INTEGRATED

MANGEMENT OF
CHILDHOOD
ILLNESSES
(IMCI)

Prepared by: Araceli Flores Surat

Clinical Instructor

ARACELI F. SURAT
BACKGROUND
 Each year more than 10 million children in low-
and middle-income countries die before they
reach their fifth birthday.
 Seven in ten of these deaths are due to just five
preventable and treatable conditions: pneumonia,
diarrhoea, malaria, measles, and malnutrition, and
often to a combination of these conditions

ARACELI F. SURAT
 Factors
 Every day, millions of parents seek health
care for their sick children, taking them to
hospitals, health centers, pharmacists,
doctors and traditional healers.

 Surveys reveal that many sick children

are not properly assessed and treated by
these health care providers, and that their
parents are poorly advised.

ARACELI F. SURAT
Factors
 At first-level health facilities in low-income
countries, diagnostic supports such as radiology
and laboratory services are minimal or non-
existent, and drugs and equipment are often
scarce.
 Limited supplies and equipment, combined
with an irregular flow of patients

ARACELI F. SURAT
Factors

 doctors leave at this level with few

opportunities to practice complicated
clinical procedures.
 they often rely on history and signs and
symptoms to determine a course of
management that makes the best use of
the available resources.

ARACELI F. SURAT
 These factors make providing quality
care to sick children a serious challenge.
 WHO and UNICEF have addressed this
challenge by developing a strategy
called Integrated Management of
Childhood Illness (IMCI).

ARACELI F. SURAT
What is IMCI?

 IMCI is an integrated approach to child

health that focuses on the well-being of the
whole child.
 IMCI includes both preventive and
curative elements that are implemented by
families and communities as well as by
health facilities.

ARACELI F. SURAT
 Objectives of IMCI

 Major objectives:
 To reduce under five mortality
and morbidity.
 To improve growth and
development of children.

ARACELI F. SURAT
In health facilities:
 the IMCI strategy promotes the accurate
identification of childhood illnesses in outpatient
settings
 ensures appropriate combined treatment of all
major illnesses
 strengthens the counselling of caretakers
 speeds up the referral of severely ill children.

ARACELI F. SURAT
In the home setting:
 it promotes appropriate care
seeking behaviors
 improved nutrition and
preventative care, and the correct
implementation of prescribed care

ARACELI F. SURAT
How does IMCI accomplish
these goals?

 Introducing and
implementing the IMCI
strategy in a country is a
phased process that requires
a great deal of coordination
among existing health
programs and services.

ARACELI F. SURAT
 The main steps involve

 Adopting an integrated approach to child health and

development in the national health policy.
 Adapting the standard IMCI clinical guidelines to
the country’s needs, available drugs, policies, and
to the local foods and language used by the
population.
 Upgrading care in local clinics by training health
workers in new methods to examine and treat
children, and to effectively counsel parents.

ARACELI F. SURAT
 The main steps involve
 Making upgraded care possible by ensuring that
enough of the right low-cost medicines and
simple equipment are available.
 Strengthening care in hospitals for those children
too sick to be treated in an outpatient clinic.
 Developing support mechanisms within
communities for preventing disease, for helping
families to care for sick children, and for getting
children to clinics or hospitals when needed

ARACELI F. SURAT
3 Main Components of
Strategy

ARACELI F. SURAT
1. Improving case management skills of the
health-care staff
 Provision of case management guidelines
and standards.
 Training of public and private health care
providers ( pre- and in-service)
 Follow-up and support supervision of trained
health workers.
 Train health workers in problem solving in
the community
ARACELI F. SURAT
2. Improving the overall health system
 Sound district planning and management
based on burden of disease.
 Facilitating essential drug supply and
management.
 Improving support supervision at health
facilities.
.

ARACELI F. SURAT
2. Improving the overall health
system
 . Strengthen the service quality and
organization at health facilities.
 Reinforce referral services
 Ensure equity of access to health care

ARACELI F. SURAT
3. Improving family and community
health care practices
 Appropriate and timely care seeking
behavior
 Appropriate feeding practices
 Appropriate home case management
and adherence to recommended
treatment prescriptions.

