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TRANSPORT MANAGEMENT

Transport refers to the act or process of transferring or conveying people, goods, or materials from one place to another.

It involves the movement of individuals, objects, or substances by various means such as vehicles, vessels, or even through digital networks.

Transport is essential for carrying out both, Facility-Based and Non-Facility-Based community health care services. These include:- bicycles, motorcycles and vehicles depend on level of Health facility. For such transport means to be useful for the intended results, some minimal management procedures or instructions need to be instituted.

Procedures for Managing Bicycles, Motorcycles, and Vehicles in Health Service Transport

To ensure the effective management of bicycles, motorcycles, and vehicles in health service transport, it is important to implement certain procedures and instructions. While the specific procedures may vary depending on the level of the health facility.

Keeping an Updated Inventory Record:

Maintain a comprehensive inventory record of all bicycles, motorcycles, and vehicles used in health service transport. This record should include details such as the make, model, registration number, and condition of each vehicle.
Regularly update the inventory record to reflect any changes, such as additions or disposals of vehicles, and identify any discrepancies or missing vehicles.
Use the inventory record to track the usage, maintenance history, and availability of each vehicle.

Servicing and Maintenance:

Establish a regular servicing and maintenance schedule for all bicycles, motorcycles, and vehicles. Such as oil changes, tire rotations, and brake checks to ensure the vehicles are in optimal condition.
Conduct routine inspections to identify any issues or defects that may affect the safety or performance of the vehicles.
Keep detailed maintenance records, including dates of service, performed tasks, and any repairs or replacements made.
Train staff members responsible for servicing and maintenance on proper procedures and safety protocols.
Address any reported issues or concerns to minimize downtime and ensure the vehicles are always available for use.

Transport policy:

Every health care organization must make a transport policy that governs their transport. It should be adhered to by all workers and managers.
Authorization and Use of Vehicles: The transport policy should clearly define who is authorized to use the organization’s vehicles and under what circumstances. It should specify the procedures for requesting and obtaining authorization to use a vehicle. The policy should outline any restrictions on carrying passengers or items in the vehicles.
Vehicle Maintenance and Disposal: The transport policy should include guidelines for the maintenance and upkeep of vehicles. It should specify the procedures for regular inspections, servicing, and repairs of vehicles. When disposing of old vehicles or purchasing new ones, the policy should adhere to relevant regulations, such as the Public Procurement and Disposal Authority (PPDA) Act 2014 for government and PNFPs.
Compliance and Training: All workers and managers should be made aware of the transport policy and their responsibilities in adhering to it. Regular training sessions should be conducted to ensure that employees understand and comply with the policy. The policy should be reviewed periodically to incorporate any necessary updates or changes.

Managing transport information:

In healthcare organizations, it involves keeping track of various documents and records related to vehicles, journeys, fuel usage, maintenance, and compliance.

Vehicle Log Book: The logbook proves your ownership of a vehicle. In addition, the vehicle logbook works as a summary of the vehicle’s key statistics: make, model, engine, etc. Log book is a book in which someone records details and events relating to something for example a journey or period of their life or a vehicle
Vehicle Journey Cards: Some organizations use journey cards or a book to record all the journeys made by each vehicle. This helps in tracking the total distance traveled and the amount of fuel consumed for each journey.
Fuel and Maintenance Receipts: It is important to keep receipts for fuel purchases and maintenance repairs. These receipts provide evidence of expenses and can be used for accounting and auditing purposes.
Tax Licenses: Healthcare organizations must ensure that all vehicles have valid tax licenses. These licenses should be kept up to date and readily accessible for inspection.

Planned Preventive Maintenance

It involves periodic maintenance tasks such as replacing oil, fluids, and grease; inspecting for wear and tear on moving components; and replacing components according to the manufacturer’s recommendations and regular inspections.
Objectives: Investing in maintenance to avoid breakdowns, Increasing the reliability of vehicles and Reducing overall running costs.
Implementation: Planned preventive maintenance is achieved through daily checks, defect identification, and regular servicing.

Inventory of Transport:

Inventory refers to a detailed list of equipment, instruments, infrastructure, and buildings, including transport, available in a unit.

Information to Collect:

Make and model of the vehicle.
Year of manufacture.
Engine and chassis numbers.
Registration number.
Main use.
Activity or program it is allocated to.
Seating capacity.
Running condition.
Person responsible.

Importance of Carrying out Inventory of Transport:

Prevents misuse of transport.
Facilitates good supervision.
Aids in scheduling use.
Restricts use to named individuals.
Supports the use of log books.
Enables the enactment of enforceable policies on private use.
Ensures strict daily vehicle checks.

Importance of Transport Management in Health Facilitie

Resource Optimization: Transport is a valuable resource that should be managed like any other asset. By efficiently managing vehicles, health facilities can maximize their utilization and achieve better outcomes without necessarily increasing the number of vehicles.
Impact on Service Delivery: Well-managed transport systems ensure that vehicles are available when and where they are needed, enabling timely delivery of healthcare services to patients.
Cost Considerations: Transport management can help minimize costs including purchase, maintenance, repairs, insurance, fuel, and replacement, freeing up resources for other needs of healthcare.
Third Largest Cost: In many health service delivery settings, transport ranks as the third largest cost after staff and medicines. Proper management of transport can help optimize spending in this area and allocate resources more effectively.
Protection of Vehicles and Equipment: Proper maintenance and use of vehicles extend their lifespan and reduce the need for repairs and replacements. This saves money and ensures that vehicles are always in good working condition.
Time Savings: Improved transport management allows for more efficient use of vehicle time, reducing delays and improving overall service delivery timelines.
Safety: Good maintenance and respect to safety protocols not only save time and money but also save lives. Well-maintained vehicles are less prone to breakdowns, reducing the need for repairs and replacements.
Reduced Liability: Effective transport management helps prevent accidents and injuries, reducing the risk of legal liability for health facilities.
Accident Prevention: Effective transport management helps minimize the risk of accidents and injuries. This protects not only the vehicle operators and users but also pedestrians and other road users.
Positive Public Image: Well-managed transport systems contribute to a positive public image for health facilities. On the other hand, poorly managed transport can lead to negative publicity and a loss of public trust.
Compliance with Regulations: Transport management must comply with relevant laws and regulations to ensure the safety and well-being of all road users. This includes adhering to traffic regulations, maintaining proper documentation, and ensuring vehicles are in compliance with legal requirements.
Divers responsinilities are respected: Ensuring the availability and use of safety equipment (e.g., warning triangles, first aid kits, fire extinguishers). Wearing high visibility clothing and other protective gear. Carrying essential tools and supplies (e.g., puncture repair kits, tow ropes, spare fuel)

Uses of Transport in Health Facilities

Emergency Medical Services (EMS): Transport plays a critical role in emergency medical services, enabling rapid response and transportation of patients to hospitals or specialized care facilities. EMS vehicles, such as ambulances, provide life-saving transportation for individuals in critical condition.
Medical Supply Delivery: Transport is important for the timely delivery of medical supplies, such as medications, vaccines, laboratory samples, and equipment, to healthcare facilities. Small quantities can be transported by foot or bicycle to community health workers.
Administrative Support: Use of public transportation for administrative tasks to conserve available vehicles for health service delivery.
Supervision: Technical support, program inspections (e.g., sanitation, water source protection).
Training:Transport for facilitators and participants during field visits and study tours Delivery of training materials and equipment (e.g., computers, projectors)
Health Outreach Programs: Transport is utilized in health outreach programs, where healthcare professionals and support staff travel to remote or underserved areas to provide medical services, health education, and preventive care.
Mobile Clinics: Transport is essential for mobile clinics, which are equipped vehicles that bring healthcare services directly to communities. These clinics provide primary care, screenings, vaccinations, and other essential services, particularly in rural or isolated areas.
Patient Transfers: Transport is involved in transferring patients between healthcare facilities for specialized treatments, surgeries, or higher levels of care.
Meetings: Attendance at meetings at various levels (e.g., Ministry of Health, district, sub-district, community.

N.B: Walking remains the most reliable method of transportation for lower-level health facilities. Other means of transportation (e.g., bicycles, vehicles) are necessary for larger distances, bulk deliveries, and emergency situations.

MANAGING INFRASTRUCTURE

The maintenance of the buildings that make up the unit is the responsibility of the in charge.

Problems such as

leaking roofs,
broken toilets and repainting and repairs due’

should be reported to the local ministry of works representative or the person who is responsible for the actual repairs.

Sometimes the ministry of works (MOW) is unable to carry out the necessary repairs and authority is then given for the work to be sub-contracted to commercial builders.

Before such work can be carried out, it MUST be put out to tender. Tenders are offers by suitably qualified contractors to carry out the work with a statement of cost and of how long the work will take. Tenders are submitted in sealed envelopes. A tender committee, made up of various officers, opens all the tenders at the same time and compares them. The builder who best meets the requirements, even if the price is not the lowest, is awarded the contract and asked to carry out the work.

The tender system is used to avoid corruption and favoritism and loss of government/organizational money through inflated estimates. Work awarded without tendering will not be paid for by the government/ most organizations even if it involves small amounts. Inspect all the buildings including staff quarters (if there are any), once a week or once a fortnight, with one or two other staff, to check on the general standard of cleanliness. Necessary maintenance can be considered at the same time. Fire risk should be considered. Buckets of sand should be available if there are no other extinguishers.

Extinguishers need routine inspection to see if they are intact and up to date. Effective security is always difficult in health facilities. It (security) can be improved by limiting access to doors and gates and under observation by guards. After duty hours these doors must be closed and locked. Make sure the watch man/Askari knows who to inform in case of emergency.

Importances of infrastructure management in health facilities.

Operational Efficiency: Well-managed infrastructure ensures that healthcare services and facilities operate efficiently and effectively. This includes planning and structuring the built environment, equipment, access, information technology systems, and processes to facilitate high-quality, accessible, responsive, and safe services.
Emergency Preparedness: Infrastructure management becomes particularly important during times of crisis. Health facilities rely on vital resources such as electricity, water, and oxygen. Having backup plans in place, such as emergency generators, ensures continuity of care even during disruptions in the supply of essential resources.
Patient Experience and Well-being: Well-planned and managed infrastructure supports improved standards of patient care and well-being. Factors such as the design of healing environments, access to green spaces, and consideration of the sensorial environment can positively impact patient experience, reduce stress, and contribute to better health outcomes.
Staff Well-being: Infrastructure management should also prioritize the well-being of healthcare staff. Facilities that provide amenities like shops, cafes, prayer rooms, and access to green spaces can contribute to a positive work environment and support the well-being of staff, which is important for ensuring better healthcare.
Sustainability: This can involve implementing energy-efficient technologies, utilizing real-time measurements and control systems, and reducing carbon emissions. Building sustainable healthcare infrastructure not only helps protect the environment but also optimizes operational costs and improves resource management.

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FINANCIAL MANAGEMENT, BUDGETING & ACCOUNTABILITY

FINANCIAL MANAGEMENT

Financial management is balancing income and expenditure to ensure that available money is used appropriately to meet ongoing needs.

Financial management has three crucial aspects:

Quantity: This means that there must be enough money to meet the organization/health facility needs regardless of other factors. This applies particularly to cash. It is not safe to have a large amount of cash at the health center as it may be stolen. For this reason, visible money is usually small in amount and is called “Petty cash”.
Liquidity: Funds must be in the suitable form for the use for which they are intended. For Example diverting money meant for medicines to other expenditures in the health facility.
Performance: Funds are allocated to the health facility based on its level of functionality and performance. For example: HCII, HCIII, HCIV and hospitals.

Importance of Financial Management at a Health Facility

Raising and Safeguarding Funds: Proper management of health facility revenue and expenditure includes raising and safeguarding funds to ensure that the facility has sufficient financial resources to operate effectively. This involves:

Developing strategies to generate revenue from various sources, such as patient fees, insurance payments, government grants, and donations.
Implementing efficient systems for collecting and recording revenue, including the use of receipts and electronic payment methods.
Establishing secure storage facilities for cash and other financial assets to prevent theft or loss.

Efficient Resource Allocation: Effective management of revenue and expenditure allows health facilities to allocate their financial resources efficiently to optimize healthcare services. This involves:

Prioritizing essential expenses, such as salaries, medical supplies, and equipment maintenance.
Identifying areas where costs can be reduced or optimized without compromising the quality of care.
Investing in cost-effective interventions and technologies to improve patient outcomes.

Community Access to Services: Proper financial management ensures that health facilities have the resources to provide essential health services to the community. This includes:

Covering the costs of staff salaries, medical supplies, and equipment necessary to deliver healthcare services.
Establishing affordable payment options for patients, including fee waivers and payment plans.
Reaching out to underserved populations and providing access to healthcare services regardless of their ability to pay.

Informed Decision-Making: Effective management of revenue and expenditure provides health facility managers with accurate financial data to support informed decision-making. This includes:

Regular financial reporting that tracks revenue, expenditure, and financial performance.
Analysis of financial data to identify trends, forecast future needs, and make evidence-based decisions.
Using financial information to plan for future investments and service expansions.

Trust and Confidence: Transparent and accountable financial management builds trust among health staff and the community. This involves:

Maintaining accurate and up-to-date financial records.
Regularly reporting financial information to stakeholders, including staff, patients, and the community.
Addressing any concerns or questions about financial matters promptly and effectively.

Others include;

Ensuring Availability of Funds for Essential Purchases: Proper management ensures that sufficient funds are available to purchase high-priority items such as drugs, medical supplies, and equipment, which are essential for providing quality healthcare.

Preventing Financial Exhaustion: By managing revenue and expenditure effectively, health units can avoid running out of funds, which could lead to disruptions in healthcare services.

Tracking Expenses: Proper management allows health units to monitor how much they are spending on specific items, such as salaries, utilities, and maintenance. This information helps identify areas where costs can be optimized or reduced.

Determining Financial Status: Effective management provides a clear understanding of the health unit’s financial status, including the amount of money available at any given time. This information is essential for planning and decision-making.

Adhering to Budget: Proper management ensures that the health unit follows the approved budget in its spending, preventing unauthorized or excessive expenditures.

Financial Management Obligations for Managers

Budget Preparation: Develops a financial plan outlining income and expenses.
Financial Projections: Forecasts future financial needs and potential risks.
Cost Analysis: Compares costs of services to identify areas for improvement.
Reporting Compliance: Meets reporting requirements for donors and government agencies.
Data-Driven Decisions: Utilizes financial reports to make informed decisions that enhance healthcare operations.

Process of Financial Management in a health facility

Collecting Money and Issuing Receipts: All revenue received, such as patient fees, insurance payments, and donations, must be collected and documented with official receipts.
Recording Exemptions and Debtors: If any patients are exempted from paying fees or receive credit, their exemptions or debts must be recorded accurately.
Safeguarding Funds: Money collected should be kept securely at the health unit or deposited in a designated bank account.
Recording Transactions: All revenue received and deposited, as well as any exemptions or debts, must be recorded in the cashbook and bank book.
Verifying Bank Statements: Bank statements should be regularly reconciled with the bankbook to ensure accuracy and prevent discrepancies.
Reconciling Records: The total amount of money recorded in the health unit’s registers should match the amount in receipts, debtors, and exemption books to ensure accountability and prevent fraud.

Sources of Health Financing

Health financing can be categorized into two main sources:

Public Funding: Funds coming from central and local Government, including funds from Health Development partners (HDPs) channeled through central and local Government budget support mechanisms, and through project mechanisms.
Private Funding: Funds coming from private or non-Government sources, including out-of-pocket payments (payment from a sick person or relative’s pocket) for health services, Insurance Prepayment scheme premiums, donations and projects and programmes funded and implemented by and through NGOs.

Service Sectors

Public Funding Sources

Private Funding Sources

Government Health

– Government of Uganda.

– Development partners.

– Central budget support.

– District Budget support.

– Private wings.

– NGO-supported projects and programs

Private Services

-Facility-based Private Not for Profit (PNFP)

– Non-facility-based PNFPs

– Private health practitioners

– Traditional and complementary medicine practitioners

– Govt subsidies or cost support to private facilities, including infrastructure development

– Contractual arrangements with private providers

– Participation in Govt-funded programs

– Multilateral and bilateral

projects and program

channeled through

central or local Govt.

– Household (user fees)

– Insurance (employer-based, community-based, national-based, and private)

– Donations (internal and external)

– Income-generating activities

– Fundraising

– Commercial marketing strategies

– NGO-supported projects and programs

Primary Methods/Mechanisms of financing and funding health care systems

Direct or Out-of-Pocket Payments: Individuals make direct payments for healthcare services as they are received. This method involves paying at the point of service delivery, often from personal funds.
General Taxation from Formal and Informal Sectors: Funding is generated through general taxation, encompassing contributions from both the formal and informal sectors. Examples include income tax (e.g., pay as you earn) and taxes levied on businesses.
Social Health Insurance: Citizens contribute compulsory premiums from their income, mandated by government law. In Uganda, this mechanism is currently under discussion, reflecting ongoing considerations about its implementation.
Voluntary, Community, or Private Health Insurance: This method involves individuals or employers paying premiums to insurance agencies for healthcare coverage. Examples include private insurers like AAR and UAP. Additionally, community health insurance models exist, where community members pool resources to collectively cover health risks and expenses for members or dependents facing illness.
Donations: Healthcare systems may receive support in the form of grants or loans from development partners. These external contributions, whether financial aid or loans, play a role in improving healthcare infrastructure and services.

BUDGETING AND BUDGET CONTROL

A budget is a quantitative statement, usually in monetary terms, of the plans and expectations of a defined area over a specific period of time. It addresses what to be done, where and when.

A budget is a financial statement which contains estimates of revenue and expenditure of an organization for a certain period of time in order to achieve predetermined objectives..

A budget is a plan of how to spend a certain amount of money for a specified period. It involves allocation of available funds to prioritized items and activities.

Terms Related to Budgeting:

Cost Centers: A cost center is a function within an organization that does not directly add to profit but still costs money to operate, such as accounting, HR, or IT departments.
Profit: Profit refers to the financial gain or positive difference between revenues and expenses.
Fixed Costs: Fixed costs are expenses that do not vary with the level of production or activity. These costs remain constant regardless of the volume of goods or services produced.
Variable Costs: Variable costs fluctuate based on the level of production or activity. They increase as production volume increases and decrease as production volume decreases.
Direct Costs: Direct costs are expenses that can be easily traced to a specific product, department, or project. Examples include raw materials, labor, and distribution costs directly associated with production.
Indirect Costs/Overhead Costs: Indirect costs are expenses that are not easily traceable to a specific product, department, or project. These costs are incurred for the overall operation of the organization and cannot be directly allocated to a specific cost object.
Operating Expenses: Operating expenses are the ongoing costs incurred by a business to conduct its normal operations. These expenses include rent, utilities, salaries, and other day-to-day expenses necessary for running the business.
Budget Variance: Budget variance is the difference between the budgeted or planned amount and the actual amount incurred or achieved. Positive variance indicates that actual performance exceeded the budget, while negative variance suggests that actual performance fell short of the budget.
Cash Flow: Cash flow refers to the movement of money in and out of a business over a specific period. Positive cash flow indicates that the business is generating more cash than it is spending, while negative cash flow indicates that the business is spending more cash than it is generating.
Contingency Fund: A contingency fund, also known as a reserve fund, is a pool of money set aside to cover unexpected expenses or emergencies. It serves as a buffer against unforeseen events that could impact the organization’s financial stability.
Budget Cycle: The budget cycle is the process through which a budget is created, approved, executed, monitored, and evaluated within an organization. It follows a recurring timeline, such as monthly, quarterly, or annually, depending on the organization’s needs.

Importance of Budgeting

Budgeting is a crucial financial planning tool and It involves the systematic allocation of financial resources to achieve specific goals and objectives.

Planning and Policy Making: Budgeting provides a framework for organizations to plan their operations and set policies. It helps them establish clear financial targets and allocate resources accordingly.
Evaluating Performance: Budgets serve as benchmarks against which actual financial performance can be measured. By comparing actual results to budgeted amounts, organizations can identify areas where they are meeting or falling short of expectations.
Determining Sources of Resources: Budgeting helps organizations determine the sources of financial resources they need to achieve their goals. This includes identifying potential revenue streams and exploring funding options.
Determining Expenditure: Budgets establish limits on how much organizations can spend on various activities. This helps control expenses and ensures that resources are allocated efficiently.
Authorizing Future Expenditure: Budgets provide authorization for future expenditures. Once approved, budgets give managers the authority to commit resources to specific projects or initiatives.
Coordinating Activities of an Organization: Budgeting helps coordinate the activities of different departments and units within an organization. It ensures that all departments are working towards common financial goals.
Regulating and Controlling Income and Expenditure: Budgets act as a regulatory mechanism to ensure that income and expenditure are managed responsibly. They help prevent overspending and ensure that resources are used effectively.
Determining the Affordability of Programs: Budgeting helps organizations determine the affordability of new programs or initiatives. By comparing the costs of proposed programs to available resources, organizations can make informed decisions about which programs to pursue.
Motivational Tool: It motivates individual members by serving as a target. Well defined goals and targets usually motivate individuals. But this needs participatory formulation of plans.

Qualities of a good Budget:

Realistic: Achievable with the available resources.
Balanced: Addresses all relevant needs in a well-proportioned manner.
Plan-Based: Follows a structured work plan.
Understood by Users: Clearly comprehensible to all users involved.
Inclusive of All Revenue Sources: Encompasses all potential sources of revenue.
Future-Bound: Forward-looking, considering future requirements.
Reflects Teamwork and Consultative Effort: Demonstrates collaboration and input from the team.

Types/Kinds/Forms of Budgets:

1. Operating Budget: Also known as an Annual Budget, this is the organization’s statement of expected revenues and expenses for the coming year. It covers a specified 12-month period and is used to measure the operational and financial performance of the organization. The operating budget can be further broken down into smaller periods such as 6 months, 4 quarters, or even monthly periods.

Revenue Budget: Represents the expected income for the budget period, such as money from patients in a hospital.
Expense Budget: Consists of salary and non-salary items and should reflect the patient care objectives and activity parameters established for the nursing unit or hospital.

2. Personnel Budget: Also known as a Salary Budget, this budget projects the salary costs that will be paid and charged to the cost center in the budget period.

3. Supply and Non-salary Expense Budget: This budget identifies the input supplies needed to operate the business or organization. In the case of a hospital or nursing unit, it includes patient-related supplies needed for operations.

4. Capital Budget: This budget is made to meet the long-term goals of an organization, such as physical renovations, new constructions, or equipment replacements planned within the budget period.

The Budgeting Process/Budgeting Cycle.

Budgeting is a process of planning and controlling future operations by comparing actual results (actual budgetary performance) with planned expectations.

Budgeting process preparation

Before the preparation of any budget in an organization, the budget period, a budget manual, responsibility for the preparation of budget, and a budget committee have to be set or/and put in place.

Steps of Budgeting process:

1. Identification of Objectives: The first step in the budgeting cycle is to identify the organization’s objectives. These objectives should be aligned with the organization’s mission, vision, and strategic plan.

2. Determination of Resource Needs: Once the objectives have been identified, the organization must determine the resources that are needed to achieve those objectives. This includes both financial and non-financial resources, such as personnel, equipment, and supplies.

3. Pricing of the Requirements: The next step is to price the requirements. This involves estimating the cost of the resources that are needed to achieve the objectives.

4. Identification of Revenue Sources: The organization must then identify the revenue sources that will be used to fund the budget. This may include revenue from sales, grants, donations, or other sources.

5. Negotiation of Budget Allocation with Superiors: Once the budget has been developed, it must be negotiated with superiors. This may involve justifying the budget to superiors and making adjustments as necessary.

6. Prioritizing the Needs: The organization must then prioritize the needs that are included in the budget. This involves determining which needs are most important and which needs can be deferred.

7. Coordination and Consolidation into Master Budget: The individual budgets for each department or unit within the organization are then coordinated and consolidated into a master budget. The master budget is a comprehensive financial plan that outlines the organization’s expected revenues and expenses for the upcoming period.

8. Approval: The master budget must then be approved by the organization’s leadership. This may involve a vote by the board of directors or other governing body.

9. On-going Review: The budget is not a static document. It should be reviewed and updated on an ongoing basis to ensure that it remains aligned with the organization’s objectives and financial performance.

Approaches or Methods or Classifications of budgeting.

The organization may choose various approaches or methods, or combination of them, for requesting departmental managers to prepare their budget requests.

1. Zero-based budget: ZBB requires starting the budgeting process from scratch, with every expense justified and evaluated. It does not rely on previous budgets and encourages a thorough review of all expenses. It assumes the base for projecting next year’s budget is zero. Managers are required to justify activities and programs as if they were being initiated for the first time.

A regional hospital, aiming to expand its services to meet the growing healthcare needs of the community, decides to implement zero-based budgeting for the upcoming fiscal year. The hospital administration identifies the need to provide new services, particularly in the maternity and emergency departments, and plans to hire additional medical staff, upgrade medical equipment, and renovate existing facilities.

