Nurses Revision

Nurses Revision
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Check general danger signs first
Young infant 0-2 months Child 2 months-5 years
Common: Malaria Pneumonia Diarrhoea Fever HIV

Results for "HIV" (Age: 2 months - 5 years)

Confirmed HIV Infection 2 months - 5 years

Link to Care / Initiate Prophylaxis & ART High match
What to tell caregiver
  • Explain the positive HIV result clearly and sensitively.
  • Explain the importance of starting and adhering to lifelong ART.
  • Explain the importance of daily Co-trimoxazole prophylaxis.
  • Provide age-appropriate feeding advice.
  • Counsel on preventing transmission if relevant (mother's health).
  • Counsel on hygiene and preventing opportunistic infections.
  • Emphasize importance of regular follow-up at ART clinic.
  • Address psychosocial needs and support systems.
  • Advise on assessing for TB regularly.

Classification for a child with a confirmed positive HIV test (DNA PCR if <18m, Rapid Test if >=18m). Requires linkage to HIV care and treatment (ART) clinic, co-trimoxazole prophylaxis, and ongoing monitoring.

Key Features
  • Definitive positive HIV test result appropriate for age.
  • Requires lifelong ART and comprehensive HIV care.
  • Requires co-trimoxazole prophylaxis to prevent opportunistic infections.
Red Flags (Warning Signs)
  • Signs of severe illness (danger signs, severe classifications like severe pneumonia, severe malnutrition).
  • Signs suggestive of advanced HIV disease or opportunistic infection (e.g., persistent diarrhoea, recurrent infections, failure to thrive, oral thrush, lymphadenopathy).
Assessment
Ask
  • Has the mother or child had an HIV test?
  • If Yes: Note mother's/child's status.
  • Confirm positive test result: Positive DNA PCR test in child OR Positive HIV rapid test in a child 18 months or older.
Classification
  • Positive DNA PCR test in child OR Positive HIV rapid test in a child >= 18 months -> CONFIRMED HIV INFECTION
Urgency / Refer urgently

Link to Care / Initiate Prophylaxis & ART

Management
Non-Pharmacological Management
  • Assess feeding and provide appropriate counselling based on age and ART status (Refer to pages 25-28).
  • Provide counselling on disclosure, adherence, psychosocial support.
  • Monitor growth and development closely.
  • Assess for TB (see page 9).
Pharmacological Treatment
  • Give Co-trimoxazole prophylaxis daily. Dose: Age 6 weeks - 6 months: 2.5ml syrup (or 1 infant tab). Age >6 months - 5 years: 5ml syrup (or 1 adult tab/2 infant tabs). Start from 6 weeks or at diagnosis if older. Continue lifelong unless stopped based on specific criteria (e.g., immune recovery on ART, national guidelines).
  • Link child to Early Infant Diagnosis (EID) / ART Clinic for initiation and continuation of Antiretroviral Therapy (ART) and comprehensive HIV care.
  • Treat any existing infections or conditions according to IMCI guidelines.
  • Ensure immunizations are up-to-date (follow specific schedule for HIV+ children, e.g., avoid BCG if symptomatic/confirmed positive before vaccination).
Monitoring & Follow-Up
  • Requires regular, lifelong follow-up at the ART clinic for clinical monitoring, CD4/viral load testing, adherence support, management of side effects or complications.
  • Follow up for acute illnesses as per IMCI guidelines.
Counselling Points
  • Explain the positive HIV result clearly and sensitively.
  • Explain the importance of starting and adhering to lifelong ART.
  • Explain the importance of daily Co-trimoxazole prophylaxis.
  • Provide age-appropriate feeding advice.
  • Counsel on preventing transmission if relevant (mother's health).
  • Counsel on hygiene and preventing opportunistic infections.
  • Emphasize importance of regular follow-up at ART clinic.
  • Address psychosocial needs and support systems.
  • Advise on assessing for TB regularly.
Differential Diagnosis
  • HIV Exposed (infant <18m with positive antibody test or mother HIV+)
  • HIV Infection Unlikely
  • Other immunodeficiency conditions (rare)
Potential Complications
  • Opportunistic Infections (Pneumocystis pneumonia [PCP], TB, severe bacterial infections, cryptococcosis, candidiasis etc.)
  • Malnutrition / Wasting / Stunting
  • HIV encephalopathy / Neurodevelopmental delay
  • Malignancies (Kaposi sarcoma, lymphoma)
  • Chronic lung disease, heart disease, kidney disease
  • Immune Reconstitution Inflammatory Syndrome (IRIS) after starting ART.
Prevention
  • Prevention of Mother-to-Child Transmission (PMTCT) interventions.
  • Safe infant feeding practices for exposed infants.
  • General HIV prevention strategies in the community.

