Course: S6: Maternal Child Health

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Topic outline

General
UNIT1:NATURAL FAMILY PLANNING
Key unit competence
Provide natural family planning services
Introductory activity 1
a. What can you suggest for Family B to do in order to achieve sustainable
development and wellbeing?
b. Do you know the methods that can be used for family planning?
c. According to you, what are the methods that can be used easily without
visiting the health facilities?
1.1 Introduction to family planning
a) What do you understand by family planning and contraception?
b) Why do you think family planning is important?
Learning activity 1.1
1.1.1 Concepts of family planning
Family planning refers to individual’s or couple’s’ conscious and informed decision
to decide when to become or not to become pregnant throughout the reproductive
years.
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Contraception is defined to the intentional use of artificial methods and/or other
techniques to prevent pregnancy as a result of doing sexual intercourse.
Natural family planning This refers to the methods of contraception which do not
use hormones and devices. Natural family planning includes abstinence, coitus
interruptus, lactation amenorrhea, and fertility awareness methods.
Modern family planning refers to all products and/ or medical procedures that
interfere with reproduction whenever there is coital activity. Some of the products
act by preventing ovulation from occurring and others may inhibit sperms from
fertilising the matured egg.
1.1.2 Benefits of family planning
Family planning can lead to sustainable development. It enables women and
couples to avoid unwanted pregnancies, attain the desired number of births,
and control the intervals between births. Family planning can contribute to
delaying pregnancy in young girls who may at increased risk of health problems
from early childbearing, and further reduces the rates of unsafe abortions and
HIV transmission. Family planning can benefit the education of girls and lead to
women’s empowerment within the community. In addition, family planning may
prevent pregnancies among older women who can be at increased risk of pregnancy
related complications.
Self-assessment 1.1
i. With examples, explain the following terms:
a.Family planning
b.Contraception
ii. Discuss the role of family planning for women in their reproductive age?
iii. What can be the role of family planning for young adolescents?
Homework 1.1
Go to the computer lab and read about principles of family planning.
1.2 Principles of family planning
Learning activity 1.2
In your own understanding, what are the principles of family planning that can be
considered in providing quality services to the clients?
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Introduction
Smaller families and increased child spacing contributes to reducing rates
of infant and child mortality. Family planning further improve the social and
economic conditions of women and their families, and improve maternal health.
Whilst providing family planning services, individuals’ and couples’ rights and
preferences have to be followed. This is achieved by following the principles of
families that are discussed in the next sections.
Autonomy
Providers should enable the women and individual couples to exercise free and
informed decision-making whilst choosing among a full range of safe, effective, and
possible family planning methods.
Accessibility
Family planning providers need to ensure that women and couples have the ability
to access accurate, clear and readily understood information about a variety of
family planning methods and how they are used. Health care facilities have to
ensure that contraceptive methods, trained providers, and contraceptive methods
are accessible to women and couples.
Acceptability
By acceptability, health care facilities, trained providers, and available family
planning options must be acceptable by women and couples. They must also meet
the medical standards, and individual preferences. Services provided and available
family planning methods must be sensitive to gender, life-cycle requirements,
dignity, and culture.
Equity and non-discrimination
Quality family planning services should be provided to women and couples free
from any form of discrimination such as age, gender, language, ethnicity, religion,
sexual orientation, income, and race. Women and couples must not be coerced
and/or violated when they seek family planning services from a healthcare provider.
Quality
Services and information provided to women and couples should be of good quality,
and should be based on the best available evidence. Quality encompasses a full
range of choices including quality contraceptive methods, accurate information,
and presence of technically competent providers, client-provider interactions that
respect the clients’, confidentiality, and preferences
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Availability
By availability, family planning enabling environment with the following is ensured:
a) Health care facilities,
b) trained providers;
c) Counselling information
d) contraceptive methods are available to ensure that individuals can exercise
full choice from a full range of contraceptive methods
e) Availability of follow-up and removal services for implants whenever necessary
and needed.
Empowerment
Women and individual couples are empowered as principal actors and agents to
decide on their family planning needs. They are also empowered to implement these
decisions through seeking information about family planning, seeking services, and
choosing a family planning method suitable for them.
Informed consent
When providing family planning services, the provider needs to always seek the
woman’s and/or the couple’s informed consent and offer her comprehensive
information about the services provided as shown below
Table 1.1: Informed consent applied to family planning services

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1.3.1 Fertility awareness and calendar methods
Learning activity 1.3.1
Students watch a YouTube video titled ‘How I Use Natural Family Planning To
Prevent Pregnancy’ about fertility awareness methods: https://www.youtube.
com/watch?v=lCsuefLt9eA&t=45s
1. What do you understand by fertility awareness as a family planning
method?
2. With examples, explain different methods of fertility awareness that can
be used to prevent unwanted pregnancy?
a. Fertility awareness method
Fertility awareness methods (FAM) also known as the rhythm method, encompass
all methods that are used based on the fertile and infertile phases of a woman’s
menstrual cycle.
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Figure 1.2: Fertile period
The fertile days are determined by correctly charting the span of the menstruation
cycle over a period of six months.
The calendar method has indications, contraindications and mode of action as
follows:
i) Indication
• To all women in reproductive age and with regular menstrual cycle.
• To all women who are capable of reading and able to chart properly.
• To all women who are capable of abstaining from sexual intercourse
during the fertile period.
• To all couples ready to use calendar method along with method with
barrier method during the fertile period to make it more effective.
ii) Contraindication
• Calendar method is not allowed to psychotic women.
• Calendar method is not allowed to non-cooperative couples.
• Calendar method cannot be used by a couple who is not ready to abstain
from sex during the woman’s fertile period.
• Calendar method is contraindicated to women who have irregular
menstrual cycle.
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iii)Mode of action
Using a calendar, the woman monitors her menstrual cycle to track down her fertility
days starting from the first day of her menstrual period. The commencement of the
fertile period is determined by deducting or subtracting 18 days from the length of
the shortest cycles. The termination of the fertile days is determined by subtracting
11 days from the extent of the longest cycle (see figure 2 below).

Table 1.2: Formula used to calculate fertility days using the calendar method

A woman keeps track of the length of her menstrual cycles for at least 6 months.
Then she calculates her fertile window by subtracting 18 days from her shortest
cycle and 11 days from her longest cycle. For a woman whose shortest cycle is 24
days and longest cycle is 28 days, the calculation would be
as follows:
Shortest cycle
24
-18
=6
Longest cycle
28
-11
=17
Based on this calculation, the woman’s fertile window would be days from 6th
to 17th day of her menstrual cycle. During these days, the woman and her male
partner should abstain from sexual intercourse or else use a condom to avoid
pregnancy in this period.
Self-assessment 1.3.1
i) How do you calculate the calendar family planning method?
ii) When is the woman most likely to become pregnant if she is using calendar
method?
iii) What precautions should be taken by the couple when they are using
calendar method?
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Learning activity 1.3.2
i) With the image above what do you understand by term ‘basal body
temperature’?
ii) What factors do you think can affect basal body temperature?
Introduction
The basal body temperature is the lowest normal temperature of a well person,
measured immediately after waking up and earlier after getting out of the bed. The
basal body temperature depends on the woman’s recognising the shift in her body
temperature around the time of ovulation. The BBT normally ranges from 36.2°C to
36.2°C during menses, and for about 5 to 7 days after. At about the time of ovulation,
a slight drop in temperature may occur, followed by a slight rise (approximately
0.4°C–0.4°C) after ovulation, in response to increasing progesterone levels. This
temperature elevation may last between 2 and 4 days before menstruation.
The basal body temperature drops to the lower levels recorded during the previous
cycle, unless pregnancy occurs.
i) Indication
• To all women who are capable of reading the thermometer measurements.
• To all women who are capable to know that their temperature has risen
from their normal temperature.
• To all women with no infection.
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ii) Contra-indication
• The women who cannot read measurements on the thermometer.
• To all women with infection. e.g. vaginitis, malaria etc.
• To all women who are not using warm blankets.
iii)Mode of action
This method works effectively if the woman has a temperature which does not
change. Hence, if a woman has a condition that may increase or lower her
temperature such as infection, fatigue, and anxiety, the method does not work.
Self-assessment 1.3.2
i) Describe how the woman’s basal body temperature changes across her
monthly cycle.
ii) When is the basal body temperature likely to rise and why?
iii) At what temperature can a couple using basal body temperature avoid
unprotected sexual intercourse?

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Learning activity 1.3.3
i) How does cervical mucus test can help the woman to predict the time of
her ovulation?
Introduction
The cervical mucus method refers to the recognition and interpretation of changes
in the amount and consistency of cervical mucus through the menstrual cycle.
Before ovulation, cervical mucus is thick and does not stretch easily. During the
fertility days, the cervical mucus becomes more abundant and thinner with an
elastic quality. After ovulation, cervical mucus becomes thick or may disappear
completely. This quality inhibits sperm from entering in the cervix. The change of
cervical mucus occurs to facilitate the viability and motility of sperm and allowing
the sperm to survive in the female reproductive tract until ovulation.
i) Indicatio
• To women who are capable of abstaining from coitus during ovulation.
• To all couples who are capable of recognising the changes in appearance
of cervical mucus during the fertile period.
• To all couples who are capable of being cooperative during the ovulation
time.
ii) Contra-indication
• This method is contraindicated to all women who feel uncomfortable
touching their genitals.
• The method is not allowed to all women with vaginal infections, sexual
transmitted infections, and hormonal imbalances should also not use
cervical mucus method.
iii)Mode of action
When a woman is using cervical mucus method, she is supposed to check her
vaginal discharge every day for consistency and recognition of the change in
appearance of her cervical mucus to determine her fertile period.
Self-assessment 1.3.3
i) Who should not use cervical mucus method in family planning?
ii) When should a woman be cautious while determining her fertile period
using cervical mucus method?
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1.3.4. Standard Days Method
Learning activity 1.3.4
Mrs. Lina have had a regular menstrual cycle of 30 days for six months. On 31st
July, she noticed that she had seen her menstrual bleeding. She is currently
using a cycle bead as a family planning method.
i) Which days will be safe for Mrs. Lina to do sexual intercourses with her
partner?
ii) Which days will Mrs. Lina cannot do unprotected sexual intercourses?
Introduction

Standards Days Methods is another fertility awareness in which women and couple
use a cycle beads necklace to track their cycles (see the picture above). The cycle
beads have 32 beads, each representing a day in the woman’s menstrual cycle.
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i) Indication
• To all women with regular menstrual cycle.
• To all women who have had 3 menstrual cycles after child birth, with the
last one recording 26 to 32 days.
ii) Contra-indication
• To avoid unprotected sexual intercourse from 8th day to 19th day of every
cycle.
• Uncooperative couples should not use SDM.
iii)Mode of action
The woman moves a rubber ring onto one bead each day based on her monthly
cycle. The red bead marks the first day of her period. Brown beads correspond to
safe days; that days when she may not likely become pregnant if she does sexual
intercourse. From the brown beads, the woman moves the rubber ring onto the
white beads. These white beads represent the when she is likely to get pregnant
and are labelled “unsafe” times to have unprotected vaginal intercourse.
Self-assessment 1.3.4
1. Mrs. Dana has given birth one month ago. As she is not breastfeeding
regularly, she has seen her menstrual bleeding on 15 June. She wants to
use the cycle beads as a method of family planning.
i) At what date would you advise to explore the use of Standard Days
Method?
ii) What would Mrs. Dana take into consideration before deciding to use a
cycle bead as a preferred family planning method?
Homework
Read the book ‘Family Planning: A Global Handbook for Providers’, Chapter 19;
Lactational Amenorrhoea, Page 257

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Learning activity 1.3.5
i) Explain how breastfeeding can delay ovulation after the birth of the baby?
ii) Who can use Lactational amenorrhea and why?