Advantages:

Strategic Focus: The hospital can strategically allocate resources to priority areas, ensuring the effective expansion of essential services.
Resource Optimization: By starting with a clean slate, the hospital can allocate resources based on current needs, avoiding unnecessary expenses and optimizing resource utilization.
Granular Visibility: Zero-based budgeting provides detailed visibility into each department’s requirements, allowing for a thorough examination of costs at a granular level.
Cost Reduction: Identifying and justifying every money spent helps the hospital identify areas for potential cost reduction, contributing to overall financial efficiency.
Adaptability to Changes: As the hospital aims for expansion, zero-based budgeting allows for easy adaptation to unforeseen changes in the healthcare landscape or community needs.
Eliminates Tradition: ZBB eliminates the traditional approach of carrying over items from the previous budget, ensuring a fresh and relevant budget.
Output Focus: The approach focuses on output in relation to value for money, aligning expenditures with measurable outcomes.
Realistic Needs: Zero-based budgeting is more realistic to the current needs of the hospital, preventing the perpetuation of outdated budgetary items.
Bottom-Up Approach: The involvement of lower cadres of staff in the budgeting process ensures a bottom-up approach, incorporating insights from those directly involved in patient care.
Encourages Creativity: ZBB encourages creativity among lower-level staff as they actively participate in decision-making processes related to budgeting.

Disadvantages:

Time-Consuming Process: The thorough line-by-line justification required for zero-based budgeting can be time-consuming, demanding extensive analysis and documentation.
Costly Implementation: Implementing ZBB can be costly, involving significant expenses in terms of time, effort, and potentially hiring external expertise.
Lower-Level Understanding: Lower-level cadres may find it hard to understand the complexities of zero-based budgeting, potentially hindering effective participation.
Skilled Personnel Requirement: Successful implementation requires highly skilled personnel, and such individuals may be scarce, leading to recruitment challenges.
Theoretical and Difficult: ZBB is very theoretical and can be difficult to apply in real-world scenarios, posing challenges in practical execution.
Limited Frequency of Use: Due to its time-intensive nature, zero-based budgeting is often not employed frequently, potentially limiting its effectiveness in ongoing financial management.
Trial and Error: The iterative nature of adjusting the budget may involve trial and error, especially for a healthcare facility navigating expansion plans.
Resource Allocation Challenges: Allocating resources without historical reference may pose challenges in accurately estimating the needs of each department.

2. Incremental Budgeting: Incremental budgeting is a traditional budgeting method where the budget for the new period is prepared by making incremental changes to the previous period’s budget. This approach is based on the assumption that the current activities and costs are still needed, without thoroughly examining them. Also called Traditional Budgeting since it involves creating a budget based on historical data and previous spending patterns.

A well-established hospital with a focus on maintaining its current standards and services chooses the incremental budgeting method for the next fiscal year. The hospital administration, aiming for budgetary stability, believes that incremental changes in the existing budget are sufficient to meet the institution’s ongoing needs.

Advantages:

Cost-Effectiveness: Incremental budgeting is a cost-effective choice for the hospital, as it doesn’t require extensive financial analysis or sophisticated calculations.
Low Skill Requirement: The method is simple to prepare, requiring no highly skilled manpower. This simplicity facilitates a quick and efficient budgeting process.
Ease of Understanding: Incremental budgeting is easy to understand, making it accessible to various staff members across different departments.
Time Efficiency: The budgeting process takes a shorter time, allowing the hospital to swiftly allocate resources and plan for the upcoming fiscal year.
Reduced Conflict: Since incremental changes are few, the approach minimizes conflicts during the budgeting process, fostering a smoother decision-making environment.
Alignment with Long-Term Goals: Incremental budgeting is suitable for maintaining the hospital’s long-term goals, providing stability and consistency in resource allocation.

Disadvantages:

Carrying Forward Deficiencies: Deficiencies from the previous year are carried forward, potentially bringing inefficiencies or misallocations.
Lack of Questioning Spending Levels: The method does not encourage questioning of the previous level of spending, possibly leading to unnecessary resource allocation.
Neglect of Specific Areas: Incremental budgeting may overlook specific areas of spending, hindering a detailed examination of each department’s needs.
Potential for Inflated Expenditure: Current expenditure could be inflated or padded, leading to a distortion of the actual financial needs of the hospital.
Disincentive to Innovation: The method may act as a disincentive to innovation or the generation of new ideas, as it tends to maintain existing spending patterns.
Risk of Maintaining Inefficiencies: Incremental budgeting may keep inefficiencies in operations, especially if the operations based on the budget have not been thoroughly evaluated for effectiveness.
Limited Scrutiny: The approach inhibits change and relationships between costs, benefits, and objectives are rarely subjected to searching scrutiny, potentially hindering organizational growth.
Budget Maintenance Strategy: Managers may learn to spend the entire budget amount established for the current year to avoid budget cuts, creating a base for the next year that may not reflect the actual needs.

3. Program budgeting / Activity-based budget: An activity-based budget (ABB) is a financial budgeting approach that links activities to costs. Program-based budgeting requires objectives, outputs, expected results, and detailed costs to be provided for each activity or program. The budget is then prepared by combining all the budgets for different activities, resulting in a comprehensive program budget. This approach promotes transparency and accountability.

A specialized medical center, catering to a wide range of healthcare services and treatments, adopts the Activity-Based Budgeting (ABB) approach for the upcoming fiscal year. The complexity of services provided, including various medical procedures, diagnostics, and specialized treatments, makes ABB an ideal choice to gain a comprehensive understanding of resource allocation and cost distribution for each program or activity.

Advantages:

Rational Framework for Decision Making: Program Budgeting provides a structured and rational framework for decision-making, ensuring that financial allocations align with the strategic goals of the health program.
Cross-Functional Decision Making: It cuts across lines of responsibility, promoting collaborative decision-making that involves various departments and functions within the health program.
Identification of Contradictions and Overlaps: Program Budgeting exposes contradictory or overlapping programs, allowing the health program to streamline its initiatives for better efficiency.
Focus on Long-Term Effects: The method concentrates on the long-term effects of budget allocations, ensuring that resources are directed toward initiatives that contribute to sustained positive outcomes.
Informed Decision Making: Program Budgeting provides valuable information on the likely impacts of alternatives, enabling the health program to make informed decisions based on comprehensive insights.
Rational Choices through Cost-Benefit Analysis: It enables a rational choice through thorough cost-benefit analysis, ensuring that investments yield optimal returns in terms of program effectiveness.
Identifying Overspending Areas: ABB helps the medical center identify areas of potential overspending by linking activities directly to costs, allowing for a more detailed financial analysis.
Efficient Resource Allocation: The approach enables the medical center to allocate resources more efficiently, ensuring that each medical procedure or service is adequately funded based on its specific resource requirements.
Setting Better Financial Goals: ABB allows for the setting of more precise financial goals, aligning budget allocations with the strategic objectives of the medical center.
Progress Monitoring and Adjustments: The medical center can easily monitor its progress by assessing the budget against actual activities. This flexibility facilitates necessary adjustments to the budget in response to changing circumstances.

Disadvantages:

Complex Process: Program Budgeting is considered a complicated process, requiring a deep understanding of the individual programs and financial implications.
Limited Availability of Required Information: The information required for effective Program Budgeting may not always be readily available, potentially posing challenges in the decision-making process.
Resource-Intensive: Implementing Program Budgeting may demand a significant amount of work, both in terms of data collection and analysis, making it resource-intensive.
Centralization Requirement: Program Budgeting often needs a pyramidal structure for decisions to be taken at the top, potentially ignoring decentralization efforts within the health program.
Time-Consuming and Resource-Intensive: Implementing ABB can be time-consuming and resource-intensive, requiring detailed assessments of various activities and their associated costs.
Complexity and Specialized Training: Itmay be complex and necessitate specialized training for individuals responsible for creating and managing the budget. This can pose challenges in terms of understanding and implementation.
Inflexibility in Plans: ABB may be inflexible and may not allow for changes in plans or activities as they occur, potentially limiting adaptability to unforeseen circumstances.
Difficulty in Understanding and Using: The complexity of ABB can make it challenging for managers to understand and use the budget effectively, which may impact decision-making.

4. Value proposition budgeting: Value proposition budgeting, also known as priority-based budgeting, is an approach that focuses on analyzing and justifying the value of each item on an expenditure list. It involves reviewing costs and determining whether they contribute to the overall value and success of the company or hospital. By analyzing each cost item, value proposition budgeting helps identify areas where resources should be allocated to maximize value and eliminate unnecessary spending.

In a hospital setting, the management team is tasked with creating a budget for the upcoming fiscal year. With limited resources and increasing demands for healthcare services, they need a budgeting approach that ensures every dollar spent contributes to the hospital’s overall value proposition.

Advantages of Value Proposition Budgeting

Rational Decision Making: Value proposition budgeting provides a rational framework for decision-making by focusing on the value created by each expenditure. This ensures that resources are allocated to initiatives that align with the hospital’s goals and objectives.
Efficient Resource Allocation: By analyzing costs and determining their contribution to overall value, value proposition budgeting helps allocate resources more efficiently. This ensures that resources are directed towards activities that generate the highest return on investment for the hospital.
Long-term Focus: Value proposition budgeting concentrates on the long-term effects of expenditures rather than short-term gains. This helps the hospital prioritize investments that will have a lasting impact on its success and sustainability.
Cost-Benefit Analysis: Value proposition budgeting enables a cost-benefit analysis of each expenditure, allowing the hospital to assess whether the value derived from an activity justifies the cost incurred. This helps prevent unnecessary spending on low-value activities.
Exposure of Contradictory Programs: Through the rigorous analysis of costs and value, value proposition budgeting exposes contradictory or overlapping programs within the hospital. This allows the management team to streamline operations and eliminate redundant activities.

Disadvantages of Value Proposition Budgeting

Complex Process: Implementing value proposition budgeting can be a complex process, requiring significant time and resources to analyze and justify each expenditure. This complexity may deter some organizations from adopting this approach.
Resource Intensive: Value proposition budgeting requires specialized training and expertise to effectively analyze costs and determine value. This may require additional resources and manpower, particularly for hospitals with limited financial capabilities.
Inflexibility: The rigid focus on value may lead to inflexibility in budgetary decisions, overlooking important but intangible factors that contribute to the hospital’s success. This lack of flexibility may hinder the hospital’s ability to respond to changing market conditions or emerging opportunities.
Difficulty in Understanding: Value proposition budgeting may be challenging for stakeholders, including staff and administrators, to understand and implement due to its complex nature. This could lead to resistance or reluctance to adopt this approach within the hospital.
Limited Consideration of External Factors: Value proposition budgeting may overlook external factors such as changes in regulations or market conditions that could impact the hospital’s operations. This narrow focus may result in decisions that are not fully aligned with external realities.

Limitations of Budgets and Budgeting:

Inflexibility: Budgets are usually static and do not account for unforeseen circumstances or changes in business conditions. This can make it difficult to adapt to unexpected events or seize new opportunities.
Time-Consuming: Budgeting is a time-intensive process that requires gathering data, analyzing trends, and making projections. This can divert resources away from other important activities.
Inaccuracy: Budgets are based on estimates and assumptions, which can lead to inaccuracies. Actual results may deviate significantly from budgeted figures, making it difficult to assess performance and make informed decisions.
Lack of Motivation: Budgets can be seen as constraints rather than motivators. Employees may become discouraged if they feel that their budgets are too restrictive or unrealistic.
Political Bias: Budgets can be influenced by political or personal agendas, leading to decisions that may not be in the best interests of the organization.
Limited Scope: Budgets do focus on financial aspects of the organization and may not consider other important factors such as market conditions, customer satisfaction, or employee morale.
Over Reliance on Historical Data: Budgets often rely heavily on historical data, which may not be relevant in a rapidly changing environment. This can lead to outdated assumptions and missed opportunities.
Lack of Accountability: If budgets are not properly monitored and enforced, they may become ineffective and fail to achieve their intended purpose.
Budgetary Slack: Employees may intentionally overestimate expenses or underestimate revenues to create a buffer for unexpected events. This can lead to inefficiencies and wasted resources.
Lack of Innovation: Budgets can discourage innovation by limiting resources for new initiatives or experimental projects. This can stifle creativity and hinder the organization’s ability to stay competitive.
Too few controllers and owners: Budgets may be controlled by a small number of individuals, leading to a lack of ownership and accountability.
Lack of good estimating: Budgets may be based on poor estimates, leading to inaccuracies and missed opportunities.
Based more on history rather than needs: Budgets may be based on historical data rather than current needs and priorities.

Conditions Necessary for Successful Budgeting:

Involvement and support of top management: Top management must be actively involved in the budgeting process and must demonstrate their support for the budget. This includes setting clear expectations, providing resources, and holding managers accountable for achieving their budget targets.
Clearly stated objectives: The budget should be aligned with the organization’s long-term strategic objectives. These objectives should be clearly defined and communicated to all employees.
Genuine and full involvement of managers: Line managers are responsible for implementing the budget and achieving the desired results. They must be fully involved in the budgeting process and must have a say in setting targets and allocating resources.
An appropriate accounting and information system: The accounting and information system should provide accurate and timely data to support the budgeting process. This includes data on revenues, expenses, assets, and liabilities.
Framework for regular revision of budgets and targets: Budgets should be reviewed and revised regularly to reflect changes in the business environment and the organization’s priorities. This ensures that the budget remains relevant and achievable.
Flexibility in the administration of budgets: Budgets should be flexible enough to accommodate unforeseen events and changing circumstances. This may involve adjusting targets or reallocating resources as needed.
Effective communication: The budget should be communicated clearly and effectively to all employees. This helps to ensure that everyone understands their role in achieving the budget targets.
Training and development: Employees should be provided with training and development opportunities to help them understand the budgeting process and to develop the skills needed to effectively manage their budgets.
Performance evaluation: Performance evaluations should be based on budget targets and achievements. This helps to hold employees accountable for their performance and to identify areas for improvement.
Continuous improvement: The budgeting process should be continuously improved to ensure that it is effective and efficient. This may involve seeking feedback from employees and making adjustments as needed.
Reward and recognition: Employees who achieve or exceed their budget targets should be rewarded and recognized. This helps to motivate employees and to reinforce the importance of budgeting.

ACCOUNTABILITY

Accountability refers to the responsibility and obligation of individuals or entities to justify and take ownership of their financial activities and decisions.

It involves ensuring that financial resources are used efficiently, effectively, and in accordance with established policies, regulations, and ethical standards.

Key Financial Records in Financial Management

Cash and bank books: These records track all cash and bank transactions, including deposits, withdrawals, and balances. They provide a detailed account of the facility’s cash flow and are essential for reconciling bank statements.
Budget: The budget outlines the facility’s planned revenue and expenditure for a specific period, typically a year. It serves as a financial roadmap and helps managers allocate resources effectively.
Cheques: Cheques are used to make payments to suppliers, staff, and other parties. They provide a secure and traceable method of transferring funds.
Requisition forms: Requisition forms are used to request the purchase of goods or services. They typically include details such as the item being requested, the quantity, and the estimated cost.
Vote books: A vote book is a memorandum accounts book intended to track government expenditures and verify that no money is spent outside of the budget. Vote books are used to track expenditure against specific budget lines. They help managers monitor spending and ensure that funds are being used as intended.
Invoices: Invoices are issued to patients and other payers for services rendered. They provide a detailed breakdown of the charges and are used to track revenue.
Payment receipts: Payment receipts are issued to patients and other payers upon receipt of payment. They serve as proof of payment and are used to reconcile revenue.
Payroll records: Payroll records track employee salaries, benefits, and deductions. They are used to calculate payroll expenses and ensure that employees are paid accurately and on time.
Inventory records: Inventory records track the quantity and value of medical supplies, equipment, and other assets on hand. They help managers optimize inventory levels and prevent overstocking or shortages.
Financial statements: Financial statements, such as the balance sheet and income statement, provide a comprehensive overview of the facility’s financial position and performance. They are used for financial reporting, analysis, and decision-making.

Receipt Book

A receipt is a formal record of the transfer of money from one person to another. It serves as proof that money has been paid for a service or goods.

Importance of Receipts:

Proof of purchase: Receipts serve as evidence that a transaction has taken place. They provide proof of purchase, which can be useful for returns, exchanges, or warranty claims.
Expense tracking: Receipts help individuals and businesses track their expenses. By keeping receipts, you can accurately record and categorize your spending, making it easier to manage your budget and track your financial health.
Tax deductions: Receipts are crucial for claiming tax deductions. They provide documentation for deductible expenses, such as business expenses, medical expenses, or charitable donations. Without receipts, it may be challenging to prove these deductions to tax authorities.
Reimbursement: Receipts are often required for reimbursement purposes. Whether it’s for business expenses or personal reimbursements, having receipts ensures that you can provide evidence of the expenses incurred.
Warranty and insurance claims: Receipts are necessary for warranty and insurance claims. If a product needs repair or replacement under warranty, the receipt serves as proof of purchase. Similarly, for insurance claims, receipts can help substantiate the value of lost or damaged items.
Budgeting and financial planning: Receipts play a vital role in budgeting and financial planning. By keeping track of your expenses through receipts, you can analyze your spending patterns, identify areas where you can save money, and make informed decisions about your financial goals.
Audit and compliance: Receipts are essential for audit and compliance purposes. They provide documentation and support for financial transactions, ensuring transparency and accountability.

Storage of Receipts:

Receipts should be filled out in duplicate. The original is given to the person giving the money.
The duplicate remains in the receipt book and is used for financial reconciliation purposes.

Handling Partial Payments:

If a person cannot pay the full amount, they should be given a receipt for the amount paid, and the remaining balance should be recorded in the Debtors’ Book.

Cash Analysis Book/Cash book

A Cash Analysis Book is used to record income and expenditure, showing money received and spent.

Purpose:

Efficient cash management: The Cash Analysis Book allows businesses to effectively manage their cash by providing a clear record of all cash transactions.
Budgeting and financial planning: Cash Analysis Book helps businesses create budgets and financial plans. It helps in forecasting future cash flows, setting financial goals, and ensuring that the organization is living within its means.
Financial reporting and compliance: The Cash Analysis Book serves as a reliable source of information for financial reporting and compliance purposes. It provides accurate records of cash transactions, which are necessary for preparing financial statements, tax returns, and other regulatory requirements.
Cash flow analysis: The Cash Analysis Book enables businesses to analyze their cash flow patterns over time, assess the timing of cash receipts and payments, and make adjustments to improve cash flow management.
Internal control and fraud prevention: Maintaining a Cash Analysis Book helps in establishing internal controls and preventing fraudulent activities, making it easier to detect unauthorized cash withdrawals or discrepancies in cash balances.
Decision-making support: The Cash Analysis Book provides valuable financial information that can be used to make informed decisions, businesses can identify areas where costs can be reduced, revenue can be increased, or investments can be made.

Categories in Cash Analysis Book:

IN (Income) categories include Inpatient User Charges, User Charges, Debt Recovery, Subventions, Medicines, Maternity.
OUT (Expenditure) categories cover Allowances, Functional expenses, Equipment and Maintenance, and Others.

Bank Deposits and Withdrawal forms

Bank deposit and withdrawal forms are used to deposit or withdraw money from the bank. They must be filled out accurately to reflect the transaction details.

Local Bank Statement: Provided by the bank, it summarizes the account’s transactions.

Bank Reconciliation: Compares transactions recorded in the Cash Analysis Book with those on the bank statement.

Quarterly Financial Report: Quarterly Financial Report summarizes monthly financial data copied into it at the end of each quarter.

Petty Cash Book: Petty cash (imprest) is a small amount of money kept for minor purchases, managed through a Petty Cash Book.

Petty Cash Requisition Voucher: Used to record petty cash expenditures, each voucher is numbered and filled out sequentially. Expenditures must be supported by receipts, and any balance should be noted for reconciliation.

MANAGING PETTY CASH

Managing money in a healthcare setting is handled by accountants or finance officers. However, in smaller health units like health centers, sometimes healthcare workers may need to manage the spending of money, known as petty cash.

Types of Money:

Invisible Money (Budgetary Allocation): This is money allocated for specific purposes, such as purchasing drugs or equipment. It’s not physically handled but requires record-keeping.
Visible Money (Cash or Petty Cash): This is physical money given to health workers for day-to-day expenses like transportation or minor purchases. It’s called petty cash and is kept in small amounts to minimize the risk of theft.

Keeping Track of Invisible Money:

An allocations ledger is used to record the spending of invisible money. This ledger details the allocated amount, purpose, and references to documents confirming the allocation. It helps ensure that money is spent only for its intended purpose.

Advantages of Allocations Ledger:

Advantages	Disadvantages
Helps track spending for specific purposes	Requires meticulous record-keeping
Ensures accountability and transparency	Time-consuming process

Using Petty Cash (Visible Money):

Petty cash, or small amounts of cash, is used for minor expenses that cannot be covered by allocations. The imprest system is commonly used to manage petty cash. In this system, a fixed amount of cash is given and replenished as needed, ensuring accountability.

Suppose that a health in charge (worker) is given an imprest of 40,000shs. He finds his office supplies are low, so he buys some stationery (carbon paper, paper clips, stamps, glue) all in one week. He spends a total of 30,000= leaving an unspent balance of 10,000=.

He then takes his receipts and petty cash book to his finance officer, who will give him 30,000= in cash to make the imprest up to 40,000= again. The imprest is now replenished. It may now take several weeks before he uses all the office supplies he bought, so that he may not need to replenish the imprest for a month or more.

Advantages of Imprest System:

Advantages	Disadvantages
Ensures accountability and control of petty cash	Requires careful documentation
Facilitates quick and small transactions	Risk of theft or misuse if not properly managed

Recording Petty Cash Transactions:

Petty cash transactions are recorded using petty cash vouchers. These vouchers detail the items purchased, amounts spent, and are accompanied by receipts. There are two methods of keeping petty cash records: the simple petty cash book and the columnar petty cash book.

Advantages of Petty Cash Vouchers:

Advantages	Disadvantages
Provides a record of petty cash transactions	Requires consistent and careful documentation
Prevents misuse of funds

Summary:

i. Financial documents such as proforma invoice, tax invoice, receipt, petty cash voucher, simple cash book, and columnar cash book are essential for managing healthcare finances. Each serves a specific purpose in tracking expenses and maintaining financial records.

ii. The two types of money used in a healthcare facility are invisible money (budgetary allocations) and visible money (petty cash).

iii. The imprest system involves providing a fixed amount of cash for petty expenses, which is replenished as needed, ensuring proper management and accountability.

FINANCIAL MANAGEMENT, BUDGETING & ACCOUNTABILITY Read More »

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS

Young infants have special characteristics which must be considered when classifying their illness. They can become sick and die very quickly from serious bacterial infection but which may manifest themselves through general signs e.g. reduced movements, fever or even hypothermia, failure to breastfeed etc.

IMNCI PROCESS FOR THE SICK YOUNG INFANT

1. GREET THE CAREGIVER

ASK: Child’s age

ASK : What are the infant’s problems?

ASK: Initial or follow-up visit for problems?

MEASURE: Weight and temperature

2. CHECK FOR

Possible serious bacterial infection (PSBI) or very severe disease
Pneumonia
Local Infection

All with severe disease require URGENT referral

3. ASSESS FOR MAIN SYMPTOMS

MAIN SYMPTOMS

Jaundice
Diarrhea
Feeding problem or LOW WEIGHT FOR AGE
Possible HIV INFECTION,
TB EXPOSURE

4. CLASSIFY

URGENT REFERRAL REQUIRED

• IDENTIFY and give pre-referral treatment

• URGENTLY REFER

TREAT IN CLINIC

• IDENTIFY TREATMENT

• TREAT

• COUNSEL caretaker

• FOLLOW-UP CARE

TREAT AT HOME

• IDENTIFY TREATMENT

• COUNSEL caretaker on home treatment

• FOLLOW-UP CARE

Signs of severe disease

Not feeding.
Severe chest indrawing or Fast breathing.
Convulsions.
No movement/Lethargy.
Temperature too high or too low.

ASSESS, CLASSIFY AND TREAT THE YOUNG INFANT

DO QUICK ASSESSMENT OF ALL SICK YOUNG INFANTS BIRTH UP TO 2 MONTHS*

ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE

Determine if this is an initial or follow-up visit for this problem
If initial visit, assess the child and classify as follows:

CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE, PNEUMONIA AND LOCAL INFECTION

ASSESS:

ASK

LOOK, LISTEN AND FEEL

Is the infant having difficulty in feeding?
Has the infant had convulsions (fits) or twitching?

ASK and LOOK:

Is the infant not able to feed or breastfeed?
Is there blood in the stool?

