1. ASSESS AND CLASSIFY CHILD AGED 2
MONTHS TO 5 YEARS
CASE MANAGEMENT
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2. Introduction to the classification tables:
2
Reference: IMCI guidelines page 2
ASSESS & CLASSIFY the Sick child:
• Signs of illness
• Classification of illness
THREE ROWS with distinct colours for quickly identifying if:
• The child has a serious illness.
• The child needs urgent attention.
• The child needs treatment/intervention with drugs
Purpose
Layout
Application
COLOUR CODING:
• Pink = Severe Classification needing admission or referral
• Yellow = A classification needing treatment/ intervention
• Green = Not serious, and in most cases no drugs are needed

3. Health Care Providers Should be able to:
3
Objectives:
 Define all the general danger signs
 Assess the general danger signs
 Classify the general danger signs
Assess &
Classify
Application

4. • Not able to drink or breastfeed
• Vomits everything
• History of convulsions in the current illness
• Lethargic or unconscious
• Convulsing now
Child with any General Danger sign needs URGENT
attention: complete assessment , give any pre referral treatment immediately and
refer.
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Check for the 5 General Danger signs

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“Not able to drink or breast-feed”: the child is not able to suck or swallow
when offered a drink or breast milk.
NB: if not sure of the mother’s answer, offer the child clean water/ breastmilk
Not able to drink or breastfeed:

6.  Vomiting everything” means;
 child is not able to hold anything down at all.
 What goes down comes back up.
 NB: if not sure of the mother’s answer, offer the child clean water/ breastmilk.
Observe if the child vomits
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Vomiting everything:

7. A convulsion is any involuntary movement in any part of the body
• A child can have this danger sign if there is history of convulsions or convulsing
during the visit.
• A history of convulsions only counts as a danger sign if the convulsions
happened during the present illness.
• Use words for convulsions that caregivers understand. eg fits or spasms
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Convulsing:

8. “Lethargic or unconscious" means that:
• the child is not awake and alert when he should be
• He is drowsy and does not show interest in what is happening around him.
• the child may stare blankly and appears not to notice what is going on around
him.; or
• Unconscious child cannot be awakened. He does not respond when touched,
shaken or spoken to
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Lethargic or Unconscious:

9. Assessing and classifying for General Danger
Signs
9
NOTE: A CHILD WITH ANY GENERAL DANGER SIGN NEEDS URGENT
ATTENTION
Refer to page 4 of the IMNCI Chart booklet

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In this exercise, you will;
 Watch a demonstration of how to assess
and classify a child with danger signs.
 Watch a case study.
 Write down your answers in the forms
provided
Case Study: General Danger Signs

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Case 1: Salina
Salina is 15 months old. She weighs 8.5 kg. Her temperature is 38.5o
C.
The health worker asked, "What are the child's problems?" The mother said, "Salina
has been coughing for 4 days, and she is not eating well." This is Salina's initial visit
for this problem.
The health worker checked Salina for general danger signs. He asked, "Is Salina able
to drink or breastfeed?" The mother said, "No. Salina does not want to breastfeed."
The health worker gave Salina some water. She was too weak to lift her head. She
was not able to drink from a cup.
Next he asked the mother, "Is she vomiting?" The mother said, "No." Then he asked,
"Has she had convulsions?" The mother said, "No."
The health worker looked to see if Salina was lethargic or unconscious. When the
health worker and the mother were talking, Salina watched them and looked around
the room. She was not lethargic or unconscious.
Now answer the questions
Use the recording forms to complete the
answer
Exercise A: General Danger signs

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Use the recording forms to complete the
answer
Write Salina's name, age, weight and temperature in the spaces provided on the top
line of the form.
b. Write Salina's problem on the line after the question "Ask -- What are the
child's problems?"
c. Tick () whether this is the initial or follow-up visit for this problem.
d. Does Salina have a general danger sign? If yes, circle her general danger sign
in the box with the question, "Check for general danger signs."
In the top row of the "Classify" column, tick () either "Yes" or "No" after the
words, "General danger sign present?"
Exercise A: General Danger signs

13. UNIT II: COUGH OR DIFFICULT IN BREATHING
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14. Health Care Providers Should be able to:
14
Objectives:
 Define all the cough & difficulty in breathing
 Describe the prevalence and transmission
 Assess the for breathing, central cyanosis & AVPU
 Classify for Cough or difficulty in breathing
Background
Assess &
Classify
Application

15. Definition: Cough or Difficult in Breathing & Pneumonia
 Cough: a rapid expulsion of air from the
lungs, typically in order to clear the lung
airways of fluid, mucus or other irritating
material..
 Difficult in Breathing: Breathlessness or
shortness of breath. This is primarily an
indication of inadequate ventilation or
insufficient amount of oxygen in the blood.
 Pneumonia: Respiratory infection that
affects the lungs.
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Source: WHO, 2016
Difficult in breathing

16. Current Situation: Pneumonia
Prevalence: 9%
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 Pneumonia is one of the leading causes of death in children under 5 years
 Pneumonia is responsible for 13% of under five deaths
 Most children with cough or difficult breathing have only a cough or a cold
 A few children with cough or difficult breathing may also have pneumonia
Source: WHO, 2016 & KDHS, 2014
Data:
REGION
ARI Prevalence In 8 Regions In Kenya (KDHS)
2008/9 2014
Coast 13% 7%
North Eastern 7% 4%
Eastern 6% 9%
Central 8% 7%
Rift Valley 8% 8%
Western 6% 13%
Nyanza 8% 10%
Nairobi 7% 6%
National 8% 9%