Introduction
Lactational Amenorrhea Method is a type of natural family planning which depends on
the woman’s breastfeeding regularly (every two to three hours) without interruption
in the first six months after delivery. When the woman breastfeeds consistently,
prolactin levels become elevated and suppress ovulation.
a. Indication
• This method can be operational within 6 months after delivery.
• If the mother has not had menstruation since the time of birth.
• When the mother is able to breastfeed her baby at least every 2 to 3 hours
regularly without stopping within six months.
b. Contra-indication
• Not to be practiced after 6 months post birth.
• Not to be used when the mother has had the return of menstrual period.
• Not to be used by mothers who are not available to breastfeed their babies
regularly.
c. Mode of action
For this method to be more effective, LAM requires constant breastfeeding. Breast
feeding stimulates prolactin hormone which is responsible for breast milk production.
This hormone further hinders gonadotropin hormone which is responsible for
ovulation to be produced. Thus, when the woman does sexual intercourse, she will
not likely become pregnant.
Self-assessment 1.3.5
i) If the couple is using Lactational amenorrhea, what do they have to care of
to prevent the woman from becoming pregnant?
ii) Discuss the factors that can influence the use Lactational Amenorrhea
Method.
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1.3.6 Coitus Interruptus or withdrawal method

Figure1.7: Coitus interruptus
Learning activity 1.3.6
Read the book titled ‘Family planning: A global Handbook for Providers’ (2018
Edition), Chapter 18 and answer the following questions:
i) What happens when a couple practises withdrawal method?
ii) Whom can you likely recommend to practice coitus interruptus and why?
iii) In your own opinion would you recommend coitus interruptus as a first
choice of family planning method?
Introduction
The male partner pulls his penis out of the vagina before ejaculation occurs to avoid
depositing sperm in or near the vagina. In so doing, he must keep his semen away
from the female partner’s external genitalia.
i) Indication
• All men in their reproductive age can use withdrawal method.
• It is indicated if there is no other family planning method available for
partners to use.
• This method requires much attention during the sexual act because at
times the man may reach climax and releases the pre-ejaculate fluid which
may contain sperm before withdrawing his penis to ejaculate outside the
vagina.
• This method might be appropriate for couples who are highly motivated
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and able to use it without failing.
• It can also be used by couples with religious or philosophical reasons for
not using other methods of contraception.
• Coitus interruptus can be used by couples who are waiting to get another
alternative method immediately but find themselves in need of sexual
intercourse without having obtained that method.
• Couples who need a temporary method while they wait the start of another
method may choose to use coitus interruptus.
• Couples who do sex infrequently can choose coitus interruptus method.
ii) Contra-indication
• Coitus interruptus must not be the method of choice if a man has premature
ejaculation issues.
• The method is also not appropriate for women with conditions that make
pregnancy an unacceptable risk because of the relatively high risk of
failure of coitus interruptus.
• This method is not allowed to couples who are not cooperative.
iii)Mode of action
When the man feels close to ejaculating, he must immediately remove his penis
from his female partner’s vagina to ejaculate outside and keeping his semen away
from her vulva. If man has ejaculated recently, before penetrating the female partner
again, he must urinate and clean the tip of his penis to remove any sperm that may
be remaining on his penis. The man should feel confident he can use withdrawal
correctly whenever he is engaged in the act of sex with his partner.

Self-assessment 1.3.6
i) How does coitus interruptus method work?
ii) Who would you recommend to not use coitus interruptus and why?
iii) Describe how a male partner may pull out his penis from the vagina if the
couple is using coitus interruptus.
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End unit assessment
1. Explain briefly the principles of family planning?
2. What are the signs that can make a woman to be conscious that is in her
fertile period with the help of cervical mucus?
3. Discuss any factors that may affect Mrs. Lina’s use of cycle bead
successfully.
4. Discuss the factors that can influence the use Lactational Amenorrhea
Method.
5. How does coitus interruptus method work?
6. The couple X have chosen to use Standard Days Method as their
preferred family planning method. The woman’s cycle in the last three
months had been between 28 and 32 days. The woman had seen her
periods on 5th April.
Draw a cycle bead and guide this couple on how they can use this method to
avoid unplanned pregnancy.
7. You are sent to the community and meet a group of women on Umuganda
day. The village head requests you to offer an educational session about
natural family planning.
Explain how you will educate the above group on different methods of natural
family planning focusing on different methods’ mode of action, indications, and
contraindications.
UNIT2:MODERN FAMILY PLANNING
Learning activity 2.4.2
2.1 Key unit competence
Provide modern family planning services
Introductory activity 2

i) What do you know about the above images?
ii) What would you consider if a woman and/or a couple seeks your assistance
in choosing any of the above family planning methods?
Introduction to modern family planning methods
Individuals and couples have to be informed about different options of available birth
control methods so that they make an informed choice on which one to use to plan
for pregnancy. Individuals’ and couples’ preferences can be influenced by a number
of factors such as beliefs, medical eligibility criteria, demographic factors, parity,
ease of use, duration of use, frequency of sexual intercourse, reliability, and the
side effects. In the previous unit, different methods of natural family planning were
discussed. In order to optimise the individuals’ and couples’ choice of contraception
suitable to them, Unit two proceeds with the discussion of different methods of
modern family planning namely oral contraceptives (pills), injectables, Implants and
IUDs.
2.1. Oral contraceptive methods
2.1.1 Introduction to oral contraceptive
Learning activity 2.1.1
Students watch the video about birth control pills found on this link: https://www.
youtube.com/watch?v=Gu11uty__OY
i) Mention the oral contraception methods of family planning methods you
know.
ii) Choose one of the methods you have mentioned above and explain its
mode of action.
iii) Briefly explain what progestin only pills are and who is eligible to use them?

Oral contraceptive methods are pills that a woman can use to prevent pregnancy.
These pills contain hormones that are similar to those of the woman’s reproductive
hormones which act by changing the woman’s body hormone balance and this
prevents the ovaries from releasing an egg each month (ovulation). The pill also
thickens the mucus in the neck of the womb and makes difficult for sperm to penetrate
the womb to reach the ovum. Oral contraceptive methods include progestin only
pills, combined oral contraceptive pills (oestrogen and progestin combined pills),
and emergency contraceptive pills.
Self-assessment 2.1.1
i. How does oral contraceptive methods work?
ii. List oral contraceptive methods.
2.1.2 Progestin only pills