Look for breathing: is the baby gasping or not breathing at all even when stimulated
Count the breaths in one minute. Repeat the count if elevated.
Look for severe chest indrawing
Look and listen for grunting or wheezing.
Look for nasal flaring.
Look for central cyanosis and pulse oximetry where available
Look and feel for bulging anterior fontanelle.
Look at the umbilicus. Is it red or draining pus? Look for severe abdominal distension. Measure axillary temperature (or feel for fever or low body temperature)
Look for skin pustules.
Look For high pitched cry.
Look at the young infant’s movements

(Young infant must be Calm)

CLASSIFY AND IDENTIFY TREATMENT

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

Any of the following signs:

Respiratory rate less than 20 breaths per minute or
Convulsions or convulsing now or
Not able to feed or breastfeed or
Fast breathing (more than 60 breaths per minute) or
Severe chest indrawing or
Grunting or wheezing or
Nasal flaring or
Bulging anterior fontanelle or
Pus draining from the ear or
Fever (37.5º C* or above or feels hot) or
Very low body temperature (less than 35.5º C* or Feels cold) or
Movement only when stimulated or
No movements at all.
Blood in stool.
Severe abdominal distension
High pitched cry
Oxygen saturation <90%

POSSIBLE

SERIOUS

BACTERIAL

INFECTION

OR VERY

SEVERE

DISEASE

• Immediately resuscitate using a bag and mask if the baby:

– Is gasping or not breathing

– Has a respiratory rate less than 20 breaths per minute

• If convulsing now, give Phenobarbitone

• Give the first dose of Benzylpenicillin & Gentamicin.

• Treat to prevent low blood sugar

• Admit or refer URGENTLY to hospital**

• Advise mother how to keep the infant warm on the way to the hospital.

• Screen for possible TB disease and check for HIV

• If oxygen saturation is less than 90%, start oxygen therapy and refer or admit

• IF REFERRAL NOT POSSIBLE (see pg 37)

Red umbilicus or draining pus or
Skin pustules. And none of the signs of very severe disease

LOCAL

BACTERIAL

INFECTION

• Give Flucloxacillin Syrup

• Teach the mother to treat local infections at home.

• Advise mother to give home care for the young infant.

• Follow-up in 2 days

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately

Fast breathing (60 breaths per minute or more) in infants 7 to 59 days old

PNEUMONIA

• Give amoxicillin for 7 days

• Advise mother to give home

care for the young infant

• Follow up on day 4 of treatment

Temperature between 35.5ºC to 36.4ºC

LOW BODY

TEMPERATURE

• Re-warm the young infant and reassess after 1 hour. (kangaroo warming)

• Treat to prevent low blood sugar

• Advise mother to give home care for the young infant

• Advise mother when to return immediately

None of the signs of Very Severe Disease or Local Bacterial Infection

INFECTION

UNLIKELY

• Advise mother to give home care for the young infant

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

THEN CHECK FOR JAUNDICE

Physiological Jaundice:

Physiological jaundice emerges between 48 to 72 hours after birth.
It reaches its peak intensity on days 4 and 5 in term babies and day 7 in preterm infants.
Generally, it disappears by day 14.
Physiological jaundice does not extend to the palms and soles, requiring no treatment.
If jaundice appears on the first day, persists for 14 days or more, and extends to palms and soles, it is considered severe jaundice and demands urgent attention.

Pathological Jaundice:

Jaundice onset within the first day of life characterizes pathological jaundice.
It lasts longer than 14 days in term infants and 21 days in preterm infants.
Jaundice accompanied by fever raises concerns.
Deep jaundice, where the palms and soles of the baby exhibit a profound yellow hue, signifies a more severe condition.

ASSESS JAUNDICE

ASK	LOOK
Does the young infant have yellow discoloration of eyes, palms or soles? If yes, for how long?	Look for jaundice (yellow eyes or skin) Look at the young infants’ palms and soles. Are they yellow?

Classify Jaundice

SIGNS	CLASSIFY AS	IDENTIFY TREATMENT
Any jaundice if age less than 24 hours or Yellow eyes, palms and soles at any age Any visible yellowness in a pre-term baby regardless of when it appears	SEVERE JAUNDICE	• Treat to prevent low blood sugar: • Refer URGENTLY to the hospital. • Advise mother how to keep the infant warm on the way or the Hospital. • Screen for possible TB disease
Yellowness appearing after 24 hours of age Yellowness in the eyes & skin Palms and Soles NOT yellow	JAUNDICE	• Advise the mother to give home care for the young infant. • Advise mother to return immediately if eyes, palms and soles appear yellow • If young infant older than 14 days refer to hospital for assessment. • Follow up in 1 day
No jaundice	JAUNDICE	Advise mother to give home care for the young infant

THEN ASSESS FOR DIARRHOEA

ASK

LOOK

DOES THE YOUNG INFANT HAVE DIARRHOEA OR SIGNS OF DEHYDRATION? IF YES ASK:

For how long?
Does the child have diarrhoea?
Is the child vomiting?
Is the child able to feed?

* 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.

Infants Movements

• Does the infant move on his/her own?

• Does the infant 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)?

• Slowly?

• Immediately?

• Assess the young infant’s ability to feed

• Assess the young infant’s urine output

Classify for DEHYDRATION

SIGNS	CLASSIFY AS	IDENTIFY TREATMENT
Two of the following signs: Movement only when stimulated or no movement at all. Sunken eyes Skin pinch goes back very slowly Child not passing urine. Child not able to feed.	SEVERE DEHYDRATION	If infant has no other severe classification: • Give fluid for severe dehydration (Plan C) OR If infant also has another severe classification: • Admit/Refer URGENTLY to hospital with mother or caregiver giving frequent sips of ORS on the way • Advise mother to continue breast feeding. • If child is not passing urine admit/refer urgently to hospital. • If child is not able to feed, admit/refer urgently to hospital.
Two of the following signs: Restless and irritable Sunken eyes Skin pinch goes back slowly.	SOME DEHYDRATION	• Give fluid and breast milk for some dehydration (Plan B) • Advise mother when to return immediately • Follow-up in 2 days if not improving • If infant also has VERY SEVERE CLASSIFICATION • Admit/Refer URGENTLY to hospital** with the mother giving frequent sips of ORS on the way if child has diarrhoea. • Advise mother to continue breast feeding • Follow-up in 3 days if not improving
Not enough signs to classify as some or severe dehydration.	NO DEHYDRATION	• Give fluids to treat diarrhoea at home and continue breast feeding at home (Plan A) • Give ORS and Zinc sulphate if child has diarrhoea • Advise mother when to return immediately • Follow-up in 2 days if not improving.

CHECK FOR HIV EXPOSURE AND INFECTION

ASK

• Has the mother and/or young infant had an HIV test? IF YES:

• What is the mother’s HIV status?:

Antibody test is POSITIVE
Antibody test is NEGATIVE

If mother is HIV positive and NO positive DNA PCR test in child ASK:

Is the mother on ART and young infant on ARV prophylaxis?

IF NO TEST:

Mother and young infant status unknown

Perform HIV test for the mother:

If positive, perform DNA PCR test for the young infant

IF the mother is NOT available, do an antibody test on the child.

If positive, do a DNA PCR test.

CLASSIFY HIV STATUS

SIGNS	CLASSIFY AS	IDENTIFY TREATMENT
POSITIVE DNA PCR test in young infant	CONFIRMED HIV INFECTION	• Initiate ART, counsel and follow up existing infections • Initiate Cotrimoxazole prophylaxis • Assess child’s feeding and provide appropriate counseling to the mother/ caregiver • Advise the mother on home care • Offer routine follow up for growth, nutrition and development • Educate caregivers on adherence and its importance • Screen for possible TB disease at every visit. • For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB disease throughout IPT • Immunize as per schedule • Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.
Mother HIV positive and negative DNA PCR in young infant. OR Mother HIV positive, young infant not yet tested. OR Positive antibody test in young infant whose mother is not available	HIV EXPOSED	• Treat, counsel and follow up existing infections • Initiate Cotrimoxazole prophylaxis • Start or continue PMTCT* prophylaxis as per the national recommendations • Assess child’s feeding and provide appropriate counseling to the mother/caregiver • Advise the mother on home care • Offer routine follow up for growth, nutrition and development • Screen for possible TB disease at every visit • Immunize as per schedule • Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.
Mother’s antibody test is NEGATIVE	HIV NEGATIVE	• Manage presenting conditions according to IMNCI and other recommended national guidelines • Advise the mother about feeding and about her own health.

THEN CHECK FOR TB

ASK

LOOK AND FEEL

For symptoms suggestive of TB

• Has the young infant had contact with a

person with Pulmonary Tuberculosis or chronic cough?

• Has the young infant had persistent fevers for 14 days or more?

• Does the young infant have pneumonia which is not responding to standard therapy?

• Has the young infant been coughing for 14 days or more?

Look or feel for physical signs of TB

• Determine weight for age

– Weight less than 1.5kg?

– Weight for age less than -3 Z score?

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

Presence of ANY of the symptoms and signs suggestive of TB OR weight less than 1.5kg or 3Z score with any symptom.

PRESUMPTIVE

• Refer to hospital for further

assessment and management

• Ask about the caregiver’s health and treat as necessary

A sick young infant with no TB symptoms or signs

PRESUMPTIVE

• Treat, counsel, and follow up

existing infections

• Ask about the caregiver’s health and treat as necessary

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED INFANTS

ASK

LOOK AND FEEL

Is the infant breastfed? If yes, how many times in 24 hours?

Does the infant usually receive any other foods or drinks?

If yes, how often? If yes, what do you use to feed the infant?

Determine weight for age.

– Weight less than 1.5 kg?

– Weight for age less than

-3 Z score?

Look for ulcers or white patches in the mouth (thrush).

ASSESS BREASTFEEDING:

• Has the infant breast-fed 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:

– More areola seen above infant’s top lip than below bottom lip

– Mouth wide open

– Lower lip turned outwards

– Chin touching breast

(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.

Classify all FEEDING

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

• Weight

< 1.5 kg, or

• Weight

< -3 Z score

VERY LOW

WEIGHT

• Treat to prevent low blood sugar.

• Refer URGENTLY to hospital.

• Teach the mother to keep the young infant warm on the

way to hospital

• Check for HIV

• Not well attached

to breast or

• Not suckling

eectively, 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)

FEEDING

PROBLEM

and/or

LOW

WEIGHT

FOR AGE

• 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 breastmilk 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 for as long as the infant wants, day

and night.

• If receiving other foods or drinks, counsel mother about

breastfeeding more, reducing other foods or drinks, and

using a cup.

• If not breastfeeding at all:

– Refer for breastfeeding counselling and possible

relactation.

– Advise about correctly preparing breastmilk substitutes and using a cup.

• Check for TB

• Advise the mother how to feed and keep the low weight

infant warm at home

• If thrush, teach the mother how to treat thrush at home.

• Advise mother to give home care for the young infant.

• Follow up FEEDING PROBLEM or thrush on day 3.

• Follow up LOW WEIGHT FOR AGE on day 14.

• Not low weight for age and no other signs of inadequate feeding

NO FEEDING PROBLEM

• 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 STATUS

Age	Vaccine
Birth*	BCG
	bOPV-0
6 Weeks	bOPV-1
	DPT / HepB / Hib -1
	PCV 10-1
	ROTA 1

Give all missed doses on this visit.
Immunize sick infant unless being reffered
Include sick babies and those without a mother child health booklet.
If the child has no booklet, issue a new one today.
Advise the mother when to return for the next dose.

Assess the child’s growth and development milestones

• Plot the child’s weight on his/her growth card (child health card or mother baby passport)

• Ask mother about what the child is now able to do in terms of physical movement,

communication and interaction.

Assess the Child for ECD / other problems including Congenital Malformations

Ask mother for any other problem or identified external malformations

• Check child for any external malformations and abnormal signs

• Refer infant to hospital, if they have any external malformations

ECD-Early Childhood Development

Assess the Mother’s Health Needs

• Check if had full course of tetanus toxoid, if not,

give an appointment.

• Ask if pregnant , if so give an antenatal appointment. If not, ask if interested to talk

about family planning.

• Ask if RCT has been done and the results.

• If mother is an adolescent, link to appropriate clinic or service provider for support.

TREAT THE YOUNG INFANT

1. Give First Doses of Intramuscular Gentamicin and Intramuscular Ampicillin

– Gentamicin: Give 5 mg/kg/day in once daily injection.

In low birthweight (<2.5kg) infants, give 4 mg/kg/day in once daily injection.

To prepare the injection: From a 2 ml vial containing 40 mg/ml, remove 1 ml gentamicin from the vial and add 1 ml distilled water to make the required strength of 20 mg/ml.

– Ampicillin: Give 50mg/kg IM

* If referral is not possible, continue treatment for seven days

2. 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 breastmilk before departure.

If not possible to give expressed breastmilk, 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 breastmilk or sugar water by nasogastric tube.

3. 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, especially in a cold environment. Dress the young infant with extra clothing, including a hat, gloves, and socks. Wrap the infant in a soft dry cloth and cover with a blanket.

4. Refer Urgently

– Write a referral note for the mother to take to the hospital.

– If the infant also has SOME DEHYDRATION OR SEVERE DEHYDRATION and is able to drink: Give the mother some prepared ORS and ask her to give frequent sips of ORS on the way. Advise the mother to continue breastfeeding.

– Use the appropriate plan, A, B or C.

5. How to Give Oral Medicines at Home

– Follow the instructions below to teach the mother about each oral medicine to be given at home. Also, follow the instructions listed with each medicine’s dosage table.

– Determine the appropriate medicines and dosage for the infant’s age or weight.

– Tell the mother the reason for giving the medicine to the infant.

– Demonstrate how to measure a dose.

– Watch the mother practice measuring a dose by herself.

– Ask the mother to give the dose to her infant.

– Explain carefully how to give the medicine, then label and package the medicine.

– If more than one medicine will be given, collect, count, and package each medicine separately.

– Explain that all the tablets or syrups must be used for the course of treatment, even if the infant gets better.

– Check the mother’s understanding before she leaves the clinic.

6. Give Oral Amoxicillin

* Local Infection: Give oral amoxicillin twice daily for 5 days

* Pneumonia (fast breathing alone) in infant 7–59 days old: Give oral amoxicillin twice daily for 7 days

AMOXICILLIN Desired range is 75 to 100 mg/kg/day divided into 2 daily oral doses. Give twice daily

WEIGHT(kg)	Dispersible Tablet (250 mg) Per Dose	Dispersible Tablet (125 mg) Per Dose	Syrup (125 mg in 5 ml) Per dose
1.5 to 2.4	1/2 tablet	1 tablet	5 ml
2.5 to 3.9	1/2 tablet	1 tablet	5 ml
4.0 to 5.9	1 tablet	2 tablets	10 ml

COUNSEL THE MOTHER

TEACH THE CAREGIVER TO TREAT LOCAL INFECTIONS 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.

Explain how the treatment is given.
Observe as the first treatment is administered in the clinic.
In case of worsening infection, the caregiver should return to the clinic.
Confirm the mother’s understanding before leaving the clinic.

TO TREAT SKIN PUSTULES OR UMBILICAL INFECTION

Apply Gentian Violet twice daily for 5 days.

The mother should:

Wash hands.
Gently cleanse pus and crusts with soap and water.
Dry the area.
Apply Gentian Violet.
Wash hands.
Administer oral antibiotics: Flucloxacillin and Ampicillin.

TO TREAT THRUSH (WHITE PATCHES IN MOUTH) OR MOUTH ULCERS

The mother should:

Wash hands.
Cleanse the mouth with a clean, soft cloth soaked in saltwater.
Administer Nystatin.
Wash hands.

If breastfed, advise the mother to wash her breast after feeds and apply the same medicine on the areola.

TREAT EYE INFECTION WITH TETRACYCLINE EYE OINTMENT

Clean both eyes 3 times daily for 5 days.
Wash hands.
Gently wipe away pus with a clean cloth and water.
Apply tetracycline eye ointment in both eyes 3 times daily.
Open the eyes of the young infant.
Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Continue treatment until redness is gone.
Do not use other eye ointments or drops, or put anything else in the eye.

TEACH THE MOTHER/CAREGIVER 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.
Explain the reason for giving the drug to the child.
Demonstrate how to measure a dose.
Observe the mother/caregiver practicing measuring a dose.
Request the mother/caregiver to give the first dose to the child.
Explain carefully how to administer the drug, then label and package the drug.
If more than one drug will be given, collect, count, and package each drug separately.
Emphasize that all oral drug tablets or syrups must be used to finish the course of treatment, even if the child improves.
Confirm the mother’s/caregiver’s understanding before they leave the clinic.

TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING

Demonstrate how to hold the infant:

With the infant’s head and body straight.
Facing her breast, with the infant’s nose opposite her nipple.
With the infant’s body close to her body.
Supporting the infant’s whole body, not just the neck and shoulders.

Show how to help the infant attach:

Touch the infant’s lips with her nipple.
Wait until the infant’s mouth is wide open.
Move the 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 not achieved, try again.
If still ineffective, ask the mother to express breast milk and feed with a cup and spoon in the clinic.
If able to feed with a cup and spoon, advise the mother to continue breastfeeding and express breast milk after each feed.
If not able to feed with a cup and spoon, refer to the hospital.

TEACH THE MOTHER TO TREAT BREAST OR NIPPLE PROBLEMS

If the nipple is flat or inverted, evert the nipple several times with fingers before each feed and put the baby on the breast.
If the nipple is sore, apply breast milk for a soothing effect and ensure correct positioning and attachment. If discomfort persists, feed expressed breast milk with a cup and spoon.
If breasts are engorged, let the baby continue to suck if possible. If the baby cannot suckle effectively, help the mother express milk and then put the young infant to the breast. Applying warm compresses on the breast may help.
If breasts develop an abscess, advise the mother to feed from the other breast and refer. If the young infant needs more milk, provide appropriate formula.

TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WITH LOW WEIGHT OR LOW BODY TEMPERATURE WARM AT HOME:

Avoid bathing the young infant with low weight or low body temperature; instead, sponge with lukewarm water to clean (in a warm room).
Promote skin-to-skin contact (Kangaroo mother care) as much as possible, day and night.
When not in skin-to-skin contact or if this is not possible:

Warm the room (>25°C) with a home heater.
Clothe the young infant in 3-4 layers of warm clothes, cover the head with a cap (include gloves and socks), and wrap him/her in a soft dry cloth, and cover with a warm blanket or shawl.
Let the baby and mother lie together on a soft, thick bedding.
Change clothes (e.g., napkins) whenever they are wet.

Periodically feel the feet of the baby—baby’s feet should always be warm to touch.

1. 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 the breast with the nose opposite to the nipple.
With the infant held close to the mother’s body.
With the infant’s whole body supported, not just the neck and shoulders.

Show her how to help the 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.
Look for signs of good attachment and effective suckling. If attachment or suckling is not good, try again.

2. 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.
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.

3. How to Express Breastmilk

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 other fingers on the underside 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 thumb and fingers a few times.
If the milk does not appear, she should reposition her thumb and fingers closer to the nipple and compress and release the breast as before.
Compress and release all the way around the breast, keeping her thumb and fingers the same distance from the nipple.
Be careful not to squeeze the nipple or rub the skin or move her thumb or fingers 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 drips from the start.

4. How to Keep the Low Weight Infant Warm at Home

Keep the young infant in the same bed with the mother.
Keep the room warm (at least 25°C) with a home heating device and ensure there is no draught 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(KANGAROO METHOD/KANGAROO MOTHER CARE):

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 the mother’s breasts. Keep the infant’s head turned to one side.
Cover the infant with the 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 a 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 breastmilk by cup).

5. How to Give Home Care for the Young Infant

EXCLUSIVELY BREASTFEED THE YOUNG INFANT (for breastfeeding mothers)

Give only breastfeeds to the young infant.
Breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and health.

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.

WHEN TO RETURN (Follow-up visit)

Infant’s Condition	Follow-up Day
JAUNDICE	Day 2
DIARRHOEA	Day 3
FEEDING PROBLEM	Day 3
THRUSH	Day 3
LOCAL INFECTION	Day 3
PNEUMONIA	Day 4
SEVERE PNEUMONIA (referral refused or not possible)	Day 4
LOW WEIGHT FOR AGE (in infant receiving no breast milk)	Day 7
LOW WEIGHT FOR AGE (in breastfed infant)	Day 14
CONFIRMED HIV INFECTION or HIV EXPOSED: POSSIBLE HIV INFECTION	Per national guidelines

WHEN TO RETURN IMMEDIATELY:

Advise the caretaker to return immediately if the young infant has any of these signs:

Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Develops fast breathing
Develops breathing problems
Palms or soles appear yellow.

Follow-up Care for the Sick Young Infant where Referral is Refused or Not Feasible

For Sick Young Infant with Possible Serious Bacterial Infection or Very Severe Disease

Clinical Severe Infection:

If using a 2-day gentamicin regimen:

Follow up on day 2 and day 4 of treatment.
Reassess the young infant at each contact.
If improving, complete the 2-day treatment with IM gentamicin.
Continue oral amoxicillin until all tablets are finished.

If using a 7-day gentamicin regimen:

Follow up during every injection contact.
Refer the infant if:

Worsening after treatment is started.
Any new sign of clinical severe infection appears.
Clinical severe infection is still present after day 8 of treatment.
No improvement on day 4 after 3 full days of treatment.

Local Bacterial Infection:

After 2 days:

Check umbilicus for redness or pus.
Check skin pustules for severity.
Check eyes for pus, swelling, or redness.
Treatment:
If issues persist or worsen, refer to the hospital.
If improved, continue the 5-day antibiotic and home treatment.
If severe pustules persist or worsen, refer to the hospital.

Jaundice:

After 1 day:

Look for jaundice.
If palms and soles are yellow or age is 14 days or more, refer to the hospital.
If not yellow and age is less than 14 days, advise on home care and return instructions.

Eye Infection:

After 2 days:

Look for pus draining from the eyes.

Treatment:

If pus persists, check treatment correctness and refer to the hospital if needed.
If no pus, continue treatment for 5 days.

Diarrhoea (Some Dehydration):

After 2 days:

Ask if diarrhoea has stopped.
Treatment:
If not stopped, assess and treat for diarrhoea.
If stopped, advise to continue exclusive breastfeeding and give zinc for 10 days.

When to Return Immediately:

Advise the caretaker to return immediately if the young infant has any of these signs:

Breastfeeding poorly.
Reduced activity.
Becomes sicker.
Develops a fever.
Feels unusually cold.
Develops fast breathing.
Develops breathing difficulty.
Palms or soles appear yellow.

Follow-up Care for Specific Conditions:

Feeding Problem:

After 2 days, reassess feeding.

Ask about any feeding problems identified during the initial visit.

Counsel the mother about any new or continuing feeding problems.
If significant changes in feeding are advised, ask her to return after 2 days.
For low weight for age, instruct the mother to return after 14 days for weight measurement.

Exception:

If feeding is not expected to improve or if the infant has lost weight, refer the child.

Low Weight or Low Birth Weight:

After 2 days, weigh the young infant and assess if still low weight for age.

Reassess feeding.

If no longer low weight for age, praise the mother and encourage continuation until normal weight is attained.
If still low weight for age but feeding well, praise the mother and advise weighing again within a month or at the next immunization visit.
If still low weight for age with a feeding problem, counsel the mother. Ask to return in 14 days (or at the next immunization visit within 2 weeks). Continue every 2 weeks until feeding improves, and weight gain is regular or no longer low weight for age.

Exception:
- If feeding is not expected to improve or if the infant has lost weight, refer to the hospital.

Thrush or Mouth Ulcers:

After 2 days, look for ulcers or white patches in the mouth (thrush).
Reassess feeding.

If thrush or mouth ulcers worsen or if there are problems with attachment or sucking, refer to the hospital.
If thrush or mouth ulcers are the same or better, and the baby is feeding well, continue with Gentian Violet or Nystatin for a total of 5 days.

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS Read More »

Manage HIV/AIDS using IMCI approach

CHECK FOR HIV EXPOSURE AND INFECTION

All children found to have pneumonia, persistent diarrhea, ear discharge or very low weight for age (any of these features) and have no urgent need or indication for referral, should be assessed for symptomatic HIV infection.

Children may acquire HIV infection from an infected mother through vertical transmission in utero, during delivery or while breastfeeding.
Without any intervention, 30 – 40% babies born to infected mothers will themselves be infected.
Most children born with HIV die before they reach their fifth birthday, with most not surviving beyond two years.
Good treatment can make a big difference to children with HIV and their families.
The child’s status may also be the first indicator that their parents are infected too.

ASSESS FOR HIV EXPOSURE AND INFECTION

ASK

LOOK, FEEL AND DIAGNOSE

• Ask for mother’s HIV status to establish child’s HIV exposure*

Is it:

Positive, Negative or Unknown (to establish child’s HIV exposure)

• Ask if child has had any TB Contact

Child <18 months

• If mother is HIV positive**, conduct DNA PCR for the baby at 6 weeks or at first contact with the child

• If the mother’s HIV status is unknown, conduct an antibody test (rapid test) on the mother to determine HIV exposure.

PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV INFECTION IN CHILDREN <18 MONTHS

• Pneumonia ***

• Oral Candidiasis /thrush

• Severe sepsis

• Other AIDS defining conditions**

Child ≥18 months

• If the mother’s antibody test is POSITIVE, the child is exposed. Conduct an antibody test on the child.

Child whose mother is NOT available:

• Child < 18 months

Do an antibody test on the child. If positive, do a DNA PCR test.

• Child ≥ 18 months

Do an antibody test to determine the HIV status of the child

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

TREATMENT

• Child < 18 months and DNA PCR test POSITIVE

• Child ≥ 18 months and Antibody test POSITIVE

CONFIRMED HIV INFECTION

• Initiate ART, counsel and follow up existing infections

• Initiate or continue cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development and HIV services

• Educate caregivers on adherence and its importance

• Screen for possible TB disease at every visit.