Reference: IMCI Chart Booklet - Page 8, Page 9 (TB check), Page 14 (Co-trimoxazole), Pages 25-28 (Feeding)

HIV Exposed 2 months - 5 years

Link to Care / Initiate Prophylaxis / Schedule Testing High match
What to tell caregiver
  • Explain the meaning of 'HIV Exposed' - child needs testing to know status.
  • Explain the importance of daily Co-trimoxazole prophylaxis.
  • Explain the importance of ARV prophylaxis for the baby if breastfeeding.
  • Provide detailed counselling on safe infant feeding options (exclusive breastfeeding for first 6 months is generally recommended for exposed infants in resource-limited settings if mother is on ART; discuss stopping breastfeeding and AFASS criteria - page 28). Emphasize exclusive feeding method.
  • Explain the schedule for EID testing (DNA PCR).
  • Counsel on importance of mother's own health and ART adherence.
  • Advise on assessing for TB.
  • Advise on signs of illness requiring immediate care.

Classification for an infant or child (<18 months) born to an HIV-positive mother who has not yet had definitive HIV testing (or had a negative DNA PCR while still breastfeeding/recently stopped) OR has a positive antibody test (<18m). Requires co-trimoxazole prophylaxis, linkage for EID testing, and specific feeding counselling.

Key Features
  • Child born to HIV-positive mother.
  • Child's definitive HIV status is not yet confirmed negative (either untested, inconclusive test timing relative to breastfeeding, or positive antibody test <18m which reflects maternal antibodies).
  • Requires co-trimoxazole prophylaxis until definitive negative status confirmed after breastfeeding cessation.
  • Requires timely EID testing (DNA PCR).
  • Requires specific counselling on safe infant feeding (AFASS criteria if considering stopping breastfeeding).
Red Flags (Warning Signs)
  • Any signs of illness (needs assessment per IMCI).
  • Poor growth or development.
  • Signs suggestive of HIV infection (thrush, recurrent infections etc.).
Assessment
Ask
  • Has the mother had an HIV test? (Mother is HIV-positive).
  • Has the child had an HIV test?
  • Is the child breastfeeding now?
  • Is the mother on ART and child on ARV prophylaxis (if breastfeeding)?
  • Determine child's status based on tests and age:
  • Case 1: Mother HIV+ AND child had negative DNA PCR test while breastfeeding or stopped < 6 weeks ago.
  • Case 2: Mother HIV+ AND child not yet tested.
  • Case 3: Mother HIV+ AND child < 18 months had positive serological (antibody) test.
Classification
  • (Mother HIV-positive AND Negative DNA PCR test in breastfeeding child or stopped < 6 weeks ago) OR (Mother HIV-positive AND Child not yet tested) OR (Mother HIV-positive AND Positive serological test in infant HIV EXPOSED
Urgency / Refer urgently

