Revised IMNCI CHART BOOKLET-1.pdf

1
WHO UNICEF
ASSESS AND CLASSIFY THE SICK
CHILD
Check For General Danger Signs.........................................1
Then Ask About Main Symptoms........................................2
Does the child have cough or difficult breathing?........2
Does The Child Have Diarrhoea?.......................................3
Does The Child Have Fever?..............................................4
Does The Child Have Ear Problem?...................................5
Then Check For Malnutrition .............................................6
Check For Anaemia............................................................7
Then Check For HIV Infection............................................8
Then Check For TB............................................................9
Check The Child’s Immunisation & Vitamin A Status ......10
TREAT THE CHILD
Pre-referral treatment ......................................................11
Give diazepam to Stop Convulsions..........................11
Give Artesunate Suppositories Or Intramuscular.......11
Artesunate Or Quinine For Severe Malaria................11
Give an Intramuscular Antibiotic.................................11
Treat The Child To Prevent Low Blood Sugar ...........12
Refer Urgently............................................................12
Plan C: Treat For Severe Dehydration Quickly .........13
Carry Out The Treatment Steps Identified On The Assess
And Classify Chart ...........................................................14
Teach The Mother To Give Oral Medicines................14
Give An Appropriate Oral Antibiotic............................14
Give Oral Anti Malarial For Malaria ...........................15
Give Paracetamol for High fever................................15
Give Extra Fluids For Diarrhoea And continue
Feeding (Plan A and Plan B).....................................16
Give Iron....................................................................17
Give Salbutamol For Wheezing.................................17
Teach The Mother To Treat Local Infections..............18
Treat the child for Tb ................................................19
Give Vitamin A And Mebendazole In Clinic...............20
Recommmended Tb Treatment Regimen.................20
Dosage of anti-TB medicines by weight band..........20
Start The Child With TB Exposure On Isoniazid Preventive
Therapy ...........................................................................20
Dosage of Isoniazid by weight band...............................20
Give Ready-To-Use Therapeutic Food.............................21
Give Ready-To-Use Therapeutic Food For Severe
Acute Malnutrition .....................................................21
Recommended Amounts of Ready-to-Use
Therapeutic Food .....................................................21
GIVE FOLLOW-UP CARE FOR ACUTE
CONDITIONS
Give Follow-Up Care .......................................................22
Pneumonia .................................................................22
Persistent diarrhoea ...................................................22
Dysentery ...................................................................22
Malaria ........................................................................23
Fever- No malaria .......................................................23
Measles with eye or mouth complications...................23
Ear infection ...............................................................23
Feeding problem .......................................................23
Anaemia .....................................................................24
Very low weight ..........................................................24
Moderate Acute Malnutrition.............................................24
Uncomplicated Severe Acute Malnutrition........................24
COUNSEL THE MOTHER
Assess The Feeding Of Sick Infants Under 2 Years........25
Feeding Recommendations..............................................26
Feeding recommendation for all children.....................26
Consel The Mother About Feeding Problems..............27
Feeding Advice For The Mother .................................28
“AFASS” criteria for stopping breastfeeding ..............28
Counsel The Mother About Responsive Care Giving
And Stimulating The Child’s Brain ..............................29
Counsel The Mother About Her Own Health ..............30
Fluids...........................................................................30
When To Return ..............................................................30
IMNCI PROCESS FOR THE SICK
YOUNG INFANT.................................................31
Signs of Severe Disease.................................................32
ASSESS, CLASSIFY AND TREAT THE
YOUNG INFANT
Check For Possible Serious Bacterial Infection ..............33
Then Check For Jaundice................................................34
Then Assess For Diarrhoea ...........................................35
Then Check For HIV Infection ........................................36
Then Check For TB .........................................................37
Then Check For Feeding Problem Or Low Weight .........38
Check Young Infant‘s Immunization Status .....................39
Assess Young Infant For Other Problems .......................39
Assess The Mother’s Health Needs ................................39
TREAT THE YOUNG INFANT
Give First Doses Of Intramuscular Gentamicin ..........40
Prevent Low Blood Sugar ..........................................40
Keep The Young Infant Warm ....................................40
Refer Urgently ............................................................40
Plan C: Treat Severe Dehydration ..............................41
Give Oral Amoxicillin ..................................................42
Plan A: Treat Diarrhoea at home ...............................43
Plan B: Treat some dehydration with ORS.................43
How To Treat Local Infections.....................................44
Immunize Every Sick Young Infant, As Needed .........44
COUNSEL THE MOTHER
Correct Positioning And Attachment For
Breastfeeding .............................................................45
How To Express Breastmilk.........................................45
How To Feed By A Cup...............................................46
How To Keep The Low Weight Infant Warm..............47
How To Give Home Care ...........................................47
GIVE FOLLOW-UP CARE
Very Severe Disease Where Referral Was Refused
Or Not Possible...........................................................48
Pneumonia Or Severe Pneumonia..............................48
Local Infection..............................................................48
Jaundice.......................................................................48
Diarrhoea......................................................................49
Feeding Problem..........................................................49
Low Weight For Age....................................................49
Thrush..........................................................................49
ANNEX
Annex1: Assess Child Development Milestones.............50
Annex2: Weight-For-Height Boys ...................................51
Annex3: Weight-For-Length Boys ..................................52
Annex4: Growth Chart Boys............................................53
Annex5: Weight-For-Height Girls.....................................54
Annex6: Weight-For-Length Girls....................................55
Annex7: Growth Chart Girls.............................................56
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
SICK CHILD
Age: 2 Months Up To 5 Years
SICK YOUNG INFANT
Age: Birth Up To 2 Months
THE REPUBLIC OF UGANDA, 2017
MOH
Give Follow-Up Care continued

1
ASK:
- Is the child able to drink or
breastfeed?
- Does the child vomit
everything?
- Has the child had convulsions?
LOOK AND FEEL
- See if the child
is lethargic or
unconscious.
- Is the child convulsing
now?
URGENT
attention
• Any general signs VERY SEVERE
DISEASE
• Give diazepam if convulsing now
• Quickly complete the assessment
• Give any pre-referral treatment immediately
• Treat to prevent low blood sugar
• Keep the child warm
• Refer URGENTLY
ASSESS AND CLASSIFY THE SICK CHILD
ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE
Determine if this is an initial or follow-up visit for this problem.
• If follow-up visit, use the follow-up instructions on
TREAT THE CHILD chart.
• If initial visit, assess the child as follows:
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
USE ALL BOXESTHAT MATCH
CHILD’S SYMPTOMS AND
PROBLEMSTO CLASSIFYTHE
ILLNESS
CHECKFORGENERALDANGERSIGNS
ASSESS CLASSIFY AS IDENTIFY TREATMENT
SICK CHILD AGE 2 MONTHS UPTO 5YEARS

2
USE ALL BOXES THAT MATCH CHILD’S SYMPTOMS AND PROBLEMS
TO CLASSIFY THE ILLNESS
• Any general
danger sign
OR
• Stridor in a
calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE
DISEASE
• Give first dose of an appropriate antibiotic
• Refer URGENTLY to hospital
- Chest indrawing
OR
- Fast breathing
PNEUMONIA • Give oral Amoxicillin for 5 days
• If wheezing (or wheezing has disappeared after
rapidly acting bronchodilator) give an inhaled
bronchodilator for 5 days
• If recurrent wheeze, refer for asthma assessment
• If chest indrawing in HIV exposed/infected child, give
first dose of amoxicillin and refer.
• Soothe the throat and relieve the cough with a safe
remedy
• If coughing for 14 days or more, check for TB
(See page 9)
• Advise mother when to return immediately
(See page 30)
• Follow-up in 3 days
• No sign of
Pneumonia
OR
• Very severe
disease
COUGH OR
COLD
• If wheezing (or wheezing has disappeared after
rapidly acting bronchodilator) give an inhaled
bronchodilator for 5 days
• If recurrent wheezing, refer for asthma assessment
• Soothe the throat and relieve the cough with a safe
remedy
• If coughing for 14 days or more, check for TB
(see page 9)
• Follow-up in 5 days if not improving
ASSESS AND CLASSIFY THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS
Ask the mother what the child’s problems are, determine whether this is an initial or follow-
up visit for this problem. If follow-up visit, use the follow-up instructions on TREAT THE
CHILD chart if initial visit, assess the child as follows:
ASSESS CLASSIFY IDENTIFY TREATMENT
SIGNS CLASSIFY AS TREATMENT
USE ALL BOXES THAT MATCH THE CHILD’S SYMPTOMS
AND PROBLEMS TO CLASSIFY THE ILLNESS.
CHECK FOR GENERAL DANGER SIGNS
ASK: LOOK:
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
A child with any general danger sign needs URGENT attention; complete the
assessment, any pre-referral treatment immediately so that referral is not delayed.
• See if the child is lethargic or
unconscious.
• Is the child convulsing now?
ASK:
For how long?
OOK, LISTEN, FEEL:
• Count the breaths in one minute.
• Look for chest indrawing.
• Look and listen for stridor
• Look and listen for wheezing.
If wheezing and either fast breathing or chest indrawing:
Give a trial of rapid acting inhaled bronchodilator for up to
three times 15–20 minutes apart. Count the breaths and
look for chest indrawing again, and then classify.
If the child is: Fast breathing is:
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
Child must
be calm Classify
COUGH or
DIFFICULT
Breathing
• Is the child able to drink or breastfeed?
• Does the child vomit everything?
• Has the child had convulsions
• Any general danger sign
OR
• Chest indrawing
OR
• Stridor in calm child
• Fast breathing
• No signs of pneumonia
OR
very severe disease
• Give first dose of an appropriate
antibiotic
• Give oral antibiotic for 5 days
• If wheezing (even if it disappeared
after rapidly acting bronchodilator)
give an inhaled bronchodilator for
5 days*
• Soothe the throat and relieve the
cough with a safe remedy
• If coughing for more than 2 weeks or
if having recurrent wheezing, refer for
assessment for TB or asthma
• Advise the mother when to return
immediately
• Follow up in 3 days
• If wheezing give oral salbutamol for
5 days*
• Soothe the throat and relieve cough
with a safe remedy
• If coughing for more than 2 weeks or
if having recurrent wheezing, refer for
assessment for TB or asthma
• Advise mother when to return
immediately
• Follow up in 5 days if not improving
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
PNEUMONIA
COUGH OR COLD
(Urgent pre-referral treatments are in bold print)
THEN ASK ABOUT MAIN SYMPTOMS:
ASK:
• For how
long?
LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
• Look for chest indrawing.
• Look and listen for stridor
• Look and listen for wheezing
If wheezing and either fast breathing or chest
indrawing: Give a trial of rapid acting inhaled
bronchodilator for up to three times 15–20
minutes apart. Count the breaths and look for
chest indrawing again, and then classify.
Child
must
be
calm
Classify
COUGH or
DIFFICULT
BREATHING
Does the child have cough or difficult breathing?
SIGN CLASSIFY AS IDENTIFY TREATMENT

3
DOESTHE CHILD HAVE DIARRHOEA?
Two of the following signs:
• Lethargic or unconscious
• Sunken eyes
• Not able to drink or drinking
poorly
• Skin pinch goes back very
slowly.
SEVERE
DEHYDRATION
• If child has no other severe classification:
→ Give fluid for severe dehydration (Plan C) OR
If child also has another severe classification:
→ Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue breastfeeding
• If child is 2 years or older and there is cholera in your
area, give antibiotic for cholera
• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
SOME
DEHYDRATION
• Give fluid, zinc supplements and food for some
dehydration (Plan B)
• If child also has a severe classification:
→ Refer URGENTLY to hospital with mother
Advise the mother to continue breastfeeding
• Follow-up in 5 days if not improving.
Not enough signs to classify as
some or severe dehydration
NO DEHYDRATION • Give fluid, zinc supplements and food to treat diarrhoea at
home (Plan A)
• Follow-up in 5 days if not improving.
• Dehydration present
SEVERE
PERSISTENT
DIARRHOEA
• Treat dehydration before referral unless the child has
another severe classification
→ Refer to hospital
• No dehydration
PERSISTENT
DIARRHOEA
• Check for HIV Infection
• Advise the mother on feeding a child who has
PERSISTENT DIARRHOEA
• Give multivitamins and minerals including zinc for 10 days
• Blood in the stool
DYSENTERY
• Give ciprofloxacin for 3 days
If dysentry present with severe dehydration or
some dehydration, treat with plan C and plan B
respectively.
* If referral is not possible, manage the child as
described in Integrated Management of Childhood
Illness, Treat the Child, Where Referral Is Not
Possible.
LOOK AND FEEL:
• Look at the child’s general
condition. Is the child:
→ Lethargic or
unconscious?
→ Restless and irritable?
• Look for sunken eyes.
• Offer the child fluid. Is the
child:
→ Not able to drink or
drinking poorly?
→ Drinking eagerly, thirsty?
• Pinch the skin of the
abdomen.
Does it go back:
→ Very slowly (longer than
2 seconds)?
→ Slowly?
IF YES, ASK:
• For how long?
• Is there blood
in the stool?
Classify
Diarrhoea
for
DEHYDRATION
and if diarrhoea
for 14 days or
more
and if blood in
stool