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB throughout IPT

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

Child<18 months

• If mother test is positive and child’s DNA PCR is negative OR

• If mother is unavailable; child’s antibody test is positive and DNA PCR is negative

HIV EXPOSED

• Treat, counsel and follow up existing infections

• Initiate or continue Cotrimoxazole prophylaxis

• Give Zidovudine and Nevirapine prophylaxis as per the national PMTCT guidelines

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development

• Repeat DNA PCR test at 6 months. If negative, repeat DNA PCR test again at 12 months. If negative, repeat antibody test at 18 months

• Continue with routine care for under 5 clinics

• Screen for possible TB at every visit

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

• No test results for child or mother

• 2 or more of the following conditions:

• Severe pneumonia

• Oral candidiasis/thrush

• Severe Sepsis

• An AIDS defining condition

SUSPECTED SYMPTOMATIC HIV INFECTION

• Treat, counsel and follow-up existing infections

• Give cotrimoxazole prophylaxis

• Give vitamin A supplements from 6 months of age every 6 months

• Assess the child’s feeding and provide appropriate counseling to the mother

• Test to confirm HIV infection

• Refer for further assessment including HIV care/ ART

• Follow-up in 14 days, then monthly for 3 months and then every 3 months or as per immunization schedule

Mother’s HIV status is NEGATIVE

Mother’s HIV status is POSITIVE and child is ≥ 18 months with antibody test NEGATIVE 6 weeks after completion of breastfeeding

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines

• Advise the mother about feeding and about her own health

THEN CHECK FOR TB

ASK

LOOK AND FEEL

For symptoms

suggestive of TB

Has the child been coughing for 14 days or more?

Has the child had persistent fever for 14 days or more?
Has the child had poor weight gain in the last one month?*

History of contact

Has the child had contact with a person with Pulmonary Tuberculosis or chronic cough?

Look or feel for physical signs of TB

Swellings in the neck or armpit
Swelling on the back
Stiff neck
Persistent wheeze not responding to

brochodilaters.

Collect sample for GeneXpert or smear microscopy

If available, send the child for laboratory tests (GeneXpert or smear microscopy) and/ or Chest X-Ray.

CLASSIFY

SIGNS	CLASSIFY AS	TREATMENT
Two or more of the following in HIV Negative child AND one or more of the following in HIV Positive child: At least two symptoms suggestive of TB Positive history of contact with a TB case Any physical signs suggestive of TB OR A positive GeneXpert or smear microscopy test	TB	• Initiate TB treatment • Treat, counsel, and follow up any co- infections • Ask about the caregiver’s health and treat as necessary • Link the child to the nearest TB clinic for further assessment and ongoing follow-up • If GeneXpert or smear microscopy test is not available or negative, refer for further assessment
Positive history of contact with a TB case and NO other TB symptoms or signs listed above	TB EXPOSURE	• Start Isoniazid at 10mg/kg for 6 months • Treat, counsel, and follow up existing infections • Ask about the caregiver’s health and treat as necessary • Link child to the nearest TB clinic
NO TB symptoms or signs	NO TB	• Treat, counsel, and follow up existing infections • Start Isoniazid in HIV positive child above 1 year at 10mg/kg for 6 months

THEN CHECK THE CHILD‘S IMMUNIZATION AND VITAMIN A STATUS

Immunization Schedule

Follow National Guidelines as per the Child Health Card/Mother Baby Passport.

Age	Vaccine
Birth	BCG*
	OPV-0
6 weeks	DPT+HepB+HIB
	OPV-1
	RTV1
	PCV1
10 weeks	DPT+HepB+HIB
	OPV-2
	RTV2
	PCV2
14 weeks	DPT+HepB+HIB
	OPV-3
	IPV
	RTV3
	PCV3
9 months	Measles

BCG: Bacillus Calmette-Guérin (given at birth)
OPV: Oral Polio Vaccine
DPT: Diphtheria, Pertussis, Tetanus
HepB: Hepatitis B
HIB: Haemophilus influenzae type b
RTV: Rotavirus Vaccine
PCV: Pneumococcal Conjugate Vaccine
IPV: Inactivated Polio Vaccine

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 DEWORMING TREATMENT

Give every child mebendazole every six months from the age of 1 year. Record the dose on the child’s chart.

Manage HIV/AIDS using IMCI approach

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.

Steps when Initiating ART in Children

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 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.

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 STEP 3 once the caregiver is willing and able to give ART.

STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY

If a 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 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 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatment:

Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
Child 3 years or older: ABC + 3TC + DTG, 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.

IMNCI Comprehensive Questions and Answers

Management of HIV in Children Using IMNCI Approach

Overview: The IMNCI guidelines provide a structured approach to managing HIV in children through systematic assessment, classification, treatment, and counseling. This follows the standard IMNCI process flow: Assess → Classify → Treat → Counsel → Follow-up.

STEP 1: ASSESSMENT (Ask and Test)

Refer to: Page 9 (Child 2 months–5 years) and Page 37 (Young Infant 0–2 months)

Before managing HIV, you must determine the status for every child not already enrolled in HIV care.

Ask the Mother:

Has the mother had an HIV test? If yes, is it Positive or Negative?
Has the child had an HIV test? If yes, was it a DNA PCR (for infants) or Rapid test (for older children), and was it Positive or Negative?

Assess Breastfeeding Risk:

Is the child breastfeeding now?
Was the child breastfeeding at the time of the test or 6 weeks before?

If Status is Unknown:

Perform an HIV test for the mother
If the mother is positive, test the child

If Mother is Positive:

Check if the mother is on ART (Antiretroviral Therapy)
Check if the child is on ARV prophylaxis (e.g., Nevirapine)

STEP 2: CLASSIFICATION

Based on assessment, the child is classified into one of three categories. The management depends entirely on this classification.

Classification	Criteria	Color Code	Management Level
CONFIRMED HIV INFECTION	Positive DNA PCR in any child <18 months Positive Rapid test in child ≥18 months	PINK - URGENT	Immediate treatment & ART linkage
HIV EXPOSED	Mother HIV positive AND child negative test but still breastfeeding (or stopped <6 weeks) Mother HIV positive AND child not yet tested Infant <18 months with positive rapid test (needs PCR confirmation)	YELLOW - CLINIC	Prophylaxis & frequent monitoring
HIV INFECTION UNLIKELY	Negative HIV test in mother or child No ongoing breastfeeding risk	GREEN - HOME	Routine care & prevention counseling

STEP 3: MANAGEMENT & TREATMENT

A. Management of CONFIRMED HIV INFECTION (Red Row)

Give Cotrimoxazole Prophylaxis:

Start immediately for all confirmed HIV-infected children
Prevents Pneumocystis jirovecii pneumonia (PCP) and other infections

Age/Weight	Formulation	Dose
< 6 months	5 ml syrup (40/200 mg per 5ml)	2.5 ml once daily
6 months – 5 years	5 ml syrup OR ½ adult tablet (80/400 mg)	5 ml or ½ tablet once daily

Assess for Tuberculosis (TB) - Page 10:
- Check for cough >14 days, fever >14 days, or poor weight gain
- Check for TB contact history
- Look for physical signs: lymph node swelling, stiff neck
Isoniazid Preventive Therapy (IPT):
- If child is HIV Positive, >1 year old, and has NO signs of TB
- Start Isoniazid 10 mg/kg daily for 6 months
- Prevents active TB disease
Linkage to Care:
- Refer child to ART Clinic or Early Infant Diagnosis (EID) point
- IMCI focuses on identification and linkage, not starting full ART in OPD
- Ensure follow-up appointment within 1 week
Immunization - Page 11:
- Do NOT give BCG vaccine if child has symptoms of HIV (clinical AIDS)
- Risk of disseminated BCG disease
- Give all other vaccines as per schedule
Treat Current Illnesses Aggressively:
- HIV-positive children are "High Risk"
- If they have Pneumonia with chest indrawing, give first dose of antibiotics and refer urgently
- If diarrhea, use ORS more liberally
- If fever, investigate thoroughly for opportunistic infections

B. Management of HIV EXPOSED (Yellow Row)

Cotrimoxazole Prophylaxis:
- Start from 6 weeks of age
- Continue until HIV infection is definitively ruled out
- Usually continued until 6 weeks after complete cessation of breastfeeding
Testing (Diagnosis):
- Do DNA PCR test immediately if not done
- If first PCR negative but child is breastfeeding, repeat test 6 weeks after breastfeeding stops
- Do not rely on rapid test until child is ≥18 months
ARV Prophylaxis:
- Ensure child is taking Nevirapine (NVP) syrup if indicated by national guidelines
- Check adherence daily
- Link to "Mother-Baby Care Point" for follow-up
Feeding Support:
- Support mother to practice exclusive breastfeeding correctly
- Counsel on safe replacement feeding only if AFASS criteria met
- Monitor child's weight and growth monthly

C. Management of HIV INFECTION UNLIKELY (Green Row)

Treat any existing infections (cough, diarrhea, etc.) using standard IMCI protocols
Counsel mother on her own health and preventing future infection
Encourage HIV testing if status changes or risk occurs
Continue routine immunizations

STEP 4: COUNSELING THE MOTHER

Feeding Advice (Page 26, 29)

Correct feeding is critical to reduce HIV transmission and ensure child survival.

Exclusive Breastfeeding (First 6 months):
- Mothers with HIV should exclusively breastfeed for the first 6 months
- Mixed feeding (breastmilk + other foods/fluids) is DANGEROUS as it damages gut lining and increases HIV transmission risk
- Exclusive breastfeeding provides antibodies and reduces infections
Continued Breastfeeding (6-12 months):
- Encourage continued breastfeeding up to 12 months
- Breastfeeding should only stop when a nutritionally adequate and safe diet can be provided
- Gradually introduce complementary foods from 6 months while continuing breastfeeding

Replacement Feeding ("AFASS" Criteria - Page 29):

Advise stopping breastfeeding ONLY if ALL these criteria are met:

AFASS	Requirements
Acceptable	Socially and culturally acceptable to mother and family
Feasible	Mother has time, knowledge, skills, and support to prepare formula 8-12 times daily
Affordable	Mother/family can afford continuous formula supply for 1 year without harming family nutrition
Sustainable	Continuous supply of formula and clean water is assured
Safe	Clean water, hygienic preparation, and feeding with cup (not bottle) can be ensured

Mouth Conditions:
- Check for oral thrush or sores in the child (Page 19, 39)
- Treat immediately with Nystatin 1 ml four times daily for 7 days
- Sores increase HIV transmission risk during breastfeeding
- Check mother's breasts for thrush and treat if present

General Care & Hygiene (Page 29)

Hygiene: Teach mother to wash hands before food preparation to prevent diarrhea (HIV children are very susceptible)
Growth Monitoring: Weigh child at every visit. Poor weight gain is a major sign of HIV progression or treatment failure
Mother's Health (Page 30):
- Counsel mother on her own nutrition and ART adherence
- Ensure she is on ART to suppress viral load (reduces transmission to baby)
- Check if she needs family planning or STI screening
- Provide psychosocial support and link to support groups

STEP 5: FOLLOW-UP

Exposed Children: Follow up monthly to monitor growth and ensure prophylactic medication (Cotrimoxazole/Nevirapine) adherence
Confirmed Children: Follow up at ART clinic as per schedule (every 2 weeks initially, then monthly)
Acute Illness: If HIV-positive child has cough or cold, follow up in 5 days rather than waiting, as they deteriorate faster
Growth Monitoring: Plot weight on growth chart at every visit; flattening curve indicates treatment failure

ADDITIONAL PROTOCOL: Initiating ART in Children

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 to specialist
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 caregiver should ideally have:

Disclosed the child's HIV Status to another adult who can assist
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 STEP 3 once the caregiver is willing and able to give ART.

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 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 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatment:
- Child up to 3 years: ABC or AZT + 3TC + LPV/r or recommended first-line regimen
- Child 3 years or older: ABC + 3TC + DTG, or recommended first-line regimen
Give co-trimoxazole prophylaxis (as per dosing table above)
Give other routine treatments: Vitamin A, immunizations, deworming
Follow-up regularly as per national guidelines

Critical Principles:

Never delay treatment while waiting for laboratory results
Always check for TB before starting ART
Ensure caregiver readiness and support before initiating ART
Monitor growth and development closely in all HIV-exposed and infected children
Maintain confidentiality while providing family-centered care

Recommended First-Line ARV Regimens

Patient Category	Indication	ARV Regimen
Adults and Adolescents (aged 10 and above)	Initiating ART	TDF+3TC+DTG
		Alternative Regimens
		TDF+3TC+DTG (Contraindications for EFV)
		ABC+3TC+DTG (Contraindications for TDF)
Pregnant or Breastfeeding Women	Initiating ART	TDF+3TC+DTG
		Alternative Regimen
		ABC+3TC+ATV/r (Contraindications for TDF or EFV)
Children (3 to <10 years)	Initiating ART	ABC+3TC+DTG
		Alternative Regimen
		ABC+3TC+NVP (Contraindications for EFV)
Children Under 3 Years	Initiating ART	ABC+3TC+LPV/r
		Alternative Regimen
		AZT+3TC+LPV/r (Hypersensitivity reaction to ABC)

Second- and Third-Line ART Regimens

Population	Patients Failing First-Line Regimens	Second-Line Regimens	Third-Line Regimens
Adults, Pregnant and Breastfeeding Women, Adolescents	TDF + 3TC + DTG	AZT+3TC+ATV/r (recommended) or AZT+3TC+LPV/r (alternative)	All 3rd line regimens guided by resistance testing
			If not exposed to INSTIs: DRV/r + DTG ± 1-2 NRTIs
			If exposed to INSTIs: DRV/r + ETV±1-2 NRTIs
		TDF + 3TC + DTG
		ABC+ 3TC+ DTG
		ABC+ 3TC+ EFV
		ABC/3TC/NVP
		TDF/3TC/NVP
		AZT/3TC/NVP
	TDF+3TC+ATV/r (recommended) or TDF+3TC+LPV/r	AZT/3TC/EFV
Children (3–<10 years)	ABC + 3TC + DTG	AZT+3TC+LPV/r	For children above 6 years, and prior exposure to INSTIs, DRV/r±1-2 NRTIs
			ABC+ 3TC + NVP
			AZT+3TC+NVP
			ABC+3TC+LPV/r
		For children below 6 years, AZT/3TC/EFV
			DRV/r+ RAL+ 2 NRTIs
			AZT+3TC+LPV/r
Children Under 3 Years	ABC+3TC+LPV/r pellets	AZT+3TC+RAL	Optimize regimen using genotype profile
			AZT+3TC+LPV/r pellets
		ABC+3TC+RAL
		AZT+3TC+NVP
		ABC+3TC+LPV/r

Principles for Selecting ARV Regimens:

Lower toxicity
Better palatability and lower pill burden
Increased durability and efficacy
Sequencing to spare other formulations for the 2nd line regimen
Harmonization across age and population
Lower cost
Facilitate achieving a recommended regimen for the majority of PLHIV

Rationale for Alternative Regimens:

TDF+3TC+DTG: EFV contraindications
ABC+3TC+DTG: TDF contraindications
ABC+3TC+ATV/r: Contraindications for TDF or EFV
ABC+3TC+NVP: EFV contraindications in children (3 to <10 years)
AZT+3TC+LPV/r: Hypersensitivity reaction to ABC (rare)

Considerations:

Dolutegravir (DTG) benefits: low potential for drug interactions, shorter time to viral suppression, higher resistance barrier, long half-life, and low cost.
ABC+3TC+EFV once-a-day dose for improved adherence.
LPV/r-based regimen for children under 3 years due to reduced risks and high resistance barrier.

ABC: Abacavir

AZT: Zidovudine

3TC: Lamivudine

LPV/r: Lopinavir/Ritonavir

RTV: Ritonavir

NVP: Nevirapine

EFV: Efavirenz

DTG: Dolutegravir

TDF: Tenofovir Disoproxil Fumarate

RAL: Raltegravir

ATV/r: Atazanavir/Ritonavir

TB/HIV Co-Infection Treatment Based on Age/Weight

AGE/WEIGHT	FIRST LINE TB/HIV CO-INFECTION
< 2 Weeks	Start TB treatment immediately, start ART (Usually after 2 weeks of age) once tolerating TB drugs
> 2 Weeks and <35 kgs	ABC/3TC/LPVr/RTV If not able to tolerate super boosted LPVr/RTV then use ABC/3TC + RAL for duration of TB treatment. After completion of TB treatment revert back to the recommended 1st line regimen ABC/3TC +LPVr. If on ABC/3TC/DTG regimen – continue If on NVP based regimen, change to EFV.
>35 kgs body weight and < 15 years age	ABC/3TC/DTG continue with the regimen AND double the dose for DTG If on PI based regimen switch the patients to DTG, hence doubling the dose

DOSAGE OF COTRIMOXAZOLE PROPHYLAXIS

WEIGHT (KG)	SUSPENSION 240MG PER 5ML	SINGLE STRENGTH TABLET 480MG (SS)	DOUBLE STRENGTH TABLET 960MG (DS)
1-4	2.5ml	1/4 SS tab	–
5-8	5ml	1/2 SS tab	1/4 DS tab
9-16	10ml	1 SS tab	1/2 DS tab
17-30	15ml	2 SS tab	1 DS
>30(Adults and adolescents)	–	2 SS	1 DS

Dose by body weight is 24-30 mg/kg once daily of the trimethoprim-sulphamethaxazole – combination drug.

• Oral thrush management– use miconazole gel

• Cotrimoxazole use is still recommended

• Most infants and children initiated on treatment take time before immune recovery occurs

• Children on LPV/r – continue with boosted ritonavir

• RAL – for those unable to tolerate super boosted LPV/r

Paediatric ARVs Dosages

WEIGHT RANGE (KG)	ABACAVIR + LAMIVUDINE 120 mg ABC + 60 mg 3TC	ZIDOVUDINE + LAMIVUDINE 60 mg ZDV + 30 mg 3TC	EFAVIRENCE (EFV) Once Daily 200mg tabs	LAMIVUDINE + ZIDOVUDINE Twice Daily 200mg tabs
3 – 5.9	0.5 tab	1 tab	–
6 – 9.9	1 tab	1.5 tabs	–
10 – 13.9	1 tab	2 tabs	1 tab	1.5 tabs
14 – 19.9	1.5 tabs	2.5 tabs	1.5 tabs	+ 1 tab in AM & 0.5 tab in PM
20 – 24.9	2 tabs	3 tabs	1.5 tabs	1 tab in AM & 0.5 tab in PM
25 – 34.9	300 mg ABC + 150 mg 3TC	300 mg ZDV + 150 mg 3TC	2 tabs	1 tab in AM & 0.5 tab in PM

Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS	APPROPRIATE CARE RESPONSE
Yellow eyes (jaundice) or abdominal pain	Stop drugs and REFER URGENTLY
Rash	If on abacavir, assess carefully. Call for advice. If severe, generalized, or associated with fever or vomiting: stop drugs and REFER URGENTLY
Nausea	Advise drug administration with food. If it persists for more than 2 weeks or worsens, call for advice or refer.
Vomiting	If medication is seen in vomitus, repeat the dose. If vomiting persists, bring the child to the clinic. REFER URGENTLY if vomiting everything or associated with severe symptoms.
Diarrhoea	Assess, classify, and treat using diarrhoea charts. Reassure that it may improve in a few weeks. Follow up as per chart booklet. Call for advice or refer if not improved after two weeks.
Fever	Assess, classify, and treat using fever chart.
Headache	Give paracetamol. If on efavirenz, reassure that it is common and usually self-limiting. Call for advice or refer if it persists for more than 2 weeks or worsens.
Sleep disturbances, nightmares, anxiety	Due to efavirenz. Administer at night on an empty stomach with low-fat foods. Call for advice or refer if it persists for more than 2 weeks or worsens.
Tingling, numb, or painful feet or legs	If new or worse on treatment, call for advice or refer.
Changes in fat distribution	Consider switching from stavudine to abacavir, consider viral load. Refer if needed.

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 fully and treat as on the ASSESS AND CLASSIFY chart.

PNEUMONIA

After 2 days

Check the child for general danger signs.

Assess the child for cough or difficult breathing.

Ask:

Is the child breathing slower?
Is there less fever?
Is the child eating better?

Treatment:

If any general danger sign, administer a dose of second-line antibiotic, then admit or refer URGENTLY to the hospital.
If chest indrawing, breathing rate, fever, and eating have not improved, switch to the second-line antibiotic and ADMIT or REFER (If this child had measles within the last 3 months or is known or confirmed HIV infection, refer).
If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.

WHEEZING

After 2 days

Check the child for general danger signs or chest indrawing.

Assess the child for cough or difficult breathing.

Ask:

Is the child breathing slower?
Is the child still wheezing?
Is the child eating better?

For Children under 1 year:

If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
If no wheezing, breathing slower, and eating better; continue the treatment for 5 days.

For Children over 1 year:

If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
If breathing rate and eating have not improved; change to second-line antibiotic and ADMIT OR REFER urgently to the hospital.
If still wheezing; continue oral bronchodilator.
If breathing slower, no wheezing, and eating better, continue the treatment for 5 days.
If the child has unilateral wheeze and is not responding to bronchodilators, TB disease is likely and should be evaluated.

PERSISTENT DIARRHOEA

After 5 days

Ask:

Has the diarrhea stopped?
How many loose stools is the child having per day?

Treatment:

If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to the hospital.
If the diarrhea has stopped (child having fewer than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child’s age, but give one extra meal every day for 1 month. Ask her to continue giving Zinc sulfate for a total of 10 days.
NB: Attention to diet is an essential part of the management of a child with persistent diarrhea

DYSENTERY

After 2 days

Assess the child for diarrhea. > 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 according to classification.
If the number of stools, the amount of blood in stools, fever, abdominal pain, or eating is worse: Admit or Refer to the hospital.

If the condition is the same: add Metronidazole to the treatment. Give it for 5 days. Advise the mother to continue ciprofloxacin and zinc and to return in 2 days.

Exceptions – if the child:
- is less than 12 months old, or
- was dehydrated on the first visit or to the hospital.
- had measles within the last 3 months , then Admit or Refer URGENTLY
If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving Ciprofloxacin and zinc sulfate until finished.

UNCOMPLICATED MALARIA

If fever persists after 3 days, or recurs within 14 days:

Do a full reassessment of the child. >See ASSESS & CLASSIFY chart. Assess for other causes of fever.

Treatment:

If the child has any general danger sign or stiff neck, treat it as VERY SEVERE FEBRILE DISEASE.
If the child has any cause of fever other than malaria, provide treatment.
If malaria is the only apparent cause of fever and confirmed by microscopy: Give oral DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ). Give paracetamol. If the child is under 5 kg and was given DHA-PPQ assess further.
Advice mother to return again in 3 days if the fever persists – If fever has been present every day for 7 days, refer for assessment.

FEVER – NO MALARIA

If fever persists after 3 days:

Do a full reassessment of the child. > See ASSESS & CLASSIFY chart (see pg 6) Assess for other causes of fever.

Treatment:

If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the child has any cause of fever other than malaria, provide appropriate treatment.
If malaria is the only apparent cause of fever:
- Treat with the first-line oral antimalarial. Give paracetamol. Advise the mother to return again in 3 days if the fever persists.
- If fever has been present every day for 7 days, refer for assessment.
If the child has persistent fever, cough, and reduced playfulness despite other treatment, evaluate for TB.

EYE OR MOUTH COMPLICATIONS OF MEASLES

After 2 days:

Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth.

Treatment for Eye Infection:

If pus is draining from the eye, ask the mother/caregiver to describe how she has treated the eye infection.
If treatment has been correct, refer to the hospital. If treatment has not been correct, teach mother/caregiver correct treatment.
If the pus is gone but redness remains, continue the treatment.
If there is 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 the hospital.
If mouth ulcers are the same or better, continue using half-strength gentian violet or Nystatin 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 the hospital.
If thrush is the same or better, and the child is feeding well, continue Nystatin for a total of 7 days.
If thrush is no better or is worse consider symptomatic HIV infection.

EAR INFECTION

After 5 days:

Reassess for ear problem. > See ASSESS & CLASSIFY chart Measure the child’s temperature.

Treatment:

If there is tender swelling behind the ear or high fever (38.5°C or above), admit or refer URGENTLY to the hospital.
Acute ear infection: if ear pain continues or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.
Chronic ear infection: Check that the mother is wicking the ear correctly. Encourage her to continue. Review in 2 weeks.
If ear discharge continues for more than 2 months: Admit or refer to the hospital.
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 till treatment is completed.

FEEDING PROBLEM

After 5 days:

Reassess feeding. See questions at the top of the COUNSEL THE MOTHER. Ask about any feeding problems found on the initial visit.

Counsel the mother/caregiver about any new or continuing feeding problems. If you counsel the mother/caregiver to make significant changes in feeding, ask her to bring the child back again after 5 days.
If the child is very low weight for age, ask the mother to return 14 days after the initial visit to measure the child’s weight gain.

