The gastrointestinal (GI) tract is a continuous, hollow, muscular tube that serves as the primary pathway for digestion and absorption. It is approximately 23 to 26 feet (7 to 8 meters) long and extends from the mouth to the anus, passing through the thoracic and abdominopelvic cavities.

Esophagus

Location: The esophagus is a collapsible tube located in the mediastinum of the thoracic cavity, situated anterior to the spine and posterior to the trachea and heart.

Structure: It is about 25 cm (10 inches) in length. Its muscular walls become distended (stretched) to allow the passage of a food bolus.

Passage: It passes through the diaphragm at an opening known as the diaphragmatic hiatus to connect to the stomach. The remaining portion of the GI tract is located within the peritoneal cavity.

Stomach

Location: The stomach is a J-shaped, distensible pouch situated in the upper left portion of the abdomen, just under the left diaphragm and to the left of the midline.

Capacity: It has a capacity of approximately 1500 mL.

Regions: The stomach is divided into four main regions:

Cardia: The entrance area surrounding the esophageal opening.
Fundus: The rounded upper portion superior and to the left of the cardia.
Body: The large central portion.
Pylorus: The lower outlet portion that connects to the small intestine.

Sphincters: Two smooth muscle sphincters regulate the passage of food:

The Lower Esophageal Sphincter (LES) or cardiac sphincter surrounds the esophagogastric junction (inlet). When it contracts, it closes off the stomach from the esophagus, preventing reflux.
The Pyloric Sphincter is a ring of circular smooth muscle at the junction of the pylorus and the duodenum. It controls the rate at which partially digested food (chyme) leaves the stomach and enters the small intestine.

Small Intestine

Structure: The small intestine is the longest segment of the GI tract, accounting for about two-thirds of its total length. It is highly coiled and folded upon itself, providing a massive surface area of approximately 7000 cm² for secretion and absorption.

Function: It is the primary site where nutrients from digested food enter the bloodstream through the intestinal walls.

Anatomic Parts: It is divided into three sections:

Duodenum: The first and shortest part (about 10 inches), where chyme from the stomach is mixed with bile and pancreatic secretions. The common bile duct and pancreatic duct empty into the duodenum at the ampulla of Vater.
Jejunum: The middle section, which is the primary site for nutrient absorption.
Ileum: The final and longest section, which absorbs vitamins (especially B12) and bile salts.

Ileocecal Valve: This valve is located at the junction of the ileum and the cecum (the beginning of the large intestine). It controls the passage of intestinal contents into the large intestine and prevents the backflow (reflux) of bacteria. The vermiform appendix is a small, finger-like pouch attached near this junction.

Large Intestine

Structure: The large intestine frames the small intestine and consists of several segments:

Ascending Colon: Travels up the right side of the abdomen.
Transverse Colon: Extends across the upper abdomen from right to left.
Descending Colon: Travels down the left side of the abdomen.

Terminal Portion: The end of the large intestine consists of two parts: the S-shaped sigmoid colon and the rectum.

Function: Its primary functions are the absorption of water and electrolytes from indigestible food matter and the storage of feces before defecation.

Rectum and Anus

The rectum is the final section of the large intestine, terminating at the anus.
The anus is the external opening of the GI tract. Its outlet is regulated by the internal and external anal sphincters, which are a network of smooth and striated (voluntary) muscles, respectively.

Blood and Nerve Supply of the GI Tract

Blood Supply

Arterial blood is supplied by arteries originating from the thoracic and abdominal aorta, primarily the gastric artery (for the stomach) and the superior and inferior mesenteric arteries (for the intestines).
Venous blood, rich in absorbed nutrients, is drained from these organs by veins that merge to form the hepatic portal vein. This nutrient-rich blood is carried directly to the liver for processing.
The blood flow to the GI tract is significant, accounting for about 20% of total cardiac output at rest and increasing substantially after eating.

Nerve Supply

The GI tract is innervated by both the sympathetic and parasympathetic divisions of the autonomic nervous system.
- Sympathetic nerves generally have an inhibitory effect: they decrease gastric secretions and motility, and cause sphincters and blood vessels to constrict.
- Parasympathetic nerves (primarily the vagus nerve) generally have a stimulatory effect: they increase peristalsis and secretory activities, and cause sphincters to relax.
The only portions of the GI tract under voluntary control are the upper esophagus (for swallowing) and the external anal sphincter (for defecation).

Primary Functions of the Digestive System

Ingestion & Digestion: To take in food and break it down from complex particles into its molecular form (e.g., carbohydrates into glucose).
Absorption: To absorb the small molecules produced by digestion into the bloodstream and lymphatic system for use by the body.
Elimination: To eliminate undigested foodstuffs, unabsorbed nutrients, and other waste products from the body as feces.

General Signs and Symptoms of Digestive System Disorders

Stomatitis: Inflammation of the mouth (oral mucosa).
Nausea and Vomiting: Nausea is a feeling of discomfort in the epigastrium with a conscious desire to vomit. Vomiting is the forceful ejection of partially digested food and secretions from the upper GI tract.
Dysphagia: Difficulty in swallowing.
Dyspepsia (Indigestion): A symptom complex including post-meal fullness, heartburn, bloating, and possibly nausea.
Achalasia: Absent or ineffective peristalsis of the distal esophagus, accompanied by the failure of the lower esophageal sphincter to relax in response to swallowing.
Hematemesis: Bloody vomitus, which can appear as fresh, bright red blood or have a 'coffee ground' appearance (dark, grain-digested blood).
Melena: Black, tarry, and often foul-smelling stools caused by the digestion of blood in the GI tract. The black appearance is due to the presence of iron.
Changes in Bowel Habits: This can include:
- Constipation: An abnormal infrequency of defecation or the passage of abnormally hard stools.
- Diarrhea: The passage of 3 or more loose or watery stools in 24 hours.
Fecal Incontinence: The involuntary passage of stool, which may be due to piles, trauma, surgery, infection, etc.
Abdominal Distension: Swelling or enlargement of the abdomen.
Abdominal Pain and Tenderness: Can be diffuse, localized, dull, burning, or sharp.
Abdominal Rigidity: Involuntary stiffness of the abdominal muscles, often indicating peritoneal irritation.
Rebound Tenderness: Pain upon removal of pressure rather than application of pressure to the abdomen.
Decreased or Absent Bowel Sounds: May indicate an ileus or obstruction.
Tenesmus: A sensation of incomplete bowel emptying.
Gas or Bloating (Flatulence): Excessive stomach or intestinal gas.
Jaundice: Yellowish discoloration of the skin and sclera due to elevated bilirubin levels.
Hepatomegaly/Splenomegaly: Enlargement of the liver and spleen, respectively.
Pruritus and Urticaria: Itching and hives, which can be associated with liver disorders.
Shock: Particularly hypovolemic shock, due to fluid or blood loss from the GI tract.

