Post on 07-May-2015
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Management of
Childhood Illness up to 5 years age
2
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years agecontents
1. the health Worker and childhood illnesses
1.1. hoW to Work – a good strategy
1.2. the health status of children is important
1.3. good communication is important
1.3.1. The steps to good communication
2. children age 2 months up to 5 years
2.2. general danger signs
2.2.1. The following danger signs should be checked in all children
2.3. checking main symptoms
2.3.1. Cough or difficult breathing – Controll
2.3.2. Diarrhoea
2.3.2.1. How severe diarrhoea – dehydration
2.3.2.2. Recommended drinks for a child with diarrhoea
2.3.2.3. Classification of dysentery
2.4. fever
2.4.1. A child having fever should be controlled for
2.4.2. Measles
2.5. ear problems
2.5.1. Important to check
2.5.2. Treatment
2.5.3. Prevention
2.5.4. Infection in the ear canal
2.6. the nutritional status –
malnutrition and anaemia
2.6.1. Poor nutrition can result in the following health problems:
2.6.2. Assessing the child’s feeding
2.6.3. Council the mother or the caretaker
3
3
3
3
4
5
5
5
6
6
7
7
9
10
10
10
11
12
12
12
13
13
13
13
13
13
2.7. checking immunization status
2.7.1. Vaccinations (Immunizations) – simple, sure protection
2.7.2. The most important vaccines
2.8. assessing other problems
2.9. if the children age 2 months
up to 5 years needs urgent medical care
2.9.1. Urgent pre–referral treatments
2.10. counselling a mother or caretaker
2.11. the advices health Worker can give
2.11.1. Advise to continue feeding and increase fluids
2.11.2. Teach how to give oral drugs or to treat local infection at home
2.11.3. Advice when to return
2.12. folloW–up care
3. young infants age 1 Week up to 2 months
3.1. assessment of sick young infants
3.2. checking for main symptoms
3.2.1. Bacterial infection
3.2.2. Important to check
3.2.3. Diarrhoea
3.3. feeding problems or loW Weight
3.3.1. Important to check
3.3.2. Feeding Problems or Low Weight?
3.4. checking immunization status
3.5. assessing other problems
3.6. counselling a mother or caretaker
3.7. folloW–up care
14
14
14
15
15
16
16
17
17
17
18
18
19
19
19
19
19
20
20
20
21
21
21
22
22
Sources: http://www.who.int/child-adolescent-health/integr.htm
http://www.hesperian.org/publications_download_wtnd.php
3
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.7. checking immunization status
2.7.1. Vaccinations (Immunizations) – simple, sure protection
2.7.2. The most important vaccines
2.8. assessing other problems
2.9. if the children age 2 months
up to 5 years needs urgent medical care
2.9.1. Urgent pre–referral treatments
2.10. counselling a mother or caretaker
2.11. the advices health Worker can give
2.11.1. Advise to continue feeding and increase fluids
2.11.2. Teach how to give oral drugs or to treat local infection at home
2.11.3. Advice when to return
2.12. folloW–up care
3. young infants age 1 Week up to 2 months
3.1. assessment of sick young infants
3.2. checking for main symptoms
3.2.1. Bacterial infection
3.2.2. Important to check
3.2.3. Diarrhoea
3.3. feeding problems or loW Weight
3.3.1. Important to check
3.3.2. Feeding Problems or Low Weight?
3.4. checking immunization status
3.5. assessing other problems
3.6. counselling a mother or caretaker
3.7. folloW–up care
1.1. How to work – a good strategy
The goals are• improvmentinfamilyandcommunityhealthcarepractices• toreducedeathandthefrequencyandseverityofillnessanddisability• tocontributetoimprovedgrowthanddevelopmentinthecountry
Principles• Togettoknowwhatarethegeneraldangersigns.• Toassess,checkthepersonsmajorsymptoms.• Toclassifyhowseveretheperson´sconditionis.• Councellingthecaretakersabouthomecare,forexampleaboutfeeding,fluidsandwhentoreturntoahealthfacility.
1.2. The health status of children is importantChildren´s health – things that affect positively• Goodmotherandchildcare• Improvementsinbreastfeeding• Childhoodvaccinations•Oralrehydrationtherapy;thechildcangetenoughfoodandfluid–>re-ductionindiarrhoeadeaths
• Effectiveantibiotics
1.3. Good communication is importantA good communicationItisimportanttocommunicateeffectively,inagoodwaywiththechild>smotherorcaretaker.Goodcommunicationtechniquesandanabilitytoas-sess,toobserve,tonoticeandjudgethecommonproblemsorsignsofdis-easeormalnutritionareneeded.
Usinggoodcommunicationhelpsthemotherorcaretakertobesurethatthechildwillreceivegoodcare.Forexampleifthemotherorcaretakerknowshowtogivethetreatmentandunderstandsitsimportance–itcanbeasuc-cesfulhometreatment.
