GIVE FOLLOW – UP CARE FOR ACUTE CONDITIONS

Utilize the follow-up guidance corresponding to the child’s initial classifications during return visits.
For any new complaints, conduct a complete assessment, classify, and manage them following the “ASSESS AND CLASSIFY” chart.

PNEUMONIA

After 2 Days:

• Re-evaluate for Danger Signs: Assess for general danger signs.

• Reassess Respiratory Status: Examine the child for cough or breathing difficulty.

• Inquire about Improvement:

  • Is the breathing rate becoming slower?

  • Is the fever reducing?

  • Is the child’s appetite improving?

Treatment:

• Danger Signs Present: If any general danger sign is identified, immediately administer a dose of a second-line antibiotic, and then URGENTLY ADMIT or REFER to hospital.

• No Improvement in Key Symptoms: If chest in-drawing, rapid breathing rate, fever, or poor eating persist, transition to a second-line antibiotic and ADMIT or REFER. (Referral is especially important if the child has a history of measles in the last 3 months or has confirmed/suspected HIV infection).

• Positive Signs of Recovery: If breathing is slower, fever is reduced, and appetite is better, continue the initial antibiotic course to complete the full 5-day treatment duration.

WHEEZING

After 2 Days:

• Check for Complications: Assess for general danger signs or chest in-drawing.

• Reassess Respiratory Condition: Evaluate the child’s cough and breathing difficulty.

• Inquire about Symptom Changes:

  • Is the breathing rate becoming slower?

  • Is wheezing still present?

  • Is the child’s appetite improving?

For Children Under 1 Year:

• Wheezing Plus Complicating Signs: If wheezing is accompanied by any general danger sign, stridor in a calm state, chest in-drawing, rapid breathing, or poor feeding:

  • Administer an intravascular or intramuscular antibiotic dose.

  • Then URGENTLY ADMIT or REFER to the hospital.

• Improved Condition: If wheezing is absent, breathing is slower, and appetite is better:

  • Continue the prescribed treatment regimen for a total of 5 days.

For Children Over 1 Year:

• Wheezing Plus Complicating Signs: If wheezing is present alongside any general danger sign, stridor in a calm state, chest in-drawing, rapid breathing, or poor feeding:

  • Administer an intravascular or intramuscular antibiotic dose.

  • Then URGENTLY ADMIT or REFER to the hospital.

• No Improvement in Breathing/Eating: If breathing rate and appetite show no improvement:

  • Change to a second-line antibiotic and URGENTLY ADMIT or REFER to the hospital.

• Persistent Wheezing: If wheezing continues:

  • Maintain the oral bronchodilator therapy.

• Positive Signs of Recovery: If breathing is slower, wheezing is absent, and appetite is better:

  • Continue the treatment plan for the full 5-day course.

• Unilateral Wheezing and Poor Bronchodilator Response: If wheezing is localized to one side and not responding to bronchodilators, consider Tuberculosis (TB) as a potential cause and investigate further.

PERSISTENT DIARRHEA

After 5 Days:

• Inquire about Diarrhea Status:

  • Has the diarrhea resolved?

  • How many loose stools is the child experiencing daily?

Treatment:

• Ongoing Diarrhea: If diarrhea persists (still 3 or more loose stools daily):

  • Perform a complete reassessment of the child’s condition.

  • Provide any necessary treatments based on the reassessment findings.

  • Then REFER to the hospital for further management.

• Diarrhea Resolution: If diarrhea has ceased (fewer than 3 loose stools per day):

  • Advise the caregiver to follow standard age-appropriate feeding recommendations.

  • Instruct them to provide one extra meal per day for a month to aid recovery.

  • Continue Zinc sulfate supplementation for a total of 10 days.

  • Note: Dietary management is crucial in managing persistent diarrhea.

DYSENTERY

After 2 Days:

• Reassess Diarrhea: Evaluate the child’s diarrhea status, as per the “ASSESS & CLASSIFY” chart.