Disorders of the Digestive System

Stomatitis

Stomatitis refers to a broad range of inflammatory conditions affecting the epithelial lining of the oral mucosa, which is the moist membrane that lines the inside of the mouth. This inflammation can manifest in various ways, from mild redness and discomfort to severe ulceration and pain, significantly impacting a person's ability to eat, speak, and maintain oral hygiene. Stomatitis is not a single disease but rather a symptom or a group of symptoms that can arise from a diverse array of local (within the mouth) and systemic (affecting the entire body) factors.

Causes and Etiology of Stomatitis

The etiology of stomatitis is multifaceted, often involving an interplay of various predisposing and precipitating factors. Understanding the underlying cause is crucial for effective diagnosis and management.

Trauma:

Mechanical Injury: This is a common cause, including accidental biting of the cheek or tongue, irritation from sharp or abrasive foods (e.g., hard crackers, bones), ill-fitting dental appliances (braces, dentures), or vigorous toothbrushing.
Thermal Injury: Burns from hot foods or liquids.
Chemical Injury: Exposure to irritating chemicals or highly acidic substances.

Infections: Oral mucosa is susceptible to various microbial invasions.

Bacterial Infections: Can lead to conditions like acute necrotizing ulcerative gingivitis (ANUG), impetigo affecting the perioral region, or secondary infections of existing lesions.
Fungal Infections:
- Candida albicans: Most commonly associated with oral thrush, presenting as creamy white patches that can be scraped off, revealing reddened, often bleeding, underlying tissue. It is particularly common in infants, immunocompromised individuals (e.g., HIV/AIDS patients, those undergoing chemotherapy), or those on long-term antibiotic or corticosteroid therapy.
Viral Infections:
- Herpes Simplex Virus (HSV): Primarily HSV-1, causing primary herpetic gingivostomatitis (especially in children) characterized by widespread oral ulcers, fever, and malaise, or recurrent herpes labialis (cold sores) around the lips.
- Varicella-Zoster Virus (VZV): Causes chickenpox (primary infection) and shingles (reactivation), both of which can involve painful oral lesions.
- Other Viruses: Coxsackievirus (hand, foot, and mouth disease), Epstein-Barr Virus (infectious mononucleosis), and Human Papillomavirus (oral warts).

Irritants: Chronic exposure to certain substances can significantly damage the oral mucosa.

Tobacco Use: Smoking, chewing tobacco, and snuff are major irritants, increasing the risk of leukoplakia, erythroplakia, and oral cancers, often preceded by chronic stomatitis.
Alcohol Consumption: Heavy alcohol use is corrosive to oral tissues and is a significant risk factor for oral lesions and cancers, especially when combined with tobacco.
Spicy Foods: Can cause temporary irritation and inflammation in sensitive individuals.

Systemic Disorders: Stomatitis can be an oral manifestation of various underlying systemic diseases, acting as an important diagnostic clue.

Renal Disorders: Uremic stomatitis can occur in patients with severe kidney failure, characterized by a white, thick, or pseudomembranous coating on the oral mucosa, often with a metallic taste due to urea breakdown products.
Liver Disorders: Chronic liver disease can lead to oral mucosal changes due to metabolic disturbances.
Hematologic Disorders:
- Anemia (e.g., iron deficiency anemia, pernicious anemia): Can cause atrophic glossitis (smooth, red, painful tongue), angular cheilitis (cracking at mouth corners), and general oral soreness.
- Leukemia, Agranulocytosis: Can lead to severe gingivitis, ulcerations, and opportunistic infections due to compromised immune function.
Autoimmune Diseases:
- Pemphigus Vulgaris, Bullous Pemphigoid: Autoimmune blistering diseases that can severely affect the oral mucosa, causing painful erosions.
- Lichen Planus: A chronic inflammatory condition that can present as white lacy patterns, red erosions, or ulcers in the mouth.
- Systemic Lupus Erythematosus (SLE): Oral lesions (ulcers, red patches) can be a feature.
- Crohn's Disease, Ulcerative Colitis (Inflammatory Bowel Diseases): Can cause oral aphthous ulcers or granulomatous lesions.
Diabetes Mellitus: Poorly controlled diabetes can predispose individuals to candidiasis and other oral infections due to impaired immune response and higher glucose levels in saliva.

Medication Side Effects: Many pharmacological agents can induce stomatitis.

Chemotherapeutic Drugs: Mucositis (a severe form of stomatitis) is a very common and debilitating side effect of many cancer chemotherapeutic agents (e.g., methotrexate, 5-fluorouracil) and radiation therapy to the head and neck, causing widespread painful ulcerations.
Antibiotics: Can disrupt the normal oral flora, leading to opportunistic infections like candidiasis.
Anticonvulsants (e.g., phenytoin): Can cause gingival hyperplasia (overgrowth of gum tissue).
Immunosuppressants: Increase susceptibility to oral infections.
Other Drugs: Certain antihypertensives, antidepressants, and anti-inflammatory drugs can also cause oral side effects.

Nutritional Deficiencies: Inadequate intake or absorption of specific nutrients can severely compromise oral tissue health.

B Vitamins (especially B1, B2, B3, B6, B12, Folate): Deficiencies can lead to glossitis, angular cheilitis, and recurrent aphthous ulcers.
Iron: Iron deficiency anemia frequently causes atrophic glossitis, oral burning, and angular cheilitis.
Vitamin C (Ascorbic Acid): Severe deficiency (scurvy) results in swollen, bleeding gums, tooth mobility, and poor wound healing.
Vitamin A: Important for maintaining healthy epithelial tissues; deficiency can lead to dry mouth and increased susceptibility to infection.
Zinc: Essential for immune function and wound healing; deficiency can impact oral health.

Poor Oral Hygiene: A primary contributor to various oral pathologies.

Allows for the accumulation of plaque and calculus, leading to gingivitis and periodontitis.
Promotes the overgrowth of pathogenic microorganisms (bacteria, fungi), increasing the risk of infections.

Denture-Related Issues:

Poor Denture Hygiene: Inadequate cleaning allows for biofilm formation and microbial proliferation, particularly Candida species, leading to denture stomatitis (inflammation of the mucosa under the denture).
Ill-Fitting Dentures: Cause chronic frictional trauma and pressure points, leading to localized inflammation, sores, and hyperplastic tissue reactions.
Continuous Night-Time Wear: Deprives the underlying mucosa of exposure to saliva and oxygen, creating an environment conducive to microbial growth and inflammation.

Other Factors:

Hormonal Changes: Fluctuations during puberty, menstruation, pregnancy, and menopause can influence oral health and susceptibility to inflammation.
High Intake of Sugary Foods: Promotes an acidic oral environment and provides substrate for bacterial growth, contributing to dental caries and potentially exacerbating inflammation.
Stress: Psychological stress can weaken the immune system and has been linked to the exacerbation of conditions like recurrent aphthous stomatitis.
Allergies: Allergic reactions to dental materials, food components, or oral hygiene products can trigger localized inflammatory responses.
Genetic Predisposition: Some individuals may be genetically more prone to certain types of stomatitis, such as recurrent aphthous ulcers.