Figure 2.3: Progestin-only pills
Learning activity 2.1.2
Using internet and library (Read chapter two of the ‘Family Planning: A Global
Handbook for Providers, edition 2018’); answer the following questions.
i) Explain how the progestin-only pills work?
ii) Which clients can you advise not to take progestin-only pills as a
contraceptive method?
Introduction
The progestin only pills contain a low dose of a progestin similar to the natural
hormone progesterone in a woman’s body. These pills do not contain oestrogen
hormones. The pills come in packs of 28 pills and women take one every day. One
pill is taken daily at approximately the same time (hour) without breaks between
packs. In order for these pills to ensure efficacy of progestin-only pills, the woman
has to avoid leaving an interval of 24 hours between pills.
The woman needs to be advised that once she initiates the use of these pills, she
is not protected from pregnancy prevention in the first seven days. For this reason,
the health provider needs to recommend her using an alternative method of birth
control along with progestin-only pills during the first week. If a woman misses a
tablet, she has to take the missed tablet as soon as she remembers and further
progress taking the next tablet at the usual time (taking two tables in one day). If
the woman misses two tablets in a row in the first or second week, she should take
two tablets the day she remembers and two tablets the next day, then she resumes
one tablet per day.
i) Indication
• A woman can start using the progestin only pills (POPs) any time she
knows that she is not pregnant.
• A woman can use progestin-only pills if she is breastfeeding.
• Women with or without children are eligible to use progestin-only pills.
• Progestin-only pills can also be the method of choice for even adolescent
girls who may need to use contraception to prevent unwanted pregnancies.
ii) Contraindication
• Progestin-only pills can be contraindicated in the following cases:
• Women with pre-existing breast cancer, cervical cancer, endometrial
cancer, ovarian cancer, uterine cancer, and vaginal cancer,
• Women with uncontrolled hypertension
• Women who smoke
• Women with pre-existing anaemia or who had anaemia in the past,
• Women who have varicose veins,
• Women living with HIV, whether or not on antiretroviral therapy.
iii)Mode of action
Progestin-only pills act by inhibiting follicular development and preventing ovulation.
Progesterone negative feedback signals the hypothalamus to decrease the pulse
frequency of gonadotropin releasing hormone, which in turn decrease the secretion
of follicle-stimulating hormone (FSH) and the secretion of Luteinizing Hormone (LH).
When the follicle is not developing, the oestradiol levels increase. When there is no
development of the follicle and no LH work, the ovulation is prevented. The pill also
thickens cervical mucus (this blocks sperm from meeting an egg). As the woman
keeps taking progestin-only pills regularly as prescribed, they cause menstrual
cycle change and this prevents the release of eggs from the ovaries (ovulation).
iv)Advantages of using progestin-only pills
Some advantages of using the progestin only pills include the following:
• The pill is more effective for lactating mothers and can be 99% effective if
used correctly and consistently by breastfeeding mothers.
• Do not interfere with breastfeeding and they are safe for breastfeeding
women and their babies because they do not affect milk production.
• The user can stop using progestin-only pills at any time without any help
of the provider.
• Do not interfere with sexual intercourse;
• Progestin-only pills use is controlled by the woman;
• Progestin-only pills cannot cause women infertile;
• Progestin-only pills do not cause diarrhoea in breastfeeding babies
v) Side effects
Some women taking progestin-only pills may develop some side effects such as
breast tenderness and breast enlargement, mood changes, headache and migraine,
nausea and vomiting.
Self-assessment 2.1.2
i. How does progestin-only pills work?
ii. What are the advantages of using progestin only pills?
iii. What do you know about indication of progestin only pills?
2.1.3 Combined oral contraceptive pills (COPs)
Learning activity 2.1.3
Using internet and books (“Introduction to Maternity and Paediatric Nursing”,
Page 111-112 about combined oral contraceptive pills), answer the following
questions:
i) What do you know about combined oral contraceptive pills?
ii) A woman who has forgotten to take 2 combined oral pills in the second
week of her last menstrual period comes to your health post for help. What
would you advise her to do?
Introduction to Combined oral contraceptive pills
Combined oral contraceptive pills contain both estrogen and progesterone
hormones. Those hormones are similar to the natural hormones produced by a
woman’s body. These pills come in packs of 21 or 28 pills. A user takes one pill
every day at the same hour. For greatest effectiveness a woman must take pills
daily, start each new pack of pills on time, and take any missed pill as soon as
possible.
Like the progestin-only pills, when a woman starts taking combined oral pills, she
may likely become pregnant in the first seven days if she does unprotected sexual
intercourses. To minimize the risk of pregnancy, an alternative method of birth
control is recommended along with combined oral pills for women who do sexual
intercourses frequently. When a woman misses a tablet, she has to take the missed
table as soon as she remembers and she has to take the next tablet at the usual
time (taking two tablets in one day). If woman misses two tablets in a row in the
first or second week, she has to take two tablets the day she remembers and two
tablets the next day, then after continues with her usual dose of one tablet per day.
i) Indication
The following are indications of using combined oral contraceptives pills:
• Have or have not had children
• Are married or are not married
• Are of any age, including adolescents and women over 40-year-old
• After childbirth and during breastfeeding after 6 months
ii) Contraindication
The contraindications to COPs are indicated in the following situations:
• Women with breast cancer,
• Women with a history of deep venous thrombosis or pulmonary embolism,
active liver disease, use of rifampicin, familial hyperlipidaemia, previous
arterial thrombosis, epilepsy, diabetes, and sickle cell disease,
• Women who are pregnant,
• Smoking,
• Women with advanced age (over 35 years),
• Women with hypertensive disorders,
• Women who are currently breastfeeding before 6 months,
• Women with irregular spontaneous menstrual cycle.
iii)Mode of action
The combined oral contraceptive pill works by stopping the ovaries from releasing
an egg each month (ovulation). It also thickens the mucus from the cervix which
makes it difficult for sperm to move through it and reach a matured egg. It also
makes the lining of the uterus (womb) thinner; it is less likely to accept a fertilized
egg.
iv)Advantages of combined oral pills
The following are the advantages of combined oral contraceptive:
• Women have control over their use and they can be stopped at any time
without a provider’s help.
• Do not interfere with sex and this method is easy to use. Reduce also the risk
of having anaemia.
• Combined oral pills may protect against pelvic inflammatory disease,
• Combined oral pills may protect against endometrial cancer and can also
reduce symptoms of premenstrual syndrome (PMS).
• Combined oral pills can reduce the risk of cancer of the ovaries, womb and
colon for women.
• Combined oral pills can be used in the post-abortion and postpartum period
by woman who desire a fast return to fertility.
Side Effects
Combined oral pills can lead to changes in bleeding patterns (lighter bleeding
and fewer days of bleeding, irregular bleeding, infrequent bleeding or no monthly
bleeding among some women. In other cases, women taking combined oral pills
may develop headaches, dizziness, nausea, breast tenderness, weight change,
and mood changes.
In rare cases, women taking combined oral pills may develop these side
effects:
• Severe headache
• Bad pains in the chest
• Leg swelling
• Breathing difficulty
• Sudden problems with sight or speech
• Numbness in an arm or leg.
Self-assessment 2.1.3
i. How does combined oral contraceptive pills works?
ii. What are the advantages of using combined oral contraceptive pills?
2.1.4 Emergency contraceptive pills
Learning activity 2.1.4

Introduction to emergency contraceptive pill
Emergency Contraceptive Pills (ECPs) also called “morning after” pills or “postcoital
contraceptives” prevent the release of an egg from the ovary or can act by delaying
its release by 5 to 7 days. If ovulation has occurred and the egg is fertilised, the
Emergency Contraceptive Pills cannot prevent implantation or disrupt an already
established pregnancy.
i) Indication
The following are indications of emergency contraceptives pills:
1. It is recommended for women who experience sexual assault
2. When current contraceptive method has failed (for example when the
condom breaks).
3. Unprotected sexual intercourse
4. Missed or late doses of hormonal contraceptives
ii) Contraindication
Emergency Contraceptive Pills are not advised for use among women with the
following cases:
• A history of thrombosis,
• Current severe liver disease,
• Focal migraine at the time of presentation
• Breastfeeding women.
iii)Mode of action
The emergency contraceptive pill works by preventing or delaying ovulation. It also
inhibits an egg from being released from the ovary when taken before ovulation .it
thickens the cervical mucus making it not to allow the sperm to meet the egg.
iv)Advantages of emergency contraceptive pills
Emergency contraceptive pills (ECPs) help a woman to avoid pregnancy after she
has had sex without contraception.
Emergency contraceptive pills also prevents pregnancy when taken up to 5 days
after unprotected vaginal sex.
v) Side Effects
The use of emergency contraceptive pills may be associated with the following side
effects:
• Changes in bleeding patterns (Slight irregular bleeding for 1–2 days after
taking emergency contraceptive pills,
• Monthly bleeding that starts earlier or later than expected especially in the
first several days after taking the pills
• Nausea,
• vomiting,
• Fatigue,
• Abdominal pain,
• Headache,
• Dizziness,
• Breast tenderness.
Self-assessment 2.1.4
i. How does emergency contraceptive pills work?
ii. What are the indications and contraindications of emergency contraceptive
pills?
Reading activity
Read about injectable family planning methods found on this link: https://www.open.
edu/openlearncreate/mod/oucontent/view.php?id=141&printable=1#maincontent.
You are going to present the information you read before the start of the next lesson.
Learning activity 2.2
i) Explain what you know about progestin-only injectables?
ii) List the progestin-only injectables you know and how they work.
iii) How long can a woman use progestin-only injectable method of family
planning?

Introduction to injectable contraceptive methods
Injectable contraceptive methods constitute of the intramuscular injection
administration into the muscle of the arm or buttock. This injection provides to the
body sufficient levels of hormones to provide contraception for one to three months.
Injectable contraceptive methods consist of progesterone-only preparations. The
most used progestin-only injectables are Depo-Provera and Noristerat. A woman
can have the progesterone-only injection at any time during her menstrual cycle as
long as she is not pregnant. Depo-Provera is given every three months whereas
Noristerat is given every two months.
i) Indication
Nearly all women fulfilling the following conditions can take Depo-Provera:
• No pregnancy
• No history of breast cancer in the family
• Absence of diabetes
• Absence of high blood cholesterol.
ii) Contraindication
• Depo-Provera should not be the method of choice if a woman has the
following conditions:
• Breast cancer or family history of breast cancer
• Diabetes or with history of diabetes in family
• Excessive high cholesterol levels in the blood
• Depression
• High blood pressure.
iii)Mode of action
This injection once administered to the woman, it slowly releases hormone
progesterone into the bloodstream which prevents ovulation from taking place each
month. It also thickens the cervical mucus, which makes difficult for sperm to sail
through the cervix. Depo-Provera further thins the lining of the womb to prevent a
fertilised egg from implanting to the uterus.
iv)Advantages
Depo-Provera has a number of advantages including the following:
• Does not require daily action
• Does not affect breastfeeding
• Does not interfere with sex
• Protects the woman’s privacy
• May protect against the risk of cancer of the lining of the uterus
• Protects against the uterine fibroids
• May help against symptomatic pelvic inflammatory disease
• Protects against iron-deficiency anaemia
• Reduces symptoms of endometriosis.
v) Side-effects
Depo-Provera may cause side effects among women using it including the
following:
• Changes in the woman’s monthly bleeding from irregular to no monthly
bleeding;
• Weight gain
• Headaches
• Dizziness
• Abdominal bloating and discomfort
• Mood changes
Self-assessment 2.2
i) If a woman does not have monthly bleeding while using progestin-only
injectables, what advice can be given to this client?
ii) What are the side effects of progestin-only injectables?
2.3 Implants

