Module 4 Diarrhoea WHO Library Cataloguing-In-Publication Data: Integrated Management of Childhood Illness: Distance Learning Course

Home , Infant formula, Oral rehydration therapy

IMCI INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

DISTANCE LEARNING COURSE Module 4 Diarrhoea WHO Library Cataloguing-in-Publication Data: Integrated Management of Childhood Illness: distance learning course. 15 booklets Contents: – Introduction, self-study modules – Module 1: general danger signs for the sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation: introduction and roll out – Logbook – Chart book 1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control. 4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance. 7.Teaching Material. I.World Health Organization. ISBN 978 92 4 150682 3 (NLM classification: WS 200)

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Printed in Switzerland IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA n CONTENTS Acknowledgements 4 4.1 Module overview 5 4.2 Introduction to diarrhoea 8 4.3 Assess a sick young infant & child for diarrhoea 10 4.4 Classify diarrhoea & dehydration 17 4.5 Treat the child with diarrhoea 23 4.6 Counsel the caregiver 37 4.7 Provide follow-up care for diarrhoea 42 4.8 Using this module in your clinic 45 4.9 Review questions 46 4.10 Answer key 47

3 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

Acknowledgements

The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated the development of these distance learning materials on the Integrated Management of Childhood illness (IMCI), in an effort to increase access to essential health services and meet demands of countries for materials to train primary health workers in IMCI at scale. These materials are intended to serve as an additional tool to increase coverage of trained health workers in countries to support the provision of basic health services for children. The technical content of the modules are based on new WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/ AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as care for development. Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) led the development of the materials with contributions to the content from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg, José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim, Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African Region of WHO. A particular debt of gratitude is owed to the principal developer, Ms Megan Towle. Megan helped in the design and content of the materials based on the field-test experiences of the materials in South Africa. A special word of thanks is also due to Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic of Tanzania WHO is grateful for the contribution of all external experts to develop the distance learning approaches for IMCI including professor Kevin Forsyth, Professor David Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open University (UK), Aisha Yousafzai who reviewed the care for development section of the well child care module, Amha Mekasha from Addis Ababa University and Eva Kudlova, who have contributed to different sections of the distance learning modules. We acknowledge the help from Ms Sue Hobbs in the design of the materials. Financial and other support to finish this work was obtained from both the MCA and HIV departments of WHO.

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4.1 MODULE OVERVIEW Diarrhoea is likely a very common problem in the children you see at your clinic. Diarrhoea can be serious – and even lead to death.

For ALL sick children – ask the caregiver about the child’s problems, check for general danger signs, assess for cough or difficult breathing, then ASK: DOES THE CHILD HAVE DIARRHOEA?

NO YES

ASSESS & CLASSIFY the child using the colour-coded classification charts for dehydration & diarrhoea.

CONTINUE ASSESSMENT: assess for main symptoms (next is fever), check for malnutrition & anaemia, check immunization status, HIV status, other problems

NOTE ON DIARHOEA IN SICK YOUNG INFANT: In Module 2, you were told to refer to this module to assess and classify diarrhoea in sick young infants. The IMCI process is similar for the two. There are some important distinctions, which you will learn about in the module.

MODULE LEARNING OBJECTIVES After you study this module, you will be able to: ✔✔ Define the types of diarrhoea and levels of dehydration ✔✔ Recognize clinical signs of dehydration ✔✔ Assess diarrhoea in sick children ✔✔ Assess dehydration in young infants and sick children ✔✔ Classify diarrhoea and severity of dehydration using IMCI charts ✔✔ Provide Plans A, B, and C for dehydration ✔✔ Counsel the caregiver about home treatment for diarrhoea and dehydration

5 MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ CONVULSIONS Remember to use Danger sign when YOUR RECORDING FORM selecting classifications Look at your IMCI recording form for the sick child. This section deals with this DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long?module: ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood in the stool? 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck For how long? ___ Days Look for runny nose If more than 7MODULE days, has fever ORGANIZATIONbeen present every Look for signs of MEASLES: day? Generalized rash and Has child hadThis measels module within the follows last 3 months? the major stepsOne of ofthe these: IMCI cough, process: runny nose, or red eyes Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever✔ cases✔ ASSESS DIARRHOEA and DEHYDRATION IN SICK CHILD Low risk: if NO obvious cause of fever Test POSITIVE?✔ P. ✔falciparumASSESS P. DEHYDRATION vivaxNEGATIVE? IN SICK YOUNG INFANT If the child has measles now or within the Look for mouth ulcers. last 3 months:✔✔ CLASSIFY DIARRHOEA and DEHYDRATIONIf yes, are they deep and extensive? Look for pus draining from the eye. ✔✔ CLASSIFY DEHYDRATIONLook IN forSICK clouding YOUNG of the cornea. INFANT DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge?✔✔ TREAT DIARRHOEA Feel for tender swelling behind the ear If Yes, for how long? ___ Days THEN CHECK✔ FOR✔ COUNSEL ACUTE MALNUTRITION CAREGIVER ONLook 4 RULES for oedema OF of both HOME feet. TREATMENT AND ANAEMIA Determine WFH/L _____ Z score. ✔ For children 6 months or older measure MUAC ____ mm. ✔ FOLLOW-UP CARE FOR DIARRHOEALook for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less thanBEFORE -3 Z scores YOU or BEGIN oedema of General danger sign? Any severe classification? both feet: What do you know now about managingPneumonia with diarrhoea? chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Before you begin studying this module,Not able toquickly finish or able practice to finish? your knowledge with these For a child less than 6 months is there a breastfeeding problem? CHECK FORmultiple-choice HIV INFECTION questions. Note mother's and/or child's HIV status Mother's HIVCircle test: the NEGATIVE best answer POSITIVE for eachNOT DONE/KNOWN question. Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive1. How and can NO diarrhoea positive virological kill test children? in child: Is the child breastfeeding now? Was the child a.breastfeeding Children at the lose time valuableof test or 6 weeks fluids, before salts, it? and sugars, which can cause shock to vital If breastfeeding: Is organsthe mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1b. ChildrenDPT+HIB-2 lose valuableDPT+HIB-3 nutrients becauseMeasles1 they cannotMeasles 2 eat Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hepc. B1DiarrhoeaHep causes B2 liverHep failure B3 RTV-1 RTV-2 RTV-3 2. Pneumo-1What are criticalPneumo-2 treatmentsPneumo-3 for children with diarrhoea and dehydration? a. Oral antibiotics b. Oral rehydration therapy and zinc c. Paracetamol for discomfort

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3. What is persistent diarrhoea? a. When a child frequently has diarrhoea over a period of 1 month, and is ill as a result b. When a child has several episodes of diarrhoea a day c. When a child has an episode of diarrhoea lasting 14 days or more, which is particularly dangerous for dehydration and malnutrition 4. Critical messages for caregivers about diarrhoea and dehydration include: a. The child must receive increased fluids, ORS, zinc, and regular feeding b. The child requires ORS, but should receive less food in order to reduce the diarrhoea c. The child should immediately receive antibiotics to stop the diarrhoea 5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She has diarrhoea. You observe a significant loss of skin elasticity. How will you manage Nidhi? a. Nidhi requires ORS immediately, as she is dehydrated. b. These are common signs of diarrhoea, as the child’s body is exhausted. c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV or nasogastric tube. After you finish the module, you will answer the same questions. This will demonstrate to you what you have learned during the course of the module!

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4.2 INTRODUCTION TO DIARRHOEA n OPENING CASE STUDY – MARY It is a busy afternoon in your clinic. A young mother comes into your clinic room, carrying a small girl. She says her daughter, Mary, has diarrhoea. You ask the mother’s name, and she says Ana. Ana says that Mary usually eats porridge and milk, but that she has had bad diarrhoea in the past few days. Ana tried giving more porridge but Mary is still sick. Ana thought it was a bad stomach from spoiled milk, and that it would pass. However, the diarrhoea has remained for several days now, and now Mary looks unwell. Ana fears that Mary is getting worse, and is feeling guilty that she did not come to the clinic sooner. Ana works in the mornings, and lives some distance from the clinic. By the time she commutes into the city for her work duties, she does not have very much time in the day to bring Mary in. She says she is worried that her family will blame her for working at the job and letting Mary get more and more sick.

WHAT IS DIARRHOEA? Diarrhoea occurs when stools contain more water than normal, and are loose or watery. In many regions diarrhoea is defined as three or more loose or watery stools in a 24-hour period. Children between the ages of 6 months and 2 years often have diarrhoea. It is more common in settings of poor sanitation and hygiene, including a lack of safe drinking water.

WHAT ARE THE TYPES OF DIARRHOEA IN CHILDREN? Most diarrhoea that causes dehydration is loose or watery. Cholera is one example, though only a small proportion of all loose or watery diarrhoeas are due to cholera. n ACUTE DIARRHOEA is an episode of diarrhoea that lasts less than 14 days. Acute watery diarrhoea causes dehydration and contributes to malnutrition. The death of a child with acute diarrhoea is usually due to dehydration. n PERSISTENT DIARRHOEA lasts 14 days or more. Up to 20% of episodes of diarrhoea become persistent, and this often causes nutritional problems and contributes to death in children. n DYSENTERY is diarrhoea with blood in the stool, with or without mucus. The most common cause of dysentery is Shigella bacteria. Amoebic dysentery is not common in young children. A child may have both watery diarrhoea and dysentery.

WHAT ARE THE TYPES OF DIARRHOEA IN YOUNG INFANTS? A young infant has diarrhoea if the stools have changed from the usual pattern, and are many and watery. This means more water than faecal matter. The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

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n How do you greet Ana and begin the assessment? You praise Ana for bringing in her daughter. You tell her that diarrhoea can be a serious problem for young children, but that there are ways to help her daughter get better. You explain that you will check her condition and decide the best treatment. Ana seems relieved. You ask Mary’s age. Ana tells you that she is 9 months old. You ask Ana if there are other problems besides the diarrhoea. She says no. This is their first time coming to the clinic for this diarrhoea. You take Mary’s weight, 8.2 kg, and temperature, 37 degrees Celsius. n You will check Mary for general danger signs. First, you check Mary for general danger signs. Ana tells you that Mary is able to drink milk and take porridge. She does not vomit. She has not had convulsions. You watch Mary. She looks very tired in Ana’s arms, but she watches you as you speak. When you reach out to her to take her hand, she grabs your finger. Does Mary have any general danger signs? n Next, you will assess Mary for cough or difficult breathing. Now you check Mary for cough or difficult breathing. You ask Ana if Mary has had a cough, or any fast or noisy breathing. Ana says that Mary had a cough about 2 months ago, but it has cleared up. This is how you will complete Mary’s recording form thus far:

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Mary Age: 9 mo Weight (kg): 8.2 kg Temperature (°C): 37 °C Ask: What are the child's problems? Diarrhoea for several days Initial Visit? X Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___X CONVULSIONS Remember to use Danger sign when selecting classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes X__ No __ For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: NowIs youthere bloodwill in assess the stool? Mary for the next main Lethargicsymptom, or unconscious? diarrhoea. This is also the problem that her Restless and irritable? mother brought her to the clinic for. 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck For how long? ___ Days Look for runny nose If more than 7 days, has fever been present every Look for signs of MEASLES: day? Generalized rash and Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? If the child has measles now or within the Look for mouth ulcers. last 3 months: If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge? Feel for tender swelling behind the ear If Yes, for how long? ___ Days THEN CHECK FOR ACUTE MALNUTRITION Look for oedema9 of both feet. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

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4.3 ASSESS A SICK YOUNG INFANT & CHILD FOR DIARRHOEA You have a very important job to do in helping a child with diarrhoea. This module will guide you through the process of assessing, classifying, and treating by the type of diarrhoea and the severity of dehydration.

HOW WILL YOU ASSESS? First, you will ASK all caregivers if the child has diarrhoea. You might need to explain diarrhoea as loose, watery stools if the caregiver needs clarification. Be sure to use words for diarrhoea that the mother understands. NO diarrhoea, ask about the next main symptom, fever. You do not need to further assess. YES or reported earlier that diarrhoea was the reason for coming to the clinic, record her answer. You will then assess in two parts: 1. Type of diarrhoea: especially if it is persistent, or dysentery 2. Signs of dehydration Open to your ASSESS chart for diarrhoea, which includes the assessment for both diarrhoea and dehydration. It contains the following instructions, which you will now learn about. Does the child have diarrhoea?

Dehydration present. Pink: Treat dehydration before referral unless the and if diarrhoea 14 SEVERE child has another severe classification days or more PERSISTENT Refer to hospital DIARRHOEA 10 No dehydration. Yellow: Advise the mother on feeding a child who has PERSISTENT PERSISTENT DIARRHOEA DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

Blood in the stool. Yellow: Give ciprofloxacin for 3 days and if blood in stool DYSENTERY Follow-up in 2 days

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DIARRHOEA: SICK CHILD ASK: FOR HOW LONG? Diarrhoea which lasts 14 days or more is persistent diarrhoea. Give the mother time to answer the question. She may need time to recall the exact number of days.

ASK: IS THERE BLOOD IN THE STOOL? Ask the mother if she has seen blood in the stools at any time during this episode of diarrhoea. As we previously reviewed, dysentery is diarrhoea with blood in the stool, with or without mucus. The most common cause of dysentery isShigella bacteria. Dysentery will require specific treatments.