ARACELI F. SURAT
3. Improving family and community health care
practices
 Community involvement I health service planning and
monitoring
 Develop interventions to strengthen community
participation.
 Promote appropriate family response to childhood illness
 Promote child nutrition
 Create safe environment for children

ARACELI F. SURAT
 How is IMCI implemented? 

 IMCI is implemented by
working with local governments
and ministries of health to plan
and adapt the principles of this
approach to local circumstances.

ARACELI F. SURAT
 Case Management Process
 - presented on a series of charts which
show the sequence of steps and
provide information for performing
them.
 Relies on case detection using simple
clinical signs and empirical treatment.
 The treatments are developed accdg to
action-oriented classification rather
than exact diagnosis.

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STEPS

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 Step #1: ASSESS the
child or young infant
means taking a history
and doing a physical
examination

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Step #2: CLASSIFY the Illness

 means taking a decision on

the severity of the illness.
 Making use of the 3 color
coded triage system:

ARACELI F. SURAT
Step #2: CLASSIFY the Illness

ARACELI F. SURAT
Step #2: CLASSIFY the Illness

ARACELI F. SURAT
Step #2: CLASSIFY the Illness

Continiation B.
The health worker advises
her about caring for the
child at home and when she
return .

ARACELI F. SURAT
Step #2: CLASSIFY the Illness

 C. A classification in green
row means that the child
does not need specific
medical treatment such as
antibiotics. The health
worker teaches the mother
how to care for her child at
home .

ARACELI F. SURAT
Step # 3: IDENTIFY treatment

 based from the selected

classification of the
disease.

ARACELI F. SURAT
 Step # 4 : TREAT the child

 means giving treatment in health center

 prescribing drugs or other
treatments to be given at home
 teaching the mother how to carry out the
treatments.

ARACELI F. SURAT
 Step # 5: COUNSEL the
mother
 Includes assessing how the
child is fed
 about the foods and fluids
to give the child
 when to bring the child back
to the health center.
 Health of the mother

ARACELI F. SURAT
Step# 6: Give FOLLOW-UP care :

 includes when to bring back the child to

the center

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 HOW TO SELECT THE
APPROPRIATE CASE
MANAGEMENT CHARTS?

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Decide which age group is in:

1. Age 1 week up to 2 months

 Use the Chart ASSESS CLASSIFY

AND TREAT THE SICK YOUNG
INFANT.

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2. Age 2 months up to 5 years
 Use ASSESS AND CLASSIFY THE SICK
CHILD AGE 2 MONTHS UP TO 5 YEARS
 means the child has not yet had his 5th birthday.
This age group includes a child who is 4 years
and 11 moths but not a child who is 5 year old.
 If the child who is 2 months old would be in the
group 2 months up to 5 years, not in the group 1
week up to 2 months

ARACELI F. SURAT
ASSESS AND CLASSIFY THE SICK
YOUNG CHILD AGED 2 MONTHS
TO 5
YEARS

ARACELI F. SURAT
WHAT TO DO:

1. When you see the mother and the sick child:

 Greet the mother appropriately and ask her to sit
with the child.
 Know the child’s age so you can choose the right
management chart. Look at the child’s record to
find the child’s age .

 If the child’s age is 2 months up to 5 years,

assess and classify the child according to the
steps on the ASSESS & CLASSIFY chart.

ARACELI F. SURAT
 If the child is 1 week up to 2 months,
assess and classify the young infant
according to the steps on the YOUNG
IFANT chart
 Look also if the child’s weight and
temperature have been measured and
recorded. If not weigh the child and
measure his temperature later when
you assess and classify the child’s
main symptoms.
 Do not undress or disturb the child
now.
ARACELI F. SURAT
2. Ask the mother what are child’s problem are and
record in the recording form using good
communication skills.
 Listen carefully to what the mother tells you. This will
show her that you are taking her concerns seriously.
 Use words the mother will understand. If she does not
understand the questions you ask, she cannot give
information you need to assess the child and to
classify his or her illness correctly.
 Give the mother time to answer the questions. She
may need time to decide whether the sign you’ve
asked about is present.