Figure 2.5: Implanon
Learning activity 2.3
Students watch a YouTube video about implants (https://www.youtube.com/
watch?v=XXRLSndJ-x4) and answer these questions:
i) Explain to the clients what an implant is and how it works?
ii) In your own understanding would you please briefly mention the advantages
of implants as modern family planning?
Introduction to implants
Implants are modern family planning that has progestin hormone. Implants
are plastic rods that are small, flexible about as size of match stick. The health
professional inserts the rod using local anaesthesia just under the skin on the
inside of the upper arm. Insertion takes place approximately one minute. Removal
requires a small incision and takes about three minutes. They are two types of
Implants in modern family planning which are currently known but one is shortterm acting
(Implanon) and another is long-term acting (Jadelle). They are both
hormonal methods of modern family planning. The implant should be removed
after 3 or 5 years depending on the type.
i) Indication
These are some of the indications of implants in modern family planning:
• Women with normal menstrual bleeding cycle.
• Women with no breast cancer and with no history of breast cancer in their
family.
• Women with no history of allergic reactions to implants.
• Women with no high blood pressure.
• Women with no liver disease or tumour.
ii) Contraindication
• These are some of contraindications of implants in modern family planning:
• Women with excessive weight.
• Women with heavy menstrual bleeding.
• Women with breast cancer or history of breast cancer in the family.
• Women with liver diseases e.g., liver tumour.
• Allergy to implants.
• Mood swings and depression.
iii)Mode of action
The implants work by releasing slowly amount of progestin hormone which
suppresses ovulation and it thickens the cervical mucus which stops sperms
from penetrating through to reach the mature egg to be fertilised. It also prevents
pregnancy to take place by thinning the endometrium which makes the implantation
not to take place.
iv)Advantages
Provide long-term pregnancy protection. Very effective for up to 5 years, depending
on the type of implant. Immediately reversible.
v) Side effects
The side effects of implants include the following:
• It increases weight gain
• Irregular bleeding pattern
• They can cause vaginitis, breast pain, acne, headaches and pharyngitis.
• The implant does not provide protection against sexually transmitted
infections.
Self-assessment 2.3
i) Give explanations on how implants work to prevent pregnancy?
ii) Explain the indications and contra indications about implants?
iii) If a client comes to you seeking advice on the implants, outline the key
points you will consider as beneficial to her.
Reading activity for the next lesson
Read the book titled ‘Introduction to Maternity and Paediatric Nursing’, page 82-83
about IUDs
2.4 Intra uterine devices (IUDs)
2.4.1 Non-hormonal intra uterine device (Copper IUD, T-shaped)
Learning activity 2.4.1
i) What do you know about intra uterine devices?
ii) What important message have you noticed that can help the population
regarding the usage of IUDs?
Introduction
Intra-uterine device, also known as intrauterine contraceptive device or coil,
is a small, often T-shaped birth control device that is inserted into the uterus to
prevent pregnancy. IUDs are one form of long-acting reversible birth control. These
intrauterine devices are in two types, hormonal and non-hormonal.
Introduction to copper Intrauterine Device
The Copper IUD is the most used as non-hormonal Intrauterine Device for women
who need long term pregnancy protection (normally between 5 to 12 years). The
copper IUD is a small, flexible plastic frame with copper sleeves or wire around it.
This device is inserted into the woman’s uterus through her vagina and cervix. Its
strings hand through the cervix into the vagina.
i) Indication
Copper IUDs can be used by women fulfilling the following conditions:
• Have or have not had children,
• Are married or are not married,
• Are of any age, including adolescents and women over 40 years old,
• Have just had an abortion or miscarriage,
• Are breastfeeding
ii) Contraindication
• Copper IUD can be contraindicated in the following conditions:
• History of pelvic inflammatory disease (PID),
• When pregnancy is suspected,
• History of ectopic pregnancy,
• Having uterine abnormalities or benign tumour in the uterus,
• Gynaecologic bleeding disorders,
• Having suspected cancer of the genital tract
• Known current cervical, endometrial, or ovarian cancer; gestational
trophoblastic disease; pelvic tuberculosis
• Women who are diagnosed with sexually transmitted infections, they
should not have an IUD inserted.
iii)Mode of action
Copper IUDs do not contain hormones. They work by using the properties of copper
to affect sperm motility and egg survival. The copper IUD causes a chemical change
that damages sperm and egg before they can meet to fertilise.
Other actions of Copper IUD include inhibiting the sperm ability to swim through
the uterine cavity and further inhibit the transport of the ovum. When the uterus is
exposed to a foreign body, a sterile inflammatory reaction occurs, which is toxic to
sperm and ovum and this impairs implantation.
iv)Advantages
Copper IUD has several advantages including:
• It is a long-term method used for 6 to 12 years.
• It is safe to use this method if the woman is breastfeeding.
• Prevents pregnancy very effectively.
• Has no further costs after the IUD is inserted.
v) Side effects
During the first days after insertion of copper IUD some women may have periodic
cramping that usually settles after a few days. Some users can report other side
effects like breast tenderness, headache, mood changes, and the period can be
changed. Spotting or frequent bleeding may manifest a side effect in the first three
to six months. For women who already have low iron blood stores before insertion,
the copper IUD can contribute to anaemia. In rare cases, the copper IUD can lead
to Pelvic inflammatory diseases especially if the woman has sexually transmitted
infections at the time of insertion.
Self-assessment 2.4.1
i) What are the advantages to the population using copper intra uterine
devices?
ii) Would you please mention the indications and contraindication of using
copper intra uterine device?
2.4.2Hormonal Intrauterine device
Learning activity 2.4.2
Read the book titled ‘Introduction to Maternity and Paediatric Nursing’,
page 82-83 about IUDs.
i) What do you understand by hormonal intra uterine device?
i) Briefly explain the advantages of hormonal intrauterine devices (Mirena)?

Introduction to hormonal intra uterine device (Mirena)
Intra uterine device (Mirena) is a hormonal intrauterine device (IUD) that can
provide long-term birth control (contraception). The device is a T-shaped plastic
frame that’s inserted into the uterus.
i) Indication
Mirena Can be inserted any time if the woman is certain that she is not pregnant.
However, she will need to a backup method for the first seven days after insertion.
Is indicated to women with heavy menstrual bleeding.
ii) Contraindication
Mirena can be contraindicated for a woman with the following medical conditions:
• Breast cancer,
• Liver disease,
• Uterine or cervical cancer,
• Uterine abnormalities (fibroids),
• Pelvic infection or current pelvic inflammatory disease.
• Blood clots.
iii)Mode of action
This type of IUD contains hormones which slowly releases a progesterone hormone
resembling that produced by the ovaries. This IUD works primarily by suppressing
the growth of the lining of the uterus to disrupt ovulation. It stays in the woman’s
uterus up for five years of use. It thickens mucus in the cervix to stop sperm from
reaching or fertilizing an egg.
iv)Advantages
Mirena helps protect against the risk of pregnancy, and iron deficiency anaemia. It
can also help protect against pelvic inflammatory disease and can reduce menstrual
cramps and symptoms of endometriosis. Mirena does not delay fertility return if
a woman stops using it. Mirena can be used up to five years and it is safe for
breastfeeding women.
v) Side effects
During the first days after insertion of Mirena, some users have periodic cramping
that may usually settle after a few days. Some users may report other side effects
including:
• Headaches,
• Mood changes
• Breast tenderness or pain
• Nausea
• Dizziness
• Ovarian cysts
Self-assessment 2.4.2
i) According to your opinion, who is eligible to use hormonal intra uterine
device (Mirena)?
ii) Can you mention some of the side effects of hormonal IUD (Mirena) that
you know?

End unit assessment
1. What do you understand by the term ‘modern family planning?’
2. Discuss the major difference between progestin-only and combined oral
contraceptive pills?
3. Briefly discuss some of the factors you may consider to advise a couple on
which modern family planning they can use in the next two years.
4. What do you know about indication of oral contraceptive method the
methods you have listed above?
5. Mention the advantages and side effects for someone who use emergency
contraceptive pills?
6. What is the mechanism of action of copper intra uterine device and its side
effects?
7. What can advise the woman who would like to use monthly injectable
contraceptive as her preferred family planning method?
8. Discuss how you can help families to have knowledge on implants as
modern family planning methods.
9. What is the difference between modern family planning and natural family
planning methods?
UNIT3:BARRIER AND PERMANENT FAMILY PLANNING
Key Unit Competence
Provide barrier and permanent family planning services
Introductory activity 3

Analyze the pictures above, and answer the questions below:
a) What are the messages conveyed by these pictures above?
b) What have you heard about the methods of family planning shown by the
above pictures?
c) In your opinion, under what circumstances should the family planning
methods shown in the above pictures can be indicated?
3.1 Introduction to barrier family planning methods
Learning activity 3.1
i. What do you know about barrier methods?
ii. What are the types of barrier methods?
Barrier methods include either physical devices that prevent sperm from reaching
an egg or chemicals that kill or damage sperm in the vaginal canal. Barrier methods’
success is highly dependent on people’s ability to use them correctly every time
they do sexual intercourses. When used correctly, barrier methods can prevent
women from becoming pregnant and can also protect both the female and male
partners against sexually transmitted infections including HIV.
Barrier contraceptives are classified into two main types: mechanical barriers and
chemical barriers.
Mechanical barriers
They are devices that provide a physical barrier between the sperm and the egg.
Examples of mechanical barriers include the male condom, female condom,
diaphragm, cervical cap, and sponge.
Chemical barriers
Chemical barriers or spermicides are sperm-killing substances, available as foams,
creams, gels, films or suppositories, which are often used in female contraception
in conjunction with mechanical barriers and other devices.
Self-assessment 3.1
i) How do barrier methods of family planning act?
ii) With examples, explain the two types of barrier family planning methods.
iii) To what extent are barrier methods of family planning successful?
3.1.1 Male condom
Learning activity 3.1.1
i) What do you know about the male condom?
ii. In what situations can you advise individuals and couples to use male
condom?
iii. Enumerate advantages and disadvantages of male Condom?
Introduction
A male condom is a covering that unrolls over a man’s erect penis and is usually
made of thin latex rubber. It keeps a man’s sperm from getting into a woman’s
vaginal canal. It can also prevent the partner from becoming infected with the
microorganisms that cause various Sexually Transmitted diseases (STIs) and
Human Immune Deficiency Virus (HIV).
a) How to use a male condom
Watch the video demonstration on how to wear a male condom found on this link:

For each sex act, one new condom must be used. Before using a condom, the
package must be checked to see if the condom is not torn or damaged. Expired
condom should not be used. Other directions on the use of the condom are outlined
in the box below.
b) Indication
The male condom should be indicated as a family planning method of choice in the
following cases
• If the couple chooses that as their preferred,
• If an individual man or woman engages in occasional sexual intercourse,
• discordant couples,
• If a man has premature ejaculation problems.
c) Contraindications
The male condom should not be the family planning method of choice in the
following cases:
• If the individual male partner is allergic to latex manifested through swelling
or difficulty breathing,
• If the individual male partner cannot maintain erection,
• For some people (both male and female) who may develop a mild, local
irritation or a rash after using a male condom.
d) Effectiveness
When used correctly on every act of sexual intercourse, male condoms are 98%
effective in protecting the woman from getting pregnant. This means that only 2
out of 100 people will become pregnant in 1 year when male condoms are used as
contraception.
e) Advantages and disadvantages of male Condom use

Self-assessment 3.1.1
i) Who should use a male condom as a family planning method?
ii) Who should not use male condom as a family planning method?
iii) Explain step by step how a condom is used.
3.1.2 Female condom