The strategy• preventiveandcurativehealthcare• toimproveandgetbetterpracticesinthehealthsystemandspeciallyathomes
1. the health Worker and childhood illnesses
4
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
1.3.1. The steps to good communication• Listencarefullytowhatthecaretakersays.Thiswillshowthemthatyoutaketheirconcerns,problemsseriously.
• Usewordsthecaretakerunderstands.Trytouselocalwordsandavoidmedicalterminology.
• Givethecaretakertimetoanswerquestions.S/hemayneedtimetoreflect,tothinkanddecide.
• Askadditionalquestionswhenthecaretakerisnotsureabouttheanswer.Acaretakermaynotbesureifasymptomisnotsoobvious.Askadditional,morequestionstohelpher/himgiveclearanswers.
5
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.1. Assessment of sick children includes• communicatewiththecaretaker–getthehistory;whoisthechild,howold,whendidthechildgetsicketc.
• checkthegeneraldangersigns;• checkthemainsymptoms;• checkthenutritionalstatus;• assessthechild’sfeeding;• checktheimmunizationstatus;and• assesstheotherproblems.
2.2. General Danger SignsAsickchildmayhavesignsthatclearlyindicateaspecificproblem.Forexam-ple,achildmayhavechestindrawingandcyanosis(cyanosismeansthatthechildgetsbluish),whichindicateseverepneumonia.
2.2.1. The following danger signs should be checked in all childrenThe child has had convulsions during the present illness Convulsionsmaybetheresultoffever.Convulsionsarewhenaperson’sbodyshakesrapidlyanduncontrollably.Allchildrenwhohavehadconvulsionsduringthepresentillnessshouldbeconsideredseriouslyill.
The child is unconscious or lethargic Anunconsciouschildislikelytobeseriouslyill.Alethargicchild,whoisawakebutdoesnottakeanynoticeofhisorhersurroundingsordoesnotrespondnormallytosoundsormovement,mayalsobeverysick.
The child is unable to drink or breastfeedAchildmaybeunabletodrinkeitherbecauses/heistooweakorbecauses/hecannotswallow.Donotrelycompletelyonthemother’sevidenceforthis,butobservewhileshetriestobreastfeedortogivethechildsomethingtodrink.
The child vomits everythingThevomitingitselfmaybeasignofseriousillness,butitisalsoimportanttonotebecausesuchachildwillnotbeabletotakemedicationorfluidsforrehydration.
2. children age 2 months up to 5 years
6
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Ifachildhasoneormoreofthesesigns,s/hemustbeconsideredseriouslyillandwillalmostalwaysneedtobecontrolledifitis– acuterespiratoryinfection(ARI),diarrhoea,andfever(especiallyassociatedwithmalariaandmeasles).
– Acheckingofnutritionalstatusisalsoimportant,asmalnutritionisan-othermaincauseofdeath.
2.3. Checking main symptomsAftercheckingforgeneraldangersigns,thehealthcareworkermustcheckformainsymptoms.
1)coughordifficultbreathing;2)diarrhoea;3)fever;and4)earproblems.
Thefirstthreesymptomsareincludedbecausetheyoftenresultindeath.Earproblemsareincludedbecausetheycancausedisabilitiesifnottreated.
2.3.1. Cough or difficult breathing – ControllThreesignsareusedtoassessasickchildwithcoughordifficultbreathing:• Respiratory rate,howmanytimesthechildbreathsperminute,whichdis-tinguisheschildrenwhohavepneumoniafromthosewhodonot;
• Lower chest wall indrawing,whichindicatesseverepneumonia;and• Stridor (noisybreathinginchildrenwhenchildbreathesin)whichindi-catesthosewithseverepneumoniawhorequirehospitalcare.
Thepointatwhichfast breathingisconsideredtobefastdependonthechild’sage.Normalbreathingratesarehigherinchildrenage2monthsupto12monthsthaninchildrenage12monthsupto5years.
Child’s Age Rate for Fast Breathing
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
Lower chest wall indrawing,definedastheinwardmovementofthebonystruc-tureofthechestwallwithinspiration,isausefulindicatorofseverepneu-monia.
7
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Stridorisaharshnoisemadewhenthechildinhales(breathesin).Sometimesawheezingnoiseisheardwhenthechildexhales(breathesout).Thisisnotstridor.Awheezingsoundismostoftenassociatedwithasthma.
2.3.2. DiarrhoeaWhenapersonhaslooseorwaterystools,hehasadiarrhoea.Diarrhoeacanbemildorserious.Diarrhoeaismorecommonandmoredangerousinyoungchildren,especiallythosewhoarepoorlynourished.
Althoughdiarrhoeahasmanydifferentcauses,themostcommonareinfec-tionandpoornutrition.Withgoodhygieneandgoodfood,mostdiarrhoeacouldbeprevented.Andiftreatedcorrectlybygivinglotsofdrinkandfood,fewerchildrenwhogetdiarrhoeawoulddie.
Mostchildrenwhodiefromdiarrhoeadiebecausetheydonothaveenoughwaterleftintheirbody.Thislackofwateriscalleddehydration.
Diarrhoeaisasymptomthatshouldbecheckedinevery childthatisnotfeel-ingwell.