ARACELI F. SURAT
 Ask additional questions when the
mother is not sure about her answer.
When you ask about a main
symptom or related sign, the mother
may not be sure if t is present. Ask
he additional questions to help her
give clearer answer.

ARACELI F. SURAT
 Communicating well with the mother helps
reassure her that her child will receive good
care.
 Determine if this is an initial visit or follow –
up visit for this problem.
 If follow-up visit: If the child was seen a
few days ago for the same illness, use the
follow-up visit for this problem
 If initial visit: If this is the child’s first visit
for this episode of an illness, assess the
child from the 1st step.

ARACELI F. SURAT
 A. Check for General Danger
Signs
 A child with a general danger sign has a
serious problem.
 Needs URGENT referral to the hospital
 Complete the rest of the assessment
immediately.

ARACELI F. SURAT
 General Danger Signs:
 1. Unable to drink or breastfeed

 2. Convulsion

 3. Vomits everything

 4. Lethargic/abnormally sleepy/unconscious

ARACELI F. SURAT
 1. Is the child able to drink or breastfeed?

 A child has the sign “not able to drink or breastfeed”

If the child is too weak to drink and is not able to
suck or swallow when offered a drink or breast
milk
 When you ask the mother if the child is able to drink,
make sure that she understand your question.
 If she says that the child is not able to drink or
breastfeed, ask her to describe her child what happens
when she offers the child something to drink.

ARACELI F. SURAT
NOTE:
 If you are not sure about the mother’s answer,
ask her to offer the child drink of clean water
or breast milk. Look to see if the child is
swallowing the water or breast milk.

 A child who is breastfed may have difficulty

sucking when his nose is blocked. If the child’s
nose is blocked, clear it. If the child can breastfed
after his nose is cleared, the child does not have
the danger sign, “not able to drink or breastfed”.

ARACELI F. SURAT
 2. Does the child vomit everything
he or she takes in?
• A child who is not able to hold anything down at all has the sign
“vomits everything”. A child who vomits everything he or she
takes in will not be able to hold down food, fluids, or oral drugs.
• What goes down goes up. A child who vomits several times but
can hold down some fluids does not have this general danger sign.
• Ask the mother how often the child vomits. Also ask, if the child
vomits each time he or she swallow foods or fluids.
• If you are no sure of the answer, ask the mother to offer the child
drink and see if the child will vomit.

ARACELI F. SURAT
 3. Has the child had convulsions?

 During a convulsion, the child’s arms and legs stiffen

because the muscles are contracting.
 The child may lose consciousness or may not be able to
respond to spoken directions and handling, even his
eyes are open.
 Ask the mother if the child has had convulsion during
this current illness.

ARACELI F. SURAT
 3. Has the child had convulsions?

 Use words the mother understands like “

fits or spasms” or “jerky movements”
 Children may shiver when the fever is
rising rapidly. A child that shivers does
not lose consciousness, he is always
awake and responds to directions and
handling.

ARACELI F. SURAT
 4. Look : See if the child is
abnormally sleepy or difficult to
awaken
 An abnormal sleepy child is not awake
and alert when he or she should be.
 He or she is drowsy
 does not show interest in what is
happening around him or her.
.

ARACELI F. SURAT
 4. Look : See if the child is abnormally
sleepy or difficult to awaken

 The child does not look at his or her

mother or watch your face when you
talk
 The child may stare blankly and
appear not to notice what is going on
around him or her

ARACELI F. SURAT
 4. Look : See if the child is abnormally
sleepy or difficult to awaken

 A child who is abnormally sleepy or is difficult to

awake does not respond when he or she touched,
shaken or spoken to.
 Ask the mother if the child seems unusually sleepy or
if she cannot wake the child.
 Look to see if the child wakens when the mother talks
or shakes the child or when you clap your hands.
 If the child is sleeping and has cough or difficult
breathing, count the number of breaths first before
you try to wake the child.