Learning activity 3.1.2
a) What do you know about the female condom?
b) Who should use the female condom as a family planning method?
c) Who should not use female condom in family planning method?
A female condom is a lubricated pouch made of thin, soft plastic that fits loosely
inside vagina used during sexual intercourse to reduce the probability of
pregnancy and/or sexually transmitted infections. A female condom can be put
into the vagina before sex, but make sure the penis does not come into contact
with the vagina before the condom has been inserted. Semen can still come out
of the penis even before a man has had an orgasm (fully ejaculated).
a) How to use a female condom
For each sex act, one new condom must be used. Before using a condom, the
package must be checked to see if the condom is not torn or damaged. Expired
condom should not be used.
• Open the packet and remove the female condom, taking care not to tear it.
• Squeeze the smaller ring at the closed end of the condom and put it into the
vagina.
• Make sure the large ring at the open end of the condom covers the area
around the opening of the vagina.
• Make sure the penis goes in the female condom, not between the condom
and the side of the vagina.
• After sex, remove the female condom immediately by gently pulling it out. You
can twist the large ring to prevent semen leaking out.
• Throw away the condom in a bin, not the toilet.
b) Mode of Action
Female condom act by forming a barrier that keeps sperm out of the vagina,
preventing pregnancy.
c) Indications
Some indications of using female condom include the following:
• Individual’s or couple’s choice
• If an individual engages in occasional sexual intercourse,
• If the couple is discordant,
• Genital tract infection, including active sexually transmitted infection including
vaginitis under treatment,
• If the female partner desires assurance that semen was not released into her
vagina,
d) Contraindication
A female condom is contraindicated for females in the following cases:
• Being allergic to latex,
• When it is impossible for the female partner to maintain erection,
• Cannot be used as a replacement for the long-term methods of contraception,
• Women who have sex three or more times a week.
e) Effectiveness
If used correctly, female condoms are 95% effective to protect women against
pregnancy and being infected by sexually transmitted infections.
f) Advantages and disadvantages of female condom

Self-assessment 3.1.2
a) Briefly explain the female condom as a barrier family planning.
b) Describe step by step how the female condom is used.
Homework 3.1
Go to the internet and search for diaphragm contraceptive and write down notes
that will be discussed in the classroom.
3.1.3 Diaphragm

Learning activity 3.1.3
a) Based on the information you have gathered on the internet, answer the
following questions:
b) What is a diaphragm?
c) What are advantages of diaphragm as a barrier method of family planning?
Diaphragm is a dome-shaped bowl made of thin, flexible silicone that sits over
the cervix, it covers the cervix before sex and left in place of at least six hours
after sex and prevents sperm passing through the cervix so sperm can’t get in and
fertilize an egg. It is better to use it with a gel that kills sperm (spermicide) that’s why
it is a barrier method of birth control.
a) Indications
The use of diaphragm may be an appropriate method of contraception for women
who prefer an intercourse-related non-hormonal method of contraception and
desire a barrier method that can provide continuous protection for up to 24 hours.
b) Contraindications
Some contraindications to diaphragm use include of the following: allergy to
rubber or latex, repeated urinary tract infections, lack of personnel trained in fitting
diaphragms or of time for proper fitting and instruction, some physical abnormalities,
inability to understand the technique.
c) Advantages and disadvantages
There are the advantages of using diaphragm like when the user like only need to
use a diaphragm when she wants to have sex. She can put it in at a convenient
time before having sex (use extra spermicide if you have it in for more than 3
hours) there are usually no serious associated health risks or side effects.
As for the disadvantages, the diaphragm use has been criticized for the following
deficits:
• Not as effective as other types of contraception as it depends on how the
person using it remembers to use it and using it correctly.
• Does not provide reliable protection against STIs.
• It can also take a time to learn how to use it.
d) Possible side effects
There are some side effects that have been reported by the users including the
following:
• Irritation of the vagina and surrounding skin or an allergic reaction,
• strong odors or vaginal discharge if the diaphragm is left in too long,
• an allergic reaction to the material in the diaphragm,
• a higher risk for urinary tract infections (UTIs),
• Risk of toxic shock syndrome if the diaphragm is left in too long.
Self-assessment 3.1.3
a) Who should not use the diaphragm?
b) What are the side effects associated with the use of diaphragm?
c) Mention at least two disadvantages of using diaphragm as a barrier
method?

Learning activity 3.1.4
Watch the video on this link:
;
and answer these questions:
a) What is a cervical cap?
b) Under what circumstances should a cervical cap may not be used as a
contraceptive method?
The cervical cap is a one of the temporary birth controls (contraceptive) devices
that prevents sperm from entering the uterus. The cervical cap is a reusable, deep
silicone cap that is inserted into the vagina and fits tightly over the cervix. The
cervical cap is held in place by suction and has a tie to help with removal. It can
insert the cap ahead of time or just before sex and the cap should be left in place for
6 hours after sex. The cervical cap is effective at preventing pregnancy only when
used with spermicide.
c) Tips to inserting the cervical cap in the vagina
Before you use the cervical cap for the first time, practice inserting the cap and
checking its placement.
To use a cervical cap, a woman must:
• Check the position of her cervix before inserting the cervical cap. To
find the cervix, a woman inserts her finger deep into her vagina. The cervix
feels like the tip of your nose. Its position will vary according to the time of the
month and the woman’s body position.
• Apply spermicide. Fill the cervical cap’s bowl with about 1/4 teaspoon (1.25
milliliters) of spermicide. Spread a thin layer of spermicide on the brim of
the cervical cap that faces the cervix. Place 1/2 teaspoon (2.5 milliliters) of
spermicide in the groove between the rim and the dome of the cervical cap.
The woman should avoid removing the cap for at least six hours after the last
time she had sex.
• Insert the cervical cap. Insert the cervical cap into the vagina before sexual
arousal to ensure proper placement. Find a comfortable position, such as
squatting. Separate the labia with one hand. With the other hand, hold the
cervical cap with the bowl facing upward and squeeze the rim of the cervical
cap between your thumb and index finger.
• Slide the cervical cap into the vagina — making sure the taller brim of the
cervical cap enters the vagina first. Push the cervical cap along the rear wall
of the vagina as far as it will go. Use finger to locate the cervix and press the
rim of the cervical cap around the cervix until it is completely covered.
• Always check the cervical cap’s position before sex. Squat, bear down,
insert your finger into your vagina and press upward on the dome to make
sure your cervix is covered. If the cervical cap is not covering your cervix
completely, either push it onto the cervix or remove it and reinsert it.
• Gently remove the cervical cap. After sex, leave the cervical cap in place
for at least six hours and up to two days. To remove the cervical cap, squat,
bear down and rotate the cap. Relax your muscles and push up on the dome
of the cervical cap to break the seal.
• Grasp the removal strap and gently pull. Be careful not to scratch your
vagina. After removal, wash the cervical cap with mild soap and warm water
and let it air-dry. Store the cervical cap in its provided container.
b) Indication
Any woman without current pelvic or cervical infections can use cervical cap.
c) Contraindication
The care provider can discourage the use of cervical cap if the woman has the
following conditions:
• Current history of pelvic, cervical, vaginal, or urinary traction infection;
• intermenstrual bleeding;
• medical procedures to the cervix;
• breast feeding;
• Recently gave birth or had a miscarriage or an abortion
• Recently had cervical surgery
• Have a history of pelvic inflammatory disease, toxic shock syndrome, cervical
cancer, third-degree uterine prolapse, uterine tract infections, or vaginal or
cervical tissue tears
• Have vaginal or cervical abnormalities that interfere with the fit, placement or
retention of the cervical cap
• Are at high risk of pregnancy (women younger than age 30; women who
have sex three or more times a week; women who have had previous
contraceptive failure with vaginal barrier methods; or women who are not
likely to consistently use the cervical cap)
• Are allergic to spermicide or silicone.
d) Advantages and disadvantages
The advantages of using the cervical are the following, it does not affect future fertility
for either the woman or the man. It is used only at the time of sexual intercourse. It
is safe to use while breastfeeding. It is less expensive than hormonal methods of
birth control.
The cervical cap is more difficult for women to learn to insert and remove than the
diaphragm. If worn for more than two days (48 hours), you run the risk of toxic
shock syndrome or unpleasant vaginal odor and discharge.
e) Effectiveness
The cap is 80.4% effective according to the Pearl Index and 89% of the women
are satisfied with using the cap. There is a 51% continuation rate over a 1-year
period. The cervical cap appears to have a satisfactory rate of contraception when
compared with other barrier methods and women are adept at its use.
f) Side effects
The possible side effects may include: from the spermicide, irritation of the vagina
and surrounding skin or an allergic reaction, strong odors or vaginal discharge if the
cap is left in too long, an allergic reaction to the material in the cap and changes in
the cervix because of irritation
Self-assessment 3.1.4
a) Describe how a cervical cap is removed from the woman’s vagina after
sexual intercourse.
b) What are the possible side effects associated with using a cervical cap as
a contraceptive method?
3.2 Permanent contraceptive methods
Learning activity 3.2.1

a) Enumerate the types of permanent methods of family planning you know.
b) What is vasectomy as a permanent contraceptive method?
Permanent contraception involves making a person incapable of reproduction.
Disrupting the tubes that carry sperm or the egg ends the ability to reproduce.
This form of contraception should always be considered permanent, although
the procedures can sometimes be reversed. Normally, permanent contraceptive
methods can only be chosen for individuals and/or couples who have had children
and have decided that their family is complete. Permanent contraceptive methods
encompass vasectomy and tubal ligation. In the next sub-sections, each method is
discussed in details.
A vasectomy also called male sterilization or male surgical contraception, it is a
permanent family planning method which is irreversible, it is a simple surgery done
by a doctor in a hospital or clinic. The small tubes in the scrotum that carry sperm are
cut or blocked off, so sperm can’t leave the body and cause pregnancy. The
procedure is very quick, and the client can go home the same day.
a) Mode of action
A vasectomy blocks or cuts each vas deferens tube, keeping sperm out of the
semen. Sperm cells stay in the testicles and are absorbed by the body. Starting
about 3 months after a vasectomy, the semen won’t contain any sperm, so it can’t
cause pregnancy. But a men will still have the same amount of semen that he did
before.
b) Indications
Some indications are: for men who do not want more children, transection and
occlusion of the vas deferens, no interference with sexual performance
c) Contraindications
There are some contra indications for vasectomy like active STIs, swollen and
tender testes, scrotal skin infection, and bilateral un-descended testes.
d) Advantages of Vasectomy
The following are the advantages of using vasectomy like Safer and more effective
than tubal ligation, Vasectomies don’t change the way having an orgasm or
ejaculating (cumming) feels, Failure is less than 1%.
e) Disadvantages of Vasectomy
The following are some of the disadvantages,
• Does not protect against sexually transmitted infections
• Need use of other contraceptives for 8-12weeks after operation.
• Does not use general Anesthesia.
• It’s non-reversible.
Reason for failure can be:
Unprotected intercourse soon (before azoospermia is documented – approx. 3
months)
Failure to occlude the vas (technical errors)
Recanalization
f) Effectiveness
A vasectomy is one of the most effective kinds of birth control. It’s almost 100%
effective at preventing pregnancy, it takes about 3 months for the semen to become
sperm free.
Although a man can have intercourse two to three days following the procedure,
the vasectomy does not work right away. It takes roughly 3 months for semen to
be entirely clear of sperm. A man or his partner should use another type of family
planning, such as condoms, throughout these three months. Alternatively, if a
woman was already using a family planning method before her partner’s vasectomy,
she can keep using it for another three months before stopping it. A vasectomy is
considered effective after three months.
Self-assessment 3.2.1
a) How vasectomy works as a permanent contraceptive method?
b) What are indication and contra indication of using the vasectomy?
c) What are advantages of vasectomy?
3.2.2 TUBAL LIGATION