PALLOR

After 14 days:

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

MALNUTRITION

After 14 days:

If the child is gaining weight, encourage the mother to continue with feeding. Counsel the mother about any feeding problem.

SEVERE MALNUTRITION WITHOUT COMPLICATIONS

After 7 days or during regular follow-up:

Do a full assessment of the child >See ASSESS AND CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for edema of both feet.
Check the child’s appetite by offering ready-to-use therapeutic food if the child is 6 months and older.

Treatment:

If the child has SEVERE MALNUTRITION WITH COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5mm or edema of both feet AND has developed a medical complication or edema, or fails the appetite test), refer URGENTLY to the hospital.
If the child has SEVERE MALNUTRITION WITHOUT COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5 mm or edema of both feet but NO medical complication and passes the appetite test) counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask the mother to return in 7 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC between 11.5 and 12.5 mm), advise the mother to continue RUTF. Counsel the mother.

MODERATE ACUTE MALNUTRITION

After 14 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 edema 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 14 days. Continue to see the child every 2 weeks 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 12.5 or more.
Assess all children with failure to thrive or growth faltering for possible TB disease. 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.

HIV EXPOSED & INFECTED CHILDREN

HIV INFECTED CHILD

After 1 month:

Assess the child’s general condition. Do a full assessment
Treat the child for any condition found.
Ask for any feeding problems, counsel the mother about any new or continuing feeding problems.
Advise the mother/caregiver to bring the child back if any new illness develops or she is worried.
Counsel the mother/caregiver on any other problems and ensure community support is being given. Refer for further psychosocial/counseling if necessary.
Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
Assess adherence to ART and Cotrimoxazole and advise accordingly.
Offer or refer child for comprehensive HIV management and care (including ART) as per the national ART guidelines.
Plan for defaulter tracking system; identification and tracking of children.
Follow up monthly.

HIV EXPOSED CHILD (<18 months): For children tested DNA PCR Negative

After 1 month:

Assess the child’s general condition. Do a full reassessment.
Ask for any feeding problems or poor appetite, counsel the mother about any new or continuing feeding problems.
Treat the child for any condition found.
Give Cotrimoxazole prophylaxis from 6 weeks and emphasize the importance of compliance.
Start or continue with ARV prophylaxis for a total of 12 weeks.
Screen for possible TB Disease.
Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
Follow-up schedule of HIV Exposed infant monthly up to 24 months.
Refer to Early Infant Diagnosis (EID) algorithm for confirmation of HIV status.
Refer to the HIV exposed infant follow-up card and register for further follow-up instructions.

Feeding Counseling

For Mothers and caregivers of infants under 18 months.

Goals:

Discuss ongoing HIV risk from breastfeeding and the implications on test results.
Support the mother as she makes choices about feeding for the infant.
Ensure that the mother understands the testing procedure for infants under 18 months.
If positive, discuss the need to start ART immediately.

Just after giving birth, the mother should be counseled on:

HIV testing for herself: if she did not test in antenatal, she should be tested soon after delivery.
Infant feeding practices.
HIV testing for the infant: at 6 weeks, the infant can be tested.

Overview of Infant Feeding Guidelines for Exposed Infants

HIV+ mothers should exclusively breastfeed infants for the first 6 months.
Complementary feeds should be introduced from 6 months.
Continue to breastfeed for 12 months.
During breastfeeding, the infant should receive daily NVP until 1 week after stopping breastfeeding.
Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.
When an infected mother decides to stop breastfeeding at any time, they should do so over the course of 1 month.

Manage HIV/AIDS using IMCI approach Read More »

TREAT THE CHILD in IMCI

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 dose

Determine the appropriate drugs & dosage for the child’s age or weight.
Tell the mother the reason for giving the drug to the child.
Demonstrate how to measure the dose.
Watch the mother practice 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 & package the drug.
If more than one drug will be given, collect, count & package each drug separately.
Explain that all the oral drugs – tablets or syrup 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

Age or Weight	Amoxicillin(Give two times daily for 5 days)
2 months up to 12 months (4 – <10 kg)	1 tablet (250 mg) or 5 ml syrup
12 months up to 3 years (10 – <14 kg)	2 tablets (250 mg) or 10 ml syrup
3 years up to 5 years (14-19 kg)	3 tablets (250 mg) or 15 ml syrup

FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:

ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole

Age	Cotrimoxazole(Give once a day starting at 4-6 weeks of age)
Less than 6 months	2.5 ml syrup
6 months up to 5 years	5 ml syrup or 2 tablets (20/100 mg)

FOR DYSENTERY:

FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacin

Age	Ciprofloxacin(Give 15 mg/kg two times daily for 3 days)
Less than 6 months	1/2 tablet (250 mg)
6 months up to 5 years	1 tablet (250 mg) or 1/2 tablet (500 mg)

FOR CHOLERA:

FIRST-LINE ANTIBIOTIC FOR CHOLERA: Erythromycin

SECOND-LINE ANTIBIOTIC FOR CHOLERA: Tetracycline

Age or Weight	Erythromycin	Tetracycline
2 years up to 5 years (10 – 19 kg)	1 tablet (250 mg)	1 tablet (250 mg)

Give four times daily for 3 days

FOR UNCOMPLICATED MALARIA

FIRST-LINE ANTIMALARIAL: ARTEMETHER + LUMEFANTRINE (AL)

SECOND-LINE ANTIMALARIAL: DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ)

Artemether + Lumefantrine Tablets Dosage

Weight (kg)	Age (Years)	AL Dosage
Below 15	Below 3	20mg Artemether and 120mg Lumefantrine
15 – 24	3 – 7	40mg Artemether and 240mg Lumefantrine

Counsel the Mother or Caregiver on Malaria Management for a Sick Child:

Show caregivers how to prepare the dispersible tablet.
If vomiting within 30 minutes, repeat the dose; if persistent, return for review.
Explain the dosing schedule and confirm understanding.
Emphasize completing all 6 doses over 3 days, even if the child feels better.
Follow up after 3 days of treatment.
Advise immediate return if the condition worsens or symptoms persist after 3 days.

SECOND LINE: DIHYDROARTEMISININ 20MG + PIPERAQUINE 160MG

Dihydroartemisinin + Piperaquine Dosage

Body Weight (kg)	Dose (mg)
5 to < 8	20 + 160
8 to <11	30 + 240
11 to < 17	40 + 320

FOR SEVERE MALARIA

FIRST-LINE TREATMENT FOR SEVERE MALARIA: ARTESUNATE

Artesunate is provided as a powder accompanied by a 1ml vial of 5% bicarbonate. The preparation involves further dilution with either normal saline or 5% dextrose, with the specific amounts varying for intravenous (IV) or intramuscular (IM) administration (refer to the table below).

Preparing IV/IM Artesunate

Component	IV	IM
Artesunate Powder (mg)	60mg	60mg
Sodium Bicarbonate (mls, 5%)	1ml	1ml
Normal Saline or 5% Dextrose (mls)	5mls	2mls
Artesunate Concentration (mg/ml)	10mg/ml	20mg/ml

Note:

Artesunate is administered IV/IM for a minimum of 24 hours.
Do not use water for injection in the preparation.
Do not administer if the solution appears cloudy.
Administer artesunate within 1 hour after preparation.

After 24 hours of artesunate administration, if the child can eat and drink, transition to a full course of artemisinin combination therapy (ACT), typically the first-line oral anti-malarial, Artemether Lumefantrine.

Quinine for Severe Malaria

For Intravenous (IV) Infusion:

Typically, use 5% or 10% dextrose.
Administer at least 1ml of fluid for each 1mg of quinine.
Do not exceed an infusion rate of 5mg/kg/hour.
Utilize 5% dextrose or normal saline for infusion, maintaining a ratio of 1ml of fluid for each 1mg of quinine.
The 20mg/kg loading dose should take 4 hours or longer.
The 10mg/kg maintenance dose should take 2 hours or longer.

For Intramuscular (IM) Quinine:

Take 1ml of the 2mls in a 600mg Quinine sulfate IV vial and add 5mls water for injection, creating a 50mg/ml solution.
For a loading dose, administer 0.4mls/kg.
For maintenance dosing, administer 0.2mls/kg.
If more than 3mls is needed (for a child over 8kg for a loading dose or over 15kg for maintenance doses), divide the dose into two IM sites, ensuring not to exceed 3mls per injection site.

Artemether for Severe Malaria

Administer a loading dose of 3.2mg/kg IM stat, followed by 1.6mg/kg IM daily until the patient can tolerate oral medications.
Subsequently, provide a complete course of Artemether Lumefantrine (AL).

Admit or refer patients with:

Severe anemia (Hemoglobin level <5g/dl or hematocrit <15%)
Two or more convulsions within a 24-hour period.
Hyperparasitemia and stability. These patients can be treated with AL, DHA-PPQ, or oral quinine if ACT is unavailable, but close monitoring is essential.

Treatment for Severe Malaria in Children with Very Severe Febrile Disease:

For Pre-referral Treatment:

Check available pre-referral treatment options (rectal artesunate suppositories, artesunate injection, or quinine).

If rectal artesunate suppository is available: Insert the first dose and urgently refer the child.

If intramuscular artesunate or quinine is available: Administer the first dose and urgently refer the child to the hospital.

If Referral is Not Possible:

For Artesunate Injection:

Administer the first dose intramuscularly.
Repeat the dose every 12 hours until the child can take oral medication.
Provide the full dose of oral antimalarial as soon as the child can take it orally.

For Artesunate Suppository:

Administer the first dose of the suppository.
Repeat the same dose every 24 hours until the child can take oral antimalarial.
Provide the full dose of oral antimalarial as soon as the child can take it orally.

For Quinine:

Administer the first dose of intramuscular quinine.
Ensure the child remains lying down for one hour.
Repeat quinine injection at 4 and 8 hours later, then every 12 hours until the child can take an oral antimalarial.
Do not continue quinine injections for more than 1 week.
If the risk of malaria is low, refrain from giving quinine to a child less than 4 months of age.

Age or Weight	Rectal Artesunate Suppository (50 mg suppositories, Dosage 10 mg/kg)	Rectal Artesunate Suppository(200 mg suppositories, Dosage 10 mg/kg)	Intramuscular Artesunate(60 mg vial, 20mg/ml, 2.4 mg/kg)	Intramuscular Quinine (150 mg/ml, in 2 ml ampoules)*	Intramuscular Quinine (300 mg/ml, in 2 ml ampoules)*
2 – 4 months (4 – <6 kg)	1		1/2 ml	0.4 ml	0.2 ml
4 – 12 months (6 – <10 kg)	2		1 ml	0.6 ml	0.3 ml
12 months – 2 years (10 – <12 kg)	2		1.5 ml	0.8 ml	0.4 ml
2 – 3 years (12 – <14 kg)	3	1	1.5 ml	1.0 ml	0.5 ml
3 – 5 years (14 – 19 kg)	3	1	2 ml	1.2 ml	0.6 ml

*Note: Dosages are given in milliliters (ml) and milligrams per kilogram (mg/kg) based on the child’s weight or age.

GIVE PARACETAMOL FOR HIGH FEVER >38.5°c OR EAR PAIN

Paracetamol for Fever or Ear Pain:

AGE or WEIGHT	Paracetamol Tablet (100 mg)	Paracetamol Tablet (500 mg)
2 months up to 3 years (4 – <14 kg)	1/4 tablet every 6 hours	Not applicable
3 years up to 5 years (14 – <19 kg)	1/2 tablet every 6 hours	1/2 tablet every 6 hours

FOR CONVULSIONS

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.

Diazepam Dosage

Age or Weight	Diazepam 10mg/2mls Dosage
2 months – 6 months (5 – 7 kg)	0.5 ml
6 months – 12 months (7 – <10 kg)	1.0 ml
12 months – 3 years (10 – <14 kg)	1.5 ml
3 years – 5 years (14-19 kg)	2.0 ml

Note: Dosages are given in milliliters (ml) based on the child’s weight or age.

**For measles, persistent diarrhea, severe malnutrition ****

Give vit A- 3 doses:

Give two doses for treatment of Measles. Give the first dose in the clinic and give mother another dose to give at home the next day.
Give one dose for other disease conditions if the child has not had a dose in the previous one month.
Give one dose as per Vitamin A schedule for prevention.
To give Vitamin A, cut open the capsule and give drops
Ask mother to bring the child back for 3rd dose 2-4 wks

Age Range	200,000 IU Capsule	100,000 IU Capsule	50,000 IU Capsule
Up to 6 months	Not applicable	1/2 capsule	1 capsule
6 months up to 12 months	1/2 capsule	1 capsule	2 capsules
12 months up to 5 years	1 capsule	2 capsules	4 capsules

For anemia***

Iron and Folate Administration Guidelines

Dosage: Give one dose at 6 mg/kg of iron daily for 14 days.
Caution: Avoid iron in a child known to suffer from Sickle Cell Anemia.
Note: Avoid folate until 2 weeks after the child has completed the dose of sulfa-based drugs.

Iron/Folate Tablet Dosage Based on Age or Weight

Age or Weight	Ferrous Sulfate 200 mg + 250 mcg Folate	Iron Tablet (200 mg)	Folic Acid Tablet (5 mg)
2 up to 4 months (4 – 6 kg)	–	1/4	1/2
4 up to 12 months (6 – 10 kg)	–	1/4	1
12 months up to 3 years(10 – 14 kg)	1/2 tablet	1/2	1
3 years up to 5 years(14 – 19 kg)	1/2 tablet	1/2	1

**Zinc Sulphate Administration for Diarrhea:

Dosage: Give once daily for 10 days.

Age	Zinc Sulphate Dispersible Tablet (20 mg)
0 months up to 6 months	1/2*
6 months up to 5 years	1

*Dispose the other half tablet of Zinc Sulphate 20mg

Deworm**

Give mebendazole if:

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
If a child is below 2yrs- give 250mg

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 is 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.

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.
Watch the mother as she does the first treatment in the clinic.
Tell her how often to do the treatment at home.
Check the mother’s understanding before she leaves the clinic.

Treat eye infection with tetracycline eye ointment

Clean both eyes 3 times daily:

Wash hands.

Ask the child to close eyes.
Use a clean cloth & water to gently wipe away the pus.

Apply tetracycline eye ointment in both eyes 4 times daily:

Ask the child to look up.
Squirt a small amount of the ointment on the inside of the lower eyelid.
Wash hands again.
Treat until there is no pus discharge.
Do not use other eye ointments or drops or put anything else in the eye.

Dry the ear by wicking

Clear the Ear by Dry Wicking and Give Ear Drops*
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 ear drops after dry wicking three times daily for two weeks.

* Quinolone ear drops may include ciprofloxacin, norfloxacin, or ofloxacin.

Treat mouth ulcers with gentian violet

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 exclusively breastfed infants.
Simple linctus.
Tea with honey.
Lemon tea.

Give these treatments only in the clinic.

Intramuscular antibiotic e.g., PPF, CAF for acute ear infection, very severe disease, & pneumonia.
Quinine for severe malaria.
Diazepam rectally for convulsing children.
Sugar water or milk by NGT in treatment/prevention of low blood sugar for a child who cannot swallow.

Treat Thrush with Nystatin

Treat thrush four times daily for 7 days
Wash hands
Wet a clean soft cloth with salt water and use it to wash the child’s mouth.
Instill nystatin 1 ml four times a day.
Avoid feeding for 20 minutes after medication.
If breastfed, check the mother’s breasts for thrush. If present, treat with nystatin.
Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon.
Give paracetamol if needed for pain

TREATMENT OF DEHYDRATION

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

Plan A: Treat diarrhoea with no dehydration(Treat Diarrhoea at Home)

Counsel the mother on the 4 Rules of Home Treatment:

Give Extra Fluid
Give Zinc Supplements (age 2 months up to 5 years)
Continue Feeding
When to Return.

1. Give Extra Fluid (Give ORS and other Fluids- as much as the child will take)

ADVISE THE MOTHER

Breastfeed frequently and for longer at each feed.
If the child is exclusively breast-fed, give ORS in addition to breast milk.
If the child is not exclusively breast-fed, give one or more of the following: ORS solution, food-based fluids (such as soup, enriched bujii, and yoghurt drinks, rice water), or safe clean water.
Give fresh fruit juice or mashed bananas to provide potassium.
Advise mothers/caregivers to continue giving ORS as instructed
Give ORS at home when: The child has been treated with Plan B or Plan C during this visit, OR if 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:

Age Group	Fluid Amount after Each Loose Stool
Up to 2 years	50 to 100 ml
2 years or more	100 to 200 ml

Advise the mother/caregiver to:

Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more slowly.
Continue giving extra fluids 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):

Age Group	Zinc Dosage
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 the tablet in a small amount of expressed breast milk, ORS or safe water, in a small cup or spoon.
Older children: Tablets can be chewed or dissolved in a small amount of water.

3. Continue Feeding

Exclusive breastfeeding if age is less than 6 months.

4. When to Return

Provide guidance on when the mother should return for further evaluation or if the condition worsens.

Plan B: Treat Diarrhoea at Facility with ORS (Some Dehydration)

Give in the clinic recommended amount of ORS over 4-hr period:

1. DETERMINE THE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HRS:

WEIGHT	AGE (Use when weight is unknown)	Amount of ORS (in ml)
< 6 kg	Up to 4 months	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

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.

2. 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.

3. AFTER 4 HOURS:

Reassess the child and classify the child for dehydration.
Select the appropriate plan to continue treatment.
Begin feeding the child in the clinic.

4. 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 the 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:

Give Extra Fluid
Give Zinc (age 2 months up to 5 years)
Continue Feeding (exclusive breastfeeding if age less than 6 months)
When to Return

Plan C: Treat severe dehydration quickly

Can you give IV fluids?

If YES:

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, use normal saline as follows:

AGE	STEP 1 (First give 30 ml/kg in:)	STEP 2 (Then give 70 ml/kg in:)
Infants (under 12 months)	1 hour*	5 hours
Children (12 months up to 5 years)	30 minutes*	2 hours 30 minutes

*Repeat once if the radial pulse is still very weak or not detectable.

Reassess the child every 1-2 hours. If the 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.
If NO

Is IV treatment available nearby (within 30 minutes)?

If YES

Admit or 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.

If NO

Are you trained to use a naso-gastric (NG) tube?

If YES:

Start rehydration by NG 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:

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.

If NO

Can the child drink?

If YES,

Start rehydration by NG tube (or mouth) with ORS solution:

If NO

Then refer URGENTLY to the hospital for IV or NGT rehydration.

Treating Shock

Give 20 ml/kg bolus of Ringer’s Lactate (<15 minutes).
Reassess the child
Signs persist? Repeat bolus of Ringer’s Lactate (<15 minutes) and proceed to Plan C.
Signs do not present? Treat child for severe dehydration – Plan C,STEP 2.

GIVE FOLLOW-UP CARE

Care for the child who returns for follow-up.
If the child has any new problems, assess, classify & treat the new problem.

If PNEUMONIA

Follow up after 2 days.

Check the child for general danger signs.
Assess the child for a cough or difficulty in breathing.
Ask!

Is the child breathing slower?
Is there less fever?
Is the child eating better?

In case of any problem, classify & treat or refer URGENTLY.

If PERSISTENT DIARRHEA

Follow up after 5 days.

Ask!

Has the diarrhea stopped?
How many loose stools is the child having per day?

In case of any problem, classify, treat & or refer URGENTLY.

If DYSENTERY

Follow up after 2 days.

Assess the child for diarrhea.
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?

Assess for persistence of the problem, establish any new problem, classify, treat or refer URGENTLY.

If MALARIA

If fever persists after 2 days or returns after 14 days, then follow up is necessary.

Do a full assessment of the child, classify, treat or refer URGENTLY.

If MEASLES

Follow up after 2 days.

Look for red eyes & pus draining from the eyes.
Look at mouth ulcers.
Smell the mouth.
Reassess, classify, treat or refer URGENTLY.

If EAR INFECTION

Follow up after 5 days.

Reassess the ear problem.
Measure the child’s temp.
Classify – acute or chronic ear infection, treat or refer URGENTLY.

If FEEDING PROBLEM

Follow up after 5 days.

Reassess feeding.
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems.
If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child’s weight.

If PALLOR

Follow up after 14 days.

If the child is not sickler, give iron.
If the child is sickler, give F/A.
Advise the mother to return after 14 days for more Fe or F/A.
Continue giving iron or folic acid every 14 days for 2 months.
If the child has palmar pallor after 2 months, refer URGENTLY.

If VERY LOW WEIGHT

Follow up after 30 days.

Weigh the child & determine if the child is still very low weight for age.
Reassess feeding.
If the child is still low weight for age, counsel about any feeding problem.
Ask the mother to return in 1 month.
Continue reassess & counseling until the child is no longer low weight for age.
If the child increasingly loses weight refer URGENTLY.

IF ANY MORE FOLLOW VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR CURRENT VISIT, ADVISE THE MOTHER OF THE NEXT FOLLOW UP VISIT. ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.

COUNSEL THE MOTHER

FOOD

Assess the child’s feeding.
Ask questions about the child’s usual feeding.
Compare the mother’s answers to the feeding recommendations.

Ask!

Do you breastfeed your child?

How many times during the day?
Do you breastfeed during the night?

Does the child take any other foods or fluids?

What food or fluids?
How many times per day?
What do you use to feed the child?
If very low weight for age: how large are the servings? does the child receive his/her own serving? who feeds the child & how?

During the illness has the child’s feeding changed? If yes. How?

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH FOR CHILDREN UP TO 6 MONTHS OF AGE

Breastfeed often as the child wants day and night, at least 8 times in 24 hrs.
Do not give other foods or fluids.

Only if the child between 4-6 months appears hungry after BF or is not gaining weight adequately, you can add complementary food as listed under 6-12 months of age.
Give these foods 1-2 times per day after BF.

6-12 MONTHS OF AGE

Breastfeed as often as the child wants.
Give an adequate serving of:

A) Thick porridge made of either maize or cassava or millet or soya floor. Add sugar and oil, mix either milk or pounded ground nuts.
B) Mixtures of mashed foods made out of posho (maize or millet) or rice or Matooke, potatoes or cassava. Mix with fish or beans or pounded ground. Add green vegetables, give a snack like an egg or banana or bread. 3 times/day if breastfed, 5 times/day if not breastfed.

12 MONTHS – 2 YEARS OF AGE

Breastfeed as often as the child wants.
Give an adequate serving of:

Mixtures of mashed foods made out of either Matooke or potatoes or cassava or posho (maize or millet) or rice.
Mix with either fish or beans or meat or pounded ground nuts.
Add green vegetables.
Thick porridge made of either maize or cassava or millet or soya, add sugar and oil, mix with either milk of pounded ground nuts.
Snacks like an egg or banana or bread or family food 5 times a day.

2 YEARS OF AGE AND OLDER

Give family foods at 3 meals each day, also twice daily give nutritious snacks between meals such as banana or eggs or bread.

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

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS

If the child is not being fed as described in the above recommendations, counsel the mother accordingly.
If the mother reports difficulty with BF, assess BF as needed.

Important is to show the mother correct positioning and attachment for Breastfeeding, and ensure general breast hygiene before BF.

If the child is less than 6 months of age and is taking other milk or foods:

Build the mother’s confidence that she can produce all the breast milk that the child needs.
Suggest giving more frequent, longer BF day and night and gradually reducing other milk or foods.
If the mother is away from the child due to work, suggest that the mother expresses breast milk to leave for the baby.
But if other milk needs to be continued, counsel the mother to BF as much as possible, including night.
Make sure that other milk is a locally appropriate breast milk substitute such as cow’s milk.
Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
Finish prepared milk within an hour.
If the child is being given diluted milk or thin porridge:

Remind mothers that thick foods which are dense in energy and nutrients are needed by infants and young children.
Do not dilute the milk.
Increase the thickness of porridge.

If the mother is using a bottle to feed the child:

Recommend substituting a cup for a bottle.
Show the mother how to feed the child with a cup.

If the child is not being fed actively, counsel the mother to:

Sit with the child and encourage eating.
Give the child an adequate serving on a separate plate or bowl.

If the mother is not giving green leafy vegetables or other foods rich in vit A:

Encourage her to provide vit A-rich foods frequently e.g. green leafy vegetables, carrots, liver.

If the child is 6 months of age and above and appropriate complementary foods have not been introduced:

Gradually introduce thick porridge mixed with available protein e.g. milk, add sugar and fat.
Gradually introduce a mixture of mashed food mixed with relish, add green leafy vegetables and fat.
Give a nutritious snack.

Child eats solid food but without enough nutrient density or variety:

Give a variety of mixtures of mashed food made out of local staples mixed with relish made out of animal or plant protein.
Add green leafy vegetables and fat.
Follow up any feeding problem in 5 days.

Advise the mother to increase fluid during illness.
For any sick child, BF more frequently & for longer at each feed.
Increase fluid e.g. rice water, yoghurt, clean water, if not exclusive BF.
For a child with diarrhea, giving extra fluid can be life-saving.
Give fluid according to Plan A, B, C.
Advise the mother on when to return to the health worker.