Thecaretakerofachildwithdiarrhoeashouldbeaskedhowlongthechildhashaddiarrhoeaandifthereisbloodinthestool.Thiswillallowidentifica-tionofchildrenwithpersistentdiarrhoeaanddysentery.
Allchildrenwithdiarrhoeafor14daysormorewithsignsofdehydrationshouldgettothehospital.
2.3.2.1. How severe diarrhoea – dehydrationAllchildrenwithdiarrhoeashouldbecheckedhowlongtimetheyhavehaddiarrhoea,ifbloodispresentinthestoolandifdehydrationispresent.
Signs of how severe the dehydration is:– Child’sgeneralcondition. Ifthechildwithdiarrhoeaislethargicorunconsciousorlookrestless/irri-table.
– Sunkeneyes. Theeyesofadehydratedchildmaylooksunken.
– Child’sreactionwhenofferedtodrink. Achildisnotabletodrinkifs/heisnotabletotakefluidinhis/hermouthandswallowit.
8
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Forexample,achildmaynotbeabletodrinkbecauses/heislethargicorunconscious.Achildisdrinkingpoorlyifthechildisweakandcannotdrinkwithouthelp.S/hemaybeabletoswallowonlyiffluidisputinhis/hermouth–thisisabadsign.
Ifthechildisdrinkingeagerly,thirstythatisgood.Noticeifthechildreach-esoutforthecuporspoonwhenyouofferhim/herwater.Whenthewateristakenaway,seeifthechildisunhappybecauses/hewantstodrinkmore–thisisagoodsign.
– Elasticity of skin. Checkelasticityofskinusingtheskinpinchtest.Whenreleased,theskinpinchgoesbackeitherveryslowly(longerthan2seconds),orslowly(skinstaysupevenforabriefinstant),orimmediately.
How to do Skin Pinch Test • Locatetheareaonthechild’sabdomenhalfwaybetweentheumbili-cusandthesideoftheabdomen;thenpinchtheskinusingthethumbandfirstfinger.
• Itisimportanttofirmlypickupallofthelayersofskinandthetissueunderthemforonesecondandthenreleaseit.
9
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.3.2.2. Recommended drinks for a child with diarrhoea– breastmilkmoreoftenthanusual– soups– ricewater– freshfruitjuices– weakteawithalittlesugar– cleanwaterfromasafesource.Ifthereisapossibilitythewaterisnotclean,itshouldbepurifiedbyboilingorfiltering.
– oralrehydrationsalts(ORS)mixedwiththeproperamountofcleanwater.
Drinksshouldbegivenfromacleancup.A feeding bottle should never be usedbecauseitishardertokeepcleanandmorelikelytocauseaninfection.
Ifthechildvomits,thecaregivershouldwaitfor10minutesandthenbeginagaintogivethedrinktothechildslowly,smallsipsatatime.
Diarrhoeausuallystopsafterthreeorfourdays.Ifitlastslongerthanoneweek,caregiversshouldseekhelpfromatrainedhealthworker.
Foods for a person with diarhhoea
Whenthepersoniswomit-ingorfeelstoosicktoeat,heshoulddrink– waterymushorbrothofrice,maizepowder,orpotato
– ricewater(withsomemashedrice)
– chicken,meat,egg,orbeanbroth
– Kool–Aidorsimilarsweeteneddrinks
– rehydrationdrink– breastmilk(smallbabies)
Assoonasthechildwillacceptfood,givefoodhelikesandaccepts.Followingfoodsorsimilarones:
Energyfoods– ripeorcookedbananas
– crackers– rice,oatmeal,orotherwell–cookedgrain
– freshmaize(wellcookedormashed)
– potatoes– applesauce(cooked)
– papaya(Ithelpstoaddalittlesugarorvegeta-bleoiltothecerealfoods.)
Body–buildingfoods– chicken(boiledorroasted)
– eggs(boiled)– meat(wellcooked,withoutmuchfatorgrease)
– beans,lentils,orpeas(wellcookedormashed)
– fish(wellcooked)
10
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.3.2.3. Classification of dysenteryAchildishavingdysenteryifthemotherorcaretakerreportsbloodandmucusinthechild’sstool.Dysenteryisespeciallysevereininfantsandinchildrenwhoareundernourished,whodevelopadehydrationduringtheirillness,orwhoarenotbreast–fed.
Allchildrenwithdysentery(bloodydiarrhoea)shouldbetreatedpromptlywithanantibioticandthatiswhytheyhavetovisitadoctor.
2.4. FeverAllsickchildrenshouldbecheckedforfever.Itmaybecausedbyminorinfec-tions,butmayalsobeasignofspecificillness,particularlymalariaorothersevereinfections,includingmeningitis,typhoidfever,ormeasles.
2.4.1. A child having fever should be controlled for
Stiff neck.Astiffneckmaybeasignofmeningitis,cerebralmalariaoranotherveryseverefebriledisease.Ifthechildisconsciousandalert,checkstuffinessbyticklingthefeet,askingthechildtobendhis/hernecktolookdownorbyverygentlybendingthechild’sheadforward.Itshouldmovefreely.