17. Transmission of Pneumonia
A child’s susceptibility to pneumonia is
increased by the following environmental
factors:
• Indoor air pollution caused by cooking
& heating
• Living in crowded homes
• Parental smoking
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Parental smoking
Indoor pollution

18. Assessing Cough or Difficult in Breathing
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Does the child have Cough or Difficult in Breathing?
NOTE: THE CHILD
MUST BE CALM
IF YES, ASK
• For how long?
LOOK, LISTEN, FEEL
• Count the breaths in one
minute
• Use respiratory rate timers
where available
• Look for chest in drawing
• Look and listen for stridor
• Look and listen for wheeze
• Check for central cyanosis
• Check for oxygen saturation
using pulse oximetry where
available
• Check AVPU
IF THE CHILD IS
2 months up to 12
months
FAST BREATHING IS:
• 50 breaths per
minute or more
12 months up to 5 years
FAST BREATHING IS:
• 40 breaths per
minute or more
Note:
• Chest in-drawing is present if the lower chest wall moves in during inspiration
• Stridor- a harsh sound heard during inspiration
• Wheeze- a musical sound heard during expiration
• AVPU – Alert, Voice, Pain and Unresponsive

19. Classifying Cough Or Difficult Breathing
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Chest indrawing
Fast breathing
Refer to page 4 of the IMNCI Chart booklet to
match symptoms to the classifications
REFER TO PARTICIPANT MANUAL PG. 27 ON
DETERMINING OXYGEN SATURATION

20. Case Study – Cough and/or Difficult
Breathing
In this exercise, you will;
 Watch a demonstration of how to assess and classify a
child with cough and/or difficult breathing
Watch a case study.
 Write down your answers in the forms provided
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21. Exercise B: Cough and/or Difficult Breathing
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Purpose: Assessment and classification
Case 1: Gyatsu
Gyatsu is 6 months old. He weighs 5.5 kg and his length is 70cm. His temperature
is 380C. This is his initial visit. His mother said he has had a cough for 2 days. The
health worker checked for general danger signs. The mother said that Gyatsu is
able to breastfeed. He has not vomited during this illness. He has not had
convulsions and is not convulsing now. Gyatsu is not lethargic or unconscious.
The health worker said to the mother, “I want to check Gyatsu’s cough. You said
he has had cough for 2 days now. I am going to county his breaths. He will need
to remain calm while I do this.”
The health worker counted 58 breaths per minute. He did not see chest indrawing.
He did not hear stridor nor wheeze.
Format. Use the recording form to complete the exercise

22. Exercise B – Cough and/or Difficult Breathing
a. Record Gyatsu's signs on the Recording Form given
b. To classify Gyatsu's illness, look at the classification table for cough or
difficult breathing in your chart booklet. Look at the pink (or top) row.
Decide: Does Gyatsu have a general danger sign? Yes___ No ___
- Does he have chest indrawing or stridor when calm? Yes __ No __
- Does he have the severe classification SEVERE PNEUMONIA OR VERY
SEVERE DISEASE? Yes___ No___
c. If he does not have the severe classification, look at the yellow (or middle) row.
- Does Gyatsu have fast breathing? Yes___ No___
d. How would you classify Gyatsu's illness? Write the classification on the Recording
Form.
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23. Exercise B:Cough and/or Difficult Breathing
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Purpose: Assessment and classification
Case 2: Pemba
Pemba is 18 months old. He weights 9kg and his length is 85cm. His temperature is
370C. His mother says he has had a cough for 3 days. This is his initial visit.
The health worker checked for general danger signs. Pemba’s mother said that he is
able to drink and has not vomited anything. He has not had convulsions and is not
convulsing now. Pemba was not lethargic or unconscious.
The health worker counted the child’s breaths. He counted 30 breaths per minute.
The mother lifted the child’s shirt. The health worker saw chest indrawing. He did not
hear stridor when he listened to the child’s breathing. He heard wheeze.
 Record Pemba’s signs on the recording form given.
 Classify this child’s illness and write your answer in the classification column.
Format. Use the recording form to complete the exercise

24. Exercise B: General Danger Signs and Cough
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Purpose: Assessment and classification
Case 3: Wambui
Wambui is 8 months old. She weighs 6 kg and her length is 65cm. Her temperature
is 390C. This is her initial visit. Her father told the health worker, "Wambui has had
cough for 3 days. She is having trouble breathing. She is very weak." The health
worker said, "You have done the right thing to bring your child today. I will examine
her now."
The health worker checked for general danger signs. The mother said, "Wambui will
not breastfeed. She will not take any other drinks I offer her." Wambui does not
vomit everything and has not had convulsions. She is not convulsing now. Wambui
is lethargic. She did not look at the health worker or her parents when they talked.
The health worker counted 55 breaths per minute. He saw chest indrawing. He
decided Wambui had stridor because he heard a harsh noise when she breathed in.
He did not hear wheeze.
 Record Wambui's signs and classification
 Be prepared to explain to your facilitator how you selected the child's
classification.