Learning activity 3.2.2
a) What is a tubal ligation as a permanent contraceptive method?
b) Who should use the tubal ligation?
c) What are advantages of tubal ligation?
A tubal ligation (also known as ‘having your tubes tied’) is a procedure to close both
fallopian tubes which means that sperm cannot get to an egg to fertilize it
a) Indication
The tubal ligation is indicated for women who want a permanent method of
contraception and are free of any gynaecologic pathology that would otherwise
dictate an alternate procedure. It is also indicated for women in whom a pregnancy
could represent a significant clinical and medical risk.
b) Contra indication
Contraindications include indecisive patients, very young age, incapable of making
a medical decision, the presence of gynecological malignancy, and morbidly obese
patient.
c) Side effects
Some women may experience long-term side effects like regret After Sterilization,
Sterilization Failure & Ectopic Pregnancy, Menstrual Cycle Changes, there is also
Post Tubal Ligation Syndrome (hot flashes, chronic fatigue, irregular or heavier
periods, loss of libido, increased depression and/or anxiety, achy, sore joints and/or
muscles, weight gain and memory lapse)
d) Advantages
Tubal ligation’ advantages are the following: permanently prevents pregnancy, so
she no longer need any type of birth control and it does not protect against sexually
transmitted infections. Tubal ligation may also decrease the risk of ovarian cancer,
especially if the fallopian tubes are removed.
e) Disadvantage
Some disadvantages of tubal ligation are the following; it is a permanent and
irreversible method, some people regret having it, especially if their circumstances
change. Tubal ligation does not protect against STIs. Using condoms is the best
way to prevent STIs.
f) The Benefits
Some benefits of tubal ligation are: It works immediately and can be performed
after childbirth, it doesn’t cause hormonal imbalance like other contraceptives,
Eliminates the need to monitor schedules for pills or cycles and it may lower the
risk of ovarian cancer.
Self-assessment 3.2.2
a) How does tubal ligation work as a permanent contraceptive method?
b) Who should not use the tubal ligation?
c) What are the disadvantages of tubal ligation
End unit assessment 3
I. True (T) or false (F) questions
1. Barrier methods exist only for males.
2. Condoms should be worn after ejaculation.
3. Barrier methods are safe and have no systemic effects.
II. Multiple-choice questions
Choose the correct answer
1. Which methods of birth control needs a prescription?
A. Birth control pill
B. Contraceptive patch
C. Cervical cap
D. all of the above
2. What do male condoms offer that other forms of birth control do not?
A. Least chance of failure
B. Best protection against STIs
C. Cheapest to use
D. All of the above
3. Which type of intrauterine device (IUD) IS available?
A. Copper
B. Titanium
C. Hormonal
D. A and C
4. Which of these methods of sterilization is permanent?
A. Tubal sterilization
B. Implants
C. Vasectomy
D. . A and C
III. Open questions
1. Who should use the male condom as a family planning method?
2. Enumerate advantages and disadvantages of male Condom?
3. Who should not use female condom in family planning method?
4. Enumerate advantages and disadvantages of female Condom?
5. What is diaphragm as barrier method?
UNIT4:PROMOTION OF HEALTH IN CHILDREN
Key Unit competence
Provide promotional activities for the wellbeing of a child
Introductory activity 4
At health center, a nurse receives a 24 months old child brought by his mother,
after he fell down from the bed this morning when he was crawling on the bed.
The mother told the nurse that when the child wakes up, he doesn’t pull himself
to standing position and crawls. The mother said that his child is the last born
in the family and she has other 2 children with 9 and 5 years respectively. The
child was born with 1.8kgs at 35 weeks of gestational age and delayed to cry for
about 15 min that led him to be admitted in neonatology for 42 days. The child
was fed with cow’s milk from the second day of life as the mother was unable to
breast feed. The nurse examined the child to see if there was no broken bone.
While the child was on the examination table, his head was supported by his
mother as he was unable to sit alone without being supported. The nurse only
noticed ecchymosis on the right arm but there was no broken bone.
Based on your knowledge, discuss the growth and development in gross motor
of the child in the scenario above
Health promotion in children aims to keep children healthy with a focus on early
interventions and implementing programs for the youngest children. The early
years of a child’s life lay the foundation for future physical, cognitive, emotional,
and social development.
Children’s health and well-being is influenced by a variety of factors, including
family characteristics, community dynamics, and other social determinants of health
(SDOH). These include systems, policies, and environmental conditions in which
children are born and grow up.
4.1 Key Concepts used in child health
Learning activity 4.1
Using different sources of information discuss the following concepts:
– Pediatric
– Child
– Adolescen
4.1.1 Pediatric
Branch of medicine that deals specifically with children, their development, childhood
diseases and their treatment.
4.1.2 Pediatric nursing
This is the art and science of giving nursing care to children from birth through
adolescent with emphasis on the physical growth, mental, emotional and
psychosocial and spiritual development of the child. It focuses on providing holistic
care to infants, children and adolescent.
4.1.3 Child
Biologically, a child is a human being between the stages of birth and puberty,
or between the developmental period of infancy and puberty. The United Nations
Convention on the Rights of the Child (UNCRC) defines a child as everyone under
18 years old.
4.1.4 Childhood
The period of life of the human being considered to extend from infancy to puberty.
4.1.5 Infant
Infant is defined as a child under the age of 1 year.
4.1.6 Toddler
A toddler is a child approximately 12 to 36 months old, though definitions vary; the
toddler years are a time of great cognitive, emotional and social development. The
word is derived from “to toddle”, which means to walk unsteadily, like a child of this
age.
4.1.7 Child health care
Specialized branch of medicine that promotes child health, prevent child illness,
care of the ill, disabled and dying child from birth through adolescent to maintain
physical, emotional and social wellbeing of that individual or child.
4.1.8 Adolescent
Adolescence is a transitional stage of physical and psychological development that
generally occurs during the period from puberty to legal adulthood. Adolescence is
the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique
stage of human development and an important time for laying the foundations of
good health.
4.1.9 Health
Health, according to the World Health Organization, is “a state of complete physical,
mental and social well-being and not merely the absence of disease and infirmity.”
4.1.10 Family centered care
Family-centered care is a way of providing services that assures the health
and well-being of children and their families through respectful family/
professional partnerships. It honors the strengths, cultures, traditions, and
expertise that families and professionals bring to this relationship.
4.1.11 Atraumatic care
Atraumatic care is the philosophy of providing therapeutic care through the
use of interventions that eliminate or minimize the psychological and physical
distress experienced by children and families.
4.1.12 Health promotion
Health promotion is the process of enabling people to increase control over, and
to improve, their health. It moves beyond a focus on individual behavior towards a
wide range of social and environmental interventions.
Self-assessment 4.1
– Identify the differences between pediatrics and pediatric nursing.
– Describe infant, toddler and adolescent periods.
4.2 Monitoring of growth and development
Growth monitoring is a process of following the growth of a child compared with
a standard by periodic frequent anthropometric measurements and assessments.
Growth monitoring and promotion is a preventive and promotional activity. It
facilitates communication and interaction between health care providers and care
givers so as to encourage appropriate timely intervention to promote optimal child
development and growth.
The main purpose of growth monitoring is to assess growth adequacy and identify
changes at early stages before the child reaches the status of under nutrition.
Weight gain is the most important sign that a child is healthy and is growing and
developing well. Also, a health check-up can detect if a child is gaining weight too
fast or too slow in comparison to his/her age
4.2.1 Steps involved in growth monitoring
5 major steps in growth monitoring are:
Step 1: Determining correct age of the child
Step 2: Accurate weighing of the child
Step 3: Plotting the weight accurately on a growth chart of appropriate gender
Step 4: Interpreting the direction of the growth curve and recognizing if the child is
growing properly.
Step 5: Discussing the child’s growth and follow up action needed with the mother.
4.2.2 Growth charts:

Figure 4.1: Height for age chart for boys

Figure 4.5: Weight for height chart for boys

Figure 4.6: Weight for height chart for girls
Stages of child development (developmental milestones)

Figure 4.7: Stages of child development
Children undergo various changes in terms of physical, speech, intellectual and
cognitive development gradually until adolescence. Specific changes occur at
specific ages of life. Known as developmental milestones, these changes can
help to identify if the child is developing at the correct pace. Failure to reach these
milestones may indicate developmental disorders or genetic conditions.
Developmental milestones are behaviors or physical skills seen in infants and
children as they grow and develop. Rolling over, crawling, walking, and talking are
all considered as milestones. The milestones are different for each age range.

4.2.3 Child development theories
Child development theories focus on explaining how children change and grow over
the course of childhood. Such theories center on various aspects of development
including social, emotional, and cognitive growth.

Psychoanalytic theory originated with the work of Sigmund Freud. Through his
clinical work with patients suffering from mental illness, Freud came to believe that
childhood experiences and unconscious desires influenced behavior.
According to Freud, conflicts that occur during each of developmental stages can
have a lifelong influence on personality and behavior. The child development occurs
in a series of stages focused on different pleasure areas of the body. During each
stage, the child encounters conflicts that play a significant role in the course of
development.
His theory suggested that the energy of the libido was focused on different erogenous
zones at specific stages. Failure to progress through a stage can result in fixation at
that point in development, which Freud believed could have an influence on adult
behavior. While some other child development theories suggest that personality
continues to change and grow over the entire lifetime, Freud believed that it was
early experiences that played the greatest role in shaping development. According
to Freud, personality is largely set in stone by the age of five.