Follow up : If the child has

Condition	Follow-up
Pneumonia, dysentery, malaria, measles	2 days
Persistent diarrhea, acute/chronic ear infection, feeding problem, any other not improving	5 days
Pallor	14 days
Very low weight for age	30 days

Advise on when to return immediately

Any sick child

-not able to drink or breastfeed

-becomes sicker

-develops a fever

If child has no pneumonia: cough or cold, return if

-fast breathing

-difficult breathing

If child has diarrhea: return if

-blood in stool Drinks or breastfeeds poorly

Counsel the mother about her own health

If the mother is sick, provide care for her or refer.
If she has a breast problem e.g. engorgement, sore nipples, breast infection provide care or refer.
Advise to eat well.
Check her immunization, give TT if needed.
Make sure she has access to FP, STD?AIDS counseling/prevention, antenatal if pregnant.

TREAT THE CHILD in IMCI Read More »

Assessing and Classification of a Sick Child and General Danger Signs.

Assessing and Classification of a Sick Child

Determine whether this is an initial visit or a return (follow up) visit.

If it is an initial visit, Ask, “what is the child’s problem”?

After knowing the problem;

Check for general danger signs.

A general danger sign is an indicator that a child has a severe problem and therefore needs urgent referral.

General danger signs include:

The child is unable to drink/feed.
Vomiting everything.
The child has convulsions.
The child is lethargic or unconscious.
Child is convulsing now.

Then ask about other main symptoms

GENERAL DANGER SIGNS

General danger signs in children are indicators of serious illness that require immediate action to save the child’s life.

These signs are seen in children aged two months up to five years and should not be ignored. The 4 general Danger signs according to World Health Organisation are;

Unable to breastfeed or drink: If a child is unable to suck or swallow when offered a drink or breastmilk, it is considered a danger sign.
Vomiting everything: If a child is not able to hold down any food, fluids, or oral medications and vomits everything, it is a cause for concern.
Convulsions: Convulsions are characterized by the child’s arms and legs stiffening due to muscle contractions or repeated abnormal movements. The child may also lose consciousness or be unresponsive to spoken directions.
Lethargic or unconscious: A lethargic child is drowsy, not alert, and shows no interest in their surroundings. They may not look at their mother or respond to stimuli. An unconscious child cannot be awakened and does not respond to touch, shaking, or spoken words.

Child with any General Danger sign needs URGENT attention: complete assessment, give any pre-referral treatment immediately and refer.

Not able to drink or breastfeed:

“Not able to drink or breast-feed” means that the child is not able to suck or swallow when offered a drink or breast milk.

NB: if not sure of the mother’s answer, offer the child clean water/breastmilk

Vomiting everything:

“Vomiting everything” means;

Child is not able to hold anything down at all.

What goes down comes back up.

NB: if not sure of the mother’s answer, offer the child clean water/breastmilk. Observe if the child vomits

Convulsions:

A convulsion is any involuntary movement in any part of the body.

A child can have this danger sign if there is a history of convulsions or convulsing during the visit.
A history of convulsions only counts as a danger sign if the convulsions happened during the present illness.
Use words for convulsions that caregivers understand. eg fits or spasms.

Lethargic or unconscious:

“Lethargic or unconscious” means that:

The child is not awake and alert when he should be.
He is drowsy and does not show interest in what is happening around him.
The child may stare blankly and appears not to notice what is going on around him.; or
Unconscious child cannot be awakened. He does not respond when touched, shaken, or spoken to

CHECK FOR GENERAL DANGER SIGNS

ASK	LOOK
–Is the child able to drink or breastfeed?	-See if the child is lethargic or unconscious.
-Does the child vomit everything?	-Is the child convulsing now? If yes, treat immediately.
-Has the child had convulsions in this illness?

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

SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign

VERY

SEVERE

DISEASE

• Give diazepam if convulsing now.

• Quickly complete the assessment.

• Give any pre-referral treatment immediately.

• Treat to prevent low blood sugar.

• Keep the child warm.

• Refer URGENTLY.

• Screen for possible TB disease and check for HIV.

*ANYTHING IN BOLD IS URGENT PRE-REFERRAL TREATMENT

THEN ASK ABOUT MAIN SYMPTOMS:

Four main symptoms

The health worker attending to a sick child MUST ask about all the four main symptoms below.

Cough or difficult breathing
Diarrhoea
Fever
Ear problem

When a symptom is present, assess further on that symptom.

Cough or Difficult breathing

Pneumonia is among the leading causes of death in children under five years.
Most children with cough or difficulty breathing have only a cough or a cold.
A few children with cough or difficulty breathing may also have pneumonia.

ASSESSING FOR COUGH OR DIFFICULT BREATHING – THE CHILD MUST BE CALM

Does the child have cough or difficult breathing?

ASK	LOOK, LISTEN, FEEL
IF YES, ASK For how long?	Count the breaths in one minute. Use respiratory rate timers where available • Look for chest in-drawing* • Look and listen for stridor • Look and listen for wheeze* • Check for central cyanosis • Check for oxygen saturation using pulse oximetry where available. • Check AVPU**** • If wheezing with either chest indrawing or fast breathing: Assess for possible Asthma. • If wheezing assesses for possible TB disease.
	-Is the child convulsing now? If yes, treat immediately.
	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

SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign

• Oxygen saturation less than 90%

• Chest indrawing or

Stridor in calm child.

• Central Cyanosis

• AVPU = V, P or U

VERY

SEVERE

DISEASE

• Give diazepam if convulsing now.

• Quickly complete the assessment.

• Give any pre-referral treatment immediately.

• Treat to prevent low blood sugar.

• Keep the child warm.

• Give fist oral dose of oral cotrimoxazole

• Give Vit A

• Refer URGENTLY.

• Screen for possible TB disease and check for HIV.

Note: *ANYTHING IN BOLD IS URGENT PRE-

REFERRAL TREATMENT

*Chest in-drawing is present if the lower

chest wall moves in during inspiration.

**Stridor – a harsh sound heard during

inspiration.

***Wheeze – a musical sound heard

during expiration.

****AVPU – Alert, responsive to Voice,

responsive to Pain, Unresponsive

Chest indrawing in

calm child

• Fast breathing

AND

• No signs of severe

pneumonia

PNEUMONIA

• Give Amoxicillin Dispersible Tablet.

• Give Vitamin A.

• Treat wheeze if present.

• If wheezing, follow-up in 2 days.

• Soothe the throat and relieve the cough with a safe remedy.

• Screen for possible TB disease and check for HIV.

• If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days

• If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma assessment.

• Review in 2 days, if not possible, admit OR refer children with chest

indrawing.

• Advise mother when to return immediately.

No signs of pneumonia or very severe disease.

NO PNEUMONIA: COUGH OR COLD

• Treat wheeze if present.

• If wheezing, follow-up in 2 days.

• Soothe the throat and relieve the cough with a safe remedy.

• Follow-up in 5 days if not improving.

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

Diarrhoea

Diarrhoea is the passage of three or more watery stools in 24 hours. It is common in children, especially those between 6 months and 2 years of age.
It is the 2nd leading cause of mortality in under-fives.
Most of these deaths are usually due to dehydration.
If an episode of diarrhoea lasts less than 14 days, it is an acute diarrhoea and if 14 days or more, it is persistent diarrhoea.
Diarrhoea with blood in the stool, with or without mucus, is called dysentery.
Frequent passage of normal stool is not diarrhoea.

Does the child have diarrhoea?

ASK

LOOK, LISTEN, FEEL

IF YES, ASK

For how long?

• Is there blood in the stool?

– Look at the child’s general conditions.

Check:

Weak/ absent pulse
Not alert; AVPU*<A
Cold hands +Temp gradient
Capillary refill >3 sec

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 than 2 seconds)?
Slowly?
Immediately?

Remember to classify all children with diarrhoea for dehydration.

for DEHYDRATION

SIGNS

CLASSIFY AS

TREATMENT

All four of:

• Weak/absent pulse

• AVPU* < A

• Cold hands + Temp

gradient

• Capillary refill > 3 sec

PLUS

• sunken eyes and very

slow/slow skin pinch.

HYPOVOLAEMIC

SHOCK

FROM

DIARRHOEA/

DEHYDRATION

• TREAT FOR SHOCK. Give Ringer’s Lactate 20mls/kg.

– A second bolus may be given if required before proceeding to step 2 of PLAN C.

• Treat for and to prevent low blood sugar.

• Assess for severe acute malnutrition.

• Assess for severe anaemia.

• NB: If HB<5g/dl transfuse urgently

• Admit or refer urgently to hospital

• Screen for possible TB disease and check for HIV

• If a child is 2yrs or older & there’s cholera in your area, give oral cotrimoxazole for cholera.

Two or more of the following

signs:

• Restless, irritable

• Sunken eyes

• Drinks eagerly, thirstily

• Skin pinch goes back slowly

SOME DEHYDRATION

If child also has a severe classification:

– Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding.

If the child has no severe classification:

– Give fluid and food for some dehydration (Plan B).

– Give vitamin A.

– Give ORS and Zinc Sulphate.

• Follow-up in 2 days if not improving.

• Screen for possible TB disease and check for HIV

• Advise mother when to return immediately.

Not enough signs to classify as

some or severe dehydration.

NO DEHYDRATION

If child also has a severe classification:

– Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding.

• If the child has no severe classification:

– Give fluid and food to treat diarrhoea at home (Plan A).

– Give vitamin A.

– Give ORS and Zinc Sulphate.

• Follow-up in 5 days if not improving.

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

and if diarrhoea 14 days or more

Dehydration present:

(hypovolaemic shock,

severe dehydration, some dehydration).

SEVERE PERSISTENT DIARRHOEA

• Treat hypovolaemic shock and any other form of dehydration before referral unless the child has another severe classification.

• Give Vitamin A.

• Give ORS and Zinc Sulphate.

• Give Multivitamin / Mineral supplements.

• Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

• Screen for possible TB disease and check for HIV.

No dehydration

PERSISTENT DIARRHOEA

• Advise the mother on feeding a child who has PERSISTENT DIARRHOEA.

• Give vitamin A.

• Give ORS and Zinc Sulphate.

• Give Multivitamin / Mineral supplements.

• Check for HIV infection.

• Follow-up in 5 days.

• Screen for possible TB disease and check for HIV

and if blood in stool

Blood in the stool.

DYSENTERY

• Treat with Ciproflaxacin.

• Give Vitamin A.

• Give ORS and Zinc Sulphate.

• Follow-up in 2 days.

• Screen for possible TB disease and check for HIV.

Fever

Fever is present if :-

There is history from parent/caregiver or
Child feels hot or
Child has temperature 37.5° c and above

A child with fever may have malaria, measles or another severe disease. Malaria currently causes 11% of under five deaths. Fever may also be due to a simple cough, cold or other viral infection.

To classify and treat fever, you must know malaria risk in your area.

High Malaria risk; > 5% of fever cases in children are due to malaria.
Low Malaria risk; 5% or less of fever cases in children are due to malaria.

Does the child have fever? (by history or feels hot or temperature 37.5°C* or above)

IF YES:

Has the child travelled to a high risk (Malaria endemic, seasonal transmission or epidemic prone) area in the last 1 month?

Decide Malaria Risk: high or low risk.

ASK

LOOK & FEEL

THEN ASK:

• For how long?

• If more than 7 days, has fever been present every day?

• Has the child had signs of measles within the last 3 months?

LOOK AND FEEL:

• 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•••

High Malaria risk:

Do a malaria test

○ Endemic Zone

○ Seasonal Transmission Zone

○ Epidemic prone areas

Low malaria risk:

○ Do a malaria test if there is no obvious cause of fever.

TEST POSITIVE

• P.falciparum PRESENT

• P.vivax PRESENT

TEST NEGATIVE

• P.falciparum or P.vivax

absent

NOTE: If you can’t test, don’t withhold treatment.

SIGNS	CLASSIFY AS	TREATMENT
• Any general danger sign or • Stiff neck. AND • Confirm malaria with a test.	VERY SEVERE FEBRILE DISEASE OR SEVERE MALARIA	• Give first dose of artesunate or quinine for severe malaria. • Give first dose of an appropriate antibiotic (Give first dose of Ceftriaxone) • Treat the child to prevent low blood sugar. • Give one dose of paracetamol in the clinic for high fever (≥38.5 °C). • Admit or Refer URGENTLY to hospital. • Screen for possible TB disease and check for HIV.
• Malaria test POSITIVE**	UNCOMPLICATED MALARIA	• Give recommended first line oral antimalarial • Give Artemether + Lumefantrine (AL). • Give one dose of paracetamol in clinic for high fever (≥38.5 °C). • Give appropriate antibiotic treatment for an identified bacterial cause of fever. • Give Vitamin A. • Follow up in 3 days if fever persists. • If fever is present every day > 7 days assess further or refer • Screen for possible TB disease and check for HIV • Advise when to return immediately.
• Malaria test NEGATIVE	FEVER: NO MALARIA	• Give one dose of paracetamol in clinic for high fever (≥38.5 °C) • Assess for other possible causes of fever • Follow up in 3 days if fever persists. • If fever is present every day for more than 7 days assess further or refer. • Screen for possible TB disease and check for HIV • Advise mother when to return immediately.

CHECK FOR COMPLICATIONS OF MEASLES

Check for Complications of MEASLES.

If the child has signs of measles now or within the last 3 months

• Look for mouth ulcers, are they deep or extensive?

• Look for pus draining from the eye

• Look for clouding of the cornea

SIGNS	CLASSIFY AS	TREATMENT
Generalized rash of measles and • One of: cough, runny nose or red eyes	SUSPECTED MEASLES	• Give Vitamin A (See page 14) • Notify, take blood sample for confirmation. • Screen for possible TB disease and check for HIV. • Advise mother when to return immediately.
Any general danger sign or • Clouding of cornea or • Deep or extensive mouth ulcers.	SEVERE COMPLICATIONS OF MEASLES	• Give Vitamin A. • Give first dose of Ceftriaxone Antibiotic. • If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment. • Notify, take blood sample for confirmation OR refer • Admit or refer URGENTLY to hospital • Screen for possible TB disease and check for HIV.
• Pus draining from the eye or • Mouth ulcers.	EYE OR MOUTH COMPLICATIONS OF MEASLES	• Give Vitamin A • If pus draining from the eye, treat eye infection with tetracycline eye ointment. • If mouth ulcers, treat with nystatin • Follow-up in 2 days. • If child has no indication for referral, notify and draw blood sample for confirmation of measles • Screen for possible TB disease and check for HIV
• No pus draining from the eye or mouth ulcers.	NO EYE OR MOUTH COMPLICATIONS OF MEASLES	• Give Vitamin A if not received in the last 1 month. • If child has no indication for referral, draw blood and send for confirmation. • Screen for possible TB disease immediately after the measles infection and check for HIV.

EAR PROBLEM

A child with an ear problem may have an ear infection.
Ear infection may cause pus to collect behind the eardrum causing pain and often fever.
If not treated, the eardrum may burst, discharge pus and the child feels less pain.
However, the child may suffer poor hearing or worse deafness.
Ear infection may lead to Mastoiditis or Meningitis.

Does the child have an ear problem?

ASK

LOOK AND FEEL

IF YES, ASK

• Is there ear pain?

• Is there ear discharge? If yes, for how long?

Look for pus draining from the ear.
Feel for tender swelling behind the ear.
Drinking eagerly, thirsty?

Pinch the skin of the abdomen.

Does it go back:

Very slowly (longer than 2 seconds)?
Slowly?
Immediately?

Classify EAR PROBLEM

SIGNS	CLASSIFY AS	TREATMENT
• Tender swelling behind the ear.	MASTOIDITIS	• Give first dose of Ceftriaxone Antibiotic. • Give first dose of paracetamol for pain • Refer URGENTLY to hospital or admit • Check for HIV.
• Pus is seen draining from the ear or • Discharge is reported for less than 14 days,or • Ear pain.	ACUTE EAR INFECTION	• Give Amoxicillin dispersible tablets for 5 days. • Give paracetamol for pain • Dry the ear by wicking • Check for HIV infection • Follow-up in 5 days
• Pus is seen draining from the ear or discharge is reported for 14 days or more.	CHRONIC EAR INFECTION	• Dry the ear by wicking • Check for HIV infection • Follow-up in 5 days
• No ear pain and No pus seen or reported draining from the ear.	NO EAR INFECTION	No treatment.

THEN CHECK FOR ACUTE MALNUTRITION

Good nutrition results from the adequate intake of macronutrients, micronutrients and water to supply the metabolic (anabolic and catabolic) processes in the body.

There are two components of nutrition;

Macronutrients
Micronutrients

What is Malnutrition?

Malnutrition is defined as a state when the body does not have enough of the required nutrients (under-nutrition) or has excess of required nutrients (overnutrition).
Inadequacies of macro or micro nutrients may result in failure to thrive, poor growth or wasting.
These processes are often measured by their anthropometric consequences (weight for age, height for age or weight for height).
Undernutrition is the most common form of malnutrition in developing countries.

ASSESS FOR MALNUTRITION

ASK

LOOK AND FEEL

Is there a history of TB contact?

• Look for oedema of both feet.

• Determine the child’s weight for Height/length (WFHL*) and plot on the IMNCI Chart booklet to determine the z-score.

• Determine the growth pattern; Is the growth faltering? (Weight curve flattening or dropping for at least 2 consecutive months?)

• Measure MUAC**mm in a child 6 months or older

• IF WFH/L less than -3 z-score or MUAC less than 115mm then:

Check for any medical complication present:

• Any general danger signs.

• Any severe classification.

• Pneumonia with chest in-drawing.

If no medical complication present:

• Conduct an appetite test.

• 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 breastfeeding problems? If child has acute Malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of IRON in RUTF

Classify Malnutrition

SIGNS

CLASSIFY AS

TREATMENT

• Oedema of both feet, OR

• WFH/L less than -3 z scores

• MUAC Less than 11.5 cm and ANY one of the following:

– medical complication present or

– not able to finish RUTF***

– Breast feeding problem (<6 months)

SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS FOR CHILDREN

• Treat the child to prevent low blood sugar.

• Keep the child warm

• Give first dose of Benzylpenicillin + Gentamicin

• Give Vitamin A

• Refer URGENTLY to hospital

• Admit or refer urgently to hospital if child has any other complications (Danger signs: Diarrhoea, Pneumonia, Fever, No appetite, etc)

• Immunize as per schedule.

• Screen for possible TB disease and check for HIV.

For all children:

• With visible severe wasting

• Oedema of both feet,

• <-3 Z Score ( weight for age or weight for height/Length) For children 6 months up to 59 months: MUAC <11.5 cm

SEVERE ACUTE MALNUTRITION

As above

• WFH/L less than -3 z scores

• MUAC Less than 11.5 cm

AND

• Able to finish RUTF

SEVERE MALNUTRITION WITHOUT COMPLICATIONS

• Give oral Amoxicillin DT for 5 days

• Give ready to use therapeutic food for child aged six months and above

• Screen for possible TB disease and check for HIV • Follow up in 7 days.

• Assess the child’s feeding and counsel the mother on the feeding recommendations.

• Immunize as per schedule.

• Advise mother when to return immediately

For all age groups:

• Static weight or losing weight

• 3 to <-2 Z- Score

If age 6 months up to 59 months MUAC 11.5 to 12.5 cm

MODERATE ACUTE MALNUTRITION

• If growth is faltering for 2 consecutive months, give Vitamin A, assess further or refer to a hospital.

• Assess the child’s feeding and counsel the mother on the feeding recommendations.

• Give Albendazole if the child is 1 year or older and has not had a dose in the previous 6 months.

• If feeding problems, follow up in 14 days.

• Screen for possible TB disease and check for HIV

• Immunize as per schedule.

• Advise mother when to return immediately

For all age groups:

• Static weight or losing weight

• -2 to <-1 Z- Score

If age 6 months up to 59 months MUAC 12.5 to 13.5cms

AT RISK OF ACUTE MALNUTRITION

• If child is less than 2 years old, and has growth faltering, assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations

• Give Albendazole if the child is 1 year or older and has not had a dose in the previous 6 months.

• Follow up in 14 days

• If feeding problem, follow-up in 5 days

• Screen for possible TB disease and check for HIV

• Immunize as per schedule

• Advise mother when to return immediately

WFH/L > -1 to +2 Z scores

MUAC > 13.5 cm

NO ACUTE MALNUTRITION

• If the 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 5 days

• Give Albendazole if child is 12 months and has not had a dose in the previous 6 months

• Immunize as per schedule

• Screen for possible TB disease and check for HIV

CHECK FOR ANAEMIA

Anaemia

The condition of having a lower-than-normal number of red blood cells or quantity of hemoglobin. Anemia diminishes the capacity of the blood to carry oxygen.

Common Causes

Iron deficiency; may result from a diet deficient in iron.
Intestinal parasites.
Repeated nosebleeds.
Haemolysis, due to: Malaria and other Inherited blood disorders like sickle cell disease)
Chronic illness, such as tuberculosis and AIDS.
Severe malnutrition (due to lack of protein to produce haemoglobin)

ASSESS FOR ANAEMIA

LOOK AND FEEL

Look for palmar pallor.

Is it:

• Severe palmar pallor?

• Some palmar pallor?

• No palmar pallor?

• Do haemoglobin level (HB) test.

SIGNS	CLASSIFY AS	TREATMENT
• Severe palmar pallor • If HB<5g/dL	SEVERE ANAEMIA	• Treat to prevent low blood sugar • Keep the child warm • Admit or refer URGENTLY to hospital • Screen for possible TB disease and check for HIV
• Some palmar pallor	ANAEMIA	• Assess the child’s feeding and counsel the mother on feeding. • If growth is faltering for 2 consecutive months, assess further or refer to hospital • Give Iron and Folate. • Give vitamin A • Give Albendazole if child is 1 year or older and has not had a dose in the last 6 months • Screen for TB disease and check for HIV • Follow up in 14 days • Immunize as per schedule • Advise mother when to return immediately.
• No Palmar pallor	NO ANAEMIA	• If child is less than 2 years old, assess the child’s feeding and counsel the mother according to the feeding recommendations • If feeding problems, follow up in 5 days • Give Albendazole if child is 1 year or older and has not had a dose in the last 6 months • Immunize as per schedule • Screen for possible TB disease and check for HIV

CHECK FOR HIV EXPOSURE AND INFECTION

Children may acquire HIV infection from an infected mother through vertical transmission in utero, during delivery or while breastfeeding.
Without any intervention, 30 – 40% babies born to infected mothers will themselves be infected.
Most children born with HIV die before they reach their fifth birthday, with most not surviving beyond two years.
Good treatment can make a big difference to children with HIV and their families.
The child’s status may also be the first indicator that their parents are infected too.

ASSESS FOR HIV EXPOSURE AND INFECTION

ASK

LOOK, FEEL AND DIAGNOSE

• Ask for mother’s HIV status to establish child’s HIV exposure*

Is it:

Positive, Negative or Unknown (to establish child’s HIV exposure)

• Ask if child has had any TB Contact

Child <18 months

• If mother is HIV positive**, conduct DNA PCR for the baby at 6 weeks or at first contact with the child

• If mother’s HIV status is unknown, conduct an antibody test (rapid test) on mother to determine HIV exposure.

PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV INFECTION IN CHILDREN <18 MONTHS

• Pneumonia ***

• Oral Candidiasis /thrush

• Severe sepsis

• Other AIDS defining conditions**

Child ≥18 months

• If the mother’s antibody test is POSITIVE, the child is exposed. Conduct an antibody test on the child.

Child whose mother is NOT available:

• Child < 18 months

Do an antibody test on the child. If positive, do a DNA PCR test.

• Child ≥ 18 months

Do an antibody test to determine the HIV status of the child

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

TREATMENT

• Child < 18 months and DNA PCR test POSITIVE

• Child ≥ 18 months and Antibody test POSITIVE

CONFIRMED HIV INFECTION

• Initiate ART, counsel and follow up existing infections

• Initiate or continue cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development and HIV services

• Educate caregivers on adherence and its importance

• Screen for possible TB disease at every visit.

