Can You Give IV Fluids?

If YES:

• Immediately start IV fluid administration.

• If the child is able to drink, give ORS orally while setting up the IV drip.

• Administer 100 ml/kg of Ringer’s Lactate Solution. If unavailable, use normal saline. Follow these administration timelines:

  • Infants (under 12 months):

    • Step 1: Give 30 ml/kg in 1 hour.*

    • Step 2: Then give 70 ml/kg in 5 hours.

  • Children (12 months up to 5 years):

    • Step 1: Give 30 ml/kg in 30 minutes.*

    • Step 2: Then give 70 ml/kg in 2 hours 30 minutes.

  *Repeat Step 1 once if the radial pulse remains very weak or undetectable.

• Reassess the child every 1-2 hours. If hydration is not improving, increase the IV drip rate.

• Start oral ORS (approximately 5 ml/kg/hour) as soon as the child can drink. This is usually after 3-4 hours for infants and 1-2 hours for children.

• Reassess hydration status after 6 hours for infants and 3 hours for children. Re-classify dehydration and choose the appropriate treatment plan (A, B, or C) to continue care.

If NO (Cannot give IV fluids):

• Is IV treatment accessible nearby (within 30 minutes)?

  • If YES:

    • URGENTLY Admit or Refer the child to a hospital for IV treatment.

    • If the child can drink, provide ORS solution to the mother and demonstrate how to give frequent sips during transit.

  • If NO:

    • Are you trained to use a naso-gastric (NG) tube?

      • If YES:

        • Begin rehydration via NG tube (or orally if possible) with ORS solution.

        • Administer 20 ml/kg/hour for 6 hours (total 120 ml/kg).

        • Reassess the child every 1-2 hours.

        • If repeated vomiting or increasing abdominal distension occurs, reduce the fluid administration rate.

        • If hydration is not improving after 3 hours, arrange for IV therapy referral.

        • After 6 hours, reassess the child, classify dehydration, and choose the appropriate plan (A, B, or C) for continued treatment.

      • If NO:

        • Can the child drink?

          • If YES:

            • Start rehydration orally with ORS solution.

          • If NO:

            • URGENTLY Refer the child to a hospital for IV or NGT rehydration.

Treating Shock

1. Administer a 20 ml/kg bolus of Ringer’s Lactate rapidly (over <15 minutes).

2. Reassess the child’s condition.

3. If shock signs persist: Repeat the 20 ml/kg Ringer’s Lactate bolus (<15 minutes) and proceed with Plan C for severe dehydration management (Step 2 onwards).

4. If shock signs resolve: Treat the child for severe dehydration following Plan C, starting from STEP 2.

GIVE FOLLOW-UP CARE

Provide appropriate care for children returning for scheduled follow-up visits.

• For New Problems: If the child presents with any new health issues, perform a complete assessment, classification, and treatment for the new problem.

Condition-Specific Follow-up Checks:

• PNEUMONIA: Follow-up after 2 days.

  • Check for general danger signs.

  • Assess cough and breathing difficulty.

  • Ask:

    1. Is the child breathing slower now?

    2. Has the fever reduced?

    3. Is the child eating better?

  • For any concerns, classify, treat, or refer URGENTLY.

• PERSISTENT DIARRHEA: Follow-up after 5 days.

  • Ask:

    1. Has the diarrhea stopped completely?

    2. How many loose stools per day currently?

  • For any problems, classify, treat, or refer URGENTLY.

• DYSENTERY: Follow-up after 2 days.

  • Assess for ongoing diarrhea.

  • Ask:

    1. Are bowel movements less frequent?

    2. Is there less blood in the stool?

    3. Has the fever decreased?

    4. Is there reduced abdominal pain?

    5. Is the child’s appetite improving?

  • Assess for persistent issues or new problems; classify, treat, or refer URGENTLY as needed.

• MALARIA: Follow-up is needed if fever persists after 2 days or recurs after 14 days.

  • Conduct a full child assessment.

  • Classify, treat, or refer URGENTLY.