25. Exercise B: Cough and/or Difficult Breathing
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Purpose: Assessment and classification
Case 4: Awiti
Awiti is 19 months old. He weights 9.5kg and his length is 87cm. His temperature is
370C. His mother says he has had a cough for 4 days. This is her initial visit.
The health worker checked for general danger signs. Awiti’s mother said that she
not able to drink and has not vomited anything. She has had convulsions and she is
not convulsing now. Awiti was lethargic but not unconscious.
The health worker counted the child’s breaths. He counted 30 breaths per minute.
The mother lifted the child’s shirt. The health worker saw chest indrawing. He did not
hear stridor when he listened to the child’s breathing. He heard wheeze.
 Record Awiti’s signs on the recording form given.
 Classify this child’s illness and write your answer in the classification column.
Format. Use the recording form to complete the exercise

26. UNIT III: DIARRHOEA
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27. Health Care Providers Should be able to:
27
Objectives:
 Define diarrhea and dehydration
 Describe the transmission and prevention
 Assess for diarrhoea and dehydration
 Classify Hypovolaemic shock, dehydration,
diarrhoea and dysentery
Background
Assess &
Classify
Application

28. Diarrhoea
Definition:
 Diarrhea is the passage of three or more loose or watery stool in twenty-four hours (a
day). The watery stool looks like soup or very light porridge (uji).
 Frequent passage of normal stool is not diarrhoea
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 Dysentery: Presence of blood and/or mucus in stools
 Persistent Diarrhea: Diarrhea lasting for 14 days or more
 Diarrhea is caused by disease causing germs from stool which is swallowed either
through direct contamination from water, food, flies or eating/feeding using hands
that are contaminated.
Source: WHO, 2016

29. Current Situation: Diarrhoea
Prevalence: 15.2% (KDHS, 2014)
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 The 2nd single leading cause of death among
children under five years.
 Approx. 19,000 children die of diarrhea
annually.
 Most of these deaths are due to dehydration.
 Every child has an average of 3 episodes of
diarrhea annually.
 Prevalence is high in children between 6 months
- 2 years of age.

30. Diarrhoea Prevalence
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REGION
Diarrhoea Prevalence In 8 Regions In Kenya (KDHS)
2008/9 2014
Coast 27.2 17.6
North Eastern 16 7.8
Eastern 14.9 14.3
Central 14.4 10.4
Rift Valley 15.9 13.2
Western 17.2 20.1
Nyanza 16.2 18.9
Nairobi 11.9 15.6
National 16.6 15.2
Class Exercise:
• What is the prevalence of diarrhoea in children under 5 in your facility?
• List 4 main contributors of diarrhoea prevalence in children under 5 in that facility.

31. Transmission of diarrhoea
 Water contamination
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 Poor hygiene and food contamination
 Passing of stool in
water
 Bathing in
rivers/streams
 Improper disposal
of feacal matter.
 Urinating in water
 Animals
contamination
Examples:
 Touching
contaminated
hands/surfaces
 Cooking with
contaminated
hands Using
contaminated
water
 Poor storage of
prepared food and
Examples:

32. Assessing for Diarrhoea
32
Does the child have diarrhoea?
IF YES, ASK
• For how
long?
• Is there
blood in the
stool
LOOK, LISTEN, FEEL
• Look at the child’s general condition
• Weak and absent pulse
• Not alert, AVPU< A
• Cold hands and temp gradient
• Capillary refill (>3 secs)
Is the child:
• Lethargic or unconscious
• Restless or irritable?
• Look for sunken eyes
• Offer the child fluid. Is the child:
• Not able to drink or
• Drinking poorly?
• Drinking eagerly, thirstily?
• Pinch the skin of the abdomen.
Does it go back;
• Very slowly (longer than 2 seconds?
• Slowly?
• Immediately?
Refer to page 5 of
the IMNCI Chart
booklet for
assessing for
Diarrhoea

33. What Happens During Diarrhoea?
Diarrhoea leads to:
 Loss of water
 Loss of electrolytes
that maintain normal
body functions
 Loss of zinc, in most
cases, in an already
deficient child

34. Classifying a child with diarrhoea
• Children with diarrhoea die as a result of dehydration.
• ALL children with diarrhoea MUST first be classified for dehydration
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35. Classifying a child with diarrhoea
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Unconscious
Signs to watch out for:
• Weak/absent peripheral pulse
• Not alert, AVPU < A
• Cold extremities
• Capillary refill
• Sunken eyes
• Skin pinch goes back very slowly
• Dehydration
• Blood in stool
Refer to page 5 of the IMNCI Chart booklet to
match symptoms to the classifications
Irritable and restless

36. Case Study – Diarrhoea
In this exercise, you will;
 Watch a demonstration of how to assess and classify a
child with diarrhoea
 Watch a case study.
 Write down your answers in the forms provided
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Purpose: Assessment and classification
Case 1: Fatuma
Fatuma is 48 months old, weighs 16kg, her temperature is 33.40C. Fatuma’s length is 105 cm and
this is her initial visit.
Her mother says she has had diarrhoea since last night and this morning her condition has
worsened. The mother says the girl has not been able to respond to her voice as she is just
sleepy. The mother reports that there has been no blood in stool.
You asses the girl for general danger signs and find she is not able to drink, has not had
convulsions and is not convulsing now. Further assessment shows she is not alert and not able to
respond to your voice. Her hands are cold, her eyes are sunken and her skin pinch goes back very
slowly. She does not respond to sternum pain. When the capillary refill was checked it was
greater than 3 seconds. Fatuma does not have a cough.
• Record Fatuma’s signs and classification
Format. Use the recording form to complete the exercise
Exercise C – Diarrhoea

38. Exercise C – Diarrhoea
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Purpose: Assessment and classification
Case 2 & 3: Pano & Jane
Pano has had diarrhea for 15 days. This is his initial visit. He has no blood in the
stool. He is irritable. His eyes are sunken. His father and mother also think that
Pano's eyes are sunken. The health worker offers Pano some water, and the child
drinks eagerly. When the health worker pinches the skin on the child's abdomen, it
goes back slowly
• Record the child's signs and classification for shock and dehydration
Jane has had diarrhea for 3 days. There was no blood in the stool. The child was
not lethargic or unconscious. She was not irritable or restless. Her eyes were
sunken. She was able to drink, but she was not thirsty. The skin pinch went back
immediately.
• Record the signs for shock and dehydration and classify them
Use the recording form to complete the exercise