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB throughout IPT

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

Child<18 months

• If mother test is positive and child’s DNA PCR is negative OR

• If mother is unavailable; child’s antibody test is positive and DNA PCR is negative

HIV EXPOSED

• Treat, counsel and follow up existing infections

• Initiate or continue Cotrimoxazole prophylaxis

• Give Zidovudine and Nevirapine prophylaxis as per the national PMTCT guidelines

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development

• Repeat DNA PCR test at 6 months. If negative, repeat DNA PCR test again at 12 months. If negative, repeat antibody test at 18 months

• Continue with routine care for under 5 clinics

• Screen for possible TB at every visit

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

• No test results for child or mother

• 2 or more of the following conditions:

• Severe pneumonia

• Oral candidiasis/thrush

• Severe Sepsis

• An AIDS defining condition

SUSPECTED SYMPTOMATIC HIV INFECTION

• Treat, counsel and follow-up existing infections

• Give cotrimoxazole prophylaxis

• Give vitamin A supplements from 6 months of age every 6 months

• Assess the child’s feeding and provide appropriate counseling to the mother

• Test to confirm HIV infection

• Refer for further assessment including HIV care/ ART

• Follow-up in 14 days, then monthly for 3 months and then every 3 months or as per immunization schedule

Mother’s HIV status is NEGATIVE

Mother’s HIV status is POSITIVE and child is ≥ 18 months with antibody test NEGATIVE 6 weeks after completion of breastfeeding

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines

• Advise the mother about feeding and about her own health

CHECK THE CHILD’S IMMUNIZATION, VITAMIN A & DEWORMING STATUS

Immunization is one of the most cost effective health interventions for disease control.
It targets children under the age of 5 years.
It needs tremendous input and effort to make it happen.
Immunization coverage can be enhanced through;

Routine Immunization
Supplemental Immunizations
Surveillance of the target diseases
Mopping up in high risk areas

A child’s body requires Vitamin A for; Growth and development, Protection against infections & reinforces the body’s immunity. Vit A deficiency may result from; Inadequate intake of vitamin A rich foods, Poor absorption of the vitamin A & rapid utilization of vitamin A stores due to illnesses

Vit A deficiency may lead to;

Increased incidence of illness
Delays recovery from infections
Leads to eye damage and may even lead to blindness
Increases the risk of death in sick children

Remember, Vit A supplementation can;

Reduces measles mortality by 50%
Reduces diarrhea mortality by 33%
Reduces all causes of mortality by 23%

CHECK CHILD’S IMMUNIZATION

*If BCG is not given at birth, it should not be given to children with symptomatic HIV /AIDS.
**Measles vaccine at 6 months is for HIV exposed/ infected children
***Yellow fever vaccine should not be given to children with symptomatic HIV/AIDS.
****RotaVirus vaccine should not be given to children over 15 months
Pentavalent not given if child had convulsion following previous dose or a child with recurrent convulsions or another active neurological disease
PCV10 & Pentavalent not given to Infants with a moderate or severe illness (temperature ≥39°C) until their condition improves.
PCV10 and Pentavalent contraindicated if severe allergic reactions or shock to a prior dose or any component of the vaccine.
Do not delay referrals of children with severe classifications to administer immunizations.

ASSESS OTHER PROBLEMS THE CHILD MIGHT HAVE

It is important to remember that the already discussed IMCI case management process ;

Does not cover all symptoms
Is not reviewing all pediatric medicine
Remember to address some complaints the caregiver may have raised, eg she may have said the child has an itchy skin, You may have observed another problem the mother didn’t say eg jiggers.
Treat any other problems according to your training, experience and clinic policy.
Refer the child for any other problem you cannot manage in the clinic.

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STRABISMUS

Strabismus, also known as “crossed eyes” or “squint,” is a condition characterized by an eye misalignment.

In individuals with strabismus, the eyes do not properly align with each other, meaning they point in different directions. One eye may look straight ahead, while the other eye may turn inward, outward, upward, or downward. This misalignment can be constant or intermittent. often referred to as: cross-eyed, crossed eyes, cockeye, weak eye, wall-eyed, wandering eyes, and/or eye turn.

Strabismus can affect people of all ages, but it commonly develops in early childhood. It is estimated to affect approximately 4% of children. If left untreated, strabismus can cause several issues, including decreased depth perception, double vision (diplopia), and amblyopia (lazy eye), where the brain favors one eye over the other.

Causes of Strabismus

Childhood strabismus often has no known cause, but it tends to run in families.

A. Muscular Factors:

Imbalance in the extraocular muscles: Strabismus can occur due to a weakness or imbalance in the muscles responsible for eye movement, leading to misalignment.
Restrictive eye muscle disorders: Certain conditions, such as thyroid eye disease or orbital fractures, can restrict the movement of the eye muscles and cause strabismus.

B. Nervous System Factors:

Nerve dysfunction: Strabismus may result from abnormalities in the nerves that control eye movements, disrupting the coordination between the eyes.
Neurological disorders: Some neurological conditions, including cerebral palsy, stroke, or brain tumors, can affect the control of eye movements and lead to strabismus.
Stroke: Stroke is a leading cause of strabismus in adults

C. Refractive Errors:

Nearsightedness (myopia): Severe nearsightedness can contribute to the development of strabismus.
Farsightedness (hyperopia): Strabismus may occur in individuals with uncorrected or significantly imbalanced farsightedness.

D. Other Factors:

Congenital factors: Some individuals are born with strabismus, which may be related to genetic or developmental factors.
Eye injuries or trauma: Trauma to the eye or eye muscles can lead to strabismus.
Graves’ disease: Overproduction of thyroid hormone in Graves’ disease can cause strabismus.

Risk/Predisposing Factors for Strabismus:

Family History:

Genetic predisposition: Strabismus can run in families, suggesting a genetic component to the condition.

Age and Development:

Early childhood: Strabismus often develops during infancy or early childhood when the visual system is still developing.

Medical Conditions:

Neurological disorders: Conditions such as cerebral palsy, Down syndrome, or hydrocephalus increase the risk of strabismus.
Premature birth: Premature infants are at a higher risk of developing strabismus compared to full-term infants.

Refractive Errors:

Nearsightedness or farsightedness: Significant refractive errors can contribute to the development of strabismus.

Other Factors:

Eye muscle imbalance: An imbalance in the strength or coordination of the eye muscles can increase the likelihood of strabismus.
Visual stress: Prolonged or intense visual activities, such as excessive screen time or reading, may contribute to strabismus development in susceptible individuals.

Pathophysiology of Strabismus

The pathophysiology of strabismus involves the extraocular muscles, cranial nerves, and the visual cortex.

Extraocular Muscles: The extraocular muscles control the movement and position of the eyes. Any problem with these muscles or the nerves that control them can lead to strabismus.
Cranial Nerves: The extraocular muscles are controlled by cranial nerves III, IV, and VI. If there is an impairment of cranial nerve III, it can cause the associated eye to deviate down and out. Impairment of cranial nerve IV can cause the eye to drift up and slightly inward. Sixth nerve palsy, which affects cranial nerve VI, causes the eyes to deviate inward.
Causes of Nerve Impairment: There can be various causes of nerve impairment leading to strabismus. Increased cranial pressure can compress the nerve as it runs between the clivus and brain stem. In some cases, twisting of the baby’s neck during forceps delivery can damage cranial nerve VI.
Visual Cortex: Evidence suggests that the input provided to the visual cortex may play a role in the development of strabismus. This means that strabismus can occur without direct impairment of cranial nerves or extraocular muscles.
Amblyopia: Strabismus can cause amblyopia, also known as lazy eye. Amblyopia occurs when the brain ignores the signals from one eye, leading to reduced visual acuity. During the early years of life, the brain learns how to interpret the signals from both eyes, and this process, called visual development, can be impaired in strabismus.

Types of Strabismus

Esotropia:

Esotropia is a type of strabismus characterized by the inward turn of one or both eyes.
It can be classified into different subtypes based on the age of onset and underlying causes.
Infantile esotropia: This type of esotropia appears within the first six months of life and is often constant.
Accommodative esotropia: It occurs due to farsightedness (hyperopia) and can be corrected with glasses.
Sixth nerve palsy: Damage to the sixth cranial nerve can cause one eye to turn inward.

Exotropia:

Exotropia is a type of strabismus characterized by the outward deviation of one or both eyes.
It can be intermittent or constant and may be more noticeable when the person is tired or daydreaming.
Exotropia can be classified into different subtypes, including intermittent exotropia, sensory exotropia, and divergence excess exotropia.

Hypertropia:

Hypertropia is a type of strabismus characterized by one eye deviating upward while the other eye maintains a straight position.
It can be classified as unilateral (affecting one eye) or bilateral (affecting both eyes).
Hypertropia can be caused by various factors, including muscle imbalance, thyroid eye disease,trochlear nerve palsy, nerve palsy, or mechanical restrictions.

Hypotropia:

Hypotropia is a type of strabismus characterized by one eye deviating downward while the other eye maintains a straight position.
It can be classified as unilateral or bilateral, similar to hypertropia.
Hypotropia can be caused by muscle imbalance, nerve palsy, or mechanical restrictions.

Note; They can also be classified by whether the problem is present in all directions a person looks (comitant) or varies by direction (incomitant).

Clinical Features of Strabismus:

Misalignment of the Eyes:

The primary clinical feature of strabismus is the misalignment of the eyes, where one eye deviates from its normal position.
The misalignment can be inward (esotropia), outward (exotropia), upward (hypertropia), or downward (hypotropia).

Double Vision:

Strabismus can cause double vision, also known as diplopia.
Double vision occurs when the brain receives conflicting visual information from the misaligned eyes.

Head Tilting or Turning:

Individuals with strabismus may tilt or turn their head to compensate for the misalignment of their eyes.
This head posture helps to align the eyes and reduce the diplopia.

Eye Fatigue and Strain:

Strabismus can lead to eye fatigue and strain due to the constant effort required to align the eyes.
The misalignment can cause the eye muscles to work harder, leading to discomfort and fatigue.

Reduced Depth Perception:

Strabismus can affect depth perception, making it difficult to accurately judge distances.
The misalignment of the eyes can disrupt binocular vision, which is essential for depth perception.

Amblyopia (Lazy Eye):

Strabismus can result in amblyopia, also known as a lazy eye.
Amblyopia occurs when the brain suppresses the visual input from the misaligned eye to avoid double vision.
This can lead to reduced visual acuity and poor development of the affected eye.

Eye Fatigue and Strain:

Strabismus can lead to eye fatigue and strain due to the constant effort required to align the eyes.
The misalignment can cause the eye muscles to work harder, leading to discomfort and fatigue.

Headaches:

Some individuals with strabismus may experience headaches, particularly after prolonged visual tasks.
The strain on the eye muscles and the disruption of binocular vision can contribute to headaches.

Difficulty Reading:

Strabismus can affect reading ability, as the misalignment of the eyes can make it challenging to track lines of text smoothly.
This can result in skipping lines, losing place, or experiencing visual disturbances while reading.

Self-esteem Issues:

Strabismus can have a psychological impact, leading to self-esteem issues and social difficulties.
The visible misalignment of the eyes may cause embarrassment or self-consciousness, particularly in children.

Challenges faced by people with strabismus.

Emotional Distress: Strabismic children commonly exhibit behaviors marked by higher degrees of inhibition, anxiety, and emotional distress. The negative perception of the child by peers can lead to feelings of embarrassment, anger, and a sense of awkwardness, thereby affecting social communication in a fundamental way.
Negative Effect on Self-esteem: Strabismus can have a negative impact on self-esteem, as individuals may feel self-conscious about their appearance and worry about how others perceive them.
Limited Opportunities: Strabismus can affect employment opportunities, as individuals may face misconceptions about their ability to work hard. This can lead to career difficulties and limitations in professional growth.
Social Stigma: The cosmetic aspect of strabismus can result in social stigma, with individuals facing negative attitudes and misconceptions about their intelligence, trustworthiness, and attractiveness. This can lead to feelings of isolation and discrimination.
Vision Difficulties: Strabismus can cause vision problems such as double vision, difficulty reading, eye strain, and headaches. The misalignment of the eyes can affect depth perception and visual coordination, making it challenging to focus on objects.

COPING MECHANISM TO STRESS FROM HAVING STRABISMUS.

One study categorized coping methods into three subcategories:

Avoidance: Some individuals may cope with the stress of having strabismus by refraining from participating in activities that they feel may draw attention to their condition.
Distraction: Deflecting attention from the condition can be a coping mechanism for individuals with strabismus. This may involve focusing on other aspects of their life or engaging in activities that help take their mind off their condition.
Adjustment: Approaching activities differently can be a coping mechanism for individuals with strabismus. This may involve finding alternative ways to accomplish tasks or adapting to situations to minimize the impact of their condition.

Diagnosis of Strabismus

Diagnosing strabismus involves a combination of medical history, symptom evaluation, and specific eye examinations.

Medical History: Gather information about the patient’s medical history, including any symptoms related to strabismus, family history of eye conditions, and any underlying health conditions that may be associated with strabismus.
Symptom Evaluation: Assess the patient’s symptoms, which may include crossed eyes, double vision, decreased depth perception, and misaligned eyes with uncoordinated movements.
Visual Acuity Test: This test measures the clarity of vision at different distances using an eye chart. It helps determine any changes in vision caused by strabismus.
Cover-Uncover Test: This test involves covering one eye at a time to observe the movement and alignment of the eyes when the cover is removed. It helps detect any deviation or misalignment of the eyes.
Ocular Alignment and Focus Test: This test evaluates the movement, focus, and coordination of the eyes. It may involve using a synoptophore, a specialized device that assesses binocular vision and eye alignment.
Refraction Test: This test measures the refractive error of the eyes using a phoropter and retinoscope. It helps determine if any corrective lenses are needed to compensate for vision changes associated with strabismus.
Retinal Examination: This examination involves observing the physical structure of the eye, including the retina, to check for any other eye diseases or conditions that may be causing the strabismus symptoms.
Additional Testing: In some cases, additional tests may be required to evaluate the involvement of other related health conditions. For example, a neurological exam may be conducted to check for conditions such as cerebral palsy or Guillain-Barre syndrome.

Management of strabismus

Management of strabismus involves various treatment options depending on the severity and underlying cause of the condition.

Aims of Management.

To improve eye alignment and coordination.
To prevent complications.
To optimize visual development.

Eyeglasses: In some cases, strabismus can be corrected or improved with the use of eyeglasses. If a child has blurry vision due to nearsightedness or farsightedness, wearing glasses can help reduce the strain on the eyes and improve alignment.
Patching or eye drops: Patching or using eye drops may be recommended by an ophthalmologist to strengthen the weaker eye. This technique, known as occlusion therapy, helps to encourage the use of the weaker eye and improve its visual development.
Vision therapy: Vision therapy involves a series of exercises and activities designed to improve eye coordination and strengthen the eye muscles. It is often used in conjunction with other treatments and can be particularly beneficial for individuals with certain types of strabismus.
Prisms: Prisms are special lenses that can be prescribed to help align the eyes and reduce double vision. They work by bending light and redirecting it to the correct position on the retina, improving visual alignment.
Botulinum toxin injections: In some cases, botulinum toxin injections may be used to temporarily weaken specific eye muscles, allowing for better alignment of the eyes. The toxin is injected in the stronger muscle, causing temporary and partial paralysis. The treatment may need to be repeated three to four months later once the paralysis wears off. This treatment is reserved for certain types of strabismus or as a temporary measure before considering surgery.
Eye muscle surgery: Eye muscle surgery is often recommended for individuals with persistent or severe strabismus. During the surgery, the ophthalmologist adjusts the tension or position of the eye muscles to improve eye alignment. This procedure is usually performed under general anesthesia and may require multiple surgeries depending on the individual case.

Nursing Diagnosis.

Risk for Injury related to impaired sensory function.

The lack of coordination between the muscles around the eyes in strabismus can result in double vision, blurry vision, and poor depth perception, increasing the risk of injury.

Disturbed Sensory Perception related to structural damage.

Evidence: Strabismus causes a lack of coordination between the muscles around the eyes, leading to double vision, blurry vision, and poor depth perception, which can result in a disturbed sensory perception.

Knowledge Deficit related to impaired vision.

Evidence: Children with strabismus may have limited understanding of their condition, treatment options, and the need for early intervention. This lack of knowledge can contribute to a knowledge deficit.

Social Isolation related to limited ability to participate in activities and impaired vision

Evidence: Strabismus can affect a child’s ability to interact socially due to the limited ability to participate in activities and impaired vision, which may lead to social isolation.

Impaired Parent-Child Interaction related to the child’s visual impairment

Evidence: Strabismus can affect the parent-child interaction due to the child’s visual impairment, which may require additional support and education for parents to effectively communicate and engage with their child.

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CONGENITAL CATARACTS

Congenital cataracts are a type of cataract that occurs at birth or during a baby’s first year of life, characterized by clouding or opacity of the lens of the eye.

A lens of the eye is the transparent tissue that helps focus light onto the retina.

Congenital cataracts cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment. Therefore, Congenital cataracts can be Visually significant or not, Stable or Progressive, Congenital or Acquire, Unilateral or Bilateral or else, Partial or Complete.

Classifications of Congenital Cataracts.

Congenital cataracts can be classified based on various factors such as morphology, age of onset, and etiology.

Morphology: Based on their physical appearance.

Polar Cataract: Lens opacities that involve the subcapsular cortex and lens capsule of the anterior or posterior pole of the lens. Anterior polar cataracts present as Small, bilateral, symmetric, non progressive opacities that do not impair vision. Posterior polar cataracts produce more visual impairment than anterior polar cataracts because they tend to be larger and are positioned closer to the nodal point of the eye.

Lamellar Cataract/Zonular Cataract: Lamellar cataracts are the most common type of congenital cataracts. The cataract is visible as an horseshoe- shaped opacity that surrounds a clearer center and is itself surrounded by a layer of clear cortex. Lamellar cataracts may be inherited or result from a transient toxic influence during embryonic lens development.

Sutural Cataract: Opacification of the Y-sutures of the fetal nucleus that commonly do not impair vision. They are usually bilateral, symmetric, and frequently inherited in an autosomal dominant pattern. These opacities often have branches or knobs projecting from them.

Coronary Cataract: Coronary cataracts consist of club-shaped cortical opacities arranged around the equator of the lens like a crown or corona. They cannot be seen unless the pupil is dilated, and they usually do not affect visual acuity. They are often inherited in an autosomal dominant pattern.

Cerulean Cataract/Blue-dot Cataract: Cerulean cataracts are small bluish opacities located in the lens cortex. They are nonprogressive and usually do not cause visual symptoms.

Nuclear Cataract: Opacities of either the embryonic nucleus alone or both the embryonic and fetal nuclei. They are usually bilateral, with a wide spectrum of severity. Eyes with congenital nuclear cataracts tend to be microphthalmic and have an increased risk of developing aphakic glaucoma.

Capsular Cataract: Small opacifications of the lens epithelium and anterior lens capsule that spare the cortex. They are differentiated from anterior polar cataracts by their protrusion into the anterior chamber, but generally do not affect vision.

Membranous Cataract: Membranous cataracts occur when lens proteins are resorbed, allowing the anterior and posterior lens capsules to fuse into a dense white membrane. They cause significant visual disability due to the resulting opacity and lens distortion.

Age of Onset:

Congenital/Infantile cataract: Lens opacities present at birth.
Acquired/Juvenile cataract: Onset after infancy, in childhood.

Etiology:

Genetic cataract/Hereditary: Caused by mutations in genes involved in lens structure or clarity. The affected individuals are usually perfectly well, and have no associated systemic illness. Associated with microphthalmos.
Metabolic cataract: Caused by metabolic disorders such as galactosemia, hypoglycemia, hypocalcemia. Galactosemia is a metabolic disorder in which the child’s body cannot metabolize galactose, a major component of milk and milk products. The baby develops typical ‘oil droplet’ cataracts which are easily seen by examining the red reflex. These are reversible, and the lens returns to normal on removing dairy products from the diet.
Traumatic cataract: Caused by external injuries to the eye. Trauma is the most common cause of unilateral cataract in children. Traumatic cataract is usually the result of a penetrating injury, though blunt trauma can also lead to cataract formation.
Secondary cataracts: Such as those secondary to marternal infection during pregnancy. TORCH syndrome: Toxoplasmosis, Others(Syphilis, Hepatitis B), Rubella, Cytomegalovirus (CMV), Herpes infection.. Usually bilateral, dense, and central. The most common maternal infection to cause congenital cataract in the child is Rubella. The cataracts caused by Rubella may be present at birth, or develop several months later.
Iatrogenic cataract: Caused by well-intentioned medical treatment, Such as Radiation, Drugs, Surgeries, e.t.c. latrogenic cataract is most commonly seen in children who have had Total body irradiation for leukemia, Organ transplants, On long-term systemic steroid therapy. These children are usually older children and do very well after cataract surgery.

Causes of Congenital Cataracts

The causes of congenital cataracts can vary and may include genetic factors, infections, physical trauma during pregnancy, hypoglycemia, and premature birth, It’s important to note that in many cases, the exact cause of congenital cataracts is not known.

Genetic Factors: In some cases, congenital cataracts are caused by a faulty gene that is passed from parents to their child. It is estimated that around 1 in every 5 cases of congenital cataracts have a family history of the condition.

Infections: Certain infections during pregnancy can increase the risk of congenital cataracts in babies. These infections include:

Infections during pregnancy, such as those caused by STORCH (Syphilis, Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes simplex), can lead to congenital cataracts.

Other infections like influenza, measles, polio, and rubella.
Other conditions: Certain conditions like hypoparathyroidism, Conradi syndrome, aniridia, anterior segment dysgenesis, persistent fetal vasculature (PFV), posterior lenticonus, and corticosteroid use can also contribute to the development of congenital cataracts.

Physical Trauma during Pregnancy: Physical trauma to the mother’s abdomen during pregnancy, such as from a car accident, a fall, or intimate partner violence, can cause injury to the baby’s eyes in the womb and lead to congenital cataracts.

Hypoglycemia during Pregnancy: Hypoglycemia, which is low blood sugar levels, can occur in pregnant women with uncontrolled diabetes. This condition may increase the risk of congenital cataracts in the baby.

Premature Birth: Babies born prematurely, before 37 weeks of pregnancy, have a higher risk of developing congenital cataracts.

Metabolic disorders: Certain metabolic disorders, such as galactosemia and hypoglycemia, can increase the risk of developing congenital cataracts.

Syndromes: Several syndromes have been associated with congenital cataracts, including Down syndrome, Lowe syndrome, Cockayne syndrome, Marfan syndrome, Trisomy 13-15, Alport syndrome, Myotonic dystrophy, Fabry disease, and Incontinentia pigmenti.

Diagnosis and Investigations for Congenital Cataracts:

Diagnosing congenital cataracts involves a comprehensive eye examination by an ophthalmologist, who specializes in eye disorders.

There is no benefit in doing a large number of tests and investigations on all children with cataract. It is better to take a careful history.

Family History and Genetic Testing: A detailed family history is important, as congenital cataracts can have a genetic component. Genetic testing may be recommended to identify specific gene mutations associated with cataract formation.
Complete Eye Examination: This includes a thorough evaluation of the infant’s eyes, including visual acuity assessment, examination of the lens, and assessment of the red reflex. The red reflex is particularly useful in estimating the size and location of the cataract within the visual axis. The red reflex test is best performed in a darkened room and involves shining a bright direct ophthalmoscope into both eyes simultaneously from a distance of 1– 2 ft.
Slit Lamp Examination: A slit lamp is a specialized microscope that allows the ophthalmologist to examine the structures of the eye in detail. It helps in visualizing the cataract and determining its characteristics, such as size, location, and morphology.
Intraocular Pressure Measurement: This test measures the pressure inside the eye and helps in assessing or ruling out other conditions.
Ultrasound of the Posterior Pole: In cases where the cataract is not clearly visible, an ultrasound may be performed to visualize the posterior pole of the eye and assess the presence of any abnormalities.
Laboratory Tests: Depending on the clinical presentation and suspected underlying cause, various laboratory tests may be performed. These may include TORCH (toxoplasmosis, rubella, cytomegalovirus, varicella) screening, Venereal Disease Research Laboratory (VDRL) test for syphilis, blood tests for calcium, phosphorus, glucose, and galactokinase levels, and urine tests for reducing sugars.

Management of Congenital Cataracts

Management and treatment of congenital cataracts involve a multidisciplinary approach and may vary depending on the specific case and underlying cause.

Aims of Management

To remove the cloudy lens and restore clear vision in the affected eye(s).
Regaining the usual level of cognition.
Recognizing awareness of sensory needs.
Preventing injury.
Identifying potential risk factors in the environment.
Reducing anxiety to a manageable level.
Providing education on coping with altered abilities

In general, the younger the child, the greater the urgency in removing the cataract, because of the risk of amblyopia.

For optimal visual development in newborns and young infants, a visually significant unilateral congenital cataract should be detected and removed before age 6 weeks, and visually significant bilateral congenital cataracts should be removed before age 10 weeks.
Some congenital cataracts are too small to affect vision, therefore no surgery or treatment will be done. If they are superficial and small, an ophthalmologist will continue to monitor them throughout a patient’s life.
Commonly, a patient with small congenital cataracts that do not affect vision will eventually be affected later in life; generally this will take decades to occur .
Congenital cataracts are one of the most common treatable causes of visual impairment and blindness during infancy, with an estimated prevalence of 1 to 6 cases per 10,000 live births.

Nursing Assessment:

Recent medication intake: Anticoagulant therapy may be withheld to reduce the risk of retrobulbar hemorrhage.
Preoperative tests: Standard preoperative tests such as complete blood count, electrocardiogram, and urinalysis may be prescribed based on the patient’s medical history.
Vital signs: Stable vital signs are necessary before surgery. These include TPR/Bp.
Visual acuity test results: Assessment of visual acuity using tests like Snellen’s chart is important.
Patient’s medical history: Assessing the patient’s medical history helps determine the required preoperative tests.

Nursing Diagnosis:

Disturbed visual sensory perception related to altered sensory reception or status of sense organs as evidenced by the patient using hand to locate environment.
Risk for trauma related to poor vision and reduced hand-eye coordination.
Anxiety related to the threat of permanent loss of vision/independence as evidenced by the patients restlessness.

