have other serious conditions like severe birth asphyxia and complications of preterm birth. If you find a reason that a young infant needs urgent referral, you should complete the assessment quickly and refer the infant to the hospital.

13

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

$66(66 &/$66,)< $1' 75($7 7+( 6,& HOW WILL YOU ASSESS FOR SEVERE DISEASE AND $*(' 83 72 0217+ LOCAL INFECTION? When you assess by looking for signs of severe disease, you will ask questions of $6. 7+( 027+(5 :+$7 7+( <281* ,1)$17¶6 352%/(06 $5( the caregiver, andx also make your own observations. These are detailed in your 'HWHUPLQH LI WKLV LV DQ LQLWLDO RU IROORZ XS YLVLW IRU WKLV SUREOHP LI IROORZ XS YLVLW XVH WKH IROORZ XS LQVWUXFWLRQV ASSESS chart. Review your ASSESS chart for very severe disease and local bacterial infection. It includes the )25 instructions below. It is important to assess the signs in &+(&. 9(5< 6(9(5( ',6($6( $1' the order on/2&$/ the chart.%$&7(5,$/ The young infant should be calm. ,1)(&7,21 $6. x ,V WKH LQIDQW KDYLQJ x +DV WKH LQIDQW KDG FRQYXOVLRQV ILWV " GLIILFXOW\ LQ IHHGLQJ"

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ASK: IS YOUR BABY HAVING DIFFICULTY IN FEEDING? Any difficulty that the caregiver mentions is important. A young infant who was feeding well earlier but is not feeding well now may have a serious infection. A newborn that has not been able to feed since birth may be premature or may have complications such as birth asphyxia. These infants who are either not able to feed or are not feeding well should be referred urgently to hospital. The caregiver may also mention difficulties such as: her infant feeds too frequently (or not frequently enough), she does not have enough milk, her nipples are sore, or she has flat or inverted nipples. You will assess these difficulties later during breastfeeding assessment.

14

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

ASK: HAS YOUR BABY HAD CONVULSIONS [FITS]? Use words the caregiver understands. For example, the caregiver may know convulsions as “fits” or “spasms”. During a convulsion, the young infant’s arms and legs may become stiff. The infant may stop breathing and become blue. Many times there may only be rhythmic movements of a part of the body, such as rhythmic twitching of the mouth or blinking of eyes. The young infant may lose consciousness.

LOOK: DOES THE SICK INFANT HAVE FAST BREATHING? Count the breathing rate as you would in an older infant or young child. Young infants usually breathe faster than older infants and young children. The breathing rate of a healthy young infant is commonly more than 50 breaths per minute. Therefore, 60 breaths per minute or more is the cut-off used to identify fast breathing in a young infant. If the first count is 60 breaths or more, repeat the count. This is important because the breathing rate of a young infant is often irregular. The young infant will occasionally stop breathing for a few seconds, followed by a period of faster breathing. If the second count is also 60 breaths or more, the young infant has fast breathing.

Fast breathing in a sick young infant is 60 or more breaths per minute LOOK: DOES THE INFANT HAVE SEVERE CHEST INDRAWING? The infant has chest indrawing if the lower chest wall (lower ribs) goes IN when the infant breathes IN. Chest indrawing occurs when the infant needs to make a greater effort than normal to breathe in. In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the infant breathes IN. When chest indrawing is present, the lower chest wall goes IN when the infant breathes IN. Only severe chest indrawing is a serious sign in a young infant. Mild chest indrawing is normal in a young infant because the chest wall is soft. Severe chest indrawing is very deep and easy to see, and is a sign of pneumonia. For chest indrawing to be present, it must be visible and present all the time you are observing the infant. The child breathing in WITHOUT chest indrawing The child breathing in WITH chest indrawing

15

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

MEASURE TEMPERATURE OR FEEL THE INFANT: FEVER OR LOW BODY TEMPERATURE? The thresholds for fever in the YOUNG INFANT chart are based on axillary temperature. Axillary temperature is measured in the armpits. The thresholds for rectal temperature are approximately 0.5 °C higher. If you do not have a thermometer, feel the infant’s abdomen or armpit and determine if it feels hot or unusually cool. Fever is defined as 37.5 °C or above (axillary). Fever is uncommon in the first two months of life. If a young infant has fever, this may mean the infant has very severe disease. Fever may be the only sign of a serious bacterial infection. Low body temperature is below 35.5 °C (axillary). Young infants can also respond to infection by dropping their body temperature. This is called hypothermia.

What is FEVER = 37.5 °C or above What is LOW BODY TEMPERATURE= below 35.5 °C (axillary temperature)

LOOK AT THE UMBILICUS: IS IT RED OR DRAINING PUS? The umbilical cord usually separates one to two weeks after birth. The wound heals within 15 days. Redness of the end of the umbilicus, or pus draining from the umbilicus, is a sign of umbilical infection. Recognizing and treating an infected umbilicus early are essential to prevent sepsis.

LOOK FOR SKIN PUSTULES Skin pustules are red spots or blisters that contain pus. Examine the skin on the entire body. If you see pustules, is it just a few pustules or are there many? A severe pustule is large or has redness extending beyond the pustule. Many or severe pustules indicate a serious infection.

LOOK AT THE YOUNG INFANT’S MOVEMENTS Young infants often sleep most of the time, and this is not a sign of illness. Observe the infant’s movements while you do the assessment. If a young infant does not wake up during the assessment, ask the caregiver to wake him. An awake young infant will normally move his arms or legs or turn his head several times in a minute if you watch him closely. If the infant is awake but has no spontaneous movements, gently stimulate the young infant. If the infant moves only when stimulated and then stops moving, or does not move at all, it is a sign of severe disease. An infant who cannot be woken up even after stimulation should also be considered to have this sign.

16

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

Watch “Demonstration: assessment of sign young infant” (disc 2) This reviews all steps in assessing for serious disease or possible bacterial infection.

SELF-ASSESSMENT EXERCISE B Answer the questions below about assessing for signs of serious illness. Remember that an answer key for all self-assessment exercises is at the end of this module.

1. How many breaths per minute is fast breathing in an infant? 2. How do you decide if an infant has fast breathing? 3. How will you measure temperature in a young infant? 4. What temperature is a fever in a young infant? 5. What temperature is considered low body temperature? 6. Which of the following statements about signs of severe disease or bacterial infection are true? Which are false? Circle your answer. If false, write the correct statement. a. Chest indrawing is identified when an infant is breathing OUT. c. Any difficulty with feeding in an important issue for young infants. d. Only severe chest indrawing is a serious sign in infants, as mild chest indrawing is normal in young infants. TRUE  FALSE

b. A healthy umbilicus is often red, and sometimes drains pus. TRUE  FALSE

TRUE FALSE TRUE  FALSE

17

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n  How do you assess Mimi? Mimi weighs 3.1 kg, and when you ask, Biya tells you her birth weight was 3.5 kg. Mimi’s axillary temperature is 34.7 degrees Celsius. Biya tries several times to put Mimi on the breast but Mimi did not attach at all. Biya says that she has had no convulsions. You count 45 breaths per minute, and because Mimi did not exceed 60 breaths per minute, you do not need to repeat the count. You observe Mimi’s breathing, her lower chest wall moves in quite severely when Mimi breathes in. She does not have skin pustules. The umbilicus is not red or draining pus. When you move Mimi’s arm to stimulate her movements, Mimi drops the arm when you release it.

n  Does Mimi have any signs of serious illness? You recognize four serious signs in Mimi. 1. First, she is having difficulty breastfeeding. 2. Second, she has a low body temperature. Her temperature of 34.7 degrees is less than 35.5 degrees Celsius. 3. Third, you observe severe chest indrawing. 4. Fourth, you see that her movements are reduced.

n   How will you fill OF in Mimi’s recording form? MANAGEMENT THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present)

Mimi Age: 6 weeks Not breastfeeding well CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Weight (kg):

3.1

Initial Visit?

X

Temperature (°C): Follow-up Visit? CLASSIFY

34.7

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin)

45

at will the young infant's palms and soles. Are they yellow? You have recorded these signs on your form.Look You learn now about classifying these signs and identifying Look at the young infant's general condition. Does the infant: Yes ___ No ___ DOES THE YOUNG INFANT HAVE treatment. move only when stimulated? DIARRHOEA? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment

18

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

HOW WILL YOU CLASSIFY SIGNS OF SERIOUS ILLNESS IN A SICK YOUNG INFANT? Open you classification table for severe disease or local bacterial infection. You will observe that there are three classifications for the signs of serious disease or local infection:

1. VERY SEVERE DISEASE 2. LOCAL BACTERIAL INFECTION 3. SEVERE DISEASE OR LOCAL INFECTION UNLIKELY L BACTERIAL INFECTION Classify ALL YOUNG INFANTS Any one of the following signs Not feeding well or Convulsions or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or Fever (37.5°C* or above) or Low body temperature (less than 35.5°C*) or Movement only when stimulated or no movement at all. Umbilicus red or draining pus Skin pustules Pink: VERY SEVERE DISEASE Give first dose of intramuscular antibiotics Treat to prevent low blood sugar Refer URGENTLY to hospital ** Advise mother how to keep the infant warm on the way to the hospital

Yellow: LOCAL BACTERIAL INFECTION Green: SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

Give an appropriate oral antibiotic Teach the mother to treat local infections at home Advise mother to give home care for the young infant Follow up in 2 days Advise mother to give home care.

None of the signs of very severe disease or local bacterial infection

Now you will read more about the three classifications and the treatments identified for each.

What happens if you see signs from multiple classifications? When you find signs from different boxes, you always classify with the more severe classification. For example: You assess signs from RED and YELLOW ➞ classify RED You assess signs from YELLOW and GREEN ➞ classify YELLOW

REMEMBER! Colour-coded classifications tell where care to be given. RED = refer urgently YELLOW = treat in clinic

resholds for rectal temperature readings are approximately 0.5°C higher.

f Childhood Illness, Management of the sick young infant module, Annex 2 "Where referral is not possible".

Page 43 of 75 

GREEN = home treatment

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

VERY SEVERE DISEASE (RED) Remember that the presence of only one sign is enough to classify as very severe disease. A young infant with severe signs may have a serious disease and be at high risk of death. A young infant with any sign of very severe disease needs urgent referral to hospital. Before referral, give a first dose of intramuscular antibiotics. The infant may have complications of preterm birth (very low birth weight or birth asphyxia), or may have a serious infection. The serious infection may be pneumonia, sepsis or meningitis. It is difficult to distinguish between these conditions in a young infant. Fortunately, it is not necessary to make this distinction in order to make initial management decisions. What are your actions? Treat to prevent low blood sugar by giving breast milk or sugar water if it is not possible to give breast milk. If the young infant is not able to feed, give breast milk by nasogastric tube. Malaria is unusual in infants of this age, so no treatment is required for possible severe malaria. Advising the caregiver to keep her sick young infant warm is very important. Young infants have difficulty maintaining their body temperature. Low temperature alone can kill young infants. If one or more severe signs is present, classify as severe

LOCAL BACTERIAL INFECTION (YELLOW) Young infants with this classification typically have an infected umbilicus or a skin infection. What are your actions? Treatment includes giving an appropriate oral antibiotic at home for 5 days. The caregiver will treat the local infection at home and give home care. She should return for follow-up in 2 days to be sure the infection is improving. Bacterial infections can progress rapidly in young infants.

SEVERE DISEASE OR LOCAL INFECTION UNLIKELY (GREEN) Young infants with this classification have none of the signs of very severe disease and local bacterial infection. What are your actions? Advise the caregiver to give homecare to the young infant.

20

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n  How will you classify Mimi? You identified four serious signs when you assessed Mimi: difficulty feeding, low body temperature, severe chest indrawing, and reduced movements. Mimi shows at least one sign of serious disease. You will classify her as having very severe disease, the red Pink: VERY SEVERE DISEASE Give first dose of intramuscular antibiotics Treat to prevent low blood sugar Refer URGENTLY to hospital ** Advise mother how to keep the infant warm on the way to the hospital

L INFECTION classification that requires urgent referral. Any one of the following signs Not feeding well or Convulsions or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or Fever (37.5°C* or above) or Low body temperature (less than 35.5°C*) or Movement only when stimulated or no movement at all. Umbilicus red or draining pus Skin pustules

YOUNG

Yellow: LOCAL BACTERIAL INFECTION Green: SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

Give an appropriate oral antibiotic Teach the mother to treat local infections at home Advise mother to give home care for the young infant Follow up in 2 days Advise mother to give home care.

None of the signs of very severe disease or local bacterial infection

You will record this classification her recording form: MANAGEMENT OF THE on SICK YOUNG INFANT Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present)

AGED UP TO 2 MONTHS 3.1 Initial Visit?

Mimi Age: 6 weeks Not breastfeeding well CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Weight (kg):

X

Temperature (°C): Follow-up Visit? CLASSIFY

34.7

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin)

45

Very severe disease (red)

at the do young infant's palms and soles. Are they yellow? n  Mimi has a severe classification:Look what you do next? move only when stimulated? You learned earlier that if you find a reason that a young infant needs urgent referral, you should complete DIARRHOEA? not move even when stimulated? the assessment quickly and refer the infant to the hospital . Is the infant restless and irritable? the skin of the abdomen. Does it go back: You will continue to assess and classify MimiPinch for jaundice, diarrhoea, HIV status, feeding problem or low Very slowly? weight, and immunization status. However, you can postpone the breastfeeding assessment, as it takes some Slowly? THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT time. You can always continue this process after the infant’s most immediate problems have been resolved. If the infant has no indication to refer urgently to hospital Is the infant breastfed? Yes ___ No ___ Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush). Look for sunken eyes.

DOES THE YOUNG INFANT HAVE

Look at the young infant's general condition. Does the infant:

Yes ___ No ___

al temperature readings are approximately 0.5°C higher. Is there any difficulty feeding? Yes ___ No ___ Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

ness, Management ofIfthe young module, Annex 2 "Where referral is not possible". yes, sick how many timesinfant in 24 hours? ___ times

21

CHECKPage 43 of 75  FOR HIV INFECTION

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE Child's virological test: NEGATIVE

POSITIVE POSITIVE

NOT DONE/KNOWN NOT DONE

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.4

ASSESS & CLASSIFY JAUNDICE

Now that you have checked all young infants for signs of severe disease, you will continue your assessment. You will now assess for main symptoms. The first is jaundice. For ALL sick young infants – ask the caregiver about the infant’s problems, check for signs of serious disease or local infection, then: LOOK: IS THE INFANT JAUNDICED?

NO

YES Classify the jaundice using the colourcoded classification table for jaundice

CONTINUE ASSESSMENT: assess for diarrhoea, check HIV status, check feeding problems and low weight, check immunization status, and other problems

WHAT IS JAUNDICE? Jaundice is a yellow discoloration of skin in young infants. Many normal babies may have jaundice during the first week of life. This is common for small babies less than 2.5 kg at birth or born before 37 weeks gestation. This jaundice usually appears on the third or fourth day of life and occurs because the infant’s liver is not fully mature to eliminate the bilirubin formed in the body. This type of jaundice is mild and disappears before the age of two weeks in full term and by the age of three weeks in preterm babies. It does not need any treatment. However, some signs indicate severe jaundice that requires urgent care.

WHEN IS JAUNDICE NOT NORMAL, BUT SIGN OF A SEVERE PROBLEM? Jaundice that appears on the first day of life is always due to an underlying disease. Deep jaundice that extends to the palms and soles can be severe and requires urgent treatment. Jaundice that persists beyond the age of two weeks needs further investigation. If not treated, it may damage the young infant’s brain. Jaundice needs special attention when it: ✔✔ Appears within 24 hours of birth ✔✔ Remains beyond 2 weeks of age

22

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

HOW WILL YOU ASSESS FOR JAUNDICE IN A SICK YOUNG INFANT? When you assess for jaundice, you observe the child for yellow discoloration in the skin. Open to your ASSESS chart for jaundice. It contains these instructions for ASSESS that you will now read about below: CHECK FOR JAUNDICE If jaundice present, ASK: When did the jaundice appear first? LOOK AND FEEL: Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow?

CLASSIFY

JAUNDICE

Any jaun than 24 h Yellow pa any age

Jaundice 24 hours Palms an yellow

LOOK: FOR YELLOW SKIN It is important to look for jaundice in natural light. To look for jaundice, press the infant’s skin over the forehead with your fingers to blanch. Remove your fingers and look for yellow discoloration. If there is yellow discoloration, the infant has jaundice.

No jaund

LOOK: AT THE INFANT’S PALMS AND SOLES OF THE FEET THEN of ASK: Does the young infant have diarrhoea*? To assess for severity disease, repeat the above process on the hands and soles of the infant’s feet. Press the infant’s skin on palms and soles with your fingers. IF YES, LOOK AND FEEL: Remove your fingers andat look yellow discoloration. As before, yellow discoloration Look the for young infant's general condition: Infant's movements Classify is your indication that the infant has jaundice.

Does the infant move on his/her own? DIARRHOEA for DEHYDRATION Does the infant not move even when stimulated but then stops? APPEAR? ASK: WHEN DID JAUNDICE Does the infant not move at all? Remember that the timing of the jaundice, and the infant’s age, is very important Is the infant restless and irritable? for this assessment. Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Jaundice that appears on the (longer first day life is always due to an underlying Very slowly thanof 2 seconds)? disease. Deep jaundice that extends to the palms and soles can be severe and or slowly?

Two of the Movem stimula movem Sunke Skin p very s

requires urgent treatment. Jaundice that persists beyond the age of two weeks needs further investigation. If not treated, it may damage the young infant’s brain.

Two of the Restle Sunke Skin p slowly

Not enoug as some o dehydratio

* What is diarrhoea in a young infant? The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more wate

Page 44 of 

23

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

HOW WILL YOU CLASSIFY JAUNDICE IN A SICK YOUNG INFANT? Review your jaundice classification table in your Chart Booklet. What do you observe about the classifications and treatments? There are three classifications for jaundice: 1. SEVERE JAUNDICE 2. JAUNDICE 3. NO JAUNDICE Any jaundice if age less than 24 hours or Yellow palms and soles at any age Jaundice appearing after 24 hours of age and Palms and soles not yellow Pink: SEVERE JAUNDICE Yellow: JAUNDICE Treat to prevent low blood sugar Refer URGENTLY to hospital Advise mother how to keep the infant warm on the way to the hospital Advise the mother to give home care for the young infant Advise mother to return immediately if palms and soles appear yellow. If the young infant is older than 14 days, refer to a hospital for assessment Follow-up in 1 day Advise the mother to give home care for the young infant

LASSIFY

JAUNDICE

No jaundice

Green: NO JAUNDICE

?

SEVERE JAUNDICE (RED) A young infant who is less than 24 hours of age and has jaundice should be classified Two of the following signs: Any Pink: If infant no other severe classification: as SEVERE JAUNDICE. young infant who has has yellow palms and soles is also Movement only when Give fluid for severe dehydration (Plan C) SEVERE classified as having SEVEREDEHYDRATION jaundice. stimulated or no OR eyesactions? What Sunken are your movement at all

assify ARRHOEA for DEHYDRATION

If infant also has another severe classification: Refer URGENTLY to hospital with Skin pinch goes back mother frequent sips ofand ORS the on Before referral, forgiving low blood sugar, very slowly. the infant will require treatment the way caregiver will be advised on keeping the infant warm. Advise the mother to continue breastfeeding Yellow: Give fluid and breast milk for some dehydration (Plan B) SOME Sunken eyes infant has anyyellow severe classification: Young infants with jaundiceDEHYDRATION over 24 hours oldIfand without palms and soles Refer URGENTLY to hospital with Skin pinch goes back should be classified as having JAUNDICE. If an infant with JAUNDICE is older mother giving frequent sips of ORS on slowly. the way than 14 days, refer to a hospital for assessment . Advise the mother to continue breastfeeding What are your actions? Advise mother when to return immediately Follow-up in 2 days if not improving Two of the following signs: JAUNDICE (YELLOW) Restless and irritable

At the end of the assessment you will advise the caregiver on home care and when Not enough signs to classify Green: Give fluids to treat diarrhoea at home and to return immediately. as some or severe continue breastfeeding (Plan A) dehydration. NO DEHYDRATION

NO JAUNDICE (GREEN)

Advise mother when to return immediately Follow-up in 2 days if not improving

A young infant who has no jaundice gets the classification NO JAUNDICE. not diarrhoea.

al pattern and are many and watery (more water than fecal matter).

What are your actions? Page 44 of 75 

You will advise the caregiver on home care at the end of your assessment.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

SELF-ASSESSMENT EXERCISE C Answer the following questions about assessing and classifying jaundice.

1. Are these statements true or false? If false, write the statement out correctly. a. Jaundice is a yellow discolouration of the skin. b. Yellow soles and palms are normal in young infants. c. Many babies may have jaundice in the first week of life, especially if they are low birth weight or premature. d. Jaundice in a young infant less than 24 hours old is very serious. e. To assess for jaundice of the skin, soles, or palms, blanch the skin and look for discolouration. f. It is best to look for jaundice indoors under a lamp g. Jaundice that persists beyond 2 weeks requires further investigation. TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE  FALSE TRUE FALSE

2. Match the signs below with the correct classification. Each “signs” box should be matched with a classification. SIGNS a. Precious is 14 days old. Her skin is not discoloured. Her palms and soles are normal. b. Kai was born last night, less than 24 hours ago. His skin is very yellow. c. Sal is 2 weeks old. She has yellow discolouration of the skin and eyes. Her palms and soles are not yellow. CLASSIFICATION SEVERE JAUNDICE JAUNDICE NO JAUNDICE

3. Biki is 21 days old. He has yellow skin, but his palms and soles are not yellow. How would you classify Biki? What action would you take for Biki?

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n  How did you assess and classify Mimi for jaundice? When you press Mimi’s skin in the natural light, you see that it is yellow. When you examine her palms and soles, and compare the colour to her caregiver, you see they are also yellow. You ask Biva when this yellow colouring appeared. She says she did not really notice it, so she is not sure. Mimi shows a sign of SEVERE JAUNDICE, because her yellow palms and soles. This is a red classification, and will need to be referred urgently. Any jaundice if age less than 24 hours or Yellow palms and soles at any age Jaundice appearing after 24 hours of age and Palms and soles not yellow Pink: SEVERE JAUNDICE Yellow: JAUNDICE Treat to prevent low blood sugar Refer URGENTLY to hospital Advise mother how to keep the infant warm on the way to the hospital Advise the mother to give home care for the young infant Advise mother to return immediately if palms and soles appear yellow. If the young infant is older than 14 days, refer to a hospital for assessment Follow-up in 1 day Advise the mother to give home care for the young infant

DICE

No jaundice

Green: NO JAUNDICE

n  How will you assess and classify Mimi on your recording form? Name: Ask: What are the infant's problems?: Two(Circle of the following ASSESS all signs present) signs:

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Mimi Age: 6 weeks Weight (kg): 3.1 Temperature (°C): 34.7 Initial Visit? X Follow-up Visit? Not breastfeeding Pink: well CLASSIFY If infant has no other severe classification: CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Movement only when Give fluid for severe dehydration (Plan C) SEVERE Is the infant having difficulty in feeding? Count the breaths in one minute. 45 ___ breaths per minute stimulated or no OR DEHYDRATION Repeat if elevated: ___ Fast breathing? Has the infant had convulsions? Very severe Look for sever chest indrawing. movement at all If infant also has another severe disease Look and listen for grunting. (red) Look at the umbiculus. Isclassification: it red or draining pus? Sunken eyes Skin pinch goes back very slowly. THEN CHECK FOR JAUNDICE When did the jaundice appear first? Fever (temperature 38°C or above fells hot) or Refer URGENTLY to hospital with low body temperature (below 35.5°C or feels cool) mother giving frequent sips of ORS Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when the way stimulated?

HYDRATION

on

Look for jaundice (yellow eyesbreastfeeding or skin) Look at the young infant's palms and soles. Are they yellow? general condition. the infant: Yellow:Look at the young infant's Two of the following signs: Yes ___ No ___ DOES THE YOUNG INFANT HAVE Give fluid andDoes breast milk for some move only when stimulated? DIARRHOEA? Restless and irritable (Plan B) SOME not move even when dehydration stimulated? Is the infant restless and If irritable? Sunken eyes infant has any severe classification: DEHYDRATION Look for sunken eyes. Refer URGENTLY to hospital with Pinch the skin of the abdomen. Does it go back: Skin pinch goes back Very slowly? You have identified two RED classifications for Mimi: one for signs of severe disease and one for jaundice. mother giving frequent sips of ORS You on slowly. Slowly?