39. Exercise C – Diarrhoea
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Purpose: Assessment and classification
Case 4 & 5: Gretel & Jose
Gretel has had diarrhea for 2 days. She does not have blood in the stool. She is
restless and irritable. Her eyes are sunken. She is not able to drink. A skin pinch
goes back very slowly.
• Record the signs for shock and dehydration and classify them
Jose has had diarrhea for five days. There is blood in the stool. The health worker
assesses the child for dehydration. The child is not lethargic or unconscious. He is
not restless and irritable. His eyes look normal and are not sunken. When offered
water, the child drinks eagerly. A skin pinch goes back immediately.
• Record the child’s signs and classify them
Use the recording form to complete the exercise

40. Exercise C – Diarrhoea
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Purpose: Assessment and classification
Case 6: Rana
Rana is 14 months old. She weighs 12 kg. Her temperature is 37.50C. Rana's
mother said the child has had diarrhoea for 3 weeks. Rana does not have any
general danger signs. She has a cough and difficult in breathing. The health worker
counted 50 breaths per minute. He did not see chest in-drawing nor did he hear a
wheeze or a stridor.
The health worker then 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’s capillary refill, which was < 3 seconds.
Further assessment on signs of dehydration showed the child was irritable
throughout the visit. Her eyes were not sunken. She drinks eagerly and the skin
pinch goes back immediately.
• Record the child’s signs and classify them on the Recording Form
Use the recording form to complete the exercise

41. UNIT IV: FEVER
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42. Health Care Providers Should be able to:
42
Objectives:
 Define Fever
 Describe the common causes of fever
 Assess for fever
 Classify for Malaria, Measles and other fever related
illnesses
Background
Assess &
Classify
Application

43. Fever
Definition:
Fever: is body temperature that is higher than normal. It is present if :-
 There is history from parent/caregiver or
 Child feels hot or
 Child has temperature 37.50
c or above
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44. Malaria
• Definition: Malaria is a disease caused by parasites of the genus plasmodium. In
Kenya the most common being Plasmodium falciparum.
• It is transmitted from one person to the other through a bite of an infected female
anopheles mosquito
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Malaria case guidelines,
2016

45. •To classify and treat fever, you need to determine malaria risk:
High Malaria Risk: > 5% of fever cases in children are due to malaria. This is
mainly in:
• Endemic- Areas of stable malaria around Lake Victoria in western Kenya
and in the coastal regions.
• Seasonal transmission- Parts of the country experience short periods of
intense malaria transmission during the rainfall seasons.
• Epidemic prone areas.- When climatic conditions favor sustainability of
minimum temperatures around 18°C.
Low Malaria Risk: 5% or less of fever cases in children are due to malaria. This
zone covers the central highlands of Kenya including Nairobi. The temperatures
are usually too low to allow completion of the sporogonic cycle of the malaria
parasite in the vector
Malaria Risk and Transmission

46. Malaria Prevention
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• Provision of prompt diagnosis and treatment of fever due to malaria
• Long lasting Insecticidal Nets (LLINs)*
• Health Education and communication
• Intermittent preventative treatment for malaria in pregnancy (IPTp)**
• Vector control strategies such as indoor residual spraying, fumigation e.t.c
Note:
*Each pregnant woman living in a malaria risk area should receive LLIN at first ANC
contact, LLINs are not a substitute for IPTp.
** Recommended in areas of high malaria transmission, IPTp is not a substitute for LLIN

47. Semi-arid, seasonal
1%
Low risk
<1%
Coast endemic
8%
Lake endemic
27%
Highland epidemic
3%
Malaria Prevalence by Zone
Percent children age 6 months to 14 years who tested positive for malaria
by microscopy
According to KMIS 2015
Prevalence in Kenya:
8%

48. Assessing for Fever
48
Does the child have fever?
IF YES
Has the child travelled to a high risk (Malaria
endemic, seasonal transmission or epidemic prone)
area in the last 1 month?
Decide Malaria Risk: High or Low
THEN ASK:
• For how long?
• If > 7 days, has fever been present everyday?
• Has the child had signs of measles within the last 3
months?
• In high malaria risk, do a malaria test
• Endemic zone
• Seasonal transmission zone
• Epidemic prone areas
In low malaria risk, do a malaria test if no obvious cause
of fever
LOOK AND FEEL
• Look or feel for stiff neck
• Look for running nose
• Look for signs of MEASLES:
• Generalized rash and one of these: cough,
runny nose, or red eyes
• Look for any other cause of fever*
TEST POSITIVE
• P. falciparum PRESENT
• P. vivax PRESENT
TEST NEGATIVE
• P. falciparum or P. vivax absent
Refer to the IMNCI guideline pg
6

49. Check for measles and complications of measles
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Refer to page 6 of the IMNCI chart booklet

50. In Summary
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Convulsion
Check for signs of :
Very severe disease
malaria
Measles and its complications
Other possible causes of fever
Refer to page 6 of the IMNCI chart booklet

51. In this exercise, you will;
 Watch a demonstration of how to assess and
classify a child with fever.
 See examples of signs related to fever and
measles.
 Practice identifying stiff neck.
 Watch a case study.
Write down your answers in the forms provided
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Exercise Case Study: Fever