ARACELI F. SURAT
 B. ASK ABOUT THE MAIN
SYMPTOMS
 1. Cough or difficult breathing

 2. Diarrhea

 3. Fever

 4. Ear Problem

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing

 A child with cough or difficult breathing

is assesses for:
 How long the child has had cough or
difficult breathing
 Fast breathing
 Chest indrawing
 Stridor in calm child.

ARACELI F. SURAT
 B1. Assess Cough or Difficult Breathing

Ask: Does the child have cough or difficult

breathing?
 If the mother says NO, look to see if you think
the child has cough or difficult breathing.
 If the child does not have cough or difficult
breathing, ask about the main symptom
diarrhea. Do not assess the child further for
signs related to cough or difficult breathing.

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
 If the mother says YES, ask the next
question
 Ask: for how long?
A child who has cough or difficult
breathing for more than 30 days has
chronic cough. This may be a sign of
tuberculosis, asthma, whooping cough or
another problem

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
Look and listen:
 Count the child’s breaths in one minute to decide if
the child has fast breathing. The child must be
quiet an calm when you look and listen to his
breathing
 Tell the mother you are going to count her child’s
breathing. Remind her to keep her child calm.
 If the child is sleeping, do not wake the child.

ARACELI F. SURAT
 B1. Assess Cough or Difficult Breathing

Cut –off for Fast breathing:

 The cut-off for fast breathing
depends on the child’s age.
 Normal breathing rates are higher in
children age 2 month up to 12
months than in children age 12
months up to 5 years.
ARACELI F. SURAT
 B1. Assess Cough or Difficult Breathing

Cut –off for Fast breathing:

 The cut-off for fast breathing depends on the
child’s age.
Fast breathing IF:
 1 week – 2 months - 60 or more breaths per
minute
 2 months – 12 months – 50 breaths or more
 12 months – 5 years - 40 breaths or more

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
 The child has chest indrawing if the
lower chest wall goes IN when the
child breath IN.
 In normal breathing: The whole chest
wall ( upper and lower) and the
abdomen move OUT when the child
breaths IN.
ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
 If can’t hardly visualize the chest indrawing
ask the mother to change the position of
the child lying flat in her lap. If still you
do not see the lower chest wall go IN
when the child breaths IN, the child does
not have chest indrawing

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
Chest indrawing should be present , must
be clearly visible at all time. If you any
see chest indrawing when the child is
crying or feeding, the child does not
have chest indrawing.

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
Look for chest indrawing when the
child breaths IN
If the child has abdominal distention and
malnutrition, what appears to be chest
indrawing may not be the “real chest
indrawing”.

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
 Look and listen for stridor

 Stridor is a harsh noise made when the child

breaths IN.
 Stridor happens when there is a swelling of the
larynx, trachea or epiglottis,. This swelling
interferes with air entering the lungs.
 It can be life threatening when the swelling
causes the child’s airway to be blocked.
 A child who has stridor is a dangerous condition.

ARACELI F. SURAT
 B1. Assess Cough or Difficult
Breathing
 Look and listen for stridor
 To look and listen for stridor,, look to see
when the child breaths IN.
 Listen for the stridor. Put your ear near the
child’s mouth because stridor can be
difficult to hear.
 The child should be calm.
 You may hear a wheezing noise when the
child breaths OUT. This is not stridor it is
ARACELI F. SURAT

WHEEZES.
B2. Classify cough or difficulty in
breathing

ARACELI F. SURAT
 B2. Classify cough or difficulty in
breathing
Classification of cough 0r
difficult breathing:
• Severe Pneumonia or Very Severe Disease

• Pneumonia

• No Pneumonia: Cough or Cold

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 2. Assess Diarrhea

 A child with diarrhea is assessed for:

 How long the child has had
diarrhea
 Blood in the stool to determine if
the child has dysentery
 Signs of dehydration

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 2. Assess Diarrhea
 ASK: Does the child have diarrhea?
 If he mother says NO, ask about the next
main symptom, fever. You do not need to
assess the child further signs related to
diarrhea.
 If the mother says YES, if the mother said
earlier that diarrhea was the reason for
coming to the health center, record her
answer. Then assess the child for signs of
dehydration, persistent diarrhea and
dysentery.
ARACELI F. SURAT
 2. Assess Diarrhea

a. ASK : For how long?