Advise the mother to continue

Not known

Severe jaundice (red)

n  This is a severe classification – what actions will you take?

know that you should continue the assessment quickly before you refer. the way THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT Determine weight for age. Low ___ Not low ___ mother to continue If the infant has no indication to refer urgently to hospital Advise the YouIs will make note of the identified pre-referral treatments for severe jaundice: Before you refer Mimi, Look for ulcers or white patches in the mouth (thrush). there any difficulty feeding? Yes ___ No ___ breastfeeding the infant breastfed? Yes ___ for No ___ you Is will need to treat her low blood sugar, and advise Biya on how to keep Mimi warm on the way to the If yes, how many times in 24 hours? ___ times Advise mother when to return immediately hospital with extra or skin-to-skin contact. Does the infant usuallyblankets receive any other foods or Follow-up in 2 days if not improving drinks? Yes ___ No ___ If yes, how often? Now you will move to the next main symptom, diarrhoea. Not do enough signs to classify Green: Give fluids to treat diarrhoea at home and What you use to feed the child? CHECK FOR HIV INFECTION as some or severe continue breastfeeding (Plan A) NO Note mother's and/or child's HIV status: dehydration. DEHYDRATION Advise mother when to return immediately Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Follow-up in 2 days if not improving Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis?

26

e many and watery (more than in fecal matter). Has the water infant breastfed the previous hour?

ASSESS BREASTFEEDING

If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.5

ASSESS & CLASSIFY DIARRHOEA IN YOUNG INFANT

YOU WILL LEARN ABOUT DIARRHOEA IN MODULE 4 You will learn about assessing and classifying for diarrhoea in Module 4. The assessment process is similar with the sick child. You can review this material now to be familiar with signs when you practice assessing a sick young infant in your clinic.

DVD EXERCISE – ASSESSING & CLASSIFYING GEMMA Watch “Case study – Gemma” on DVD disc 2 to assess and classify Gemma for signs of severe disease and local infection, and diarrhoea.

As you watch the video, use the recording form below to assess and classify. The video will review the classifications with you.

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively

27

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

SELF-ASSESSMENT EXERCISE D Complete the two case studies below. Read the case information, and complete the recording form as you greet, ask information, assess, and classify.

1. HENRI. Henri was born 6 hours ago at home. His weight is 3.0 kg. His axillary temperature is 36.5 °C. He is brought to the health facility because he did not cry immediately after birth and is having difficult breathing. The health worker first checks the young infant for signs of VERY SEVERE DISEASE and LOCAL BACTERIAL INFECTION. The father says that the young infant has not had convulsions and has not yet been fed. The health worker counts 74 breaths per minute. He repeats the count. The second count is 70 breaths per minute. He finds that the young infant has severe chest indrawing. The young infant moves only when he is stimulated. The umbilicus is normal, and there are no skin pustules. There is no jaundice. Henri does not have diarrhoea.

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively

28

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U

Return for next immunization on:

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2. SASHI. Sashi is 1 week old. Her weight is 3.4 kg. Her axillary temperature is 37 °C. Her caregiver brought her to the clinic because she has a rash. The health worker assesses for signs of very severe disease and local bacterial infection. Sashi’s caregiver says that there were no convulsions and that the infant is feeding well. Sashi’s breathing rate is 55 per minute. She has no chest indrawing. Her umbilicus is normal. The health worker examines her entire body and finds a red rash with a few skin pustules on her buttocks. She is awake and has spontaneous movements. She has neither jaundice nor diarrhoea.

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

29

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.6

TREAT THE YOUNG INFANT REQUIRING URGENT REFERRAL

HOW DO YOU KNOW WHEN A YOUNG INFANT REQUIRES URGENT REFERRAL? A young infant with any severe classification (RED) needs to be urgently referred.

IMCI FOR THE SICK YOUNG INFANT (up to 2 months of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick young infant) ASK: what are the infant’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

ASSESS MAIN SYMPTOMS ASSESS FOR GENERAL DANGER SIGNS for very severe disease Even if present

•• •• •• •• •• ••

Jaundice Diarrhoea HIV status or mother’s HIV status Feeding problem and growth Check immunizations Assess other problems and mother’s health

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

WHAT CLASSIFICATIONS REQUIRE URGENT REFERRAL OF A YOUNG INFANT? If the infant has any of the following classifications (RED) they require urgent referral: •• VERY SEVERE DISEASE •• SEVERE JAUNDICE •• SEVERE DEHYDR ATION in some cases: the infant with SEVERE DEHYDRATION needs rehydration with IV fluids. If you can give IV therapy, you can treat in clinic and do not need to refer. If you cannot give IV therapy

30

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

you must refer urgently. If the infant has SEVERE DEHYDRATION and another severe classification, they must be referred.

WHAT DOES THE YOUNG INFANT REQUIRE BEFORE REFERRAL? Before urgently referring a young infant to hospital, give all appropriate pre-referral treatments. Urgent pre-referral treatments are in bold print on the chart. Some treatments should not be given before referral because they are not urgently needed and would delay referral. For example, do not teach a caregiver how to treat a local infection before referral. Do not give immunizations before referral.

HOW DO YOU GIVE PRE-REFERRAL TREATMENTS? The TREAT THE YOUNG INFANT charts in your Chart Booklet include instructions on how to give the following pre-referral treatments: ✔✔ VERY SEVERE DISEASE: Give first dose of intramuscular antibiotics, treat to prevent low blood sugar, and teach caregiver how to keep child warm ✔✔ SEVERE JAUNDICE: give all pre-referral treatments as for VERY SEVERE DISEASE except the first dose of intramuscular antibiotics ✔✔ Give an appropriate oral antibiotic. If the infant needs an oral antibiotic for LOCAL BACTERIAL INFECTION and has not received intramuscular antibiotics, give a first dose of oral antibiotic before referral. ✔✔ SEVERE DEHYDRATION and VERY SEVERE DISEASE: teach caregiver to give frequent sips of ORS on the way, and advise caregiver to continue breastfeeding. Now you will read more about these pre-referral treatments.

How will you treat to prevent low blood sugar? Your treatment and instructions to the caregiver will depend if the infant is able to feed and swallow. If the infant is: 1. ABLE TO BREASTFEED, ask caregiver to breastfeed 2. UNABLE TO BREASTFEED, BUT ABLE TO SWALLOW ✔✔ Give 20–50 ml (10 ml/kg) expressed breast milk before departure ✔✔ If not possible, give 20–50 ml (10 ml/kg) sugar water (to make, dissolve 4 level teaspoons of sugar, or 20 grams, in a 200 ml cup of clean water) 3. UNABLE TO SWALLOW, give 20–50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube

REVIEW: TREAT TO PREVENT LOW BLOOD SUGAR ✔✔ Can breastfeed: ask caregiver to breastfeed ✔✔ Can’t breastfeed, but can swallow: give expressed breast milk or sugar water ✔✔ Can’t swallow: give expressed breast milk or sugar water by nasogastric tube

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

How will you give the first dose of intramuscular antibiotics? Young infants get two intramuscular antibiotics: 1. Gentamicin and 2. Ampicillin

WHY ARE TWO INTRAMUSCULAR ANTIBIOTICS GIVEN? Young infants with VERY SEVERE DISEASE are often infected with a broader range of bacteria than older infants. The combination of Gentamicin and Ampicillin is effective against this broader range of bacteria. Use the table in your Chart Booklet to find dose instructions.

HOW DO YOU USE GENTAMICIN? Read the vial of Gentamicin to determine its strength. Check whether it should be used undiluted or should be diluted with sterile water. When ready to use, the strength should be 10 mg/ml. Choose the dose from the row of the table that is closest to the infant’s age and weight.

HOW DO YOU USE AMPICILLIN? To use a vial of 250 mg Ampicillin, add 1.3 ml sterile water. This will give 250 mg TREAT AND COUNSEL per 1.5 ml solution. Choose the dose from the row of the table that is closest to the infant’s weight.

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

If you have a vial with a different amount of Gentamcin or Ampicillin, or if you use a different amount of sterile water than described here, the dosing table on the YOUNG INFANT chart will not be correct. In that situation, carefully follow the manufacturer’s Give First Dose of Intramuscular Antibiotics directions for adding sterile water and recalculate the doses. Give first dose of ampicillin intramuscularly and Give first dose of gentamicin intramuscularly. AMPICILLIN Dose: 50 mg per kg To a vial of 250 mg WEIGHT Add 1.3 ml sterile water = 250 mg/1.5ml 1-<1.5 kg 1.5-<2 kg 2-<2.5 kg 2.5-<3 kg 3-<3.5 kg 3.5-<4 kg 4-<4.5 kg 0.4 ml 0.5 ml 0.7 ml 0.8 ml 1.0 ml 1.1 ml 1.3 ml GENTAMICIN Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 sterile water to 2 ml vial containing 80 mg* = 8 ml at 10 mg/ml AGE <7 days AGE >= 7 days Dose: 5 mg per kg Dose: 7.5 mg per kg 0.6 ml* 0.9 ml* 0.9 ml* 1.3 ml* 1.1 ml* 1.7 ml* 1.4 ml* 2.0 ml* 1.6 ml* 2.4 ml* 1.9 ml* 2.8 ml* 2.1 ml* 3.2 ml*

* Avoid using undiluted 40 mg/ml gentamicin.

Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.

What if the caregiver is not going to take the infant to the hospital? If an infant with VERY SEVERE DISEASE cannot go to a hospital, it is possible to continue Page 49 of 75  treatment using these intramuscular antibiotics.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

How will you keep an infant warm? Keeping an infant warm is very important care during travel to the hospital. Advise the caregiver to provide skin to skin contact, or keep the infant covered as much as possible at all times. Dress with extra clothing – hat, gloves, socks – and wrap in a soft dry cloth and cover with a blanket. KEEP INFANT WARM ON WAY TO HOSPITAL ✔ Skin to skin contact ✔ Extra clothing or wrapping

Then you refer the young infant: There are some steps to follow as you prepare to refer. You can also refer to MODULE 1. 1. REFERRAL NOTE Prepare a referral note and explain to the caregiver the reason you are referring the infant. 2. TEACH ABOUT CARE Teach her anything she needs to do on the way, such as keeping the young infant warm, breastfeeding, and giving sips of ORS. 3. EXPLAIN IMPORTANCE, ESPECIALLY FOR YOUNG INFANTS In addition, explain that young infants are particularly vulnerable. When they are seriously ill, they need hospital care and need to receive it promptly. Many cultures have reasons NOT to take a young infant to hospital. If this is the case, you will have to address these reasons and explain that the infant’s illness can best be treated at the hospital. What if the caregiver is not going to take the infant to the hospital? If the caregiver is not going to take the infant to hospital, follow the guidelines: where referral is not possible, located in the Annex.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

n  How will you treat and refer Mimi? As you classified Mimi, you identified immediate pre-referral treatment for Mimi. These were the bold treatments in the classification charts: 1. Give first dose of intramuscular antibiotics ➞ for SEVERE DISEASE classification 2. Treat to prevent low blood sugar ➞ for SEVERE DISEASE and SEVERE JAUNDICE classifications 3. Advise caregiver to keep infant warm on way to hospital ➞ for SEVERE DISEASE and SEVERE JAUNDICE classifications

n  How will prepare Mimi’s intramuscular antibiotic? Mimi weighs 3.1 kg. You use the chart in your Chart Booklet to determine the appropriate antibiotic dosages for the given formulations: ✔✔ Ampicillin: 1.0 ml ✔✔ Gentamicin: 2.4 ml

n  Next, how will you treat Mimi to prevent low blood sugar? You use the instructions in your Chart Booklet to decide on this treatment. Mimi cannot breastfeed, but she can swallow. You ask Biya to express breast milk into a cup, and measure just over 30 ml to give Mimi. You should give 10 ml per kg, and Mimi weighs 3.1 kg. If Biya needed help on learning how to express breast milk, you have instructions for this counselling in the next sections. If Biya was unable to express breast milk, the other way you could treat Mimi’s low blood sugar is by giving the same amount (31 ml) of sugar water.

n  Next, how you will prepare Mimi to keep Biya warm? You also teach Biya how to keep Mimi warm on the way to the hospital. You ask Biya to put Mimi’s hat and socks on, and you show her how to rewrap the blanket to keep Mimi covered.

n  Finally, how you will prepare Mimi for referral? Finally, you prepare a referral note for Biya. You explain to Biya that Mimi needs to go to the hospital urgently to receive treatment for her severe signs, and so that she can begin feeding again. You ask Biya if her husband and caregiver will let her go to the hospital. She is worried that they will be upset about the transportation costs. However because Mimi stopped feeding today and is looking so serious, she thinks they will support her.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.7

TREAT THE YOUNG INFANT NOT REQUIRING URGENT REFERRAL

WHAT YOUNG INFANTS DO NOT REQUIRE REFERRAL? Yellow and green colour-coded classifications do not require referral. They can be treated in the clinic or home. In the sick young infant section of the chart booklet, the TREAT charts give instructions about treatment.

IMCI FOR THE SICK YOUNG INFANT (up to 2 months of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick young infant) ASK: what are the infant’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

ASSESS MAIN SYMPTOMS ASSESS FOR GENERAL DANGER SIGNS for very severe disease Even if present

•• •• •• •• •• ••

Jaundice Diarrhoea HIV status or mother’s HIV status Feeding problem and growth Check immunizations Assess other problems and mother’s health

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

HOW WILL YOU DETERMINE REQUIRED TREATMENTS? As you ASSESS and CLASSIFY, you will: 1. Record identified treatments for each classification, using your use recording form 2. After you complete the assessment, determine the integrated treatment 3. Provide necessary treatments in the clinic, as necessary 4. Advise the caregiver on home treatment, and when to return to the clinic

WHAT IS INCLUDED IN THESE TREATMENTS? You will learn more about the following treatments in this section: ✔✔ Oral antibiotics ✔✔ Treating local infections ✔✔ Treating dehydration and diarrhoea ✔✔ Managing jaundice

How do you determine an appropriate antibiotic treatment? Use the chart in your Chart Booklet to identify recommended antibiotic for local bacterial infection. When deciding on antibiotics: 1. Determine the appropriate local first and second line antibiotics 2. Determine the dose based on the young infant’s weight CO-TRIMOXAZOLE (trimethoprim/suphamethoxazole) Give two times daily for 5 days AGE or WEIGHT Birth to 1 month (under 4 kg) 1 to 2 months (4 to under 6 kg) a

AMOXICILLIN Give two times daily for 5 days SYRUP (40/200 mg) 1.25mla 2.5 ml TABLET (250 mg) 1/4 ½ SYRUP (125 mg/5 ml) 2.5 ml 5 ml

ADULT TABLET single strength (80/400 mg)

PEDIATRIC TABLET (20/100 mg) ½a

1/4

1

Avoid giving Cotrimoxazole to a young infant less than 1 month of age who is premature or jaundiced. Give this infant Amoxicillin instead.

HOW WILL YOU ADMINISTER ANTIBIOTIC TREATMENTS? You will give the first dose in the clinic. Then you will teach the caregiver how to continue the treatment at home. Follow the steps in the Chart Booklet for teaching a caregiver how to give an oral antibiotic at home. That is, teach her how to measure a single dose. Show her how to crush a tablet and mix it with breast milk. Guide her as needed to give the first dose, and teach her the schedule. Watch the caregiver and ask checking questions to be sure she knows how to give the antibiotic. We will learn more about good counselling skills in the next section.

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

How will you manage jaundice? Young infants with JAUNDICE need home care just like those without any problem. They do not need any medication. However, the caregiver needs to be counselled to return immediately if palms and soles appear to be yellow. Also, you should follow up infants with jaundice in 1 day to assess if jaundice is worsening. If the young infant is older than 14 days, refer to hospital for assessment.

What local infections can be treated at home? There are three types of local infections in a young infant that a caregiver can treat at home: ✔✔ An umbilicus which is red or draining pus, ✔✔ Skin pustules, or ✔✔ Oral thrush Twice each day, the caregiver should clean the infected area and then apply gentian violet. Half-strength gentian violet must be used in the mouth.

HOW DO YOU TEACH THE CAREGIVER TO TREAT LOCAL INFECTIONS AT HOME? Explain and demonstrate the treatment to the caregiver. Then watch her and guide her as needed while she gives the treatment. Remember to send supplies home with the caregiver. If the caregiver will treat skin pustules or umbilical infection, give her a bottle of full strength (0.5%) gentian violet. If the caregiver will treat thrush, give her a bottle of half-strength (0.25%) gentian violet. Discuss when the caregiver should return to the clinic. She should return for follow-up in 2 days, or sooner if the infection worsens. She should stop using gentian violet after 5 days. Ask her checking questions to be sure that she knows to give the treatment twice daily and when to return.

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SELF-ASSESSMENT EXERCISE E Return to Sashi and Henri’s recording forms that you used earlier in this module.

Review the classifications on the recording form, to remind you of the infant’s condition. You will now decide on treatments required. Refer to the YOUNG INFANT chart as needed. For each infant, decide how to answer the following questions. Write your complete answers below, including specific treatments (e.g. schedule, dosing). a. Should the infant be urgently referred? What pre-referral treatments are required? b. If the infant does not need to be urgently referred, write all recommended treatments and advice for the caregiver. 1. HENRI:

2. SASHI:

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2.8

PROVIDE FOLLOW-UP CARE FOR THE SICK YOUNG INFANT

WHY IS FOLLOW-UP CARE SO IMPORTANT FOR THE YOUNG INFANT? Follow-up visits are especially important for a young infant because they progress quickly in their illness. During a follow-up visit, you will do two things. 1. RE-ASSESS the conditions that you classified and treated during the initial visit. Are these conditions:

 Improving?  The same?  Worsening? 2. RE-ASSESS USING IMCI TO IDENTIFY NEW ISSUES, if there are any. You will use a second recording form for this visit.

WHEN SHOULD AN INFANT COME FOR A FOLLOW-UP VISIT? The time required for a follow-up visit is established for all conditions. You will record this follow-up date on the recording form and advise the caregiver. RETURN FOR FOLLOW-UP VISIT If the infant has… ✔ Jaundice ✔ Local bacterial infection ✔ Thrush ✔ Diarrhoea Return for first follow-up in… 1 day 2 days

WHERE ARE THE INSTRUCTIONS FOR FOLLOW-UP VISITS? Your Chart Booklet has charts with instructions for follow-up care for each condition. These charts follow the section on treatment. These instructions will re-assess by ASKING, LOOKING, FEELING, and LISTENING. You will now learn the instructions from these charts. As you read this section, follow along in your Chart Booklet.

LOCAL BACTERIAL INFECTION (follow-up 2 days) A young infant classified with local bacterial infection should return for follow up in 2 DAYS. At the follow-up, you will: ✔✔ LOOK at the umbilicus. Is it red or draining pus? ✔✔ LOOK for skin pustules. Are they less in number? Are they drying up?

 UMBILICUS PUS/REDNESS OR SKIN PUSTULES ARE IMPROVED Tell the caregiver to complete the 5 days of an antibiotic that she was given during the initial visit. Improved means there is less pus and redness has reduced.

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Similarly, if skin pustules have improved, which means they are less in number and are drying up, tell the caregiver to continue giving the antibiotic. Emphasize that it is important to continue giving the antibiotic even when the infant is improving. She should also continue treating the local infection at home for 5 days. This includes cleaning the area and applying gentian violet.

  UMBILICUS PUS/REDNESS OR SKIN PUSTULES ARE SAME OR WORSE The infant is not improving, or is getting worse. Refer the infant to hospital if skin pustules or umbilicus is the same or worse than before.

JAUNDICE (follow-up 1 day) An infant with jaundice should return in 1 DAY. During the follow-up visit: ✔✔ LOOK for jaundice – are palms and soles yellow?

 JAUNDICE HAS STARTED DECREASING Reassure the caregiver and ask her to continue home care. Ask her to return for follow-up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer the young infant to a hospital for further assessment.



JAUNDICE HAS NOT DECREASED, BUT PALMS & SOLES NOT YELLOW

Advise the caregiver on home care and ask her to return for follow up in 1 day.

 PALMS AND SOLES ARE YELLOW This child is getting worse. The child needs urgent referral to the hospital.

THRUSH (follow-up 2 days) When a young infant who had thrush returns for follow-up in 2 DAYS, you will: ✔✔ LOOK for ulcers or white patches in mouth (thrush) ✔✔ Reassess the infant’s feeding

  THRUSH IS BETTER OR SAME, AND THE INFANT IS FEEDING WELL Continue treatment with half-strength gentian violet. Stop using gentian violet after 5 days.

 THRUSH IS WORSE, OR PROBLEMS ATTACHING OR SUCKLING Refer to hospital. It is very important that the infant be treated so that he can resume good feeding as soon as possible.

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n  How will you provide follow-up care to Mimi? Now you will return to Mimi and her caregiver, Biya. You referred Mimi urgently for signs of severe disease, and for jaundice. Biya was very worried about Mimi, especially because she was not feeding. She assured you that she would take Mimi to the hospital.

n  So what happened to Mimi? Biya took Mimi to the nearby district hospital, and she was admitted to the newborn care ward. Mimi was given intravenous fluids and parenteral antibiotics. She was put in a warm room. After some time in the hospital, she started to suck well. Her body temperature returned to 37.0 degrees, which is safe for a young infant. Mimi was discharged after 5 days stay in the hospital. Two days later, Biya brought Mimi for her follow-up appointment at the clinic. How will you provide follow-up care to Mimi? How will you counsel Biya?

SELF-ASSESSMENT EXERCISE F You will return to Sashi’s case to discuss follow-up care for this infant.

Sashi is 1 week old. The health worker classified her as having LOCAL BACTERIAL INFECTION because she had some skin pustules on her buttocks. Her caregiver got pediatric tablets of cotrimoxazole to give at home, and learned how to clean the skin and apply gentian violet at home. She has returned for a follow-up visit after 2 days. Sashi has no new problems. At this clinic, local bacterial infections are treated with co-trimoxazole. 1. How would you reassess Sashi?

When you look at the skin of her buttocks, you see that there are fewer pustules and less redness. 2. What treatment does Sashi need now?

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Feeding problems and counselling the caregiver

PART II

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

2.9

ASSESS FEEDING PROBLEMS OR LOW WEIGHT

WHY IS FEEDING SO IMPORTANT FOR THE YOUNG INFANT? Adequate feeding is essential for the infant’s health, growth and development. Poor feeding during infancy increases the risk of infection and death. It also impairs growth and may have lifelong effects such as increasing the risk of poor development, or obesity.

WHEN DO YOU NEED TO ASSESS A YOUNG INFANT’S FEEDING? You will assess feeding in all young infants except those that have severe classifications. For ALL sick young infants - ask the caretaker about the infant’s problems, check for signs of serious disease or local infection, assess for jaundice and diarrhoea, then FOR ALL YOUNG INFANTS THAT DO NOT REQUIRE URGENT REFERRAL ASK: DOES THE INFANT HAVE ANY PROBLEMS FEEDING?

NO

YES 1. ASSESS & CLASSIFY feeding problems and low weight

CHECK immunization status and other problems. Assess the mother’s health.

WHY DO SOME YOUNG INFANTS HAVE FEEDING PROBLEMS? Some feeding and weight problems are associated with prematurity (born before 37 weeks of pregnancy), or low birth weight. A low birth weight baby (LBW) is small for gestational age. He did not grow well enough in the uterus during pregnancy. LBW babies are more likely to have breathing and feeding problems and develop infection and die than babies with a normal birth weight. LBW babies who survive are likely to have more medical and developmental problems than normal term babies. Some communities believe that these babies are born to die. As a health worker you have important role to change this belief and help caregivers and family members to provide the extra care the LBW baby needs.

LOW BIRTH WEIGHT = under 2500 grams (2.5 kg) VERY LOW BIRTH WEIGHT = under 1500 grans (1.5 kg)

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WHAT ARE CRITICAL FEEDING RECOMMENDATIONS FOR YOUNG INFANTS? The best way to feed a child from birth to 6 months is to breastfeed exclusively. There are two important things to emphasize about this breastfeeding: EXCLUSIVE BREASTFEEDING means that the child takes only breast milk and no additional food, water, or other fluids. Medicines and vitamins are exceptions. Exclusive breastfeeding reduces the risk of diarrhoea and pneumonia as well as the risk of mortality. BREASTFEEDING ON DEMAND means children at this age should receive breast milk as often as they want, day and night. This will be at least 8 times in 24 hours.

ALL INFANTS UP TO 6 MONTHS SHOULD BREASTFEED: n  EXCLUSIVELY: infant takes only breast milk and nothing else n  ON DEMAND: as often as they want, day and night n  AT LEAST 8 TIMES IN 24 HOURS

WHAT WILL YOU RECOMMEND TO A CAREGIVER WHO IS NOT BREASTFEEDING? If a child under 6 months old is receiving food or fluids other than breast milk, encourage and help the caregiver to gradually change back to more or exclusive breastfeeding. Suggest giving more frequent, longer breastfeeds, day and night. As breastfeeding increases, the caregiver should gradually reduce other milk or food. Since this is an important change in the child’s feeding, be sure to ask the caregiver to return for follow-up in 5 days. She will need your help and support. If the caregiver is HIV positive, she will need separate advice. This is discussed in your modules on feeding recommendations and HIV/AIDS.