• Inquire about Symptom Changes:

  • Are there fewer stools being passed?

  • Is there less blood present in the stool?

  • Is the fever decreasing?

  • Is abdominal pain reducing?

  • Is the child’s appetite improving?

Treatment:

• Dehydration Present: If the child is dehydrated, manage dehydration based on its classification.

• Worsening Symptoms: If stool frequency, blood in stools, fever, abdominal pain, or eating is worsening:

  • ADMIT or REFER to the hospital.

• Condition Unchanged: If the condition remains the same:

  • Add Metronidazole to the current treatment regimen for a 5-day course.

  • Advise the caregiver to continue Ciprofloxacin and Zinc and return for review in 2 days.

  • Exceptions requiring immediate ADMISSION or REFERRAL:

    • Children younger than 12 months.

    • Children who were dehydrated at the initial visit.

    • Children with recent measles (within the last 3 months).

• Improving Condition: If there are fewer stools, less blood, reduced fever and abdominal pain, and improved appetite:

  • Continue Ciprofloxacin and Zinc sulfate treatment until the course is completed.

UNCOMPLICATED MALARIA

If Fever Persists After 3 Days or Returns Within 14 Days:

• Full Reassessment Needed: Perform a complete reassessment of the child, referring to the “ASSESS & CLASSIFY” chart.

• Evaluate for Other Fever Causes: Investigate for alternative reasons for the persistent or recurrent fever.

Treatment:

• Danger Signs or Stiff Neck Present: If any general danger sign or stiff neck is found, manage as VERY SEVERE FEBRILE DISEASE.

• Fever Due to Other Cause: If the fever is attributed to a condition other than malaria, provide appropriate treatment for that condition.

• Malaria Confirmed and Apparent Cause: If malaria is confirmed by testing and is the apparent cause of ongoing fever:

  • Administer oral DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ).

  • Give Paracetamol for fever management.

  • For children under 5 kg who receive DHA-PPQ, conduct further assessment.

  • Advise caregiver to return again in 3 days if fever continues.

  • If fever has been present every day for 7 days, refer for expert evaluation.

FEVER – NO MALARIA

If Fever Persists After 3 Days:

• Complete Reassessment Required: Conduct a thorough reassessment of the child, using the “ASSESS & CLASSIFY” chart.

• Assess for Other Fever Origins: Determine if there are alternative causes for the ongoing fever.

Treatment:

• Danger Signs or Stiff Neck Present: If any general danger sign or stiff neck is identified, manage as VERY SEVERE FEBRILE DISEASE.

• Fever Caused by Another Condition: If the fever is due to a condition other than malaria, administer suitable treatment for that condition.

• Malaria as Apparent Cause: If malaria is deemed the most likely cause of fever:

  • Treat with the recommended first-line oral antimalarial medication.

  • Administer Paracetamol for fever control.

  • Advise the caregiver to return in 3 days if the fever continues.

  • If fever has been present daily for 7 days, refer for further assessment.

• Persistent Fever, Cough, and Reduced Playfulness: If fever, cough, and decreased activity persist despite other treatments, evaluate for potential TB.

EYE OR MOUTH COMPLICATIONS OF MEASLES

After 2 Days:

• Examine Eyes and Mouth:

  • Check for redness and pus discharge from the eyes.

  • Evaluate the condition of mouth ulcers.

  • Assess breath odor for foul smell.

Treatment for Eye Infection:

• Pus Discharge Present: If pus is still draining from the eye, inquire about the caregiver’s treatment methods.

  • If treatment was appropriate, REFER to the hospital.

  • If treatment was incorrect, educate the caregiver on the correct method.

• Pus Resolved, Redness Remains: If pus has cleared but eye redness persists, continue the current treatment.

• No Pus or Redness: If both pus and redness are absent, discontinue eye infection treatment.

Treatment for Mouth Ulcers:

• Worsening Ulcers or Foul Odor: If mouth ulcers are worsening, or there is a very bad odor from the mouth, REFER to the hospital.