 Diarrhea which last 14 days or more
is persistent diarrhea.
 Give the mother time to answer the
question. She may need time to
recall the exact number of days.

ARACELI F. SURAT
 2. Assess Diarrhea

b. ASK : Is there blood in the stool?

Ask the mother if she has seen blood in the
stools at any time during the episode of
diarrhea.

ARACELI F. SURAT
2. Assess Diarrhea

c. CHECK for signs of Dehydration

 at first restless and irritable.
 If dehydration continues, the child becomes
abnormally sleepy or difficult to awaken
 As child’s body loses fluids,, eyes may look
sunken
 When pinched, skin goes back slowly or very
slowly

ARACELI F. SURAT
2. Assess Diarrhea
d. LOOK for the condition of the child
• abnormally sleepy or difficult to
awaken?
• Restless and irritable?
A child has the sign restless and irritable
if the child is restless and irritable
• Has sunken eyes?

ARACELI F. SURAT
 2. Assess Diarrhea
d. LOOK for the condition of the child
 Ask the mother if she thinks her child’s eyes look
unusual. Her opinion helps you confirm that the child’s
eyes are sunken.
 In a severely malnourished child who is visibly wasted
( that is, who has marasmus), the eyes may always look
sunken, even if the child is not dehydrated. Even though
sunken eyes is less reliable in a visibly wasted child, still
use the sign to classify the child’s dehydration.

ARACELI F. SURAT
 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
 Ask the mother to offer the child some water in a
cup or a spoon. Watch the child drink. If the child is
exclusively breastfeed, offer expressed breast milk.
 A child is not able to drink if he is not able to take
fluid in his mouth and swallow it. or not able to
suck and swallow.

ARACELI F. SURAT
 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
 A child is drinking poorly if the
child is weak and cannot drink
without help.
 He may be able to swallow only if
fluid is put in his mouth.

ARACELI F. SURAT
 2. Assess Diarrhea
e. Offer the child fluid. Is the child not able to dink or
drinking poorly? Drinking eagerly, thirsty?
 A child is drinking eagerly, thirsty if it is clear
that the child wants to drink.
 The child reaches out for the cup or spoon when
you offer him water.
 When the water is taken away, see if the child is
unhappy because he wants to drink more

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the

skin of the abdomen, assess skin
turgor
 Ask the mother to place the child on the
examining table so that the child is flat on his
back with his arms at his sides ( not over his
head) and his legs straight. Or ask the mother to
hold the child so he is lying flat in her lap.

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the

skin of the abdomen, assess skin
turgor
 Locate the area on the child’s abdomen halfway
between the umbilicus and the side of he
abdomen.
 Use you thumb and first finger, do not use your
fingertips because this will cause pain.

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the

skin of the abdomen, assess skin
turgor
 Place your hand in line up and down the child’s
body and not across the child’s body.
 Firmly pick up all the layers of the ski and the
tissue under them.
 Pinch the skin for one second and then release
it.

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the

skin of the abdomen, assess skin
turgor
Look if the skin goes goes back
• Very slowly (longer than 2
seconds)
• Slowly?
• Immediately

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the skin of the

abdomen, assess skin turgor
 In a child with marasmus, the skin may go
back slowly even if the child is not dehydrated.
 In an overweight child or a child with edema,
the skin may go back immediately even if the
child is dehydrated.