HOW WILL YOU ASSESS FOR FEEDING PROBLEMS AND LOW WEIGHT? You will assess every young infant for feeding problems and low weight, except those who have severe classifications. The assessment has two parts. You will now learn about each part of the assessment:

ASSESS FOR FEEDING PROBLEM OR LOW WEIGHT

PART A:

IF INFANT HAS FEEDING PROBLEM OR BREASTFEEDS LESS THAN 8 TIMES IN 24 HOURS

ASSESS BREASTFEEDING

PART B:

HIV-exposed infants not breastfeeding have a separate assessment you will read later.

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MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present)

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT Age: Weight (kg): Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

Repeat if elevated: ___ Fast breathing? PART A. ASSESS FOR FEEDING Look for sever PROBLEM chest indrawing. OR LOW WEIGHT Look and listen for grunting. Look at the umbiculus. Is it red or draining pus?

Count the breaths in one minute. ___ breaths per minute

This first part of the assessmentFever (temperature 38°C or above fells hot) or will give you an overall picture of the infant’s feeding low body temperature (below 35.5°C or feels cool) and identify any issues. You will also determine if the infant is low weight for age. Look for skin pustules. Are there many or severe pustules?

WHO DO YOU THEN CHECK FOR JAUNDICE When did the jaundice appear first?

ASSESS FOR FEEDING PROBLEMS AND LOW WEIGHT? Look for jaundice (yellow eyes or skin) No ___

Movement only when stimulated or no movement even when stimulated?

Every sick young infant is assessed for feeding problems orAre low weight. Look at the young infant's palms and soles. they yellow? The only Look at the young infant's general condition. Does the infant: DOES THE YOUNG INFANT HAVE Yes ___ exception is young infants with move a severe classification. These infants should be only when stimulated? DIARRHOEA? not move even when stimulated? referred immediately.

LOCATE THIS ASSESSMENT ON YOUR RECORDING FORM: THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: this table for all young infants except HIV-exposed young infants not breastfed because their mother f Mother's HIV test: NEGATIVE Use POSITIVE NOT DONE/KNOWN mother has chosen Child's virological test: NEGATIVE the POSITIVE NOT DONE formula feeding. For these HIV-exposed non-breastfed young infants use the following Child's serological NEGATIVE POSITIVE NOT DONE the instructions in the ASSESS chart: NON-breastfed infants. Open test: to your chart booklet to review If mother is HIV positive and and NO positive virological test in young infant: If an infant has no indications to refer urgently to hospital: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Ask: LOOK, LISTEN, FEEL: Not well attached to

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE

HOW WILL YOU ASSESS?

CHECK THE ASK: CHILD'S (Circle immunizations ISIMMUNIZATION THERE ANYSTATUS DIFFICULTY FEEDING? needed today) BCG OPV-0 200,000 I.U vitamin A to Any difficulty that the caregiver mentions is important. This mother Ask about mother's own health counselling or specific help with a difficulty. OTHER PROBLEMS: DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1 Hep B 2

Has the infant breastfed in the previous hour?yes, how If the infant has in the previous hour, ask the mother to put her many times in not 24 fed Look Classify FEEDING for ulcers or white the in breastfeed for 4 minutes. hours? infant to the breast. Observe patches the mouth Is the infant able to attach? To check attachment, look for: Does the infant usually (thrush). Chin touching receive any other foods or breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ drinks? If yes, how often? Lower lip turned outward: Yes ___ No ___ If yes, what do you use to above than below the mouth: Yes ___ No ___ More areola feed the infant? not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively

Is the infant breastfed? If

Determine weight for age.

or Not suckling effectiv Less than 8 breastfe 24 hours or Receives other food drinks or Low weight for age Thrush (ulcers or w patches in mouth).

caregiver may

Return for next immunization on: ________________ need (Date)

ASSESS

If a caregiver says that the infant is not able to feed , you will assess breastfeeding or watch her try to feed the infant with a cup to see what she means by this. An infant who is not able to feed may have a serious infection or other lifethreatening problem and should be referred urgently to hospital.

ASK: IS THE INFANT BREASTFEEDING? HOW MANY TIMES IN THE LAST 24 HOURS? The recommendation is that the young infant be breastfed as often and for as long as the infant wants, day and night. This should be 8 or more times in 24 hours. ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (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 45 feed again.) Is the infant well attached? not well attached Chin touching breast good attachment TO CHECK ATTACHMENT, LOOK FOR: Page 71 of 75 

Not low weight for a no other signs of inadequate feeding.

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

ASK: DOES THE INFANT RECEIVE OTHER FOOD OR DRINKS? IF YES, HOW OFTEN? A young infant should be exclusively breastfed. Find out if the young infant is receiving any other foods or drinks such as other milk, juice, tea, thin porridge, dilute cereal, or even water. Ask how often he receives it and the amount. You need to know if the infant is mostly breastfed, or mostly fed on other foods.

DETERMINE WEIGHT FOR AGE Some young infants who are low weight for age were born with low birth weight. Some did not gain weight well after birth. Use a weight for age chart in the IMCI Chart Booklet. You will find the intersection of the lines for the child’s weight and age. You will determine if this point is considered low weight for age. IMPORTANT TIPS FOR YOUR WEIGHT-FOR-HEIGHT CHART: ✔✔ FIND THE LOW WEIGHT FOR AGE LINE: you will use this line to determine if young infants are low weight for age. Do not use the line for very low weight for age, which is used for older infants and children. ✔✔ AGES ARE IN WEEKS: because the young infant is under 2 months (8 weeks) old. The weight for age chart for children 2 months and older is labelled in months. ✔✔ SAME FOR BOYS AND GIRLS: The chart for young infants is the same for boys and girls. In older children there are separate charts for boys and girls.

EXAMPLE: A young infant is 6 weeks old and weighs 3 kg. Here is how the health worker checked if the infant was low weight for age:

1. Locate the infant’s weight: 3 kg

LOW WEIGHT FOR AGE LINE use for young infants

SUMMARY: The star is the point where the lines for age and weight meet. The point is BELOW the low weight for age line. THE INFANT IS LOW WEIGHT FOR AGE

2. Locate infant’s age: 6 weeks

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IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

LOOK FOR ULCERS OR THRUSH Young infants may also have ulcers or white patches in the mouth. It is important to treat these infections so that the young infant feeds well. Look for thrush. Look inside the mouth at the tongue and inside of the cheek. Thrush looks like milk curds on the inside of the cheek, or a thick white coating of the tongue. Try to wipe the white off. The white patches of thrush will remain.

SELF-ASSESSMENT EXERCISE G Practice assessing and classifying young infants for feeding problems.

1. What are three very important recommendations you will give to caregivers about the best way to feed a young infant from 0–6 months?

2. TRUE OR FALSE: a young infant with severe jaundice should be assessed for feeding problems and low weight. 3. Practice charting weight for age in young infants: WEIGHT a. 2.5 kg b. 3 kg c. 4 kg d. 3.2 kg e. 4.5 kg f. 3.3 kg AGE 1 month 2 weeks 8 weeks 4 weeks 3 weeks 2 weeks Is this infant low weight for age? YES NO

g. 3.1 kg 7 weeks

4. What is low birth weight? 5. What is very low birth weight? You have finished learning how to assess an infant for feeding problems. Now you will learn about part 2 of the assessment. This is an assessment of breastfeeding, when needed.

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THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: DOES THE YOUNG INFANT HAVE move only when stimulated? DIARRHOEA? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? You need to assess breastfeeding Slowly? if the infant:

Yes ___ No ___

PART B. ASSESS BREASTFEEDING

WHEN WILL YOU ASSESS HOW AN INFANT IS BREASTFEEDING?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

Determine weight for age. Low ___ Not low ___ If the infant has no indication referneed urgently to hospital ✔ ✔ Doesto not urgent referral Look for ulcers or white patches in the mouth (thrush). Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ ✔✔ Is feeding less than 8 times in 24 hours If yes, how many times in 24 hours? ___ times THEN Does the infant usually receive any other foods or CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE ✔✔No Mixed feeding: is Use taking other food or drinks drinks? Yes ___ ___ this table for all young infants except HIV-exposed young infants not breastfed because their mother follows the If yes, how often? the mother has chosen formula feeding. For these HIV-exposed non-breastfed young infants use the following table "THE What do you use the child? ✔✔ to Iffeed the caregiver’s answers indicate NON-breastfed infants. difficulty with breastfeeding

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or status: for age (remember that this is often due to low birthweight, and ✔✔ Ischild's low HIV weight Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Ask: LOOK, LISTEN, FEEL: Child's virological test: NEGATIVE POSITIVE NOTespecially DONE low birthweight infants are likely to have breastfeeding problems) Is the infant breastfed? Determine weight for age. Child's serological test: NEGATIVE POSITIVE NOT DONE If Classify FEEDING yes, how many timesinfant: in 24 Look for ulcers or white If mother is HIV positive and and NO positive virological test in young hours? patches in the mouth Is the infant breastfeeding now? Does the infant usually (thrush). Was the infant breastfeeding at the time of test or 6 weeks before it? receive any other foods or If breastfeeding: Is the mother and infant on ARV prophylaxis?

If an infant has no indications to refer urgently to hospital:

LOCATE THIS ASSESSMENT ON YOUR RECORDING FORM:

Has the infant breastfed in the previous hour?

drinks? If yes, how often? If yes, what do you use to If the infant has not fed in the previous hour, ask the mother to put her feed the infant?

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0

infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother

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).

Ye

ASSESS OTHER PROBLEMS:

HOW WILL YOU ASSESSAsk BREASTFEEDING? about mother's own health

DPT+HIB-1 OPV-1

DPT+HIB-2 OPV-2

Hep B 1

Return for next immunization on: ________________ (Date)

Assessing breastfeeding requires careful observation. Review your chart booklet. The ASSESS chart provides the following instructions: ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (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 well attached? not well attached good attachment TO CHECK ATTACHMENT, LOOK FOR: Chin touching breast Mouth wide open Lower lip turned outwards More areola visible above than below the mouth (All of these signs should be present if the attachment is good.) Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding. * Unless not breastfeeding because the mother is HIV positive.

Not low weight for age and no other signs of inadequate feeding.

G

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Now you will learn what to look for in this assessment.

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ASK: HAS THE INFANT BREASTFED IN THE PREVIOUS HOUR? IF YES, ask the caregiver to wait and tell you when the infant is willing to feed again. In the meantime, complete the assessment by checking the infant’s immunization status. You may also decide to begin any treatment that the infant needs, such as giving an antibiotic for local bacterial infection or ORS solution for some dehydration. IF INFANT HAS NOT BREASTFED IN PAST HOUR , he may be willing to breastfeed. Ask the caregiver to put her infant to the breast. Observe a whole breastfeed if possible, or observe for at least 4 minutes. Sit quietly and watch the infant breastfeed.

LOOK: IS THE INFANT ABLE TO ATTACH? You will look for four signs of good attachment to assess this. You will determine if the infant is well attached, not well attached, or not attaching at all.

WHAT ARE THE SIGNS OF GOOD ATTACHMENT ? The infant is well attached if you see all four signs of good attachment: 1. Chin touching breast, or very close 2. Mouth wide open 3. Lower lip turned outward 4. More areola visible above than below the mouth

Good attachment

Poor attachment

WHEN IS THE INFANT NOT WELL ATTACHED? The infant is not well attached if you see any of the four signs of poor attachment: 1. Chin not touching breast 2. Mouth not wide open, lips pushed forward 3. Lower lip turned in, or 4. More areola (or equal amount) visible below infant’s mouth than above it If a very sick infant cannot take the nipple into his mouth and keep it there to suck, he has no attachment at all, and is not able to breastfeed at all.

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WHAT HAPPENS IF AN INFANT IS NOT WELL ATTACHED? If an infant is not well attached, it may cause pain or damage to the nipples. Or the infant may not remove breast milk effectively, which may cause engorgement of the breast. The infant may be unsatisfied after breastfeeds and want to feed very often or for a very long time. The infant may get too little milk and not gain weight, or the breast milk may dry up. All these problems may improve if attachment can be improved.

SELF-ASSESSMENT EXERCISE H Circle the signs of good attachment. Cross-out the signs of poor attachment.

Chin away from breast More areola visible above than below mouth Narrow mouth with lips pushed forward Equal amount areola visible below/above mouth

Mouth wide open Lower lip turned outward Chin touching breast Lower lip turned in

LOOK TO SEE IF THE INFANT IS SUCKLING EFFECTIVELY The infant is suckling effectively if he suckles with slow deep sucks and sometimes pauses. You may see or hear the infant swallowing. If you can observe how the breastfeed finishes, look for signs that the infant is satisfied. If satisfied, the infant releases the breast spontaneously (that is, the caregiver does not cause the infant to stop breastfeeding in any way). The infant appears relaxed, sleepy, and loses interest in the breast. An infant is not suckling effectively if he is taking only rapid, shallow sucks. You may also see indrawing of the cheeks. You do not see or hear swallowing. The infant is not satisfied at the end of the feed, and may be restless. He may cry or try to suckle again, or continue to breastfeed for a long time. An infant who is not suckling at all is not able to suck breast milk into his mouth and swallow. Therefore he is not able to breastfeed at all. If a blocked nose seems to interfere with breastfeeding, clear the infant’s nose. Then check whether the infant can suckle more effectively.

SELF-ASSESSMENT EXERCISE I Match signs with how well the infant is suckling. a. Unable to suck breast milk. Nose is not blocked. b. Suckles deeply, sometimes pausing. Releases on own when satisfied. c. Rapid, shallow sucks. Cannot hear swallowing. Cheeks draw in. Restless. SUCKLING EFFECTIVELY NOT SUCKLING EFFECTIVELY NOT SUCKLING AT ALL

Watch “Demonstration: breastfeeding assessment” (disc 2) In this video you will see all steps in breastfeeding assessment, and examples of good attachment and suckling.

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HOW WILL YOU CLASSIFY FEEDING PROBLEMS & LOW WEIGHT? Open to your classification table for feeding problems and low weight. What do you observe? There are two possible classifications for feeding problem or low weight: 2. NO FEEDING PROBLEM (GREEN) 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). Yellow: FEEDING PROBLEM OR LOW WEIGHT If not well attached or not suckling effectively, teach correct positioning and attachment If not able to attach well immediately, teach the mother to express breast milk and feed by a cup If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. Advise the mother to breastfeed as often and as long as the infant wants, day and night If receiving other foods or drinks, counsel the 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 preparing breast-milk substitutes and using a cup Advise the mother how to feed and keep the low weight infant warm at home 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 Not low weight for age and no other signs of inadequate feeding. Green: NO FEEDING PROBLEM Advise mother to give home care for the young infant Praise the mother for feeding the infant well

W WEIGHT FOR AGE

d young infants not breastfed because their mother follows the national recommendations to avoid all breastfeeding or when 1. FEEDING PROBLEM or LOW WEIGHT (YELLOW) exposed non-breastfed young infants use the following table "THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in

ital:

Classify FEEDING

WHY IS NOT ABLE TO FEED NOT ON THIS CLASSIFICATION CHART? The first and most severe classification, NOT ABLE TO FEED, was assessed when you checked for signs of serious disease or possible local infection. As such, this classification is not included on the classification chart for feeding problem or low weight for age. If the infant was NOT ABLE TO FEED, it was a severe classification (RED) because this infant has a life-threatening problem. The infant requires the same urgent prereferral as SEVERE DISEASE, and then must be urgently referred.

.

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FEEDING PROBLEM OR LOW WEIGHT (YELLOW) The classification of is feeding problem or low weight includes infants who are low weight for age or infants who have some sign that their feeding needs improvement. They are likely to have more than one of these signs. What are your actions? Advise the caregiver of any young infant in this classification to breastfeed as often and for as long as the infant wants, day and night. Short breastfeeds are an important reason why an infant may not get enough breast milk. The infant should breastfeed until he is finished. Teach each caregiver about any specific help her infant needs, such as better positioning and attachment for breastfeeding, or treating thrush.

NO FEEDING PROBLEM (GREEN) A young infant classified as having no feeding problem is exclusively and frequently breastfed. Not low weight for age means that the infant’s weight for age is not below the line for “Low Weight for Age”. What are your actions? The infant’s caregiver may still require counselling on good feeding to ensure that the infant gains weight properly.

n  How did you assess and classify Mimi’s feeding? Biya breastfeeds Mimi. She explained earlier that she came to the clinic because Mimi had not been feeding well for the past few days, and since this morning she was not taking the breast at all. When you ask Biya to try and breastfeed, Mimi will not attach. This is a severe sign, as you classified earlier for SEVERE DISEASE (RED). You are not able to assess breastfeeding with Biya because Mimi will not take the breast. You checked Mimi for thrush and ulcers, and she has none.

n  Is Mimi low weight for her age? Mimi is 6 weeks old and weighs 3.1 kg. Biya has told you that she is at a lower weight now than she was at birth. Mimi is low weight for age, because her weight falls below the low weight for age line used for young infants.

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WHAT IF THE INFANT DOES NOT TAKE ANY BREAST MILK? If the infant takes no breast milk, you will skip the previous two-part assessment. You will instead complete a different assessment.

You will assess what the caregiver is feeding, and how. You will also use this chart when an HIV positive has chosen not to breastfeed. THEN caregiver CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE in NON-breastfed inf What does the ASSESS chart lookurgently like forto this assessment? indications to refer hospital:

Use this chart for HIV EXPOSED infants when the national authorities recommend to avoid all breast

LOOK, LISTEN, FEEL: Ask: What milk are you giving? Determine weight for age. How many times during Look for ulcers or white the day and night? patches in the mouth (thrush). How much is given at each feed? How are you preparing the milk? Let mother demonstrate or explain how a feed is prepared, and how it is given to the infant. Are you giving any breast milk at all? What foods and fluids in addition to replacement feeds is given? How is the milk being given? Cup or bottle? How are you cleaning the feeding utensils?

Classify FEEDING

Milk incorrec unhygienica

Giving inapp replacemen

Giving insuf replacemen

An HIV posi mixing brea feeds before

Using a feed

Low weight Thrush (ulc patches in m

Not low wei no other sig inadequate

W WEIGHT FOR AGE in NON-breastfed infants

onal authorities recommend to avoid all breastfeeding or when the mother has chosen formula feeding AND the infant has no

You will CLASSIFY with the following chart: Milk incorrectly or unhygienically prepared or Giving inappropriate replacement feeds or Giving insufficient replacement feeds or An HIV positive mother mixing breast and other feeds before 6 months or Using a feeding bottle 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. Green: NO FEEDING PROBLEM Yellow: FEEDING PROBLEM OR LOW WEIGHT Counsel about feeding Explain the guidelines for safe replacement feeding Identify concerns of mother and family about feeding. If mother is using a bottle, teach cup feeding Advise the mother how to feed and keep the low weight infant warm at home 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 Praise the mother for feeding the infant well

Classify FEEDING

Please refer to the HIV module for more information on assessing and classifying. The HIV module also contains information for counselling HIV-positive women on infant feeding.

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2.10 CHECK IMMUNIZATIONS WHY ARE IMMUNIZATIONS IMPORTANT? Immunizations help protect young infants from infections that can be especially dangerous at their young age. Health workers have an important responsibility to ensure that young infants are on schedule with their immunizations, and to counsel caregivers about the importance of immunizations on schedule. See Module 8 for more details.

HOW WILL YOU CHECK IMMUNIZATION STATUS? You will check immunization status by examining: ✔✔ Has the young infant received all the immunizations recommended for his age? ✔✔ Does the young infant need any immunizations today?

CK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN WHAT IMMUNIZATIONS ARE SCHEDULED FOR YOUNG INFANTS? The immunization schedule relevant for young infants includes:

HEDULE:

AGE Birth 6 weeks 10 weeks

VACCINE BCG DPT+HIB-1 DPT+HIB-2

OPV-0 OPV-1 OPV-2

Hepatitis B0 Hepatitis B1 Hepatitis B2

VITAMIN A 200 000 IU to the mother within 6 weeks of delivery

doses on this visit. Remember that you should not give OPV 0 to an infant who is more than 14 days old. ts unless being referred. Therefore, if an infant has not received OPV 0 by the time he is 15 days old, you should ker when to return for the next dose. wait to give OPV until he is 6 weeks old. Then give OPV 1 together with DPT 1. When included in the National Immunization schedule, give three doses of Hepatitis B and three doses of Haemophilus influenzae type b (Hib) vaccine; at 6 weeks, 10 weeks and 14 weeks, just like DPT.

OTHER PROBLEMS

HOW DO YOU MANAGE ANY REQUIRED IMMUNIZATIONS?

Administer any immunizations that the young infant needs today. Tell the caregiver when to bring the infant for the next immunizations, and record this on your recording form. If young infant is going to be referred, do not immunize before referral.

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SELF-ASSESSMENT EXERCISE J Decide if the infant needs any immunizations today, and which ones. AGE 16 days 7 weeks 4 weeks 8 weeks STATUS Received BCG Received DPT-1, HIB-1 Received BCG, OPV-0 What does the infant need today, if anything? How will you handle the case?

MANAGEMENT OF THE SICK INFANT AGED UP TO 2 MONTHS Received BCG, OPV-0.YOUNG Infant is Name: the infant's problems?: Ask: What are ASSESS (Circle all signs present)

being urgently referred today. Age:

Weight (kg):

Initial Visit?

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION FINALLY, YOU WILL ASSESS FOR OTHER PROBLEMS: Is the infant having difficulty in feeding? Has the infant had convulsions?

Temperature (°C): Follow-up Visit? CLASSIFY

Repeat if elevated: ___ Fast breathing? Assess any other problems that the caregiver mentions or that you observe. Refer to Look for sever chest indrawing. Look and listen for grunting. other guidelines on treatment of those problems. If you think the infant has a serious Look at the umbiculus. Is it red or draining pus? problem, or if you do not know Fever (temperature 38°C or above fells hot) or how to help the infant, refer the infant to hospital.

Count the breaths in one minute. ___ breaths per minute

WHAT WILL YOU ASK THE CAREGIVER ABOUT HER OWN HEALTH? THEN CHECK FOR JAUNDICE When did the jaundice appear first?

low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated?

This can provide valuable background information about the caregiver, the child’s Look for jaundice (yellow eyes or skin) Look at the youngThis infant's palms and soles. Are they yellow? you to better health status, and the household situation. information will allow Look at the young infant's general condition. Does the infant: DOES THE YOUNG INFANT HAVE Yes ___ No ___ move only when stimulated? counsel the caregiver. DIARRHOEA? Is the infant restless and irritable? Assessing a caregiver’s well-being should Look for sunken eyes. include the following: Very slowly? complications (e.g. infections, bleeding, ✔✔ Preventing and detecting postpartum Slowly? THEN CHECKanaemia) FOR FEEDING PROBLEM OR LOW WEIGHT Determine weight for age. Low ___ Not low ___ If the infant has indication to refer or urgently to hospital anaemia ✔no ✔ Preventing managing (iron and folic acid supplementation) Look for ulcers or white patches in the mouth (thrush). Is there any difficulty feeding? Yes ___ No ___ ✔ ✔ Providing information and counselling on nutrition, safe sex and family planning Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times ✔ ✔ Providing contraception Does the infant usually receive any other foods or drinks? Yes ___ No ___ ✔ ✔ Planning postnatal care, including advice on danger signs and emergency If yes, how often? What do you use to feed the child? preparedness CHECK FOR HIV INFECTION Note mother's child's HIV status: ✔✔and/or Promoting use of insecticide treated nets Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Pinch the skin of the abdomen. Does it go back: not move even when stimulated?

n  How will you manage immunizations for Mimi today? You have classified Mimi with several severe signs, and she requires urgent referral. ASSESS BREASTFEEDING Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her Mimi is due for her immunizations at 6 weeks: DPT-1 + HIB-1, OPV-1, and Hepatitis B1. You will not give Mimi infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able You to attach? To check attachment, for: these immunizations these immunizations now, because it will delay referral. will include a notelook about Chin touching breast: Yes ___ No ___ on her referral note so the staff can decide what to give her. Mouth wide open: Yes ___ No ___ More areola above than below for the mouth: Yes ___ No ___ Biya told you when she arrived that she had made an appointment her own post-natal care. Your first not well attached good attachment priority is to stabilize Mimi for severe signs, and then you will assess Biya’s health. The recording form gives Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? you space to make notes from this assessment. not sucking sucking effectively Lower lip turned outward: Yes ___ No ___

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1 Hep B 2 200,000 I.U vitamin A to mother

effectively

Return for next immunization on: ________________ (Date)

ASSESS OTHER PROBLEMS:

Ask about mother's own health

n  How will you fill out this section of Mimi’s recording form?