Risk of malaria and other infections. Malariariskcanvarybyseasonorplaces.Thenationalmalariacontrolpro-grammenormallydefinesareasofmalariariskinacountry.
Runny nose. Whenmalariariskislow,achildwithfeverandarunnynosedoesnotneedanantimalarial.Thischild’sfeverisprobablyduetoacommoncold.
Duration of fever. Mostfeversgoawaywithinafewdays.Afeverthathaslastedeverydayformorethanfivedayscanmeanthatthechildhasamoreseverediseasesuchastyphoidfever.
Important to checkBodytemperatureshouldbecheckedinallsickchildren.Childrenareconsideredtohavefeveriftheirbodytemperatureisabove37.5°Caxil-lary(38°Crectal).Ifyoudon’thaveathermometer,childrenareconsid-eredtohavefeveriftheyfeelhot.
11
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.4.2. MeaslesChildrenwithfevershouldbeassessedforsignsofcurrentorpreviousmeasles(withinthelastthreemonths).
Measlesisaseriousvirusinfection.Theusualsignsarefeverwithageneralisedrash,plusatleastoneofthefollowingsigns:redeyes,runnynose,orcough.Themothershouldbeaskedaboutifsomebodynearthefamily/childhashadmeaslesduringthelastthreemonths.
Thechildususallybecomesincreasinglyill.Themouthmaybecomeverysoreandhemaydevelopdiarrhoea.
After2or3daysafewtinywhitespotslikesaltgrainsappearinthemouth.Adayor2latertherashappears—firstbehindtheearsandontheneck,thenonthefaceandbody,andlastonthearmsandlegs.Aftertherashappears,thechildusuallybeginstogetbetter.Therashlastsabout5days.Sometimestherearescatteredblackspotscausedbybleedingintotheskin(‘blackmea-sles’).Thismeanstheattackisverysevere.Getmedicalhelp.
Treatment:– Thechildshouldstayinbed,drinklotsofliquids,andbegivennutritiousfood.Ifhecannotswallowsolidfood,giveherliquidslikesoup.Ifababycannotbreastfeed,givebreastmilkinaspoon.
– Ifpossible,givevitaminAtopreventeyedamage.– Forfeveranddiscomfort,giveacetaminophen(oribuprofen).– Ifearachedevelops,giveanantibiotic.– Ifsignsofpneumonia,meningitis,orseverepainintheearorstomachdevelop,getmedicalhelp.
Prevention of measles:Childrenwithmeaslesshouldkeepfarawayfromotherchildren,evenfrombrothersandsisters.Especiallytrytoprotectchildrenwhoarepoorlynour-ishedorwhohavetuberculosisorotherchronicillnesses.Childrenfromotherfamiliesshouldnotgointoahousewherethereismeasles.Ifchildreninafamilywherethereismeasleshavenotyethadmeaslesthemselves,theyshouldnotgotoschoolorintostoresorotherpublicplacesfor10days.
Topreventmeaslesfromkillingchildren,makesureallchildrenarewell-nourished.Haveyourchildrenvaccinatedagainstmeasleswhentheyare12to15monthsofage.
12
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.5. Ear problemsEarproblemsarecommoninsmallchildrenandshouldbecheckedinallchildrenbroughttotheoutpatienthealthfacility.
Theinfectionoftenbeginsafterafewdayswithacoldorastuffyorpluggednose.Thefevermayrise,andthechildoftencriesorrubsthesideofhishead.Sometimespuscanbeseenintheear.Insmallchildrenanearinfectionsometimescausesvomitingordiarrhoea.Sowhenachildhasdiarrhoeaandfeverbesuretocheckhisears.
2.5.1. Important to checkWhenotoscopy(aninstrumentusedtolookintotheear)isnotavailable,lookforthefollowingsimpleclinicalsigns:
Tender swelling behind the ear. Themostseriouscomplicationofanearinfectionisadeepinfectioninthemastoidbone(thebonedirectlybehindtheear).Itcanbetenderswellingbehindoneofthechild’sears.Ininfants,thistenderswellingalsomaybeabovetheear.
Ear pain. Intheearlystagesofacuteotitis,achildmayhaveearpain,whichusuallycausesthechildtobecomeirritableandrub,touchtheearfrequently.
Ear discharge or pus. Thisisanotherimportantsignofanearinfection.Whenamotherreportsaneardischarge,thehealthcarepro-vidershouldcheckforpusdrainagefromtheearsandfindouthowlongthedischargehasbeenpresent.
2.5.2. Treatment• Itisimportanttotreatearinfectionsearly• Carefullycleanpusoutoftheearwithcotton,butdonotputaplugofcot-ton,astick,leaves,oranythingelseintheear.
• Childrenwithpuscomingfromanearshouldbatheregularlybutshouldnotswimordiveforatleast2weeksaftertheyarewell.