ARACELI F. SURAT
 2. Assess Diarrhea

f. FEEL for the following . Pinch the skin of the

abdomen, assess skin turgor
 Even though skin pinch is less reliable in these
children, still use it to classify the child’s
dehydration.

ARACELI F. SURAT
 B2. Classify Diarrhea
 There are three classification tables for classifying
diarrhea:
 All children with diarrhea are classified for
dehydration
 If the child had diarrhea for 14 days or more,
classify the child for persistent diarrhea
 If the child has blood in the stool, classify the
child with dysentery.

ARACELI F. SURAT
 B3. Classify Dehydration
 To classify the child’s dehydration , begin
with the pink row.

 If two or more of The signs in the

pink row are present, classify the
child as having SEVERE
DEHYDRATION

ARACELI F. SURAT
 B3. Classify Dehydration

 If two or more of the signs are not

present, look at the yellow row. If
two or more of the signs are present,
classify the child as having SOME
DEHYDRATION

ARACELI F. SURAT
 B3. Classify Dehydration

 If two or more of the sign from the

yellow row are not present,
classify the child having NO
DEHYDRATION.

ARACELI F. SURAT
 B4. Classify Persistent Diarrhea

 Severe Persistent Diarrhea - If a

child has had diarrhea for 14 days or
more and also has some or severe
dehydration.
 Persistent Diarrhea – A child who has
had diarrhea for 14 days or more and
who has no signs of dehydration.

ARACELI F. SURAT
Classify Dysentery
 Dysentery – blood in the
stool

ARACELI F. SURAT
SELECTING THE APPROPRIATE TREATMENT
PLAN ACCORDING THE DEGREE OF
DEHYDRATION

ARACELI F. SURAT
TREATMENT PLAN A:
TREAT DIARRHEA AT HOME

ARACELI F. SURAT
A. Counsel the mother regarding the 3 Rules of Home
Treatment:

1. . Give Extra Fluid ( as much as the child will take)

 a. Tell the mother:
 Breastfeed frequently and for a longer time at
each feeding
 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:

ARACELI F. SURAT
A. Counsel the mother regarding the 3 Rules of
Home Treatment:

1. . Give Extra Fluid ( as much as the child will

take)
 a. Tell the mother:
 If the child is not exclusively breastfed, give
one or more of the following:
 ORS solution, food-based fluids ( such s soup, rice
water, or buko juice) or clean water.
 Give the child frequent sips from a cup
 If the child vomits, wait for 10 minutes. Then
continue, but more slowly

ARACELI F. SURAT
A. Counsel the mother regarding the 3 Rules of Home
Treatment:
1. . Give Extra Fluid ( as much as the child will take)
 a. Tell the mother:
 If the child is not exclusively breastfed, give
one or more of the following:
 Continue giving the extra fluid until the diarrhea
stops
 It is especially important to give ORS at home when:
 The child has been treated with Plan B or Plan C
during the visit
 The child cannot return to a health center if the
diarrhea gets worse

ARACELI F. SURAT
A. Counsel the mother regarding the 3 Rules of
Home Treatment:
1. . Give Extra Fluid ( as much as the child will
take)
B. 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 the child
in addition to he
 child’s usual fluid intake:
 Up to 2 years 50 to 100 ml after each loose
stool evacuation
 2 years or more 100 to 200 ml after each loose
evacuation
ARACELI F. SURAT
B. Continue Feeding
 Assess the child’s feeding pattern
 Ask questions about the child’s usual
feeding and his or her feeding during
illness. Compare the mother’s answers
with the Feeding Recommendations for
the child’s age n the Box below.

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B. Continue Feeding
 Assess the child’s feeding pattern
 ASK:
 Do you breastfeed your child?
 How many times do you do so during the day?
 Do you also breastfeed during the night?
 Does the child take in any other food or fluid?

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B. Continue Feeding
 What food or fluid does the child take
in?
 How many times per day does the child
take in this food or fluid?
 What do you use to feed the child?
 If he child has very low weight for age:
How large are his or her servings? Is the
child given hi or her own serving? Who feeds the chills and how?