Clinical Manifestations of Stomatitis

The signs and symptoms of stomatitis vary depending on the cause, location, and severity of the inflammation, but commonly include:

Changes in Salivation: Can range from excessive salivation (sialorrhea), often due to irritation or pain, to pronounced dryness of the mouth (xerostomia), which can exacerbate discomfort and increase infection risk.
Halitosis (Bad Breath): A common symptom, resulting from bacterial overgrowth, tissue breakdown, or metabolic products associated with certain systemic diseases.
Glossitis: Inflammation of the tongue, causing it to appear red, swollen, smooth (due to atrophy of papillae), and often exquisitely painful. This can be a sign of nutritional deficiencies (e.g., B vitamins, iron) or systemic diseases.
Oral Ulcers: Painful, open sores that can occur on any part of the oral mucosa, including the gums, palate, buccal mucosa (inner cheeks), and lips. These can range from small aphthous ulcers to large, irregular erosions characteristic of viral infections or autoimmune conditions.
Thrush (Oral Candidiasis): Characterized by creamy white, cottage-cheese-like patches on the tongue, inner cheeks, palate, or throat. These lesions are typically adherent but can be scraped off, revealing an erythematous (red) and sometimes bleeding base. It is a hallmark of fungal infection, especially in immunocompromised or debilitated individuals (e.g., infants, HIV/AIDS patients, those on prolonged antibiotics or corticosteroids).
Gingivitis: Swelling, redness, and bleeding of the gums, often an early sign of periodontal disease but can also be part of a generalized stomatitis.
Denture Stomatitis: A specific form of inflammation seen in denture wearers, presenting as reddening and sometimes swelling of the mucosa directly under the denture-bearing area, often associated with a fungal infection.
Dysphagia and Odynophagia: Difficulty and pain during swallowing, respectively, especially if the inflammation extends to the throat or pharynx.
Dysgeusia: Altered taste sensation.
Pain and Discomfort: Ranging from a mild burning sensation to severe, constant pain that interferes with eating and speaking.

Investigations and Diagnosis

Diagnosing stomatitis involves a thorough clinical examination and, often, specific laboratory tests to identify the underlying cause.

Mouth Swab: A sample taken from the affected area for:

Microscopy: Direct visualization of microorganisms (e.g., fungal hyphae in candidiasis).
Culture and Sensitivity: To grow and identify bacterial or fungal pathogens and determine their susceptibility to various antimicrobial agents.
PCR (Polymerase Chain Reaction) or Viral Culture: To detect viral DNA/RNA (e.g., HSV).

Blood Tests:

Complete Blood Count (CBC): To check for signs of anemia, infection, or other hematologic abnormalities.
Nutritional Deficiencies: Serum levels of vitamins (e.g., B12, folate) and minerals (e.g., iron, ferritin).
Inflammatory Markers: ESR (Erythrocyte Sedimentation Rate) or CRP (C-reactive protein) if systemic inflammation is suspected.
Rapid Plasma Reagin (RPR) or VDRL: Blood tests for syphilis, which can cause oral lesions (e.g., mucous patches, gummas).
HIV Serology: To rule out HIV/AIDS, as these patients are highly susceptible to recurrent and severe oral infections, particularly candidiasis and herpes.
Random Blood Sugar (RBS) or HbA1c: To screen for or monitor diabetes, as hyperglycemia can promote fungal growth and impair healing.
Liver and Kidney Function Tests: To assess for underlying systemic diseases (e.g., uremic stomatitis).
Autoantibody Tests: If an autoimmune condition is suspected (e.g., ANA for SLE, anti-desmoglein for pemphigus).

Biopsy: In cases of persistent, atypical, or suspicious lesions (e.g., white patches that cannot be scraped off, chronic ulcers), a tissue biopsy is essential to rule out dysplasia or malignancy.

Imaging Studies: Rarely needed for primary stomatitis, but may be used to investigate underlying systemic causes or complications.

Treatment and Management Strategies

Effective management of stomatitis is multimodal, focusing on treating the underlying cause, alleviating symptoms, and preventing recurrence.

Treat the Underlying Cause: This is the cornerstone of effective therapy. Antimicrobial Therapy:

Broad-spectrum Antibiotics: For identified bacterial infections (e.g., metronidazole for ANUG).
Antifungals: For oral candidiasis, systemic antifungals (e.g., fluconazole, itraconazole) may be necessary for widespread or resistant infections, in addition to topical agents.
Antivirals: For severe or recurrent viral infections (e.g., acyclovir, valacyclovir for HSV).

Nutritional Supplementation: Correcting identified vitamin or mineral deficiencies through dietary changes and/or supplements.

Management of Systemic Diseases: Controlling underlying conditions like diabetes, kidney disease, or autoimmune disorders.

Discontinuation or Adjustment of Medications: If a drug is identified as the cause, a physician may consider adjusting the dosage or switching to an alternative medication.

Correction of Traumatic Factors: Removing sharp food edges, adjusting or replacing ill-fitting dental appliances.

Oral Hygiene Measures: Meticulous oral hygiene is fundamental to both treatment and prevention.

Saline Rinses: Rinsing the mouth 3-4 times a day with a warm salt solution (e.g., 1/2 teaspoon of salt in 1 cup of warm water) helps to soothe inflamed tissues, cleanse the mouth, and promote healing.
Antiseptic Mouthwashes:
- Hydrogen Peroxide Solution (6%): Diluted (e.g., 15 ml in 200 ml of warm water) can be used as an oxygenating rinse, particularly beneficial for anaerobic infections and debridement.
- Chlorhexidine Mouthwash (0.2%): An effective broad-spectrum antiseptic, used twice daily, helps reduce bacterial load and plaque formation. Note: Can cause temporary tooth staining with prolonged use.
Gentle Brushing: Using a soft-bristled toothbrush and non-irritating toothpaste to clean teeth and gums gently, avoiding affected areas if too painful initially.

Denture Care: Specific instructions for denture wearers are vital to prevent and treat denture stomatitis.

Remove Dentures at Night: Allows the oral mucosa to rest and be exposed to saliva and oxygen.
Improve Denture Hygiene: Regular cleaning by brushing the denture and soaking it daily in an appropriate denture cleanser (e.g., hypochlorite cleanser – 10 drops of household bleach in a cup of water, or commercial denture tablets). The fitting surface of the denture should also be brushed to remove accumulated plaque and fungi.
Replace Ill-Fitting Dentures: Essential to eliminate chronic trauma and pressure points.

Dietary Modification:

Reduce Irritants: Avoid highly acidic, spicy, salty, or very hot/cold foods and beverages that can irritate inflamed mucosa.
Soft, Bland Diet: Encourage consumption of soft, bland, and nutrient-dense foods (e.g., mashed potatoes, soft cooked vegetables, pureed soups, yogurt) to ensure adequate nutrition without causing further discomfort.
Reduce Sugar Intake: Especially important in cases of candidiasis, as sugar promotes fungal growth.
Hydration: Drink plenty of fluids to maintain oral moisture and prevent dehydration.