13
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.5.3. Prevention• Teachchildrentowipebutnottoblowtheirnoseswhentheyhaveacold.• Donotbottlefeedbabies–orifyoudo,donotletbabyfeedlyingonhisback,asthemilkcangouphisnoseandleadtoanearinfection.
• Whenchildren’snosesarepluggedup,usesaltdropsandsuckthemucusoutofthenose.
2.5.4. Infection in the ear canalTofindoutwhetherthecanalortubegoingintotheearisinfected,gentlypulltheear.Ifthiscausespain,thecanalisinfected.Putdropsofwaterwithvinegarintheear3or4timesaday.(Mix1spoonofvinegarwith1spoonofboiledwater.)Ifthereisfeverorpus,getmedicalhelp.
2.6. The nutritional status – malnutrition and anaemiaGoodfoodisneededforapersontogrowwell,workhard,andstayhealthy.Manycommonsicknessescomefromnoteatingenough.Apersonwhoisweakorsickbecausehedoesnoteatenough,ordoesnoteatthefoodshisbodyneeds,issaidtobepoorlynourished–ormalnourished.Hesuffersfrommalnutrition.
2.6.1. Poor nutrition can result in the following health problems:• thechildisnotgrowingorgainingweightnormally• slownessinwalking,talking,orthinking• bigbellies,thinarmsandlegs• lackofenergy,childissadanddoesnotplay• swellingoffeet,face,andhands,oftenwithsoresormarksontheskin
2.6.2. Assessing the child’s feedingAgoodfooddoesnotonlyhelppreventdisease,ithelpsthesickbodyfightdiseaseandbecomewellagain.Sowhenapersonissick,eatingenoughnu-tritiousfoodisespeciallyimportant.
Unfortunately,somemothersstopfeedingachildorstopgivingcertainnu-tritiousfoodswhenheissickorhasdiarrhoea–sothechildbecomesweaker,cannotfightofftheillness,andmaydie.Sickchildrenneedfood!Ifasickchildwillnoteat,encouragehimtodoso.
2.6.3. Council the mother or the caretakerAllchildrenlessthan2yearsoldandallchildrenclassifiedasanaemiaorlow(orverylow)weightneedtobeassessedforfeeding.
14
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Councilthemotherorthecaretakertofeedthechildasmuchashewilleatanddrink.Andbepatient.Asickchildoftendoesnotwanttoeatmuch.Socounciltofeedhimsomethingmanytimesduringtheday.Also,trytomakesurethathedrinksalotofliquidsothathepees(passesurine)severaltimesaday.Ifthechildwillnottakesolidfoods,counciltomashthefoodandgivethemasamushorgruel.
Oftenthesignsofpoornutritionfirstappearwhenapersonhassomeothersickness.Forexample,achildwhohashaddiarrhoeaforseveraldaysmayde-velopswollenhandsandfeet,aswollenface,darkspots,orpeelingsoresonhislegs.Thesearesignsofseveremalnutrition.Thechildneedsmoregoodfood!Andmoreoften.
Feedthechildmanytimesduringtheday.Duringandafteranysickness,itisveryimportanttoeatwell.
2.7. Checking immunization statusTheimmunizationstatusofeverysickchildbroughttoahealthfacilityshouldbechecked.
2.7.1. Vaccinations (Immunizations) – simple, sure protectionVaccinesgiveprotectionagainstmanydangerousdiseases.Eachcountryhasitsownscheduleofvaccinations.Vaccinationsareusuallygivenfree.Ifhealthworkersdonotvaccinateinyourvillage,takeyourchildrentothenearesthealthcentertobevaccinated.Itisbettertotakethemforvaccina-tionswhiletheyarehealthythantotakethemfortreatmentwhentheyaresickordying.
2.7.2. The most important vaccines1. DPT,fordiphtheria,whoopingcough(pertussis),andtetanus.Forfullpro-tection,achildneeds4or5injections.Usuallytheinjectionsaregivenat2months,4months,6months,and18monthsold.Insomecountriesonemoreinjectionisgivenwhenachildisbetween4and6yearsold.
2. Polio(infantileparalysis).Thechildneedsdropsinthemouth4or5times.Insomecountriesthefirstvaccinationisgivenatbirthandtheother3dosesaregivenatthesametimeastheDPTinjections.Inothercountries,thefirst3dosesaregivenatthesametimeastheDPTinjections,thefourthdoseisgivenbetween12and18monthsofage,andafifthdoseisgivenwhenthechildis4yearsold.
3. BCG,fortuberculosis.Asingleinjectionisgivenundertheskinoftheleftarm.Childrencanbevaccinatedatbirthoranytimeafterwards.Ifany
15
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
memberofthehouseholdhastuberculosis,itisimportanttovaccinateba-biesinthefirstfewweeksormonthsafterbirth.Thevaccinemakesasoreandleavesascar.
4. Measles. Achildneeds1injectiongivennoyoungerthan9monthsofage,andoftenasecondinjectionat15monthsorolder.Butinmanycoun-triesa‘3in1’vaccinecalledMMRisgiven,thatprotectsagainstmeasles,mumps,andrubella(Germanmeasles).Oneinjectionisgivenwhenthechildisbetween12and15monthsold,andthenasecondinjectionisgivenbetween4and6yearsofage.