52. Demonstration: Fever
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Purpose: Demonstration
Part1: Photographs 8-11
Study photographs 8-11. They show examples of common childhood rashes. Read the
explanation for each of these photographs.
Photograph 8: This child has the generalized rash of measles and red eyes.
Photograph 9: This example shows a child with heat rash. It is not the generalized rash of
measles.
Photograph 10: This is an example of scabies. It is not the generalized rash of measles.
Photograph 11: This is an example of a rash due to chicken pox. It is not a measles rash.
Format. Demonstration & discussion

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Purpose: Identification
Part1: Photographs 12-21
Study photographs 12 through 21. They show children with rashes.
For each photograph, tick whether the child has the generalized rash of measles.
• Use the answer sheet provided
Format. Record in the answer sheet provided.
Demonstration: Fever

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Purpose: Assessment and classification
Case Study: Atika
Atika is 5 months old. She weighs 5 kg. Her temperature is 36.50C.The risk of Malaria is high. Her
family brought her to the clinic because she feels hot and has had cough for 2 days.
She is able to drink. She has not vomited or had convulsions, and is not lethargic or unconscious.
The health worker said, "I am going to check her cough now." The health worker counted 43 breaths
per minute. There was no chest indrawing and no stridor when Atika was calm. Atika did not have
diarrhea.
"Now, I will check her fever," said the health worker. Atika lives in an area where many cases of malaria
occur all year long (high malaria risk). Her mother said, "Atika has felt hot off and on for 2 days." She
has not had measles within the last 3 months. She does not have stiff neck or runny nose.
Atika has a generalized rash. Her eyes are red. She has mouth ulcers. They are not deep and
extensive. She does not have pus draining from the eye. She does not have clouding of the cornea.
• Record the child's signs and classify them
Format. Use the recording form to complete the exercise
Demonstration: Fever

55. UNIT V: EAR PROBLEM
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56. Ear Problem
 A child with an ear problem may have an ear infection.
 Ear infection may cause pus to collect behind the ear
drum causing pain and often fever.
 If not treated, the ear drum may burst ,discharge pus and
the child feels less pain.
 However, the child may suffer poor hearing or worse
deafness
 Ear infection may lead to Mastoiditis or Meningitis
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57. Assessing for Ear Problem
57
Does the child have an ear problem?
Refer to IMNCI chart booklet page 7

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Purpose: Assessment and Classification
Case 1:Mbira
Mbira is 3 years old. She weighs 13 kg. Her temperature is 37.5 C, and her height is 85 cm. Her
mother came to the clinic today because Mbira has felt hot for the last 2 days. She was crying last
night and complained that her ear was hurting.
The health care worker checked and found no general danger signs. Mbira does not have cough or
difficult breathing. She does not have diarrhea. Her malarial risk and Malaria test is positive. Her
fever was classified as MALARIA.
Next the health worker asked about Mbira’s ear problem. The mother said she was sure Mbira has
ear pain. The child cried most of the night because her ear hurt. There ha been discharge coming
from Mbira’s ear on and off for about a year, said the mother. The health worker did not see any
pus draining form the child’s ear. He felt behind the child’s ears and felt tender swelling behind
one ear.
Format. Record in the answer sheet provided.
Exercise D: Ear Problem

59. Exercise D: Ear Problem
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Purpose: Assessment and Classification
Case 2: Dana
Dana is 18 months old. She weighs 9 kg, length is 78 cm. Her temperature is 370C. Her
mother said that Dana had discharge coming from her ear for the last 3 days.
Dana does not have any general danger signs. She does not have cough or difficult
breathing. She does not have diarrhoea and she does not have fever.
The health care worker asked about Dana’s ear problem. The mother said that Dana does
not have ear pain, but the child’s right ear has been coming from the ear for 3 o 4 days. The
health care worker saw us draining from the child’s ear. He did not feel any tender swelling
behind either ear.
Format. Record in the answer sheet provided.

60. UNIT V: NUTRITION
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61. 61
How can you use power point to enhance your messages?
Health Care Providers Should be able to:
Objectives:
 Define malnutrition.
 Describe Types of malnutrition.
 Describe causes of malnutrition.
 Assess and Classify malnutrition
Background
Assess &
Classify
Application

62. Components of Good Nutrition
Nutrition is the intake of food considered in relation to the
body’s dietary needs.
Good nutrition results from the adequate intake of
macronutrients, micronutrients and water to supply the
metabolic (anabolic and catabolic) processes in the body.
There are two components of nutrition
• Macronutrients- are required in large amounts to
maintain body functions and carry out the activities of
daily life.
• There are three broad classes of macronutrient: proteins,
carbohydrates and fats.
• Micronutrients- are needed only in minuscule amounts,
these substances are the “magic wands” that enable the
body to produce enzymes, hormones and other
substances essential for proper growth and development.
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Source: WHO, 2016

63. Definitions of Malnutrition
• Malnutrition is defined as a state when the body
does not have enough of the required nutrients
(under-nutrition) or has excess of required
nutrients (over-nutrition).
• Inadequacies of macro or micro nutrients may
result in failure to thrive, poor growth or wasting.
• These processes are often measured by their
anthropometrical consequences (weight for age,
height for age or weight for height).
• Under nutrition is the most common form of
malnutrition in developing countries.
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Under-nutrition
over-nutrition