Pharmacological Treatment (Symptomatic Relief and Specific Therapies):

Antifungals:
- Nystatin Suspension (100,000 IU/mL): A common topical antifungal for oral thrush. Typically, the patient is instructed to "swish and swallow" 5-10 ml 4-6 times daily for 7-14 days (or at least 48 hours after symptoms resolve). The "swish and swallow" method ensures contact with the oral mucosa and allows some medication to reach the esophagus if candidiasis has extended.
- Clotrimazole Troches: Lozenges that dissolve slowly in the mouth, providing prolonged contact time with the oral mucosa.
Topical Medications:
- Topical Anesthetics: Viscous lidocaine or benzocaine preparations can be applied directly to painful ulcers before meals to allow for easier eating.
- Corticosteroids: Topical steroids (e.g., triamcinolone acetonide in an adhesive paste) can be used for non-infectious inflammatory conditions like aphthous ulcers or lichen planus to reduce inflammation and promote healing.
- Protective Barriers: Over-the-counter gels or rinses that form a protective barrier over ulcers, shielding them from irritation.
Analgesics (Pain Relievers):
- Systemic Analgesics: Over-the-counter pain relievers like Paracetamol (acetaminophen) (e.g., 500mg or 1g every 4-6 hours, not exceeding daily maximums) or NSAIDs (non-steroidal anti-inflammatory drugs like ibuprofen) can help manage pain and inflammation, especially in widespread or severe cases. Duration of use typically 3 to 5 days, or as directed by a healthcare professional.
- Topical Analgesics: As mentioned above, for localized pain relief.
Sialagogues: If xerostomia is a significant issue, medications or products that stimulate saliva flow (e.g., pilocarpine) or artificial saliva substitutes may be beneficial.

Patient Education: Educating the patient on the importance of adhering to treatment, maintaining good oral hygiene, and recognizing signs of recurrence is vital for long-term management.

Complications of Stomatitis

If left untreated or improperly managed, stomatitis can lead to a range of complications that can significantly impact a patient's health and quality of life. These complications can be localized to the oral cavity or have systemic repercussions.

Severe Pain and Discomfort: Persistent and intense pain is perhaps the most immediate and debilitating complication. It can severely interfere with daily activities.

Nutritional Deficiencies and Malnutrition:

Difficulty and pain upon eating lead to reduced food intake.
This can result in significant weight loss, dehydration, and deficiencies in essential macro and micronutrients, particularly in children, elderly, or already debilitated individuals.
In severe cases, it may necessitate alternative feeding methods like nasogastric tube feeding.

Dehydration: Painful swallowing and general discomfort can lead to inadequate fluid intake, increasing the risk of dehydration, especially in vulnerable populations.

Spread of Infection:

Uncontrolled local infections (bacterial, fungal, viral) can spread beyond the oral cavity to adjacent structures (e.g., pharynx, esophagus, larynx) or even enter the bloodstream (sepsis), leading to more severe systemic infections, particularly in immunocompromised patients.
Oral candidiasis can extend to cause esophagitis.

Speech Impairment (Dysarthria): Significant inflammation and pain can make speaking difficult and unclear.

Psychological Impact:

Chronic pain and difficulty with eating and speaking can lead to social isolation, anxiety, and depression.
Halitosis associated with stomatitis can also cause embarrassment and affect self-esteem.

Impaired Oral Health:

Difficulty with brushing and flossing due to pain can lead to increased plaque accumulation, gingivitis, and progression to periodontitis (gum disease) and dental caries.
Chronic inflammation can sometimes lead to precancerous lesions, especially if associated with irritants like tobacco and alcohol, or certain infectious agents (e.g., HPV).

Chronic Ulceration and Scarring: Persistent or recurrent ulcers can lead to chronic inflammation and, in rare cases, scarring that might affect oral function.

Impact on Underlying Systemic Conditions: In patients with chronic diseases (e.g., diabetes, autoimmune disorders), severe stomatitis can complicate the management of their primary condition and reduce their overall quality of life.

Prevention of Stomatitis

Preventing stomatitis involves addressing the predisposing factors and maintaining optimal oral and general health. A proactive approach is key.

Maintain Excellent Oral Hygiene:

Regular Brushing: Brush teeth at least twice daily with a soft-bristled toothbrush and fluoride toothpaste.
Flossing: Floss daily to remove plaque and food particles from between teeth and under the gum line.
Antiseptic Mouthwashes: Use non-alcohol based mouthwashes as recommended by a dental professional, especially if prone to gum inflammation.
Tongue Cleaning: Gently clean the tongue to remove bacteria and food debris.

Regular Dental Check-ups:

Visit the dentist at least twice a year for professional cleaning and examination.
Early detection and management of dental problems (e.g., cavities, gum disease) and ill-fitting restorations can prevent irritation.

Proper Denture Care:

Remove dentures at night to allow oral tissues to rest.
Clean dentures daily using a denture brush and appropriate cleanser.
Ensure dentures fit well and are relined or replaced as needed to prevent trauma and pressure sores.

Balanced Nutrition:

Consume a diet rich in fruits, vegetables, whole grains, and lean proteins to ensure adequate intake of essential vitamins and minerals, especially B vitamins, iron, zinc, and vitamin C.
Consider nutritional supplements if dietary intake is insufficient or if specific deficiencies are identified.

Avoid Oral Irritants:

Tobacco and Alcohol: Abstain from or significantly reduce the use of tobacco products (smoking, chewing) and limit alcohol consumption, as these are major contributors to oral inflammation and malignancy.
Spicy and Acidic Foods: If prone to irritation, limit intake of excessively spicy, acidic, or abrasive foods.
Avoid Very Hot Beverages: Allow hot drinks to cool slightly before consuming.

Stay Hydrated: Drink plenty of water throughout the day to maintain adequate salivary flow and keep the oral mucosa moist. This helps in cleansing and protecting the mouth.

Manage Underlying Systemic Conditions:

Effectively manage chronic diseases such as diabetes, autoimmune disorders, and kidney disease, as good control can prevent oral manifestations.

Judicious Use of Medications:

Be aware of potential oral side effects of medications.
If undergoing chemotherapy or radiation to the head and neck, follow all recommended mucositis prevention protocols (e.g., cryotherapy, specific rinses).

Stress Reduction: Implement stress-reduction techniques, as stress can sometimes exacerbate conditions like recurrent aphthous stomatitis.

Address Traumatic Habits: Avoid habits like cheek biting, lip biting, or tongue thrusting that can cause chronic irritation.

Stomatitis lecture notes Read More »

MALNUTRITION IN CHILDREN

Nursing Notes - Malnutrition

MALNUTRITION

Malnutrition is a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients. It refers to any condition in which the body does not receive enough nutrients for proper function, encompassing both undernutrition and overnutrition.

Forms of Malnutrition

Undernutrition: An insufficient intake of energy and nutrients to meet an individual's needs to maintain good health. This includes conditions like stunting, wasting, and being underweight.
Overnutrition: An excessive intake of nutrients, especially calories, leading to conditions like overweight and obesity.
Imbalance: Disproportionate consumption of nutrients, which can lead to adverse health effects even if calorie intake is adequate.
Specific Deficiency: A lack of one or more specific micronutrients (vitamins or minerals), such as iron deficiency or vitamin A deficiency.