DEHYDRATION: SICK CHILD & YOUNG INFANT WHAT IS DEHYDRATION? Diarrhoea can be a serious problem – and even lead to death – if child becomes dehydrated. Dehydration is when the child loses too much water and salt from the body. This causes a disturbance of electrolytes, which can affect vital organs. A child who is dehydrated must be treated to help restore the balance of water and salt. Many cases of diarrhoea can be treated with Oral Rehydration Salts (ORS), a mixture of glucose and several salts. ORS and extra fluids can be used as home treatment to prevent dehydration. Low osmolarity ORS should be used to treat dehydration.

HOW WILL YOU ASSESS DEHYDRATION? There are several signs that help you decide the severity of dehydration. When a child becomes dehydrated, he is at first restless or irritable. As the body loses fluids, the eyes may look sunken, and skin loses elasticity. If dehydration continues, the child becomes lethargic or unconscious.

LOOK: AT THE CHILD’S GENERAL CONDITION When you checked for general danger signs, you checked to see if the child was lethargic or unconscious. If the child is lethargic or unconscious, he has a general danger sign. Remember to use this general danger sign when you classify the child’s diarrhoea. A child is classified asrestless and irritable if s/he is restless and irritable all the time or every time s/he is touched and handled. If an infant or child is calm when breastfeeding but again restless and irritable when he stops breastfeeding, s/he has the sign restless and irritable. Many children are upset just because they are in the clinic. Usually these children can be consoled and calmed, and do not have this sign.

FOR THE YOUNG INFANT: watch the infant’s movement. Does he move on his own? Does the infant only move when stimulated, but then stops? Is the infant restless and irritable?

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LOOK FOR SUNKEN EYES The eyes of a child who is dehydrated may look sunken. Decide if you think the eyes are sunken. Then ask the mother if she thinks her child’s eyes look unusual. Her opinion can help you confirm. NOTE: In a severely malnourished child (see Module 6) who is wasted, the eyes may always look sunken, even if the child is not dehydrated. Still use the sign to classify dehydration.

DVD EXERCISE – SUNKEN EYES Watch “Assess sunken eyes” (disc 1). It is very useful to practice with a video. Record your answers as you watch, and the video will review them. Do these children have sunken eyes? CHILD 1  YES  NO CHILD 3  YES  NO CHILD 5  YES  NO CHILD 2  YES  NO CHILD 4  YES  NO CHILD 6  YES  NO

LOOK: TO SEE HOW THE CHILD DRINKS Ask the mother to offer the child some water in a cup or spoon. Watch the child drink. A child is not able to drink if he is not able to suck or swallow when offered a drink. A child may not be able to drink because he is lethargic or unconscious. 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. A child has the sign drinking eagerly and acts thirsty if it is clear that the child wants to drink. Look to see if 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. If the child takes a drink only with encouragement and does not want to drink more, he does not have the sign drinking eagerly, thirsty.

FEEL: BY PINCHING THE SKIN OF THE ABDOMEN This skin pinch tests is an important tool for testing dehydration. When a child is dehydrated, the skin loses elasticity. To assess dehydration using the skin pinch: 1. 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 on her lap. 2. USE YOUR THUMB AND FIRST FINGER to locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen. Do not use your fingertips because this will cause pain. The fold of the skin should be in a line up and down the child’s body. 3. PICK UP all the layers of skin and the tissue underneath them. 4. HOLD the pinch for one second. Then release it.

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5. LOOK to see if the skin pinch goes back very slowly (more than 2 seconds), slowly, (less than 2 seconds, but not immediately), or immediately. If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back slowly. The photographs below show you how to do the skin pinch test and what the skin looks like when the pinch does not go back immediately.

Skin pinch Skin pinch going back very slowly

NOTE: The skin pinch test is not always an accurate sign. In a child with severe malnutrition, the skin may go back slowly even if the child is not dehydrated. In a child is overweight or has oedema, the skin may go back immediately even if the child is dehydrated. However you should still use it to classify the child’s dehydration.

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DVD EXERCISE – SKIN PINCH Watch “Assess skin pinch” (disc 1) to see how skin pinches look. How do you assess the 5 children in the video? Record your answers, and the video will review answers with you.

1 2 3 4 5 VERY SLOWLY SLOWLY IMMEDIATELY

Watch “Demonstration: assess and classify diarrhoea” (disc 1) This video reviews all steps in assessing diarrhoea. It is useful to see in a clinical setting.

nMANAGEMENT How will you assess OF THEMary’s SICK diarrhoea? CHILD AGED 2 MONTHS UP TO 5 YEARS Name: Age: Weight (kg): Temperature (°C): AnaAsk: Whathas alreadyare the child's reported problems? that Mary has diarrhoea. You ask Ana how many daysInitial she Visit? has had diarrhoea,Follow-up Visit? and sheASSESS tells (Circle you all3 signsdays. present) You ask Ana if there is blood in her daughter’s stool, and she tells you no. CLASSIFY NowCHECK you FOR will GENERALexamine Mary’sDANGER condition. SIGNS She seems restless and irritable, especially when you touchGeneral her. danger You sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? beginVOMITS to examine EVERYTHING Mary for signs of dehydration.CONVULSING You check NOW to see if she has sunken eyes, and it appearsYes ___ No that ___ sheCONVULSIONS does. Ana agrees that her daughter’s eyes look unusual. You offer her some water to drink Rememberand notice to use how she responds. She drinks the water eagerly. Danger sign when selecting Next, you give Mary a pinch test to determine how dehydrated she is. You ask Ana to place Mary classificationson the examiningDOES THE tableCHILD so HAVE that COUGHshe is flat OR DIFFICULTon her back BREATHING? with her arms at her sides, and her legs straight. YouYes __do Nopinch __ the Forskin how of long? Mary’s ___ Days abdomen, and it goes backCount in 1 the second. breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing How will you record these signs on Mary’sLook and recording listen for stridor form? Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __X No __ For how long? ___3 Days Look at the childs general condition. Is the child: Is there blood in the stool? 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ ThenDecide in malaria the risk:next High section, ___ Low you___ No___ will learn how toLook assess or feel for Mary’s stiff neck diarrhoea using the signs you have assessed. For how long? ___ Days Look for runny nose On Ifthe more next than 7page days, hasyou fever will been have present the every opportunityLook forto signs practice of MEASLES: assessing signs in two case studies. day? Generalized rash and Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? If the child has measles now or within the Look for mouth ulcers. last 3 months: If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge? Feel for tender14 swelling behind the ear If Yes, for how long? ___ Days THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

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SELF-ASSESSMENT EXERCISE A Read the case study below. Assess and classify the child’s diarrhoea and dehydration. Maya is at the clinic today because she has had diarrhoea for 4 days. She is 25 months old. She weighs 9 kg. Her temperature is 37.0 °C. Maya has no general danger signs. She does not have cough or difficult breathing. The health worker said to the mother, “When Maya has diarrhoea, is there any blood in the stool?” The mother said, “No.” The health worker checked for signs of dehydration. Maya is not lethargic or unconscious. She is not restless or irritable. Her eyes are not sunken. Maya drinks eagerly when offered some water. Her skin pinch goes back immediately. Record Maya’s signs and classify them.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ CONVULSIONS Remember to use Danger sign when selecting classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood in the stool? 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck For how long? ___ Days Look for runny nose If more than 7 days, has fever been present every Look for signs of MEASLES: day? Generalized rash and Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? If the child has measles now or within the Look for mouth ulcers. last 3 months: If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge? Feel for tender swelling behind the ear If Yes, for how long? ___ Days THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia15 with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

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SELF-ASSESSMENT EXERCISE B Read the case study below. Assess and classify the child’s diarrhoea and dehydration. Rana is 14 months old. She weighs 12 kg. Her temperature is 37.5 °C. Rana’s mother said the child has had diarrhoea for 3 weeks. Rana does not have any general danger signs. She does not have cough or difficult breathing. The health worker assessed her diarrhoea. He noted she has had diarrhoea for 21 days. He asked if there has been blood in the child’s stool. The mother said, “No.” The health worker checked Rana for signs of dehydration. The child is irritable throughout the visit. Her eyes are not sunken. She drinks eagerly. The skin pinch goes back immediately.Record Rana’s signs and classify.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ CONVULSIONS Remember to use Danger sign when selecting classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood in the stool? 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck For how long? ___ Days Look for runny nose If more than 7 days, has fever been present every Look for signs of MEASLES: day? Generalized rash and Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Look for any other cause of fever. Do malaria test if NO general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P. falciparum P. vivaxNEGATIVE? If the child has measles now or within the Look for mouth ulcers. last 3 months: If yes, are they deep and extensive? Look for pus draining from the eye. Look for clouding of the cornea. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge? Feel for tender swelling behind the ear If Yes, for how long? ___ Days THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia16 with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

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4.4 CLASSIFY DIARRHOEA & DEHYDRATION HOW WILL YOU CLASSIFY FOR MAIN SYMPTOM DIARRHOEA? This main symptom has more than one classification table in the ASSESS AND CLASSIFY charts. You will now classify both diarrhoea and dehydration. When classifying: ✔✔ All children with diarrhoea are classified for dehydration ✔✔ If the child has had diarrhoea for 14 days or more, classify for persistent diarrhoea ✔✔ If the child has blood in the stool, classify the child for dysentery

DEHYDRATION: SICK CHILD & YOUNG INFANT HOW DO YOU CLASSIFY DEHYDRATION? There are three possible classifications for the type of diarrhoea. These are: 1. SEVERE DEHYDRATION 2. SOME DEHYDRATION 3. NO DEHYDRATION Open your Chart Booklet to the dehydration classification table. What do you observe? You will now read about these classifications and identified treatments. Does the child have diarrhoea?

Dehydration present. Pink: Treat dehydration before referral unless the and if diarrhoea 14 SEVERE child has another severe classification days or more PERSISTENT Refer to hospital DIARRHOEA No dehydration. Yellow: Advise the mother on feeding a child who has PERSISTENT PERSISTENT DIARRHOEA DIARRHOEA 17 Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

Blood in the stool. Yellow: Give ciprofloxacin for 3 days and if blood in stool DYSENTERY Follow-up in 2 days

Page 6 of 75 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SEVERE DEHYDRATION (RED) Classify as SEVERE DEHYDRATION if the child has two or more of the following signs: lethargic or unconscious, not able to drink or drinking poorly, sunken eyes, or very slow skin pinch.

What are your actions? Any child with dehydration needs extra fluids. A child classified with SEVERE DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids.The box “Plan C: Treat Severe Dehydration Quickly” on the TREAT chart describes how to give fluids to severely dehydrated children. You will learn more about Plan C in the next section.

SOME DEHYDRATION (YELLOW) If the child does not have signs of SEVERE DEHYDRATION, look at the next row. Does the child have signs of SOME DEHYDRATION? If the child has two or more of the following signs – restless, irritable; drinks eagerly, thirsty; sunken eyes; skin pinch goes back slowly – classify as SOME DEHYDRATION.

What are your actions? If a child has one sign in the red (top) row and one sign in the yellow (middle) row, classify the child in the yellow row (SOME DEHYDRATION). A child who has SOME DEHYDRATION needs fluid, foods, and zinc supplements. Treat the child with ORS solution. In addition to fluid, the child with SOME DEHYDRATION needs food. Breastfed children should continue breastfeeding. Other children should receive their usual milk or some nutritious food after 4 hours of treatment with ORS. The treatment is described in the box“Plan B: Treat Some Dehydration with ORS”. You will learn more about ORS and zinc supplements in the next section.

NO DEHYDRATION (GREEN) A child who does not have two or more signs in the red or yellow row is classified as having NO DEHYDRATION. This child needs extra fluid and foods to prevent dehydration. The four rules of home treatment are: 1. Give extra fluid 2. Give zinc supplements 3. Continue feeding 4. Return immediately if the child develops danger signs, drinks poorly, or has blood in stool

What are your actions? The treatment box called “Plan A: Treat Diarrhoea At Home” describes what fluids to teach the mother to give and how much she should give. A child with NO DEHYDRATION also needs food and zinc supplements. You will learn more about Plan A and zinc in the next section.