4
IF YES, ASK:
• For how long?
• If more than 7
days, has fever
been present
every
• Has the child had
measles within
the last 3 months?
Do a Malaria Test IF
NO general danger
sign or severe
classification
(by history or feels hot or temperature 37.5°C** or above)
LOOK AND FEEL:
• Look or feel for stiff neck.
• Look for runny nose.
Look for signs of MEASLES
• Generalized rash and
• One of these: cough, runny
nose, or red eyes.
• Look for mouth ulcers. Are
they deep and extensive?
• Look for pus draining from
the eye.
• Look for clouding of the
cornea.
Classify
FEVER
• Any general danger sign or
• Stiff neck
• Malaria test POSITIVE
• Give first dose of Artesunate or quinine
for severe malaria
• Treat the child to prevent low blood sugar
• Give one dose of paracetamol in clinic for
high fever (38.5°C or above)
• Give Artemether-Lumefantrine(AL)
• Give one dose of paracetamol in clinic for
high fever (38.5°C or above)
• Follow-up in 2 days if fever persists
• If fever is present every day for more than
7 days, refer for assessment
VERY SEVERE
FEBRILE DISEASE
MALARIA
DOES THE CHILD HAVE FEVER?
If the child has measles now or within the last 3 months.
** These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5°C higher.]
*** Other important complications of measles — pneumonia, stridor, diarrhoea, ear infection, and malnutrition - are classified in other tables.
• Any general danger sign or
• Clouding of cornea or
• Deep or extensive mouth
ulcers
• Pus draining from the eye or
• Mouth ulcers
• Measles now or within the last
3 months
• Give Vitamin A treatment
• If clouding of the cornea or pus draining
from the eye, apply tetracycline eye
ointment
• If pus draining from the eye, treat eye
infection with tetracycline eye ointment
• If mouth ulcers, treat with gentian violet
• Follow-up in 3 days.
SEVERE
COMPLICATED
MEASLES***
MEASLES WITH
EYE OR MOUTH
COMPLICA TIONS***
MEASLES
** These temperatures are based on axillary temperature.
Rectal temperature readings are approximately 0.5°C
higher.
*** Other important complications of measles —
pneumonia, stridor, diarrhoea, ear infection, and
malnutrition - are classified in other tables.
• Any general
danger sign or
• Stiff neck
VERY
SEVERE
FEBRILE
DISEASE
• Give 1st dose of rectal artesunate (10 mg/kg) or IM/IV artesunate
(3 mg/kg if < 20 kg, 2.4 mg/kg if > 20 kg)
• Give 1st dose of appropriate antibiotic
• Treat child to prevent low blood sugar (breastfeed or give
expressed breast milk or breastmilk substitute or sugar water by
cup or NGT)
• Give one dose of paracetamol 10 mg/kg for high fever (38.5°C)
• Malaria test
POSITIVE
MALARIA
• Give Artemether-Lumefantrine/Artemether-Amodiaquine
• If fever is present every day for more than 7 days, refer for
further assessment
• Malaria test
Negative
• Other causes of
fever PRESENT
FEVER
NO
MALARIA
• Give one dose of paracetamol in the clinic for high fever
(38.5 degree C or above)
• Give appropriate antibiotic treatment for an identified bacterial
cause of fever
• If fever is present every day for more than 7 days, refer for
assessment
• Check for TB if fever is present for 14 days or more (see page 9)
• Any general
danger sign or
• Clouding of
cornea or
• Deep extensive
mouth ulcers
SEVERE
COMPLICATED
MEASLES***
• If clouding of the cornea or pus draining from the eye, apply
tetracycline eye ointment
• Pus draining from
the eye or
• Mouth ulcers
MEASLES
WITH EYE
OR MOUTH
COMPLICA
TIONS ***
• If pus draining from the eye, treat eye infection with tetracycline eye
ointment
• If mouth ulcers, treat with gentian violet
• Measles now or
within the last 3
months
MEASLES • Give Vitamin A treatment
IF YES:
Then ask: Look and feel:
• For how long?
• If more than 7 days,
has fever been pres-
ent every day?
measles within the
last 3 months?
• Look or feel for stiff neck
• Look for runny nose
• Look for any bacterial
cause of fever
• Look for any other
cause of fever
• Generalized rash and
one of these: cough,
runny nose, or red eyes.
Do a malaria test for all children with fever:
If NO severe classification
If the child has measles
now or within the last 3
months
• Look for mouth ulcers
• Are they deep and ex-
tensive?
• Look for pus draining
from the eye
• Look for clouding of the
cornea
Classify
FEVER
Classify
MEASLES
DOESTHE CHILD HAVE FEVER?

5
IF YES, ASK:
• Is there ear pain?
• Is there ear
discharge? If yes,
for how long?
LOOK AND FEEL:
• Look for pus draining from
the ear.
• Feel for tender swelling
behind the ear cornea.
Classify
EAR PROBLEM
• Tender swelling behind the ear.
• Pus is seen draining from the
ear and discharge is reported
for less than 14 days, or
• Ear pain.
• Pus is seen draining from the
ear and discharge is reported
for 14 days or more.
• No ear pain and No pus seen
draining from the ear.
• Give first dose of an appropriate antibiotic.
• Give first dose of paracetamol for pain.
• Refer URGENTLY to hospital.
• Give Amoxicillin for 5 days.
• Give paracetamol for pain.
• Dry the ear by wicking.
• If ear discharge, check for HIV Infection.
• Dry the ear by wicking.
• Treat with topical quinolone eardrops for
2 weeks.
• Check for HIV Infection.
• No treatment.
MASTOIDITIS
ACUTE EAR
INFECTION
CHRONIC EAR
INFECTION
NO EAR INFECTION
DOES THE CHILD HAVE EAR PROBLEM?
.
DOESTHE CHILD HAVE EAR PROBLEM?
(See page 8) and TB (see page 9)
• T
ender swelling behind
the ear MASTOIDITIS
• Give first dose of paracetamol for pain
•
• Pus is seen draining from
the ear and discharge is
reported for less than 14
days,
OR
• Ear pain
ACUTE EAR
INFECTION
• Give Amoxicillin for 5 days
• Give paracetamol for pain
• Dry the ear by wicking
• If ear discharge, check for HIV Infection
• Pus is seen draining from
the ear and discharge is
reported for 14 days or
more
CHRONIC EAR
INFECTION
• Dry the ear by wicking
• Treat with topical quinolone eardrops for 2 weeks
• Check for HIV Infection (See page 8) and
TB (see page 9)
• No ear pain and No pus
seen draining from the ear
NO EAR
INFECTION
• No treatment

6
• Oedema of both feet
OR
• WFH/L less than -3 zscores
OR MUAC less than 115 mm AND any
one of the following:
• Medical complication present
OR
• Not able to finish RUTF
OR
• Breastfeeding problem
COMPLICATED
SEVERE ACUTE
MALNUTRITION
• Keep the child warm
• WFH/L less than -3 zscores
OR
• MUAC less than 115 mm
AND
• Able to finish RUTF
UNCOMPLICATED
SEVERE ACUTE
MALNUTRITION
• Give oral antibiotics for 5 days
• Give ready-to-use therapeutic food for a child aged 6 months
or more
• Counsel the mother on how to feed the child.
• Check for TB (see page 9)
• WFH/L between -3 and -2 z-scores
OR
• MUAC 115 up to 125 mm
MODERATE ACUTE
MALNUTRITION
• Assess the child’s feeding and counsel the mother on the feeding
recommendations
• If feeding problem, follow up in 7 days
• Advise mother when to return immediately (See page 16)
• WFH/L - 2 z-scores or more
OR
• MUAC 125 mm or more
NO ACUTE
MALNUTRITION
• Give mebendazole if child is 1 year or older and has not had a dose
in the previous 6 months.
• If child is less than 2 years old, assess the child’s feeding and
counsel the mother on feeding according to the FOOD box on the
COUNSEL THE MOTHER chart.
• If feeding problem, follow-up in 7 days.
• Advise mother when to return immediately. (See page 30)
CHECK FOR ACUTE MALNUTRITION
LOOK AND FEEL:
Look for signs of acute malnutrition
• Look for oedema of both feet.
• Determine WFH/L* ___ z-score.
• Measure MUAC**____ mm in a child
6 months or older.
If WFH/L less than -3 z-scores or MUAC less
than 115mm, then:
Check for any medical complication present:
• Any general danger signs
• Any severe classification
• Pneumonia with chest indrawing
If no medical complications present:
• Child is 6 months or older, offer RUTF***
to eat. Is the child:
- Not able to finish RUTF portion?
- Able to finish RUTF portion?
• Child is less than 6 months, assess
breastfeeding:
Does the child have a breastfeeding
problem?
Classify
NUTRITIONAL
STATUS
SIGNS CLASSIFY AS IDENTIFY TREATMENT
THEN CHECK FOR MALNUTRITION
Check for Malnutrition
* WFH/L is Weight-for-Height or Weight-for-Length
determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using
MUAC tape in all children 6 months or older.
*** RUTF is Ready-to-Use Therapeutic Food for conducting
the appetite test and feeding children with severe acute
malnutrition.

7
• Severe palmar
pallor SEVERE
ANAEMIA
• If child has any history or symptoms suggestive of SCD
recommend testing for SCD
• Some
pallor
ANAEMIA
• Give iron**
• Give mebendazole if child is 1 year or older and has not had a dose in
the previous 6 months
• If child has any history or symptoms suggestive of SCD recommend
testing for HbS
• If child is already confirmed with SCD refer
• No palmar
pallor
NO ANAEMIA
• If child is less than 2 years old, assess the child’s feeding and counsel
the mother according to the feeding recommendations
• If feeding problem, follow-up in 5 days
Look and Feel for palmar pallor
Is it:
• Severe palmar pallor?
• Some palmar pallor?
If palmar pallor present, assess for history and
symptoms of Sickle Cell Disease(SCD);
Ask: Look and Feel for
• Family history of SCD
OR
• Death of sibling from
anaemia
• Painful joints and bones
• History of previous
blood transfusion more
than once
• History of unexplained
episodes of severe pain,
such as pain in the
abdomen, chest, bones
or joints
• Swelling of hands &
feet with persistent
crying in infants due
to pain
• Features suggestive
of a stroke i.e.
weakness of one side
of the body
• Bossing skull
Classify
ANAEMIA
CHECK FOR ANAEMIA
**If child has confirmed sickle disease and or severe acute malnutrition and is receiving RUTF, DO NOT give iron.

8
• Positive DNA PCR test in child
OR
• Positive HIV rapid test in a
child18 months or older
CONFIRMED
HIV INFECTION
• Give cotrimoxazole prophylaxis*
• Link child to Early Infant Diagnosis (EID) /ART
Clinic for follow up care
• Assess the child’s feeding and provide
appropriate counselling to the mother
• Advise the mother on home care
• Mother HIV-positive AND
negative DNA PCR test in a
breastfeeding child or if only
stopped less than 6 weeks ago
OR
• Mother HIV-positive, child not
yet tested
• Positive serological test in a
infant less than 16 months
HIV EXPOSED • Give cotrimoxazole prophylaxis
• Link child to ART/Mother Baby care point to start
or continue ARV prophylaxis
• Do DNA PCR test to confirm HIV status**
• Assess the child’s feeding and provide
appropriate counselling to the mother
• HIV test not done for mother
or infant child less than 18
months old.
HIV INFECTION
STATUS
UNKNOWN
• Encourage mother to go for HIV counseling and
testing in a health facility
• Negative HIV test in mother
or child.
HIV INFECTION
UNLIKELY
• Treat, counsel and follow-up existing infections
Classify ALL
YOUNG
INFANTS
* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children until confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breastfeeding has stopped; if serological test is positive, do a virological test
as soon as possible.
ASK:
Has the mother or child had an HIV test?
Then note mother’s and/or child’s HIV status:-
IF YES:
• Mother:
-- POSITIVE or NEGATIVE
• Child:
-- DNA PCR test POSITIVE or NEGATIVE
-- Rapid HIV test POSITIVE or NEGATIVE
IF MOTHER IS HIV POSITIVE AND CHILD’S
STATUS IS NEGATIVE OR UNKNOWN,
ASK:
• Was the child breastfeeding at the time or 6
weeks before the test?
• Is the child breastfeeding now?
• If breastfeeding ASK: Is the mother on ART and
child on ARV Prophylaxis?
IF NO: Mother & child HIV status unknown:-
• Then TEST mother
• If positive, then test the child
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care. If already in HIV care, go to the next step and assess for TB.