Causes and Risk Factors for Malnutrition

Inadequate Dietary Intake: This is a primary cause, where a child does not consume enough food, or the right kinds of food, to meet their body's needs. This is often linked to a lack of knowledge about adequate feeding practices or poor weaning methods.
Infections and Disease Conditions: Illness increases the body's metabolic needs while often decreasing appetite. Conditions like chronic diarrhea, malabsorption syndromes, childhood cancers, congenital heart defects, and cystic fibrosis impair the body's ability to absorb and utilize nutrients.
Poor Socioeconomic Status: Poverty, insufficient education, food insecurity, inadequate sanitation, and large family sizes are major contributing factors to malnutrition.
Cultural Influences: Deep-rooted beliefs, customs, food taboos, and specific cooking practices can restrict the intake of essential nutrients. For example, some cultures may deny children protein-rich foods like eggs or chicken.
Social and Political Factors:
- Social issues like inadequate child spacing, neglect, or separation from parents put a child at risk.
- Political instability and conflict displace populations, disrupting access to food and healthcare.
- Natural disasters like droughts or floods can destroy crops and lead to famine.
Inadequate Health Services: Lack of access to primary healthcare, nutrition rehabilitation centers, and preventative services like immunization contributes to the cycle of illness and malnutrition.
Biological Factors: Premature babies have higher nutritional needs and are at greater risk. The nutritional status of the mother during pregnancy also plays a crucial role. Worm infestations are also a common cause, as parasites compete with the host for nutrients.

PROTEIN-ENERGY MALNUTRITION (PEM)

Protein-Energy Malnutrition (PEM), also known as Protein-Calorie Malnutrition (PCM), is a group of clinical conditions resulting from varying degrees of protein and/or energy (calorie) deficiency. It is primarily caused by an inadequate intake of food in both quantity and quality.

Classification of PEM

Kwashiorkor: Primarily a deficiency of protein, with adequate or near-adequate energy intake.
Marasmus: A severe deficiency of both protein and calories (total energy).
Marasmic-Kwashiorkor: A mixed form with features of both Marasmus and Kwashiorkor. The child is wasted but also has edema.
Nutritional Dwarfing (Stunting): A chronic condition where a child has a significantly low height for their age due to long-term undernutrition, without other specific signs of Kwashiorkor or Marasmus.

Kwashiorkor

This condition is mainly found in preschool children (typically 1-3 years) after being weaned from breast milk onto a diet high in carbohydrates but low in protein. The name is said to mean "the sickness the older child gets when the new baby comes."

Clinical Features of Kwashiorkor

Essential Features (Always Present):
- Edema: Pitting edema is the hallmark sign, usually starting in the lower limbs and progressing to the face and upper limbs, giving a "moon face" appearance.
- Growth Retardation: Marked failure to gain weight and height.
- Muscle Wasting: Significant muscle wasting is present, but it can be masked by the edema and retention of some subcutaneous fat.
- Psychomotor Changes: The child is typically apathetic, lethargic, irritable, and lacks interest in their surroundings. Appetite is poor.
Non-Essential Features (May or May Not Be Present):
- Hair Changes: Hair becomes thin, dry, brittle, and may change to a reddish-brown or light color. It is easily pluckable. The "flag sign" (alternating bands of light and dark hair) indicates periods of poor nutrition.
- Skin Changes: Characterized by "flaky paint" dermatosis, with patches of hyperpigmentation that peel off to reveal hypo-pigmented or raw skin underneath.
- Hepatomegaly: Enlarged, fatty liver due to impaired synthesis of lipoproteins.
- Associated Problems: Increased susceptibility to infections (GI tract, respiratory), vitamin deficiencies, and diarrhea due to villous atrophy.

Marasmus

This condition results from a severe, prolonged deficiency of all nutrients, especially energy (calories) and protein. It is common in infants and toddlers. It is also known as infantile atrophy.

Clinical Features of Marasmus

Essential Features (Always Present):
- Severe Wasting: Marked wasting of both muscle and subcutaneous fat. The child appears emaciated ("skin and bones").
- Severe Growth Retardation: The child is significantly underweight (<60% of expected weight for age) and stunted.
- No Edema: Absence of edema is a key distinguishing feature from kwashiorkor.
Non-Essential Features (May or May Not Be Present):
- Appearance: The face appears shriveled and old ("wizened face") due to the loss of the buccal pad of fat. Loose skin folds are prominent, especially on the buttocks ("baggy pants").
- Psychomotor Changes: The child is often irritable and fretful, but may also be apathetic. Unlike in kwashiorkor, the child usually has a good appetite (craving for food).
- Hair and Skin: Hair may be thin and sparse, but changes are less pronounced than in kwashiorkor. The skin is dry, thin, and inelastic.
- Associated Problems: Prone to infections, dehydration, anemia, and hypothermia. The liver is usually shrunken.

Management of Severe Acute Malnutrition (SAM)

Management depends on the severity of the condition and the presence of complications. It can take place at home, in a nutritional rehabilitation center, or in a hospital.

Hospital-Based Management

This is essential for children with severe PEM who have complications like severe edema, infections, dehydration, shock, or persistent loss of appetite. The WHO outlines a 10-step plan for inpatient management.

Treat/Prevent Hypoglycemia: Give glucose or a sugar solution immediately.
Treat/Prevent Hypothermia: Keep the child warm with blankets and skin-to-skin contact.
Treat/Prevent Dehydration: Rehydrate slowly using a special low-osmolarity solution (ReSoMal), not standard ORS.
Correct Electrolyte Imbalances: Provide potassium and magnesium supplements. Avoid diuretics for edema.
Treat Infections: Administer broad-spectrum antibiotics, as signs of infection are often masked.
Correct Micronutrient Deficiencies: Provide multivitamins, but give iron only after the initial stabilization phase (usually after week 2).
Start Cautious Feeding: Begin with small, frequent feeds of a therapeutic starter formula (F-75).
Achieve Catch-Up Growth: Gradually transition to a higher-calorie, higher-protein formula (F-100) or ready-to-use therapeutic food (RUTF) to promote rapid weight gain.
Provide Sensory Stimulation and Emotional Support: Engage the child in play therapy and provide a caring environment to support developmental recovery.
Prepare for Follow-Up After Discharge: Educate caregivers on continued feeding, hygiene, and the importance of regular follow-up visits.

Micronutrient Deficiencies

Vitamins and minerals are essential for bodily functions. Deficiencies can lead to specific disorders.

Fat-Soluble Vitamins

Vitamin A: Essential for normal vision, immune function, and cell growth. Sources: Liver, egg yolk, butter, cheese, green leafy vegetables, yellow/orange fruits. Deficiency: Leads to night blindness and xerophthalmia (dry eyes).
Vitamin D: Promotes calcium and phosphorus absorption for bone mineralization. Sources: Sunlight, fortified milk, fish, egg yolk. Deficiency: Causes rickets in children (bone deformities) and osteomalacia in adults.
Vitamin E: An antioxidant that protects cells from damage. Sources: Vegetable oils, nuts, seeds. Deficiency: Is rare, but can cause neurological problems.
Vitamin K: Essential for blood clotting. Sources: Green leafy vegetables, soybeans. Deficiency: Leads to bleeding disorders due to prolonged clotting time.