18 Does the child have diarrhoea?

Two of the following signs: Pink: If child has no other severe classification: If yes, ask: Look and feel: Lethargic or unconscious Give fluid for severe dehydration (Plan C) For how long? Look at the child's general SEVERE Sunken eyes DEHYDRATION OR Is there blood in the stool? condition. Is the child: for DEHYDRATION Not able to drink or If child also has another severe Lethargic or drinking poorly classification: unconscious? Classify DIARRHOEA Skin pinch goes back Refer URGENTLY to hospital with Restless and irritable? very slowly. mother giving frequent sips of ORS Look for sunken eyes. on the way Offer the child fluid. Is the Advise the mother to continue child: breastfeeding Not able to drink or If child is 2 years or older and there is drinking poorly? cholera in your area, give antibiotic for Drinking eagerly, cholera thirsty? Two of the following signs: Yellow: Give fluid, zinc supplements, and food for Pinch the skin of the Restless, irritable SOME some dehydration (Plan B) abdomen. Does it go back: Sunken eyes DEHYDRATION If child also has a severe classification: Very slowly (longer Drinks eagerly, thirsty Refer URGENTLY to hospital with than 2 seconds)? Skin pinch goes back mother giving frequent sips of ORS Slowly? slowly. on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA as some or severe NO diarrhoea at home (Plan A) dehydration. DEHYDRATION Advise mother when to return immediately Follow-up in 5 days if not improving After you classify dehydration, classify the child for persistent diarrhoea if the child Dehydration present. Pink: Treat dehydration before referral unless the and if diarrhoea 14 has had diarrhoea for 14 daysSEVERE or more. Thenchild you has classify another for severe dysentery. classification PERSISTENT Refer to hospital Does the child have diarrhoea? days or more DIARRHOEA DIARRHOEA: SICK CHILD TwoNo of dehydration. the following signs: Yellow:Pink: AdviseIf child hasthe motherno other on severe feeding classification: a child who has If yes, ask: Look and feel: Lethargic or unconscious PERSISTENT PERSISTENTGive fluid DIARRHOEAfor severe dehydration (Plan C) For how long? Look at the child's general HOW DO YOU CLASSIFY DYSENTERYSEVERE IN A CHILD? Sunken eyes DEHYDRATIONDIARRHOEA Give multivitamins andOR Is there blood in the stool? condition. Is the child: for DEHYDRATION Not able to drink or mineralsIf child also(including has another zinc) for 14severe days Lethargic or If the child has diarrhoea and any blood in the stool, you will classify as DYSENTERY. drinking poorly Follow-upclassification: in 5 days unconscious? Classify DIARRHOEA Review the classification table in your Chart Booklet. Skin pinch goes back Refer URGENTLY to hospital with Restless and irritable? very slowly. mother giving frequent sips of ORS Look for sunken eyes. Blood in the stool. Yellow: Giveon ciprofloxacin the way for 3 days Offer the child fluid. Is the and if blood in stool DYSENTERY Follow-upAdvise in the 2 days mother to continue child: breastfeeding Not able to drink or If child is 2 years or older and there is drinking poorly? A child with dysentery should be treated for choleradehydration. in your area,You shouldgive antibiotic also give for an Drinking eagerly, cholera thirsty? antibiotic recommended for Shigella in your area. Finding the actual cause of the Two of the following signs: Yellow: Give fluid, zinc supplements, and food for Pinch the skin of the dysentery requires a stool culture for which it can take at least 2 days to obtain the Restless, irritable SOME some dehydration (Plan B) abdomen. Does it go back: laboratorySunken eyes results. You willDEHYDRATION assume Shigella isIf the child cause also hasbecause: a severe classification: Very slowly (longer Drinks eagerly, thirsty Refer URGENTLY to hospital with than 2 seconds)? ✔✔ ShigellaSkin pinch causes goes back about 60% of dysentery casesmother seen in giving clinics. frequent sips of ORS Slowly? Page 6 of 75 slowly. on the way ✔✔ Shigella causes nearly all cases of life-threateningAdvise dysentery. the mother to continue breastfeeding Advise mother when to return immediately HOW DO YOU CLASSIFY PERSISTENT Follow-upDIARRHOEA in 5 days ifIN not A improving CHILD? IfNot the enough child signs has hadto classify diarrhoeaGreen: for 14 days orGive more fluid,, youzinc supplements,will classify and for food persistent to treat as some or severe NO diarrhoea at home (Plan A) diarrhoea.dehydration. Health workersDEHYDRATION often mismanageAdvise persistent mother when todiarrhoea, return immediately so these instructions are important: Follow-up in 5 days if not improving

Dehydration present. Pink: Treat dehydration before referral unless the and if diarrhoea 14 SEVERE child has another severe classification days or more PERSISTENT Refer to hospital DIARRHOEA No dehydration. Yellow: Advise the mother on feeding a child who has PERSISTENT PERSISTENT DIARRHOEA DIARRHOEA Give multivitamins and minerals (including zinc) for 14 days Follow-up in 5 days

Blood in the stool. Yellow: Give ciprofloxacin for 3 days and if blood in stool SEVERE PERSISTENT DIARRHOEADYSENTERY (RED)Follow-up in 2 days If a child has had diarrhoea for 14 days or more and also has some or severe dehydration, is classified SEVERE PERSISTENT DIARRHOEA. Children who are classified with SEVERE PERSISTENT DIARRHOEA should be referred to hospital.

What are your actions?

TreatPage 6 of 75 the child’s dehydration before referral unless the child has another severe classification. Treating dehydration in children with another severe disease can be difficult. These children should be treated in a hospital. These children need special attention to help prevent loss of fluid. They may need a change in diet. They may also need laboratory tests to identify the cause of the diarrhoea.

19 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

PERSISTENT DIARRHOEA (YELLOW) A child who has had diarrhoea for 14 days or more and who has no signs of dehydration is classified as having PERSISTENT DIARRHOEA.

What are your actions? Special feeding is the most important treatment for persistent diarrhoea.

DVD EXERCISE – JOSH CASE STUDY Watch “Case study Josh” (disc 1). This is a great way to practice assessing and classifying a child for general danger signs, respiratory problems, and diarrhoea. As you watch the video, complete the recording form below as you would a normal case. Assess and classify using this form and your Chart Booklet. Does Josh present with any general danger signs? How do you classify Josh for respiratory illness? How do you classify Josh’s diarrhoea?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ CONVULSIONS Remember to use Danger sign when selecting classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long? ___ Days Count the breaths in one minute ___ breaths per minute. Fast breathing? Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood in the stool? 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 slowsly (longer then 2 seconds)? Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck For how long? ___ Days Look for runny nose If more than 7 SELF-ASSESSMENTdays, has fever been present every EXERCISELook forC signs of MEASLES: day? Generalized rash and Has child had Answermeasels within the the questionslast 3 months? below aboutOne of these: assessing cough, runny and nose, classifying or red eyes diarrhoea and Look for any other cause of fever. Do malaria test if NOdehydration. general danger sign High risk: all fever cases Low risk: if NO obvious cause of fever Test POSITIVE? P.1. falciparum How many P. vivax signsNEGATIVE? are needed to classify a child with SOME DEHYDRATION? If the child has measles now or within the Look for mouth ulcers. last 3 months: If yes, are they deep and extensive? Look for pus draining from the eye. 2. Give two signs that may indicateLook for cloudingthat a of child the cornea. has SEVERE DEHYDRATION. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear pain? Look for pus draining from the ear Is there ear discharge? Feel for tender swelling behind the ear If Yes, for how long? ___ Days THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet. AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar20 pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is the child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

Page 65 of 75 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

3. What type of ORS should be used to treat dehydration?

4. Which children need zinc supplements?

5. What are the 4 rules of home treatment of diarrhoea?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS SELF-ASSESSMENT EXERCISE D Name: Age: Weight (kg): Temperature (°C): Ask: What are theAssess child's problems? and classify dehydration in these children. Be sure to circleInitial Visit? the signs youFollow-up Visit? ASSESS (Circle all signs present) CLASSIFY use to classify. CHECK FOR GENERAL DANGER SIGNS General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING1. PANO has had diarrhoea forCONVULSING five days. NOWHe has no blood in the stool. He is irritable.Yes ___ No ___ CONVULSIONS His eyes are sunken. His father and mother also think that Pano’s eyes are sunken.Remember to use Danger sign when The health worker offers Pano some water, and the child drinks eagerly. When selecting the health worker pinches the skin on the child’s abdomen, it goes back slowly.classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long? ___ Days Count the breaths in one minute Record the child’s signs and___ classificationbreaths per minute. Fast for breathing? dehydration on the Recording Form. Look for chest indrawing Look and listen for stridor Look and listen for wheezing DOES THE CHILD HAVE DIARRHOEA? Yes __ No __ For how long? ___ Days Look at the childs general condition. Is the child: Is there blood in the stool? Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? MANAGEMENT OF THE SICK CHILDDrinking eagerly, AGED thirsty? 2 MONTHS UP TO 5 YEARS Pinch the skin of the abdomen. Does it go back: Name: Age:Very slowsly (longer then 2 seconds)?Weight (kg): Temperature (°C): Ask: What are the child's problems? Slowly? Initial Visit? Follow-up Visit? ASSESS (Circle all signs present) DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) YesCLASSIFY __ No __ CHECKDecide malaria FOR risk: GENERAL High ___ Low DANGER ___ No___ SIGNS Look or feel for stiff neck General danger sign ForNOT how ABLE long? TO ___ DRINK Days OR BREASTFEED LETHARGICLook for runny OR nose UNCONSCIOUS present? IfVOMITS more than EVERYTHING 72. days, JANE has fever has been had present diarrhoea every forCONVULSINGLook 3 fordays. signs Thereof NOW MEASLES: was no blood in the stool. The childYes ___ No ___ day?CONVULSIONS was not lethargic or unconscious.Generalized She was rash andnot irritable or restless. Her eyes wereRemember to use Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes Danger sign when Look for any other cause of fever. Do malaria test if NO generalsunken. danger She sign was able to drink, but she was not thirsty. The skin pinch went back selecting High risk: all fever casesimmediately. classifications DOESLow risk: THE if NO CHILDobvious causeHAVE of COUGHfever OR DIFFICULT BREATHING? Yes __ No __ TestFor POSITIVE? how long? P. ___ falciparumRecord Days P. the vivax NEGATIVE?child’s signs andCount classification the breaths in one minutefor dehydration on the Recording Look___ breaths for mouth per ulcers. minute. Fast breathing? If the child has measles now or within the Look for chest indrawing last 3 months: Form. If yes, are they deep and extensive? Look forand pus listen draining for stridor from the eye. Look forand clouding listen for of wheezing the cornea. DOES THE CHILD HAVE ANDIARRHOEA? EAR PROBLEM? Yes __ No __ IsFor there how ear long? pain? ___ Days Look atfor the pus childs draining general from condition.the ear Is the child: Is there bloodear discharge? in the stool? FeelLethargic for tender or swelling unconscious? behind the ear If Yes, for how long? ___ Days Restless and irritable? Look for sunken eyes. Look for oedema of both feet. THEN CHECK FOR ACUTE MALNUTRITION Offer the child fluid. Is the child: Determine WFH/L _____ Z score. AND ANAEMIA Not able to drink or drinking poorly? For children 6 months or older measure MUAC ____ mm. Drinking eagerly, thirsty? Look for palmar pallor. Pinch the skin of the abdomen. Does it go back: Severe palmar pallor? Some palmar pallor? Very slowsly (longer then 2 seconds)? Is there any medical complication? If child has MUAC less than 115 mm or Slowly? WFH/L less than -3 Z scores or oedema of General danger sign? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)Any severe classification? Yes __ No __ bothDecide feet:malaria risk: High ___ Low ___ No___ LookPneumonia or feel for stiffwith neck chest indrawing? For how long? ___ Days ForLook a child for runny 6 months nose or older offer RUTF to eat. Is the child: If more than 7 days, has fever been present every LookNot for able signs to21 offinish MEASLES: or able to finish? day? For aGeneralized child less than rash 6 andmonths is there a breastfeeding problem? Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes CHECK FOR HIV INFECTION Look for any other cause of fever. Do malariaNote mother's test if NO and/or general child's danger HIV status sign High risk:Mother's all fever HIV cases test: NEGATIVE POSITIVE NOT DONE/KNOWN Low risk:Child's if NO virological obvious cause test: ofNEGATIVE fever POSITIVE NOT DONE Test POSITIVE?Child's serological P. falciparum test: NEGATIVEP. vivaxNEGATIVE? POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: If the Ischild the child has breastfeeding measles now?now or within the Look for mouth ulcers. last 3Was months: the child breastfeeding at the time of test or 6 weeks beforeIf yes, it?are they deep and extensive? If breastfeeding: Is the mother and child on ARV prophylaxis?Look for pus draining from the eye. Look for clouding of the cornea. CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: Is there ear pain? Look for pus draining from the ear OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______Is there ear discharge?Hep B1 Hep B2 Hep FeelB3 for tender swelling behind the ear (Date) HepIf B0Yes, for how long? ___ Days RTV-1 RTV-2 RTV-3 Look for oedema of both feet. THEN CHECK FORPneumo-1 ACUTE MALNUTRITIONPneumo-2 Pneumo-3 AND ANAEMIA Determine WFH/L _____ Z score. For children 6 months or older measure MUAC ____ mm. Look for palmar pallor. Severe palmar pallor? Some palmar pallor? If child has MUAC less than 115 mm or Is there any medical complication? WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification? both feet: Pneumonia with chest indrawing? For a child 6 months or older offer RUTF to eat. Is thePage 65 of 75 child: Not able to finish or able to finish? For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

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CHECK FOR JAUNDICE

If jaundice present, ASK: LOOK AND FEEL: n How Anywill jaundice you classify if age less Mary’sPink: diarrhoea? Treat to prevent low blood sugar When did the jaundice Look for jaundice (yellow than 24 hours or SEVERE Refer URGENTLY to hospital appear first? eyes or skin) CLASSIFY Mary has hadYellow diarrhoea palms and for soles 3 days, at whichJAUNDICE is an acute episodeAdvise of diarrhoea. mother how She to does keep not the have infant persistent JAUNDICE Look at the young infant's diarrhoea,any which age lasts 14 days or more. She does not have warmdysentery, on the as way there to isthe no hospital blood in the stool. palms and soles. Are they Jaundice appearing after Yellow: Advise the mother to give home care for the yellow? Every child with diarrhoea is also classified for dehydration. 24 hours of age and JAUNDICE young infant n How Palmswill youand soles classify not Mary’s dehydration? Advise mother to return immediately if palms yellow and soles appear yellow. When you assessed Mary, you observed the following signs:If the young infant is older than 14 days, refer to a hospital for assessment — She has sunken eyes Follow-up in 1 day — SheNo is jaundiceeager to drink Green: Advise the mother to give home care for the NO JAUNDICE young infant — Her skin pinch goes back slowly With these signs, you classify Mary with SOME DEHYDRATION. Look at your classification table. What do you observe about the identified treatments for this classification? THEN ASK: Does the young infant have diarrhoea*?

IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification: Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C) Infant's movements Classify stimulated or no DEHYDRATION OR Does the infant move on his/her own? DIARRHOEA for movement at all If infant also has another severe Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification: then stops? Skin pinch goes back Refer URGENTLY to hospital with Does the infant not move at all? very slowly. mother giving frequent sips of ORS on Is the infant restless and irritable? the way Look for sunken eyes. Advise the mother to continue breastfeeding Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Two of the following signs: Yellow: Give fluid and breast milk for some or slowly? Restless and irritable SOME dehydration (Plan B) Sunken eyes DEHYDRATION If infant has any severe classification: Skin pinch goes back Refer URGENTLY to hospital with slowly. mother giving frequent sips of ORS on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 2 days if not improving Not enough signs to classify Green: Give fluids to treat diarrhoea at home and as some or severe NO continue breastfeeding (Plan A) dehydration. DEHYDRATION Advise mother when to return immediately Follow-up in 2 days if not improving

* What is diarrhoea in a young infant? You tell Ana that Mary has some dehydration. It is not serious enough to send her to the hospital. You can A young infant has diarrhoea if the stools have changed from usual pattern and are many andbegin watery treatment (more water at thanthe clinic, fecal matte and sher). can continue treatment at home. Ana looks relieved. The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea. You will now learn more about treatment in the next section. Page 44 of 75

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4.5 TREAT THE CHILD WITH DIARRHOEA Children with diarrhoea are treated for dehydration. They are also treated for their diarrhoea, if they have persistent diarrhoea or dysentery.

WHAT TREATMENTS ARE IDENTIFIED FOR DIARRHOEA AND DEHYDRATION? Open your classification tables for dehydration, persistent diarrhoea, and dysentery and review the “IDENTIFY TREATMENT” columns. Thecolour-coded classifications also indicate where the treatment can be delivered – by urgent referral, at the clinic, or at home. Identified treatments are listed below. These are all new treatments, so you will learn about all of them in this section: ✔✔ Plans A, B, and C for giving fluids and food ✔✔ Giving ORS for dehydration ✔✔ Zinc supplementation ✔✔ Ciproflaxacin for dysentery

DEHYDRATION: SICK CHILD & YOUNG INFANT HOW DO YOU TREAT DEHYDRATION? When you classified the severity of dehydration, you identified the appropriate treatment to replenish fluids or prevent dehydration. There are three plans to provide fluid and replace water and salts lost in diarrhoea: n PLAN A – treat diarrhoea at home n PLAN B – treat SOME DEHYDRATION with low osmolarity oral rehydration salts (ORS) n PLAN C – treat SEVERE DEHYDRATION quickly with intravenous (IV) fluids In the following pages, you will now learn how to give Plans A, B, and C.

PLAN C (SEVERE DEHYDRATION) Urgent treatment

PLAN B (SOME DEHYDRATION) Treat at clinic

PLAN A (NO DEHYDRATION) Treat at home

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PLAN C (SEVERE DEHYDRATION) Urgent treatment

HOW IS PLAN C GIVEN? Severely dehydrated children and young infants need to have water and salts quickly replaced. Plan C requires rapid hydration using IV fluids or a nasogastric (NG) tube. It is important to note that rehydration therapy using IV fluids or using a nasogastric (NG) tube is recommended only for children who have SEVERE DEHYDRATION.

WHERE IS PLAN C GIVEN? Open to Plan C in your Chart Booklet. There is a flow chart determining where is the safest place to treat the severely dehydrated child. You will observe that the treatment of the severely dehydrated child depends on: n Type of available equipment at your clinic or at a nearby clinic or hospital, n Training you have received n If the child can drink

IN YOUR CLINIC, WHERE IS THE SAFEST PLACE TO GIVE PLAN C? This is important for you to determine based on available equipment and your training. If you cannot give IV or NG fluid and the child cannot drink, refer the child urgently to the nearest hospital that can give IV or NG treatment. If IV (intravenous) treatment is available within a 30-minute drive, refer urgently to hospital for treatment with IV fluids. On the way to hospital, have the mother offer frequent sips of ORS to her sick child.

Are you able to provide Plan C in your clinic? If not, where will you refer?

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PLAN B (SOME DEHYDRATION) Treat at clinic

A child or young infant with some dehydration needs fluid, zinc supplementation, and food. You will give zinc just as you will for Plan A.

HOW IS PLAN B GIVEN? Plan B begins with a 4-hour treatment period at the clinic. During the 4 hours, the mother slowly gives a recommended amount of ORS solution. If a child who has SOME DEHYDRATION needs treatment for other problems, you should start treating the dehydration first. Then provide the other treatments. After the 4 hours, you will reassess and classify the child’s dehydration. If the signs are gone, put the child on Plan A for home treatment. If there is still some dehydration, the child repeats Plan B. If the child now has SEVERE DEHYDRATION, put the child on Plan C.

WHAT HAPPENS IF A CHILD HAS A SEVERE CLASSIFICATION AND NEEDS PLAN B? A child who has a severe classification and SOME DEHYDRATIONneeds urgent referral to hospital.1 Do not try to rehydrate the child before he leaves. Quickly give the mother some ORS solution. Show her how to give frequent sips to child on the way to the hospital.

HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS IN THE CLINIC? Now study Plan B in your TREAT THE CHILD section. It contains the following instructions: 1. DETERMINE AMOUNT of ORS to give during first 4 hours. Use the chart in Plan B to determine how much ORS to give. To find the recommended amount, look below the child’s weight (or age only if the weight is not known). The child will usually want to drink as much as he needs. If the child wants more or less than the estimated amount, give him what he wants. The mother should also breastfeed whenever the baby wants to, then resume the ORS solution. 2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. Find a comfortable place in the clinic for the mother to sit with her child. Tell her how much ORS solution to give over the next 4 hours. Show her the amount in units that are used in your area. If the child is less than 2 years, show her how to give a spoonful frequently. If the child is older, show her how to give frequent sips from a cup. Sit with her while she gives the child the first few sips from a cup or spoon. Ask her if she has any questions.

1 The exception is a child with the severe classification, SEVERE PERSISTENT DIARRHOEA. This child should be rehydrated then referred.

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REFRESH: how do you decide amount of ORS to give? 1. Use chart in Plan B with child’s weight 2. If no chart, multiple child’s weight (kg) by 75 (Example: 8 kg child x 75 ml = 600 ml)

WHAT WILL YOU DO WHILE THE MOTHER GIVES ORS FOR 4 HOURS? n Show the caregiver where to wash her hands, and where she can change the child’s nappy or where the child can use a toilet. n Check with the mother from time to time to see if she has problems. If the child is not drinking the ORS solution well, try another method of giving the solution. You may try using a dropper or a syringe without the needle. n This also provides valuable time to teach the mother about care for her child. The first concern is to rehydrate the child. When the child is obviously improving, the mother can turn her attention to learning. Teach her about mixing and giving ORS solution (Plan A). n It is a good idea to have printed information that the mother can study while she is sitting with her child. Posters on the wall can also reinforce this information.

TIPS FOR THE YOUNG INFANT During the first 4 hours of rehydration, encourage the mother to pause to breastfeed the infant whenever the infant wants, then resume giving ORS. Give a young infant who does not breastfeed an additional 100–200 ml clean water during this period.

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HOW WILL YOU REASSESS THE CHILD AFTER 4 HOURS? After four hours you will reassess the child using the ASSESS AND CLASSIFY chart. Classify the dehydration. Choose the appropriate plan to continue treatment. If the child is not taking the ORS solution, or seems to be getting worse, reassess before four hours. Depending on your classifications, you will take further action: n If the child has NO DEHYDRATION, move to Plan A. Counsel on home care. n If the child has SOME DEHYDRATION, choose Plan B again. Begin feeding the child in clinic. Offer food, milk, or juice. Continue to breastfeed frequently if child is breastfed. n If the child is worse and now has SEVERE DEHYDRATION, begin Plan C. If the child’s eyes are puffy, it is a sign ofoverhydration . It is not a danger sign or a sign of hypernatraemia. It is simply a sign that the child has been rehydrated and does not need any more ORS solution at this time. The child should be given clean water or breastmilk, and ORS according to Plan A when the puffiness is gone.

WHAT HAPPENS IF A CAREGIVER MUST LEAVE BEFORE FINISHING 4 HOURS OF ORS? 1. Show the caregiver how to prepare ORS solution and have her practice. 2. Show her how much ORS to give to complete the 4-hour treatment at home. 3. Give her packets to complete rehydration PLUS 2 more packets as recommended in Plan A. 4. Explain 4 rules of home treatment

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SELF-ASSESSMENT EXERCISE E Answer the following questions about PLAN B for dehydrated children. 1. The following children are classified SOME DEHYDRATION. Write the range of amounts of ORS solution each child is likely to need in the first 4 hours of treatment:

Name Age or Weight Range of Amounts of ORS Solution a. Andras 3 years b. Gul 10 kg c. Nirveli 7.5 kg d. Sami 11 months

2. Vinita is 5 months old and has diarrhoea. She is classified as SOME DEHYDRATION. There is no scale for weighing Vinita at the small clinic. Vinita’s mother died during childbirth, so Vinita has been taking infant formula. The grandmother has recently started giving cooked cereal as well. a. Vinita should be given ml of during the first hours of treatment. She should also be given ml of during this period. b. What should the grandmother do if Vinita vomits during the treatment?

c. When should the health worker reassess Vinita?

d. When Vinita is reassessed, she has NO DEHYDRATION. What treatment plan should Vinita be put on?

3. Yasmin is 9 months old and weighs 8 kg. Her mother brought her to the clinic with diarrhoea. The health worker assesses Yasmin as SOME DEHYDRATION. The health worker chooses Plan B. He asks if Yasmin still breastfeeds. Her mother says that she breastfeeds several times each day. She also eats 3 meals each day of rice along with vegetables, pulses, and sometimes bits of meat. a. Approximately how much ORS solution should Yasmin’s mother give her during the first 4 hours?

b. During the first 4 hours of treatment, should Yasmin eat or drink anything in addition to the ORS solution? If so, what?

c. After 4 hours of treatment, the health worker reassesses Yasmin. She is still classified as SOME DEHYDRATION. What is the appropriate plan to continue her treatment?

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PLAN A (NO DEHYDRATION) Treat at home

A child with diarrhoea but no dehydration requires fluid, zinc, and food to prevent dehydration. This child can be treated at home with Plan A.

WHAT IS PLAN A? Plan A is based on the four rules of home treatment. These are critical for you to remember. Plan A requires you to counsel the child’s mother about the 4 rules of home treatment. As such, your teaching and advising skills are an important part of Plan A. Plan A is also an important treatment plan because eventually, all children with diarrhoea will require Plan A. Children with diarrhoea who come to a health worker with NO DEHYDRATION are put on Plan A right away. Child with more serious dehydration will first be treated with Plan B or C, and then they will be put on Plan A.

WHAT ARE THE 4 RULES OF HOME TREATMENT? The four rules of home treatment are very important to remember: 1. Give extra fluid – as much as the child will take 2. Give zinc 3. Continue feeding 4. When to return (for a follow-up visit, or immediately if danger signs develop) Now you will learn more about the four rules of home treatment. Open to Plan A in your Chart Booklet to read along with the instructions.

RULE 1: GIVE EXTRA FLUID

Tell the caregiver to give as much fluid as the child will take. It is very important for the child to have extra fluid – as much as the child will take. The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to prevent dehydration. The critical action is to give more fluid than usual, as soon as the diarrhoea starts.

HOW SHOULD THE CAREGIVER GIVE EXTRA FLUID? Tell the mother that breastfeeding should continue, with the addition of ORS and clean water. If the child is exclusively breastfed, it is important for this child to be breastfed more frequently than usual. Breastfed children under 4 months should first be offered a breastfeed then given ORS. If the child is not being breastfed, the child should receive ORS solution, food- based fluids (soup, rice water, yoghurt drinks), and clean water. In your country, the national programme for diarrhoeal disease control may have specified several food-based fluids to use at home.

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TIPS FOR THE YOUNG INFANT n If infant is exclusively breastfed, it is important not to introduce a food-based fluid. n If infant will be given ORS solution at home, you will show how much ORS to give the infant after each loose stool. Mother should first offer a breastfeed, then give ORS.

HOW WILL YOU TEACH THE CAREGIVER TO MIX ORS? Teach the caregiver how to mix and give ORS. Ask the caregiver to practice doing it as you observe. The steps for making ORS are (follow along in drawings below): ✔✔ Wash your hands with soap and water ✔✔ Pour all the powder from one packet into a clean container. Use any available container, such as a jar, bowl or bottle. ✔✔ Measure 1 litre of clean water (or correct amount for packet used). It is best to boil and cool the water, but if this is not possible, use the cleanest drinking water available. ✔✔ Pour the water into the container. Mix well until the powder is completely dissolved. ✔✔ Taste the solution so you know how it tastes. The caregiver should mix fresh ORS every day, in a clean container. She should keep the container covered. She should throw away any solution remaining from the day before.