9
Classify
TB Status
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
ASSESS SIGNS CLASSIFY IDENTIFY TREATMENT
ASK:-
For symptoms
suggestive of TB
• Has the child been
coughing for 14 days or
more?
persistent fever for 14
days or more?
• Has the child had poor
weight gain in the last
one month?*
LOOK AND FEEL
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
* Poor weight gain (Weight loss, or very low weight (weight-for-age
less than -3 z-score), or underweight (weight-for age less than
-2 z-score), or confirmed weight loss (>5%) since the last visit, or
growth curve flattening), yellow and red MUAC colour code. * Refer the TB case that the child was in contact with to the nearest TB clinic for comprehensive contact tracing
THEN CHECK FOR TB
Collect sample for GeneXpert or smear microscopy
If available, send the child for laboratory tests (GeneXpert or
smear microscopy) and/ or Chest X-Ray.
ASK: History of contact
Has the child had contact with a person with Pulmonary
Tuberculosis or chronic cough?

10
Immunization Schedule:
• Follow National Guidelines:
AGE VACCINE VITAMIN A SUPPLEMENTATION
Birth BCG* OPV-O
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
*Children confirmed to be HIV positive should not be given BCG due to associated BCG disease among HIV infected children.
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 mabendazole every six
months from the age of 1 year. Record the
dose on the child’s chart.
Assess the child’s growth and
development milestones
• Plot the child’s weight on his/her growth
card (immunization or mother baby
passport)
• Ask mother about what the child is now
able to do in terms of physical movement,
communication and interaction.
• See annex 1 for details of expected
milestones for various age groups
Assess the Child for 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
• Check if had full course of tetanus toxid, if not,
give an appointment.
• Ask if pregnant , if so give 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.
Assess the Mother’s Health Needs
THEN CHECK THE CHILD‘S IMMUNIZATION AND VITAMIN A STATUS

11
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
GIVE ARTESUNATE SUPPOSITORIES OR INTRAMUSCULAR
ARTESUNATE OR QUININE FOR SEVERE MALARIA
For children being referred with very severe febrile disease:
Check which pre-referral treatment is available in your clinic (rectal artesunate
suppositories, artesunate injection or quinine).
Artesunate suppository: Insert first dose of the suppository and refer child urgently
Intramuscular artesunate or quinine: Give first dose and refer child urgently to
hospital.
If referral is not possible:
WEIGHT
< 5kg
5 – < 10kg
10 – < 15kg
15 – 19 kg
AGE
< 6 months
6 – < 12 months
1 – < 3 years
4 – < 5years
DOSE OF DIAZEPAM
(10mg/2mls
0.5 ml
1.0 ml
1.5ml
2.0 ml
For quinine:
→ Give first dose of intramuscular quinine.
→ The child should remain lying down for one hour.
→ Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the
child is able to take an oral antimalarial. Do not continue quinine injections for more
than 1 week.
2 months up to 4 months
(4 - <6 kg)
(6 - <10 kg)
12 months up to 2 years
(10 - <12 kg)
2 years up to 3 years
(12 - <14 kg)
(14 - 19 kg)
RECTAL
ARTESUNATE
SUPPOSITORY
INTRAMUSCULAR
ARTESUNATE
INTRAMUSCULAR
QUININE
50 mg
suppositories
Dosage
10 mg/kg
1
2
2
3
3
200 mg
suppositories
Dosage
10 mg/kg
-
1
1
60 mg
vial (20mg/ml)
2.4 mg/kg
1/2 ml
1 ml
1.5 ml
1.5 ml
2 ml
150 mg/ml*
(in 2 ml
ampoules)
0.4 ml
0.6 ml
0.8 ml
1.0 ml
1.2 ml
300 mg/ml*
(in 2 ml
ampoules)
0.2 ml
0.3 ml
0.4 ml
0.5 ml
0.6 ml
AGE or WEIGHT
Treat the child to prevent low blood sugar
If the child is able to breastfeed:
TREAT THE SICK CHILD AND COUNSEL THE MOTHER
mouth
hospital.
For artesunate injection:
→ Give first dose of artesunate intramuscular injection
→ Repeat dose after 12 hrs and daily until the child can take orally
WEIGHT
< 5kg
5 – < 10kg
10 – < 15kg
15 – 19 kg
AGE
< 6 months
6 – < 12 months
1 – < 3 years
4 – < 5years
DOSE OF DIAZEPAM
(10mg/2mls
0.5 ml
1.0 ml
1.5ml
2.0 ml
For quinine:
than 1 week.
(4 - <6 kg)
(6 - <10 kg)
(10 - <12 kg)
(12 - <14 kg)
(14 - 19 kg)
RECTAL
ARTESUNATE
SUPPOSITORY
INTRAMUSCULAR
ARTESUNATE
INTRAMUSCULAR
QUININE
50 mg
suppositories
Dosage
10 mg/kg
1
2
2
3
3
200 mg
suppositories
Dosage
10 mg/kg
-
1
1
60 mg
vial (20mg/ml)
2.4 mg/kg
1/2 ml
1 ml
1.5 ml
1.5 ml
2 ml
150 mg/ml*
(in 2 ml
ampoules)
0.4 ml
0.6 ml
0.8 ml
1.0 ml
1.2 ml
300 mg/ml*
(in 2 ml
ampoules)
0.2 ml
0.3 ml
0.4 ml
0.5 ml
0.6 ml
AGE or WEIGHT
Ask the mother to breastfeed the child
If the child is not able to breastfeed but is able to swallow:
• Explain to the mother why the drug is given
• Determine the dose appropriate for the child’s weight (or age)
• Use a sterile needle and sterile syringe when giving an injection
• Measure the dose accurately
• Give the drug as an intramuscular injection
• If the child cannot be referred follow the instructions provided
hospital.
→ Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
→ Give first dose of suppository
→ Repeat the same dose of suppository every 24 hours until the child can take
oral antimalarial. Give full dose of oral antimalarial as soon as the child is able
to take orally
2 years up to 3
(12 - <14 kg)
3 years up to 5
(14 - 19 kg)
Treat th
If the chil
Ask the m
If the chil
→ Give
→ If ne
→ Give
If the chil
→ Give
If the child is classified as severe disease, give pre-referal treatment and refer urgently
TREAT THE CHILD
mouth
hospital.
WEIGHT
< 5kg
5 – < 10kg
10 – < 15kg
15 – 19 kg
AGE
< 6 months
6 – < 12 months
1 – < 3 years
4 – < 5years
DOSE OF DIAZEPAM
(10mg/2mls
0.5 ml
1.0 ml
1.5ml
2.0 ml
For quinine:
than 1 week.
(4 - <6 kg)
(6 - <10 kg)
(10 - <12 kg)
(12 - <14 kg)
(14 - 19 kg)
RECTAL
ARTESUNATE
SUPPOSITORY
INTRAMUSCULAR
ARTESUNATE
INTRAMUSCULAR
QUININE
50 mg
suppositories
Dosage
10 mg/kg
1
2
2
3
3
200 mg
suppositories
Dosage
10 mg/kg
-
1
1
60 mg
vial (20mg/ml)
2.4 mg/kg
1/2 ml
1 ml
1.5 ml
1.5 ml
2 ml
150 mg/ml*
(in 2 ml
ampoules)
0.4 ml
0.6 ml
0.8 ml
1.0 ml
1.2 ml
300 mg/ml*
(in 2 ml
ampoules)
0.2 ml
0.3 ml
0.4 ml
0.5 ml
0.6 ml
AGE or WEIGHT
mouth
hospital.
WEIGHT
< 5kg
5 – < 10kg
10 – < 15kg
15 – 19 kg
AGE
< 6 months
6 – < 12 months
1 – < 3 years
4 – < 5years
DOSE OF DIAZEPAM
(10mg/2mls
0.5 ml
1.0 ml
1.5ml
2.0 ml
For quinine:
than 1 week.
(4 - <6 kg)
(6 - <10 kg)
(10 - <12 kg)
(12 - <14 kg)
(14 - 19 kg)
RECTAL
ARTESUNATE
SUPPOSITORY
INTRAMUSCULAR
ARTESUNATE
INTRAMUSCULAR
QUININE
50 mg
suppositories
Dosage
10 mg/kg
1
2
2
3
3
200 mg
suppositories
Dosage
10 mg/kg
-
1
1
60 mg
vial (20mg/ml)
2.4 mg/kg
1/2 ml
1 ml
1.5 ml
1.5 ml
2 ml
150 mg/ml*
(in 2 ml
ampoules)
0.4 ml
0.6 ml
0.8 ml
1.0 ml
1.2 ml
300 mg/ml*
(in 2 ml
ampoules)
0.2 ml
0.3 ml
0.4 ml
0.5 ml
0.6 ml
AGE or WEIGHT
• If the child cannot be referred follow the instructions provided
hospital.
to take orally
2 years up to 3 y
(12 - <14 kg)
3 years up to 5 y
(14 - 19 kg)
Treat the
If the child
Ask the m
If the child
→ Give
→ If nei
→ Give
If the child
→ Give
If the child is classified as severe disease, give pre-referal treatment and refer urgently
• If the child cannot be referred, follow the instructions provided
If the child is classified as severe disease, give pre-referral treatment and refer urgently
→ Repeat dose after 12 hrs and every 24 hours until the child can take orally
→ Give full dose of oral antimalarial as soon as the child is able to take orally.
→ Repeat the same dose after 12 hours, then every 24 hours until the child can take
oral antimalarial. Give full dose of oral antimalarial as soon as the child is able to
take orally
For quinine:
→ Repeat the quinine 8 hours later, and then every 8 hours until the child is able to
take an oral antimalarial. Do not continue quinine injections for more than 1 week.
• Position the child appropriately and clear the airway. Avoid putting things in the
mouth
• Give 0.5mg/kg diazepam injection solution per rectum using a small syringe
• Check for low blood sugar, then treat or prevent
• If convulsions have not stopped after 10 minutes, repeat diazepam dose
PRE-REFERRAL TREATMENT
Give Artesunate Suppositories Or Intramuscular
Artesunate Or Quinine For Severe Malaria
refer child urgently
refer child urgently to

12
Determine the dose appropriate for the child’s weight (or age)
Use a sterile needle and sterile syringe when giving an injection
Measure the dose accurately
Give the drug as an intramuscular injection
If the child cannot be referred follow the instructions provided
Give an Intramuscular Antibiotic
Give to children being referred urgently
Give Ampicillin (50 mg/kg) and Gentamicin (7.5mg/kg)
age
EN
ld
Ampicillin
→ Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml)
Gentamicin
→ 7.5mg/kg/day once daily
→ IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin
injection every 6 hours
→ Where there is a strong suspicion of meningitis the dose of ampicillin can be
increased 4 times
AGE
2 up to 4 months
4 up to 12 months
1 up to 3 years
3 up to 5 years
WEIGHT
4 – <6kg
6 – <10kg
10 – <15kg
15 – 20kg
Ampicillin 500 mg vial
1 ml
2 ml
3 ml
5 ml
Gentamicin 2ml vial/40
mg/ml*
0.5 – 1.0 ml
1.1 – 1.8 ml
1.9 – 2.7 ml
2.8 – 3.5 ml
* Lower value for lower range of age/weight.
A
te
hospital.
to take orally
(10 - <12 kg)
(12 - <14 kg)
(14 - 19 kg)
3
3
1
1
1.5 ml
2 ml
1.0 ml
1.2 ml
0.5 ml
0.6 ml
→ Give expressed breast milk or breast-milk substitute
→ If neither of these is available give sugar water
→ Give 30–50 ml of milk or sugar water before departure
To make sugar water: Dissolve 4 level teaspoons of sugar
(20 grams) in a 200ml cup of clean water
If the child is not able to swallow:
→ Give 50ml of milk or sugar water by nasogastric tube
• Write a referal 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 mother to continue breastfeeding
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 mother to continue breastfeeding
Refer Urgently
Give an Intramuscular Antibiotic Treat the child to prevent low blood sugar
Refer Urgently
,
,
breastmilk substitute