Water-Soluble Vitamins

Vitamin B Complex:
- B1 (Thiamine): Causes Beriberi.
- B2 (Riboflavin): Causes angular stomatitis (cracks at corners of the mouth), glossitis.
- B3 (Niacin): Causes Pellagra (characterized by the 3 D's: Dermatitis, Diarrhea, Dementia).
- B12 (Cyanocobalamin): Causes megaloblastic anemia. Not found in plant foods.
- Folic Acid: Causes megaloblastic anemia and glossitis. Crucial for preventing neural tube defects in pregnancy.
Vitamin C (Ascorbic Acid): Essential for collagen formation, iron absorption, and immune function. Sources: Citrus fruits (oranges, lemons), guava, tomatoes, green vegetables. Deficiency: Causes Scurvy (swollen, bleeding gums; subcutaneous bruising; poor wound healing).

Minerals

Calcium: For bone/teeth formation, muscle contraction, nerve conduction, and blood coagulation. Sources: Milk, fish, eggs, green leafy vegetables. Deficiency: Can contribute to rickets and osteoporosis.
Phosphorus: Key role in bone formation and energy metabolism. Widely available in foods, so deficiency is rare.
Iron: Essential for hemoglobin formation and oxygen transport. Sources: Meat, liver, eggs, fortified cereals. Deficiency: The most common nutritional deficiency worldwide, causing iron-deficiency anemia.
Iodine: Essential for thyroid hormone synthesis. Sources: Iodized salt, seafood. Deficiency: Causes goiter and cretinism (impaired neurological function).

Diagnosis and Assessment of Malnutrition

Nutritional Anthropometry

This is the science of body measurements to assess nutritional status.

Weight-for-Age: A general indicator of nutritional status but does not distinguish between acute and chronic malnutrition.
Height-for-Age (Stunting): Indicates chronic or long-term malnutrition. A child who is stunted is too short for their age.
Weight-for-Height (Wasting): Indicates acute or recent malnutrition. A child who is wasted is too thin for their height.
Mid-Upper Arm Circumference (MUAC): A simple, effective measure to identify severe acute malnutrition, especially in community settings. A MUAC of <11.5 cm in children aged 6-59 months indicates SAM.
Growth Charts: Used to plot a child's measurements over time to monitor growth trends and identify deviations from the norm.

Laboratory Investigations

These are used to identify complications and associated conditions:

Blood Glucose: To check for hypoglycemia.
Serum Electrolytes: To assess for imbalances, especially potassium.
Complete Blood Count (CBC) & Hemoglobin: To check for anemia.
Blood Smear: To test for malaria parasites.
Blood/Urine Cultures: To identify underlying infections.

MALNUTRITION IN CHILDREN Read More »

Growth Monitoring and Promotion

Nursing Notes - Child Growth and Development

Growth Monitoring and Promotion

Growth Monitoring

Growth monitoring involves regularly weighing a child, plotting the weight on a child health card (also known as a growth chart), interpreting the results, and counseling parents or caregivers. It's a proactive and preventative health measure to track a child's developmental progress over time and identify potential issues early.

Monitoring includes a range of anthropometric measurements to provide a holistic view of the child's physical development. These parameters are compared against standardized growth charts, which show the typical growth patterns of healthy children.

Parameters Used to Monitor Growth:

Height for age: Indicates linear growth and identifies stunting (chronic malnutrition) or tall stature. It reflects long-term nutritional status and overall health.
Weight for age: A general indicator of nutritional status and acute malnutrition (underweight). It reflects both current and past nutritional experience.
Head circumference: Especially important for infants and toddlers (usually up to 2-3 years of age), as it's a proxy for brain growth and development. Deviations can indicate neurological issues.
Body Mass Index (BMI) for age: Calculated from weight and height, BMI for age is used to screen for overweight, obesity, and wasting (acute malnutrition). It is a better indicator of body proportionality than weight-for-age alone.
Skinfold thickness: Measures subcutaneous fat, providing an estimate of body fat reserves. Commonly measured at the triceps and subscapular areas, it helps assess nutritional status, particularly for under- and over-nutrition.

Importance of Growth Monitoring:

Early Recognition of Abnormal Growth: Children whose growth deviates significantly from the standard growth curve are easily recognized from the growth chart, allowing for timely intervention.
Identification of Chronic Disorders: Abnormal growth patterns can be early indicators of underlying chronic diseases, endocrine disorders, or genetic conditions, facilitating early diagnosis and treatment.
Attainment of Optimal Nutritional Status: Regular monitoring helps in assessing the effectiveness of nutritional interventions and guides dietary adjustments to improve overall nutrition.
Supports Research and Public Health: Longitudinal growth data contributes valuable information for public health research, identifying trends, and evaluating the impact of health programs on child populations.
Empowers Parents/Caregivers: It helps parents to gain nutritional knowledge, reduces anxiety by providing clear information about their child’s health, and offers reassurance when growth is on track. It fosters active parental involvement in their child's health.
Addresses Influential Psychosocial and Social Factors: Deviations in growth can signal underlying psychosocial issues. Growth monitoring helps identify if there are influential psychological or social factors (e.g., parental neglect or separation, orphans, family stress) that may affect the growth of the child, prompting social support or intervention.
Determines Natural Short Stature: It helps parents understand if their child's short stature is due to genetic predisposition (familial short stature) rather than a pathological cause, reducing unnecessary worry.
Prevents Illness, Malnutrition, and Death: Early identification of growth faltering allows for interventions that can prevent progression to severe malnutrition, reduce susceptibility to illness, and ultimately prevent mortality.
Evaluates Health or Nutritional Interventions: It serves as a crucial tool to evaluate the effectiveness of health interventions, such as exclusive breastfeeding campaigns, complementary feeding programs, or deworming initiatives, by observing their impact on growth patterns.
Determines if the Child is Failing to Thrive: A consistent pattern of poor weight gain or growth across multiple parameters can indicate "failure to thrive," a clinical term for inadequate growth, necessitating comprehensive medical and social assessment.

Growth Promotion

To effectively combat growth problems and ensure optimal child development, a comprehensive approach to growth promotion is essential. This involves a continuum of care starting from the antenatal period and continuing through various stages of childhood, integrating health, nutrition, and social support.

Antenatal Care (During Pregnancy):

Prevent, Detect, and Treat Pregnancy-Related Complications: Regular check-ups help manage conditions like pre-eclampsia, gestational diabetes, and infections, ensuring a healthy environment for fetal growth.
Provide Advice on Breastfeeding: Educate expectant mothers on the benefits of exclusive breastfeeding, proper latch, and positioning, preparing them for successful initiation post-delivery.
Provide Health Education on Dangers of Smoking, Alcohol Consumption, and Drug Abuse: Emphasize the severe adverse effects of these substances on fetal development, promoting a healthy pregnancy.
Health Education on Good Baby Care: Prepare parents for newborn care, including hygiene, safe sleep practices, and early developmental stimulation.
Identify Parents Who May Need Extra Support: Screen for and provide targeted support to parents with learning disorders, mental health problems, or other vulnerabilities that might impact their ability to care for the child.
Health Education on Good Nutrition: Advise on balanced dietary intake for pregnant women, including essential micronutrients, to prevent maternal and fetal malnutrition.
Provide Preventive Treatment: Administer Intermittent Presumptive Treatment (IPT) for malaria in endemic areas, iron and folic acid supplements to prevent anemia, and deworming tablets where necessary.
Monitor the Progress of Pregnancy: Regular assessments of fetal growth, maternal weight gain, and general health to identify any deviations.
Health Education on Hygiene: Promote handwashing, safe water practices, and personal hygiene to prevent infections for both mother and baby.
Encourage Hospital Delivery: Advocate for delivery in health facilities with skilled birth attendants to manage delivery complications and ensure immediate postnatal care for mother and baby.