Figure 4.9: Erikson’s psychosocial developmental theory
Erikson’s eight-stage theory of psychosocial development describes growth and
change throughout life, focusing on social interaction and conflicts that arise during
different stages of development.
His eight-stage theory of human development described this process from infancy
through death. There are 5 stages in childhood until adolescence as stages are
based on the age. During each stage, people are faced with a developmental
conflict that impacts later functioning and further growth. At each stage, children
face a developmental crisis that serves as a major turning point:
A. Trust versus Mistrust
Trust versus mistrust occurs between birth and 1 year. The task of this stage
is for the baby to recognize that there are people in his life, generally parents
that can be trusted to take care of basic needs. The baby’s struggle becomes
evidenced in the recognition that not everyone or every situation is “safe.” Through
trust the baby learns to have confidence in personal worth and well-being along
with connectedness to others. Failure to master this stage leaves a sense of
hopelessness and disconnectedness.
B. Autonomy versus Shame and Doubt
Autonomy versus Shame and Doubt occurs between 1 and 3 years. The task of
this stage is for the child to balance independence and self-sufficiency against the
predictable sense of uncertainty and misgiving when placed in life’s situations. It
is the time for the child to establish willpower, determination, and a can-do attitude
about self. An example of this stage happens when the toddler wants to choose
clothing and dress independently. The struggle happens when the parents allow
the child to make personal choices yet expect the choices to be socially acceptable.
C. Initiative versus Guilt
Initiative versus guilt occurs between 3 and 6 years. The child’s task during this
stage is to develop the resourcefulness to achieve and learn new things without
receiving self-reproach. It is difficult for a young child to resolve the conflict between
wanting to be independent and needing to stay attached to parents. The child’s
writing plays or new songs, games, or jokes are good examples of initiative.
The child feels confident to try new ideas. It is important that parents and teachers
encourage this initiative to help the child develop a sense of purpose. If initiative is
discouraged or ignored, the child may feel guilt and lack of resourcefulness.
D. Industry versus Inferiority
Industry versus inferiority occurs between the ages of 6 and 12. In this stage, the
child develops a sense of confidence through mastery of tasks. This sense of
accomplishment can be counterbalanced by a sense of inadequacy or inferiority
that comes from not succeeding. The realization that the child is competent is one of
the important building blocks in the development of self-esteem. Industry is evident
when the child is able to do homework independently and regulate social behavior.
Performing the prescribed tasks at school or home also show industry. If the child
cannot accomplish realistic expected tasks, the feeling of inferiority may result.
E. Identity versus Role Confusion
Identity versus role confusion occurs between the ages of 12 and 18. This is
a time of forging ahead and acquiring a clear sense of self as an individual in
the face of new and at times conflicting demands or desires. During this stage
the adolescent wants to define “what to be when I grow up.” She begins to
concentrate on goals and life plans separate from those of peers and family.
At this point, the child has the ability to think about self as well as others and
proceeds accordingly.

Figure 4.10: Attachment theories
Attachment refers to the bond or emotional and physical connection that develops
between an infant and caregiver that tends to endure. Early theorists associated
attachment with the mother who met the infant’s innate drive to be fed and nurtured.
Other examples of attachment behaviors are dressing, bathing, diapering, cuddling,
loving, playing, and comforting.
Both the infant and the caregiver rely on the quality of the interaction between
them. In other words, a healthy infant–mother relationship is contingent on the
characteristic value of the communication between them

Self-assessment 4.2
1. Enumerate the steps involved in growth monitoring.
2. Describe the oral stage of Freud’s psychosexual developmental theory.
3. Discuss any 2 stages of Erikson’s psychosocial developmental theory.
4.3 Nutrition in children
Learning activity 4.3
Identify the differences between the two babies on the picture below

The questions a healthcare provider asks regarding nutrition are based on the
child’s age. If the infant is breastfed, information is gathered as to how often and for
how long the child is fed at each feeding, and how many wet diapers are changed
in the course of one day. With sufficient breast milk intake, the infant will have six or
more wet diapers and gain weight. Newborns often lose 10% of their birth weight.
This weight loss is usually by the 12th day of life.
For the infant who is receiving formula, information is gathered as to the type of
formula, the amount taken at each feeding, and the number of feedings per day. It
is also important to note if and when juices or solid foods have been started, and
whether supplements or vitamins have been prescribed.
When assessing children and adolescents, a 24-hour recall elicits the food items
eaten in a typical day and reflects sociocultural trends. The nurse can document
the amount and type of milk, juices, and all other liquids. In addition, the healthcare
provider must document food allergies for all children. Analysis of the food intake is
compared to the foods suggested in the Food Guide Pyramid for Young Children.
4.3.1 Importance of nutrition in children
Proper nutrition supports normal growth, development and aging. It also helps to
maintain a healthy body weight and reduces the risk of chronic diseases.
For children, adequate nutrition is one of the most important factors influencing
growth and immunity. A balanced diet must contain the proper amount of
protein, carbohydrate, fats, calcium, iron, vitamins and fiber. The foundation for
lifelong health is largely set during the first 1,000 days (this is the most critical
developmental period of brain growth and function). It is widely recognized as a
time of enormous vulnerability but also a time of tremendous potential to impact the
long-term health of the child. Due to the specific nutritional requirements during this
rapid period of growth, even small nutritional deficits may negatively impact growth,
neurodevelopment and adult health.
4.3.2 Nutrition screening and assessment

Nutrition screening is a rapid and simple identification of children who may be
malnourished or at risk of malnutrition and need more detailed nutrition assessment.
Nutrition screening requires standardized training in line with national and local
health policy.
Nutrition assessment includes taking anthropometric measurements and collecting
information about a child’s medical history, clinical and biochemical characteristics,
dietary practices, current treatment and food security situation.
Importance of nutrition assessment is to:
1. Identify children at risk of malnutrition for early intervention or referral before
they become malnourished.
2. Identify malnourished children for treatment- malnourished children who are
not treated early have longer hospital stay, slower recovery from infection
and complications and higher mobility and mortality.
3. Track child growth.
4. Identify medical complications that affect the body’s ability to digest food
and utilize nutrients.
5. Detect practices that increase the risks of malnutrition and infections.
6. Inform nutrition education and counselling.
7. Establish appropriate nutrition care plan.
Nutrition assessment should be done in:
• Infants 0 to <6 months of age: at birth and on every scheduled postnatal
visit
• Infants 6 to 59 months of age: during monthly growth monitoring sections
for children under 2 and every 3 months for older children.
• Children of 5 years and above: on every clinic visit.
• Adolescents: on every clinic visit
4.3.3 Types of nutrition assessment
Types of nutrition assessment are remembered with mnemonics ABCD:
A: Anthropometric is the measurement of the size, weight and proportion of the body.
Common anthropometric measurement include weight, height, MUAC (Mid Upper
Arm Circumference), head circumference and skin folds. Body mass index (BMI)
and weight-for-height are anthropometric measurements presented as indexes.
B: Biochemical means checking level of nutrients in a child’s blood, urine or stools.
Lab tests results can give useful information about medical problems that may
affect appetite or nutritional status.
C: Clinical assessment includes checking for visible signs of nutritional deficiencies
such as bilateral pitting edema, emaciation (a sign of wasting, which is a loss of
muscle and fat tissue as a result of low energy intake and/or nutrients loss from
infection), hair loss, and change in hair color. It also includes taking a medical
history to identify co-morbidities with nutritional implications, opportunistic infections,
other medical complications, usage of medications with nutritional related side
effects, food and drug interactions and risk factors for disease, inability to suck and
ineffective breastfeeding.
Figure 4.11: Pitting edema on feet
Bilateral pitting edema also called nutritional edema is a swelling in both feet
or legs (bilateral) caused by accumulation of excess fluid under the skin in the
spaces within tissues. It is a sign of severe malnutrition on its own regardless of
the results of anthropometric assessment. Any child with severe bilateral pitting
edema (grade+++), even with appetite and no medical complications should be
admitted for inpatient management. A child with bilateral pitting edema Grade+ or
++ with appetite and no medical complications should be treated for severe acute
malnutrition.
D: Dietary: assessing food and fluid intake is an essential part of nutrition
assessment. It provides information on dietary quantity and quality, changes in
appetite, food allergies and intolerance, and reasons for inadequate food intake
during and after illness. To counsel the parents how to improve their diet to prevent
malnutrition or treat conditions affected by food intake and nutritional status example
cardiovascular disease, cancer, obesity, diabetes and hyperlipidemia
4.3.4 Various forms of malnutrition