5. HepB(HepatitisB).Thisvaccineisgiveninaseriesof3injectionsatinter-valsofabout4weeksaftereachother.GenerallytheseinjectionsaregivenatthesametimeasDPTinjections.InsomecountriesthefirstHepBisgivenatbirth,thesecondat2monthsold,andthethirdwhenthebabyis6monthsold.
6. Td or TT (Tetanustoxoid),fortetanus(lockjaw)foradultsandchildrenover12yearsold.Throughouttheworld,tetanusvaccinationisrecommendedwith1injectionevery10years.InsomecountriesaTdinjectionisgivenbetween9and11yearsofage(5yearsafterthelastDPTvaccination),andthenevery10years.Pregnantwomenshouldbevaccinatedduringeachpregnancysothattheirbabieswillbeprotectedagainsttetanusofthenewborn.
2.8. Assessing other problemsWehavetalkedaboutmainsymptoms.Nevertheless,healthcareprovidersstillneedtoconsiderothercausesofsevereoracuteillness.Itisimportanttocontrollalsothechild’sothercomplaintsandtoaskquestionsaboutthecaretaker’shealth(usually,themother’s).
2.9. If the children age 2 months up to 5 years needs urgent medical careAll infants and children with a severe problems shall be taken to a hospital assoonasassessmentiscompletedandnecessarypre–referraltreatmentisdone.
Itisimportanttocounselthecaretakereffectivelyifthechildisobviouslyseverelyill.Ifthemotherorcaretakerdoesnotacceptreferral,availableoptions(totreatthechildbyrepeatedclinicorhomevisits)shouldbeconsid-
Vaccinate your children on time.Besuretheygetthecompleteseriesofeachvaccinetheyneed.
16
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
ered.Ifthecaretakeracceptsreferral,s/heshouldbegivenashort,clearrefer-ralnote,andshouldgetinformationonwhattododuringreferraltransport,particularlyifthehospitalisdistant.
2.9.1. Urgent pre–referral treatments for children age 2 months up to 5 years • Appropriateantibiotic• Quinine(forseveremalaria)• VitaminA• Preventionofhypoglycemiawithbreastmilkorsugarwater• Oralantimalarial• Paracetamolforhighfever(38.5°Corabove)orpain• ORSsolutionsothatthemothercangivefrequentsipsonthewaytothehospital
Note:Thefirstfourtreatmentsaboveareurgentbecausetheycanpreventseriousconsequencessuchasprogressionofbacterialmeningitisorcerebralmalaria,cornealruptureduetolackofvitaminA,orbraindamagefromlowbloodsugar.Theotherlistedtreatmentsarealsoimportanttopreventwors-eningoftheillness.
Ifachilddoesnotneedurgentreferral,checktoseeifthechildneedsnon–urgentreferralforfurtherassessment;forexample,foracoughthathaslastedmorethan30days,orforfeverthathaslastedfivedaysormore.Thesereferralsarenotasurgent,andothernecessarytreatmentsmaybedonebeforetransportingforreferral.
2.10. Counselling a mother or caretakerAchildwhoisseenattheclinicneedstocontinuetreatment,feedingandfluidsathome.Thechild’smotherorcaretakeralsoneedstorecognizewhenthechildisnotimproving,orisbecomingsicker.
Whenyouteachamotherhowtotreatachild,usethreebasicteachingsteps:• giveinformation;• showanexample;• letherpractice.
Whenteachingthemotherorcaretaker:• usewordsthats/heunderstands;• useteachingaidsthatarefamiliar;
17
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
• givefeedbackwhens/hepractices,praisewhatwasdonewellandmakecorrections;
• allowmorepractice,ifneeded;and• encouragethemotherorcaretakertoaskquestionsandthenanswerallquestions.
Finally,itisimportanttocheckthemother’sorcaretaker’sunderstanding.
2.11. The advices health worker can giveWhatyouasahealthworkergiveasadvicewilldependonthechild’scondi-tion.Belowsomebasicthingsthatshouldbeconsideredwhencounsellingamotherorcaretaker:• Advisetocontinuefeedingandincreasefluidsduringillness;• Teachhowtogiveoraldrugsortotreatlocalinfection;• Counseltosolvefeedingproblems(ifany);• Advisewhentoreturn.
2.11.1. Advise to continue feeding and increase fluidsDuringillness,children’sappetitesandthirstmaybedecreased.However,mothersandcaretakersshouldbecounselledtoincreasefluidsandtoofferthetypesoffoodrecommendedforthechild’sage,asoftenasrecommended,eventhoughachildmaytakesmallamountsateachfeeding.Afterillness,goodfeedinghelpsmakeupforweightlossandhelpspreventmalnutrition.Whenthechildiswell,goodfeedinghelpspreventfutureillness.