Link to Care / Initiate Prophylaxis / Schedule Testing

Management
Non-Pharmacological Management
  • Assess feeding and provide appropriate counselling based on mother's choice and circumstances (breastfeeding vs replacement feeding - counsel on AFASS criteria Page 28 if considering stopping breastfeeding).
  • Link child to ART/Mother Baby care point for follow-up, ARV prophylaxis (if breastfeeding), and EID testing.
  • Monitor growth and development.
  • Assess for TB (see page 9).
Pharmacological Treatment
  • Give Co-trimoxazole prophylaxis daily. Start at 6 weeks of age (or at first contact if older). Dose: Age 6 weeks - 6 months: 2.5ml syrup (or 1 infant tab). Age >6 months - 5 years: 5ml syrup (or 1 adult tab/2 infant tabs). Continue until HIV infection definitively excluded after cessation of breastfeeding.
  • Ensure child receives appropriate ARV prophylaxis according to national PMTCT guidelines (especially if breastfeeding).
  • Perform DNA PCR test to confirm HIV status at appropriate time points (e.g., 6 weeks, after breastfeeding cessation - follow national EID algorithm). If DNA PCR is positive -> Confirmed HIV Infection. If negative after breastfeeding cessation -> HIV Infection Unlikely.
  • Ensure immunizations are up-to-date (follow schedule, give BCG at birth unless symptomatic).
Monitoring & Follow-Up
  • Regular follow-up at Mother-Baby care point/ART clinic for EID testing, monitoring, ARV prophylaxis refills, and continued co-trimoxazole.
  • Final HIV test (usually rapid test) around 18-24 months or after breastfeeding cessation to confirm status.
Counselling Points
  • Explain the meaning of 'HIV Exposed' - child needs testing to know status.
  • Explain the importance of daily Co-trimoxazole prophylaxis.
  • Explain the importance of ARV prophylaxis for the baby if breastfeeding.
  • Provide detailed counselling on safe infant feeding options (exclusive breastfeeding for first 6 months is generally recommended for exposed infants in resource-limited settings if mother is on ART; discuss stopping breastfeeding and AFASS criteria - page 28). Emphasize exclusive feeding method.
  • Explain the schedule for EID testing (DNA PCR).
  • Counsel on importance of mother's own health and ART adherence.
  • Advise on assessing for TB.
  • Advise on signs of illness requiring immediate care.
Differential Diagnosis
  • Confirmed HIV Infection
  • HIV Infection Unlikely
Potential Complications
  • Risk of acquiring HIV infection if PMTCT is suboptimal.
  • Increased risk of common childhood illnesses.
  • Side effects of prophylactic medications (rare).
Prevention
  • Effective PMTCT including maternal ART.
  • Infant ARV prophylaxis.
  • Safe infant feeding practices.
  • Co-trimoxazole prophylaxis.

Reference: IMCI Chart Booklet - Page 8, Page 9 (TB check), Page 14 (Co-trimoxazole), Pages 25-28 (Feeding, AFASS)

HIV Infection Unlikely 2 months - 5 years

Routine Care High match
What to tell caregiver
  • Reassure mother about the negative HIV status.
  • Provide counselling for any presenting illness.
  • Provide general health and feeding advice.
  • Advise on ongoing HIV prevention measures for the mother/family.

Classification for a child whose mother has tested HIV negative OR the child (<18m) tested negative via DNA PCR after cessation of breastfeeding OR the child (>=18m) tested negative via rapid test. Requires routine care.

Key Features
  • Confirmed negative HIV status for the mother or child (using appropriate test and timing).
  • Indicates very low likelihood of HIV infection.
  • Requires standard IMCI management for presenting conditions.
Assessment
Ask
  • Has the mother or child had an HIV test?
  • Confirm negative test result:
  • Mother tested HIV-negative OR
  • Child tested negative by DNA PCR after complete cessation of breastfeeding (>6 weeks prior) OR
  • Child >= 18 months tested negative by HIV rapid test.
Classification
  • Negative HIV test in mother or child (definitive) -> HIV INFECTION UNLIKELY
Urgency / Refer urgently

Routine Care

Management
Non-Pharmacological Management
  • Provide routine assessment and management for any presenting illness using standard IMCI protocols.
  • Provide age-appropriate feeding counselling.
Pharmacological Treatment
  • Treat any current illness according to IMCI guidelines.
  • Co-trimoxazole prophylaxis is NOT indicated.
Monitoring & Follow-Up
  • Follow up for presenting illness as needed.
  • Continue routine child health services (growth monitoring, immunization).
Counselling Points
  • Reassure mother about the negative HIV status.
  • Provide counselling for any presenting illness.
  • Provide general health and feeding advice.
  • Advise on ongoing HIV prevention measures for the mother/family.
Prevention
  • Continued safe practices to prevent HIV acquisition.