1 litre bottle

HOW WILL THE CAREGIVER GET ORS TO USE IN THE HOME? Give the caregiver 2 packets of ORS to use at home. Show her how much fluid should be given in addition to the usual fluid intake: n Up to 2 years: 50–100 ml after each loose stool n 2 years or older: 100–200 ml after each loose stool

HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS? Finally, give the caregiver instructions for giving ORS: 1. Give frequent small sips from a cup 2. If child vomits, wait 10 minutes. Then continue, but more slowly. 3. Continue giving extra fluid until the diarrhoea stops

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WHEN IS ORS ESPECIALLY IMPORTANT? It is especially important to give ORS at home when: ✔✔ Child was treated with Plan B or C during this visit – in other words, the child has just been rehydrated and needs ORS to prevent dehydration from coming back ✔✔ Child cannot return to the clinic if the diarrhoea gets worse – for example, if the family lives far away or the mother has a job that she cannot leave

RULE 2: GIVE ZINC SUPPLEMENTS Zinc treatment can considerably reduce the duration and severity of a child’s diarrhoeal episode. It is also shown to decrease stool output and decrease the need to hospitalize a child with diarrhoea. Zinc is only given to children 2 months up to 5 years. This box describes how much zinc to give a child with diarrhoea. Review this information in Plan A in your Chart Booklet.

GIVE ZINC SUPPLEMENTS (one tablet is 20 mg zinc) Remind the caregiver to give zinc supplements for the full 14 days Tell the caregiver how much zinc to give Up to 6 months: ½ tablet per day, for 14 days 6 months or older: 1 tablet per day, for 14 days Show the caregiver how to give zinc supplements Infants: dissolve the tablet in a small amount of breast milk, ORS, or clean water in a small cup or spoon Older children: tablets can be chewed or dissolved in small amount of clean water in a cup or spoon

RULE 3: CONTINUE FEEDING You will learn more about special feeding recommendations if the child has persistent diarrhoea.

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RULE 4: WHEN TO RETURN You have learned the signs when a caregiver should return immediately to a health worker. Tell the mother of any sick child that the signs to return are: •• Not able to drink or breastfeed •• Becomes sicker •• Develops a fever If the child has diarrhoea, also tell the mother to return if the child has: •• Blood in stool •• Drinking poorly – also includes not able to drink or breastfeed

SELF-ASSESSMENT EXERCISE F Answer the following questions about PLAN A for children with diarrhoea. 1. At your clinic, what are the recommended fluids for children with diarrhoea with NO DEHYDRATION?

2. Somi is a 4-year-old boy who has diarrhoea. He has no general danger signs. He was classified as having diarrhoea with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. He will be treated according to Plan A. a. What are the 4 rules of home treatment of diarrhoea?

b. What fluids should the health worker tell his mother to give?

3. Kasit is a 3-month-old boy who has diarrhoea. He has no general danger signs. He was classified as NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. He is exclusively breastfed. What should the health worker tell his mother about giving him extra fluids?

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4. For which children with NO DEHYDRATION is it especially important to give ORS at home?

5. The following children came to the clinic because of diarrhoea. They were assessed and found to have no general danger signs. They were classified as NO DEHYDRATION. Write the amount of extra fluid that the mother should give after each stool.

Name Age Amount of extra fluid to give after each loose stool a. Kala 6 months b. Sam 2 years c. Kara 15 months d. Lalita 4 years

DIARRHOEA: SICK CHILD Treatment is required for children who have persistent diarrhoea or dysentery.

HOW WILL YOU TREAT SEVERE PERSISTENT DIARRHOEA? Children with this classification have persistent diarrhoea (14 days or longer) and signs of dehydration. These children should be referred to hospital. They need special attention to prevent fluid loss. You should treat dehydration before referral, unless child has another severe classification.

HOW WILL YOU TREAT PERSISTENT DIARRHOEA? Children with this classification have persistent diarrhoea (14 days or longer) and no signs of dehydration. Special feeding is the most important treatment for persistent diarrhoea with no signs of dehydration. Children with persistent diarrhoea may have difficulty digesting milk other than breastmilk. They need to temporarily reduce the amount of other milk in their diet. Special feeding advice for a child with PERSISTENT DIARRHOEA includes: ✔✔ 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 yogurt, OR — Replace half the milk with nutrient-rich semi-solid food. ✔✔ For other foods, follow feeding recommendations for the child’s age: give small, frequent meals (at least 6 times a day), and avoid very sweet foods or drinks. The child also should receive zinc for 14 days. The child should follow up in 5 days.

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HOW WILL YOU TREAT DYSENTERY? Children with dysentery should receive ciprofloxacin for 3 days (or another oral antibiotic recommended for Shigella in your area). The box “Give an Appropriate Oral Antibiotic” on the TREAT THE CHILD chart tells the recommended antibiotics. Refer to Module 3 to review counselling the caregiver on oral medicines. They should also receive zinc supplements. Zinc should be given in the same way that you learned previously in Plans A and B. Treat dehydration as classified. Children should follow-up for the dysentery in 2 days.

WHEN SHOULD ANTIBIOTICS BE USED FOR DIARRHOEA? Antibiotics are not effective in treating most diarrhoea. They rarely help and make some children sicker. Unnecessary use of antibiotics may increase the resistance of some pathogens. In addition, antibiotics are costly. Money is often wasted on ineffective treatment. Therefore, do not give antibiotics routinely. The only types of diarrhoea that should be treated with antibiotics are DYSENTERY and diarrhoea with SEVERE DEHYDRATION with cholera in the area.

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SELF-ASSESSMENT EXERCISE G Answer the questions below about treatment for diarrhoea and dehydration. 1. How will you give zinc supplements to a 4 month old infant, weight 7.3 kg, with SOME DEHYDRATION?

2. How will you give zinc supplements to a 37 month old infant, weight 12 kg, with NO DEHYDRATION?

3. How would you treat a 9 month old, weighing 8.3 kg, with a classification of DYSENTERY?

4. How would you treat a 36 month old, weighing 15 kg, with a classification of DYSENTERY?

5. How would you treat a 7 month old with SEVERE PERSISTENT DIARRHOEA?

6. You are talking with the mother of a 15-month-old child who is no longer breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feedings of cow’s milk and 1 meal of family foods each day. His diet has not changed during the diarrhoea. Which of the following are appropriate to say when counselling this mother? Tick appropriate comments.  a. You were right to keep feeding your child during the diarrhoea. He needs food to stay strong.  b. Your child needs more food each day. Try to give him 3 family meals plus 2 feedings between meals.  c. Cow’s milk is very bad for your child.  d. Your child may be having trouble digesting the cow’s milk, and that may be the reason that the diarrhoea has lasted so long.  e. Give your child yoghurt instead of milk (until follow-up visit in 5 days). Or give only half the usual milk and increase the amount of family foods to make up for this.

35 Does the child have diarrhoea?

Two of the following signs: Pink: If child has no other severe classification: If yes, ask: Look and feel: Lethargic or unconsciousIMCI DISTANCE LEARNING COURSE | MODULEGive 4.fluid DIARRHOEA for severe dehydration (Plan C) For how long? Look at the child's general SEVERE Sunken eyes DEHYDRATION OR Is there blood in the stool? condition. Is the child: for DEHYDRATION Not able to drink or If child also has another severe Lethargic or drinking poorly classification: unconscious? Classify DIARRHOEA Skin pinch goes back Refer URGENTLY to hospital with Restless and irritable? n Whatvery slowly. treatment will Mary require? mother giving frequent sips of ORS Look for sunken eyes. on the way Mary has an acute episode of diarrhoea lasting for 3 days, and there is no blood in the stool, so you did not Offer the child fluid. Is the Advise the mother to continue classify her for persistent diarrhoea or dysentery. child: breastfeeding Not able to drink or You classified Mary’s dehydration as SOME DEHYDRATION. IfReview child whatis 2 treatmentsyears or older were identifiedand there for is SOME drinking poorly? DEHYDRATION. cholera in your area, give antibiotic for Drinking eagerly, cholera thirsty? Two of the following signs: Yellow: Give fluid, zinc supplements, and food for Pinch the skin of the Restless, irritable SOME some dehydration (Plan B) abdomen. Does it go back: Sunken eyes DEHYDRATION If child also has a severe classification: Very slowly (longer Drinks eagerly, thirsty Refer URGENTLY to hospital with than 2 seconds)? Skin pinch goes back mother giving frequent sips of ORS Slowly? slowly. on the way Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat Youas willsome remember or severe from this section that SOMENO DEHYDRATIONdiarrhoea requires at Planhome B for(Plan fluids, A) foods, and zinc. Plan Bdehydration. will require Ana to give ORS to MaryDEHYDRATION for 4 hours in the clinic,Advise then youmother will whenre-assess to return Mary’s immediately dehydration. Open your Chart Booklet to review Plan B. Follow-up in 5 days if not improving The steps of Plan B are: Dehydration present. Pink: Treat dehydration before referral unless the 1. Determine the amount of ORS to give for the first 4 hours in the clinic. Mary is 8 kg and 9 months old. child has another severe classification and if diarrhoea 14 We review the chart in Plan B and decideSEVERE that she should receive between 450 and 800 ml of ORS. If we Refer to hospital days or more had calculated with the second method,PERSISTENT multiplying her weight 8 kg by 75 ml, we would have calculated DIARRHOEA 560 ml, which is within the chart range. No dehydration. Yellow: Advise the mother on feeding a child who has 2. Teach Ana how to give the ORS solution. You explain to Ana that Mary has diarrhoea with some PERSISTENT PERSISTENT DIARRHOEA dehydration. She needs fluids and food. You ask Ana to stay at the clinic to give Mary ORS solution. Show DIARRHOEA Give multivitamins and Ana how much ORS to give from a cup. minerals (including zinc) for 14 days You take Ana to a corner where she can sit with Mary andFollow-up give the ORS. in 5 Youdays show her where you can wash her hands, and where she can change Mary or use the toilets. You make sure she is comfortable. She does not have any questions for you, but it worried about staying too late at the clinic because her husband willBlood worry. in theYou stool. assure her that sheYellow: can give all of the ORSGive now, ciprofloxacinand then you will for work 3 days with her to decide and if blood in stool about treatment later tonight at home.DYSENTERY Ana props Mary onFollow-up her lap. Shein 2 slowlydays begins to give her ORS from a cup. You also encourage Ana to breastfeed if Mary wants to. 3. After 4 hours, you reassess Mary. She had NO DEHYDRATION. Her diarrhoea continued, but you think that she is ready to go home on Plan A. Plan A will also include giving zinc and food.

Page 6 of 75

36 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.6 COUNSEL THE CAREGIVER Good teaching and advising skills are particularly important when treating dehydration and diarrhoea. As you read in the previous section on treatment, the caregiver gives many of the treatments in the clinic or at home. This requires you to teach them how to give the treatment.

WHAT ARE THE 4 RULES OF HOME TREATMENT? It is very important to counsel caregivers on the 4 rules of home treatment. This is required for Plan A. Child classified with NO DEHYDRATION need Plan A. After children who required Plan B or C have completed this plan, they will also require Plan A at home. 1. Give extra fluid – as much as the child will take 2. Give zinc 3. Continue feeding 4. When to return (for a follow-up visit, or immediately if danger signs develop)

RULE 1. How will you counsel a caregiver to give extra fluid? You will tell a caregiver that during illness, a child loses fluid due to fever, fast breathing, or diarrhoea. The child will feel better and stay stronger if he drinks extra fluid to prevent dehydration. Extra fluid is especially important for children with diarrhoea.

FIRST, TELL THE CAREGIVER TO GIVE AS MUCH FLUID AS THE CHILD WILL TAKE. The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to prevent dehydration. The critical action is to give more fluid than usual as soon as the diarrhoea starts. More fluid can be given by: •• Breastfeeding more frequently, and for longer feeds. If the child is exclusively breastfed, also give ORS or clean water in addition. •• If child is not breastfed, increase fluid with food-based fluids (soup, rice water, yoghurt drinks), or ORS •• ORS is especially important at home if the child was treated on Plan B or C, or if the child cannot return to the clinic if the diarrhoea gets worse

SECOND, teach the caregiver how to mix and give ORS. Review these teaching steps in the previous TREAT section. Ask the caregiver to practice doing it as you observe. You will review these steps, which are also discussed in Plan B in the previous section: 1. Wash hands with soap and water 2. Pour the ORS powder into a clean container

37 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

3. Measure 1 litre of water (or specified amount). It is best to boil and cool water. 4. Pour the water into the container with the powder. Mix and taste. 5. Give solution to the child slowly, by cup. If the child vomits, wait for 10 minutes and then continue more slowly. 6. Always make fresh ORS solution each day. Keep the solution covered.

RULE 2. How will you counsel a caregiver to give zinc? Your TREAT chart and the previous section describe how much zinc to give a child with diarrhoea. Zinc is only given to children 2 months up to 5 years. Show the mother how to give the zinc to her baby with diarrhoea. For example, infants can be given the tablet dissolved in a small amount of expressed breast milk ORS, or clean water in a cup. Older children can chew the tablet or take it in a small amount of clean water. The mother should give her child the first zinc supplement. If a child is 2 months up to 6 months, he can have half a 20 mg tablet daily for 14 days. A child 6 months or older can take a whole 20 mg tablet. Explain how she will continue to give this treatment for 14 days. Check her understanding with checking questions, and answer any problems she has.