2.11.2. Teach how to give oral drugs or to treat local infection at homeSimplestepsshouldbefollowedwhenteachingamotherorcaretakerhowtogiveoraldrugsortreatlocalinfections.Thesestepsinclude:– whatistherightdrugsanddosageforthechild’sageorweight;– tellthemotherorcaretakerwhatthetreatmentisandwhyitshouldbegiven;
– showhowtomeasureadose;– watchthemotherorcaretakerpractisemeasuringadose;– askthemotherorcaretakertogivethedosetothechild;– explaincarefullyhow,andhowoften,todothetreatmentathome;– explainthatAlloraldrugtabletsorsyrupsmustbeusedtofinishthecourseoftreatment,evenifthechildgetsbetter;
– checkthemother’sorcaretaker’sunderstanding.
18
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
2.12. Follow–up careSomesickchildrenwillneedtoreturnforfollow–upcare.Atafollow–upvisit,seeifthechildisimproving,gettingbetteronthedrugorothertreat-mentthatwasprescribed.Somechildrenmaynotrespondtoaparticularantibioticorantimalarial,andmayneedtotryananotherdrug.Childrenwithpersistentdiarrhoeaalsoneedfollow–uptobesurethatthediarrhoeahasstopped.Childrenwithfeveroreyeinfectionneedtobeseeniftheyarenotimproving.Follow–upisespeciallyimportantforchildrenwithafeedingproblemtoensuretheyarebeingfedadequatelyandaregainingweight.
Whenachildcomesforfollow–upofanillness,askthemotherorcaretakerifthechildhasdevelopedanynewproblems.Ifsheanswersyes,thechildrequiresafullassessment:checkforgeneraldangersignsandassessallthemainsymptomsandthechild’snutritionalstatus.
2.11.3. Advice when to returnEverymotherorcaretakerwhoistakingasickchildhomeneedstobeadvisedaboutwhentoreturntoahealthfacility.– teachsignsthatmeantoreturnimmediatelyforfurthercare;– advisewhentoreturnforafollow–upvisit;and– tellwhenthenextwell–childorimmunizationvisitshallbedone.
Adviseamotherorcaretakertoreturntoahealthfacility:Anysickchild– Notabletodrinkordrinkorbreastfeed– Becomessicker– Developsafever
Ifchildhasnopneumonia:coughorcold,alsoreturnif:– Fastbreathing– Difficultbreathing
Ifchildhasdiarrhoea,alsoreturnif:– Bloodinstool– Drinkingpoorly
19
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
3.1. Assessment of sick young infantsWhiletherearesimilaritiesinthecaretakingofsickyounginfants(age1weekupto2months)andchildren(age2monthsupto5years),somesignsobservedininfantsdifferfromthoseinolderchildren.
Assessmentincludesthefollowingsteps:• Checkingforpossiblebacterialinfection;• Assessingiftheyounginfanthasdiarrhoea;• Checkingforfeedingproblemsorlowweight;• Checkingtheyounginfant’simmunizationstatus;• Assessingotherproblems.
Itisimportanttorememberthattheguidelinesabovearenotusedforasicknew–bornwhoislessthan1weekold.Inthefirstweekoflife,new–borninfantsareoftensickfromconditionsrelatedtolabouranddelivery,orhaveconditionsthatrequirespecialmanagement.
3.2. Checking for Main Symptoms3.2.1. Bacterial infectionWhilethesignsofpneumoniaandotherseriousbacterialinfectionscannotbeeasilyseeninthisagegroup,itisrecommendedthatallsickyoungin-fantsbeassessedfirstforsignsofpossiblebacterialinfection.
3.2.2. Important to checkManysignspointtopossiblebacterialinfectioninsickyounginfants.Themostinformativeandeasytochecksignsare:
Convulsions (as part of the current illness). Assessthesameasforolderchildren.
Fast breathing. Younginfantsusuallybreathefasterthanolderchildrendo.Thebreathingrateofahealthyyounginfantiscommonlymorethan50breathsperminute.Therefore,60breathsperminuteisthecut–offratetoidentifyfastbreathinginthisagegroup.
Ifthecountis60breathsormore,thecountshouldberepeated,becausethebreathingrateofayounginfantisoftenirregular.Theyounginfantwilloccasionallystopbreathingforafewseconds,followedbyaperiodoffasterbreathing.Ifthesecondcountisalso60breathsormore,theyounginfanthasfastbreathing.
3. young infants age 1 Week up to 2 months
20
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Severe chest indrawing. Mildchestindrawingisnormalinayounginfantbecauseofsoftnessofthechestwall.Severechestindrawingisverydeepandeasytosee.Itisasignofpneumoniaorotherseriousbacterialinfectioninayounginfant.
Nasal flaring (whenaninfantbreathesin)andgrunting(whenaninfantbreathesout)areanindicationoftroubledbreathingandpossiblepneumo-nia.
A bulging fontanel(whenaninfantisnotcrying),skin pustules, umbilical redness or pus draining from the earareothersignsthatindicatepossiblebacterialinfection.
Lethargy or unconsciousness, or less than normal movementalsoindicateaseriouscondition.