Reference: IMCI Chart Booklet - Page 8

HIV Infection Status Unknown 2 months - 5 years

Offer HIV Testing & Counselling High match
What to tell caregiver
  • Explain the importance of knowing HIV status for the health of both mother and child.
  • Offer HIV testing and counselling sensitively.
  • Explain the testing process and confidentiality.
  • Provide general health messages.

Classification for an infant or child (<18 months) whose mother's HIV status is unknown AND the child has not been tested. Requires counselling and offering of HIV testing for the mother (and child if mother tests positive).

Key Features
  • HIV status of mother and child is unknown.
  • Child is young enough (<18m) that maternal status is the primary determinant for exposure risk assessment.
  • Requires offering HIV testing and counselling (HTC) to the mother.
Red Flags (Warning Signs)
  • Child presenting with signs suggestive of HIV infection (recurrent severe infections, failure to thrive, thrush etc.) increases urgency for testing.
Assessment
Ask
  • Has the mother or child had an HIV test? (Answer is No, or status unknown).
  • Confirm child is less than 18 months old (as management differs slightly for older children where child testing might be offered directly).
Classification
  • HIV test not done for mother or infant child less than 18 months old -> HIV INFECTION STATUS UNKNOWN
Urgency / Refer urgently

Offer HIV Testing & Counselling

Management
Non-Pharmacological Management
  • Encourage mother to go for HIV counselling and testing in a health facility.
  • Provide general health and feeding advice based on age.
Pharmacological Treatment
  • Treat any current illness according to IMCI guidelines.
  • Withhold Co-trimoxazole until mother/child status is known (unless child is severely malnourished or has confirmed TB where prophylaxis might be indicated regardless - check national guidelines).
Monitoring & Follow-Up
  • Follow up depends on whether mother accepts testing.
  • If mother tests positive, manage child as HIV Exposed.
  • If mother tests negative, manage child as HIV Infection Unlikely.
  • Follow up for presenting illness as needed.
Counselling Points
  • Explain the importance of knowing HIV status for the health of both mother and child.
  • Offer HIV testing and counselling sensitively.
  • Explain the testing process and confidentiality.
  • Provide general health messages.
Differential Diagnosis
  • Child could be HIV Exposed or HIV Unlikely depending on mother's actual status.
Potential Complications
  • Delayed diagnosis of HIV infection in mother or child.
  • Missed opportunity for PMTCT in future pregnancies.
  • Child may unnecessarily lack prophylaxis if exposed, or receive it if not needed.
Prevention
  • Routine offering of HIV testing in antenatal care, labour/delivery, postnatal care, and child health services.

Reference: IMCI Chart Booklet - Page 8

Severe Persistent Diarrhoea 2 months - 5 years

Refer URGENTLY (after treating dehydration if severe) High match
What to tell caregiver
  • Explain that the long duration of diarrhoea combined with dehydration is serious and requires hospital care.
  • Explain any dehydration treatment being given.
  • Advise mother to continue breastfeeding frequently.
  • Advise on keeping child warm during transport.
  • Write a detailed referral note mentioning duration of diarrhoea, dehydration status, and any treatments given.

Classification for a child whose diarrhoea has lasted 14 days or more AND who has signs of dehydration present. Requires urgent referral for specialized management.

Key Features
  • Diarrhoea duration of 14 days or more.
  • Presence of signs classifying as SOME DEHYDRATION or SEVERE DEHYDRATION.
  • High risk for malnutrition and underlying infections (including HIV).
Red Flags (Warning Signs)
  • Signs of Severe Dehydration.
  • Signs of severe malnutrition.
  • Signs of associated sepsis or other severe infection.
Assessment
Ask
  • Does the child have diarrhoea?
  • For how long? (Response is 14 days or more).
  • Assess for Dehydration (Look/Feel for signs of Some or Severe Dehydration - see IMCI_2M5Y_005 & 006 assessments).
Classification
  • Diarrhoea for 14 days or more AND Dehydration present (Signs of Some or Severe Dehydration) -> SEVERE PERSISTENT DIARRHOEA
Urgency / Refer urgently