64. Global Situation of Malnutrition
• Over 2 million children are severely malnourished at any given time.
• 5 million out of 10 million child deaths are a result of malnutrition related causes
• Moderate and Severely Malnourished children have 3 – 9 times higher chances of death
than well nourished children.
• Widespread hunger & malnutrition is mainly attributed to natural calamities, wars, drought
& disease
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Kenya Situation of Malnutrition
• Kenya has a high infant and under five mortality rates (at 39 and 52/1000 live births
respectively 2014 KDHS ) of which half has malnutrition as the main underlying cause
• National levels of malnutrition is at 41% in Kenya
• HIV and AIDS pose a new and significant challenge in addressing acute malnutrition as the
two are intrinsically related

65. Common types of Malnutrition in children
 Protein-energy malnutrition. This may lead to:
• The child becoming severely wasted, a sign of marasmus.
• The child becoming stunted (too short for age).
• The child becoming underweight (low weight for age)
• The child developing oedema, a sign of kwashiorkor.
 Micronutrient deficiency diseases. This may lead to:
• Inadequate intake of Vitamins such as vitamin A or minerals such as iron.
 Anaemia as a result of infections, worm infestation, malaria, sickle cell diseases etc.
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66. Macronutrients
• Protein, fat and carbohydrates are macronutrients that make up the bulk of a diet
and supply the body’s energy Fats supply energy and are important in cell
formation.
• Proteins are required to build new tissue and are derived mostly from animal
origin such as milk, meat and eggs.
• These animal by-products contain essential amino acids that cannot be produced
by the body but must be eaten.
• Protein from cereals and pulses alone do not provide the sufficient balanced
essential amino acids.
• To obtain the correct balance without requiring protein from animal sources,
cereals and pulses must be combined when planning a meal

67. Micronutrients
• Micronutrients include- iodine, iron, Vitamins A and C
• Deficiencies in these micronutrients do not affect growth (i.e. the individual
can have normal growth with appropriate weight and still be deficient in
micronutrients
• Deficiency in these micronutrients is not determined by anthropometric
measurement.
• Deficiencies in these micronutrients will cause major illness such as anaemia,
scurvy and impaired immunity.

68. Micronutrients
• Other micronutrients include- magnesium, sulphur, nitrogen, essential
amino-acids, phosphorus, zinc, potassium, sodium and chloride
• They are essential for growth and tissue repair.
• They are required only in small quantities, but the correct balance is
essential for good health.
• A deficiency in any of these micronutrients will lead to growth failure
measured by stunting and wasting.

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70. Reductive Adaptation
Definition
It is a physiological response through which the body conserves energy. This is
achieved through;
• Reducing physical activity and growth
• Reducing basal metabolism by:
• Slowing protein turnover
• Reducing functional reserve of organs
• *slowing and reducing na+/K+ pumps
• Reducing inflammatory and immune responses

71. IMPORTANCE OF CHECKING FOR ACUTE
MALNUTRITION & ANAEMIA IN ALL CHILDREN
 A child with malnutrition has a higher risk of many types of disease and death.
 Malnutrition is an underlying cause in 60% of under five mortality
 Sick children brought to clinic may not have specific complaints that point to
malnutrition or anemia.
 Health workers or the child's family often fail to detect malnutrition.
 Identifying and treating malnutrition can help prevent many severe diseases and
death.
 Severe cases need referral to hospital whereas less severe cases may be managed
at home.
 In malnourished children, checking for TB and HIV infection is important.
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72. Nutritional Assessment
• It is a key component in growth monitoring
• In nutritional assessment, various anthropometric measurements are taken including;
1. Weight for height/length
2. Weight for age
3. MUAC(Mid Upper Arm Circumference)
• Weight for height/length is done to determine the z-score which is used to classify acute malnutrition
• Weight for age is used for growth monitoring (Acute and chronic malnutrition)
• Age for height/ length is used for growth monitoring (Stunting)
• MUAC is used for mass screening of malnutrition(commonly used at community level)
 NB; Z-score is also known as standard deviation score or SD score.
 It is the measure of the distance between the child’s value and the expected value of the reference population
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73. Determining MUAC
• MUAC(mid upper arm
circumference) is the
circumference of the mid upper
arm measured at the mid point
between the tip of the shoulder
and tip of the elbow, taken with
the arm hanging down.
• It is measured in a child more than
6 months
• Refer to chart booklet page 8
• See video
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74. Z-SCORE
• Z-score is also known as standard deviation score or SD score
• It is the measure of the distance between the child’s value and the expected
value of the reference population
• REFER TO PAGES 55 & 56 OF THE CHART BOOKLET TO DETERMINE THE Z-
SCORE
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75. Check and classify malnutrition
• After taking height/length and weight, use the tables in chart
booklet pg. 56&57 to determine the z-score.
• Measure MUAC in a child 6 months or older.
• Check for oedema of both feet and any other medical complications
(refer to chart booklet pg. 8)
• If no medical complication is present in acute malnutrition and
anaemia, conduct the appetite test
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76. THE APPETITE TEST
• It is a test performed to children aged 6 months and above with severe acute
malnutrition to determine if the will be managed as outpatient or inpatient
• A poor appetite test means that the child has significant infection or a major
metabolic abnormality such as liver dysfunction, electrolyte imbalance, cell
membrane damage.
• This are the patients at immediate risk of death
• To perform the test, refer to chart booklet pg 25
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77. Exercise – Malnutrition
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Watch a case study.