13
NO
NO
NO
NO
Plan C: Treat for Severe dehydration Quickly
Follow the arrows. If answer is “yes”, go across. If “no”, go down
Can you give
intravenous (IV) fluid
immediately?
Is IV treatment available
nearby (within 30
minutes)?
Refer URGENTLY to
hospital for IV or NG
treatment
Start Iv fluid immediately.
If the child can drink, give ORS by mouth while the drip is set up.
Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided
as follows:
Reassess the child every 1–2 hours. If hydration status is not improving, give the IV
drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3–4
hours (infants) or 1–2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration.
Then choose the appropriate plan (A, B, or C) to continue treatment.
AGE
Infants (under 12 months)
Children (12 months up to 5 years)
First give 30ml/kg in
1 hour
30 minutes
Then give 70ml/kg in
5 hours
2½ hours
Refer URGENTLY to hospital for IV treatment.
If the child can drink, provide the mother with ORS solution and show her how to give
frequent sips during the trip or give ORS by naso-gastic tube.
Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours
(total of 120 ml/kg).
Reassess the child every 1–2 hours while waiting for transfer:
→ If there is repeated vomiting or abdominal distension, give the fluid more slowly.
→ If the hydration status is not improving after 3 hours, send the child for IV
Therapy.
After 6 hours reassess the child. Classify dehydration. Then choose the appropriate
plan (A, B, or C) to continue treatment.
NOTE:
If the child is not referred to hospital, observe the child at least 6 hours after rehydration
to be sure the mother can maintain hydration giving the child ORS solution by mouth.
IMMUNIZE EVERY SICK CHILD, AS NEEDED
YES
YES
YES
Are you trained to use
a Naso-Gastric (NG)
tube for rehydration?
Can the child drink?
Plan C: Treat for Severe dehydration Quickly
Refer URGENTLY to
nasogastic tube.
IV
IV fluid

14
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
Teach the mother to give oral medicines at home
Follow the instructions below for every oral medicine to be given at
home. Also follow the instructions listed with each medicine’s dosage
table.
• Determine the appropriate medicine s and dosage for the child’s age or weight
• T
ell the mother the reason for giving the medicine to the child
• Demonstrate how to measure a 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 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 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
1. Give an appropriate oral antibiotic
For pneumonia, acute ear infection:
First-line antibiotic: Oral Amoxicillin
AMOXYCILLIN*
Give two times daily for 5 days
AGE or WEIGHT DISPERSIBLE
TABLET (250 mg)
SYRUP (250 mg /5ml)
2 months up to 12 months (4 - <10 kg) 1 5 ml
12 months up to 5 years (10 - <19 kg) 2 10 ml
For prophylaxis, confirmed HIV or HIV exposed child:
ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
CO-TRIMOXAZOLE
Give once a day starting at 6 weeks of age to:
→ All infants HIV Exposed until HIV is definitively ruled
out
→ All infants and children with confirmed HIV infection.
AGE
5 ml syrup
40/200 mg
Single strength
Dispersible tablet
20/ 100 mg
Single strength
adult tablet
80/400 mg
Less than 6 months 2.5 ml 1 tablet -
6 months up to 5 years 5 ml 2 tablets 1/2 tablet
For dysentery give ciprofloxacin 15mg/kg/day ---
2 times a day for 3 days:
250 mg TABLET 500 mg TABLET
AGE or WEIGHT DOSE/tabs DOSE/ tabs
Less than 6 months 1/2 tablet 1/4 tablet
6 months up to 5 years 1 tablet 1/2 tablet

15
,
2. Give oral Antimalarial for Malaria
If Artemether-Lumefantrine (AL)
• Give the first dose of Artemether-Lumefantrine (AL) in the clinic and observe for one hour
• If child vomits within an hour repeat the dose. Give the 2nd dose at home after 8 hours
• Then twice daily for further two days as shown below
• Artemether-Lumefantrine (AL) should be taken with food
Coartem tablets
(20mg artemether and 120mg lumefantrine)
WEIGHT Age 0hr 8hr 24hr 36hr 48hr 60hr
5–15 kg 4 months - <3 yrs 1 1 1 1 1 1
15–24 kg 4–8 years 2 2 2 2 2 2
25–34 kg 9–14 years 3 3 3 3 3 3
>34 kg >14 years 4 4 4 4 4 4
Artesunate Amodiaquine (AS + AQ)
If AL is not available:
• Give the first dose of Artemether- amodiaquine (AS+AQ) in the clinic and observe for one hour.
If child vomits within an hour repeat the dose.
• Then daily for 2 days as per the table below using the fixed dose combination
Dose in mg (No. of tablets)
Artesunate (50mg) Amodiaquine (153 mg)
WEIGHT Age Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
5–15 kg 4 months -
<3 years
25 (½ tab) 25(½ tab) 25 (½ tab) 76 (½ tab) 76 (½ tab) 76 (½ tab)
15–24 kg 4–8 years 50 (1) 50 (1) 50 (1) 153 (1) 153 (1) 153 (1)
25–34 kg 9–14 years 100 (2) 100 (2) 100 (2) 306 (2) 306 (2) 306 (2)
>34 kg >14 years 200 (4) 200 (4) 200 (4) 612 (4) 612 (4) 612 (4)
Note: Do not use amodiaquine alone, use with artesunate tablets
3. Give Paracetamol for High fever
(> 38.50) or Ear pain
Give Paracetamol every 6 hours until high fever or ear pain is gone
AGE OR WEIGHT PARACETAMOL TABLET (500mg)
2 months up to 4 months (4 - <6kg) 1/4
4 months up to 12 months (6 - <10 kg) 1/2
12 months up to 5 years (10 - 19 kg) 1

16
Give extra fluid for diarrhoea and continue feeding
Plan A: Treat for diarrhoea at Home Plan B: Treat for Some dehydration with ORS
Counsel the mother on the 4 rules of Home Treatment:
1. Give Extra Fluid 2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding 4. When to return
1. Give extra fluid (as much as the child will take)
Tell the mother:
→ Breastfeed frequently and for longer at each feed
→ If the child is exclusively breastfed, give ORS or clean water in addition to
breast milk
→ If the child is not exclusively breastfed, give one or more of the following:
Food-based fluids (such as soup, rice water, and yoghurt drinks), or ORS
It is especially important to give ORS at home when:
→ The child has been treated with Plan B or Plan C during this visit
→ The child cannot return to a clinic if the diarrhoea gets worse
Teach the mother how to mix and give ORS. Give the mother 2 packets of
ORS to use at home.
Show the mother how much fluid to give in addition to the usual fluid intake:
→ Up to 2 years: 50–100 ml after each loose stool
→ 2 years or more: 100–200 ml after each loose stool
Tell the mother to:
→ Give frequent small sips from a cup.
→ If the child vomits, wait 10 minutes then continue - but more slowly
→ Continue giving extra fluid until the diarrhoea stops
2. Give zinc (age 2 months up to 5 years)
Tell the mother how much zinc to give (20 mg tab):
→ 2 months up to 6 months —— 1/2 tablet daily for 10 days
→ 6 months or more —— 1 tablet daily for 10 days
Show the mother how to give zinc supplements
→ Infants—dissolve tablet in a small amount of expressed breast milk, ORS
or clean water in a cup
→ Older children—tablets can be chewed or dissolved in a small amount of
clean water in a cup
3. Continue feeding (exclusive breastfeeding if age less than 6 months)
4. When to return
In the clinic, give recommended amount of ORS over-hour period
Determine amount of ORS to give during first hours
* 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 below 6 months who are not breastfed, also give 100–200ml clean water
during this period
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 breast feeding whenever the child wants
After 4 hours:
→ Reassess the child and classify the child for dehydration
→ Select the appropriate plan to continue treatment
→ Begin feeding the child in clinic
If the mother must leave before completing treatment:
→ Show her how to prepare ORS solution at home
→ Show her how much ORS to give to finish 4-hour treatment at home
→ Give her instructions how to prepare salt and sugar solution for use at home
→ Explain the 4 Rules of Home Treatment:
1. Give extra fluid
2. Give zinc (age 2 months up to 5 years)
3. Continue feeding (exclusive breast feeding if age less than 6 months)
4. When to return
Up to 6
months
< 6 kg
200–450
6 months up
to 12 months
6–< 10 kg
450–800
12 months
up to 2 yrs
10–< 12 kg
800–960
2 years up to
5 years
12–<20kg
960–1600
AGE*
WEIGHT
Amount of fluid
(ml) over hours
: Tell mother to return if;
- Child has blood in stool
- and OR is drinking poorly
4. Give extra fluid for diarrhoea and continue feeding
breastmilk
breastmilk,
breastfeeding
breastfeeding

17
AGE OR WEIGHT Salbutamol Three times daily for 5 days
2 mg
tablet
4 mg
tablet
Syrup
Inhaler (preferably
use a spacer)
(Less than 10 kg)
1/2 1/4 2.5ml Give 2 doses (200 µg)
(10 – 19 kg)
1 1/2 5.0ml Give 2 doses (200 µg)
• From salbutamol metered dose inhaler (100µg/puff ) give 2 puffs.
• Repeat up to 3 times every 15 minutes before classifying pneumonia
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child
under 5 years should be given an inhaler without a spacer. A spacer works as well as a
nebuliser if correctly used.
Spacers can be made in the following way:
For older children:
• Use a 500ml drink bottle or similar.
• Cut a hole using a sharp knife in the bottle base in the same shape as the Mouth piece
of the inhaler.
• Flame the edge of the cut bottle with a candle or a lighter to soften it.
AGE or WEIGHT
IRON/FOLATE TABLET
Ferrous sulfate200 mg + 250 µg
Folate (60 mg elemental iron)
IRON SYRUP
Ferrous fumarate 100 mg per 5
ml (20 mg elemental iron per ml)
FOLIC ACID TABLET
5mg
2 months up to 4 months (4 – <6 kg) 1.0 ml (< 1/4 tsp) 1/2
4 months up to 12 months (6 – <10kg) 1.25 ml (1/4 tsp) 1
12 months up to 3 years (10 – <14 kg) 1/2 tablet 2.0 ml (<1/2 tsp) 1
3 years up to 5 years (14 – 19 kg) 1/2 tablet 2.5 ml (1/2 tsp) 1
Give Iron
Give one dose daily for 14 days
For a small baby:
• Use a 500ml drink bottle or similar.
• Cut a hole using a sharp knife in the bottle base in the same shape as the
mouth piece of the inhaler.
• Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper
quarter of the bottle.
• Cut a small V in the border of the large open part of the bottle to fit to the child’s nose
and be used as a mask.
• Flame the edge of the cut bottle with a candle or a lighter to soften it.
Alternatively commercial spacers can be used if available.
To use an inhaler with a spacer:
• Remove the inhaler cap. Shake the inhaler well.
• Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup.
• The child should put the opening of the bottle into his mouth and breathe in and out
through the mouth.
• A carer then presses down the inhaler and sprays into the bottle while the child
continues to breathe normally.
• Wait for three to four breaths and repeat for total of five sprays.
• For younger children place the cup over the child’s mouth and use as a spacer in the
same way.
* If a spacer is being used for the first time, it should be primed by 4–5 extra puffs from
the inhaler.
6. Give salbutamol for wheezing
Dosaging for Salbutamol
5. Give Iron

18
Teach the mother to treat local infections at home
Explain to the mother what the treatment is and why it should be given
Describe the treatment steps listed in the appropriate box
Watch the mother as she gives the first treatment in the clinic (except for remedy
for cough or sore throat)
Tell her how often to do the treatment at home
If needed for treatment at home, give mother a tube of tetracycline ointment or a
small bottle of gentian violet or Nystatin
Check the mother’s understanding before she leaves the clinic
Clear the ear by dry wicking and give eardrops*
Do the following 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
→ Instil quinolone eardrops for two weeks
Safe remedies to recommend:
→ Breast milk for a breastfed infant
→ Simple linctus
→ Tea with lemon
Harmful remedies to discourage:
→ Ipecacuaanna
→ Phenergan
→ Codeine
→ Piriton
Clean both eyes 4 times daily.
→ Wash hands.
→ Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
→ Squirt a small amount of ointment on the inside of the lower lid.
→ Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.
Treat for mouth ulcers twice daily
→ Wash hands
→ Wash the child’s mouth with a clean soft cloth wrapped around the inger and
wet with salt water
→ Paint the mouth with 1/2 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
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 1ml four times a day
→ Avoid feeding for 20 minutes after medication
→ If breastfed check 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
→ If severe, recurrent or pharyngeal thrush consider symptomatic HIV
→ Give paracetamol if needed for pain
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin
Soothe the throat, relieve the cough with a safe remedy
Treat eye infection with tetracycline eye ointment
Treat mouth ulcers with gentian violet (GV)
Treat Thrush with Nystatin
* Quinolone eardrops may contain ciprofloxacin, norfloxacin, or ofloxacin on clear the ear
• Explain to the mother what the treatment is and why it should be
given
• Describe the treatment steps listed in the appropriate box
• Watch the mother as she gives the first treatment in the clinic (except for
remedy for cough or sore throat)
• Tell her how often to do the treatment at home
• If needed for treatment at home, give mother a tube of tetracycline oint-
ment or a small bottle of gentian violet or Nystatin
• Check the mother’s understanding before she leaves the clinic
7. Teach the mother to treat local infections at home
,
Treat Oral Thrush with Nystatin