Refer URGENTLY (after treating dehydration if severe)

Pre-referral treatment
  • Stabilize hydration as much as possible (start Plan C or B).
  • Give other essential pre-referral treatments if needed for co-existing severe classifications.
  • Keep child warm.
  • Advise mother to continue breastfeeding.
Management
Non-Pharmacological Management
  • Treat dehydration first (Plan C if severe, Plan B if some) BEFORE referral, unless the child has another severe classification requiring immediate referral.
  • If referring, keep child warm.
Pharmacological Treatment
  • Treat dehydration as per Plan C or Plan B.
  • If child has another severe classification (e.g., Very Severe Febrile Disease), give pre-referral treatments for that condition (e.g., antibiotic, antimalarial).
Monitoring & Follow-Up
  • To be managed at referral hospital, which will investigate cause and provide specialized feeding/treatment.
Counselling Points
  • Explain that the long duration of diarrhoea combined with dehydration is serious and requires hospital care.
  • Explain any dehydration treatment being given.
  • Advise mother to continue breastfeeding frequently.
  • Advise on keeping child warm during transport.
  • Write a detailed referral note mentioning duration of diarrhoea, dehydration status, and any treatments given.
Differential Diagnosis
  • Persistent Diarrhoea (without dehydration)
  • Acute Diarrhoea with Dehydration
  • Secondary lactose intolerance
  • Cow's milk protein allergy
  • Other food intolerances/allergies
  • Post-enteritis syndrome
  • Giardiasis
  • Cryptosporidiosis (especially if HIV+)
  • Other specific enteropathogens
  • Malnutrition-associated gut changes
Potential Complications
  • Severe malnutrition
  • Micronutrient deficiencies
  • Severe dehydration and shock
  • Sepsis
  • Electrolyte imbalance
  • Death
Prevention
  • Appropriate management of acute diarrhoea (ORS, Zinc, continued feeding).
  • Good nutrition, Vitamin A.
  • Measles vaccination.
  • Handwashing, safe water/sanitation.
  • Early identification and management of HIV infection.

Reference: IMCI Chart Booklet - Page 3, Pages 13, 16

Persistent Diarrhoea 2 months - 5 years

Routine Management / Dietary Counselling High match
What to tell caregiver
  • Explain the importance of special feeding during persistent diarrhoea.
  • Provide specific, practical advice on recommended foods and feeding frequency based on local availability and child's age.
  • Explain how to give multivitamins and zinc.
  • Advise on giving extra fluids.
  • Advise when to return immediately (danger signs, signs of dehydration).
  • Advise on follow-up visit in 5 days.

Classification for a child whose diarrhoea has lasted 14 days or more but who currently has NO signs of dehydration. Requires specific dietary advice and follow-up.

Key Features
  • Diarrhoea duration of 14 days or more.
  • Absence of signs of dehydration.
  • Management focuses on nutritional rehabilitation and investigating potential underlying causes.
Red Flags (Warning Signs)
  • Development of dehydration.
  • Significant weight loss or failure to gain weight.
  • Signs of specific nutrient deficiencies.
  • Refusal to eat.
Assessment
Ask
  • Does the child have diarrhoea?
  • For how long? (Response is 14 days or more).
  • Assess for Dehydration: Confirm NO DEHYDRATION (Not enough signs for Some or Severe Dehydration).
Classification
  • Diarrhoea for 14 days or more AND No Dehydration -> PERSISTENT DIARRHOEA
Urgency / Refer urgently