Temperature (fever or hypothermia) mayalsoindicatebacterialinfection.Fever(axillarytemperaturemorethan37.5°Correctaltemperaturemorethan38°C)isuncommoninthefirsttwomonthsoflife.Feverinayounginfantmayindicateaseriousbacterialinfec-tion,andmaybetheonlysignofaseriousbacterialinfection.Younginfantscanalsorespondtoinfectionbydroppingtheirbodytemperaturetobelow35.5°C(36°Crectal).
3.2.3. DiarrhoeaAllsickyounginfantsshouldbecheckedfordiarrhoea.
3.3. Feeding problems or low weightAllsickyounginfantsseeninhealthfacilitiesshouldbeassessedforweightandadequatefeeding,aswellasforbreast–feedingtechnique.
3.3.1. Important to check• Determine weight for age.Assessthesameasforolderchildren.• Assessment of feeding.Assessmentoffeedinginyounginfantsissimilartothatinolderchildren.
Thehealthworkershouldaskabout:– breastfeedingfrequencyandnightfeeds;– whatothertypesfoodsorfluidsthechildhaseaten,howoftenandifthechildhaseatenlately;and
– howthechildhaseatennowduringthisillness.
21
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
Ifaninfanthasdifficultyfeeding,orisbreastfedlessthan8timesin24hours,ortakingotherfoodsordrinks,orlowweightforage,thenbreast-feedingshouldbeassessed.Assessmentofbreastfeedinginyounginfantsincludescheckingiftheinfantisabletoattach,iftheinfantissucklingeffec-tively(slow,deepsucks,withsomepausing),andifthereareulcersorwhitepatchesinthemouth(thrush).
3.3.2. Feeding Problems or Low Weight?– Not able to feed – possible serious bacterial infection.Theyounginfantwhoisnotabletofeed,ornotattachingtothebreastornotsucklingeffectively,hasalife–threateningproblem.Thiscouldbecausedbyabacterialinfec-tionoranotherillness.Theinfantshouldbetakentoadoctor.
– Infantswithfeeding problems or low weightarethoseinfantswhohavefeed-ingproblemslikenotattachingwelltothebreast,notsucklingeffectively,gettingbreastmilkfewerthaneighttimesin24hours,receivingotherfoodsordrinksthanbreastmilk,orthosewhohavelowweightforageorthrush(ulcers/whitepatchesinmouth).
– Infantswithno feeding problemsarethosewhoarebreastfedexclusivelyatleasteighttimesin24hoursandwhoseweightisnotclassifiedaslowweightforageaccordingtostandardmeasures.
3.4. Checking immunization statusAsforolderchildren,immunizationstatusshouldbecheckedinallsickyounginfants.Equally,illnessisnotacontraindicationtoimmunization.
3.5. Assessing other problemsAsforolderchildren,allsickyounginfantsneedtobeassessedforotherpotentialproblemsmentionedbythemotherorobservedduringtheexami-nation.Ifapotentiallyseriousproblemisfoundorthereisnomeansintheclinictohelptheinfant,s/heshouldbereferredtohospital.
Breastfeeding - Signs that the baby is feeding well– thebaby’swholebodyisturnedtowardsthemother– thebabyisclosetothemother– thebabyisrelaxedandhappy– thebaby’smouthiswideopen– thebabytakeslong,deepsucks
22
© 2007 MKFC Stockholm College
Management of Childhood Illness up to 5 years age
3.6. Counselling a mother or caretakerAswitholderchildren,thesuccessofhometreatmentdependsonhowwellthemotherorcaretakerknowshowtogivethetreatment,understandsitsimportance,andknowswhentoreturntoahealthcareprovider.
Counsellingthemotherorcaretakerofasickyounginfantincludesthefol-lowingessentialelements:• Teachhowtogiveoraldrugsortotreatlocalinfection.• Teachcorrectpositioningandattachmentforbreastfeeding: –showthemotherhowtoholdherinfant –withtheinfant’sheadandbodystraight –facingherbreast,withinfant’snoseoppositehernipple –withinfant’sbodyclosetoherbody –supportinginfant’swholebody,notjustneckandshoulders.• Lookforsignsofgoodattachmentandeffectivesuckling.Iftheattachmentorsucklingisnotgood,tryagain.
• Adviseaboutfoodandfluids:advisetobreastfeedfrequently,asoftenaspossibleandforaslongastheinfantwants,dayandnight,duringsicknessandhealth.
3.7. Follow–up careIfthechilddoesnothaveanewproblem• Assessthechildaccordingtotheinstructions;• Usetheinformationaboutthechild’ssignstoselecttheappropriatetreat-ment;
• Givethetreatment.
Advice when to return• teachsignsthatmeantoreturnimmediatelyforfurthercare;• advisewhentoreturnforafollow-upvisit;and• tellwhenthenextwell-childorimmunizationvisitshallbedone.
Advise to return immediately if the infant has any of these signs:• Breastfeedingordrinkingpoorly• Becomessicker• Developsafever• Fastbreathing• Difficultbreathing• Bloodinstool