19
.
Types of disease
REGIMEN
Intensive phase Continuation phase
All forms of TB (excluding TB
meningitis and Bone TB)
2RHZE 4RH
TB meningitis Bone
(Osteoarticular) TB
2RHZE 10RH
All TB medicines should be taken under direct observation by a treatment supporter (Directly
Observed Therapy – DOT). TB treatment is divided into 2 phases: an initial (intensive) phase for
2 months and a continuation phase for 4 or 10 months depending on the type of TB disease.
TB treatment regimen is documented in a standard format, e.g. 2RHZE/4RH where:-
• Letters represent abbreviated anti-TB medicine names (R - Rifampicin; H – Isoniazid;
• Z – Pyrazinamide; E – Ethambutol)
• Numbers represent the duration in months / (forward slash sign) division between
treatment phases
Initiate Treatment for The Child with TB
TB treatment regimen for a child who is diagnosed with TB
* Ethambutol is safe for use in children provided the dose is within the recommended range.
* Streptomycin is no longer recommended for use in the treatment of susceptible TB.
* Children with TB meningitis or airway obstruction due to TB adenopathy should be referred to hospital.
* Children diagnosed with drug resistant TB should be referred to the nearest MDR TB treatment site for
further management.
Weight
bands
Number of tablets
Intensive Phase(2 months) Continuation Phase (4 months)
RHZ
75/50/150
E100 RH 75/50
4-7 kg 1 1 1
8-11 kg 2 2 2
12-15 kg 3 3 3
16-24 kg 4 4 4
Dosage of anti-TB medicines by weight band
* Continuation phase: 4 months for all forms of TB (excluding TB meningitis and Bone TB) and 10 months for TB
meningitis and Bone TB.
* If available, give pyridoxine at a dose of 12.5 mg/day for children < 5 years in addition to anti-TB medicines.
However, absence of pyridoxine should not stop a health worker from initiating TB treatment.
Start Isoniazid preventive therapy for the Child with TB Exposure and HIV
positive child above 1 year with no TB
Isoniazid reduces the risk of TB development among children with a history of
TB exposure as well as children living with HIV. Isoniazid is given at a dose of
10mg/kg/ day for 6 months
Dosage of Isoniazid by weight band
Tablet
strength
Weight band
3–5.9kg 6–9.9kg 10–13.9kg
14–19.9
kg
20–24.9kg
Isoniazid
100 mg
½ Tablet 1 Tablet
1½
Tablets
2 Tablet
2½
Tablets
* If available, give pyridoxine at a dose of 12.5 mg/day for children < 5 years in addition to Isoniazid.
However, absence of pyridoxine should not stop a health worker from initiating TB treatment.

20
8. Give Vitamin A and mebendazole in clinic
1. Explain to the mother why the drug is given
2. Determine the dose appropriate for the child’s weight (or age)
3. Measure the dose accurately
Give Vitamin A
Vitamin A Supplementation:
Give Vitamin A to all children to prevent severe illness:
- First dose in breastfed children to be given any time after 6 months of age
- Hereafter Vitamin A should be given every six months to ALL CHILDREN
Vitamin A Treatment:
- Give an extra dose of Vitamin A (same dose) for treatment if the child has
measles or PERSISTENT DIARRHOEA. If the child has had a dose of
Vitamin A within the past month or if the child is on RUTF for treatment
of severe acute malnutrition, DO NOT GIVE VITAMIN A
- Always record the dose of Vitamin A given on the child’s chart
Age VITAMIN A DOSE
6 up to 12 months 100 000IU
One year and older 200 000IU
Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
→ Hookworm/whipworm is a problem in your area
→ The child is 1 year of age or older, and
→ Has not had a dose in the previous 6 months

21
GIVE READY-TO-USE THERAPEUTIC FOOD
Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION
- Wash hands before giving the ready-to-use therapeutic food (RUTF).
- Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
- Encourage the child to eat the RUTF without forced feeding.
- Give small, regular meals of RUTF and encourage the child to eat often 5-6 meals per day
- If still breastfeeding, continue by offering breast milk first before every RUTF feed.
- Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended
for the age (See Feeding recommendations in COUNSEL THE MOTHER chart).
- When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
- Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.
CHILD'S Packets per day Packets per
WEIGHT (kg) (92 g Packets Week Supply
Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
Recommended Amounts of Ready-to-Use Therapeutic Food

22
Give follow-up care
Care for the child who returns for follow-up using all the boxes that match the child’s
previous classification
If the child has any new problems, assess, classify and treat the new problem as on the
ASSESS AND CLASSIFY chart
Dysentery
Pneumonia
Persistent diarrhoea
After 3 days:
→ Check the child for general danger signs.
→ Assess the child for cough or difficult breathing.
Ask:
→ Is the child breathing slower?
→ Is there less fever?
→ Is the child eating better?
Assess for HIV infection
Treatment:
→ If chest indrawing or a general danger sign, give a dose of second-line antibiotic or
intramuscular chloramphenicol. Then refer URGENTLY to hospital.
→ If breathing rate, fever and eating are the same, change to the second-line antibiotic
and advise the mother to return in 2 days or refer. (If this child had measles within
the last 3 months or is known or suspected to have Symptomatic HIV Infection, refer.)
→ If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.
After 5 days:
Ask:
→ Has the diarrhoea stopped?
→ How many loose stools is the child having per day?
Assess for HIV infection
Treatment:
→ If the diarrhoea has not stopped (child is still having 3 or more loose stools per day)
do a full assessment of the child. Treat for dehydration if present. Then refer to
hospital including for assessment for ART.
→ If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the
mother to follow the usual feeding recommendations for the child’s age.
After 2 days:
Assess the child for diarrhoea > See ASSESS & CLASSIFY chart
Ask:
→ Are there fewer stools?
→ Is there less blood in the stool?
→ Is there less abdominal pain?
Treatment:
→ If the child is dehydrated, treat for dehydration.
→ If number of stools, blood in the stools, fever, abdominal pain, or eating is worse or
the same
Change to second-line oral antibiotic recommended for shigella in your area. Give
it for 5 days. Advise the mother to return in 2 days. If you do not have the second
line antibiotic, REFER TO HOSPITAL.
Exceptions:
If the child is less than 12 months old or was dehydrated on the first visit, or if he had
measles within the last 3 months, REFER TO HOSPITAL.
→ If fewer stools, less fever, less abdominal pain, and eating better, continue giving
ciprofloxacin until finished.
Ensure that the mother understands the oral rehydration method fully and that she
also understands the need for an extra meal each day for a week.
→ Care for the child who returns for follow-up using all the boxes that match the child’s
→ If the child has any new problems, assess, classify and treat the new problem as on
the ASSESS AND CLASSIFY chart
See ASSESS &
CLASSIFY chart
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
refer URGENTLY to hospital.
refer.
refer to
After 2 days:
Assess the child for diarrhoea > See ASSESS & CLASSIFY chart
Ask:
→ Are there fewer stools?
→ Is there less blood in the stool?
→ Is there less abdominal pain?
Treatment:
→ If the child is dehydrated, treat for dehydration.
→ If number of stools, blood in the stools, fever, abdominal pain, or eating is worse or
the same:
- Change to second-line oral antibiotic recommended for shigella in your area.
Give it for 5 days.
- Advise the mother to return in 2 days.
- If you do not have the second line antibiotic, REFER TO HOSPITAL.
Exceptions:
If the child is less than 12 months old or was dehydrated on the first visit, or if he had
measles within the last 3 months, REFER TO HOSPITAL.
→ If fewer stools, less fever, less abdominal pain, and eating better, continue giving
ciprofloxacin until finished.
Ensure that the mother understands the oral rehydration method fully and that she
also understands the need for an extra meal each day for a week.
→ Care for the child who returns for follow-up using all the boxes that match the child’s
→ If the child has any new problems, assess, classify and treat the new problem as on
the ASSESS AND CLASSIFY chart
3. Dysentery
1. Pneumonia
2. Persistent Diarrhoea
refer.)

23
If fever persists after 3 days, or returns within 7 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 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:
- Treat with the second-line oral antimalarial (if no second-line antimalarial is
available, refer to hospital.)
- Advise the mother to return again in 2 days if the fever persists.
→ If fever has been present for 7 days, refer for assessment.
7. Ear infection
After 5 days:
→ Reassess for ear problem. > See ASSESS & CLASSIFY chart.
→ Measure the child’s temperature.
→ Check for HIV infection.
Treatment:
→ If there is tender swelling behind the ear or high fever (38.5°C or above), refer
URGENTLY to hospital.
→ Acute ear infection: if ear pain or discharge persists, treat with 5 more days of the
same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.
→ Chronic ear infection: Check that the mother is wicking the ear correctly.
Encourage her to continue.
→ If no ear pain or discharge, praise the mother for her careful treatment. If
she has not yet finished the 5 days of antibiotic, tell her to use all of it before stopping.
If fever persists after 3 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 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:
- Treat with the first-line oral antimalarial.
- Advise the mother to return again in 2 days if the fever persists.
→ If fever has been present for 7 days, refer for assessment.
5. Fever - No Malaria
After 5 days:
→ Reassess feeding > See questions at the top of the COUNSEL chart.
→ Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel
the mother to make significant changes in feeding, ask her to bring the child back
again.
If the child is very low weight for age, ask the mother to return 30 days after the
initial visit to measure the child’s weight gain.
After 3 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 to describe how she has treated the
eye infection. If treatment has been correct, refer to hospital. If treatment has not
been correct, teach mother correct treatment.
→ If the pus is gone but redness remains, continue the treatment.
→ If no pus or redness, stop the treatment.
Treatment for Mouth Ulcers:
→ If mouth ulcers are worse, or there is a very foul smell coming from the mouth,
refer to hospital.
→ If mouth ulcers are the same or better, continue using half-strength gentian violet for
a total of 5 days.
→ Care for the child who returns for follow-up using all the boxes that match the
child’s previous classification
→ If the child has any new problems, assess, classify and treat the new
problem as on the ASSESS AND CLASSIFY chart
8. Feeding Problem
4. Malaria
6. Measles with eye or mouth complications

24
11. Moderate Acute Malnutrition
After 30 days:
Assess the child using the same measurement (WFH/L or MUAC)
used on the initial visit: If WFH/L, weigh the child, measure height
or length and determine if WFH/L.
- If MUAC, measure using MUAC tape.
- Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER
chart.
Treatment:
- If the child is no longer classified as MODERATE ACUTE
MALNUTRITION, praise the mother and encourage her to
continue.
- If the child is still classified as MODERATE ACUTE
MALNUTRITION, counsel the mother about any feeding
problem found. Ask the mother to return again in one month.
Continue to see the child monthly until the child is feeding well
and gaining weight regularly or his or her WFH/L is -2 z-scores
or more or MUAC is 125 mm. or more.
Exception:
If you think that feeding will not improve, or if the child has lost
weight or his or her MUAC has diminished, refer the child.
refer
refer
If you think that feeding will not improve, or if the child has lost weight or his or her
MUAC has diminished, refer the child.
9. Anaemia
After 14 days:
• Give iron. Advise mother to return in 14 days for more iron.
• Continue giving iron every 14 days for 2 months.
• If the child has palmar pallor after 2 months, refer for assessment.
10. Very low weight for age
After 3 days:
Weigh the child and determine if the child is still very low weight for age. Reassess
feeding. See questions at the top of the COUNSEL chart.
Check for HIV infection.
Treatment:
• If the child is no longer very low weight for age, praise the mother and encourage her to continue.
• If the child is still very low weight for age, counsel the mother about any feeding problem found. Ask the mother
to return again in one month. Continue to see the child monthly until the child is feeding well and gaining weight
regularly or is no longer very low weight for age.
Exception:
If you think that feeding will not improve, or if the child has lost weight or his or her MUAC has diminished, refer the
child.
12. Uncomplicated Severe Acute Malnutrition
After 7 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit. Check for
oedema of both feet.
Check the child’s appetite by offering ready-to use therapeutic food if the child is 6 months or older.
Treatment:
- If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3
z-scores or
- MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
- If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than
-3 z-scores or MUAC is less than 115 mm or oedema of both feet but NO medical
complication and passes appetite test), counsel the mother and encourage her to
continue with appropriate RUTF feeding. Ask mother to return again in 7 days.
- If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and
-2 z-scores or MUAC between 115 and 125 mm), advise the mother to continue
RUTF. Counsel her to start other foods according to the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart). Tell her to return again in 14
days. Continue to see the child every 14 days until the child’s WFH/L is -2 z-scores or
more, and/or MUAC is 125 mm or more.
- If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC
is 125 mm or more), praise the mother, STOP RUTF and counsel her about the age
appropriate feeding recommendations (see COUNSEL THE MOTHER chart).