Routine Management / Dietary Counselling

Management
Non-Pharmacological Management
  • Advise the mother on feeding a child with PERSISTENT DIARRHOEA:
  • If still breastfeeding: Breastfeed more frequently and longer, day and night.
  • If taking other milk: Replace with fermented milk products (e.g., yoghurt) OR Replace half the milk with nutrient-rich semisolid food (e.g., porridge).
  • For other foods: Ensure adequate energy intake. Give small, frequent meals (at least 6 times/day). Use foods rich in energy and nutrients. Mix foods well.
  • Give foods rich in potassium (e.g., bananas, coconut water).
  • Ensure adequate fluid intake using ORS or recommended home fluids after loose stools.
  • Check for HIV Infection (refer to HIV assessment algorithm page 8).
Pharmacological Treatment
  • Give multivitamins and minerals (including zinc) for 10 days (or longer per local guidelines). Ensure Zinc dose is 10mg (=6m) daily.
Monitoring & Follow-Up
  • Follow up in 5 days.
  • At follow-up (Day 5):
  • Ask: Has diarrhoea stopped? How many stools per day?
  • Assess feeding and check for dehydration.
  • If diarrhoea has not stopped: Do a full reassessment. Treat dehydration if present. Refer to hospital for assessment (including for ART if HIV+).
  • If diarrhoea has stopped: Tell mother to follow usual age-appropriate feeding recommendations. Complete 10 days of zinc.
Counselling Points
  • Explain the importance of special feeding during persistent diarrhoea.
  • Provide specific, practical advice on recommended foods and feeding frequency based on local availability and child's age.
  • Explain how to give multivitamins and zinc.
  • Advise on giving extra fluids.
  • Advise when to return immediately (danger signs, signs of dehydration).
  • Advise on follow-up visit in 5 days.
Differential Diagnosis
  • Severe Persistent Diarrhoea (if dehydration develops)
  • Secondary lactose intolerance
  • Cow's milk protein allergy
  • Other food intolerances/allergies
  • Giardiasis
  • Cryptosporidiosis
  • Malnutrition
  • HIV infection
Potential Complications
  • Malnutrition
  • Micronutrient deficiencies
  • Dehydration (if fluid/feeding advice not followed)
  • Increased susceptibility to other infections
Prevention
  • Appropriate management of acute diarrhoea (ORS, Zinc, continued feeding).
  • Good nutrition, Vitamin A.
  • Measles vaccination.
  • Handwashing, safe water/sanitation.
  • Early identification and management of HIV infection.

Reference: IMCI Chart Booklet - Page 3, Page 22, Page 26 (Feeding Recs), Page 8 (HIV)

Chronic Ear Infection (Chronic Suppurative Otitis Media - CSOM) 2 months - 5 years

Routine Management / Treat with Topical Drops High match
What to tell caregiver
  • Explain the diagnosis (chronic ear infection).
  • Emphasize the importance of keeping the ear dry through regular, careful wicking. Demonstrate the technique.
  • Teach how to instill the eardrops correctly after wicking.
  • Explain the duration of treatment (2 weeks).
  • Advise to avoid water entering the ear.
  • Advise when to return immediately (swelling behind ear, facial weakness, severe pain, danger signs).
  • Advise on follow-up visit in 5 days.

Classification for a child with ear problem presenting with pus draining from the ear for 14 days or more, and NO tender swelling behind the ear. Requires topical ear drop treatment and careful drying.

Key Features
  • Pus seen draining from ear for 14 days or more.
  • Absence of tender swelling behind the ear.
  • Requires meticulous ear cleaning (dry wicking) and topical antibiotic ear drops (quinolone).
  • Oral antibiotics are generally NOT effective for uncomplicated CSOM.
Red Flags (Warning Signs)
  • Development of tender swelling behind the ear (Mastoiditis).
  • Development of facial weakness.
  • Development of vertigo or severe headache.
  • Foul-smelling discharge suggesting cholesteatoma.
  • Failure to improve after 2 weeks of topical treatment.
Assessment
Ask
  • Does the child have an ear problem?
  • Is there ear discharge? If yes, for how long?
  • Confirm duration of discharge is 14 days or more.
  • Confirm absence of Tender Swelling behind the ear.
  • Look: Look for pus draining from the ear.
Classification
  • Pus seen draining from ear for >= 14 days AND No tender swelling behind ear -> CHRONIC EAR INFECTION
Urgency / Refer urgently