78. 78
How can you use power point to enhance your messages?
Health Care Providers Should be able to:
Objectives:
 Define Anemia.
 Describe causes of Anemia.
 Assess and Classify Anemia
Background
Assess &
Classify
Application

79. Anemia
• The condition of having a lower-than-normal number of red blood cells or quantity of
hemoglobin.
• Anemia diminishes the capacity of the blood to carry oxygen.
Common Causes
• Iron deficiency; may result from a diet deficient in iron
• Intestinal parasites
• Repeated nose bleeds
• Haemolysis, due to: Malaria and other Inherited blood disorders like sickle cell disease)
• Chronic illness, such as tuberculosis and AIDS
• Severe acute malnutrition (due to lack of protein to produce haemoglobin)
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80. 29/05/2023
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ASSESS for ANAEMIA
Look for palmar pallor. Is it:
• Severe palmar pallor
• This is where the palm looks white
• Where the Hb can be done, then
Hb<5g/dl
Some palmar pallor
• this is where the palm looks pale
• Where Hb can be done, then
Hb<8g/dl
• No palmar pallor?
To classify Anemia, refer to chart booklet pg
8

81. Exercise
 Case; Kalisa
 Kalisa is 11months old, he weighs 7kgs, his temperature is 37. His mother
says he has had a dry cough for the ;last 3 days. Kalisa does not have any
general danger signs. The health worker assessed his cough. It has been
present for 21 days. He counted 41 breaths per minute. The health worker
does not see chest in drawing. There is no stridor or wheeze. Kalisa does not
have diarrhea, he has not had a fever during this illness. He does not have
an ear problem. The health worker checked Kalisa for malnutrition and
anemia and took Kalisa’s height 73cm, MUAC 11cm. There is no history of
TB contact. His palms are very pale and appear almost white. There is no
oedema of both feet. The health worker determined Kalisa’s weight for age.
(look at the weight for age, length for age and determine Kalisa’s z’score.
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82. UNIT VI: HIV EXPOSURE
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83. CHECK FOR HIV EXPOSURE AND INFECTION
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• Children may acquire HIV infection from an infected
mother through vertical transmission in utero, during
delivery or while breastfeeding.
• Without any intervention, 30 – 40% babies born to
infected mothers will themselves be infected.
• Most children born with HIV die before they reach
their fifth birthday, with most not surviving beyond
two years
• Good treatment can make a big difference to
children with HIV and their families.
• The child’s status may also be the first indicator that
their parents are infected too
To asses and classify for HIV infection and exposure,
refer to chart booklet pg. 9
From mother to child

84. UNIT VII: CHECK FOR CHILD’S
DEVELOPMENTAL MILESTONES
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85. 85
How can you use power point to enhance your messages?
Health Care Providers Should be able to:
Objectives:
 Understand care for child development
 Understand background information:
Brain development, child’s skills domains and play &
communication
 Assess child’s development milestones
 Classify child’s development milestones
Background
Assess &
Classify
Application
 Complete sample exercises
 Counsel caregivers on home play and stimulation
practices /activities for care for child development

86. What is care for child development ?
• Care for child development include play and
stimulation interventions in early life to promote
physical, social, emotional , language and
cognitive development
• This is done through responsive interactions
between caregiver and the child by talking,
playing and providing a stimulating environment
• Care for child development is a more
comprehensive approach to early life going
beyond existing child survival interventions to
also promote thriving.

87. Brain Development
• Brain development is most rapid from conception and the first three years of life.
• Stimulation is critical during the time the brain is sensitive
• Lack of stimulation during this period affects the child’s cognitive, physical,
emotional and social development.

88. Stimulated vs Non-Stimulated Brain
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89. Child’s Skill Domains
1. Physical/Motor skills—: This involves coordinated movements
 Reaching and grabbing
 Follows objects with eyes
 Turns head towards sound
 Sitting, crawling, standing
2. Cognitive skills—This involves changes in child’s thought, intelligence, and language
 Seeing, hearing, moving, touching;
 recognize people, things, and sounds
 compare sizes and shapes.
3. Social skills—This involves changes
 In the child’s relationships with other people
 How he/she communicates interests and needs
 Expresses self through verbal and non-verbal skills
4. Emotional skills—It involves
 Having appropriate emotional reactions to own efforts and other people
 Being able to receive and express appropriate emotions and affection

90. Assessing Milestones for Age Cohort
Age in Months Developmental Milestones
0-2 • Social smile ( Baby smiles back
• Baby follows a colorful object
dangles before their eye
2-4 • Hold the head upright
• Follows the object or face with
their eyes
• Turns the head or response in any
other way to sound
• Smiles when you speak
4-6 • Rolls over
• Reaches for and grabs object with
hand
• Takes objects to the mouth
• Bubbles ( makes Sounds
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91. Assessing Milestones for Age Cohort
Age in Months Developmental Milestones
6-9 • Sits without support
• Moves object from one hand to the
other
• Repeats syllables (bababa,
mamama)
• Play Peek Aboo (hide & Seek)
9- 12 • Takes steps with support
• Picks up small object or string with
two fingers
• Says 2- 3 words
• Imitates simple gestures ( claps
hands, bye)
12-18 • Walks without support
• Drinks from a cup
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92. Assessing Milestones for Age Cohort
Age in Months Developmental Milestones
18- 24 • Kicks a ball
• Build tower with 3 blocks or small
boxes
• Points at pictures on requests
• Speak in small sentences
24 months & Older • Jumps
• Undresses and dresses themselves
• Says first name, tells short story
• Interested in playing with other
children
REFER to PAGE 10 for ASESS, CLASSIFY AND IDENTIFY TREATMENT ON
CHARTBOOKLET
* Refer to COUNSEL THE CAREGIVER (Recommendation for Care for child’s
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93. ASSESS FOR INTERACTION,
COMMUNICATION AND RESPONSIVENESS
• Through play and communication with the child, the caregiver
learns to be sensitive to the child’s signals and appropriately
respond to the child’s attempts to communicate
• The counselling card suggests play and communication activities
to help families stimulate the development of the child’s skills
from conception
• At different ages, a child needs stimulating environment to
learn new skills.
• The recommendations for play and communication change and
become more complex as the child grows older.
• The activities also help the family learn how to care for the child
to promote the healthy growth and psychosocial development
for the child
 To assess, classify and identify treatment REFER to page 11 of
the Chart Booklet