ARACELI F. SURAT
B. Continue Feeding
 During this illness, has the child’s feeding changed? If
yes,, in what way has it changed?
 Advise the mother to increase the child’s Fluid Intake
during Illness
 For any sick child:
 Breastfeed the child more frequently an for
a longer time each feed
 Increase the child’s fluid intake. For
example, give the child soup, rice water,
buko juice or clean water

ARACELI F. SURAT
B. Continue Feeding
 During this illness, has the child’s feeding changed? If
yes,, in what way has it changed?
 Advise the mother to increase the child’s Fluid Intake
during Illness
 For a Child with diarrhea:
 Giving the child extra fluid can save his or life.
Give the child fluid according to Plan A or Plan B
on the TREAT the CHILD chart.
 Instruct the mother what are the recommended
food to be given to the child depending on the
child’s age

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C. Counsel the mother about the child’s
feeding problems
 If the child is not being fed as described in
the above recommendations, counsel the
mother accordingly.
 If the mother reports difficulty with
breastfeeding, assess the child’s breast
feeding. If needed show the mother the
correct positioning and attachment for
breastfeeding.

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 If the child is less than 4 months old and is taking
other kinds of milk of foods:
 Build the mother’s confidence by telling her that
she can produce all the breast milk that her child
needs.
 Suggests giving the child more frequent, longer
breastfeed, day and night, and gradually reducing
the child’s intake of other kinds of milk or foods.

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C. Counsel the mother about the child’s feeding
problems
 If the child’s intake of other kinds of milk needs to be
continue, counsel the mother to:
 Breastfeed the child often as possible, including at
night.
 Make sure that the other kind of milk to be given to
h child is a locally appropriate breast milk
substitute, and give it to the child only when
necessary,
 Make sure that the other kind of milk to be given Is
correctly and hygienically prepared, and that it is given
in adequate amounts

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 Prepare only an amount of milk that the child
can consume within an hour. Discard leftover
milk, If any.
 If the mother is using a bottle to feed the child:
 Recommend substituting a cup for a bottle
 Show the mother how to feed the child using a
cup

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 IF the child is not being fed actively,
counsel the mother to:
 Sit with the child while the latter is
eating, and encourage him or her to eat
 Give he child an adequate serving in a
separate late or bowl.
 Observe what the child likes and consider
these in the preparation of hjs or her food.

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 If the child I not feeding well during illness,
counsel the mother to:
 Breastfeed the child more frequently and for a
longer time at each feed, if possible.
 Give the child soft, varied and appetizing foods, as
well as the child’s favorite foods, to encourage
him or her to eat as much as possible and offer the
child frequent small feedings.

ARACELI F. SURAT
C. Counsel the mother about the child’s
feeding problems
 Clear the child’s blocked nostril if they
interfere with his o her feeding.

 Expect the child’s appetite to improve as he

or she gets better.

ARACELI F. SURAT
Feeding Recommendations for a
child who has Persistent
Diarrhea:
.

ARACELI F. SURAT
 If the child is still breastfeeding, give him
or her more frequent, longer breastfeeds,
day and night

ARACELI F. SURAT
 If the child is taking other kinds of milk,
such as milk supplements:
 Replace these with increased beast
feeding or
 Replace half the child’s milk intake with
nutrient rich, semi-solid foods
 Do not give the child condensed milk or
evaporated milk.
 For other foods, follow the feeding
recommendations for the child’s age.

ARACELI F. SURAT
 Know when to Return
 Advise the mother regarding when to return to
the Health Center if the child has any of these
signs:
 Persistent diarrhea
 Return after 5 days
 Ask: Has the diarrhea stopped?
 How many times does the child evacuate
loose stool per day?

ARACELI F. SURAT
 Treatment:
 If the diarrhea has not stopped ( the child still
evacuates loose stool 3 or more times per day),
conduct a full assessment of the child. Give him or her
any treatment he or she needs. Then, refer the child to
a hospital.
 If the diarrhea has stopped ( the child evacuates loose
stool less than 3 times per day), tell the mother to
follow he usual recommendations for the child’s age.