RULE 3. How will you counsel a caregiver to continue feeding? The caregiver should continue feeding, as explained in the previous TREAT section. You will also remember that children with persistent diarrhoea have special feeding needs. If may be difficult for these children to digest milk other than breast milk. Caregivers need to temporarily reduce the amount of other milk in the child’s diet. To make up for this reduction, the child must take more breast milk or other foods. Continue other foods appropriate for the child’s age. The child with persistent diarrhoea should be seen again in 5 days for follow-up, and will be given further feeding instructions during this visit.

RULE 4. How will you counsel a caregiver to return to clinic? You will advise on follow-up care as you would with all other conditions. Remember that if the child is required to follow up for more than one illness, they should return for follow-up at the earliest definite date. The child should follow up:

Immediately if  The child is not able to breastfeed or drink  Becomes sicker  Develops a fever  Has blood in the stool In 3 days if The child has dysentery In 5 days if The child has persistent diarrhoea

38 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE H Complete this case study. CASE STUDY: Health worker Basaka must teach a mother to prepare ORS solution for her child with diarrhoea. First he explains how to mix the ORS, then he shows her how to do it. He asks the mother, “Do you understand?” The mother answers “yes”. So Basaka gives her 2 ORS packets and says good-bye. 1. What are the four rules of home treatment that must be explained to the mother?

2. What information did Basaka give the mother about the task?

3. Did he show her an example?

4. Did he ask her to practice?

5. How did Basaka check the mother’s understanding?

6. Did Basaka check the mother’s understanding correctly?

7. How would you have checked the mother’s understanding?

39 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

SELF-ASSESSMENT EXERCISE I Answer these questions about counselling a caregiver. 1. A 4-year-old boy has diarrhoea. He has no general danger signs. He was classified with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT. The health worker has taught his mother Plan A and given her 2 packets of ORS to use at home. Tick all the fluids that the mother should encourage her son to drink as long as the diarrhoea continues.  Tea that the child usually drinks with meals  Fruit juice that the child usually drinks each day  Water from the water jug. The child can get water whenever he is thirsty.  ORS after each loose stool  Yoghurt drink when the mother makes some for the family 2. A mother brought her 11-month-old daughter, Aviva, to the clinic because she has diarrhoea. Aviva usually eats cereal and bits of meat, vegetables and fruit. Her mother has continued to breastfeed her as well. The mother says she lives far from the clinic and might not be able to come back for several days, even if the child gets worse. The health worker assesses Aviva and finds she has no general danger signs and no other disease classifications. He classifies her as NO DEHYDRATION. He decides Aviva needs treatment according to Plan A. a. Should the health worker give this mother ORS packets to take home? If so, how many one-litre packets should he give?

b. What should the mother do if the child vomits while being fed the solution?

c. How long should Aviva’s mother continue giving extra fluid?

d. The health worker will tell the mother to continue feeding Aviva. He will also teach her the signs to return immediately. What signs should the health worker teach Aviva’s mother?

3. Which of the following is the best checking question after advice about increasing fluids during diarrhoea? Tick( one.) a.  Do you remember some good fluids to give your child? b.  Will you be sure to give your child extra fluid? c.  How much fluid will you give your child

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n What do you advise Ana about home treatment? You classified Mary withSOME DEHYDRATION and gave her Plan B in the clinic. You re-assessed after Ana had been giving her ORS for 4 hours, and Mary showed signs of NO DEHYDRATION. You will now counsel Ana on home treatment of diarrhoea with Plan A. You give Ana a Mothers’ Card to take home. This card reminds her of important information like what fluids and food to give her child. n What are the 4 rules of home treatment you will teach Ana? 1. You tell Ana to give extra fluid, as much as Mary will take. This will include breast milk, clean water, ORS, or food-based fluids such as soup, rice water, yogurt drinks. You ask Ana which of these options she will use to give Mary more fluid. Ana says that Mary takes rice water well, and she will still breastfeed. She will also try to get some yogurt from a neighbour who makes some. You remind Ana to breastfeed as often as Mary will. You previously taught Ana how to make the ORS when you were preparing it in the clinic. You ask her checking questions to make sure she remembers how to make it. — You ask, “How much clean water do you need for 1 packet of ORS?” Ana says, “1 litre.” — You ask, “How will you give the ORS?” Ana says, “With a cup, as she sits in my lap.” — You also ask Ana, “How often will you give ORS?” “What will you do if Mary vomits?” You remind Ana that if Mary vomits, she should wait 10 minutes, then continue again, but more slowly. You give Ana 2 packets of ORS to take home. 2. You advise Ana how to give Mary zinc tablets. Mary is 9 months old, so she will take 1 full tablet a day for 14 days. You show Ana how to dissolve the tablet in a spoon with breast milk or clean water. You explain why you are giving zinc to Ana, that it is a good nutrient for the body that will help with Mary’s diarrhoea. 3. You advise Ana to continue feeding, and that Mary should get between 50–100 ml of solution after each loose bowel movement. 4. You advise Ana to return to the clinic immediately if Mary develops the following: she is not able to breastfeed or drink, she becomes sicker, she develops a fever, she has blood in the stool. You use Ana’s Mother’s Card to demonstrate these signs. Mary does not have other illnesses that require specific follow- up, or else you would have given them a specific date to return. Your conversation with Ana also gives her a chance to ask questions. Your checking questions gave you an idea of how much she understands home treatment. After you talk with Ana, you feel confident that she understands home treatment, and you say goodbye to her and Mary.

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4.7 PROVIDE FOLLOW-UP CARE FOR DIARRHOEA DO YOU REMEMBER THE STEPS FOR PROVIDING FOLLOW-UP CARE? First, you will re-assess your earlier classifications. Is the child:  Improving?  The same?  Worsening? Second, you will reassess the child using IMCI to see if there are any new issues. You will use a second recording form for this visit.

DIARRHOEA IN SICK YOUNG INFANT (FOLLOW-UP 2 DAYS) When an infant with diarrhoea follows-up in 2 DAYS, you will: ✔✔ ASK – Has the diarrhoea stopped?

 DIARRHOEA HAS STOPPED Tell the mother to continue exclusive breastfeeding. If the infant’s signs are improving, tell the mother to continue giving the infant the fluids and breastfeeding according to plan A.

  DIARRHOEA HAS NOT STOPPED If the diarrhoea has not stopped, reassess the young infant for diarrhoea. Classify the dehydration and select a fluid plan. If the signs are the same or worse, refer the infant to hospital. If the young infant has developed fever, give intramuscular antibiotics before referral, as for VERY SEVERE DISEASE.

PERSISTENT DIARRHOEA (FOLLOW-UP 5 DAYS) First you will ASK: ✔✔ Has the diarrhoea stopped? ✔✔ How many loose stools is the child having per day?

 DIARRHOEA HAS STOPPED (less than 3 stools/day) Tell the mother to follow the usual feeding recommendations for the child’s age. If the child is not normally fed in this way, you need to teach her the feeding recommendations on the COUNSEL chart.

 DIARRHOEA HAS NOT STOPPED (more than 3 stools/day) Do a full reassessment of the child. Identify and manage any problems that require immediate attention such as dehydration. Then refer the child to hospital.

42 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

DYSENTERY (FOLLOW-UP 3 DAYS) First you will ASK: ✔✔ Are there fewer stools? ✔✔ Is there less blood in the stool? ✔✔ Is there less fever? ✔✔ Is there less abdominal pain? ✔✔ Is the child eating better?

 FEWER STOOLS, LESS BLOOD IN STOOLS, LESS FEVER, LESS ABDOMINAL PAIN, AND EATING BETTER The child is improving on the antibiotic ciprofloxacin. Usually all of these signs will diminish if the antibiotic is working. If only some signs have diminished, use your judgment to decide if the child is improving. Tell the mother to finish the 3 days of the ciprofloxacin prescribed. Review with the mother the importance of finishing the antibiotic.

 CHILD IS DEHYDRATED Use the classification table to classify the child’s dehydration. Select the appropriate fluid plan and treat the dehydration.

 MORE STOOLS, BLOOD IN STOOLS, FEVER, ABDOMINAL PAIN, AND EATING IS SAME OR WORSE The child is not improving on the antibiotic. Stop the first antibiotic and give the second-line antibiotic recommended for Shigella for 5 days. Refer to TREAT chart. Antibiotic resistance of Shigella may be causing the lack of improvement. Advise the caretaker to return in 2 days. What actions will you take? ✔✔ Give the first dose of the new antibiotic in the clinic. ✔✔ Teach the caregiver how and when to give the antibiotic and help her plan how to give it. ✔✔ Advise the caregiver to bring the child back again after two more days. What actions will you take on the follow-up visit in 2 days? If the child has received the second-line antibiotic for two days, and has not improved, the child may have amoebiasis. This child may be treated with metronidazole if it is available or can be obtained by the family, or referred for treatment. Amoebiasis can only be diagnosed with certainty when trophozoites of E. histolytica containing red blood cells are seen in a fresh stool sample.

REFER if the non-improving child has any of these 3 high-risk factors: 1. Less than 12 months old, or 2. Was dehydrated on the first visit, or 3. Had measles within the last 3 months,

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n How do you provide Mary with follow-up care? You classified Mary with SOME DEHYDRATION, and she received Plan B in the clinic. Then you re-assess her, and classified with NO DEHYDRATION. You counselled her mother Ana on Plan A home treatment, and sent them home. Ana and Mary were only supposed to return for follow-up if Mary’s dehydration and diarrhoea did not improve. You are pleased that Mary does not return to the clinic for follow-up. You hope this means that the fluid plan worked, and Mary was no longer dehydrated and acting unwell.

SELF-ASSESSMENT EXERCISE J Answer questions for this case about follow-up of DYSENTERY or PERSISTENT DIARRHOEA. Details about this clinic: This clinic refers children with severe dehydration because health workers cannot give IV or NG therapy. A hospital nearby can give IV therapy. Evaristo was brought for follow-up of PERSISTENT DIARRHOEA after 5 days. He is 9 months old and weighs 6.5 kg. His temperature is 36.5 °C today. He is no longer breastfed. His mother feeds him cereal twice a day and gives him a milk formula 4 times each day. When you saw him last week, you advised his mother to give him only half his usual amount of milk. You also advised the mother to replace half the milk by giving extra servings of cereal with oil and vegetables or meat or fish added. 1. What is your first step for reassessing Evaristo?

2. Evaristo’s mother says the diarrhoea has not stopped. What do you do next?

You do a complete reassessment of Evaristo, as on the ASSESS & CLASSIFY chart. You find that Evaristo has no general danger signs. He has no cough. When you reassess his diarrhoea, his mother says that now he has had diarrhoea for about 3 weeks. There is no blood in the stool. Evaristo is restless and irritable. His eyes are not sunken. When you offer him some water, he takes a sip but does not seem thirsty. A skin pinch goes back immediately. Evaristo’s mother tells you that he has no other problems. 3. Is Evaristo dehydrated?

4. How will you treat Evaristo?

5. If your reassessment found that Evaristo had some dehydration, what would you have done before referral?

44 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.8 USING THIS MODULE IN YOUR CLINIC How will you begin to apply the knowledge you have gained from this module in managing children with diarrhoea? In the coming days, you should focus on these key clinical skills. Practicing these skills in your clinic, and using your IMCI job aids, will allow you to observe and better understand the signs needed to assess and classify a child with dehydration and diarrhoea.

ASSESS ✔✔ Assess children for diarrhoea – how long has the diarrhoea lasted? Is there blood in the stool? ✔✔ Assess children for signs of dehydration, including sunken eyes, skin pinches, the child’s condition, and the child’s willingness and ability to drink. ✔✔ Practice giving children skin pinches and assessing if it returns very slowly, slowly, or immediately. ✔✔ Practice observing children’s conditions (restless, irritable, unconscious, lethargic) and willingness to drink.

CLASSIFY ✔✔ Use your chart booklet to classify the signs of dehydration ✔✔ Classify if a child has persistent diarrhoea or dysentery

TREAT ✔✔ Determine if children need Plans A, B, or C. ✔✔ Determine how you will give Plan C in your facility – what equipment do you have for intravenous fluid? Is there a facility within a 30 minute drive that can give this fluid? Are you trained to use Naso-Gastric tubes for rehydration? ✔✔ Advise a caregiver on giving Plan B in your facility. Determine correct amount of ORS. ✔✔ Advise a caregiver about giving Plan A. Focus on the 4 rules of home treatment.

COUNSEL ✔✔ Teach a caregiver how to make and give ORS. Determine the amounts required. ✔✔ Advise a caregiver on giving extra fluid and continue breast feeding in the home. ✔✔ Advise a caregiver on giving zinc, and show them how to give tablets. Advise on how often zinc should be given. ✔✔ Advise a caregiver on continued feeding, especially for children with persistent diarrhoea. ✔✔ Counsel a caregiver about when to return for follow-up for diarrhoea or dehydration. ✔✔ Counsel a caregiver about when to return immediately.

Remember to use your logbook for MODULE 4: n Complete logbook exercises, and bring completed to the next meeting n Record cases on IMCI recording forms, and bring to the next meeting n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be valuable notes to share with your study group and facilitator.