Less than 6 Weeks (Newborn Period):

Physical/Medical Examination of the Child: Comprehensive newborn check-up to detect congenital anomalies, birth injuries, and establish baseline health.
Immunization: Administer initial vaccinations like Polio 0 (at birth) and BCG (Bacillus Calmette–Guérin) for tuberculosis prevention.
Exclusive Breastfeeding: Promote and support exclusive breastfeeding from birth up to six months of age, providing all necessary nutrients and antibodies.
Hygiene - Cord Care: Educate on proper umbilical cord care to prevent infection.
Growth Monitoring/Weighing: Initial weighing and assessment to establish birth weight and track early weight gain.
Early Detection of Disease: Vigilance for signs of common newborn illnesses like fever, diarrhea, or respiratory distress, and prompt treatment.

At 6 Weeks:

Physical Examination: Comprehensive check-up to assess overall health and development.
Immunization: Administer 6-week vaccinations, typically including Polio 1, DPT 1 (Diphtheria, Pertussis, Tetanus), Hib 1 (Haemophilus influenzae type b), and Hepatitis B 1.
Care Safety: Educate parents on infant safety measures, including safe sleep, preventing falls, and childproofing.
Growth Monitoring: Regular weighing and plotting on the growth chart.
Proper Nutrition: Reinforce exclusive breastfeeding and address any feeding difficulties.
Hygiene: Continue education on general infant hygiene.
Early Detection of Disease: Continued emphasis on recognizing and seeking care for signs of illness.

At 2, 3, 4 Months of Age (Scheduled Immunization Visits):

Immunization: Follow the national immunization schedule:
- At 10 weeks: Polio 2, DPT 2, Hib 2, Hep B 2.
- At 14 weeks: Polio 3, DPT 3, Hib 3, Hep B 3.
Check Weight: Consistent growth monitoring at each visit to track progress and identify any faltering.
Developmental Screening: Brief checks for age-appropriate developmental milestones.

8 Months, 2 Years, 3 Years (Key Developmental Milestones and Check-ups):

Immunization: Administer the Measles vaccine at 9 months. Ensure all other immunizations are up-to-date.
Respond to Mothers' Concerns: Actively listen to and address parental concerns about their children’s development, behavior, or health.
Prevent, Detect, and Treat Illnesses: Ongoing vigilance for common childhood illnesses, prompt diagnosis, and appropriate treatment.
Monitor Growth: Continue regular growth monitoring, including height and weight, to track long-term trends.
Hygiene: Reinforce practices of good hygiene, especially as children become more mobile and exposed to different environments.
Good Nutrition: Provide guidance on appropriate complementary feeding (after 6 months), portion sizes, diverse food groups, and healthy eating habits as the child grows.
Developmental Guidance: Provide anticipatory guidance on age-appropriate stimulation, language development, and social-emotional growth.

At 4-5 Years (Preschool Check-up/School Entry Readiness):

Review at School Entry: A comprehensive review around school entry provides a crucial opportunity to ensure overall child readiness.
Immunization Status: Check that all immunizations are up-to-date according to the national schedule, including booster doses if required, to ensure protection before entering a group setting.
Access to Healthcare: Ensure children have continued access to routine immunization and dental care, which are vital for overall health.
Assessment and Intervention for Problems: Provide appropriate assessment and intervention for any physical, social, emotional, or developmental problems identified before school entry, ensuring children are well-prepared for learning.
Information for Parents and School Staff: Provide children, parents, and school staff with information about specific health issues relevant to the school environment, such as allergies, chronic conditions, or healthy lifestyle choices.
Check Weight and Height: Continue anthropometric measurements to monitor growth trends as the child approaches school age.

School Entry - 5 Years (School Nurse Assessment):

School Nurse Checks:
- Weight and Height: Routine anthropometric measurements are taken to continue growth monitoring within the school setting.
- Reviews Immunization Status: The school nurse verifies that the child's immunization record is complete and up-to-date, important for preventing outbreaks in schools.
- Vision and Hearing Screening: Often conducted at school entry to detect any impairments that could affect learning.
- Basic Health Assessment: A general check of the child's health to identify any immediate concerns or conditions that might require ongoing support or accommodation in school.

Child Health Card

The Child Health Card is a vital clinical tool designed for the comprehensive monitoring of children's health from birth up to 5 years of age. While specifically mentioned as a tool used by the Ministry of Health (MoH) Uganda, similar child health records or growth charts are employed globally to track growth, immunizations, and overall well-being. It serves as a continuous record of a child's health journey, facilitating informed decision-making by healthcare providers and empowering parents in their child's care.

Components of the Child Health Card

A well-designed Child Health Card typically includes several key sections to capture essential information:

Family Information: This section captures crucial demographic data, including the child's name, birth weight, sex, date of birth, and birth order. It also records parents' details (names, occupations) and the family's address. This information helps in identifying the child and understanding their socio-economic context.
Immunization Schedule: A pre-printed or designated section that lists the recommended immunizations according to the national schedule, along with spaces to record the dates of administration and the next due dates. This ensures children receive timely vaccinations to protect against preventable diseases.
Growth Chart: A graphical representation used to track key growth parameters, most notably weight for age. It typically includes percentile curves or Z-score lines that allow healthcare providers to plot a child's measurements and compare them against a reference population, identifying patterns of healthy growth, faltering growth, or overweight.
Interpretation Section: Provides clear guidelines and instructions for healthcare workers on how to interpret the plotted growth trends. This helps in understanding the significance of a child's growth pattern (e.g., if a child is growing well, showing signs of malnutrition, or at risk of overweight).
Vitamin A Supplementation: A record-keeping area for documenting the dates and dosages of Vitamin A administered to both the child and, sometimes, the mother (postpartum). Vitamin A is crucial for immune function, vision, and growth.
Special Care Categories: This section allows healthcare providers to flag or indicate children who require specific attention or follow-up due to particular circumstances or risk factors.
Remarks and Referrals: A free-text area where healthcare providers can note additional comments, observations, or significant events in the child's health history. It also serves as a log for referrals to other health services or specialists.

Child demographics specifically include: Child’s name, birth weight, sex, date of birth, birth order, mother’s occupation, father’s name and occupation, and where the child lives.

Counseling the Mother After Weighing the Child

Effective counseling is a critical component of growth monitoring, empowering mothers with knowledge and practical advice tailored to their child's growth status. The approach differs based on whether the child has gained adequate weight or not.