• MEASLES: Follow-up after 2 days.

  • Check for red eyes and pus discharge.

  • Examine mouth for ulcers.

  • Check for any unusual mouth odor.

  • Reassess, classify, treat, or refer URGENTLY.

• EAR INFECTION: Follow-up after 5 days.

  • Reassess the ear problem.

  • Measure the child’s temperature.

  • Classify as acute or chronic ear infection; treat or refer URGENTLY.

• FEEDING PROBLEM: Follow-up after 5 days.

  • Reassess feeding practices.

  • Inquire about feeding issues identified during the initial visit.

  • Counsel the mother on any new or ongoing feeding problems.

  • If the child is very underweight for age, schedule a follow-up weight check 30 days after the initial visit.

• PALLOR: Follow-up after 14 days.

  • If not a sickle cell patient, start iron supplementation.

  • If a sickle cell patient, provide folic acid supplementation.

  • Advise mother to return in 14 days for further iron or folic acid supply.

  • Continue iron or folic acid every 14 days for 2 months.

  • If palmar pallor is still present after 2 months, refer URGENTLY.

• VERY LOW WEIGHT: Follow-up after 30 days.

  • Weigh the child to determine if they are still very underweight for their age.

  • Reassess feeding practices.

  • If still underweight, counsel on any feeding problems.

  • Schedule a follow-up visit in another month.

  • Continue reassessment and counseling until the child is no longer underweight for age.

  • If the child is losing weight progressively, refer URGENTLY.

IF ADDITIONAL FOLLOW-UP VISITS ARE REQUIRED based on the initial or current assessment, inform the mother of the next scheduled visit. Also, clearly advise the mother about when to return immediately.

COUNSEL THE MOTHER

FOOD

1. Assess the child’s current feeding practices.

2. Inquire about usual feeding habits.

3. Compare reported feeding to recommended guidelines.

Feeding Assessment Questions:

• Breastfeeding:

  1. Do you breastfeed your child?

  2. How many times a day?

  3. Do you breastfeed during the night?

• Other Foods/Fluids:

  1. Does the child consume any other foods or fluids?

  2. What types of food and fluids?

  3. How many times per day?

  4. What method do you use for feeding?

  5. (If very underweight) How large are the servings? Does the child have their own serving? Who feeds the child and how?

• Feeding Changes During Illness: Has the child’s feeding pattern changed during this illness? If yes, how?

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH FOR CHILDREN UP TO 6 MONTHS OF AGE

• Breastfeed frequently, whenever the child desires, day and night, at least 8 times in 24 hours.

• Avoid giving any other foods or fluids.

  • Exceptions: If the child between 4-6 months appears hungry after breastfeeding or is not gaining adequate weight, complementary foods can be introduced (see 6-12 months age recommendations). Introduce these foods 1-2 times per day after breastfeeding.

6-12 MONTHS OF AGE

• Continue breastfeeding as often as the child wants.

• Provide adequate servings of:

  • A) Thick porridge: Made from maize, cassava, millet, or soya flour. Enhance with sugar and oil, and mix with milk or pounded groundnuts.

  • B) Mashed food mixtures: Combine ‘posho’ (maize or millet) or rice or ‘Matooke’, potatoes, or cassava. Mix with fish, beans, or pounded groundnuts. Add green vegetables. Offer snacks like egg, banana, or bread.

    • Give 3 times daily if breastfed, 5 times daily if not breastfed.

12 MONTHS – 2 YEARS OF AGE

• Continue breastfeeding as often as the child wants.

• Provide adequate servings of:

  • 1. Mashed food mixtures based on ‘Matooke’, potatoes, cassava, ‘posho’ (maize or millet), or rice.

  • 1. Mix with fish, beans, meat, or pounded groundnuts.

  • 1. Include green vegetables.

  • 1. Thick porridge from maize, cassava, millet, or soya, with added sugar and oil, and mixed with milk or pounded groundnuts.

  • 1. Offer snacks like egg, banana, bread, or family food, 5 times a day.