94. EXERCISE C
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Purpose: Behaviors and Practice
Class Discussion
Ask participants to mention the behaviours and practices of caregivers from their
communities.
• Note down all the responses and summarize them
Divide the participants into groups and ask them to discuss how the practices are
performed
• With affection
• With responsiveness to the child
Format. Demonstration, Role play
The behaviors and practices of caregivers, include:
Providing food
Health care
Stimulation
Emotional support

95. EXERCISE D
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Purpose: Importance of Stimulation
Class Discussion
Distribute to participants, organized in pairs, the visuals on the importance of assessing and
promoting child development.
• Ask them to review the images and explain to each other what they see in them.
Then invite a participant to share his or her idea about the visual.
• Ask others to contribute. Reinforce what’s missing from the explanation.
Invite one person to explain in local language and pretending to talk to a mother, why they
should check how their children are developing, and play and talk with their children.
• Analyze the explanation together:
• Was it clear?
• Was it complete?
Use the visual aids on the importance of stimulation
Format. Participants will be divided into pairs.
Use visual aids on the importance of stimulation

96. EXERCISE E
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Purpose: Assessment and Action
Case 1 : Mary
Mary is a 9 month old baby who lives with her grandmother and her 2 older siblings. The
child is albino and lives in a house made of makeshift materials. Mary cannot pick an object
with 2 fingers at 9 months, she has also not started crawling. She is currently admitted in
hospital with a fever.
Action.
The health care provider counsels the grandmother and recommends that she gives Mary
clean, safe household things to handle, bang and drop. The older siblings should continue
playingwith the Mary. Other recommendations given include: gentle massage of the baby
during bath time.
If the grandmother notices no change after 30 days of intensive stimulation, she should
bring back Mary to hospital for referral to a specialist.

97. EXERCISE F
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Purpose: Assessment and Action
Case 1 : Peter
Peter is the father of a 2 year old son, Peter leaves very early daily for fishing and returns
late in the evening. He leaves his son in the care of a neighbour. The child is unable to
speak, he is only able to make sounds but cannot utter any word.
Action
The health care provider counsels and encourages Peter on creating time to spend with his
son and making simple toys to enhance play and communication. Peter should also
encourage his child to talk and answer the child’s questions. Peter should also teach his
child stories, songs and games, by doing this he will be stimulating his son’s laguage
development.

98. UNIT VIII: CHECK THE CHILD’S
IMMUNIZATION
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99. Vaccination Coverage by County
Percent of children age 12-23 months
fully vaccinated
*Kirinyaga county figure based on fewer than 25-49 unweighted cases.
*

100. Childhood Vaccinations
Percent of children age 12-23 months vaccinated
Pentavalent Polio Pneumococcal
KDHS, 2014

101. CHILD’S IMMUNIZATION
• Immunization is one of the most cost effective health intervention for disease
control.
• It targets children under the age of 5 years.
• It needs tremendous inputs and effort to make it happen.
• Immunization coverage can be enhanced through;
• Routine Immunization
• Supplemental Immunizations
• Surveillance of the target diseases
• Mopping up in high risk areas
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102. CHECK THE CHILD’S VITAMIN A
SUPPLEMENTATION STATUS
• A child's body require Vitamin A for; Growth and development, Protection
against absorption of the vitamin A & rapid utilization of vitamin A stores
due to illnesses
• Vit A deficiency may lead to
• Increased incidence of illness
• Delays recovery from infections
• Leads to eye damage and may even lead to blindness
• Increases the risk of death in sick children
 Remember, Vit A supplementation can;
 Reduces measles mortality by 50%
 Reduces diarrhea mortality by 33%
 Reduces all causes of mortality by 23%
For immunization and Vit A schedule, refer to pg 12
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103. CHECK THE CHILD’S DEWORMING STATUS
 Deworming involves giving an anthelmintic drug to children to rid them of parasites
and worms e.g. roundworms, flukes and tapeworms.
 Deworming acts as both a treatment and preventive measure
 Children are particularly susceptible to intestinal worms and bilharzia through
contaminated soil and water respectively
 Chronic worm infestations often make children malnourished, anemic and vulnerable
to illnesses.
 It is important to deworm children as it improves health and immunity, and protects
them from chronic illnesses caused by worms
REFER TO CHART BOOKLET PG 12 FOR THE VITAMIN A AND DEWORMING SCHEDULE
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104. IMPORTANT POINTS TO CONSIDER
 *Do not give BCG to a child with symptomatic HIV/AIDS. In child exposed to
TB disease at birth, do not give BCG, instead give child isoniazid Prophylaxis
for 6 monthsthen administer BCG 2 weeks after completetion of IPT
 **Measles rubella vaccine at 6 months is for HIV exposed/ infected children.
Repeat at 9 months and 18 months
 ***Yellow fever vaccine should not be given to children with HIV /AIDS and
is only offered in ( Baringo, Elgeyo Marakwet ) in Rift valley region.
 ****Rota Virus vaccine should not be given to children over 12 months
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105. UNIT IX: ASSESS FOR OTHER PROBLEMS
THAT THE CHILD MAY HAVE
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