• Ulcers Stable or Improving: If mouth ulcers are the same or improving, continue using half-strength Gentian Violet or Nystatin for a total of 5 days.

Treatment for Thrush:

• Thrush Worsening: If thrush is getting worse, confirm that the treatment is being administered correctly.

• Swallowing Difficulty: If the child has trouble swallowing, REFER to the hospital.

• Thrush Stable or Improving and Good Feeding: If thrush is neither worse nor better and the child is feeding well, continue Nystatin for a full 7-day course.

• Persistent or Worsening Thrush: If thrush does not improve or worsens, consider the possibility of symptomatic HIV infection.

EAR INFECTION

After 5 Days:

• Reassess Ear Problem: Re-evaluate the ear condition, referring to the “ASSESS & CLASSIFY” chart.

• Measure Temperature: Check the child’s body temperature.

Treatment:

• Mastoiditis Signs or High Fever: If there is tender swelling behind the ear or a high temperature (38.5°C or higher), URGENTLY ADMIT or REFER to the hospital.

• Acute Ear Infection: If ear pain or discharge continues:

  • Extend the same antibiotic treatment for another 5 days.

  • Continue ear drying by wicking.

  • Schedule a follow-up in 5 days.

• Chronic Ear Infection: Confirm the caregiver is correctly performing ear wicking.

  • Encourage continued wicking.

  • Review again in 2 weeks.

  • If ear discharge persists beyond 2 months: ADMIT or REFER to the hospital.

• No Pain or Discharge: If there’s no ear pain or discharge, commend the caregiver for effective treatment. If the 5-day antibiotic course is not yet completed, advise them to finish the treatment.

FEEDING PROBLEM

After 5 Days:

• Reassess Feeding Practices: Re-evaluate feeding, referencing the questions in the “COUNSEL THE MOTHER” section. Inquire about feeding issues identified during the initial visit.

• Counsel on Feeding: Counsel the caregiver on any new or ongoing feeding challenges. If significant feeding changes are recommended, schedule a follow-up visit in 5 days.

• Very Low Weight for Age: For children with significantly low weight for age, schedule a follow-up 14 days after the initial visit to monitor weight gain.

PALLOR

After 14 Days:

• Iron and Folate Supplementation: Provide iron and folate supplements.

• Continued Supplementation: Advise the caregiver to return in 14 days for more iron and folate.

• Extended Treatment: Continue daily iron and folate supplementation for a total of 2 months.

• Persistent Pallor: If palmar pallor remains after 2 months of supplementation, refer for further assessment.

MALNUTRITION

After 14 Days:

• Weight Gain Assessment: If the child is gaining weight, encourage the caregiver to continue current feeding practices.

• Feeding Counseling: Counsel the caregiver on any identified feeding problems.

SEVERE MALNUTRITION WITHOUT COMPLICATIONS

After 7 Days or During Regular Follow-Up:

• Comprehensive Reassessment: Perform a full assessment using the “ASSESS AND CLASSIFY” chart.

• Repeat Anthropometric Measurements: Re-measure Weight-for-Height/Length (WFH/L) and Mid-Upper Arm Circumference (MUAC) as done at the initial visit.

• Check for Edema: Examine for bilateral pitting edema in both feet.

• Appetite Test: Assess appetite in children 6 months and older by offering Ready-to-Use Therapeutic Food (RUTF).

Treatment:

• Progression to SEVERE MALNUTRITION WITH COMPLICATIONS: If the child now meets criteria for complicated severe acute malnutrition (WFH/L less than -3 z-scores, MUAC less than 11.5mm, or bilateral edema AND presence of a medical complication, edema worsening, or failed appetite test), URGENTLY REFER to the hospital.

• SEVERE MALNUTRITION WITHOUT COMPLICATIONS Persisting: If the child still has uncomplicated severe acute malnutrition (WFH/L less than -3 z-scores, MUAC less than 11.5 mm, or edema but NO medical complication and passed appetite test), continue counseling the caregiver and encourage consistent RUTF feeding. Schedule a follow-up in 7 days.