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2.11 COUNSEL THE CAREGIVER ON FEEDING REFRESH! In the introduction to these self-study modules, you learned some important communications skills when counselling caregivers. Refer to PART 1 of this book to review these good communications skills.

WHY IS COUNSELLING A CAREGIVER ABOUT THE YOUNG INFANT SO CRITICAL? Counselling the caregiver is a vital component of IMCI for the sick young infant. You learned at the beginning of this module that young infants have special characteristics, and require certain care for disease protection, healthy growth, and development. Families need to fully understand these important care measures.

WHAT ARE THE MOST IMPORTANT MESSAGES ABOUT THE YOUNG INFANT? ✔✔ BREASTFEED – caregivers should breastfeed exclusively and on demand ✔✔ KEEP INFANTS WARM – especially low weight infants ✔✔ WASH HANDS – before handling infants ✔✔ KEEP UMBILICAL CORD CLEAN ✔✔ BRING INFANT TO CLINIC IMMEDIATELY – if infant shows any signs of severe disease or local infection

You will learn how to counsel on breastfeeding in this section (2.2.3). In the next section (2.2.4) you will learn how to counsel on these other care measures.

HOW WILL YOU COUNSEL A CAREGIVER ABOUT FEEDING? Feeding is a very important topic to counsel the caregiver about. There are four particularly critical topics you must cover, including: 1. Correct positioning and attachment for breastfeeding 2. Expressing breast milk 3. Feeding by cup 4. Addressing other feeding problems You will read more about these four topics in the following pages.

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FEEDING #1 HOW WILL YOU TEACH CORRECT BREASTFEEDING POSITIONING AND ATTACHMENT? If the young infant is not correctly positioned or attached, they are not feeding optimally.

WHAT ARE THE REASONS FOR POOR ATTACHMENT OR INEFFECTIVE SUCKLING? There are several reasons that an infant may be poorly attached or not able to suckle effectively. Perhaps the infant was small and weak, or there was a delay starting to breastfeed. The child may have had bottle feeds, especially in the first few days after delivery. His caregiver may be inexperienced, or had some difficulty like flat nipples and nobody was there to help or advise her.

HOW WILL YOU TEACH A CAREGIVER TO IMPROVE POSITIONING AND ATTACHMENT? If in your assessment of breastfeeding you found any difficulty with attachment or suckling, help the caregiver position and attach her infant better. Make sure that the caregiver is comfortable and relaxed, for example, sitting on a low seat with her back straight. Then follow the steps in the box below.

TEACH CORRECT POSITIONING & ATTACHMENT FOR BREASTFEEDING Show her how to hold her infant: ✔✔ With the infant’s head and body in line ✔✔ With the infant approaching breast with nose opposite to the nipple ✔✔ With the infant held close to the caregiver’s body ✔✔ With the infant’s whole body supported, not just neck and shoulders Show her how to help the infant to attach. She should: ✔✔ Touch her infant’s lips with her nipple ✔✔ Wait until her infant’s mouth is opening wide ✔✔ Move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again.

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WHAT ARE GOOD PRACTICES WHEN OBSERVING A BREASTFEED? Always observe a caregiver breastfeeding before you help her, so that you understand her situation clearly. Do not rush to make her do something different. ENCOURAGE If you see that the caregiver needs help, first say something encouraging, like: “She really wants your breast milk, doesn’t she?” GIVE POSITIVE SUGGESTIONS Then explain what might help and ask if she would like you to show her. For example, say something like, “Breastfeeding might be more comfortable for you if your young infant took a larger mouthful of breast. Would you like me to show you how?” If she agrees, you can start to help her. DO NOT TAKE OVER As you show the caregiver how to position and attach the infant, be careful not to take over from her. Explain and demonstrate what you want her to do. Then let the caregiver position and attach the infant herself. CHECK & CORRECT Then look for signs of good attachment and effective suckling again. If the attachment or suckling is not good, ask the caregiver to remove the infant from her breast and to try again.

Infant ready to attach. Nose is opposite nipple, mouth is open wide.

ONCE THE INFANT IS WELL POSITIONED, WHAT INFORMATION IS IMPORTANT? When the infant is suckling well, explain to the caregiver that it is important to breastfeed long enough at each feed. She should not stop the breastfeeding before the infant wants to.

“Demonstration: teach correct positioning & attachment” (disc 2) This video shows examples of good and poor positioning, and instructions on how to show the caregiver how to position properly.

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Feeding #2 HOW WILL YOU TEACH A CAREGIVER TO EXPRESS BREAST MILK? All health workers who care for breastfeeding caregivers and young infants should be able to teach caregivers how to express their milk. Expressing breast milk is usually required for feeding infants who do not suck effectively, but can swallow well. This is often the case of low birth weight babies. Expressing milk is also useful to:

➞ Relieve engorgement, ➞ Feed a sick young infant who cannot suckle enough, ➞ Keep up the supply of breast milk when a caregiver or young infant is ill, or ➞ Leave breast milk for a young infant when his caregiver goes out or to work WHAT IS THE BEST WAY TO EXPRESS MILK? Hand expression is the most useful way to express milk. It needs no appliance, so a woman can do it anywhere, at any time. It is easy to hand express when the breasts are soft. It is more difficult when the breasts are engorged and tender. As such, teach a caregiver how to express her milk in the first or second day after delivery. Do not wait until the third day, when her breasts are full. Many caregivers are able to express plenty of breast milk using different techniques. If a caregiver’s technique works for her, let her continue to do it that way. But if a caregiver is having difficulty expressing enough milk, teach her a more effective technique.

HOW SHOULD YOU SHOW A WOMAN HOW TO EXPRESS? A woman should express her own breast milk. The breasts are easily hurt if another person tries. If you are showing a woman how to express, show her on your own body as much as possible, while she copies you. If you prefer not to use your own body, use a model breast, or practice on the soft part of your arm or cheek. If you need to touch her to show her exactly where to press her breast, be very gentle.

WHEN SHOULD A CAREGIVER START TO EXPRESS MILK? A caregiver should start to express milk on the first day, within six hours of delivery if possible. She may only express a few drops of colostrum at first, but it helps breast milk production to begin, in the same way that a young infant suckling soon after delivery helps breast milk production to begin. She should express as much as she can as often as her young infant would breastfeed. This should be at least every 3 hours, including during the night. If she expresses only a few times, or if there are long intervals between expressions, she may not be able to produce enough milk.

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WHAT IF A CAREGIVER IS EXPRESSING MORE THAN HER INFANT NEEDS? If a caregiver is expressing more than her low birth weight young infant needs, let her express the second half of the milk from each breast into a different container. Let her offer the second half of the expressed breast milk first. Her young infant gets more hind milk, which helps him to get the extra energy that he needs. This helps a young infant to grow better.

WHAT ARE THE STEPS FOR TEACHING HOW TO EXPRESS BREAST MILK? PREPARATIONS 1. Choose a cup, glass or jug with a wide mouth. Wash the cup in soap and water. Pour boiling water into the cup, and leave it for a few minutes. Boiling water will kill most of the germs. Pour water out of cup when ready to express milk. 2. Wash hands thoroughly 3. Get comfortable WHEN READY TO EXPRESS MILK 4. Hold a wide necked container under nipple and areola 5. Place thumb on top of the breast and the first finger on the underside of the breast so they are opposite each other (at least 4 cm from the tip of the nipple). See illustration below. 6. Compress and release the breast tissue between her finger and thumb a few times – see illustration below. If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before. 7. Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. See illustration below. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on the skin. 8. Express one breast until the milk just drips, then express other breast until the milk just drips. 9. Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes. Stop expressing when the milk no longer flows but drips from the start. EXPRESSING BREAST MILK BY HAND 1. Place thumb on top of breast, 2. Compress and release the breast tissue. 3. Compress and release all the way and first finger on underside. around the breast. Keep fingers the same distance from nipple.

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Feeding #3 HOW WILL YOU TEACH A CAREGIVER TO FEED BY CUP? If a young infant cannot breastfeed, he should be fed expressed breast milk by a cup. If the caregiver cannot or has chosen not to breastfeed, the infant should be fed a breast milk substitute by a cup.

TEACH THE CAREGIVER HOW TO FEED BY A CUP ✔✔ Put a cloth on the infant’s front to protect his clothes as some milk can spill ✔✔ Hold the infant semi-upright on the lap ✔✔ Put a measured amount of milk in the cup ✔✔ Hold the cup so that it rests lightly on the lower lip ✔✔ Tip the cup so that the milk just reaches the infant’s lips ✔✔ Allow the infant to take the milk himself. DO NOT pour the milk into the infant’s mouth.

WHY IS CUP FEEDING SAFER THAN BOTTLE FEEDING? ✔✔ Cups are easy to clean with soap and water, if boiling is not possible. ✔✔ Cups are less likely than bottles to be carried around for a long time, which gives bacteria time to breed ✔✔ A cup cannot be left beside a young infant, for the young infant to feed himself. The person who feeds a young infant by cup has to hold the young infant and look at him, and give him some of the contact that he needs. ✔✔ A cup does not interfere with suckling at the breast. ✔✔ A cup enables a young infant to control his own intake.

WHY IS CUP FEEDING PREFERABLE TO SPOON FEEDING? ➤ Spoon feeding takes longer ➤ Caregivers often find spoon feeding difficult, especially at night ➤ You need 3 hands to spoon feed: to hold the infant, the cup of milk, and the spoon ➤ Some caregivers give up spoon feeding before the young infant has had enough ➤ Some spoon-fed babies do not gain weight well. However, spoon feeding is safe if a caregiver prefers it, and if she gives the young infant enough. Also, if a young infant is very ill, for example with difficult breathing, it is sometimes easier to feed him with a spoon for a short time. SUMMARY OF FEEDING TIPS: Feeding from a cup is safer than a bottle. Cups are often easier to use than spoons, though spoons are safe.

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Feeding #4 WHEN WILL YOU COUNSEL A CAREGIVER ABOUT OTHER FEEDING PROBLEMS? ➤ If a caregiver is breastfeeding less than 8 times in 24 hours: Advise her to increase the frequency of breastfeeding. The caregiver should breastfeed as often and for as long as the infant wants, day and night. ➤ If the infant receives other foods or drinks: Counsel the caregiver about breastfeeding more, reducing the amount of the other foods or drinks, and if possible, stopping altogether. Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle. ➤ If a caregiver does not breastfeed at all: Consider referring her for breastfeeding counselling and possible relactation. If the caregiver is interested, a breastfeeding counsellor may be able to help her to overcome difficulties and begin breastfeeding again. Advise a caregiver who does not breastfeed about choosing and correctly preparing an appropriate breastmilk substitute. Also advise her to feed with a cup, and not a bottle.

SELF-ASSESSMENT EXERCISE K Practice what you have learned on counselling a caregiver about infant feeding.

1. Are the following statements TRUE or FALSE? a. Spoon feeding is not safe b. Cup feeding is the preferred method of feeding c. Bottle feeding is unsafe d. Cup feeding is preferred over spoon feeding e. Bottle feeding is most recommended for young infants to practice suckling TRUE  TRUE  TRUE  TRUE  FALSE FALSE FALSE FALSE

TRUE  FALSE

2. Srilekha is unsure how to hold her infant while breastfeeding. How will you show her how to hold?

3. Yoonhee is unsure how to help her infant attach. What should she do? 4. How frequently should a caregiver breastfeed in 24 hours? 5. Jaya breastfeeds but also gives her 4-month old some watery porridge. What do you recommend for her feeding?

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Follow-up WHEN SHOULD A CAREGIVER FOLLOW-UP ABOUT THESE FEEDING PROBLEMS? Young infants are asked to return sooner than older infants and young children. This is because they should be growing quickly, and are at higher risk if they do not gain weight. Quick follow-up is especially important if you are recommending a change in the way the infant is fed.

FEEDING PROBLEM OR THRUSH (FOLLOW-UP 2 DAYS) When a young infant who had a feeding problem returns for follow-up in 2 days: ✔✔ Refer to the young infant’s chart or follow-up note for a description of the feeding problem found at the initial visit and previous recommendations. ✔✔ ASK: how have you carried out these recommendations? Did you have problems? What actions will you take? Counsel the caregiver about new or continuing feeding problems. Refer to the recommendations in the box “Counsel the Caregiver About Feeding Problems” on the COUNSEL chart and the box “Teach Correct Positioning and Attachment for Breastfeeding” on the YOUNG INFANT chart. For example, you may have asked a caregiver to stop giving an infant water or juice in a bottle, and to breastfeed more frequently and for longer. You will assess how many times she is now breastfeeding in 24 hours and whether she has stopped giving the bottle. Then advise and encourage her as needed.

LOW WEIGHT FOR AGE (FOLLOW-UP 14 DAYS) When a young infant classified as low weight for age returns in 14 DAYS, you will: ✔✔ Determine if the young infant is still low weight for age. ✔✔ Reassess his feeding by asking the questions the ASSESS box. ✔✔ Assess breastfeeding if the young infant is breastfed.

 NO LONGER LOW WEIGHT Praise the caregiver for feeding the infant well. Encourage her to continue feeding the infant as she has been or with any additional improvements you have suggested.

  STILL LOW WEIGHT, BUT FEEDING WELL Praise the caregiver. Ask her to have her infant weighed again within a month or when she returns for immunization. You will want to check that the infant continues to feed well and continues gaining weight. Many young infants who were low birth weight will still be low weight for age, but will be feeding and gaining weight well.

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 STILL LOW WEIGHT, AND STILL HAS FEEDING PROBLEM Counsel the caregiver about the problem. Ask the caregiver to return with her infant again in 14 days. Continue to see the young infant every few weeks until you are sure he is feeding well and gaining weight regularly or is no longer low weight for age.

 LOST WEIGHT, NO WEIGHT GAIN IN 14 DAYS This young infant should be referred to the hospital. This is also the case if you think the problem will not improve.

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2.12 COUNSEL THE CAREGIVER ON INFANT CARE AFTER FEEDING, WHAT TOPICS WILL YOU DISCUSS WITH A CAREGIVER? You will advise a caregiver on other important care for infants. To review these topics: 1. Keeping an infant warm 2. Maintaining good hygiene 3. When to follow-up

Infant care #1 WHY IS IT IMPORTANT TO KEEP AN INFANT WARM AT HOME? It is important to maintain the body temperature of the newborn between 36.5 and 37.4 °C. Low temperature in the newborn has an adverse impact on the sick newborn and increases the risk of death. Low birth weight infants need greater attention to temperature care than those infants who do have not low birth weight.

WHAT ARE GOOD PRACTICES FOR KEEPING AN INFANT WARM? There are several practices you should advise: •• Keep the infant in her bed in a warm room – with room temperature at least 25oC •• Avoid bathing the low weight infant •• Keep the infant dry at all times •• Periodically feel the hands and feet of the infant to make sure that they are warm. Skin-to-skin contact is the best way to re-warm the infant if the hands and feet are cold, and to prevent the infant getting cold.

HOW DOES SKIN-TO-SKIN CONTACT WORK? Skin-to-skin contact can be provided by the caregiver or any adult. The adult body will transfer heat to the newborn. To keep the infant in skin-to-skin contact in the clinic, provide privacy to the caregiver and request her to sit or recline comfortably. 1. Undress infant gently, except for cap, nappy and socks. 2. Place infant against the caregiver’s bare chest in an upright and extended posture, between her breasts. 3. Turn infant’s head to one side to keep airways clear. 4. Cover the infant with caregiver’s blouse or gown. Then wrap caregiver-baby pair with an extra blanket or shawl. 5. Breastfeed the young infant frequently.

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If skin-to-skin contact is not possible, dress and wrap the young infant ensuring that head, hands and feet are also well covered. Hold the young infant close to the caregiver’s body, in a room warmed by a heating device. Ask the caregiver to breastfeed the young infant frequently.

Infant care #2 HOW WILL YOU COUNSEL ON GOOD HYGIENE CARE? There are two very important hygiene practices when caring for a young infant: n  WASH HANDS every time before handling the infant Counsel the caregiver on the importance of washing hands before handling the infant. Emphasize that everyone in the household who handles the young infant should follow this practice. Everyone in the household must also wash hands after going to the toilet. Demonstrate to the caregiver how to properly wash hands with soap and water. This should emphasize the correct length of time, and scrubbing nails. n  KEEP UMBILICAL CORD CLEAN Cleaning the umbilical cord and area around it is an essential care practice. This area is particularly vulnerable to infection in the first weeks of a young infant’s life. The cord must be kept clean and dry until the stump falls off. If rubbing alcohol is available, this may help keep the stump dry and hygienic. This alcohol is very dangerous to drink and families must be careful in storing it away. If rubbing alcohol is not available, the caregiver should use clean water and soap to gently clean. With good cord care, the umbilical cord usually separates one to two weeks after birth. The wound often heals within 15 days. Even if it appears to be about to fall, advise parents they should not remove the stump.

Infant care #3 HOW WILL YOU COUNSEL ON WHEN TO BRING THE INFANT BACK TO THE CLINIC? Tell the caregiver when to return for a follow-up visit and when to return immediately. These are different visits, so you must explain them fully to the caregiver. FOLLOW-UP VISIT is arranged to check on the conditions that you classified today. INFANT CLASSIFIED AS: ✔ Jaundice ✔ Local bacterial infection ✔ Feeding problem ✔ Low weight for age ✔ Thrush ✔ Diarrhoea RETURN FOR FOLLOW-UP VISIT IN: 1 day 2 days 14 days

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RETURNING IMMEDIATELY is required when young infant starts showing signs of serious illness. These signs are very important and caregivers should know them. RETURN IMMEDIATELY if the infant: ✔ Breastfeeds poorly ✔ Reduces activity ✔ Becomes sicker ✔ Develops a fever ✔ Feels unusually cold ✔ Is breathing fast or having difficulty breathing ✔ Difficult breathing ✔ Palms and soles appear yellow

Teach the caregiver about these signs. Use the caregiver’s card to explain the signs. Ask her checking questions to be sure she knows when to return immediately.

SELF-ASSESSMENT EXERCISE L In this exercise, you will use the case study SASHI from earlier in this module. Use Sashi’s recording form for this activity. Refer to the YOUNG INFANT chart as needed.

Review the infant’s assessment findings, classifications, and treatments needed. Answer the additional questions below about treating each case. 1. In addition to treatment with antibiotics, Sashi needs treatment at home for her local infection, that is, the pustules on her buttocks. List below the steps that her caregiver should take to treat the skin pustules at home.

2. How often should her caregiver treat the skin pustules?

3. Sashi also needs “home care for the young infant.” What are the 3 main points to advise the caregiver about home care?

4. What would you tell Sashi’s caregiver about when to return?

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2.13 USING THIS MODULE IN YOUR CLINIC HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE FROM THIS MODULE IN YOUR CLINIC? Use your Chart Booklet and IMCI recording forms for the sick young infant as you practice in the clinic. In the coming days, you should focus on the clinical skills below.

PART I GREETING ✔✔ Greet caregivers and use good communication skills to make them feel welcome ✔✔ Ask for important information from the caregiver: infant’s name, age, problems, history, temperature, and weight CHECK ALL YOUNG INFANTS FOR SIGNS OF SERIOUS ILLNESS ✔✔ Assess if the infant is having difficulty feeding ✔✔ Look for severe chest indrawing ✔✔ Count breathing – is the young infant breathing too fast? ✔✔ Look at the umbilicus for signs of infection ✔✔ Look for skin pustules ✔✔ Assess the young infant’s movements ✔✔ Determine if the young infant has had convulsions ASSESS & CLASSIFY THE SICK YOUNG INFANT ✔✔ Check all infants for jaundice, and assess and classify ✔✔ Check all infants for diarrhoea, and assess and classify TREAT THE SICK YOUNG INFANT ✔✔ Provide pre-referral treatments in classification tables and prepare referral notes ✔✔ Treat infants to prevent low blood sugar ✔✔ Provide antibiotics and care for local infections

PART II ASSESS & CLASSIFY THE SICK YOUNG INFANT ✔✔ Assess all infants for feeding problems and low weight, and classify ✔✔ Assess breastfeeding – look for signs of good attachment and positioning ✔✔ Check for immunizations ✔✔ Check for other problems, or any health problems the caregiver is having

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COUNSEL A CAREGIVER ON FEEDING ✔✔ Counsel a caregiver on correct positioning and attachment for breastfeeding ✔✔ Teach a caregiver to express breast milk ✔✔ Teach a caregiver to feed by cup ✔✔ Counsel a caregiver on other feeding problems COUNSEL ABOUT INFANT CARE ✔✔ Counsel about keeping an infant warm ✔✔ Show caregivers how to provide skin-to-skin care ✔✔ Counsel on hygiene and demonstrate good handwashing ✔✔ Counsel caregivers on when to return to the clinic for follow-up ✔✔ Counsel caregivers on the signs for immediate return to the clinic

Remember to use your logbook for MODULE 2: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

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2.14 REVIEW QUESTIONS AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING SICK YOUNG INFANTS? Before you began studying this module, you practiced your knowledge on with several multiple-choice questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. Why do young infants require different care than sick children? a. Young infants are much quicker to recover from illness because they are young. b. Young infants show signs of illness differently. They can also become ill and die from an infection very quickly. c. Young infants very rarely get sick. 2. Which of the following is important care for a young infant? a. Keeping the infant loosely bundled so he can begin to move his arms and legs b. Keeping the umbilical cord moist so that it falls off quickly c. Keeping the infant warm through skin-to-skin care 3. What are the feeding recommendations for sick young infants? a. Exclusive, on-demand breastfeeding for at least 6 months b. Breastfeeding and additional sources of fluid, like water, to hydrate c. Soft complementary foods as soon as the child is ready 4. What are signs that a young infant is seriously ill and needs urgent referral and care? a. Breathing more than 60 breaths per minute b. Skin pustules c. Some jaundice, where the eyes are yellow but not the palms or soles 5. A young infant presents at your clinic, and his caregiver says the infant has been feeding well, but in the past 2 days is unable to breastfeed at all. What actions will you take? a. Counsel the caregiver on positioning and attachment so that the infant can breastfeed better. b. The infant is seriously ill if they are unable to feed. You must urgently refer. c. Recommend that the caregiver give other safe fluids by cup. Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

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2.15 ANSWER KEY NOTE: All video exercises discuss answers in the video.

REVIEW QUESTIONS QUESTION 1 2 3 4 5 ANSWER B C B A B Did you miss the question? Return to this section to read and practice: PART I PART I II PART I PART II INTRODUCTION TO SICK YOUNG INFANT INTRODUCTION TO SICK YOUNG INFANT COUNSEL THE CAREGIVER ON FEEDING ASSESS & CLASSIFY FOR SIGNS OF SERIOUS DISEASE ASSESS & CLASSIFY FEEDING PROBLEMS OR LOW WEIGHT

EXERCISES PART I EXERCISE A 1. Are these statements true or false? If they are false, write out the correct statement. a. TRUE Young infants are up to 2 months of age. b. FALSE. Correct: The IMCI process is the same for both the sick young infant and the sick child. They require separate charts because some signs and symptoms are age-specific. c. TRUE Severe infections are the most serious illness in the first two months of life. d. FALSE. Correct:Young infants show signs of illness very differently than older infants or children. This is why they are assessed for different signs and symptoms. e. FALSE. Correct: Sami is a sick child. Young infants are up to 2 months, so this does not include a child that is 2 months old. 2. Correct special care measures: ➝ Skin-to-skin contact (kangaroo care) to keep the infant warm ➝ Seek care immediately if infant develops signs of serious illness ➝ Exclusive, on-demand breastfeeding ➝ Give immunizations on schedule ➝ Wash hands before handling the young infant

EXERCISE B 1. 60 breaths or more per minute, counted twice. 2. Make sure infant is calm. Count breathing. If over 60 breaths per minute, count a second time to confirm. 3. Taking axillary (armpit) temperature, feeling the infant, or rectal temperature (temperature thresholds are .5 degrees higher) 4. 37.5 or more degrees Celsius 5. Below 35.5 degrees Celsius

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6. If false, write the correct statement. a. FALSE Correct statement: Chest indrawing is identified when the infant breathes IN. In normal breathing, when the infant breathes IN, the abdomen and chest wall move out. With chest indrawing, the chest wall moves IN. b. FALSE Correct statement: If the umbilicus is red or draining pus, it is a sign of infection. c. TRUE d. TRUE

EXERCISE C 1. Answers below: a. T b. F c. T d. T e. T f. F g. T 2. Answers below: a. NO JAUNDICE (GREEN) b. SEVERE JAUNDICE (RED) c. JAUNDICE (YELLOW) 3. Biki has jaundice after 14 days of life. He should be referred for assessment.