Routine Management / Treat with Topical Drops

Management
Non-Pharmacological Management
  • Teach mother how to dry the ear carefully by wicking 3 times daily (as described for AOM). Stress the importance of keeping the ear dry.
  • Advise to avoid getting water in the ear during bathing.
Pharmacological Treatment
  • Treat with topical Quinolone eardrops (e.g., Ciprofloxacin, Ofloxacin - check local availability/guideline) for 2 weeks. Instill drops after dry wicking.
  • Check for HIV Infection (refer to HIV assessment algorithm page 8).
  • Check for TB (assess symptoms, contact history - see page 9, especially if discharge persists or other symptoms).
Monitoring & Follow-Up
  • Follow-up in 5 days.
  • At follow-up (Day 5): Reassess ear discharge. Check mother's wicking technique.
  • If tender swelling behind ear: Treat as Mastoiditis - Refer URGENTLY.
  • If discharge persists: Check wicking technique is correct. Encourage mother to continue. Continue eardrops for full 2 weeks.
  • If discharge stopped: Praise mother. Advise to finish 2-week course of eardrops.
  • If discharge persists after 2 weeks of treatment, refer for further assessment (e.g., ENT specialist).
Counselling Points
  • Explain the diagnosis (chronic ear infection).
  • Emphasize the importance of keeping the ear dry through regular, careful wicking. Demonstrate the technique.
  • Teach how to instill the eardrops correctly after wicking.
  • Explain the duration of treatment (2 weeks).
  • Advise to avoid water entering the ear.
  • Advise when to return immediately (swelling behind ear, facial weakness, severe pain, danger signs).
  • Advise on follow-up visit in 5 days.
Differential Diagnosis
  • Mastoiditis
  • Acute Ear Infection
  • Otitis Externa
  • Foreign body with secondary infection
  • Cholesteatoma (suspect if discharge persists despite treatment, foul smell, or granulation tissue)
Potential Complications
  • Hearing loss (conductive)
  • Cholesteatoma formation
  • Mastoiditis
  • Intracranial complications (meningitis, abscess - less common than with AOM/mastoiditis but possible)
  • Facial nerve palsy
Prevention
  • Prompt and effective treatment of Acute Otitis Media.
  • Immunizations (PCV, Hib).
  • Good nutrition.
  • Avoiding exposure to smoke.

Reference: IMCI Chart Booklet - Page 5, Page 8 (HIV), Page 9 (TB), Page 18 (Wicking, Topical Drops details assumed based on text 'Treat with topical quinolone eardrops for 2 weeks'), Page 23 (Follow-up)

Severe Dehydration 2 months - 5 years

Immediate Treatment (Plan C) / Refer URGENTLY if IV not possible High match
What to tell caregiver
  • If Plan C given in clinic: Explain the procedure and need for close monitoring. Reassure the mother.
  • If referring: Explain the seriousness of dehydration and the need for hospital treatment (IV fluids). Show how to give ORS sips frequently during transport. Advise on keeping child warm. Advise mother to continue breastfeeding whenever child wants.

Classification for a child with diarrhoea who exhibits two or more signs of severe dehydration, indicating a life-threatening fluid deficit requiring immediate IV fluid resuscitation (Plan C) or urgent referral.

Key Features
  • Requires TWO or more of the following signs: Lethargic/unconscious, Sunken eyes, Not able to drink/drinking poorly, Skin pinch goes back very slowly (>2 seconds).
  • Indicates significant fluid and electrolyte loss.
  • Requires immediate fluid resuscitation, preferably with IV fluids (Plan C).
Red Flags (Warning Signs)
  • Lethargic or unconscious state
  • Not able to drink or drinking poorly
  • Skin pinch goes back very slowly (> 2 seconds)
  • Signs of shock (cold extremities, weak/fast pulse, capillary refill > 3 sec)
Assessment
Ask
  • Does the child have diarrhoea?
  • For how long?
  • Is there blood in the stool?
Look, listen, feel
  • Look at the child's general condition. Is the child Lethargic or unconscious?
  • Look for sunken eyes.
  • Offer the child fluid. Is the child Not able to drink or drinking poorly?
  • Pinch the skin of the abdomen. Does it go back Very slowly (longer than 2 seconds)?
Classification
  • Two or more of the following signs: (Lethargic or unconscious) OR (Sunken eyes) OR (Not able to drink or drinking poorly) OR (Skin pinch goes back very slowly) -> SEVERE DEHYDRATION
Urgency / Refer urgently