• MODERATE ACUTE MALNUTRITION: If the child has moderate acute malnutrition (WFH/L between -3 and -2 z-scores or MUAC between 11.5 and 12.5 mm), advise the caregiver to continue RUTF, and provide ongoing counseling.

MODERATE ACUTE MALNUTRITION

After 14 Days:

• Re-evaluate Nutritional Status: Assess the child using the same anthropometric measurement (WFH/L or MUAC) as at the initial visit.

  • For WFH/L, weigh, measure height/length, and calculate WFH/L z-score.

  • For MUAC, measure with a MUAC tape.

• Check for Edema: Examine for bilateral pitting edema.

• Reassess Feeding: Review feeding practices, using questions from the “COUNSEL THE MOTHER” chart.

Treatment:

• No Longer Moderate Acute Malnutrition: If the child no longer meets the criteria for moderate acute malnutrition, praise the caregiver and encourage continued healthy practices.

• Still MODERATE ACUTE MALNUTRITION: If the child still has moderate acute malnutrition, counsel the caregiver on any feeding problems identified. Schedule another follow-up in 14 days. Continue bi-weekly follow-ups until the child is feeding well and consistently gaining weight, or their WFH/L is -2 z-scores or greater, or MUAC is 12.5 cm or more.

• Evaluate for TB: Assess all children with failure to thrive or growth faltering for possible Tuberculosis.

• Referral Consideration: If you anticipate feeding will not improve, or if the child has lost weight or MUAC has decreased, refer the child for specialized care.

HIV EXPOSED & INFECTED CHILDREN

HIV INFECTED CHILD

After 1 Month:

• Assess General Condition: Evaluate the child’s overall health status. Perform a complete reassessment.

• Treat Any Conditions: Manage any new health conditions found.

• Feeding Assessment: Inquire about feeding problems, counsel on any new or ongoing feeding issues.

• Caregiver Education: Advise the caregiver to bring the child back if any new illness occurs or if they have concerns.

• Counseling and Support: Counsel the caregiver on any other identified problems and ensure access to community support resources. Refer for further psychosocial support/counseling if needed.

• Routine Follow-Up: Continue regular follow-up for growth, development, nutrition, immunization, Vitamin A, and deworming.

• ART and Cotrimoxazole Adherence: Assess adherence to ART and Cotrimoxazole prophylaxis and provide adherence counseling as needed. Offer or refer the child for comprehensive HIV management and care (including ART) according to national ART guidelines.

• Defaulter Tracking: Implement a system for tracking and identifying children who miss appointments or discontinue treatment.

• Monthly Follow-Up: Schedule monthly follow-up visits.

HIV EXPOSED CHILD (<18 months): For children tested DNA PCR Negative

After 1 Month:

• Assess General Condition: Evaluate the child’s overall health. Perform a complete reassessment.

• Feeding and Appetite Assessment: Inquire about feeding problems or poor appetite, counsel the caregiver on any new or persistent feeding issues.

• Treat Any Conditions: Manage any health conditions identified.

• Cotrimoxazole Prophylaxis: Continue Cotrimoxazole prophylaxis started at 6 weeks and emphasize the importance of adherence.

• ARV Prophylaxis: Continue or initiate ARV prophylaxis for a total duration of 12 weeks.

• TB Screening: Screen for possible Tuberculosis Disease.

• Routine Follow-Up: Continue regular follow-up for growth, development, nutrition, immunization, Vitamin A, and deworming.

• Monthly Follow-Up: Schedule monthly follow-up visits up to 24 months of age for HIV-exposed infants.

• EID Algorithm: Refer to the Early Infant Diagnosis (EID) algorithm for HIV status confirmation.

• HIV Exposed Infant Follow-up Card: Utilize and refer to the HIV exposed infant follow-up card and register for detailed follow-up instructions.