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Henri Name: Age: 6 hours Weight (kg): 3.0 Temperature (°C): 36.5 Ask: What are the infant's problems?: ASSESS (Circle all signs present)

EXERCISE D 1. Henri:

Difficult breathing, did not cry after birth 70

Initial Visit?

✗

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

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Very severe disease (red)

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

✗

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

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Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant:

IMCI DISTANCE LEARNING COURSE | MODULE 2. THE SICK YOUNG INFANT

MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Sashi Name: Age: 1 week Weight (kg): 3.4 Temperature (°C): 37 Ask: What are the infant's problems?: ASSESS (Circle all signs present)

2. Sashi:

Rash Is the infant having difficulty in feeding? Has the infant had convulsions?

Initial Visit?

✗

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Follow-up Visit? CLASSIFY

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly?

55

Local infection (yellow)

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

✗

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

Determine weight for age. Low ___ Not low ___ If the infant has no indication to refer urgently to hospital Look for ulcers or white patches in the mouth (thrush). Is there any difficulty feeding? E Yes ___ No ___ EXERCISE Is the infant breastfed? Yes ___ No ___ If yes, how many in 24 hours? ___ times 1. times HENRI: Henri must be urgently referred. You classified him as VERY SEVERE DISEASE. Does the infant usually receive any other foods or He drinks? Yes ___ No ___requires the following pre-referral treatments: If yes, how often? What do you use to feed the child? ✔ ✔ First dose of intramuscular antibiotics: AMPICILLIN 1.0 ml and GENTAMICIN 1.6 ml

CHECK FOR HIV INFECTION

referred. She requires the following treatments: ASSESS BREASTFEEDING Has the infant breastfed in the previous hour?

Note mother's and/or child's HIV to status: ✔ ✔ Treat prevent low blood sugar (you will need to determine if he can breastfeed Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN or swallow) Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE ✔✔ Advise caregiver how to keep Henri If mother is HIV positive and and NO positive virological test in young infant:warm on way to hospital Is the infant breastfeeding now? Was the infant at the time of test or 6 weeks before it? 2. breastfeeding SASHIE: Sashie was classified LOCAL INFECTION. She does not need to be urgently If breastfeeding: Is the mother and infant on ARV prophylaxis? the infant has not fed in the previous hour, ask the mother to put her ✔✔ Give an oral antibiotic,If and preferably syrup so that she drink it. If you have infant to the breast. Observe the breastfeed for can 4 minutes. Is the infant able to attach? To check attachment, look for: COTRIMOXAZOLE, she will require 1.25 ml syrup, twice a day for 5 days. If you Chin touching breast: Yes ___ No ___ have AMOXICILLIN, she will Mouth require 2.5 ml syrup, twice a day for 5 days. wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___

✔✔ You will give the first dose in the clinic and counsel the caregiver how to More areola above thanthen below the mouth: Yes ___ No ___ not well attached good attachment give the remaining dosesIs –the twice a day for 5 days. You will teach her how to give infant sucking effectively (that is, slow deep sucks, sometimes pausing)? (GIVE INFORMATION, SHOW HER HOW TO DO IT AS YOU GIVE THE FIRST DOSE, not sucking sucking effectively AND ASK HER TO SHOW YOU HOW SHE WILL DO IT). You will confirm that she effectively CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next understands by using checking questions. BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U

________________ vitamin A to ✔✔ You will OPV-2 teach the caregiver how to treat the skin pustules. She should do the (Date) mother treatment twice a day for days. Sheown will: wash hands, gently wash the pus and Ask 5 about mother's health ASSESS OTHER PROBLEMS: crusts with soap and water, dry the area, paint the skin with gentian violet (.5%), and then wash her hands again.

immunization on:

✔✔ You will counsel her to follow-up for the local infection in 2 DAYS. ✔✔ You will review the signs that the caregiver must watch for, and return immediately.

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EXERCISE F 1. You will reassess by looking at the skin pustules. Decide if there are many or severe pustules. See if the redness and pus of the pustules is improved. 2. Tell Sashi’s caregiver that the infection is improving, but that she must complete the 5 days of antibiotic. She should also continue cleaning the skin and applying gentian violet on those days.

EXERCISES PART II EXERCISE G 1. Exclusive breastfeeding is recommended until at least 6 months of age. The three points are: a. Exclusive: no other fluids or foods are given, only breastmilk b. On demand: the infant should breastfeed whenever he wants, day and night c. The infant should breastfeed at least 8 times in 24 hours 2. FALSE – the infant has a severe classification (RED) and requires urgent referral, so you will skip the feeding and low weight assessment. 3. Answers below: a. YES b. NO c. YES d. YES e. NO f. NO g. YES 4. Low birth weight is when a baby weighs less than 2.5 kg (2500 grams) at birth. 5. A very low birth weight baby weighs less than 1.5 kg (1500 grams) at birth.

EXERCISE H Circle the signs of good attachment. Cross-out the signs of poor attachment: Chin away from breast More areola visible above than below mouth Chin touching breast Mouth wide open Lower lip turned outward Narrow mouth with lips pushed forward

Equal amount areola visible below/above mouth Lower lip turned in

EXERCISE I a. Not suckling at all b. Suckling effectively c. Not suckling effectively

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EXERCISE J AGE 16 days 7 weeks 4 weeks 8 weeks STATUS Received BCG Received DPT-1, HIB-1 Received BCG, OPV-0 Received BCG, OPV-0. Infant is being urgently referred today. What does the infant need today, if anything? How will you handle the case? None, appointment for 6 weeks of age OPV1, Hep B 1 None, give appointment for 6 weeks No vaccines now. Urgently transfer to hospital.

EXERCISE K 1. Are the following statements TRUE or FALSE? a. FALSE c. TRUE d. TRUE e. TRUE f. FALSE 2. Show Srilekha how to hold her infant: ✔✔ With the infant’s head and body in line ✔✔ With the infant approaching breast with nose opposite to the nipple ✔✔ With the infant held close to the caregiver’s body ✔✔ With the infant’s whole body supported, not just neck and shoulders 3. Show Yoonhee how to help her infant attach: ✔✔ Touch her infant’s lips with her nipple ✔✔ Wait until her infant’s mouth is opening wide ✔✔ Move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple 4. At least 8 times in 24 hours 5. Jaya should: ✔✔ Breastfeed more (on demand, at least 8 times in 24 hours) ✔✔ Stop the porridge and breastfeed exclusively – determine why she began giving porridge and what issues she is having with feeding

EXERCISE L 1. Steps that her caregiver should take to treat the skin pustules at home: a. Wash hands b. Gently wash off pus and crusts with soap and water c. Dry the area d. Paint with gentian violet e. Wash hands 2. Twice each day

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3. The 3 main points to advise the caregiver about home care are: a. Food/Fluids: Breastfeed frequently, as often and for as long as the infant wants, day and night, during sickness and health b. When to return c. Make sure the young infant stays warm at all times 4. Return in 2 days for follow-up (to be sure the skin pustules are improving). Return immediately if Sashie is breastfeeding poorly, becomes sicker, develops a fever, breathing becomes fast or difficult, or if there is blood in her stool.

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ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Module 1 General danger signs for the sick child

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

n CONTENTS Acknowledgements 4 1.1 1.2 1.3 1.4 1.5 1.6 Module overview Checking all sick children for general danger signs Care when urgent referral is required Using this module in your clinic Review questions Answer key 5 8 18 22 23 24

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

1.1

MODULE OVERVIEW

During the first face-to-face meeting you learned that the IMCI process always begins by checking all children for signs of serious illness. In the sick child aged 2 months up to 5 years these are called general danger signs. In this module you will learn about these signs A sick child is 2 months up to 5 years of age. This means the child has not had his 5th birthday.

Note that the signs of serious illness for the sick young infant (under 2 months of age) are called general danger signs of serious disease. In Module 2 you will learn more about these signs and care for the sick young infant.

MODULE LEARNING OBJECTIVES After you study this module, you will know how to: ✔✔ Greet a caregiver and get important information for IMCI ✔✔ Recognize general danger signs in a sick child ✔✔ Provide urgent pre-referral treatment according to IMCI instructions ✔✔ Refer a child when danger signs are present

MODULE ORGANIZATION This module is divided into the following sections: ✔✔ Greet the caregiver ✔✔ Check for general danger signs ✔✔ Care when urgent referral is required

WHERE DOES THIS MODULE FIT IN THE IMCI PROCESS? This module will focus specifically on the first two steps in the IMCI process – greeting and caregiver and checking for general danger signs. Look at the chart below to identify these two steps; they are the first two boxes.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

IMCI FOR THE SICK CHILD (2 months up to 5 years of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick child ) ASK: what are the child’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

CHECK FOR GENERAL DANGER SIGNS •• •• •• •• Unable to drink or breastfeed Vomits everything Convulsions Lethargic or unconscious Even if present

ASSESS MAIN SYMPTOMS •• •• •• •• Cough or difficult breathing Fever Malnutrition and anaemia Check immunizations •• •• •• •• Diarrhoea Ear problems HIV status Others

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

WHAT SECTION OF THE IMCI RECORDING FORM IS USED DURING THIS MODULE? Review your IMCI recording form for the sick infant. The top portions of this recording form are relevant to this module:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back:

Yes __ No __

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

BEFORE YOU BEGIN What do you know now about general danger signs? Before you begin studying this module, quickly practice your knowledge with the questions below. Do not look up the answers. This is for your own exercise. After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module! Fill in the blanks: 1. If a child arrives at your clinic with a sign of serious illness, they should be immediately referred. What are these signs? a. b. c. d. Circle one answer for each question: 2. When is a child lethargic? a. The child will not wake, even after shaking b. The child is sleeping more often than usual, but will wake up if you set them down to walk c. The child is drowsy and will not follow movement or noise in the room 3. When is a child unconscious? a. The child will not wake, even after shaking. However, his eyes might be open. b. The child is drowsy and will not follow movement or noise in the room c. The child is sleeping very deeply 4. If you identify a child with serious illness that requires referral, your course of action is: a. Stop your assessment of the child, and tell the caregiver they must hurry to the hospital b. Provide urgent treatments, prepare the caregiver for travel to the hospital, and prepare supplies and a referral note c. Keep the child at your clinic to monitor them and see if they will improve during the course of the day, and then refer only when necessary 5. Why do some children require urgent referral? a. The parents do not want to receive care in the clinic b. It is quickest if the child receives important care at a different facility c. They show signs of serious illness that require advanced care that is usually available at a referral facility, like a hospital.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

1.2

CHECKING ALL SICK CHILDREN FOR GENERAL DANGER SIGNS

You will begin this module with a case study. This scene should be similar to situations that you see in your clinic. After you read the case study, you will learn how to: (a) greet the caregiver and get important information about the child, and (b) check for general danger signs.

n  OPENING CASE STUDY – LEBO Lebo’s grandmother carries him into the clinic. Lebo does not look well. She has walked for one hour to the clinic. She tells you that she is also taking care of 4 other grandchildren. Lebo is her youngest grandchild and she is very worried about him. She says he is acting very unwell and has had a cough for 7 days. The grandmother tells you as she sits down that Lebo’s mother died 2 months ago. She says she does not know what caused the mother to die. Lebo’s father works away and does not come home, only once every year or so. The grandmother is very worried about Lebo and very tired from her walking. She tells you this is the first time she is bringing Lebo in to the clinic. You ask her how old Lebo is. She says he is 19 months old. You ask Lebo’s grandmother her name. She tells you that her name is Nthabeleng.

WHAT IS THE FIRST THING YOU DO WHEN NTHABELENG COMES TO THE CLINIC? The first step in the IMCI process is to greet the caregiver and ask about the child. Greeting the caregiver has two purposes. First, greeting makes a caregiver feel welcome in the clinic. Greeting and welcoming a caregiver is an important first step in building trust. It begins good and caring communication. Second, it helps you to gather important information about why the child is coming to the clinic.

WHY IS GOOD COMMUNICATION WITH A CAREGIVER IMPORTANT? Caregivers can be very stressed and emotional when a child is ill. It is important for health workers to communicate concern and care for the child’s health, and the family’s situation. Good communication helps to reassure the caregiver that her child will receive good care. When you treat the child’s illness later in the visit, you will need to teach and advise the caregiver about caring for her sick child at home. Good communication and trust is essential here. It is important to have good communication with the caregiver from the beginning of the visit.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

WHAT ARE GOOD COMMUNICATION SKILLS? Good communication skills involve the following: ✔✔ LISTEN – Listen carefully to what the caregiver tells you. This shows you are taking her concerns seriously. ✔✔ SIMPLIFY WORDS – Use words the caregiver understands. If she does not understand what you ask her, she cannot give the information you need to assess and classify the child correctly. ✔✔ GIVE HER TIME – Give the caregiver time to answer the questions. She might need time to decide if a sign you are asking about is present. ✔✔ BE CLEAR – Ask additional questions when the caregiver is not sure about her answer. If she is not sure that a certain symptom or sign is present, ask additional questions. Help her make her answers clearer. ✔✔ PRAISE – Praise the caregiver for what she is doing right. This will reinforce good practices.

WHAT IS THE IMPORTANT INFORMATION YOU GATHER DURING A GREETING? When you greet a caregiver you begin to ask important information about the child. This will help you in your assessment. Age The child’s age determines which IMCI charts to use – the sick child or the young infant. Child’s problem Another important piece of information is why the caregiver is bringing the child to the clinic. By asking the caregiver about the problem, you can make note of the symptoms or health problems that are worrying them. If necessary, you can ask further detail. For example, you might ask how long the symptom has been present, or if it has been getting worse. You can also ask the caregiver how she has been addressing the health problem thus far. This will give you background about previous care given in the home, community, or other facilities. Weight and temperature Lastly, you will determine the child’s weight and temperature. Check if this is already recorded on the child’s card. If not, weigh the child and measure his temperature later when you assess and classify the child’s main symptoms. Do not undress or disturb the child now. Initial or follow up visit You also want to know if this is the first visit for this problem, or if this is a follow-up visit. These visits are different, so this is another important piece of information.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

ASK: first time coming to the clinic for this problem? 

YES INITIAL VISIT ASSESS and CLASSIFY according to IMCI

NO FOLLOW-UP VISIT Give follow-up care according to IMCI

This is an initial visit if it is the child’s first for this episode of illness. This is a follow-up visit if the child was seen a few days ago for the same problem. You will learn more about what to do for follow-up visits in the later modules. Watch “Introduction” on the IMCI DVD (disc 1) This video will review the important steps of the IMCI greeting.

SELF-ASSESSMENT EXERCISE A Complete this exercise, and try not to look back at the material. Remember that you can check your answers to all of the self-assessment exercises at the end of the module. 1. What charts will you use for this child? Check your answer. Sick child Sam is 6 weeks old Mari is 2 months old Jera is 4 years, 10 months Thabo is 7 weeks old Paulo is 3 years old Sick young infant

2. List the important pieces of information you gather during a greeting: a. b. c. d. e. f.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

n  LET US RETURN TO THE CASE OF LEBO Which charts will you use for Lebo? Nthabeleng said that Lebo is 19 months old, so you will use charts for the sick child. If child is 2 MONTHS up to 5 YEARS

What is Lebo’s problem?

Use the charts:

•• ASSESS & CLASSIFY SICK CHILD Nthabeleng tells you that Lebo has had a cough for 7 •• TREAT THE CHILD days. She also says that he has not been eating well. Nthabeleng is very worried about this. She says that in the past two days, he cannot take anything at all and she says he is very weak. This is concerning to you.

Is Lebo coming for an initial or follow-up visit? Nthabeleng told you that this is her first time bringing him to the clinic for this issue. This is an initial visit. Lebo’s temperature and weight were recorded when he came into the clinic, he weighs 10 kg and his temperature is 37 Celsius.

How will you fill out the top of Lebo’s recording form?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Lebo Age: 19 mo Weight (kg): 10 kg Ask: What are the child's problems? Cough, not feeding well (not eating for last 2 days) Initial Visit? X ASSESS (Circle all signs present) Temperature (°C): Follow-up Visit? CLASSIFY

37 °C

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

AFTER GREETING THE CAREGIVER, HOW DO YOU BEGIN ASSESSING THE OR CHILD? DOES THE CHILD HAVE COUGH DIFFICULT BREATHING? For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

The first thing you check every sick child for is general danger signs. These signs are critically important. If Lebo shows any one of these signs, he is in danger. He needs urgent pre-referral treatment and immediate referral to the hospital. Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. the child fluid. Is the child: ALL sick children – askOffer the caregiver about the child’s problems, Not able to drink or drinking poorly? Drinking eagerly, thirsty? CHECK EVERY SICK CHILD FOR GENERAL DANGER SIGNS Pinch the skin of the abdomen. Does it go back: Very slowsly (longer then 2 seconds)? Slowly?

Yes __ No __

For

then

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)

present Decide malaria risk: High ___ NO Low signs ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE?

Look or feel for stiff neck YES, one or more signs present Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes urgent referral. Child requires Look for any other cause of fever.

Yes __ No __

Continue assessment quickly so referral is not delayed.

If the child has measles now or within the last 3 months:

CONTINUE ASSESSMENT: or difficult breathing, diarrhoea, fever, ear problems), check for malnutrition & anaemia, DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ Is there ear pain? Look for pus draining from theand ear other problems check immunization status, HIV status, THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem?

Look for mouth ulcers. If yes, are they deep and extensive? Look for for pus draining from the eye.(cough assess main symptoms Look for clouding of the cornea.

No __

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

WHAT IS A GENERAL DANGER SIGN? A general danger sign is present if:

Assess and classify the sick child aged 2 m ASSESS CLASSIFY ✔✔ Child vomitsAND everything ✔✔ Child has had more than one convulsion or prolonged convulsions, or is convulsing ✔✔ Child is not able to drink or breastfeed

ASSESS

CLASSIFY

ASK THE MOTHER WHAT THE CHILD'S PROBLEMS ARE

✔✔ Child is lethargic or unconscious

HOW WILL YOU CHECK FOR A GENERAL DANGER SIGN? Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATC CHILD'S SYMPTOMS AND PRO Assessing for general danger signs involves four steps. You will ASK three questions problem. TO CLASSIFY THE ILLNES and LOOK to observe the child’s actions. if follow-up visit, use the follow-up instructions on TREAT THE CHILD chart. Open your Chart Booklet to the chart for general danger signs. You will if initial visit, assess the child as follows: see these instructions: CHECK FOR GENERAL DANGER SIGNS Ask: Look: Is the child able to drink or See if the child is lethargic breastfeed? or unconscious. Does the child vomit Is the child convulsing everything? now? Has the child had convulsions? Any general danger sign URGENT attention

P V D

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatm

ASK – IS YOUR CHILD ABLE TO DRINK OR BREASTFEED? A child has the sign not able to drink or breastfeed if the child is not able to suck or swallow when offered a drink or breast milk. When you ask the caregiver if the child is able to drink, make sure that she understands the question. If she says that her child is not able to drink or breastfeed, ask her to describe what happens when she offers the child something to drink. For example, is the child able to take fluid into his mouth and swallow it? If you are not sure about the caregiver’s answer, ask her to offer the child a drink of clean water or breast milk. Look to see if the child is swallowing the water or breast milk. A child who is breastfed may have difficulty sucking when his nose is blocked. If the child’s nose is blocked, clear it. If the child can breastfeed after the nose is cleared, the child does not have the danger sign, “not able to drink or breastfeed.”

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ASK – DOES YOUR CHILD VOMIT EVERYTHING? A child who is not able to hold anything down at all has the sign “vomits everything” – everything that goes down comes back up. A child who vomits everything will not be able to hold down food, fluids, or oral drugs. A child who vomits several times but can hold down some fluids does not have this general danger sign. When you ask the question, use words that the caregiver understands. Give her time to answer. If the caregiver is not sure if the child is vomiting everything, help her to make her answer clear. For example, ask the caregiver how often the child vomits. Also ask if each time the child swallows food or fluids, does the child vomit? If you are not sure of the caregiver’s answers, ask her to offer the child a drink. See if the child vomits.

ASK – HAS YOUR CHILD HAD CONVULSIONS? Ask the caregiver if the child has had more than one convulsion, or prolonged convulsions, during this current illness. During a convulsion, the child’s arms and legs stiffen because the muscles are contracting. The child may lose consciousness or not be able to respond to spoken directions. Use words the caregiver understands. For example, the caregiver may call convulsions “fits” or “spasms.”

LOOK – IS THE CHILD LETHARGIC OR UNCONSCIOUS? A lethargic child is not awake and alert when she should be. The child is drowsy and does not show interest in what is happening around her. Often the lethargic child does not look at his caregiver or watch your face when you talk, or will not respond if you clap or snap your fingers. The child may stare blankly and appear not to notice what is going on around him. An unconscious child cannot be wakened. He does not respond when he is touched, shaken, or spoken to. Ask the caregiver if the child seems unusually sleepy or if she cannot wake the child. Look to see if the child wakens when the caregiver talks or shakes the child or when you clap your hands. Watch “Demonstration: danger signs” (disc 1) This video shows examples of children with general danger signs. It is very useful to see these signs in the clinical setting.

WHAT DO YOU DO IF A CHILD SHOWS ONE OR MORE GENERAL DANGER SIGNS? A child with a general danger sign has a serious problem. Most children with a general danger sign need urgent referral to hospital. The child might need lifesaving treatment with injectable antibiotics, oxygen, or other treatments that may not be available in your clinic.

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IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

If a child has a general danger sign, you must take IMMEDIATE ACTION 1. Complete assessment immediately – the child has a severe problem. There must be no delay in treatment. 2. Provide urgent pre-referral treatment 3. Refer child to hospital

DVD EXERCISE – GENERAL DANGER SIGNS Watch “Assess general condition” (disc 1) to identify if the four children are lethargic or unconscious. Write your answers and reasons below. The video will review the correct answers with you. Lethargic or unconscious? 1 2 3 4 What are your reasons?

SELF-ASSESSMENT EXERCISE B (GENERAL DANGER SIGNS) Check the boxes below if the sign is a general danger sign. Is this a general danger sign? The child is vomiting frequently. When you give milk, he holds it down. The child will not take the mother’s breast. The child lies in his caregiver’s arms. When you clap he follows you. The child had convulsions last night and today. The child has been ill for 4 days. The child’s eyes are open, but he is limp and will not respond to you. The child will not move, but after efforts to wake him, he walks around.  YES  NO  YES  NO  YES  NO  YES  NO  YES  NO  YES  NO

SELF-ASSESSMENT EXERCISE C (SALINA) Now you will practice on a case study. Read the following case study and complete the recording form as instructed. Salina is 15 months old. She weighs 8.5 kg. Her temperature is 38.5 °C. The health worker asked, “What are the child’s problems?” The mother said, “Salina has been coughing for 4 days, and she is not eating well.” This is Salina’s initial visit for this problem. The health worker checked Salina for general danger signs. He asked, “Is Salina able to drink or breastfeed?” The mother said, “No. Salina does not want to breastfeed.” The health worker gave Salina some water. She was too weak to lift her head. She was not able to drink from a cup. Next he asked the mother, “Is she vomiting?” The mother said, “No.” Then he asked, “Has she had convulsions?” The mother said, “No.” The health worker looked to see if Salina was lethargic or unconscious. When the health worker and the mother were talking, Salina watched them and looked around the room.

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Here is the top part of a Recording Form: 1. Write Salina’s name, age, weight and temperature in the spaces provided. 2. Write Salina’s problem on the line after the question “Ask-What are the child’s problems?” 3. Tick (✓ ) whether this is the initial or follow-up visit for this problem. 4. Does Salina have a general danger sign? If yes, circle her general danger sign in the box with the question, “Check for general danger signs.” 5. In the top row of the “Classify” column, tick either Yes or No if “Danger sign present?”