Medical Management: Pharmacologic Therapy:

Dilating drops: These are administered pre and postoperatively to dilate the pupil and facilitate surgery.
Antibiotic drugs: Prophylactic administration of antibiotics helps prevent postoperative infection and inflammation.
Intravenous sedation: Sedation may be used to minimize anxiety and discomfort before surgery.

Surgical Intervention:

Surgery is the mainstay of treatment for congenital cataracts.
Pediatric ophthalmologists who specialize in congenital cataract surgery perform the procedure.
During surgery, a small incision is made in the eye, and the cloudy lens is removed.
In some cases, additional surgical procedures may be required, such as intraocular lens implantation or capsulotomy.

Lens Replacement:

Phacoemulsification: This procedure involves removing a portion of the anterior capsule, extracting the lens nucleus and cortex, and leaving the posterior capsule and zonular support intact. Different lens replacement options include aphakic glasses, contact lenses, and intraocular lens (IOL) implants.
Extracapsular cataract extraction (ECCE): This procedure removes the anterior lens and cortex, leaving the posterior capsule intact.
Intracapsular cataract extraction: This procedure removes the entire lens within the intact capsule.

Timing of Surgery:

The timing of surgery depends on various factors, including the age of the child, the severity of the cataract, and the presence of any associated eye conditions.
Early surgery is generally recommended to prevent visual deprivation and promote normal visual development.
In some cases, surgery may be delayed if there are other medical conditions that need to be addressed first.

Correction of Refractive Errors:

After cataract surgery, children may develop refractive errors, such as nearsightedness or farsightedness.
Corrective measures, such as glasses or contact lenses, may be prescribed to optimize visual acuity.

Amblyopia Management:

Amblyopia, also known as lazy eye, is a common complication of congenital cataracts.
Amblyopia occurs when the brain favors one eye over the other due to visual deprivation.
Treatment may involve patching or blurring the stronger eye to encourage the use and development of the weaker eye.

Regular Follow-up and Monitoring:

Children with congenital cataracts require long-term follow-up and monitoring by a pediatric ophthalmologist.
Regular eye examinations are essential to assess visual acuity, monitor for any complications, and adjust treatment as needed.

Complications of congenital cataracts

Cloudy Vision: After cataract surgery, a condition called posterior capsule opacification (PCO) can occur. This is when part of the lens capsule thickens and causes cloudy vision. PCO is not the cataract returning, but rather the growth of cells over the artificial lens. It usually develops within 4 to 12 months after surgery and may require another operation to correct it.
Lazy Eye: Lazy eye, also known as amblyopia, can occur if there is weaker vision in one eye. The brain may ignore the visual signals from the weaker eye, leading to improper development of vision. Treatment for lazy eye usually involves wearing a patch over the stronger eye.
Glaucoma: Increased pressure inside the eye, known as glaucoma, can affect vision. Children who have had cataract surgery are at a lifelong risk of developing glaucoma and will need regular eye pressure measurements by an optician.
Squint: A squint, also called strabismus, is a condition where the eyes look in different directions. It can occur as a complication after cataract surgery.
Pupil Abnormalities: Pupil abnormalities, such as the pupil becoming a more oval shape, can occur but usually do not affect vision significantly.
Retinal Detachment: Retinal detachment is a condition where the retina becomes separated from the inner wall of the eye, leading to vision impairment. It can be a complication after cataract surgery.
Cystoid Macular Edema: Cystoid macular edema is the buildup of fluid between layers of the retina, which can affect vision.
Infection: In rare cases, an infection called endophthalmitis can occur after cataract surgery. It may require medication or further surgery for treatment

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VISUAL IMPAIRMENT

Visual impairment also known as vision impairment or vision loss , is a decreased ability to see to a degree that causes problems not fixable by usual means, such as glasses.

Visual impairment refers to any kind of vision loss, ranging from partial vision loss to complete blindness.

Visual impairment is often defined as a best corrected visual acuity of worse than either 20/40 or 20/60.

To understand Visual Acuity numbers,

Visual acuity numbers are used to measure the clarity or sharpness of a person’s vision. They are expressed as a fraction, such as 20/20 or 20/40. The interpretation of these numbers is as follows:

The Top Number: The top number in the visual acuity measurement represents the distance at which the person is standing from the eye chart during the test. For example, if the top number is 20, it means the person is standing 20 feet away from the chart.
The Bottom Number: The bottom number indicates the distance at which a person with normal vision can read the same line on the chart that the individual being tested can read. For instance, if the bottom number is 20, it means a person with normal vision can read that line from a distance of 20 feet.

Causes of Visual Impairement

The most common causes of visual impairment globally are uncorrected refractive errors (43%), cataracts (33%), and glaucoma (2%). Visual impairment can be caused by various factors, including genetic conditions, eye injuries, infections, and age-related diseases.

Genetic Conditions:

Retinitis pigmentosa: A genetic disorder that causes the breakdown and loss of cells in the retina, leading to progressive vision loss.
Congenital cataracts: Clouding of the lens present at birth, which can cause visual impairment if not treated.
Glaucoma: A group of eye conditions that damage the optic nerve, often caused by genetic factors.

Eye Injuries:

Trauma: Injuries to the eye, such as from accidents, sports-related incidents, or workplace hazards, can result in vision loss or impairment.
Corneal injuries: Damage to the cornea, the clear front part of the eye, can lead to vision problems.
Corneal Opacification: Corneal opacification, which refers to the clouding or scarring of the cornea, corneal abrasion can be a cause of corneal opacity. In some cases, eye swelling can also cause damage to the cornea that results in opacity.

Infections:

Ocular infections: Infections of the eye, such as conjunctivitis, uveitis, or keratitis, can cause visual impairment if left untreated.
Infections during pregnancy: Certain infections, like German measles (rubella), can be transmitted from the mother to the fetus and result in visual impairment in the baby.
Trachoma: Trachoma is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis. It is a public health problem in 42 countries, and is responsible for the blindness or visual impairment of about 1.9 million people.

Age-Related Diseases:

Cataracts: Clouding of the lens in the eye, commonly associated with aging, can cause blurry vision and visual impairment.
Age-related macular degeneration (AMD): A progressive condition that affects the macula, the central part of the retina, leading to loss of central vision.
Glaucoma: Increased pressure within the eye can damage the optic nerve and result in vision loss.
Childhood Blindness: Various conditions, including genetic disorders, infections, and developmental abnormalities, can cause visual impairment in children

Other Causes:

Diabetic retinopathy: Damage to the blood vessels in the retina due to diabetes, which can lead to vision impairment or blindness.
Amblyopia (lazy eye): Reduced vision in one eye due to abnormal visual development during childhood.
Medications: Certain medications, such as those used in chemotherapy or for treating autoimmune diseases, can have side effects that affect vision.
Undercorrected refractive error: Refractive errors, such as nearsightedness, farsightedness, and astigmatism, can cause visual impairment if not corrected with glasses or contact lenses.
Undetermined: A significant percentage of visual impairment cases were categorized as undetermined, indicating that the cause could not be identified

Signs and Symptoms of Visual Impairment

Blurred Vision: Objects may appear fuzzy or out of focus.
Double Vision: Seeing two images instead of one.
Floaters: Seeing spots, specks, or cobweb-like shapes drifting across your field of vision.
Flashes of Light: Seeing sudden flashes of light, especially in peripheral vision.
Halos: Seeing circles of light around objects, particularly when looking at bright lights.
Changes in Iris Color: Noticing a change in the color of the iris, such as a darkening or lightening.
Eye Pain: Experiencing sudden or recurrent pain in or around the eye.
Sensitivity to Light: Feeling discomfort or pain when exposed to bright lights.
Difficulty Seeing at Night: Struggling to see clearly in low-light conditions.
Loss of Peripheral Vision: Having a reduced ability to see objects or movement in the outer edges of your visual field.
Inability to see shapes: An inability to see shapes refers to the difficulty in perceiving and recognizing the outlines and forms of objects.
Cloud vision: Cloudy vision refers to a hazy or blurred visual perception, which can make it difficult to see objects clearly.
Seeing only shadows: Seeing only shadows means that a person can perceive the presence of light and darkness but cannot distinguish detailed visual information.
Tunnel vision: Tunnel vision is a condition where a person’s peripheral vision is significantly reduced, resulting in a narrowed field of view.

Visual impairments can also impact daily activities which include:

Reading: Holding reading material closer to the face, difficulty reading in low light, or experiencing a decrease in reading speed.
Mobility: Bumping into objects, having trouble navigating stairs or uneven surfaces, or experiencing a loss of depth perception.
Recognizing Faces and Objects: Difficulty identifying faces or objects, especially from a distance.
Color Perception: Trouble distinguishing between colors or selecting clothing with appropriate color combinations.
Eye Strain: Experiencing eye fatigue, headaches, or discomfort after prolonged visual tasks.

Diagnosis, Tests, and Investigations for Ruling Out Visual Impairment

These assessments help in evaluating the visual functions and identifying any abnormalities or impairments.

History and External Examination:

A complete history, including family history of visual impairment, is taken.
External examination of the eye is conducted, which includes assessing the lids, conjunctiva, cornea, iris, lens, etc..

Visual Acuity Test:

The Snellen test, also known as the visual acuity test, is commonly used.
The patient reads progressively shortening random letters and numbers from a chart placed at a distance of 6 meters.
The ability to read the letters at each size determines the visual acuity.
The test provides a score, represented by two numbers, indicating the patient’s ability to read compared to a person with healthy vision.

Visual Field Test:

Perimetry and visual field testing are used to assess the integrity of the field of view.
This test evaluates vision outside the macula and measures the range of peripheral vision.
The patient’s field of vision is assessed by flashing lights in their peripheral vision, and they are asked to respond when they see the lights.
Any gaps or abnormalities in the field of vision can be detected through this test.

Tonometry Test:

Tonometry is performed to evaluate the fluid pressure inside the eye, which helps in detecting glaucoma.

Ocular Motility Assessment:

This test assesses the movement of the eyeballs and checks for any squint or other problems.

Additional Tests:

In certain cases, additional tests may be prescribed, such as Visually Evoked Potential (VEP), Electroretinogram (ERG), and Electro-oculogram (EOG).
These tests evaluate the transmission of signals from the eye to the brain and can be helpful in diagnosing visual impairment, especially in young patients or those with multiple handicaps

Classification of Visual Impairement

The International Classification of Diseases 11 (2018) provides a classification system for vision impairment, categorizing it into two groups: distance vision impairment and near vision impairment. It is assessed by reading an eye chart from a specific distance.

Distance Vision Impairment:

Mild: Presenting visual acuity worse than 6/12 – This means that a person with mild distance vision impairment can see at 6 meters what a person with normal vision can see at 12 meters.
Moderate: Presenting visual acuity worse than 6/18 – Individuals with moderate distance vision impairment can see at 6 meters what a person with normal vision can see at 18 meters.
Severe: Presenting visual acuity worse than 6/60 – People with severe distance vision impairment can see at 6 meters what a person with normal vision can see at 60 meters.
Blindness: Presenting visual acuity worse than 3/60 – This category includes individuals with very limited or no ability to perceive visual information.

Near Vision Impairment:

Presenting near visual acuity worse than N6 or M.08 with existing correction – This refers to difficulties in seeing objects up close, even with corrective measures.

N6: N6 refers to the near visual acuity measurement. It indicates the level of visual clarity or sharpness at a close distance. The “N” stands for “near,” and the number represents the visual acuity scale. N6 refers to the ability to see at a distance of 40 cm (16 inches) with existing correction. In the International Classification of Diseases 11 (2018), N6 is used to classify near vision impairment.

40 cm: 40 cm (or 16 inches) is the standard working distance used to measure near visual acuity. It represents the distance at which a person is tested for their ability to see objects up close. This measurement is commonly used in vision assessments and is considered the standard distance for near vision testing

M.08 refers to presenting near visual acuity worse than N6 or M.08 at 40 cm. This means that individuals with M.08 near vision impairment have difficulty seeing objects clearly at close distances, even with existing correction such as glasses or contact lenses.

Note; Blindness in combination with hearing loss is known as deafblindness .

Management of Visual Impairment

Management ranges from Surgery, Pharmacological, Rehabilitation and Prevention.

Patient Reception:

Greet the patient and their caretaker with empathy and understanding.
Collect relevant medical history, including information about the visual impairment and any existing assistive devices.
Provide a comfortable waiting area with appropriate lighting and signage to assist visually impaired individuals.

Medical Assessment and Diagnosis:

Conduct a thorough examination by an ophthalmologist to determine the cause and severity of the visual impairment.
Perform necessary tests, such as visual acuity measurements, visual field tests, and imaging studies.
Discuss the diagnosis with the patient and their caretaker, explaining the implications and available treatment options.

Treatment and Management:

On return of the results, Prescribe appropriate corrective lenses, such as eyeglasses or contact lenses, if applicable.
Recommend assistive devices and technology based on the patient’s needs, such as magnification systems, visual aids, and adaptive technology.
Refer the patient to low vision rehabilitation programs for specialized training and support.
Provide information about available support services, such as counseling, support groups, and registration as visually impaired if necessary.

Rehabilitation and Training:

Arrange orientation and mobility training to help the patient navigate their environment safely and independently.
Offer daily living skills training to enhance independence in activities of daily living.
Provide access to Braille literacy programs for those interested in learning Braille. Braille is a tactile writing system used by people who are blind or visually impaired. It consists of raised dots arranged in cells, which can be read by touch.
Facilitate low vision rehabilitation programs to maximize the patient’s remaining vision through training and adaptive strategies.

Emotional and Psychological Support:

Offer counseling services to address emotional and psychological challenges associated with visual impairment.
Connect the patient and their caretaker with support groups to share experiences and receive peer support.
Collaborate with mental health professionals to address any psychological issues related to visual impairment.

Ongoing Monitoring and Follow-up:

Schedule regular follow-up appointments to monitor the patient’s visual health and adjust the management plan as needed.
Provide educational resources and information to the patient and their caretaker for continued self-care and support.

Discharge:

Ensure that the patient and their caretaker understand the management plan and have access to necessary resources and support services.
Provide written instructions, including medication details, follow-up appointments, and contact information for further assistance.
Coordinate with other healthcare professionals involved in the patient’s care to ensure a smooth transition post-discharge.

Surgical Management:

Surgical management is crucial according to the cause of the visual impairement.

Cataract Surgery:

Cataract surgery is a common surgical procedure to treat visual impairment caused by cataracts.
During the surgery, the clouded natural lens of the eye is removed and replaced with an artificial lens called an intraocular lens (IOL).
This procedure is usually highly successful in restoring vision and improving visual acuity.

Corneal Transplant:

In cases where visual impairment is caused by a scarred or damaged cornea, a corneal transplant may be considered.
During the procedure, the damaged cornea is replaced with a healthy cornea from a donor.
Corneal transplants can help improve vision and restore clarity to the cornea.

Retinal Surgery:

Retinal surgery may be performed to address visual impairment caused by retinal conditions such as retinal detachment or macular holes.
The specific surgical techniques used depend on the underlying condition and may involve repairing or reattaching the retina.
Laser surgery may also be used to treat certain retinal conditions, such as diabetic retinopathy or retinal tears.

Glaucoma Surgery:

In cases where visual impairment is caused by glaucoma, surgical interventions may be necessary to manage the condition.
Different types of glaucoma surgeries are available, including trabeculectomy, tube shunt surgery, and laser trabeculoplasty.
These procedures aim to reduce intraocular pressure and prevent further damage to the optic nerve, thus preserving vision.

Prevention

Eat a Nutritious Diet: Consuming a balanced diet rich in fruits, vegetables, and omega-3 fatty acids can help maintain good eye health.
Get Regular Eye Exams: Regular eye exams are crucial for early detection and treatment of vision problems. The frequency of eye exams may vary depending on age and risk factors.
Know Your Family’s Eye History: Understanding your family’s history of eye problems can help identify potential risks and take preventive measures.
Follow a Healthy Lifestyle: Maintaining a healthy lifestyle, including regular exercise and not smoking, can contribute to overall eye health.
Protect Your Eyes from Trauma: When engaging in activities that pose a risk to your vision, such as sports or working with hazardous materials, wear durable eye protection to prevent injuries.
Avoid Harmful Substances: Avoid smoking, as it is a major risk factor for vision problems such as macular degeneration and cataracts. Additionally, minimize exposure to harsh chemicals and protect the eyes from harmful substances.
Protect Your Eyes from UV Radiation: Wear sunglasses that provide 99-100% protection against UVA and UVB rays to shield your eyes from the harmful effects of UV radiation.
Practice Good Eye Hygiene: Take breaks when using digital devices or performing concentrated activities to prevent eyestrain. Blink regularly to keep your eyes lubricated and use artificial tears if needed.
Manage Chronic Conditions: Properly manage chronic conditions like diabetes and high blood pressure, as they can contribute to vision problems.
Genetic testing: Genetic testing can be helpful in prevention of genic eye disorders such as Retinitis pigmentosa.

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STINGS AND BITES

STINGS AND BITES.

Stings and bites refer to injuries caused by animals, insects, or plants that break the skin surface and can result in various reactions, ranging from minor irritation to severe medical conditions.

The terms “sting” and “bite” are used to differentiate between the type of injury and the mechanism by which it occurs.

Insect bites occur when insects like mosquitoes, fleas, or bedbugs use their mouthparts to break the skin and feed on blood. These bites usually cause itching.
Insect stings occur when insects, such as bees, wasps, or hornets, use a barbed stinger or another body part to pierce the skin and inject venom as a defense mechanism.

Other Animal Bites and Stings:

Animal bites, such as dog bites, occur when an animal uses its teeth to break the skin.
Animal stings, like those from jellyfish or scorpions, occur when an animal uses a specialized body part to inject venom into the skin.
Plant Stings: Some plants have tiny needles or hairs on their leaves that can break off and lodge into the skin, causing discomfort. These are known as stinging plants

INSECTS STINGS AND BITES

Causes of Insect Stings and Bites:

Insects: Insects such as bees, wasps, hornets, mosquitoes, and ants are common causes of stings and bites.
Arachnids: Arachnids like spiders and ticks can also cause stings and bites.
Environmental Factors: Spending time outdoors in areas where insects are prevalent, such as forests, gardens, or fields, increases the risk of being stung or bitten.
Provocation: Insects may sting or bite if they feel threatened or provoked. For example, bees and wasps may sting if they perceive a threat to their nest or hive.
Attractants: Certain scents, perfumes, bright colors, and sweet foods can attract insects and increase the likelihood of being stung or bitten.
Seasonal Factors: Insect activity tends to be higher during warmer months, increasing the chances of encountering stinging or biting insects.
Geographic Location: The prevalence of specific insects varies by region, so the risk of stings and bites may be higher in certain areas.

Pathophysiology of Insect Stings and Bites:

Exposure: When an insect stings or bites, it injects venom or saliva into the skin through its mouthparts or stinger.
Venom/Saliva: The venom or saliva contains various substances that can trigger an immune response and cause local and systemic effects.
Immune Response: The immune system recognizes the foreign substances in the venom or saliva and releases chemicals, such as histamine, to defend against them.
Local Effects: The release of histamine and other chemicals leads to local inflammation, causing redness, swelling, pain, and itching at the site of the sting or bite.
Systemic Effects: In some cases, the venom or saliva can cause systemic effects, affecting other parts of the body. This can occur due to an allergic reaction or a toxic reaction to the venom.

Signs and Symptoms of Insect Stings and Bites:

When it comes to insect stings and bites, there are several signs and symptoms that can occur. These can range from mild irritation to more severe allergic reactions.

Localized Reactions:

Localized redness and swelling at the site of the sting or bite.
Itching and irritation.
Pain or tenderness.
Formation of a small blister or weal.
Development of a rash or hives.
In some cases, a visible puncture mark or stinger may be present.

Systemic Reactions:

Dizziness.
Weakness.
Nausea.
Headache.

Signs and Symptoms of Anaphylaxis:

Anaphylaxis is a severe allergic reaction that can occur in response to an insect sting or bite. It is a medical emergency and requires immediate attention. The signs and symptoms of anaphylaxis may include:

Difficulty breathing or wheezing.
Swelling of the face, lips, tongue, or throat.
Rapid heartbeat or palpitations.
Severe itching or hives over a large area of the body.
Nausea, vomiting, or abdominal pain.
Feeling of impending doom or anxiety.
Loss of consciousness or collapse.

Management of Insect bites and stings.

Reassure the casualty and keep them calm.
Apply constant firm pressure to the sting area using the edge of a blunt object or your fingernail. Scrape or brush off the sting. Avoid using tweezers as they may squeeze the venom sac and increase venom release.
If the sting is on the fingers or hands, remove any rings or watches in case of swelling.
Remove the sting by scraping with a straight-edged object across the stinger. Do not use tweezers – these may squeeze the venom sac and increase the amount of venom released.
Wash the site thoroughly with soap and water. Then, follow these steps:
Place ice (wrapped in a washcloth) on the site of the sting for 10 minutes and then off for 10 minutes. Repeat this process. Avoid direct contact with the skin to prevent frostbite.
If necessary, take an antihistamine or apply creams that reduce itching.
Over the next several days, watch for signs of infection (such as increasing redness, swelling, or pain).
Advise the casualty to see a doctor if the pain and swelling persist.
DO NOT apply a tourniquet or give the person stimulants, aspirin, or other pain medicine unless prescribed.

Diagnosis.

History of a bite or stung by an insect
Physical exam-view of the swollen site.
Skin allergic test

Medical management.

In mild cases, insect stings and bites may be managed without drug therapy. However, in more severe cases, the following drug therapies may be used:

Anti-histamines: These can help relieve itching and reduce allergic reactions.
Steroids: Systemic steroids may be prescribed to reduce inflammation and allergic responses.
Epinephrine: In cases of anaphylaxis, epinephrine (adrenaline) may be administered to reverse severe allergic reactions.
Prophylactic antibiotics: In certain cases, antibiotics may be prescribed to prevent infection.

Safety precautions to consider:

Use insect repellents to help prevent insect stings.
Wear long pants and a T-shirt to minimize exposed skin.
If you encounter an attack, cover your face and run in a straight line as quickly as possible.
Grab a net, coat, towel, or any object that can provide temporary protection.
Seek shelter in a house, tent, or car with windows and doors closed.
Avoid other people as they may also come under attack.
Be aware that bees can pursue for up to 400 meters.
Bees are slow fliers, and most people can outrun them.
Stay alert for bees entering or exiting through cracks in walls.
Once you notice a bee colony, do not provoke it and keep a safe distance.

When to Seek Emergency Care:

Trouble breathing, wheezing, or experiencing shortness of breath.
Swelling anywhere on the face or in the mouth.
Throat tightness or difficulty swallowing.
Feeling weak or experiencing a sudden drop in blood pressure.
Turning blue or experiencing a loss of consciousness.

Prevention of Insect stings and bites.

Avoid rapid, jerky movements around insect hives or nests.
Avoid wearing perfumes and clothing with floral patterns or dark colors, as they can attract insects.
Use appropriate insect repellents and wear protective clothing, such as long sleeves and pants.
Exercise caution when eating outdoors, especially around garbage cans or sweetened beverages that may attract bees.
If you have severe allergies to insect bites or stings, it is important to have an emergency kit and an EpiPen. Ensure that your friends and family know how to use it in case of a reaction.

ANIMAL BITES

Animal bites, especially in children, are a common occurrence and can result in puncture wounds. It is important to properly manage these bites to prevent complications such as infection and the transmission of diseases like rabies.

General Wound Care:

Rinse the wound with saline water or sterile water under pressure to remove any dirt or debris.
Wash the surrounding skin with soap and water to reduce the risk of infection.
Apply a clean dressing to protect the wound and promote healing.
If possible, elevate the affected body part to help control bleeding.

Medical Interventions:

Tetanus toxoid should be administered if the person has not been adequately vaccinated against tetanus.
Prophylactic antibiotics may be prescribed to prevent infection, especially in high-risk wounds or individuals with immune deficiencies.
Debridement of lacerations may be necessary to remove damaged tissue and promote healing.

Suspected Rabies Infection:

If there is a suspicion of rabies infection, immediate medical attention is crucial.
Anti-rabies immunoglobulins, such as inactivated rabies vaccines, may be administered to induce an active immune response.
Rabies Ig (preformed antibodies) may also be given to provide immediate protection against the virus.

Animal Safety:

Teach children how to prevent interactions with unfamiliar animals.
Vaccinate your pets regularly to protect them against diseases and reduce the risk of bites.
Avoid teasing or provoking animals, as this can lead to aggressive behavior.
Do not make direct eye contact with a threatened animal, as it may perceive it as a challenge.
Never pull an animal’s tail or take away its food, as this can agitate them.
Approach restrained animals with caution and respect their space.
Avoid running in front of a dog, as it may trigger their instinct to chase.
Do not allow inexperienced individuals to feed dogs, as they may not understand proper handling techniques.
Alert animals to your presence before approaching them to avoid surprising or startling them.
Consider spraying your pets with appropriate insect repellents to prevent bites from insects like fleas and ticks.
Socialize your animals to ensure they are comfortable and well-behaved around people.
Do not allow children to lead dogs, as they may not have the necessary control or understanding of the animal’s behavior.

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