ARACELI F. SURAT
 Feeding problem

 return after 5 days

 Reassess the child’s feeding
 ASK about any feeding problem found in the
initial visit
 Counsel the mother about any new or
continuing feeding problem of the child.
If you will counsel the mother to
implement significant changes in feeding,
ask her to brig the child back to the health
center for follow-up

ARACELI F. SURAT
 TREATMENT PLAN B : TREAT
SOME DEHYDRATION WITH ORS

ARACELI F. SURAT
 Determine the amount of ORS to give to the
child during the first 4 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 ) by 75.
 If the child wants more ORS than
shown, give him or her more.

ARACELI F. SURAT
 For infants under 6 months of age who
are not being breastfeed, give 100 -200
ml clean water as well during this period.
 Show the mother how to give ORS
solution to her child:
 Give the child frequent sips from a cup.
 If the child vomits, wait for 10 minutes.
Then continue, but more slowly.
 Continue breastfeeding whenever the
child wants o be breastfeed.

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 After 4 hours:
 Reassess the child and
classify him or her for
dehydration
 Select the appropriate plan to
use in continuing the
treatment
 Begin feeding the child in
the health center

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 If the mother must leave before completing the
treatment:

 Show her how to prepare ORS solution at home

 Show her how much ORS to give her child to finish the 4
hour treatment at home.
 Give her enough ORS packets to complete her child’s
rehydration. Also, give her 2 packs as recommended in
Plan A.
 Explain to her the 4 rules of home treatment:
 Give Extra fluid
 Continue feeding
 Know when to return
 Zinc supplement

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 TREATMENT PLAN C : TREAT
SEVERE DEHYDRATION QUICKLY

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 Assess the following:

 can you give intravenous fluid immediately

 Is IV treatment available nearby ( within 30
minutes)
 Are you trained to use a NGT for
rehydration?
 Can the child drink?

 Refer urgently to a hospital for IV or NG

treatment.
ARACELI F. SURAT
 IF YOU CAN GIVE INTRAVENOUS FLUID
TO THE PATIENT :

 Start IV fluid immediately. If he child can drink,

give ORS by mouth while the drip is being set
up. Give 100 ml/kg Ringer’s Lactate Solution
( if not available, use normal saline), divided as
follows:
 Repeat once the radial pulse is still very weak
or is not detectable.
 Reassess the child every 1 -2 hours. If the child’s
hydration status does not improve, give the IV drip
more rapidly.

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 Also give ORS (about 5 ml/kg/hr) as
soon as the child can drink: usually
after 3 – 4 hours ( infants) or 1- 2
hour ( children)

 Reassess an infant after 6 hours and

a child after 3 hours. Classify the
dehydration. Then choose the
appropriate plan ( A,B,C) to continue
the treatment.

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 IF THERE IS IV TREATMET
AVAILABLE EARBY WITHIN 30
MINUTES:

 Refer the child urgently o a hospital

for IV treatment
 If he child can drink, provide the
mother with ORS solution and show
how to give the child frequent sips of
it during the trip.

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 IF YOU ARE TRAINED TO PLACE
NGT FOR REHYDRATION AND IF
THE CHILD ABLE TO DRINK:

 Start the rehydration by tube ( mouth) with

ORS solution: Give 20 ml/kg/hr for 6 hours
( total of 120 ,l/kg)
 Reassess the child every 1 – 2 hours
 If there is repeated vomiting or
increasing abdominal distention, give
the fluid more slowly.

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 If the child’s hydration status has not
improved after 3 hours, send the child for
IV therapy.

 After 6 hours, reassess the child.

Classify the dehydration. Then choose
the appropriate plan ( A, B, C ) to
continue the treatment.
 If possible, observe the child at least
6 hours after rehydration to be sure
that the mother can maintain the
hydration, giving the child ORS
solution by mouth.
ARACELI F. SURAT