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Lebo is showing two general danger signs – he is unable to drink and lethargic. He needs to be Decide malaria risk: High ___ Low ___ No___ referred immediately to the hospital. For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign Name: High risk: all fever cases Ask: What are the child's problems? Low risk: if NO(Circle obvious of fever ASSESS all cause signs present) Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __ For how long? ___ Days Look at the childs generalsays, condition. Is not the child: You ask if Lebo is able to drink or breastfeed, and Nthabeleng “no, today, he is too tired.” You try Is there blood in the stool? Lethargic or unconscious? to give him some water from a cup but he is too weak and does not swallow. You ask Nthabeleng if Lebo is Restless and irritable? for sunken eyes. vomiting, and she says “no.” You ask if LeboLook is having convulsions, and Nthabeleng says “no.” Offer the child fluid. Is the child: Not able to drink or drinking poorly? You look at Lebo’s condition. He is not paying Drinking attention to you or Nthabeleng as you talk, and only stares eagerly, thirsty? Pinch the skin ofdoes the abdomen. Does it the go back: ahead. You snap your fingers in front of his face, but he not look at fingers. You ask Nthabeleng to slowsly (longer then 2 seconds)? bounce Lebo and speak to him, and when sheVery says “Lebo! Lebo!” he does not look up at her. Slowly?

n  Does Lebo show any general danger signs?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Lebo Age: 19 mo Weight (kg): 10 kg Cough, not feeding well (not eating for last 2 days) Initial Visit? X Temperature (°C): Follow-up Visit? CLASSIFY

37 °C

If the child hasTO measles now or within the NOT ABLE DRINK OR BREASTFEED VOMITS EVERYTHING last 3 months: CONVULSIONS

CHECK FOR GENERAL DANGER SIGNS

DOES THE CHILD HAVE AN EAR PROBLEM?

Look for mouth ulcers. LETHARGIC OR UNCONSCIOUS If yes, are they deep and extensive? CONVULSING NOW Look for pus draining from the eye. Look for clouding of the cornea.

Is there ear pain? Look for pus draining from the ear Is DOES there ear discharge? Feel for tender swelling behind the ear THE CHILD HAVE COUGH OR DIFFICULT BREATHING? If Yes, forhow how long? ___ Days For long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Look for chest indrawing Determine WFH/L _____ Z score. AND ANAEMIA Look and listen for stridor For children 6 months or older measure MUAC ____ mm. Lookfor and listen for wheezing Look palmar pallor. DOES THE CHILD HAVE DIARRHOEA? Severe palmar pallor? Some palmar pallor? how long? ___ Days themedical childs general condition. Is the child: Is Look thereat any complication? If childFor has MUAC less than 115 mm or Is there blood in the stool? Lethargic or unconscious? General danger sign? WFH/L less than -3 Z scores or oedema of Restless and irritable? Any severe classification? Look for sunken eyes. both feet: Pneumonia with chest indrawing? Offer the child fluid. Is the child: For a Not child 6 months or drinking older offer RUTF to eat. Is the child: able to drink or poorly? Not able eagerly, to finishthirsty? or able to finish? Drinking For a child than months is there a breastfeeding problem? Pinch the less skin of the6 abdomen. Does it go back:

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting Yes __ No __ classifications Yes __ No __

Yes __ No __

CHECK FOR HIV INFECTION

Note mother's and/or child's HIV status DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN or feel for stiff neck Child's virological test: ___ NEGATIVE POSITIVE NOTLook DONE Decide malaria risk: High Low ___ No___ Look for runny nose Child's serological test: NEGATIVE POSITIVE NOT DONE For how long? ___ Days Look for signs of MEASLES: If mother is HIV-positive and fever NO positive virological If more than 7 days, has been present every test in child:

Very slowsly (longer then 2 seconds)? Slowly?

15

Yes __ No __

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

n  What will you do for Lebo and Nthabeleng? You tell Nthabeleng that you think Lebo needs further treatment at the hospital because he is unable to drink and now acting very tired. You tell her that it is very important that he go to the hospital right away. You will help arrange for her to get there. She looks very scared and asks if Lebo will die like his mother. She says that this must be because of something she has done. You affirm Nthabeleng and tell her that this is because Lebo is sick, not because of her actions. You explain that the treatment in the hospital will be able to help. You reassure her that she was a very good grandmother to bring Lebo to the clinic for care. She was very alert to notice that he was unwell. You tell her that you will start some immediate treatment now so that he can be stable during the journey to the hospital. Reassure her that you will help her, and that this treatment is very important. You will then complete the assessment with Lebo and decide what pre-referral treatment is necessary. Nthabeleng told you that Lebo has a cough. You have determined that he has two general danger signs. You must complete his classification for the cough during your assessment to determine necessary pre-referral treatment. Now you will learn more about how to identify and administer pre-referral treatment.

HOW DOES THE ASSESSMENT CONTINUE AFTER CHECKING FOR GENERAL DANGER SIGNS? A child with any general danger sign needs URGENT attention. You should complete the assessment and administer any pre-referral treatment immediately so that the referral is not delayed.

For ALL sick children – ask the caregiver about the child’s problems, then CHECK EVERY SICK CHILD FOR GENERAL DANGER SIGNS

NO signs present

YES, one or more signs present Child requires urgent referral. Continue assessment quickly so referral is not delayed.

CONTINUE ASSESSMENT: assess for main symptoms (cough or difficult breathing, diarrhoea, fever, ear problems), check for malnutrition & anaemia, check immunization status, HIV status, and other problems

You will learn much more about this assessment process in the following self-study modules. For now, remember that you will follow the IMCI instructions through this process. Your chart booklet walks you through these instructions.

16

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

First, assess for main symptoms These are symptoms of the most common causes of illness and death in children under five years. When a main symptom is present, a child could have a serious illness. These symptoms include cough or difficult breathing (Module 3), diarrhoea (Module 4), and fever (Module 5). A number of illnesses – including pneumonia, malaria, or an infection – cause these symptoms. Second, assess the child’s nutritional status You have learned that undernutrition is a very common underlying cause of child mortality. Even children with mild and moderate malnutrition have an increased risk of death. When a caregiver brings her child to the clinic, it is usually because the child has an acute illness. A sick child can be malnourished, but you or the child’s family may not notice the problem. The child may have no complaints that point to malnutrition or anaemia. Module 6 discusses how to assess, classify, and treat malnutrition and anaemia. Then check immunizations, HIV status, and other problems Modules 7, 8, 9, and additional modules explain these assessments.

17

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

CLASSIFY

IDENTIFY TREATMENT

S

Two of the following signs: Pink: If child has no other severe classification: Lethargic or unconscious Give fluid for severe dehydration (Plan C) SEVERE OR Sunken eyes DEHYDRATION for DEHYDRATION If child also has another severe Not able to drink or classification: drinking poorly THAT MATCH THE sifyvisit DIARRHOEA up for this USE ALL BOXES Refer URGENTLY to hospital with WHEN IS URGENT Skin pinch goes back REFERRAL REQUIRED? CHILD'S SYMPTOMS AND PROBLEMS mother giving frequent sips of ORS very slowly. with general danger signs and/or any TO Children CLASSIFY THE ILLNESS on the waycondition with a red p instructions the mother continue These classification require urgent pre-referralAdvise treatment andtoreferral. breastfeeding classifications indicate very serious illness. Review the CLASSIFY table for general follows: If child is 2 years or older and there is danger signs below. This is a red classification. You will area, alsogive see antibiotic the identified cholera in your for cholera

1.3

CARE WHEN URGENT REFERRAL IS REQUIRED

treatments in the right-side TREAT column. Two of the following signs: Restless, irritable Sunken eyes Any general danger sign Drinks eagerly, thirsty Skin pinch goes back slowly. Yellow: SOME DEHYDRATION Pink: VERY SEVERE DISEASE

URGENT attention

Give fluid, zinc supplements, and food for some dehydration (Plan B) If child also has a severe classification: Refer URGENTLY to hospital Give diazepam if convulsing nowwith mother giving the frequent sips of ORS Quickly complete assessment on the way Give any pre-referal treatment immediately Advise the mother to continue Treat to prevent low blood sugar breastfeeding Keep the child warm Advise mother when to return immediately Refer URGENTLY. Follow-up in 5 days if not improving

Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat tention; complete the assessment and any pre-referral treatment immediately so referral is not delayed. as some or severe diarrhoea at home (Plan A) NO It is important to remember that once you have identified a general danger sign, dehydration. DEHYDRATION Advise mother when to return immediately

you must conduct the IMCI assessment and determine Follow-up in 5any dayspre-referral if not improvingtreatment so that you do not delay the referral. Dehydration present.

and if diarrhoea 14 days or more

HOW DO YOU

Urgent pre-referral treatments are in bold print on the classification charts in your No dehydration. Advise the mother on feeding a child who has chart booklet. Open your Yellow: classification tables: do you see the treatment identified PERSISTENT DIARRHOEA PERSISTENT in bold? For example, the DYSENTERY belowand specifies ciprofloxacin Give multivitamins DIARRHOEA classification minerals (including zinc) for 14 days as a pre-referral treatment. Page 4 of 75 

Pink: SEVERE DETERMINE URGENT PERSISTENT DIARRHOEA

Treat dehydration before referral unless the child has another severe classification PRE-REFERRAL TREATMENT? Refer to hospital

Follow-up in 5 days

and if blood in stool

Blood in the stool.

Yellow: DYSENTERY

Give ciprofloxacin for 3 days Follow-up in 2 days

These are specified because some treatments should not be given before referral. Treatments that are not urgently needed will only delay referral. For example, do not teach a caregiver how to treat a local infection or give immunizations before referral. Page 6 of 75  FLIP THROUGH YOUR CHART BOOKLET TO SEE THE PRE-REFERRAL TREATMENTS:

As you look through your charts, can you see the bold pre-referral treatments? Look through each chart and identify the pre-referral treatments in bold. Here are some examples of what you will see. You will learn more about the classifications below in upcoming modules.

18

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

CLASSIFICATION SEVERE PNEUMONIA or VERY SEVERE DISEASE PNEUMONIA SEVERE or SOME DEHYDRATION (with another severe classification) VERY SEVERE FEBRILE DISEASE MEASLES SEVERE ACUTE MALNUTRITION Measles-related classifications

PRE-REFERRAL TREATMENT IDENTIFIED Requires first dose of an appropriate antibiotic, treat for low blood sugar First dose of oral amoxicillin Requires the caregiver to give frequent sips of ORS on the way to hospital, and continue breastfeeding Requires treatment for malaria, if necessary, and first doses of antibiotic and paracetamol for high fever Requires treatment for malaria, if necessary, and first dose of paracetamol for high fever Requires treatment for low blood sugar, keeping child warm, and first dose of antibiotic Requires Vitamin A treatment, and treatment if complications

HOW DO YOU URGENTLY REFER THE CHILD? There are four steps to referring a child or a sick young infant to hospital: 1. EXPLAIN to the caregiver the need for referral, and get her agreement to take the child. If you suspect that she does not want to take the child, find out why. Possible reasons might be: •• She thinks hospitals are places where people often die. She fears her child will die there too. •• She does not think that the hospital will help the child. •• She cannot leave home and stay in the hospital to care for her child, if there is no one to take care of her other children, or she is needed for farming, or she may lose a job. •• She does not have money to pay for transportation, hospital bills, medicines, or food for herself during the hospital stay. 2. CALM the caregiver’s fears and help her resolve any problems. For example: if the caregiver fears that her child will die at the hospital, reassure her that the hospital has physicians, supplies, and equipment that can help cure her child. ✔✔ Explain what will happen at the hospital and how that will help her child. ✔✔ If the caregiver needs help at home while she is at the hospital, ask questions and make suggestions about who could help. For example, ask whether her husband, sister or caregiver could help with the other children or with meals while she is away. ✔✔ Discuss how she can travel to the hospital. Help arrange transportation if necessary. ✔✔ You may not be able to help the caregiver solve her problems and be sure that she goes to the hospital. However, it is important to do everything you can to help.

19

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

3. WRITE A REFERRAL NOTE for the caregiver to carry. Tell her to give it to the health worker there. The note should include: •• The name and age of the infant or child •• The date and time of referral •• Description of the child’s problems •• The reason for referral (signs/symptoms for classification) •• Treatment that you have given •• Any other information that the hospital needs to know in order to care for the child, such as earlier treatment of the illness or immunizations needed •• Your name and the name of your clinic 4. GIVE SUPPLIES AND INSTRUCTIONS NEEDED to care for her child on the way to the hospital: If the hospital is far, give the caregiver additional doses of antibiotic and tell her when to give them during the trip (according to dosage schedule on the TREAT chart). If you think the caregiver will not actually go to the hospital, give her the full course of antibiotics, and teach her how to give them. ✔✔ Tell the caregiver how to keep the young child warm during the trip. ✔✔ Advise the caregiver to continue breastfeeding. ✔✔ If the child has some or severe dehydration and can drink, give the caregiver some ORS solution for the child to sip frequently on the way. REMEMBER: any child with a general danger sign or a serious classification requires urgent referral.

WHAT IF REFERRAL IS NOT POSSIBLE? The best possible treatment for a child with a very severe illness is usually at a hospital. Sometimes referral is not possible or not advisable. Distances to a hospital might be too far; the hospital might not have adequate equipment or staff to care for the child; transportation might not be available. Sometimes parents refuse to take a child to a hospital, in spite of the health worker’s effort to explain the need for it. If referral is not possible, you should do whatever you can to help the family care for the child. If referral is not possible, continue with prereferral treatment until the child is able to leave for the hospital. If the child improves on pre-referral treatment, initiate treatment in the clinic (e.g. the YELLOW classification). Advise the caregiver on all available treatment. To help reduce deaths in severely ill children who cannot be referred, you may need to arrange to have the child stay in or near the clinic where he may be seen several times a day. If not possible, arrange for visits at home. There is more information about when a referral is not possible in the ANNEX.

20

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

When you can refer, remember to: 1. 2. 3. 4. Explain to the mother Calm fears Write a referral note Give supplies & instructions for journey

n  How will you refer Lebo? You have completed Lebo’s assessment. You give him the urgent pre-referral treatments indicated in bold on the classification charts where you classified his other conditions. You prepare the referral note for Nthabeleng and Lebo, give her the necessary instructions for treatment on the way to the hospital. She is nervous but you tell her that this treatment is urgent and should help Lebo, and that she is taking very good care of him to be so alert and bring him to the clinic all herself. You tell her that she is being a very good grandmother for taking him to the hospital for this treatment, and that it is very important for his health.

SELF-ASSESSMENT EXERCISE D What will you do for the children who have general danger signs? Which statements below are true, and which are false? If the statement is false, rewrite it so that it is true. 1 2 3 4 Stop immediately and send the child to the hospital Continue the assessment, determine pre-referral treatment, treat, and refer. Continue to assess the child and send child to hospital with referral note about all of the treatments you identified. If referral is not possible, there is nothing you can do. Send the child home.  TRUE   FALSE  TRUE   FALSE  TRUE   FALSE  TRUE   FALSE

21

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

1.4

USING THIS MODULE IN YOUR CLINIC

HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE YOU HAVE GAINED FROM THIS MODULE IN YOUR CLINIC? Use your Chart Booklet and IMCI recording forms as you practice in the clinic. In the coming days, you should focus on the clinical skills below. Greeting ✔✔ Greet caregivers and use good communication skills to make them feel welcome in the clinic. ✔✔ Ask for important information from the caregiver: child’s name, age, problems, history, etc. General danger signs ✔✔ Check all children for general danger signs ✔✔ Use your Chart Booklet when checking children to ensure that you ASK, LOOK, and FEEL for all signs ✔✔ Record what you find on the IMCI recording form for sick children ✔✔ If the child has a general danger sign, classify as VERY SEVERE DISEASE ✔✔ If a child has a danger sign, practice preparing a caregiver for referral

Remember to use your logbook n Now that you have completed the module, remember to complete your logbook for MODULE 1: n Complete Module 1 exercises n Record cases from your clinic as you check children for general danger signs n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and at the face-to-face meeting

22

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

1.5

REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT GENERAL DANGER SIGNS? Before you began studying this module, you practiced your knowledge. Now that you have finished the module, answer the same questions and see how much you have learned. Fill in the blanks: 1. If a child arrives at your clinic with a sign of serious illness, they should be immediately referred. What are these signs? a. b. c. d. Circle one answer for each question: 2. When is a child lethargic? a. The child will not wake, even after shaking b. The child is sleeping more often than usual, but will wake up if you set them down to walk c. The child is drowsy and will not follow movement or noise in the room 3. When is a child unconscious? a. The child will not wake, even after shaking. However, his eyes might be open. b. The child is drowsy and will not follow movement or noise in the room c. The child is sleeping very deeply 4. If you identify a child with serious illness that requires referral, your course of action is: a. Stop your assessment of the child, and tell the caregiver they must hurry to the hospital b. Provide urgent treatments, prepare the caregiver for travel to the hospital, and prepare supplies and a referral note c. Keep the child at your clinic to monitor them and see if they will improve during the course of the day, and then refer only when necessary 5. Why do some children require urgent referral? a. The parents do not want to receive care in the clinic b. It is quickest if the child receives important care at a different facility c. They show signs of serious illness that require advanced care that is usually available at a referral facility, like a hospital. Check your answers on the next page. How did you do? ............... complete out of 5. Did you miss questions? Turn back to the section recommended to re-read and practice the self-assessment exercises.

23

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

1.6

ANSWER KEY

NOTE: All video exercises discuss answers in the video.

REVIEW QUESTIONS QUESTION 1 ANSWERS Order of these 4 answers does not matter 1. Child is lethargic or unconscious 2. Child is vomiting everything 3. Child has had convulsions, or is convulsing now 4. Child cannot breastfeed or drink C A B C Did you miss the question? Return to this section to read and practice: CHECKING ALL CHILDREN

2 3 4 5

CHECKING ALL CHILDREN CHECKING ALL CHILDREN CARE WHEN URGENT REFERRAL IS REQUIRED CHECKING ALL CHILDREN, CARE WHEN URGENT REFERRAL IS REQUIRED

EXERCISE A (GREETING & INTRODUCTION) 1. What charts will you use for this child? Sick child Sam is 6 weeks old Mari is 2 months old Jera is 4 years, 10 months Thabo is 7 weeks old Paulo is 3 years old ✘ ✘ ✘ ✘ Sick young infant ✘

2. Child’s name, child’s age, what the child’s problems are, if this is an initial or followup visit, weight, and temperature. You can also get the caregiver’s name and background information on the family or household situation. You can learn how the caregiver has been trying to address the child’s problem up to now. This greeting is important to build rapport and trust with good communication skills. This will help you get more information from the caregiver.

EXERCISE B (GENERAL DANGER SIGNS) Is this a general danger sign? The child is vomiting frequently. When you give milk, he holds it down. The child will not take the mother’s breast. The child lies in his caregiver’s arms. When you clap he follows you. The child had convulsions last night and today. The child has been ill for 4 days. The child’s eyes are open, but he is limp and will not respond to you. The child will not move, but after efforts to wake him, he walks around. ✘ NO ✘ YES ✘ NO ✘ YES ✘ YES ✘ NO

24

IMCI DISTANCE LEARNING COURSE | MODULE 1. GENERAL DANGER SIGNS FOR THE SICK CHILD

EXERCISE C (SALINA)

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Salina Age: 15 months Ask: What are the child's problems? Cough for 4 days, not eating well ASSESS (Circle all signs present) Weight (kg):

8.5 kg

Initial Visit?

✓

Temperature (°C): Follow-up Visit? CLASSIFY

38.5 °C

CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

LETHARGIC OR UNCONSCIOUS CONVULSING NOW

General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications

✓

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

EXERCISE D DOES THE CHILD HAVE DIARRHOEA? Is there blood in the stool?

1. FALSE. Actual true statement is: Continue the assessment quickly, identify all preYes __ treatments needed, treat, urgently. For how long? ___referral Days Look and at the refer childs general condition. Is the child: Restless and irritable? 2. TRUE. Continue the assessment, determine pre-referral treatment, treat, and refer. Offer the child fluid.should Is the child: 3. FALSE. Actual true statement is: You deliver the necessary pre-referral Not able to drink or drinking poorly? treatment before they leave yourDrinking clinic eagerly, for thethirsty? hospital. Look for sunken eyes. Lethargic or unconscious?

Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing

Yes __ No __

No __

slowsly (longer then 2 essential seconds)? care (further discussed in 4. FALSE. Actual true statementVery is: Y ou can provide Slowly? Annex), work with the family to encourage them to go to the hospital, or bring the child DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ Look or feel for stiff neck near to the clinic to monitor treatment and progress . Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measels within the last 3 months? Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Pinch the skin of the abdomen. Does it go back:

No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication? General danger sign? Any severe classification? Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? Yes __ No __

THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet:

CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Vitamin A Mebendazole

Return for next immunization on: ________________ (Date)

25

ISBN 978 92 4 150682 3



INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

IMCI

DISTANCE LEARNING COURSE

Introduction Self-study modules

WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3         (NLM classification: WS 200)

© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland

IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

n CONTENTS Acknowledgements 4 Course overview: Introduction Part I 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Course objectives & structure Course calendar Learning process Expectations for participants Planning & managing study groups Overview of IMCI What do the IMCI guidelines explain? Case management by age Using the chart booklet & recording forms 5 6 7 8 13 14 16 17 22 25 26 34

The IMCI process: Introduction Part 2

0.10 Using good communications and counselling skills

3

IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

Acknowledgements The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

4

IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

Introduction Part I

COURSE OVERVIEW

5

IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

0.1

COURSE OBJECTIVES & STRUCTURE

Welcome to this distance-learning course for Integrated Management of Childhood Illness (IMCI). Congratulations on your efforts to participate in this course. It is an exciting effort to bring IMCI training to even more health professionals.

What are the objectives of this course? At the end of this distance learning course, you will be able to: n Use integrated case management for common health problems in sick young infants and children n Use the IMCI chart booklet and recording forms as job aids in your clinic n Counsel caregivers on home treatment, feeding, well child care, and disease prevention

HOW IS THE COURSE STRUCTURED? There are several activities in this course, as shown in the chart below. You will meet with your course three (3) times for a one-day meeting. During the self-study periods, you will study at your home and practice IMCI in your clinic.

WHAT MATERIALS DO I NEED FOR THIS COURSE? Your facilitator will give you the following materials during your first face-to-face meeting: ✔✔ THIS SELF-STUDY MODULES BOOK , which has three parts: (1) this introductory section on the course, (2) IMCI overview, (3) the course reading modules. ✔✔ IMCI DVD (2 DISCS) to watch as you study. The videos are very useful learning tools. ✔✔ LOGBOOK , which includes exercises to complete after you read each module. It may also include the IMCI recording forms to use while you practice in your clinic. ✔✔ IMCI CHART BOOKLET, an important job aid for using IMCI in your clinic. Orientation 1st face-to-face meeting (today) 3–4 weeks Review & practice 2nd face-to-face meeting (1 day) 6–8 weeks Final synthesis 3rd face-to-face meeting (1 day)

Self-study period 1 (Modules 1 & 2)

Self-study period 2 (Remaining modules)

Practice IMCI in clinic, using Chart Booklets and recording forms Review with study groups Work with mentors 2 to 3 months

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

0.2

COURSE CALENDAR

During the first face-to-face meeting, you facilitator will discuss the course calendar with you. Fill in the meeting locations and dates in the calendar below:

COURSE CALENDAR SESSIONS ORIENTATION 1st face-to-face meeting OBJECTIVES  Introduce IMCI process  Distribute learning materials and introduce content to Modules 1 and 2  Review distance learning course structure and expectations  Clinical practice with group  Read modules and complete self-assessment exercises as you read  Practice in clinic and record cases on recording forms in logbook  Complete logbook assessment exercises  Meet with study group  Maintain contact with mentors and facilitators     Review progress and issues in self-study Examine cases from clinical practice Introduce content from upcoming modules Clinical practice with group LOCATION DATE

Meeting place

To fill

SELF-STUDY PERIOD 1 Modules 1 & 2

Home facilities

3–4 weeks

REVIEW & PRACTICE 2nd face-to-face meeting

Meeting place

To fill

SELF-STUDY PERIOD 2 Remaining modules

 Read modules and complete self-assessment exercises as you read  Practice in clinic and record cases on recording forms in logbook  Complete logbook assessment exercises  Meet with study group  Maintain contact with mentors and facilitators       Review progress & issues in self-study Examine cases from clinical practice Review content from all modules Clinical practice with group Course assessment Individual plans for continued learning

Home facilities

8–9 weeks

FINAL SYNTHESIS 3rd face-to-face meeting

Meeting place

To fill

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

0.3

LEARNING PROCESS

There are several components of distance learning in this course. These are detailed below.

1. SELF-STUDY MODULES Self-study modules provide the content of this course. During distance learning, you will study on your own. You will also strengthen what you have learned through clinical practice, group study, and working with mentors. Distance learning is flexible, but also requires participants to manage their time very well, and study responsibly. You should complete all modules by the end of this course. You are able to complete the modules at your own pace – however you are asked to complete Module 1 and Module 2 before the 2nd face-to-face meeting.