2 YEARS OF AGE AND OLDER

• Provide family foods at 3 main meals daily.

• Offer nutritious snacks twice daily between meals, such as banana, eggs, or bread.

  • A good daily diet should be sufficient in quantity and include energy-rich foods (e.g., thick cereal with oil), meat, fish, eggs, fruits, and vegetables.

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS

If the child’s feeding does not align with the above recommendations, counsel the mother appropriately.

• Breastfeeding Difficulties: If the mother reports breastfeeding challenges, assess breastfeeding technique if needed.

  • Demonstrate correct positioning and attachment for breastfeeding.

  • Emphasize general breast hygiene before breastfeeding.

• Infants Under 6 Months Taking Other Milks or Foods:

  1. Build the mother’s confidence in her breast milk supply adequacy.

  2. Suggest more frequent and longer breastfeeding sessions, day and night, to gradually reduce other milks or foods.

  3. If the mother is working, advise expressing breast milk to leave for the baby.

  4. If other milk is necessary, counsel to continue breastfeeding as much as possible, including at night.

  5. Ensure any other milk is a locally appropriate breast milk substitute, such as cow’s milk.

  6. Verify correct and hygienic preparation and adequate quantities of other milk.

  7. Prepared milk should be consumed within one hour.

• Diluted Milk or Thin Porridge:

  • Remind mothers that infants and young children need energy- and nutrient-dense thick foods.

  • Advise against diluting milk.

  • Encourage increasing the thickness of porridge.

• Bottle Feeding:

  • Recommend transitioning from bottle to cup feeding.

  • Show the mother how to feed the child using a cup.

• Passive Feeding:

  • If the child is not being actively fed, counsel the mother to:

    • Sit with the child and encourage eating.

    • Provide an adequate serving on a separate plate or bowl for the child.

• Lack of Vitamin A-Rich Foods:

  • If the diet lacks green leafy vegetables or other vitamin A-rich foods, encourage their frequent inclusion (e.g., green leafy vegetables, carrots, liver).

• Delayed Introduction of Complementary Foods (Child 6+ Months):

  • Gradually introduce thick porridge mixed with a protein source (e.g., milk), plus sugar and fat.

  • Progressively introduce mashed food mixtures with ‘relish’ (sauce/stew), green leafy vegetables, and fat.

  • Incorporate nutritious snacks.

• Limited Nutrient Density/Variety in Solid Foods (Child eating solids):

  • Advise on providing a variety of mashed food mixtures using local staples combined with a ‘relish’ made from animal or plant protein.

  • Ensure inclusion of green leafy vegetables and fat.

• Follow-up on Feeding Problems: Schedule a follow-up visit in 5 days for any identified feeding problems.

Fluid Intake During Illness:

1. Advise increasing fluid intake during illness.

2. For any sick child, breastfeed more frequently and for longer durations at each feed.

3. If not exclusively breastfeeding, increase fluid intake with options like rice water, yogurt drinks, or clean water.

4. For children with diarrhea, extra fluid intake is crucial and potentially life-saving.

5. Administer fluids according to Plan A, B, or C for dehydration treatment.

6. Advise the mother about when to return to the health worker for further care.

Follow-up Schedule:

Advise on When to Return Immediately:

For any sick child, advise immediate return if:

• Not able to drink or breastfeed.

• Condition worsens.

• Develops a fever.

For a child without pneumonia but with cough or cold, return if:

• Fast breathing develops.

• Difficult breathing develops.

For a child with diarrhea, return if:

• Blood in the stool.

• Drinks or breastfeeds poorly.

Counsel the Mother About Her Own Health

• If the mother is unwell, provide care or refer her for appropriate treatment.

• For breast problems (e.g., engorgement, sore nipples, breast infection), provide care or refer.

• Advise on maintaining a healthy diet.

• Check her immunization status and administer Tetanus Toxoid (TT) vaccine if needed.

• Ensure access to Family Planning (FP) services and Sexually Transmitted Disease (STD)/AIDS counseling/prevention, and antenatal care if pregnant.