25
ASSESS THE FEEDING OF SICK CHILD UNDER 2 YEARS
(or if child has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED)
Ask questions about the child’s usual feeding and feeding during this illness. Note whether the mother is HIV infected, uninfected, or does not
know her status. Compare the mother’s answers to the Feeding Recommendations for the child’s age
COUNSEL THE MOTHER
breastfeeding
has the child’s feeding changed?
If the child is receiving any breastmilk, ASK:
→ How many times during the day?
→ Do you also breastfeed during the night?
Does the child take any other food or fluids?
→ What food or fluids?
→ How many times per day?
→ What do you use to feed the child?
If low weight for age, ASK:
→ How large are servings?
→ Does the child receive his own serving?
→ Who feeds the child and how?
During this illness, has the child’s feeding changed?
→ If yes, how?
If child is receiving replacement milk, ASK:
→ What replacement milk are you giving?
→ How many times during the day and night?
→ How much is given at each feed?
→ How is the milk prepared?
→ How is the milk being given? Cup or bottle?
→ How are you cleaning the utensils?
→ If still breastfeeding as well as giving replacement milk could the mother give extra
breastmilk instead of replacement milk (especially if the baby is below 6 months)
ASK — How are you feeding your child?

26
Feeding recommendation for all children during sickness and health, and including children on ARV or HIV exposed
Up to 6 Months
of Age
6 Months up to 12 Months 12 Months up to 2 Years 2 Years and Older
• Breastfeed as often as
the child wants, day
and night at least 8
times in 24 hours
• Do not give other foods
or fluids
• If a child between 4
and 6 months appears
hungry after breast-
feeding or is not gain-
ing weight adequately,
add complimentary
foods (listed under
6 months up to 12
months)
• Give those foods 1 or
2 times per day after
breastfeeding
• Breastfeed as often as the child wants
• Introduce child to some soft foods such as:
- Thick porridge made out of either
maize or cassava/millet/soya flour. Add
sugar and oil mixed with wither milk or
pounded ground nut.
- Mixture of mashed foods made out
of either matooke/potatoes/cassava/
posho (maize/beans/pounded ground-
nuts. Add green vegetables
- Start with 2-3 heaped tablespoons per
feed and gradually increase to atleast
one third of a nice plastic cup
• Feed child with soft foods three times a
day if breastfeeding; and five times if child
is not breastfeeding
• Give a snack like egg/banana/bread in
between the feeds
• Breastfeed as often as the child wants
and breastfed child atleast for 24
months
• In addition, give three to five feeds:
- Mixtures of mashed foods made
out of either matooke/potatoes/
cassava/posho (maize/millet/rice.
Mix with fish/beans/pounded
groundnuts. Add green vegeta-
bles.
- Thick porridge made out of either
maize/cassava/millet/soya flour.
Add sugar and oil mix with wither
milk or pounded groundnuts
• Give a nutritious snack in between
feeds
• If child is HIV exposed, mother
should be encouraged to discontinue
breastfeeding at 12 months
Feeding Recommendations
for a child who has PERSISTENT
DIARRHOEA
If still breastfeeding, give more
frequent, longer breastfeeds, day
and night. If taking other milk:
• Replace with increased
breastfeeding OR
• Replace with fermented milk
products, such as yoghurt OR
• Replace half the milk with
nutrient-rich semisolid food
• Give family foods at least 3
meals each day. Also give a
nutritious snack twice daily such
as banana/eggs/bread.
FEEDING RECOMMENDATIONS

27
Counsel the mother about feeding problems
If the mother reports difficulty with breastfeeding, assess breast-feeding (see YOUNG INFANT chart).
As needed, show the mother correct positioning and attachment for breastfeeding.
If the child is less than 6 months old and is taking other milk or foods*:
→ Build mother’s confidence that she can produce all the breast milk that the child needs.
→ Suggest giving more frequent, longer breastfeeds day or night, and gradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother to:
→ Breastfeed as much as possible, including at night.
→ Make sure that other milk is a locally appropriate breast milk substitute.
→ Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
→ Finish prepared milk within an hour.
If the mother is using a bottle to feed the child:
→ Recommend substituting a cup for bottle.
→ Show the mother how to feed the child with a cup.
If the child is not feeding well during illness, counsel the mother to:
→ Breastfeed more frequently and for longer if possible.
→ Use soft, varied, appetizing, favourite foods to encourage the child to eat as much as possible, and offer frequent small feeds.
→ Clear a blocked nose if it interferes with feeding.
→ Expect that appetite will improve as child gets better.
If the child has a poor appetite:
→ Plan small, frequent meals.
→ Give milk rather than other fluids except where there is diarrhoea with some dehydration.
→ Give snacks between meals.
→ Give high energy foods.
→ Check regularly.
If the child has sore mouth or ulcers:
→ Give soft foods that will not burn the mouth, such as eggs, mashed potatoes, pumpkin or avocado.
→ Avoid spicy, salty or acid foods.
→ Chop foods finely.
→ Give cold drinks or ice, if available.
* if child is HIV exposed, counsel the mother about the importance of not mixing breast-feeding with replacement feeding.
Counsel the mother about feeding problems

28
“AFASS”criteria for stopping breastfeeding for HIV
exposed
Acceptable:
Mother perceives no problem in replacement feeding.
Feasible:
Mother has adequate time, knowledge, skills, resources, and support to correctly mix
formula or milk and feed the infant up to 12 times in 24 hours.
Affordable:
Mother and family, with community can pay the cost of replacement feeding without
harming the health and nutrition of the family.
Sustainable:
Availability of a continuous supply of all ingredients needed for safe replacement feeding
for up to one year of age or longer.
Safe:
Replacement foods are correctly and hygienically prepared and stored.
Feeding advice for the mother of a child with confirmed
HIV infection
• The child should be fed according to the feeding recommendations for his/her age.
• Mothers should be encouraged to breastfeed up to 12 months and discontinue
thereafter
• Children with confirmed HIV infection often suffer from poor appetite and mouth sores,
give appropriate advice.
• If the child is being fed with a bottle, encourage the mother to use a clean cup as this is
more hygienic and will reduce episodes of diarrhoea.
• Inform the mother about the importance of hygiene when preparing food because her
child can easily get sick. She should wash her hands after going to the toilet and before
preparing food. If the child is not gaining weight well, the child can be given an extra
meal each day and the mother can encourage him to eat more by offering him snacks
that he likes if these are available.
• Advise mother about her own nutrition and the importance of a well balanced diet to
keep herself healthy. Encourage mother to plant vegetables to feed her family

29
Newborn
Birth up to
1 week
1 week
up to 6
months
Play: Give your child clean safe
household things to handle,
bang and drop.
6 months
up to 12
months
Communicate: Respond to your
child’s sounds and interests.
Tell your child the name of the
things and people, sample toys
12 months
up to
2 years
Play: Give your child things to
stuck up.
Communicate: Ask your child
simple questions, respond to
your child’s attempt to talk.
Show and talk about nature,
picture and things.
Play: help your child count,
name and compare things.
Make simple colorful toys
for your child.
Communicate: Encourage
your child to talk and answer
your child questions, teach
your child stories, songs and
games.
2 years
and older
CARE FOR CHILD DEVELOPMENT AND STIMULATION
Your baby learns from birth.
Play: provide ways for your
baby to see ,hear, move
arms and legs freely,
Gently stroke and hold your
baby.
Communicate: Look into
baby’s eyes and talk to your
baby, when breast feeding.
Even a new born baby sees
your face and hears your
voice.
Play: provide ways for your
child to see, hear, feel and
move, show colorful things
for your child.
Communicate: smile and
laugh with your child, get a
conversion going by copying
your child sounds and
gestures.
Counsel the mother about responsive care giving and stimulating the child’s brain
Newborn birth up
to 1week
2 years and older
12 months up to 2
years
6 months up to12
months
1 week up to 6 months
Your baby learns from birth.
Play: Provide ways for your
baby to see ,hear, move arms
and legs freely, Gently stroke
and hold your baby.
Communicate: Look into
baby’s eyes and talk to your
baby, when breast feeding.
Even a new born baby sees
your face and hears your voice.
Play: Provide ways for your
child to see, hear, feel and
move, show colorful things for
your child.
Communicate: Smile and
laugh with your child, get
a conversation going by
copying your child sounds
and gestures.
Play: Give your child clean safe
household things to handle, bang
and drop.
Communicate: Respond to your
child’s sounds and interests.
Tell your child the name of the
things and people, sample toys
Play: Give your child things to
stack up.
Communicate: Ask your child
simple questions, respond to
your child’s attempt to talk. Show
and talk about nature, picture
and things
Play: Help your child count,
name and compare things.
Make simple colorful toys
for your child.
Communicate: Encourage
your child to talk and answer
your child questions, teach
your child stories, songs and
games.
Counsel the mother about early childhood development: Responsive care giving and stimulating the child’s brain

30
Counsel the mother about her own health
Fluid
If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection),
provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother’s immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counselling on STD and AIDS prevention.
Encourage every mother to be sure to know her own HIV status and to seek HIV
testing if she does not know her status or is concerned about the possibility of HIV in
herself or her family.
Advise the Mother to Increase Fluid During Illness
For any sick child:
If child is breastfed, breastfeed more frequently and for longer at each feed.
If child is taking breast-milk substitutes, increase the amount of milk given Increase
other fluids. For example, give soup, rice water, yoghurt drinks or clean water.
For child with diarrhoea:
Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B
on the TREAT THE CHILD chart
WHEN TO RETURN
Advise the mother when to return to health worker
Follow-up visit
If the child has
• Pneumonia
• Dysentery 2 days
• Malaria, if fever persists
• Fever-malaria unlikely, if fever persists
• Measles with eye or mouth complications
• Persistent diarrhoea
• Acute ear infection
• Chronic ear infection
• Feeding problem
• Cough or cold, if not improving
• Anaemia
• Confirmed hiv infection
• Suspected symptomatic hiv infection
• HIV exposed/ possible hiv
• Very low weight for age
Return for first follow-up in3
3 days
5 days
14 days
30 days
Advise the mother to come for follow-up at the earliest time listed for the child’s problems.
When to return immediately
Advise mother to return immediately if the child
has any of these signs:
Any sick child
If child has NO PNEUMONIA:
COUGH OR COLD, also
return if:
→ If child has Diarrhoea, also
return if:
→ Not able to drink or
breastfeed
→ Becomes sicker
→ Develops a fever
→ Fast breathing
→ Difficult breathing
→ Blood in stool
→ Drinking poorly
Counsel the mother about her own health
Fluids
WHEN TO RETURN
refer
refer
HIV infection
HIV infection
HIV infection
- Family planning
- Counselling on STD and AIDS prevention.
• If the mother is sick, provide care for her, or refer her for help.
• If she has a breast problem (such as engorgement, sore nipples, breast infection),
provide care for her or refer her for help.
• Advise her to eat well to keep up her own strength and health.
• Check the mother’s immunization status and give her tetanus toxoid if needed.
• Make sure she has access to:
- Family planning
- Counselling on STD and HIV prevention.
• Encourage every mother to be sure to know her own HIV status and to seek HIV testing
if she does not know her status or is concerned about the possibility of HIV in herself or
her family.
Advise the Mother to Increase Fluid During Illness
For any sick child:
If child is breastfed, breastfeed more frequently and for longer at each feed.
If child is taking breast-milk substitutes, increase the amount of milk given Increase other
fluids. For example, give soup, rice water, yoghurt drinks or clean water.
For child with diarrhoea:
Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B
on the TREAT THE CHILD chart

31
TREAT AT HOME
REFERRAL NOT REQUIRED
• IDENTIFY TREATMENT
• COUNSEL caretaker on home treatment
• FOLLOW-UP CARE
URGENT REFERRAL
URGENT REFERRAL REQUIRED
• IDENTIFY pre-referral treatment
• URGENTLY REFER
TREAT IN CLINIC
REFERRAL NOT REQUIRED
• IDENTIFY TREATMENT
• TREAT
• COUNSEL caretaker
• FOLLOW-UP CARE
SICK YOUNG INFANT AGE: BIRTH UP TO 2 MONTHS
ASSESS FOR MAIN SYMPTOMS
Jaundice
Diarrhea
Feeding problem or LOW WEIGHT FOR AGE
Possible HIV INFECTION,
TB EXPOSURE
GREET THE CAREGIVER
ASK: Child’s age ASK: Initial or follow-up visit for problems?
ASK : What are the infant’s problems? MEASURE: Weight and temperature
ASSESS FOR
SIGNS OF SEVERE DISEASE
CLASSIFY
All with severe
disease require
URGENT
referral
IMNCI PROCESS FOR THE SICK YOUNG INFANT