Immediate Treatment (Plan C) / Refer URGENTLY if IV not possible

Pre-referral treatment
  • If referring urgently: Ensure airway is clear. Give frequent sips of ORS on the way if child can drink. Keep child warm. Give other essential pre-referral treatments based on other classifications (e.g., antibiotic for severe pneumonia).
Management
Non-Pharmacological Management
  • If providing Plan C in clinic: Ensure availability of IV fluids, cannulas, giving sets. Monitor hydration status closely.
  • If referring: Keep child warm during transport. Continue giving ORS sips frequently if the child can drink.
Pharmacological Treatment
  • TREAT WITH PLAN C:
  • If IV Therapy Possible Immediately: Start IV fluid immediately. Give 100 ml/kg Ringer's Lactate Solution (or Normal Saline if RL not available), divided as follows: Age < 12 months: Give 30ml/kg in 1 hour, THEN 70ml/kg in 5 hours. Age 12 months - 5 years: Give 30ml/kg in 30 minutes, THEN 70ml/kg in 2 ½ hours.
  • Reassess the child every 1-2 hours. If hydration status is not improving, give IV drip more rapidly.
  • Also give ORS (about 5 ml/kg/hour) by mouth as soon as the child can drink (usually after 3-4 hrs for infants, 1-2 hrs for children).
  • Reassess dehydration status after the initial IV phase (e.g., after 6 hrs for infants, 3 hrs for children) and choose appropriate plan (A, B, or repeat C if needed).
  • If IV Therapy Not Available Nearby (<30 mins) or Not Possible:
  • If trained in NG tube insertion: Start rehydration by NG tube with ORS solution: give 20 ml/kg/hour for 6 hours (total 120 ml/kg). Reassess every 1-2 hours. If vomiting persists or distension occurs, slow the rate. If hydration not improving after 3 hrs, refer urgently for IV.
  • If child can drink: Refer URGENTLY to hospital for IV/NG treatment. Give mother ORS solution and show her how to give frequent sips during the trip.
  • If child is 2 years or older AND cholera is in your area: Give appropriate antibiotic for cholera (e.g., Erythromycin).
  • If child also has another severe classification (e.g., Severe Pneumonia): Refer URGENTLY after stabilizing airway/breathing and giving essential pre-referral treatments (e.g., antibiotic), give frequent sips of ORS on the way.
Monitoring & Follow-Up
  • Managed initially under Plan C, then reassessed and managed according to Plan A or B.
  • If discharged on Plan A or B, follow-up as per those plans.
Counselling Points
  • If Plan C given in clinic: Explain the procedure and need for close monitoring. Reassure the mother.
  • If referring: Explain the seriousness of dehydration and the need for hospital treatment (IV fluids). Show how to give ORS sips frequently during transport. Advise on keeping child warm. Advise mother to continue breastfeeding whenever child wants.
Differential Diagnosis
  • Some Dehydration
  • Septic shock (may mimic dehydration signs)
  • Severe malnutrition with oedema (skin changes may be misleading)
  • Other causes of altered consciousness (meningitis, severe malaria)
Potential Complications
  • Hypovolemic shock
  • Acute kidney injury
  • Seizures (due to electrolyte imbalance or hypoglycemia)
  • Cerebral edema (if rehydrated too rapidly with hypotonic fluids, rare with ORS/RL/NS)
  • Death
Prevention
  • Exclusive breastfeeding for 6 months.
  • Use of safe water and sanitation.
  • Handwashing with soap.
  • Appropriate complementary feeding.
  • Measles vaccination.
  • Rotavirus vaccination (if available).
  • Prompt use of ORS and Zinc at the start of diarrhoea.
  • Continued feeding during diarrhoea.

Reference: IMCI Chart Booklet - Page 3, Page 13 (Plan C), Page 16

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