For Children 0-6 Months (Gained Adequate Weight):

When a baby in this age group shows healthy weight gain, the counseling focuses on reinforcement and positive affirmation, while also subtly assessing for any underlying issues or misconceptions.

Acknowledge and Congratulate: Show the mother the growth curve on the card and congratulate her for the child’s healthy weight gain. This positive reinforcement encourages continued good practices.
Assess Breastfeeding Knowledge: Gently inquire about what the mother knows or believes about exclusive breastfeeding (feeding only breast milk, no other foods or liquids). This helps identify any gaps in understanding.
Check for Maternal Well-being: Ask if the mother is experiencing any sickness or problems (physical or emotional), as maternal health directly impacts breastfeeding and infant care.
Reinforce Positive Practices: Find out how the mother is currently feeding her child and reinforce correct and effective breastfeeding practices.

For Children 0-6 Months (Did Not Gain Adequate Weight):

If the baby has not gained weight as expected, the counseling approach shifts to a more investigative and supportive dialogue to identify potential causes and provide targeted solutions.

Create Rapport: Begin by establishing a trusting and supportive environment. This is crucial for open communication, as mothers may feel sensitive or blamed.
Explain the Growth Curve: Show the mother the child's growth curve and explain, in a non-judgmental way, that the baby did not gain weight as expected. Focus on the factual observation.
Inquire About Child's Health: Ask if the baby is sick or has been experiencing any health problems (e.g., fever, diarrhea, cough), which could affect appetite or absorption.
Assess Feeding Practices (Non-Breastmilk): Find out if the baby is being fed on other foods, liquids, or formula in addition to breast milk. This helps identify practices that might displace breast milk intake.
Assess Maternal Nutrition: Inquire if the mother’s nutrition is appropriate and adequate, as maternal diet can affect breast milk supply and quality (though quantity is primarily supply-demand driven).
Check for Sucking Problems: Ask if the baby appears to have problems with sucking (e.g., weak suck, difficulty latching), which could indicate oral issues or neurological concerns.
Assess Latch and Positioning: Find out if the mother has problems with attaching the baby to the breast during breastfeeding, as poor latch is a common cause of insufficient milk transfer.

Key Questions to Ask (for 0-6 months, inadequate weight gain):

Frequency of Feeding: "How many times a day and night does the baby breastfeed?" (A baby should typically feed 8-12 times in 24 hours).
Duration of Feeding: "Does the baby breastfeed long enough to empty the breast?" (Full emptying ensures the baby gets the richer, hindmilk).
Introduction of Other Foods/Liquids: "Is the child fed on other liquids or foods besides breast milk?"
Maternal Separation: "Does the mother stay away from the baby any time during the day?" (Separation can affect feeding frequency and milk supply).

Information to Provide to the Mother (for 0-6 months, inadequate weight gain):

Frequent Feeding: Encourage the mother to breastfeed frequently, at least 8-10 times per day (or on demand, whenever the baby shows signs of hunger).
Complete Breast Emptying: Emphasize encouraging the mother to allow the baby to feed long enough to empty one breast before moving to the other.
Correct Latch and Position: Help the mother to know and practice the correct position and attachment of the baby to the breast. This is critical for effective milk transfer.
Exclusive Breastfeeding: Reiterate and encourage exclusive breastfeeding unless there are compelling medical reasons for supplementation.
Immunization Status: Check the child’s immunization status and ensure all due vaccines are administered.
Vitamin A: Check and administer Vitamin A if due and appropriate for age.

For Children 6-12 Months (Gained Adequate Weight):

Counseling continues to build upon previous advice, now incorporating the introduction of complementary foods.

Repeat Counseling Steps: Follow similar counseling steps as for 0-6 months with adequate weight gain, reinforcing positive practices.
Inquire About Complementary Foods: Specifically ask about the additional foods being given besides breast milk (e.g., types, frequency, consistency, quantity) to ensure appropriate and adequate complementary feeding.

For Children 6-12 Months (Did Not Gain Adequate Weight):

For this age group, inadequate weight gain often points to issues with complementary feeding or ongoing illness.

Explain Growth Status: Show the mother the card and explain, gently, that the baby did not

Growth Monitoring and Promotion 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 »

Pediatrics

IMNCI Cumulative Quiz

Integrated Management of Childhood Illness

IMNCI Cumulative Quiz

Assessment Complete!

IMNCI Identify Treatment Quiz

Integrated Management of Childhood Illness

IMNCI Treatment

Assessment Complete!

IMNCI Session One Cont. Assessment

Integrated Management of Childhood Illness

IMNCI Session One

Assessment Complete!

IMNCI Session One Quiz

Integrated Management of Childhood Illness

IMNCI Session One

Assessment Complete!

STOMATITIS

REVIEW: Anatomy of the Gastrointestinal (GI) Tract

Esophagus

Stomach

Small Intestine

Large Intestine

Rectum and Anus

Blood and Nerve Supply of the GI Tract

Blood Supply

Nerve Supply

Primary Functions of the Digestive System

General Signs and Symptoms of Digestive System Disorders

Disorders of the Digestive System

Stomatitis

Causes and Etiology of Stomatitis

Clinical Manifestations of Stomatitis

Investigations and Diagnosis

Treatment and Management Strategies

Complications of Stomatitis

Prevention of Stomatitis

MALNUTRITION

Forms of Malnutrition

Causes and Risk Factors for Malnutrition

PROTEIN-ENERGY MALNUTRITION (PEM)

Classification of PEM

Kwashiorkor

Clinical Features of Kwashiorkor

Marasmus

Clinical Features of Marasmus

Management of Severe Acute Malnutrition (SAM)

Hospital-Based Management

Micronutrient Deficiencies

Fat-Soluble Vitamins

Water-Soluble Vitamins

Minerals

Diagnosis and Assessment of Malnutrition

Nutritional Anthropometry

Laboratory Investigations

Growth Monitoring and Promotion

Growth Monitoring

Parameters Used to Monitor Growth:

Importance of Growth Monitoring:

Growth Promotion

Antenatal Care (During Pregnancy):

Less than 6 Weeks (Newborn Period):

At 6 Weeks:

At 2, 3, 4 Months of Age (Scheduled Immunization Visits):

8 Months, 2 Years, 3 Years (Key Developmental Milestones and Check-ups):

At 4-5 Years (Preschool Check-up/School Entry Readiness):

School Entry - 5 Years (School Nurse Assessment):

Child Health Card

Components of the Child Health Card

Counseling the Mother After Weighing the Child

For Children 0-6 Months (Gained Adequate Weight):

For Children 0-6 Months (Did Not Gain Adequate Weight):

Key Questions to Ask (for 0-6 months, inadequate weight gain):

Information to Provide to the Mother (for 0-6 months, inadequate weight gain):

For Children 6-12 Months (Gained Adequate Weight):

For Children 6-12 Months (Did Not Gain Adequate Weight):

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS

IMNCI PROCESS FOR THE SICK YOUNG INFANT

1. GREET THE CAREGIVER

2. CHECK FOR