32
32
32
Assess for signs of severe disease
Severe chest indrawing or
fast breathing
Severe chest indrawing or
fast breathing

33
ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE
- Determine if this is an initial or follow-up visit for this problem
ASSESS, CLASSIFY AND TREAT THE YOUNG INFANT
AGE: BIRTH UP TO 2 MONTHS
DO QUICK ASSESSMENT OF ALL YOUNG INFANTS BIRTH UP TO 2 MONTHS
USE ALL BOXES THAT MATCH INFANT’S SYMPTOMS AND PROBLEMS TO CLASSIFY
- If initial visit, assess the child and classify as follows:
CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY
SEVERE DISEASE, PNEUMONIA AND LOCAL INFECTION
Any one or more of the following
signs:
• Not able to feed since birth, stopped
feeding well or not feeding at all or
• Convulsions or
• Severe chest indrawing or
• Fever (38°C* or above) or
• Low body temperature (less than
35.5°C*) or
• Movement only when stimulated or
no movement at all, or
• Fast breathing (60 breaths per minute
or more) in infants less than 7 days old
POSSIBLE
SERIOUS
BACTERIAL
INFECTION
OR VERY
SEVERE
DISEASE
• Give first dose of intramuscular
antibiotic
• Refer URGENTLY to hospital **
• Teach the mother how to keep
the infant warm on the way to
the hospital
• 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
• Also treat per any others
• Umbilicus red or draining pus
• Skin pustules
LOCAL
INFECTION
• Give amoxicillin for 5 days
• Teach mother to treat local
infections at home
• Follow up on day 3
• No signs of bacterial infection or very
severe disease
SEVERE
DISEASE OR
INFECTION
UNLIKELY
LOOK AND FEEL:
• Count the breaths in one
minute
Repeat the count if 60 or
more breaths per minute.
• Look for severe chest
indrawing.
Classify ALL
YOUNG
INFANTS
* These thresholds are based on axillary temperature.
** If referral is refused or not possible, see page 12.
YOUNG
INFANT
MUST
BE CALM
}
ASK:
• Is the infant
having difficulty
in feeding?
• Has the infant
had convulsions
(fits)?
• Measure axillary temperature.
• Look at the young infant’s movements. If
infant is sleeping, ask the mother to wake
him/her:
- Does the infant move on his/her own?
If the infant is not moving, gently
stimulate him/her.
- Does the infant move only when
stimulated but then stops?
- Does the infant not move at all?
• Look at the umbilicus. Is it red or draining
pus?
• Look for skin pustules

34
- Any jaundice if age less
than 24 hours or
- Yellow palms and soles at
any age
SEVERE
JAUNDICE
- Jaundice appearing after
24 hours of age and
- Palms and soles not
yellow
JAUNDICE • Advise mother to give home care
for the young infant
• Advise mother to return
immediately if palms and soles
appear yellow
• If young infant is older than 14
days, refer to a hospital for
assessment
• Follow up in 1 day
No Jaundice NO JAUNDICE Advise mother to give homecare for
the young infant
THEN CHECK FOR JAUNDICE
USE ALL BOXES THAT MATCH INFANT’S SYMPTOMS AND PROBLEMS TO CLASSIFY
LOOK AND FEEL
- Look for jaundice (yellow
eyes or skin)
- Look at the young infant’s
palm and soles. Are they
yellow?
If jaundice
present , ASK:
- When did
the jaundice
appear first?
Classify
ALL
YOUNG
INFANTS

35
THEN ASSESS FOR DIARRHOEA
• Movement only when
stimulated or no
movement at all
• Sunken eyes.
• Skin pinch goes back very
slowly.
SEVERE
DEHYDRATION
Infant has no other severe classification:
• Give fluid for severe dehydration (Plan C)
• Start IV fluid immediately, or Refer
URGENTLY for IV fluid. If that is not possible,
start rehydration by NG tube OR
• If infant also has another severe
classification:
• Refer URGENTLY to hospital with mother
• Advise the mother to continue breastfeeding
• Teach the mother how to keep the infant
warm on the way to the hospital
• Restless, irritable.
• Sunken eyes.
• Skin pinch goes back
slowly.
SOME
DEHYDRATION
• Give fluid and breastmilk for some
dehydration (Plan B)
If infant has any severe classification:
•
• Refer URGENTLY to hospital with mother
• Advise the mother to continue breastfeeding
Not enough signs to
classify as some or severe
dehydration. NO
DEHYDRATION
• Give fluids to treat diarrhoea at home and
continue breastfeeding (Plan A)
ASK: Does the young infant have diarrhoea*?
IF YES, LOOK AND FEEL:
Look at the young infant’s general condition:
- Infant’s movements
• Does the infant move on his/her own?
• Does the infant not move even when stimulated but
then stops?
• Does the infant not move at all?
• Is the infant restless and irritable?
- Look for sunken eyes.
- Pinch the skin of the abdomen. Does it go back:
• Very slowly (longer than 2 seconds)?
• or slowly?
Classify
DIARRHOEA for
DEHYDRATION
* What is diarrhoea in a young infant?
A young infant has diarrhoea if the stools have changed from usual
pattern and are many and watery (more water than faecal matter).
The normally frequent or semi-solid stools of a breastfed baby are
not diarrhoea.

36
THEN CHECK FOR HIV INFECTION
Classify HIV
INFECTION by
test results
ASK:
• Has the mother had an HIV test?
If yes:
– Serological test POSITIVE or NEGATIVE?
– Has the infant had an HIV test?
If yes:
– Virological test POSITIVE or NEGATIVE?
– Serological test POSITIVE or NEGATIVE?
If mother is HIV positive and there is NO positive
virological test in infant,
ASK:
• Is the young infant breastfeeding now?
• Was the young infant breastfeeding at the time
of test or before it?
• Are the mother and young infant on ePMTCT
ARV prophylaxis?
IF NO test: Mother and young infant status
unknown
• Perform HIV test for the mother. If positive,
perform virological test for the young infant
• Infant has positive virological
test
CONFIRMED HIV
INFECTION
• Give cotrimoxazole prophylaxis from age 6 weeks
• Link infant to Early infant Diagnosis (EID)/Mother
Baby Care point for follow up
• Assess the infant’s feeding and counsel as
necessary
• Mother HIV positive AND
negative virological test
in young infant who is
breastfeeding or stopped less
than 6 weeks ago
OR
• Mother HIV positive, young
infant not yet tested
OR
• Infant has positive serological
test (HIV antibody test)
HIV EXPOSED:
POSSIBLE HIV
INFECTION
• Give cotrimoxazole prophylaxis from age 6 weeks
• Start or continue ARV’s for prophylaxis
• Assess the infant’s feeding and give appropriate
feeding advice
• Do virological test at age 6 weeks or repeat 6
weeks after the infant stops breastfeeding
• Follow-up regularly
• HIV test not done for mother
or infant
HIV INFECTION
STATUS
UNKNOWN
• Encourage HIV testing where it is available
• Negative HIV test for mother
or infant
HIV UNLIKELY • Treat, counsel and follow-up existing infections
• Advise the mother about feeding and about her
own health

37
Classify
TB Status
ASSESS SIGNS CLASSIFY IDENTIFY TREATMENT
* Refer young infants with dangers signs as well as those where TB treatment is not available.
THEN CHECK FOR TB
Presence of ANY of the symptoms suggestive
of TB OR weight less than 1.5kg or -3Z score
with any symptom.
PRESUMPTIVE
TB
• 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
NO
PRESUMPTIVE
TB
• Treat, counsel, and follow up
existing infections
• Ask about the caregiver’s health
and treat as necessary
ASK:-
For symptoms
suggestive of TB
• Has the young infant
had contact with a
person with Pulmonary
Tuberculosis or chronic
cough?
had persistent fevers for
14 days or more?
• Does the young infant
have pneumonia which
is not responding to
standard therapy?
been coughing for 14
days or more?
LOOK AND FEEL
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?
* Poor weight gain (Weight loss, or very low weight (weight-forage
less than -3 z-score), or underweight (weight-for age less
than -2 z-score), or confirmed weight loss (>5%) since the last
visit, or growth curve flattening), yellow and red MUAC colour codes.

38
• 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
• Not well attached
to breast or
• Not suckling
effectively, or
• Less than 8
breastfeeds in 24
hours, or
• Receives other
foods or drinks, or
• Low weight for
age, or
• Thrush (ulcers or
white patches in
mouth)
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 (See card 37)
• 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.
LOOK AND FEEL:
• 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).
Classify
ALL
FEEDING
ASK:
• 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?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED INFANTS
ASSESS BREASTFEEDING:
• Has the
infant
breastfed in
the previous
hour?
If the infant has not fed in the previous hour, ask
the mother to put her infant to the breast. Observe
the breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the
mother if she can wait and tell you when the infant
is willing to feed again.)
• Is the infant well attached?
not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
- 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.

39
THEN CHECK YOUNG INFANT‘S IMMUNIZATION AND VITAMIN A STATUS:
39
Ask and check for any postpartum complications such as bleeding and infections. Ask if mother has identified and has been counselled about
family planning; if not link to FP clinic. If mother is an adolescent, link to appropriate clinic or service provider for support.
ASSESS THE MOTHER’S HEALTH NEEDS
ASSESS YOUNG INFANT FOR 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 or problems that you cannot handle
VACCINES*
BCG** OPVO
DPT1
+ HepB + HIB OPV1 RTV1 PCV1
DPT2
+ HepB + HIB OPV2 RTV2 PCV2
3rd
Dose at 14 weeks
Ask and check for any postpartum complications such as bleeding and infections. Ask if mother has identified and has been counselled about
family planning; if not link to FP clinic. If mother is an adolescent, link to appropriate clinic or service provider for support.
ASSESS THE MOTHER’S HEALTH NEEDS
ASSESS YOUNG INFANT FOR 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 or problems that you cannot handle
THEN CHECK THE YOUNG INFANT‘S IMMUNIZATION STATUS
* Vaccines should be provided in line with the national immunization policy.
** Young infants who are HIV positive or unknown are HIV status with symptoms
consistent with HIV should not be given BCG

40
TREAT THE YOUNG INFANT
IF THE YOUNG INFANT IS CLASSIFIED AS POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE
DISEASE, GIVE PRE-REFERRAL TREATMENTS AND Refer URGENTLY
1. Give First Doses of Intramuscular Gentamicin
and Intramuscular Ampicillin
Gentamicin: Give 5 mg/kg/day in once daily injection. In low birth weight
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 refferal 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 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 mother to continue
breastfeeding.

41
11
TREAT THE YOUNG INFANT WITH SEVERE DEHYDRATION QUICKLY WITH PLAN C
Follow the arrows. If answer is Yes, go across. If No, go down.
• Start IV fluid immediately.
• If the young infant can drink, give ORS by mouth while the drip is set up.
• Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows:
AGE First give 30 ml/kg in : Then give 70 ml/kg in :
Infants (under 12 months) 1 hour 5 hours
• Reassess the young infant every 1–2 hours. If hydration status is not improving, give the IV drip more
rapidly.
• Also give ORS (about 5 ml/kg/hour) as soon as the young infant can drink: usually after 3–4 hours.
• Reassess a young infant after 6 hours. Classify dehydration. Then choose the appropriate plan (A, B or C)
to continue treatment.
• Refer URGENTLY to hospital for IV treatment.
• If the infant can drink, provide the mother with ORS solution and show her how to give frequent sips
during the trip or give ORS by nasogastric tube.
• Start rehydration by tube (or mouth) with ORS solution: Give 20 ml/kg/hour for 6 hours (total of 120
ml/kg).
• Reassess the young infant every 1–2 hours while waiting for transfer:
– If there is repeated vomiting or abdominal distension, give the fluid more slowly.
– If the hydration status is not improving after 3 hours, send the young infant for IV therapy.
• After 6 hours reassess the young infant. Classify dehydration. Then choose the appropriate plan (A, B or C)
to continue treatment.
NOTE:
• If the young infant is not referred to hospital, observe the young infant at least 6 hours after rehydration
to be sure the mother can maintain hydration giving the young infant ORS solution by mouth.
Can you give
intravenous (IV)
fluid
immediately?
Refer URGENTLY to hospital
for IV or NG treatment.
YES
YES
YES
NO
NO
NO
NO
Is IV treatment
available nearby
(within 30 minutes)?
Are you trained to use
a nasogastric (NG)
tube for rehydration?
Can the young infant
drink?
PLAN C : TREAT SEVERE DEHYDRATION QUICKLY
IV
Refer URGENTLY to hospital

42
6. 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 practise measuring a dose by herself.
• Ask the mother to give the first 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 to finish the course of
treatment, even if the infant gets better.
• Check the mother’s understanding before she leaves the clinic.
7. 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
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 kg 1/2 tablet 1 tablet 5 ml
2.5 to 3.9 kg 1/2 tablet 1 tablet 5 ml
4.0 to 5.9 kg 1 tablet 2 tablets 10 ml