SELF-STUDY MODULES 1 General danger signs Identifying signs of severe illness in sick children Care of the sick young infant Using the IMCI strategy with sick young infants Part I: Assess, classify, and treat the young infant Part II: Infant feeding and counselling the caregiver Cough or difficult breathing Assess, classify, and treat cough or difficult breathing in sick child Diarrhoea Assess, classify, and treat diarrhoea and dehydration in sick child Fever Assess, classify, and treat fever in sick child Malnutrition and anaemia Assess nutritional status and address malnutrition, anaemia, or feeding problems Selfstudy period 2 Selfstudy period 1

2

3 4 5 6

ADDITIONAL, OPTIONAL MODULES: 7 8 9 Ear problems HIV/AIDS Well child care

How much time should you take for each module? You should set a personal study calendar with goals for studying modules. This will help you keep a study pace that fits your other commitments, but also makes sure you complete all modules. You should write this calendar with specific goals – for example, which page numbers you will complete by a certain day. Hang this calendar near the space where you study, so you can easily see it. It may take about a week for each module, although some might take more time to study than others. If you need help setting a study calendar, ask your facilitator for advice.

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

2. FACE-TO-FACE MEETINGS WITH FACILITATOR There are three (3) face-to-face meetings with your course facilitators and fellow participants. This is good time to learn about IMCI, discuss your progress in selfstudy, answer questions, and practice in the clinic together.

What should I bring with me to each face-to-face meeting? It is important to bring the following materials to the second and third meetings. 1. This book – including any notes on reading, exercises, or review questions 2. Your logbook – with completed written exercises and recording forms 3. IMCI Chart Booklet

n  1st meeting – ORIENTATION The first meeting is an orientation to IMCI, the course structure, and your course materials. You will be given self-study modules. You will learn about the IMCI process in videos and during clinical demonstrations.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Explain the objectives and structure of this distance learning course, including the importance of clinical practice, mentors, and study groups •• Identify key causes of childhood mortality •• Explain the meaning and purpose of integrated case management •• Describe the major steps in the IMCI strategy •• Demonstrate how chart booklets and recording forms are job aids for the IMCI strategy •• Recognize the general danger signs in children •• Identify important care for young infants •• Explain the importance of assessing for signs of severe disease and feeding problems in young infants •• Describe how a welcoming environment is important for case management •• Explain and demonstrate key communication skills •• Plan self-study, group study, and clinical practice for Modules 1 and 2

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

n  2nd meeting – REVIEW AND PRACTICE During the second face-to-face meeting you will review self-study of Modules 1 and 2, and practice skills. Facilitators will arrange opportunities for clinical demonstration and practice. This meeting might be arranged on-site in order to practice clinical skills. This session will introduce materials from the remaining Modules. You should bring completed recording forms and logbook exercises from Modules 1 and 2 for the facilitators.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Review self-study period 1, including cases from clinical practice, and address problem areas •• Demonstrate skills from Modules 1 and 2 in a clinical setting •• Explain and demonstrate how to use IMCI chart instructions to assess, classify, and treat main symptoms and conditions in a sick child •• Plan self-study, group study, work with mentors, and clinical practice for remaining modules

n  3rd meeting – FINAL SYNTHESIS All participants will return 6-8 weeks later for the Final Synthesis meeting. This meeting finishes the course. It will take place about 3 months after the first face-to-face meeting. During this meeting you will discuss how you are using IMCI in your clinics. Facilitators will help participants with any difficult areas. Facilitators will arrange opportunities for clinical demonstration and practice. Participants complete an assessment and receive certificates of completion. Then all participants will be asked to create individual action plans. These will include plans for continued skills development, refresher training, seeking mentorship, using IMCI in the clinic, and disseminating information to supervisors and colleagues.

MEETING LEARNING OBJECTIVES At the end of this meeting, participants should be able to: •• Review self-study period 2, including cases from clinical practice, and address problem areas •• Explain and demonstrate IMCI clinical process with sick children and young infants •• Demonstrate good use of IMCI charts and recording forms in clinical practice •• Design an individual action plan for using IMCI and continuing to improve skills

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

3. USING YOUR LOGBOOK The logbook is an important place for you to practice material and record cases as you study. The facilitators will review your logbook at each face-to-face meeting to check if you are having any challenges, and to address these with you. You will also discuss the exercises and your clinical cases during the meetings with the other participants. If you have problems, you should ask them for explanation and help. For each module, you should complete the following in the logbook: 1. EXERCISES: after reading each module, you should complete the exercises in the logbook on your own. This is to test your knowledge on the material you have just completed. 2. RECORDING FORMS: as you practice in the clinic, you will use these IMCI recording forms. In your Orientation meeting your facilitator will tell you how many forms are required for each module. In addition to these required cases, the more cases you record, the better your facilitators and peers will be able to give you useful feedback. 3. CHECKLIST OF CLINICAL SIGNS: as you practice in the clinic, use this checklist when you see signs. This will help your facilitator understand the exposure you are having in your clinic.

Remember to bring your logbook to each meeting. Your facilitators will review the exercises and recording forms. You will also be marked in this course based on how well you complete the logbook.

4. PRACTICING IMCI IN YOUR CLINIC This course’s objective is to improve your clinical skills through the IMCI strategy. As you read each module, practice the material in your clinic. It is important that IMCI becomes a central part of the way you care for children in your clinic. You will have valuable tools for practicing IMCI in your clinic during the course: n CHART BOOKLET: You will receive your IMCI chart booklet during the first face-to-face meeting. Read INTRODUCTION PART 2 for details on the chart booklet. n RECORDING FORMS in the LOGBOOK: You will be introduced to the recording forms for the sick child and young infant during your first face-to-face meeting. INTRODUCTION PART 2 has details about using the recording form with your chart booklet. When you practice IMCI in your clinic during the course, you should use recording forms. You will not be able to fill out all of the form right away. There is a module for each section of the form, so you will only know how to complete the entire form at the end of the course.

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BRING YOUR RECORDING FORMS TO FACE-TO-FACE MEETINGS The more cases you record, the better your facilitators and peers will be able to give you useful feedback. If you have problems with any areas, you should ask them for explanation and help.

5. STUDYING WITH GROUPS During self-study periods, you will ideally meet with other participants that live or work nearby on a regular basis, like once or twice a week. Learning in groups is very valuable. It gives you a time to explain information, discuss review questions, and practice in the clinic together if necessary. In the pages ahead, SECTION 0.5 includes more information on study groups.

6. CONTACT WITH COURSE FACILITATORS Your facilitators are experienced clinicians. They have been trained in IMCI case management and IMCI facilitation. They will have a good understanding of national health policies. They will instruct you about IMCI and also help you develop your skills as health professionals. You should ask for help from your facilitators if you have questions or confusions. They are here to help you best develop your skills. At the Orientation meeting, your facilitator will tell you how to stay in contact with him/her as you study on your own.

7. REGULAR CONTACT WITH YOUR MENTORS Mentorship is very important for distance learning. You should work with your facilitators who should help you identify mentors that can support you during your self-study. Mentors can help explain material from your modules, or show you how to use IMCI. For example, if you need help looking for a certain sign, you might go to a mentor at the district hospital who could show you relevant cases of sick young infants or children. You may also send SMS messages asking for specific questions and they can help you answer them. Your facilitators will tell you more about mentors during your self-study.

8. SUPPORT AT YOUR FACILITY It is important for you to discuss this IMCI course with your in-charge officer and colleagues. Explain what you are learning and ask for feedback as you practice IMCI in your clinic. This can help you learn more. You will also keep your in-charge office and colleagues aware of IMCI tools if you explain what you are learning. They should also be aware that you will need extra support in your facility as you begin using IMCI with patients. You will also require time to study, attend face-toface meetings, practice in the clinic, and meet your study group.

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0.4

EXPECTATIONS FOR PARTICIPANTS

WHO ARE THE PARTICIPANTS IN THIS COURSE? This course is designed for health professionals who manage children at first-level facilities. This includes nurses, nurse assistants, and clinical health workers.

WHAT IS EXPECTED OF PARTICIPANTS? In order to complete this course, you will be expected to: ✔✔ Read all self-study materials ✔✔ Practice IMCI in your home facilities and record cases in your logbook ✔✔ Complete exercises in logbook ✔✔ Attend 3 face-to-face meetings ✔✔ Demonstrate eager participation in the course ✔✔ Learn with others as much as possible and seek mentors ✔✔ Notify facilitators, study groups, and mentors if you are going to be late for a meeting ✔✔ Practice with normal ethnical and professional conduct standards of the facilities

WHAT SHOULD I PLAN TO COMMIT TO THIS COURSE? Before the course begins, participants and in-charge officers should understand that the course is a significant commitment of time and attention. Participants will be out of clinic each of the face-to-face meetings. They will need time to study and practice IMCI in their clinic. Ideally, in-charge officers will offer encouragement to participants who are trying to improve their clinical skills.

HOW WILL I BE ASSESSED IN THE COURSE? Assessments will check that you understand the course material. It will also check that you have developed skills to use IMCI with patients. You be assessed by three things: ACTIVITY 1. Logbook exercises OBJECTIVES These are multiple-choice and true-false questions about each module. Your work on them shows that you have read and understand the material. SUBMISSION DATE 2nd face-to-face (Modules 1 and 2) 3rd face-to-face (all other Modules)

2. Recording forms These recording forms (number as requested by facilitator) 2nd face-to-face (Modules 1 and 2) from cases should demonstrate that you are practicing IMCI in the clinic. 3rd face-to-face (all other Modules) 3. Final course assessment This assesses your abilities to use IMCI with sick young infants and children. It includes a clinical skills assessment and a written examination. During 3rd face-to-face meeting

WHAT WILL I RECEIVE AFTER COMPLETING THE COURSE? If you fully satisfy the course requirements, you will receive a certificate of completion. This will certify that you are trained in IMCI through the distancelearning course.

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0.5

PLANNING & MANAGING STUDY GROUPS

Why is group learning important? Working with others is very important for effective distance learning. Group study can benefit your studying in two ways: 1. GROUP STUDY CAN IMPROVE THE QUALITY OF YOUR LEARNING During group learning you learn from each other. You will be required to test your knowledge as you explain material to your peers. Discussing questions and problems with your group helps to improve your understanding of concepts. Working in a group can also motivate you. You have a sense of responsibility to your group and finishing your work so that you can contribute to the group study. 2. Group STUDY can help develop skills n Teamwork skills – leadership skills, doing activities as a group, supporting group members n Analytical skills – critical thinking, problem solving, analysing tasks and requirements, evaluating the work of others, understanding material n Collaborative skills – conflict management, negotiating, compromising, accepting feedback n Organisational skills – time management, working efficiently (i.e. not leaving work until the last minute, preparing for group studying with plenty of time), planning and managing a group study session

HOW DO YOU MANAGE STUDY GROUPS? Ideally, groups will meet regularly (e.g. once or twice a week) to review modules and cases from the clinic. Groups might want to review the self-assessment exercises, or decide its own ways to study together. Group study has the above benefits if the group is well planned and managed. Steps for managing study groups are below. Step 1: Determine who will be in the study group Groups manage best with 2 to 5 members. Groups over 5 members are not recommended. They are too big to work efficiently. The course facilitators will help participants organize into study groups. Study group arrangements will depend on where participants live and work. At least one member of the group should have access to a DVD player so that they can do exercises from the IMCI video together. Step 2: Establish group members’ role(s) and responsibilities Efficient groups divide tasks so that each member has a certain role or responsibility. For example, these roles might include: a group leader, a scheduler, or a note-taker. Step 3: Define group procedures It is important to have clear, detailed guidelines and procedures for group that all members should follow. Each activity should be clear in purpose and function.

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

Step 4: Schedule group meetings When organizing meetings, groups must consider: ✔✔ travel time and cost from multiple locations ✔✔ part-time or full-time work commitments ✔✔ family responsibilities ✔✔ disabilities among members These are not minor issues. Group study requires additional time and energy for attending and contributing to group meetings. Planning must consider each member’s available time and work schedule. Below is a sample schedule for group study.

HOW DO YOU SCHEDULE EFFECTIVE GROUP MEETINGS? When scheduling meetings, it is best to agree on the specific date, time, location, and material to be covered before the meeting. This will make the group meeting time as effective as possible for all group members. Groups are also encouraged to watch DVD videos and practice in the clinic together. MEETING DATE & TIME July 24, 2010 5:00 PM July 31, 2010 5:00 PM August 7, 2010 5:00 PM August 14, 2010 5:00 PM LOCATION District resource centre District resource centre District resource centre District resource centre CHAPTER & SECTION Part 1: Course overview Part 2: Introduction to IMCI Self-study module 1: General danger signs, p. 1–21 Self-study module: Young infant, section 1 and 2, p. 25–45 Self-study module: Young infant, section 3 and 4, p.45–67 TIME 1 hour 1 hour 1 hour 1 hour

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Introduction Part 2

THE IMCI PROCESS

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0.6

OVERVIEW OF IMCI

IMCI aims to reduce childhood mortality and improve the quality of care for major childhood illnesses, especially at first-level health facilities. Over 100 countries around the world have adopted IMCI, and thousands of healthcare professionals have been trained in IMCI.

WHAT IS THE STATE OF CHILD HEALTH TODAY? Every year around the world, 6.6 million children in developing countries die before they reach their fifth birthday. The large majority of these deaths are from preventable causes – acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition. Children often die from a combination of these conditions.

Major causes of death in neonates and children under-five World - 2011 What causes children to die globally Pneumonia   13%   Pertussis   1%   Meningi5s/   encephali5s   2%   Pneumonia   5%   Preterm  birth   complica5ons   14%  

Other  condi5ons   9%  

Neonatal   deaths:  43%  

Birth  asphyxia  &  trauma   10%  

NCDs   8%   Neonatal  sepsis  &  other   infec5ons   5%   Malaria   7%   HIV/AIDS   2%   Measles   2%   Diarrhoea   9%   Other  condi5ons   3%   Congenital   Neonatal  tetanus   abnormali5es   1%   4%   Diarrhoea   1%  

Injuries   4%  

45% of global under-five deaths are associated with nutrition-related factors*

Sources:

(1) WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html) (2) *For undernutrition: Black et al. Lancet, 2013

Sources: (1) WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html) (2) *For undernutrition: Black et al. Lancet, 2013

2|

TITLE from VIEW and SLIDE MASTER | October 8, 2013

Countries may have some variation in child mortality, especially if disease burden like HIV and malaria incidence is especially high.

WHAT ARE FACTORS OF POOR HEALTH? Mortality is higher in children living in the poorest households, in rural areas, or with mothers that have little education. This tells us that there are many factors that influence a child’s health.

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

What could some of these factors be? ✔✔ Poor access to health facilities, for example, because of poor roads or transportation costs to the family. ✔✔ Access to education, particularly for the mother. This is a very important factor for child health. ✔✔ Food insecurity due to poverty or not enough food from farming. ✔✔ Lack of basic resources that help prevent disease spread, like clean water, sanitary toilets, and waste disposal. 150 146

120

121 114 101 114

90

90

91

62 60

67 51

30

Poorest

Second

Middle

Fourth

Rural

Urban

None

Primary

Wealth Source: UNICEF/WHO Child Mortality Report 2011

Residence

Mother’s education

HOW CAN IMCI HELP MANAGE SICK INFANTS AND CHILDREN? Every day, millions of caregivers take children with illnesses to first-level health facilities.1 Some of these illnesses are possibly fatal. Most sick children present with signs and symptoms related to more than one condition. For example, the graph on the previous page showed that while a child might have diarrhoea, there is a strong chance that she is also undernourished. This overlap means that a single diagnosis may not be possible or appropriate for the child. Treatment may need to combine therapy for several conditions.

1

First-level facilities include clinics, health centres, and outpatient departments of hospitals.

18

Secondary or higher

0

Richest

IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

WHY WAS IMCI CREATED? In most developing countries, first-level facilities do not have many diagnostic tools like laboratory services or radiology equipment to diagnose multiple conditions. Without many diagnostic tools, health providers at the first level often use patient history, signs, and symptoms to determine how to provide the best care with the available resources. Due to limited supplies, human resources, and equipment, healthcare providers at first-level facilities often need to refer more complicated clinical procedures to second-level facilities. Providing quality care to sick children in these conditions is a serious challenge. In response to this challenge, WHO and UNICEF developed a strategy known as Integrated Management of Childhood Illness (IMCI). IMCI integrates case management of the most common childhood problems, especially the most important causes of death.

WHAT DOES INTEGRATED MANAGEMENT MEAN? With the IMCI process, you will always be given a list of conditions that you will check in children and infants. You will assess and treat children for all conditions that are present. Let us consider a typical situation in your clinic, the story of Suku. Nidhi brings her son Suku into the clinic and tells you he has diarrhoea. You will normally examine Suku and give treatment for his diarrhoea. This is important because diarrhoea is a major cause of dehydration and death in children. However, it is possible that Suku also has a fever, or that he is malnourished because of a feeding problem. Nidhi might not notice these issues. Maybe she is most worried about the diarrhoea so that is what she told you about. You will be busy making sure you diagnose his diarrhoea. You do not always have a strategy to check for other health problems. IMCI gives you instructions to manage Suku’s diarrhoea based on the severity of dehydration and the type of diarrhoea. IMCI also gives you instructions to examine Suku for a list of common health problems in children. For each condition, IMCI explains what signs to ask the caregiver about, or look and feel for yourself. For example, if Suku has a fever, it could be a symptom of malaria, measles, or another serious infection. You will examine Suku for several signs relating to causes of fever. You will use IMCI charts based on the signs he shows to decide how severe the problem is. The charts will also give instructions about treatment. You will check Suku for all conditions and then decide on an overall treatment for all of the problems he has. If Suku shows signs of a severe condition, he requires referral. IMCI guidelines will explain how you will treat before urgent referral. If his conditions are serious

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but do not require urgent referral, the guidelines will explain what treatment to give in your clinic. If the conditions are not severe, the guidelines will identify home-based treatment. IMCI instructions also provide advice on counselling Nidhi about treating Suku at home, feeding problems, well child care, and disease prevention. IMCI also explains when they should return to the clinic. IMCI guidelines explain how to provide follow-up care when Nidhi and Suku come back.

Using IMCI allows you to provide more comprehensive care for Suku

WHAT IS THE BENEFIT OF INTEGRATED CASE MANAGEMENT? IMCI guides you through comprehensive care. This ensures that you will examine Suku for common health problems, nutrition, and immunizations. With the IMCI instructions, you might find health issues that you would not have otherwise. IMCI also helps you to give rapid and affordable interventions. For example, you know when to give Suku home treatment, instead of treatment in the clinic. Or you will know when Suku is most serious and needs referral, so that you do not unnecessarily send families to the hospital. At the same time, IMCI identifies when Suku has serious issues that require urgent attention.

Key points about IMCI guidelines: •• Assess all young infants and children for all common causes of illness and death •• Charts help you classify a problem •• Charts identify treatment and tell you where to treat the child

HOW CAN IMCI HELP YOU IMPROVE YOUR SKILLS AS A CARE PROVIDER? By providing an algorithm for integrated management of the child, IMCI seeks to improve: ✔✔ Your case management and counselling skills ✔✔ Your knowledge of, and ability to follow, national health guidelines ✔✔ The way your facility and health system manages childhood illness ✔✔ Family and community practices, particularly in giving home treatment, preventing disease, and minimizing health risks around the home

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WHY DOES IMCI ALSO FOCUS ON THE CAREGIVER? Case management is most effective when families bring sick children to a trained health worker for care in a timely way. A child is more likely to die if a family waits to bring a child to a clinic until the child is extremely sick, or if the family takes the child to an untrained provider. Therefore, teaching families when to seek care is an important part of case management.

WHO CAN USE IMCI, AND WHEN? IMCI is designed for first-level facilities, such as a clinic, health centre, or an outpatient department of a hospital. Any health professional caring for children under five years of age can use IMCI. IMCI guidelines are age-specific for sick young infants and sick children. You will learn more about this in the next section. As you read in Suku’s case, the IMCI guidelines describe how to care for a child coming to a clinic with an illness (called an initial visit) or a scheduled follow-up visit to check the child’s progress (called a follow up visit). In this course you will learn how to use the IMCI guidelines to recognize clinical signs, decide appropriate treatments, and counsel caregivers.

WHO CAN USE IMCI? All health professionals caring for children from birth up to 5 years of age

ARE THERE LIMITATIONS TO USING IMCI? The IMCI guidelines address most, but not all, of the major reasons a sick child is brought to a clinic. A child returning with chronic problems or less common illness may require special care that is not described in your IMCI modules. Additionally, the guidelines do not describe how to manage trauma or other acute emergencies due to accidents or injuries. You will need to refer a child to a hospital for special care if the child’s illness does not respond to the standard treatments described, the child becomes severely malnourished, or the child returns to the clinic repeatedly. Now you will learn more details about the IMCI process.

Overall, the goal of IMCI is to decrease childhood deaths, reduce how often children are sick, reduce the severity of illness, and improve growth and development in the children you care for.

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0.7

WHAT DO THE IMCI GUIDELINES EXPLAIN?

The IMCI case management process involves these steps; refer to the flow charts on next pages.

ASSESS IMCI uses simple signs to detect cases. As few clinical signs as possible are used. These signs are based on expert clinical opinion and research results. That means detection of conditions for treatment is based on your observations. You will ASSESS all sick infants and children for: 1. Signs of serious illness that requires urgent referral, then 2. Signs of common health conditions, and then 3. Nutrition status, immunization status, and other problems.

CLASSIFY You will classify each health condition using colour-coded IMCI charts. You will classify based on the history given, signs the child shows, and tests as indicated. The chart also identifies treatment for the condition. These classifications cover the most likely diseases, and reflect your national treatment guidelines. The three colour-coded classifications also tell you where to give these treatments: ✔✔ 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 Some children will show signs from multiple boxes. You will always use the more severe classification. For example, if a child shows signs from a red and yellow box, you will use the red. If a child has multiple conditions, he will have a classification for each condition.

TREAT After classifying all conditions, you will review all treatments identified in each classification. Then you will develop an integrated treatment plan. If a child requires urgent referral, give essential treatment before the patient is transferred. If a child needs treatment at the clinic, you will often give the first dose in the clinic. Give immunizations if needed. You will advise caregivers on home treatment.

COUNSEL A critical component of IMCI is counselling caregivers on home treatment (e.g. treating local infections, giving oral drugs), feeding and fluids, breastfeeding, and other well child care. Then counsel the caregiver about her own health. Advise the caregiver to return for follow-up on a specific date. Teach caregivers when to return immediately if child shows signs of severe illness.

PROVIDE FOLLOW-UP CARE When a child returns to the clinic as requested, give follow-up care as required. Re-examine conditions to see if the issues are improving, the same, or worsening. Use the full IMCI process again to check the child for new problems.

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IMCI FOR THE SICK CHILD (2 months up to 5 years of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick child ) ASK: what are the child’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

CHECK FOR GENERAL DANGER SIGNS •• •• •• •• Unable to drink or breastfeed Vomits everything Convulsions Lethargic or unconscious Even if present

ASSESS MAIN SYMPTOMS •• •• •• •• Cough or difficult breathing Fever Malnutrition and anaemia Check immunizations •• •• •• •• Diarrhoea Ear problems HIV status Others

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

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IMCI FOR THE SICK YOUNG INFANT (up to 2 months of age) GREET THE CAREGIVER ASK: child’s age (this chart is for sick young infant) ASK: what are the infant’s problems? ASK: initial or follow-up visit for problems? MEASURE: weight and temperature

ASSESS MAIN SYMPTOMS ASSESS FOR GENERAL DANGER SIGNS for very severe disease Even if present

•• •• •• •• •• ••

Jaundice Diarrhoea HIV status or mother’s HIV status Feeding problem and growth Check immunizations Assess other problems and mother’s health

All danger signs require urgent referral

CLASSIFY

URGENT REFERRAL (RED) URGENT REFERRAL REQUIRED

TREAT IN CLINIC (YELLOW) REFERRAL NOT REQUIRED

TREAT AT HOME (GREEN) REFERRAL NOT REQUIRED

•• IDENTIFY pre-referral treatment •• URGENTLY REFER

•• •• •• ••

IDENTIFY TREATMENT TREAT COUNSEL caretaker FOLLOW-UP CARE

•• IDENTIFY TREATMENT •• COUNSEL caretaker on home treatment •• FOLLOW-UP CARE

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0.8

CASE MANAGEMENT BY AGE

HOW DO YOU DETERMINE A YOUNG INFANT OR CHILD? IMCI is age-specific because young infants and children show different signs of illness.

Up to 2 months of age is a young infant Age 2 months up to 5 years is a child HOW WILL YOU DETERMINE THE CHILD’S AGE? Depending on the procedure for registering patients in your clinic, the child’s name, age and other information may have been recorded before they come to see you. If not, you will begin by asking the caregiver about the child’s name and age to determine the chart to use.