45 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.9 REVIEW QUESTIONS AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT MANAGING DIARRHOEA AND DEHYDRATION? Before you began studying this module, you practiced your knowledge on with several questions. Now that you have finished the module, you will answer the same questions. This will help demonstrate what you have learned. Circle the best answer for each question. 1. How can diarrhoea kill children? a. Children lose valuable fluids, salts, and sugars, which can cause shock to vital organs b. Children lose valuable nutrients because they cannot eat c. Diarrhoea causes liver failure 2. What are critical treatments for children with diarrhoea and dehydration? a. Oral antibiotics b. Oral rehydration therapy and zinc c. Paracetamol for discomfort 3. What is persistent diarrhoea? a. When a child frequently has diarrhoea over a period of 1 month, and is ill as a result b. When a child has several episodes of diarrhoea a day c. When a child has an episode of diarrhoea lasting 14 days or more, which is particularly dangerous for dehydration and malnutrition 4. Critical messages for caregivers about diarrhoea and dehydration include: a. The child must receive increased fluids, ORS, zinc, and regular feeding b. The child requires ORS, but should receive less food in order to reduce the diarrhoea c. The child should immediately receive antibiotics to stop the diarrhoea 5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She has diarrhoea. You observe a significant loss of skin elasticity. How will you manage Nidhi? a. Nidhi requires ORS immediately, as she is dehydrated. b. These are common signs of diarrhoea, as the child’s body is exhausted. c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV or nasogastric tube.

Check your answers on the next page. How did you do? ...... complete out of 5. Did you miss questions? Turn back to the section to re-read and practice the exercises.

46 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

4.10 ANSWER KEY REVIEW QUESTIONS Did you miss the question? Return to this section QUESTION ANSWER to read and practice: 1 A INTRODUCTION 2 B CLASSIFY, TREAT 3 C CLASSIFY 4 A TREAT, COUNSEL THE CAREGIVER 5 C CLASSIFY, TREAT MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS EXERCISEName: A (MAYA) Age: Weight (kg): Temperature (°C): Ask: What are the child's problems? Initial Visit? Follow-up Visit? MANAGEMENTASSESS (Circle all signs present) OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARSCLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign Name: NOTMaya ABLE TO DRINK OR BREASTFEED LETHARGICAge: 25 mo OR UNCONSCIOUSWeight (kg): 9 kg Temperature (°C):present?37 °C Ask: VOMITS What are EVERYTHING the child's problems? Diarrhoea CONVULSING NOW Initial Visit? X Follow-upYes ___ Visit? No ___ ASSESS CONVULSIONS (Circle all signs present) RememberCLASSIFY to use Danger sign when General danger sign CHECK FOR GENERAL DANGER SIGNS selecting NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? classifications VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___X DOESCONVULSIONS THE CHILD HAVE COUGH OR DIFFICULT BREATHING? RememberYes __ No to __ use For how long? ___ Days Count the breaths in one minute Danger sign when ___ breaths per minute. Fast breathing? selecting Look for chest indrawing classifications Look and listen for stridor DOES THE CHILD HAVE COUGH OR DIFFICULTLook BREATHING? and listen for wheezing Yes __ No __X For how long? ___ Days Count the breaths in one minute Yes __ No __ DOES THE CHILD HAVE DIARRHOEA? ___ breaths per minute. Fast breathing? X For how long? ___ Days Look at the childs general condition. Is the child: 4 Look for chest indrawing Is there blood in the stool? Lethargic or unconscious? No Look and listen for stridor No Restless and irritable? Look and listen for wheezingNo Look for sunken eyes. DOES THE CHILD HAVE DIARRHOEA? Offer the child fluid. Is the child: Yes __ No __ For how long? ___ Days LookNot at ablethe childs to drink general or drinking condition. poorly? Is the child: No visible Is there blood in the stool? DrinkingLethargic eagerly, or unconscious? thirsty? Yes dehydration PinchRestless the skin and of theirritable? abdomen. Does it go back: LookVery for sunkenslowsly eyes.(longer then 2 seconds)? OfferSlowly? the child fluid. Is the child: Not able to drink or drinking poorly? Yes __ No __ DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)Drinking eagerly, thirsty? MANAGEMENT OF THE SICK CHILDLook or feel for AGED stiff neck 2 MONTHS UP TO 5 YEARS Decide malaria risk: High ___ Low ___ No___ Pinch the skin of the abdomen. Does it go back: Look for runny nose For how long? ___ Days Very slowsly (longer then 2 seconds)? EXERCISEName: B (RANA) LookAge: for signs of MEASLES: Weight (kg): Temperature (°C): Ask:If Whatmore arethan the 7 days, child's has problems? fever been present every Slowly? Initial Visit? Follow-up Visit? day? Generalized rash and ASSESSDOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) (Circle all signs present) YesCLASSIFY __ No __ Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes MANAGEMENT OF THE SICK CHILDLook or feel for AGED stiff neck 2 MONTHS UP TO 5 YEARS DecideCHECK malaria FOR risk: GENERAL High ___ Low DANGER ___ No___ SIGNS Look for any other cause of fever. General danger sign Do malaria test if NO general danger sign Look for runny nose ForNOT how ABLE long? TO ___ DRINK Days OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? Name:High risk:Rana all fever cases LookAge: for14 signs mo of MEASLES: Weight (kg): 12 kg Temperature (°C): 37.5 °C Ask:IfVOMITS Whatmore arethan EVERYTHING the 7 days, child's has problems? fever been present every CONVULSING NOW Initial Visit? Follow-upYes ___ Visit? No ___ Low day? risk: if NO obvious cause of fever Generalized rash and X ASSESSCONVULSIONS (Circle all signs present) Diarrhoea RememberCLASSIFY to use Test Has POSITIVE? child had P. measels falciparum within P. the vivax lastNEGATIVE? 3 months? One of these: cough, runny nose, or red eyes Danger sign when Look for any other cause of fever. General danger sign IfDoCHECK the malaria child FOR test has if GENERALNO measles general danger DANGER now sign or within SIGNS the Look for mouth ulcers. selecting NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? High risk: all fever cases If yes, are they deep and extensive? classifications lastVOMITS 3 months: EVERYTHING CONVULSING NOW Low risk: if NO obvious cause of fever Look for pus draining from the eye. Yes ___ No ___X DOESCONVULSIONS THE CHILD HAVE COUGH OR DIFFICULTLook BREATHING? for clouding of the cornea. Yes __ No __ Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Remember to use DOESFor how THE long? CHILD ___ Days HAVE AN EAR PROBLEM? Count the breaths in one minute DangerYes __ sign No when__ Look___ breaths for mouth per ulcers. minute. Fast breathing? If theIs there child ear haspain? measles now or within the Look for pus draining from the ear selecting LookIf yes,for chest are they indrawing deep and extensive? lastIs 3there months: ear discharge? Feel for tender swelling behind the ear classifications Look forand pus listen draining for stridor from the eye. If Yes, for how long? ___ Days DOES THE CHILD HAVE COUGH OR DIFFICULTLook BREATHING? forand clouding listen for of wheezing the cornea. Yes __ No __X THENFor howCHECK long? ___FOR Days ACUTE MALNUTRITION LookCount for the oedema breaths of in both one feet.minute DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ DOES THE CHILD HAVE DIARRHOEA? Determine___ breaths WFH/L per minute. _____ Fast Z score. breathing? X ANDIsFor there ANAEMIA how ear long? pain? ___ Days Look forat the pus childs draining general from condition.the ear Is the child: 21 ForLook children for chest 6 monthsindrawing or older measure MUAC ____ mm. Is there earblood discharge? in the stool? FeelLethargic for tender or swelling unconscious? behind the ear No Look forand palmar listen forpallor. stridor No If Yes, for how long? ___ Days Restless and irritable? LookSevere and listen palmar for pallor?wheezing SomeYes palmar pallor? THEN CHECK FOR ACUTE MALNUTRITION Look for oedemasunken eyes. of both feet. IfDOES child THE has CHILDMUAC HAVEless than DIARRHOEA? 115 mm or Is there any medical complication? Yes __ No __ DetermineOfferGeneral the child WFH/L danger fluid. _____ sign?Is the Zchild: score. WFH/LANDFor ANAEMIA how less long? than ___ -3Days Z scores or oedema of Look at the childs general condition. Is the child: Some For AnyNotchildren ablesevere 6to months drinkclassification? or ordrinking older measure poorly? MUAC ____ mm. Is there blood in the stool? Lethargic or unconscious? dehydration both feet: LookPneumoniaDrinking for palmar eagerly, withpallor. chest thirsty? indrawing?Yes Restless and irritable? ForPinch aSevere child the 6skin palmarmonths of the pallor? or abdomen. older Some offer Does palmarRUTF it go topallor? eat.back: Is the child: Look for sunken eyes. Is thereNotVery any able slowsly medical to finish (longer complication? or able then to 2 finish? seconds)? If child has MUAC less than 115 mm or Offer the child fluid. Is the child: For aGeneralSlowly? child less danger than 6sign? months is there a breastfeeding problem? WFH/L less than -3 Z scores or oedema of Not able to drink or drinking poorly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)Any severe classification? Yes __ No __ bothCHECK feet: FOR HIV INFECTION PneumoniaDrinking eagerly, with chest thirsty? indrawing? DecideNote malaria mother's risk: and/or High child's___ Low HIV ___ status No___ Look or feel for stiff neck ForPinch a child the 6skin months of the or abdomen. older offer Does RUTF it goto eat.back: Is the child: For Mother'show long? HIV ___ test: Days NEGATIVE POSITIVE NOTLook DONE/KNOWN for runny nose NotVery able slowsly to47 finish (longer or able then to 2 finish? seconds)? If moreChild's than virological 7 days, has test: fever NEGATIVE been present POSITIVE every NOTLook DONE for signs of MEASLES: For aSlowly? child less than 6 months is there a breastfeeding problem? day? Generalized rash and DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)Child's serological test: NEGATIVE POSITIVE NOT DONE Yes __ No __ CHECKIfHas mother child FOR is had HIV-positive HIV measels INFECTION within and NO the positive last 3 months? virological test in child:One of these: cough, runny nose, or red eyes Look or feel for stiff neck DecideNote Ismalaria mother'sthe child risk: and/orbreastfeeding High child's___ Low HIV now? ___ status No___ Look for any other cause of fever. Do malaria test if NO general danger sign Look for runny nose For WasMother'show thelong? childHIV ___ test: breastfeeding Days NEGATIVE at the time POSITIVE of test or 6 weeksNOT DONE/KNOWN before it? High risk: all fever cases Look for signs of MEASLES: If moreIfChild's breastfeeding: than virological 7 days, Ishas test: the fever mother NEGATIVE been and present child POSITIVE on every ARV prophylaxis? NOT DONE Lowday? risk:Child's if NO serological obvious cause test: ofNEGATIVE fever POSITIVE NOT DONEGeneralized rash and Return for next CHECKTestIfHas POSITIVE?mother child THE is had HIV-positive CHILD'SP. measels falciparum within and IMMUNIZATION P.NO the vivax positive lastNEGATIVE? 3 months? virological STATUS test in child: (CircleOne of immunizations these: cough, runny needed nose, or redtoday) eyes Look for any otherMeasles1 cause of fever.Measles 2 Vitamin A immunization on: DoBCG malariaIs the test child if NO breastfeedingDPT+HIB-1 general danger now? signDPT+HIB-2 DPT+HIB-3Look for mouth ulcers. IfOPV-0 the child hasOPV-1 measles now OPV-2or within the OPV-3 Mebendazole ______Was the child breastfeeding at the time of test or 6 weeks beforeIf yes, it?are they deep and extensive? lastHigh risk:3 months: all fever casesHep B1 Hep B2 Hep B3 (Date) Hep B0If breastfeeding: Is the mother and child on ARV prophylaxis?Look for pus draining from the eye. Low risk: if NO obviousRTV-1 cause of fever RTV-2 RTV-3 CHECK THE CHILD'S IMMUNIZATION STATUS Look(Circle for clouding immunizations of the cornea. needed today) Return for next Test POSITIVE? P. Pneumo-1falciparum P. vivaxPneumo-2NEGATIVE? Pneumo-3 Measles1 Measles 2 Vitamin A immunizationYes __ No __ on: DOESBCG THE CHILDDPT+HIB-1 HAVE AN EARDPT+HIB-2 PROBLEM?DPT+HIB-3Look for mouth ulcers. IfOPV-0 theIs there child ear haspain?OPV-1 measles now OPV-2or within the OPV-3Look for pus draining from the ear Mebendazole ______If yes, are they deep and extensive? lastIs 3there months: ear discharge?Hep B1 Hep B2 Hep B3Feel for tender swelling behind the ear (Date) Hep B0 Look for pus draining from the eye. If Yes, for how long? ___ Days RTV-1 RTV-2 RTV-3Look for clouding of the cornea. THEN CHECK FORPneumo-1 ACUTE MALNUTRITIONPneumo-2 Pneumo-3Look for oedema of both feet. DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ AND ANAEMIA Determine WFH/L _____ Z score. Is there ear pain? ForLook children for pus 6draining months from or older the earmeasure MUAC ____ mm. Is there ear discharge? LookFeel forfor tenderpalmar swelling pallor. behind the ear Page 65 of 75 If Yes, for how long? ___ Days Severe palmar pallor? Some palmar pallor? THEN CHECK FOR ACUTE MALNUTRITION IsLook there for any oedema medical of complication?both feet. If child has MUAC less than 115 mm or Determine WFH/L _____ Z score. WFH/LAND ANAEMIA less than -3 Z scores or oedema of General danger sign? For Anychildren severe 6 months classification? or older measure MUAC ____ mm. both feet: Look for palmar pallor. Pneumonia with chest indrawing? Page 65 of 75 For aSevere child 6 palmarmonths pallor? or older Some offer palmarRUTF topallor? eat. Is the child: If child has MUAC less than 115 mm or Is thereNot any able medical to finish complication? or able to finish? WFH/L less than -3 Z scores or oedema of For aGeneral child less danger than 6sign? months is there a breastfeeding problem? Any severe classification? bothCHECK feet: FOR HIV INFECTION Pneumonia with chest indrawing? Note mother's and/or child's HIV status For a child 6 months or older offer RUTF to eat. Is the child: Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Not able to finish or able to finish? Child's virological test: NEGATIVE POSITIVE NOT DONE For a child less than 6 months is there a breastfeeding problem? Child's serological test: NEGATIVE POSITIVE NOT DONE CHECKIf mother FOR is HIV-positive HIV INFECTION and NO positive virological test in child: NoteIs mother'sthe child and/orbreastfeeding child's HIV now? status WasMother's the childHIV test: breastfeeding NEGATIVE at the time POSITIVE of test or 6 weeksNOT DONE/KNOWN before it? IfChild's breastfeeding: virological Is test: the mother NEGATIVE and child POSITIVE on ARV prophylaxis? NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE Return for next CHECKIf mother THE is HIV-positive CHILD'S and IMMUNIZATION NO positive virological STATUS test in child: (Circle immunizations needed today) Measles1 Measles 2 Vitamin A immunization on: BCG Is the child breastfeedingDPT+HIB-1 now? DPT+HIB-2 DPT+HIB-3 OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______Was the child breastfeeding at the time of test or 6 weeks before it? (Date) Hep B0If breastfeeding:Hep Is B1 the mother andHep child B2 on ARV prophylaxis?Hep B3 RTV-1 RTV-2 RTV-3 CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next Pneumo-1 Pneumo-2 Pneumo-3 BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