43
PLAN A: TREAT DIARRHOEA AT HOME
Counsel the mother on the Rules of Home Treatment
for Young Infant:
1. Give Extra Fluids
2. When to Return
1. GIVE EXTRA FLUID (as much as the young infant will
take) TELL THE MOTHER:
- Breastfeed frequently and for longer at each feed.
- Also give ORS or clean water in addition to breastmilk.
It is especially important to give ORS at home when:
- The young infant has been treated with Plan B or Plan C during this
visit.
- The young infant cannot return to a clinic if the diarrhoea gets worse.
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE
MOTHER 2 PACKETS OF ORS TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO
THE USUAL FLUID INTAKE:
Up to 2 years, 50 to 100 ml after each loose stool
Tell the mother to:
- Give frequent small sips from a cup.
- If the infant vomits, wait 10 minutes. Then continue, but more slowly.
- Continue giving extra fluid until the diarrhoea stops.
2. WHEN TO RETURN
To Treat the Young Infant with Diarrhoea, Give Extra Fluids and Continue Feeding
If the young infant has NO DEHYDRATION, use Plan A. If the young infant has SOME DEHYDRATION, use Plan B.
PLAN B: TREAT SOME DEHYDRATION WITH ORS
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
WEIGHT < 6 kg
AGE* Up to 4 months
ORS 200 – 450 ml
* Use the age only when you do not know the weight. The approximate amount of ORS required
(in ml) can also be calculated by multiplying the young infant’s weight (in kg) times 75.
- If the young infant wants more ORS than shown, give more.
- For young infants who are not breastfed, also give 100 - 200 ml clean water during this
period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
- Give frequent small sips from a cup.
- If the young infant vomits, wait 10 minutes. Then continue, but more slowly.
- Continue breastfeeding whenever the young infant wants.
AFTER 4 HOURS:
- Reassess the young infant and classify the infant for dehydration.
- Select the appropriate plan to continue treatment.
- Continue breastfeeding the young infant in clinic.
IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
- Show her how to prepare ORS solution at home.
- Show her how much ORS to give to finish 4-hour treatment at home.
Give her enough ORS packets to complete rehydration. Also give her 2 packets as
recommended in Plan A.
Explain the Rules of Home Treatment for Young Infant:
1. GIVE EXTRA FLUIDS. Breastfeed frequently and for longer at each feed.
2. WHEN TO RETURN

44
How to Treat Local Infections at Home
 Explain how the treatment is given.
To Treat Skin Pustules or Umbilical Infection
The mother should do the treatment twice daily for 5 days:
 Wash hands
 Gently wash off pus and crusts with soap and water
 Dry the area
 Paint the skin or umbilicus/cord with full strength gentian violet (0.5%)
 Wash hands again
To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment 4 times daily for 7 days:
 Wash hands
 Paint the mouth with half-strength gentian violet (0.25%)
using a clean soft cloth wrapped around the finger
 Wash hands again
 Watch her as she does the first treatment in the clinic.
 Tell her to return to the clinic if the infection worsens.

45
COUNSEL THE MOTHER
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 breast with nose opposite to the nipple
- With the infant held close to the mother’s body
- With the infant’s whole body supported, not just neck and shoulders.
 Show her how to help the infant to attach. She should:
- Touch her infant’s lips with her nipple
- Wait until her infant’s mouth is opening wide
- Move her infant quickly onto her breast, aiming the infant’s lower lip
well below the nipple.
 Look for signs of good attachment and effective suckling. If the
attachment or suckling is not good, try again.
3. 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.
2. 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 first finger
on the under side of the breast so they are opposite
each other (at least 4 cm from the tip of the nipple).
 Compress and release the breast tissue between her
finger and thumb a few times.
 If the milk does not appear she should re-position her
thumb and finger closer to the nipple and compress and
release the breast as before.
 Compress and release all the way around the breast,
keeping her fingers the same distance from the nipple.
Be careful not to squeeze the nipple or to rub the skin
or move her thumb or finger on the skin.
 Express one breast until the milk just drips, then express
the other breast until the milk just drips.
 Alternate between breasts 5 or 6 times, for at least 20 to
30 minutes.
 Stop expressing when the milk no longer flows but drips
from the start.

46
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 home heating
device and make sure that 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:
• 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 mother’s clothes (and an
additional warm blanket in cold weather).
 When not in skin to skin contact, keep the young
infant clothed or covered as much as possible at
all times. Dress the young infant with extra clothing
including hat and socks, loosely wrap the young
infant in a soft dry cloth and cover with a blanket.
 Check frequently if the hands and feet are warm. If cold,
re-warm the baby using skin to skin contact.
 Breastfeed the infant frequently (or give expressed
breastmilk by cup).
5. How to Give Home Care for the Young Infant
1. 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.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
– In cool weather cover the infant’s head and feet and dress the infant with extra
clothing.
3. WHEN TO RETURN:
21
COUNSEL THE MOTHER
 Advise the Mother to Give Home Care for the Young Infant
Advise the car
immediately if t
has any of t
 Breastfeedin
 Reduced ac
 Becomes sic
 Develops a f
 Feels unusu
 Develops fas
 Develops dif
 Palms or sol
1. 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 healt
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
– In cool weather cover the infant’s head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
WHEN TO RETUR
Follow up visit
If the infant has: Return for first follow-up on:
• JAUNDICE Day 2 of treatment
• DIARRHOEA
• FEEDING PROBLEM
• THRUSH
• LOCAL INFECTION
Day 3
• PNEUMONIA
• SEVERE PNEUMONIA where referral is refused
or not possible
Day 4
• LOW WEIGHT FOR AGE in infant receiving no
breastmilk
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 difficult breathing
 Palms or soles appear yellow

47
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
1. Pneumonia or Severe Disease
Follow up on day 4 of treatment.
→ Reassess the young infant for POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE, PNEUMONIA AND
LOCAL INFECTION as on page 2.
→ Refer young infant if:
• Infant becomes worse after treatment is started or
• Any new sign of VERY SEVERE DISEASE appears while on treatment
→ If the young infant is improving, ask the mother to continue giving the oral amoxicillin twice daily until all the tablets are finished.
→ Ask the mother to bring the young infant back in 4 more days.
→ Young infants with fast breathing alone should be checked as often as possible but it is mandatory to do so on day 4 of treatment.
3. Jaundice
On day 2: LOOK for jaundice. Are palms or
soles yellow?
→ If palms or soles are yellow, refer to hospital.
→ If palms or soles are not yellow, but jaundice has not
decreased, advise the mother about home care and ask her
to return for follow up again tomorrow.
→ If jaundice has started decreasing, reassure the mother and
ask her to continue home care. Ask her to return for follow up
at 3 weeks of age.
After 3 weeks of age: If jaundice continues beyond 3
weeks, refer the young infant to hospital for further
assessment.
2. Local Infection
On day 3 of treatment:
• Look at the umbilicus. Is it red or draining pus?
• Look for skin pustules.
Treatment:
→ If umbilical pus or redness remains same or is worse,
refer to hospital. If pus and redness are improved, tell
the mother to continue giving the 5 days of antibiotic and
continue treating the local infection at home.
→ If skin pustules are same or worse, refer to hospital. If
improved, tell the mother to continue giving the 5 days of
antibiotic and continue treating he local infection at home.

48
4. Diarrhoea
On day 3,
ASK: Has the diarrhoea stopped?
• If the diarrhoea has not stopped, assess and treat
the young infant for diarrhoea (see page 4)
• If the diarrhoea has stopped, tell the mother to
continue exclusive breastfeeding.
5. Feeding Problem
On day 3:
Reassess feeding. Use “Then Check for Feeding
Problem or Low Weight for Age” above (page 6 or 7).
Ask about any feeding problems found on the initial
visit.
• Counsel the mother about any new or continuing
feeding problems. If you counsel the mother to
make significant changes in feeding, ask her to
bring the young infant back again.
• If the young infant is low weight for age, ask the
mother to return 14 days after the initial visit to
measure the young infant’s weight gain.
Exception:
• If you think that feeding will not improve or if the
young infant has lost weight, refer to HOSPITAL.
6. Low Weight For Age
On day 14 (or on day 7 if the infant is receiving no breastmilk):
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. Use “Then Check for Feeding Problem or Low Weight for Age”
on page 6 or 7.
• If the infant is no longer low weight for age, praise the mother and encourage her
to continue.
• If the infant is still low weight for age, but is feeding well, praise the mother. Ask
her to have her infant weighed again within a month or when she returns for
immunization.
• If the infant is still low weight for age and still has a feeding problem, counsel the
mother about the feeding problem. Ask the mother to return again in 14 days (or
when she returns for immunization, if this is within 14 days). Continue to see the
young infant every few weeks until the infant is feeding well and gaining weight
regularly or is no longer low weight for age.
Exception:
• If you think that feeding will not improve or if the young infant has lost weight,
refer to hospital.
7. Thrush
On day 3 of treatment:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. Use “Then Check for Feeding Problem or Low Weight for Age”
(page 6 or 7).
• If thrush is worse, or the infant has problems with attachment or suckling, refer to
hospital.
• If thrush is the same or better, and if the infant is feeding well, continue half-
strength gentian violet for a total of 7 days.

49
AGE GROSS MOTOR FINE MOTOR SPEECH AND LANGUAGE ADAPTIVE AND SOCIAL SKILLS
6 weeks Prone-lifts-chin intermittently
10 weeks Prone- arms extended forward Pulls at clothes Coos
14 weeks
Prone-raises head and chest, rolls
rolls over front to back, no head
lag
Reach and grasp, objects to
mouth
Responds to voice
6 months Prone-weight on hands, tripod sit Ulnar grasp
Begins to babble, responds to
name
Stranger anxiety
9 months Pulls to stand Finger-thumb grasp Mama, dada, imitates one word Plays games, separation anxiety
12 months Walks with support,“cruises” Pincer grasp, throws
2 other words with meaning
besides mama or dada
Plays peek-a-boo, drinks with cup
15 months Walks without support Draws a line Jargon Points to needs
18 months Up steps with help Piles up to three levels, scribbling
10 words, follows simple
commands
Uses spoon, points to body parts
24 months Up 2 feet per step, runs, kicks ball
Piles things up to six levels,
undresses
2–3 word phrases, uses I, me, you,
25% intelligible
Parallel play, helps to undress
Assess child development milestones
ANNEX
ANNEX1

50
WHO Child Growth Standards
Weight-for-height BOYS
2 to 5 years (z-scores)
Height (cm)
Weight
(kg)
65 70 75 80 85 90 95 100 105 110 115 120
6
8
10
12
14
16
18
20
22
24
26
28
30
6
8
10
12
14
16
18
20
22
24
26
28
30
-2
-3
3
1
-1
2
0
w

51
Weight-for-length BOYS
Birth to 2 years (z-scores)
Length (cm)
Weight
(kg)
45 50 55 60 65 70 75 80 85 90 95 100 105 110
2
4
6
8
10
12
14
16
18
20
22
24
2
4
6
8
10
12
14
16
18
20
22
24
-2
-3
3
1
-1
2
0
ANNEX3

52
18
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Months 2nd Year
Months 1st Year
Weight the child during each visit, properly record on the card and interpret to the mother or caretaker
Weight for age: BOY (Birth to 2 years)
IMPORTANT: Give your baby only breast milk for
the first 16 months
Add foods and other liquids only at 6 months
GROWTH CHART
ANNEX4

53
Weight-for-Height GIRLS
2 to 5 years (z-scores)
Height (cm)
Weight
(kg)
65 70 75 80 85 90 95 100 105 110 115 120
6
8
10
12
14
16
18
20
22
24
26
28
30
32
6
8
10
12
14
16
18
20
22
24
26
28
30
32
-2
-3
3
1
-1
2
0
ANNEX5

54
Weight-for-length GIRLS
Birth to 2 years (z-scores)
Length (cm)
Weight
(kg)
45 50 55 60 65 70 75 80 85 90 95 100 105 110
2
4
6
8
10
12
14
16
18
20
22
24
2
4
6
8
10
12
14
16
18
20
22
24
-2
-3
3
1
-1
2
0
ANNEX6

55
Months
2nd Year
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Months
2nd Year
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Months
2nd Year
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Months 2nd Year
Months 1st Year
Weight the child during each visit, properly record on the card and interpret to the mother or caretaker
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Weight for age: GIRL (Birth to 2 years)
IMPORTANT: Give your baby only breast milk for
the first 16 months
Add foods and other liquids only at 6 months
GROWTH CHART
17
ANNEX7

56
2017 Revision and updates with support from

Revised IMNCI CHART BOOKLET-1.pdf

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