HOW DO YOU DETERMINE WHICH IMCI CHARTS TO USE FOR EACH? The IMCI charts are organized into two sections for the sick child and sick young infant. You will learn about these charts and the chart booklet in the next section. FOR ALL SICK CHILDREN up to 5 years of age who are brought to the clinic

GREET THE CAREGIVER and ASK THE CHILD’S AGE

If child is up to 2 MONTHS old Use the charts: l ASSESS & CLASSIFY SICK YOUNG INFANT l TREAT THE SICK YOUNG INFANT

If child is 2 MONTHS up to 5 YEARS Use the charts: l ASSESS & CLASSIFY SICK CHILD l TREAT THE CHILD

In this course, read more in: l MODULE 2

In this course, read more in: l MODULES 1,3,4,5,6 and 7

WHAT DOES ‘UP TO 5 YEARS’ MEAN? Up to 5 years means the child has not yet had his or her fifth birthday. For example, this age group includes a child who is 4 years 11 months, but not a child who is 5 years old.

WHAT IF A CHILD IS EXACTLY 2 MONTHS OLD? If the child is not yet 2 months of age, the child is considered a young infant. A child who is 2 months old is a sick child, not a young infant.

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0.9

USING THE CHART BOOKLET & RECORDING FORMS

HOW WILL YOU USE THE IMCI CHART BOOKLET AND RECORDING FORM? IMCI charts provide instructions to: •• Assess symptoms and health conditions •• Classify the illness and identify treatment for each classification •• Treat the child or young infant •• Counsel the caregiver •• Give follow-up care The charts follow the same order as the IMCI recording form. This is where you will records notes on the IMCI process. It also helps you record critical health information about the child. These charts are organized into a Chart Booklet. This booklet is a useful job aid, and you should keep it with you as you see patients. It guides you through the entire IMCI process. You will grow more comfortable using it as you practice.

HOW IS THE CHART BOOKLET ORGANIZED? The Chart Booklet has a section for the sick child, and a section for the sick young infant. You must immediately determine a child’s age so you know which section of charts to use.

HOW DO YOU USE RECORDING FORMS? The recording form helps you keep notes as you assess, classify, identify treatment, and treat. The IMCI recording form follows the instructions on the IMCI charts. Each section on the form is for a particular symptom or health problem. It helps you follow the process and not forget anything. Remember two important points about recording forms: ✔✔ There are separate recording forms for the sick child and one for the sick young infant ✔✔ You will use a second recording form when the child or infant returns for a follow-up visit

NOW YOU WILL READ ABOUT USING THE CHART BOOKLET AND RECORDING FORMS The following pages show you how the chart booklet instructions translate into the recording forms. As you read, follow along with your own chart booklet and a copy of recording forms. You will find recording forms in this section, in your logbook, or at the back of your chart booklet. Open your chart booklet and follow along as you read the next pages.

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ASSESS AND CLASSIFY CHARTS The ASSESS AND CLASSIFY chart describes how to assess the child, classify the child’s illnesses and identify treatments. The ASSESS column on the left side of the chart describes how to take a history and do a physical examination. You will note the main symptoms and signs found during the examination in the ASSESS column of the case recording form. The CLASSIFY column on the ASSESS AND CLASSIFY chart lists clinical signs of illness and their classifications. ‘Classify’ means to make a decision about the severity of the illness. For each symptom, you will select a classification and write it in the CLASSIFY column of the recording form. ASSESS AND CLASSIFY CHART CASE RECORDING FORM (FRONT)

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IDENTIFY TREATMENT COLUMN The TREATMENT column of the ASSESS AND CLASSIFY chart shows the recommended treatment for each classification. You will write the treatments identified for each classification on the reverse side of the recording form. When a child has more than one classification, you will record treatments for each classification. ASSESS AND CLASSIFY CHART CASE RECORDING FORM (BACK)

On the following page, you will see an example of a recording form with identified treatments recorded on the back. Once you have classified all of a child’s symptoms or problems, you will review all of the treatments you have listed. You will determine integrated treatment for the child. You will see some notes on integrated treatment on the next page.

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EXAMPLE OF REVERSE SIDE OF FOLDED RECORDING FORM

37.5

✔

Pneumonia

Acute Ear Infection No Anaemia, Not Very Low Weight

ooooooooooooooooooooooooooooooooooooooo Antibiotic for pneumonia, 5 days ooooooooooooooooooooooooooooooooooo Soothe throat, relieve cough with safe remedy ooooooooooooooooooooooooooooooooooooooo F/up: 2 days ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo Antibiotic for ear infection, 5 days ooooooooooooooooooooooooooooooooooooooo Paracetamol for ear pain ooooooooooooooooooooooooooooooooooooooo Dry ear by wicking ooooooooooooooooooooooooooooooooooooooo F/up: 5 days ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo Because child is less than 2 years old, assess feeding/counsel ooooooooooooooooooooooooooooooooooooooo mother on feeding. If feeding problem, f/up 5 days. ooooooooooooooooooooooooooooooooooooooo 2 days Measles ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooooooooooo

Fold

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TREAT THE CHILD CHARTS The IMCI chart titled TREAT THE CHILD shows how to give the identified treatments. You will TREAT in the clinic or teach about giving treatment at home. TREAT charts include information about medicines, and their doses and when they should be given. It also describes treatments to be given in the clinic, and in the home. TREAT THE CHILD CHART (TOP)

COUNSEL THE CAREGIVER CHARTS The chart titled COUNSEL THE CAREGIVER includes recommendations on feeding, fluids, home treatment, and when to return to the clinic. You will counsel all caregivers about these topics if the child is going home. You will write the results of any feeding assessment on the bottom of the case recording form. You will record the earliest date to return for follow-up on the reverse side of the case recording form. COUNSEL THE MOTHER CHART CASE RECORDING FORM (TOP) (FRONT)

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During a sick child visit, listen for any problems that the caregiver herself may be having. The caregiver may need treatment or referral for her own health problems. You will also advise the caregiver about her own health. The next section discusses important communication skills counselling caregivers.

FOLLOW-UP CARE CHARTS Several treatments in the ASSESS AND CLASSIFY chart include a follow-up visit. At a follow-up visit you can see if the child is improving on the drug or other treatment that was prescribed. The GIVE FOLLOW-UP CARE section of the TREAT THE CHILD chart has instructions for follow-up care for each condition. There is a box for follow-up care for each of the classifications or health problems. TREAT THE CHILD CHART (BOTTOM)

Now, review the IMCI recording forms in full: The following two pages include recording forms for the young infant and the child. You will see how the recording form follows the IMCI guidelines in your chart booklet. As a reminder, you should begin using these forms and your chart booklet in your clinic. These two tools are critical job aids when using the IMCI strategy. They provide a structure for each clinical visit with a child and family.

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MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Ask: What are the child's problems? Age: Weight (kg): Initial Visit? Height/Length (cm): Follow-up Visit? Temperature (°C):

ASSESS (Circle all signs present)

CLASSIFY LETHARGIC OR UNCONSCIOUS CONVULSING NOW General danger sign present? Yes ___ No ___ Remember to use Danger sign when selecting classifications Yes __ No __

CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how long? ___ Days

DOES THE CHILD HAVE DIARRHOEA? For how long? ___ Days Is there blood in the stool?

Count the breaths in one minute: ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer then 2 seconds)? Slowly? Look or feel for stiff neck Look for runny nose Look for signs of MEASLES: Generalized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever.

Yes __ No __

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Decide malaria risk: High ___ Low ___ No___ For how long? ___ Days If more than 7 days, has fever been present every day? Has child had measles within the last 3 months? Do a malaria test, if NO general danger sign in all cases in high malaria risk or NO obvious cause of fever in low malaria risk: Test POSITIVE? P. falciparum P. vivax NEGATIVE?

Yes __ No __

If the child has measles now or within the last 3 months: DOES THE CHILD HAVE AN EAR PROBLEM? THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Is there ear pain? Is there ear discharge? If Yes, for how long? ___ Days

Look for mouth ulcers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. Look for pus draining from the ear Feel for tender swelling behind the ear Look for oedema of both feet. Determine WFH/L z-score:____ Less than -3? Between -3 and -2? -2 or more ? For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? Is there any medical complication: General danger sign? Any severe classification? Pneumonia with chest indrawing? Child 6 months or older: Offer RUTF to eat. Is the child: Not able to finish? Able to finish? Child less than 6 months: Is there a breastfeeding problem? Yes __ No __

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or oedema of both feet: CHECK FOR HIV INFECTION

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 Hep B0 DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1 DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2 DPT+HIB-3 OPV-3 Hep B3 RTV-3 Pneumo-3 Measles1 Measles 2 Vitamin A Mebendazole

Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis?

Return for next immunization on: ________________ (Date)

ASSESS FEEDING if the child is less then 2 years old, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your child? Yes ___ No ___ If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___ Does the child take any other foods or fluids? Yes ___ No ___ If Yes, what food or fluids? How many times per day? ___ times. What do you use to feed the child? If MODERATE ACUTE MALNUTRITION: How large are servings? Does the child receive his own serving? ___ Who feeds the child and how? During this illness, has the child's feeding changed? Yes ___ No ___ If Yes, how? Ask about mother's own health ASSESS OTHER PROBLEMS:

FEEDING PROBLEMS

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MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS Name: Ask: What are the infant's problems?: ASSESS (Circle all signs present) Age: Weight (kg): Initial Visit? Temperature (°C): Follow-up Visit? CLASSIFY

CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficulty in feeding? Has the infant had convulsions?

THEN CHECK FOR JAUNDICE When did the jaundice appear first?

Count the breaths in one minute. ___ breaths per minute Repeat if elevated: ___ Fast breathing? Look for sever chest indrawing. Look and listen for grunting. Look at the umbiculus. Is it red or draining pus? Fever (temperature 38°C or above fells hot) or low body temperature (below 35.5°C or feels cool) Look for skin pustules. Are there many or severe pustules? Movement only when stimulated or no movement even when stimulated? Look for jaundice (yellow eyes or skin) Look at the young infant's palms and soles. Are they yellow? Look at the young infant's general condition. Does the infant: move only when stimulated? not move even when stimulated? Is the infant restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly? Determine weight for age. Low ___ Not low ___ Look for ulcers or white patches in the mouth (thrush).

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes ___ No ___

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgently to hospital Is there any difficulty feeding? Yes ___ No ___ Is the infant breastfed? Yes ___ No ___ If yes, how many times in 24 hours? ___ times Does the infant usually receive any other foods or drinks? Yes ___ No ___ If yes, how often? What do you use to feed the child?

CHECK FOR HIV INFECTION

ASSESS BREASTFEEDING

Note mother's and/or child's HIV status: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive virological test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophylaxis? Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant able to attach? To check attachment, look for: Chin touching breast: Yes ___ No ___ Mouth wide open: Yes ___ No ___ Lower lip turned outward: Yes ___ No ___ More areola above than below the mouth: Yes ___ No ___ not well attached good attachment Is the infant sucking effectively (that is, slow deep sucks, sometimes pausing)? not sucking sucking effectively effectively Hep B 2 200,000 I.U vitamin A to mother Return for next immunization on: ________________ (Date)

CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) BCG OPV-0 DPT+HIB-1 OPV-1 DPT+HIB-2 OPV-2 Hep B 1

ASSESS OTHER PROBLEMS:

Ask about mother's own health

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0.10 USING GOOD COMMUNICATIONS AND COUNSELLING SKILLS It is important to have good communication with caregivers from the beginning of the visit.

WHY ARE COMMUNICATION SKILLS SO IMPORTANT? Using good communication helps to reassure the caregiver or caregiver that the child will receive good care. Good communication skills also help you get important information about the child’s situation. Good communication skills also help you counsel and teach a caregiver on care. For example, often a young infant or child who is treated at clinic needs to continue treatment at home. The success of home treatment depends on how well you communicate with the child’s caregiver or caregiver. She needs to know how to give the treatment. She also needs to understand the importance of the treatment.

WHEN USING IMCI, WHAT WILL YOU BE COUNSELLING CAREGIVERS ABOUT? There are several counselling topics that the IMCI COUNSEL charts include. You will learn about these in this section, and in each of the self-study modules.

(1) HOME TREATMENTS – giving oral drugs, treating local infections (2) FEEDING & FLUIDS – breastfeeding, feeding problems and recommendations FOLLOW-UP (3) WHEN TO RETURN RETURN IMMEDIATELY (4) COUNSEL MOTHER – on her own health and other care

WHAT COMMUNICATION SKILLS WILL YOU LEARN ABOUT IN THIS SECTION? This section includes the following important information on counselling and communication: ✔✔ The APAC process (ASK, PRAISE, ADVISE, CHECK UNDERSTANDING) ✔✔ 3 basic teaching steps ✔✔ How to determine the priority of advice ✔✔ Counselling on returning to the clinic You will read about these on the following pages.

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WHAT IS THE APAC PROCESS? The APAC process is a reminder of important skills that you should use every time you see a patient and caregiver. You will read more details below. ASK and listen to find out what the child’s problems are PRAISE the caregiver for what she has done well ADVISE her how to care for her child at home CHECK the caregiver’s understanding

ASK and LISTEN You have already learned that asking questions is critical for assessing the child’s problems. Listen carefully to find out what the child’s problems are. Listen to what the caregiver is already doing for the child. Then you will know what she is doing well, and what practices need to be changed. PRAISE It is likely that the caregiver is doing something helpful for the child, for example, a caregiver breastfeeding. Praise the caregiver for something helpful she has done. Be sure that the praise is genuine. Only praise actions that are indeed helpful to the child. ADVISE Some advice is simple. For example, you may only need to tell the caregiver to return with the child for follow-up in 2 days. Other advice requires that you teach the caregiver how to do a task. Teaching how to do a task requires several steps. Think about how you learned to write, cook or do any other task that involved special skills. You were probably first given instruction. Then you may have watched someone else. Finally you tried doing it yourself. You will read about basic teaching steps on the next page. Advise against any harmful practices that the caregiver may have used. When correcting a harmful practice, be clear, but also be careful not to make the caregiver feel guilty. Explain why the practice is harmful. CHECK understanding After you give advice, you want to be sure that the caregiver understands correctly. Ask questions to find out what the caregiver understands and what needs further explanation. When asking the caregiver questions to check her understanding, ask checking questions. Praise the caregiver for correct understanding. If she does not understand correctly, explain your advice again.

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WHAT ARE THE 3 STEPS WHEN TEACHING A CAREGIVER HOW TO DO SOMETHING? When you teach a caregiver how to treat a child, use 3 basic teaching steps: 1. GIVE INFORMATION Explain how to do the task, for example: ✔✔ Apply eye ointment ✔✔ Prepare ORS ✔✔ Soothe a sore throat 2. SHOW AN EXAMPLE Show how to do the task, for example: ✔✔ How to hold a child still and apply eye ointment ✔✔ How to mix the right amount of water with a packet of ORS ✔✔ How to make a safe remedy to soothe the throat 3. LET HER PRACTICE Ask the caregiver to do the task while you watch. For example, have the caregiver: ✔✔ Apply eye ointment in her child’s eye ✔✔ Mix ORS solution ✔✔ Describe how she will prepare a safe remedy to soothe the throat Letting a caregiver practice is the most important part of teaching a task. If a caregiver does a task while you observe, you will know what she understands and what is difficult. You can then help her do it better. The caregiver is more likely to remember something that she has practised than something that she has heard. In some cases, you can ask her to describe how she will do the task at home. 3. Let caregiver practise 1. Give information

2. Show an example

WHAT ARE OTHER IMPORTANT TIPS WHEN TEACHING? Here are some good tips to remember when teaching a caregiver. Your effectiveness as a counsellor can depend on how well you use this advice. ✔✔ SIMPLIFY LANGUAGE – Use words that she understands. ✔✔ USE VISUAL AIDS – Use teaching aids that are familiar, such as common containers. ✔✔ GIVE FEEDING – When she practices. Praise what was done well and make corrections. ✔✔ MORE PRACTICE – Allow more practice, if needed. ✔✔ ENCOURAGE & ANSWER QUESTIONS – Encourage the caretaker to ask questions. Answer all questions.

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WHAT ARE CHECKING QUESTIONS, AND HOW WILL YOU USE THEM? Checking questions find out what a caregiver has learned. They are especially important to check a caregiver’s understanding after you have taught something, or counselled on a topic. Good checking questions require the caregiver to describe something. From her answer you can tell if she has understood you and learned what you taught her about the treatment. If she cannot answer correctly, give more information or explain your instructions more clearly. Checking questions must be phrased so that the caregiver answers more than “yes” or “no”. Questions that can be answered with a “yes” or “no” do not show you how much a caregiver knows. To do this, they should begin with question words, such as why, what, how, when, how many, and how much. These are called “open-ended” questions. Checking questions also do not suggest the right answer, for example, “you will remember to give the medicine three times a day, right? ”

Checking questions begin with how, what, when, where, why A good checking question cannot be answered “yes” or “no” WHAT ARE EXAMPLES OF CHECKING QUESTIONS? First, consider if you asked a basic question to a caregiver. For example, you taught a caregiver how to give an antibiotic. What if you ask a question like this: “Do you know how to give your child his medicine? ” The caregiver would probably answer “yes”. This question does not require her to discuss the medicine further. She could answer “yes” even if she does not understand, because she may be embarrassed to say she does not understand. However, if you ask a few good checking questions, you are asking the caregiver to describe instructions that you have given: “ When will you give your child the medicine?” “ How many tablets will you give each time?” “For how many days will you give the tablets?” Asking good checking questions like the ones below help you make sure that the caregiver learns and remembers how to treat her child. The poor questions below can be answered “yes” or “no”. GOOD CHECKING QUESTIONS How will you prepare the ORS solution? How often should you breastfeed your child? On what part of the eye do you apply the ointment? How much extra fluid will you give after each loose stool? Why is it important for you to wash your hands?

POOR QUESTIONS Do you remember how to mix the ORS? Should you breastfeed your child? Have you used ointment on your child before? Do you know how to give extra fluids? Will you remember to wash your hands?

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WHAT DO YOU DO AFTER ASKING A QUESTION? After you ask a question, pause. Give the caregiver a chance to think and then answer. ✔✔ Do not answer the question for her. ✔✔ Do not quickly ask a different question. Asking checking questions requires patience. The caregiver may know the answer, but she may be slow to speak. She may be surprised that you really expect her to answer. She may fear her answer will be wrong. She may feel shy to talk to an authority figure. Wait for her to answer. Give her encouragement. If the caregiver answers incorrectly or says she does not remember, be careful not to make her feel uncomfortable. Teach her to give the treatment again. Give more information, examples or practice to make sure she understands. Then ask her good checking questions again.

After teaching, what do I do? n GIVE TIME for caregiver to ask questions n REPEAT INFORMATION if needed n ADDRESS CONCERNS that the caregiver has

WHAT IF THE CAREGIVER HAS PROBLEMS WITH THE RECOMMENDED TREATMENT? A caregiver may understand but may say that she cannot do as you ask. She may have a problem or objection. Common problems are lack of time or resources to give the treatment. A caregiver may object that her sick child was given an oral drug rather than an injection, or a home remedy rather than a drug. Help the caregiver think of possible solutions to her problems and respond to her objections. For example, if you ask, “When will you apply the eye ointment in your child’s eye?” The caregiver may answer that she is not at home during the day. She may tell you that she can only treat her child in the morning and in the night. Ask her if she can identify someone (a grandparent, an older sibling) who will be at home during the day and can give the mid-day treatment. Help her plan how she will teach that person to give the treatment correctly. If you ask, “What container will you use to measure 1 litre of water for mixing ORS?” The caregiver may answer that she does not have a 1-litre container at home. Ask her what containers she does have at home. Show her how to measure 1 litre of water in her container. Explain how to mark the container at 1 litre with an appropriate tool or how to measure 1 litre using several smaller containers.

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If you ask, “How will you soothe your child’s throat at home?” A caregiver may answer that she does not like the remedy that you recommended. She expected her child to get an injection or tablets instead. Convince her of the importance of the safe remedy rather than the drug. Make the explanation clear. She may have to explain the reason for the safe remedy to family members who also expected the child to be treated differently.

HOW DO YOU DETERMINE THE PRIORITY OF THE ADVICE? WHEN CHILD HAS ONLY ONE PROBLEM TO BE TREATED: Give all of the relevant treatment instructions and advice listed on the charts. WHEN CHILD HAS SEVERAL PROBLEMS: When a child has several problems, the instructions to caregivers can be quite complex. In this case, you will have to limit the instructions to what is most important. You will have to determine: ✔✔ How much can this caregiver understand and remember? ✔✔ Is she likely to come back for follow-up treatment? If so, some advice can wait until then. ✔✔ What advice is most important to get the child well? If a caregiver seems confused or you think that she will not be able to learn or remember all the treatment instructions, select only those instructions that are most essential for the child’s survival. Essential treatments include giving antibiotic or antimalarial drugs and giving fluids to a child with diarrhoea. Teach the few treatments well and check that the caregiver remembers them.

IF YOU NEED TO LIMIT INFORMATION, WHICH TREATMENTS SHOULD YOU DELAY? If necessary, omit or delay the following treatments. They are important, but not the most essential treatments for immediate survival. You can give these treatment instructions when the caregiver returns for the follow-up visit. ✔✔ Feeding assessment and feeding counselling, unless you are treating malnutrition. ✔✔ Home treatments that may be lower priority at the moment because they are not life essential, like soothing remedy for cough or cold or wicking an ear. ✔✔ Second doses of Vitamin A, iron, immunizations, or other measures that can be addressed in the follow-up visit.

HOW WILL YOU COUNSEL ABOUT RETURNING TO THE CLINIC? You will need to advise a caregiver when to return to the clinic for 3 situations: 1. Scheduled follow-up visit for the child’s current problems 2. For next well child visit and immunizations 3. Immediately if child shows signs of severe illness

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

WHEN SHOULD A CHILD RETURN FOR A FOLLOW-UP VISIT? Certain problems require follow-up in a specific number of days. At the end of the visit, tell the caregiver or caregiver when to return for follow-up. Some problems need follow-up to ensure that the treatment is working. For example, pneumonia, dysentery and acute ear infection require follow-up to ensure that an antibiotic is working. Persistent diarrhoea requires follow-up to ensure that feeding changes are working.

What is follow-up needed for more than one problem? Child should return at earliest definite time. Some other problems only need follow-up if the problem persists. This is the case of fever, or pus draining from the eye. Sometimes an infant or child may need follow-up for more than one problem. In such cases, tell the caregiver the earliest definite time to return. Also tell her about any earlier follow-up that may be needed if a problem, such as fever, persists. Both the COUNSEL THE CAREGIVER chart and the YOUNG INFANT chart show summaries of the follow-up times for different problems. You will review follow-up times in each module.

WHEN SHOULD A CHILD RETURN FOR A WELL CHILD VISIT? Remind the caregiver or caregiver of the next visit her child needs for immunization unless the caregiver already has a lot to remember and will return soon anyway. For example, if a caregiver must remember a schedule for giving an antibiotic, home care instructions for another problem, and a follow-up visit in 2 days, do not describe a well-child visit needed one month from now. However, do record the date of the next immunization on the Caregiver’s Card.

WHEN SHOULD A CHILD RETURN IMMEDIATELY? You must counsel caregivers about signs that the infant or child will show if they have serious illness. These signs are listed in the section WHEN TO RETURN on both the COUNSEL THE CAREGIVER and YOUNG INFANT charts. They are also included below. For all infants and children who are going home, you will teach the caregiver certain signs that mean to return immediately for further care. Remember that this is an extremely important section. Caregivers must know these signs.

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IMCI DISTANCE LEARNING COURSE | INTRODUCTION – SELF-STUDY MODULES

SICK YOUNG INFANT Advise the caregiver to return immediately if the young infant has any of these signs: ✔ Breastfeeding poorly ✔ Reduced activity ✔ Becomes sicker ✔ Develops a fever ✔ Feels unusually cold ✔ Fast breathing ✔ Difficult breathing ✔ Palms and soles appear yellow

SICK CHILD Advise the caregiver to return immediately if the child has any of these signs: ✔ Any sick child: ✔ Not able to drink or breastfeed ✔ Becomes sicker ✔ Develops a fever If child has NO PNEUMONIA: COUGH OR COLD: ✔ Fast breathing ✔ Difficult breathing If child has diarrhoea, also return if: ✔ Blood in stool ✔ Drinking poorly Exceptions: ✔ If the child already has fever, the child does not need to return immediately for fever. ✔ If the child already has blood in the stool, you do not need to tell the caregiver to return immediately for blood, just for drinking poorly.

USING A MOTHER/CAREGIVER’S CARD Use a take-home card to explain the signs and help her/him remember. The card should display signs in both words and drawings. Circle the signs that the caregiver must remember. Use local terms that the she will understand. Ask checking questions to be sure that she understands.

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ISBN 978 92 4 150682 3