Page 65 of 75

Page 65 of 75 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE C (CLASSIFY) 1. 2 SIGNS from any of the following – sunken eyes, restless/irritable, drinks eagerly/ thirsty, and slow skin pinch (faster than 2 seconds, but not immediate). 2. 2 SIGNS from any of the following – lethargic/unconscious, sunken eyes, not able to drink/drinking poorly, very slow skin pinch (over 2 seconds) 3. Low osmolarity ORS. MANAGEMENT4. Children OF with THE diarrhoea SICK that doCHILD not require AGED immediate 2 MONTHS referral – that UP is, children TO 5 with YEARS

Name: diarrhoea and some or no dehydration.Age: Children withWeight persistent (kg): diarrhoeaTemperature (°C): receive Ask: What are the child'szinc problems? for 14 days. Zinc supplements are a very important part ofInitial treating Visit? diarrhoea.Follow-up Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL5. 4 rules DANGERof home SIGNStreatment of diarrhoea: General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present? VOMITS EVERYTHING1. Give extra fluid – as muchCONVULSING as the child NOW will take Yes ___ No ___ CONVULSIONS 2. Give zinc Remember to use Danger sign when 3. Continue feeding selecting 4. When to return (for a follow-up visit, or immediately if danger signs develop) classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __ For how long? ___ Days Count the breaths in one minute EXERCISE D (CLASSIFY) ___ breaths per minute. Fast breathing? MANAGEMENT OF THE SICK CHILDLook for chest AGEDindrawing 2 MONTHS UP TO 5 YEARS 3. PANO Look and listen for stridor Name: LookAge: and listen for wheezing Weight (kg): Temperature (°C): Ask:DOES What THE are theCHILD child's HAVE problems? DIARRHOEA? Initial Visit? Follow-upYes X__ Visit? No __ ASSESSFor how (Circle long? all ___ 5signs Days present) Look at the childs general condition. Is the child: CLASSIFY CHECKIs there FOR blood GENERALin the stool? No DANGER SIGNS Lethargic or unconscious? No General danger sign NOT ABLE TO DRINK OR BREASTFEED LETHARGICRestless and OR irritable?UNCONSCIOUSYes present? Look for sunken eyes. VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ CONVULSIONS Offer the child fluid. Is the child: Not able to drink or drinking poorly? RememberSome to use Drinking eagerly, thirsty? Yes Dangerdehydration sign when Pinch the skin of the abdomen. Does it go back: selecting Very slowsly (longer then 2 seconds)? classifications DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?Slowly? Yes Yes __ No __ DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)For how long? ___ Days Count the breaths in one minute Yes __ No __ Decide malaria risk: High ___ Low ___ No___ Look___ breaths or feel forper stiff minute. neck Fast breathing? Look for chest indrawing For how long? ___ Days Look for runny nose Look and listen for stridor 4. JANEIf more than 7 days, has fever been present every Look for signs of MEASLES: Look and listen for wheezing day? Generalized rash and DOESHas childTHE had CHILD measels HAVE within DIARRHOEA?the last 3 months? One of these: cough, runny nose, or red eyes Yes X__ No __ Look for any other cause of fever. Do malariaFor how test long? if NO ___3 general Days danger sign Look at the childs general condition. Is the child: Is there blood in the stool? Lethargic or unconscious? High risk: all fever cases No No Restless and irritable? No Low risk: if NO obvious cause of fever Look for sunken eyes. Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Offer the child fluid. Is the child: No dehydration If the child has measles now or within the LookNot for able mouth to drink ulcers. or drinking poorly? Drinking eagerly, thirsty? last 3 months: If yes, are they deep and extensive? LookPinch for the pus skin draining of the abdomen.from the eye. Does it go back: LookVery for cloudingslowsly (longer of the cornea.then 2 seconds)? DOES THE CHILD HAVE AN EAR PROBLEM? Slowly? Yes __ No __ DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)Is there ear pain? Look for pus draining from the ear Yes __ No __ DecideIs there malaria ear discharge?risk: High ___ Low ___ No___ FeelLook for or tenderfeel for swellingstiff neck behind the ear If Yes, for how long? ___ Days Look for runny nose For how long?EXERCISE ___ Days E (PLAN B) THENIf more CHECK than 7 days, FOR has ACUTE fever been MALNUTRITION present every Look for oedemasigns of MEASLES:of both feet. Generalized rash and ANDday? ANAEMIA Determine WFH/L _____ Z score. Has child had 1.measels Answers within the below: last 3 months? For Onechildren of these: 6 months cough, or olderrunny measure nose, or MUACred eyes ____ mm. Look for any other cause of fever. Do malaria test if NO general danger sign Look for palmar pallor. Severe palmar pallor? Some palmar pallor? High risk: all fever cases Name Age or Weight Range of Amounts of ORS Solution Is there any medical complication? IfLow child risk: ifhas NO obviousMUAC cause less ofthan fever 115 mm or a. Andras 3 years General900–1400 danger sign?ml WFH/LTest POSITIVE? less than P. falciparum -3 Z scores P. vivax orNEGATIVE? oedema of b. Gul 10 kg Any 750severe ml classification? or 700–900 ml bothIf the feet:child has measles now or within the LookPneumonia for mouth withulcers. chest indrawing? last 3 months: c. Nirveli 7.5 kg For aIf child yes,562.5 6are months they ml ordeep or 400–700older and offer extensive? RUTFml to eat. Is the child: LookNot for able pus todraining finish or from able the to eye.finish? d. Sami 11 months ForLook a child for400–700 clouding less than of ml 6 the months cornea. is there a breastfeeding problem? CHECKDOES THE FOR CHILD HIV INFECTION HAVE AN EAR PROBLEM? Yes __ No __ NoteIs there mother's ear pain? and/or child's HIV status Look for pus draining from the ear Is thereMother's ear discharge?HIV test: NEGATIVE POSITIVE NOTFeel DONE/KNOWN for tender swelling behind the ear If Yes,Child's for howvirological long? ___test: Days NEGATIVE POSITIVE NOT DONE THENChild's CHECK serological FOR test:ACUTE NEGATIVE MALNUTRITION POSITIVE NOTLook DONE for oedema of both feet. ANDIf mother ANAEMIA is HIV-positive and NO positive virological test in child:Determine WFH/L _____ Z score. Is the child breastfeeding now? For children 6 months or older measure MUAC ____ mm. Was the child breastfeeding at the time of test or 6 weeksLook before for palmar it? 48 pallor. If breastfeeding: Is the mother and child on ARV prophylaxis?Severe palmar pallor? Some palmar pallor? CHECKIf child hasTHE MUAC CHILD'S less IMMUNIZATION than 115 mm or STATUSIs (Circle there any immunizations medical complication? needed today) Return for next WFH/LBCG less thanDPT+HIB-1 -3 Z scores orDPT+HIB-2 oedema of DPT+HIB-3General dangerMeasles1 sign? Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Any severe classification? Mebendazole ______both feet: Pneumonia with chest indrawing? (Date) Hep B0 Hep B1 Hep B2 Hep B3 For a child 6 months or older offer RUTF to eat. Is the child: RTV-1 RTV-2 RTV-3 Not able to finish or able to finish? Pneumo-1 Pneumo-2 Pneumo-3For a child less than 6 months is there a breastfeeding problem? CHECK FOR HIV INFECTION Note mother's and/or child's HIV status Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Child's virological test: NEGATIVE POSITIVE NOT DONE Child's serological test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive virological test in child: Is the child breastfeeding now? Page 65 of 75 Was the child breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and child on ARV prophylaxis? CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on: OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ______(Date) Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 Pneumo-1 Pneumo-2 Pneumo-3

Page 65 of 75 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

2. Answers below: a. Vinita should be given 400–700ml of low osmolarity ORS solution during the first 4 hours of treatment. She should also be given 100–200 ml of clean water during this period. b. She should wait 10 minutes before giving more ORS solution. Then she should give Vinita the ORS solution more slowly. c. After Vinita is given ORS solution for 4 hours on Plan B d. Because Vinita has been reassessed as NO DEHYDRATION, she should be put on Plan A. e. 2 one-litre packets f. To continue treatment at home, the grandmother should give Vinita 50–100 ml of ORS solution after each loose stool. 3. Answers below: a. 400–700 ml of ORS solution b. Yes, Yasmin should breastfeed whenever and as much as she wants. c. Because Yasmin is still classified as SOME DEHYDRATION, she should continue on Plan B.

EXERCISE F (PLAN A) 1. Answers will vary 2. Somi answers: a. Give extra fluid, Give zinc, Continue feeding, Advise when to return b. ORS solution, food-based fluids (such as soup, rice water, yoghurt drinks), clean water 3. The health worker should tell Kasit’s mother to breastfeed him more frequently than usual. The health worker should also tell the mother that after breastfeeding, she should give Kasit ORS solution or clean water. 4. Children who have been treated with Plan B or Plan C during the visit, or children who cannot return to a clinic if the diarrhoea gets worse. 5. Answers below: Name Age Amount of extra fluid to give after each loose stool

Name Age Amount of extra fluid to give after each loose stool a. Kala 6 months 500–100 ml b. Sam 2 years 100–200 ml c. Kara 15 months 50–100 ml d. Lalita 4 years 100–200 ml

49 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE G (TREAT) 1. 10 mg (1/2 of a 20 mg tablet) once each day for 14 days. Tablet should be crushed and dissolved in breast milk, ORS, or clean water. It is important to give zinc for all 14 days. 2. 20 mg tablet given once each day for 14 days. Tablets can be chewed or dissolved in fluid. It is important to give zinc for all 14 days. 3. Give 1ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days 4. Give 3ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days 5. Start treatment for dehydration, give Vitamin A dose, teach mother to give frequent sips of ORS on the way, give other urgent pre-referral treatment as other classifications require, and refer URGENTLY. 6. Correct answers are A, B, D, E

EXERCISE H (CASE STUDY COUNSEL) 1. Rules are: a. GIVE EXTRA FLUID: Explain what extra fluids to give. Since the child is being treated with Plan B during this visit, the mother should give ORS at home. Explain how much ORS solution to give after each loose stool. b. CONTINUE FEEDING: Instruct her how to continue feeding during and after diarrhoea. c. GIVE ZINC: explain dosing and schedule for 14 days of zinc, how to give, why it is given d. WHEN TO RETURN: Teach her the signs to bring a child back immediately. 2. How to mix ORS into water. He did not include what containers to use, what ratio of packets and water, how to give the ORS to her child, or instructions for frequency of treatment. 3. YES 4. NO 5. WITH A YES/NO QUESTION (“DO YOU UNDERSTAND?”). THIS IS NOT A CHECKING QUESTION. 6. NO. THE QUESTION DOES NOT SHOW IF THE CAREGIVER LEARNED. 7. CHECKING QUESTION –for example “How will you prepare the ORS for your child?”

EXERCISE I (CASE STUDY COUNSEL) 1. All five answers should be checked. 2. Aviva answers: a. YES, 2 PACKETS b. The mother should wait 10 minutes before giving more fluid. Then she should give the solution more slowly. c. Aviva’s mother should continue giving extra fluid until the diarrhoea stops d. Drinking poorly or not able to drink or breastfeed, Becomes sicker, Develops a fever, Blood in stool 3. Only C “How much fluid will you give your child?” is a good checking question

50 IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA

EXERCISE J (EVARISTO FOLLOW-UP) 1. Ask: Has Evaristo’s diarrhoea stopped? How many loose stools is he having per day? 2. Reassess Evaristo completely as described on the ASSESS & CLASSIFY chart. Treat any problems that require immediate attention. Then refer him to hospital. 3. NO 4. Refer him to a hospital. He does not need any treatments before he leaves. 5. Rehydrate him according to Plan B before referral.

51 ISBN 978 92 4 150682 3