Figure 4.12: Various forms of malnutrition
a. Undernutrition
There are 4 broad sub-forms of undernutrition: Wasting, stunting, underweight and
deficiencies in vitamins and minerals. Undernutrition makes children in particular
much more vulnerable to disease and death.
Low weight-for-height is known as wasting. It indicates recent and severe weight
loss because the child has not had enough food to eat and/or they have had an
infectious disease such as diarrhea which has caused them to lose weight and this
may lead this to increase risk of death but treatment is possible.
Low height-for-age is known as stunting. It is the result of chronic reoccurrence
undernutrition usually associated with poor socioeconomic conditions, poor
maternal health and nutrition, frequent illness and/or inappropriate infant and young
child feeding and care in early life. Stunting holds children back from reaching their
physical and cognitive potential.
Children with low weight-for-age are known as underweight. A child who is
underweight may be stunted, wasted or both.
b. Micronutrient related malnutrition
Micronutrients enable the body to produce enzymes, hormones and other
substances that are essential for proper growth and development. Iodine, vitamin
A and iron are the most important and their deficiency represents a major threat to
the health and development of the children.
Overweight and obesity result from an imbalance between energy consumed (too
much) and energy expended (too little). Body mass index is an index of weight-forheight
commonly used to classify overweight and obesity. It is defined as a person’s
weight in kilograms divided by the square of his/her height in meters (kg/m2).
Body Mass Index in children (BMI)
• A BMI-for-age plotted below the 5th percentile indicates a child who is
underweight;
• A BMI-for-age between the 5th and 85th percentile is considered a healthy
weight;
• Children with a BMI-for-age between the 85th and 95th percentile are
considered at risk for obesity;
• Children with a BMI-for age _95% are considered obese.
Self-assessment 4.3
1. Discuss various forms of malnutrition.
2. What are the elements of nutritional clinical assessment?
4.4 Assessment of a child: History taking
Learning activity 4.4
Children are not small adults. Taking a history with children differs from adults and
comes with a set of unique challenges. Symptoms are typically reported by a parent
or guardian, who may not be able to accurately transmit the information from the
child to the examiner and characterize the child’s concerns. To fill in the gaps, a
health care provider must have good communication skills and the ability to develop
a rapport with children as well as their families.
Taking a history from a patient is a skill necessary for examinations. It tests both
your communication skills as well as your knowledge about what to ask. Specific
questions vary depending on what type of history you are taking.
The basics components of a pediatric history
• Introduce yourself, identify your patient and gain consent from the parents
to speak with them. Should you wish to take notes as you proceed, ask the
patients permission to do so.
• Chief Complaint: brief statement of primary problem (including duration) that
caused family to seek medical attention.
• History of present illness: similar to history taking in adult population,
the history of present illness in pediatric history is to explore the patient’s
primary concerns, and must be tailored to the individual presenting complaint.
Generally, you will want to try to characterize the symptoms of concern and get
a sense of the onset, timing, aggravating and alleviating factors, associated
symptoms, and if anything, similar has happened to the patient before.
• Past History: The past history establishes a complete picture of the child’s
health to date, and should cover events from the prenatal period until the
child’s current presentation. The prenatal history includes inquiring about
maternal age, and number of previous pregnancies and the outcomes of
those pregnancies. It may be relevant to ask if the child is a product of natural
conception or if assistive reproductive technology was required. Ask about
whether prenatal care was accessed, medications used, substances and
toxins and if there were any abnormal results or concerns identified on routine
screening for infections and chronic diseases or ultrasounds. Additional
exposures that may be relevant include the mother’s occupation.
• Pregnancy and birth history:
• Maternal health during pregnancy: ask about bleeding, trauma,
hypertension, fevers, infectious illnesses, medications, drugs, alcohol,
smoking, rupture of membranes
• Gestational age at delivery
• Labor and delivery: length of labor, fetal distress, type of delivery (vaginal,
cesarean section), use of forceps, anesthesia, breech delivery
• Neonatal period: APGAR scores, breathing problems, use of oxygen, need
for intensive care, hyperbilirubinemia, birth injuries, feeding problems,
length of stay, birth weight.
• Growth History: Growth history is an important part of the pediatric history
as prolonged illness or chronic conditions may impact the child’s growth and
result in deviations from an established growth. When asking about growth
history, the pattern of growth, not just the child’s measurement at the present
is key as alterations in pattern of growth are often early signs of pathology.
Plot the child’s growth on a growth chart, and look at both numbers (z-scores)
and percentiles. It may be helpful to ask regarding growth and size of family
members, as marked deviations in a child’s growth from what is expected from
family trends could help in distinguishing constitutional or familial variants
from a pathologic growth pattern. Healthy children should achieve a minimum
growth velocity of 5 cm per year.
• Developmental History: Developmental history consists of the 5 domains
of child development: gross motor, fine motor, speech & language,
cognitive, and social/emotional development
• Ages at which milestones were achieved and current developmental
abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st
word, toilet training, riding tricycle, etc
• School: present grade, specific problems, interaction with peers
• Behavior: enuresis, temper tantrums, thumb sucking, pica, nightmares
etc.
• Medical History:
• Previous hospital admissions with dates and diagnoses
• Major medical illnesses: cardiac disease, hypertension, stroke, diabetes,
cancer, abnormal bleeding, allergy and asthma, epilepsy.
• Major surgical illnesses, Trauma-fractures, lacerations, list operations
and dates
• Medication History: Medication history includes both prescription and
non-prescription medications such as over the counter medications,
vitamins and supplements. One commonly overlooked group of
medications is inhalers, so it might be helpful to ask specifically if the child
uses any inhalers. It is also important to ask specifically about herbal
or homeopathic remedies, as parents may not report this unless directly
asked. Additionally, do not forget to ask about allergies to any drugs, foods
or environmental triggers.
• Immunization History: Immunization history is an essential part of the pediatric
history. Ask if the child has received all of his/her routine immunizations, as
well as if the child has received any additional vaccines such as the seasonal
influenza vaccine or travel immunizations. It may be relevant to ask when the
child last received a vaccination for various presentations including febrile
seizures or fever.
• Feeding History:
• Breast or bottle fed, types of formula, frequency and amount, reasons for any
changes in formula
• Solids: when introduced, problems created by specific types
• Family History: Family history may begin with clarifying ethnicity when
relevant, and then establishing if any medical conditions have occurred in the
family that may relate to the child’s current presentation. It may be helpful to
draw out a pedigree to better understand the health and relationships between
individuals in the family. Again, many items in this component of the pediatric
history may be sensitive, and it is important to approach these topics in an
open and non-judgmental manner. Mental retardation, congenital anomalies,
chromosomal problems, growth problems, etc.
• Social History: The social history includes parental employment status, any
financial issues, health coverage and drug plans, and family composition.
This part of the history may lead to discussion about the impact of the child’s
illness on both the child and the family, and can allow the care team to better
support the family
Self-assessment 4.4
– Identify elements to include in pediatric history taking
– Why do we need to know prenatal history of pediatric patients?
4.5 Assessment of a child: Review of systems
Learning activity 4.5.1
A review of systems Much like the physical examination, the review of systems
is best conducted with a “head-to-toe” approach, starting with a general question
regarding each body system. It can also be conducted by asking questions during
the physical examination.
It is a technique used by healthcare providers for eliciting a medical history from
a patient and often structured as a component of an admission note covering
the organ systems, with a focus upon the subjective symptoms perceived by the
patient (as opposed to the objective signs perceived by the clinician). Along with
the physical examination, it can be particularly useful in identifying conditions that
do not have precise diagnostic tests. The review of systems serves as a guide to
help identify potential or underlying illnesses or disease states subjectively, thus
allowing the health care provider to prioritize system for follow up and objective
examination. This will also help to obtain information about the chief concern as
well as the history of present illness.
Whatever system a specific condition may seem restricted to, it may be reasonable
to review all the other systems in a comprehensive history.
Review of systems includes the following areas:
a. General: usual weight, change in weight, weakness, fatigue, fever or
allergies.
b. Head, Eyes, Ears, Nose, Throat (HEENT): injury to head, headaches,
dizziness; eye infections, itching or watering eyes, behaviors indicating
change in visual acuity, use of glasses, date of last eye exam; ear
infections, behaviors indicating change in hearing; nose bleeds, colds,
hay fever, sinus infections; sore throats, tonsils, dentition, caries.
c. Neck: neck pain, enlarged lymph glands, neck range of motion
d. Skin and Lymph: rashes, adenopathy, lumps, bruising and bleeding,
pigmentation changes
e. Cardiac: cyanosis and dyspnea, heart murmurs, exercise tolerance,
squatting, chest pain, palpitations
f. Respiratory: pneumonia, bronchiolitis, wheezing, chronic cough, sputum,
hemoptysis, Tuberculosis
g. Gastro-Intestinal: stool color and character, diarrhea, constipation,
vomiting, hematemesis, jaundice, abdominal pain, colic, appetite
h. Genito-Urinary: frequency, dysuria, hematuria, discharge, abdominal
pains, quality of urinary stream, polyuria, previous infections, facial edema
i. Musculoskeletal: joint pains or swelling, fevers, scoliosis, myalgia or
weakness, injuries, gait changes
j. Pubertal: secondary sexual characteristics, menses and menstrual
problems, pregnancies, sexual activity
k. Allergy: urticaria, hay fever, allergic rhinitis, asthma, eczema, drug
reactions
l. Neurological: seizures, tics, psychiatric diseases, anxiety, depression
m.Endocrine: history or symptoms of thyroid disease or diabetes or diseases
that affect normal growth
Self-assessment 4.5
1. Describe the constitutional symptoms in the review of systems.
2. Explain any 4 systems that can be reviewed during history taking.
4.6 Assessment of a child: Physical examination
Learning activity 4.6
1. What should be done during pediatric physical examination?
2. Why is it relevant to perform pediatric physical examination?
In physical examination, medical examination or clinical examination, a medical
practitioner examines a patient for any possible medical signs or symptoms of a
medical condition. It generally consists of a series of questions about the patient’s
medical history followed by an examination based on the reported symptoms.
Together, the medical history and the physical examination help to determine a
diagnosis and devise the treatment plan. These data then become part of the
medical record.
Differences in Performing a Pediatric Physical Examination Compared to an
Adult:
I. General Approach
a. Gather as much data as possible by observation first
b. Position of child: parent’s lap vs. exam table
c. Stay at the child’s level as much as possible. Do not tower!!
d. Order of exam: least distressing to most distressing
e. Rapport with child:
– Include child - explain to the child’s level
– Distraction is a valuable tool
f. Examine painful area last-get general impression of overall attitude
g. Be honest. If something is going to hurt, tell them that in a calm fashion.
Don’t lie or you lose credibility!
h. Understand developmental stages’ impact on child’s response. For
example, stranger anxiety is a normal stage of development, which tends
to make examining a previously cooperative child more difficult.
II. Vital signs
a. Normal differ from adults, and vary according to age
b. Temperature: Tympanic, oral, axillary and rectal
c. Heart rate: In infants, auscultate or palpate apical pulse or palpate femoral
pulse. In older children, palpate antecubital or radial pulse
d. Respiratory rate: Observe for a minute. Infants normally have periodic
breathing so that observing for only 15 seconds will result in a skewed
number.
e. Blood pressure: Appropriate size cuff - 2/3 width of upper arm
f. Growth parameters: must plot on appropriate growth curve (Weight,
Height/length, Occipital Frontal Circumference: Across frontal-occipital
prominence so greatest diameter).

III. Unique findings in pediatric patients (See outline below)
Outline of a Pediatric Physical Examination
I. Vitals - see above
II. General
a. Statement about striking and/or important features. Nutritional status, level
of consciousness, toxic or distressed, cyanosis, cooperation, hydration,
dysmorphology, mental state
b. Obtain accurate weight, height and OFC
III. Skin and Lymphatics
a. Birthmarks - nevi, hemangiomas, mongolian spots etc
b. Rashes, petechiae, desquamation, pigmentation, jaundice, texture, turgor
c. Lymph node enlargement, location, mobility, consistency
d. Scars or injuries, especially in patterns suggestive of abuse
IV. Head
a. Size and shape
b. Fontanelle(s): determine its Size in a calm environment and in the sitting
up position
c. Sutures - overriding
d. Scalp and hair
e. Eyes
• General: Strabismus, Slant of palpebral fissures, Hypertelorism or
telecanthus
• EOM
• Pupils
• Conjunctiva, sclera, cornea
• Plugging of nasolacrimal ducts
• Red reflex
• Visual fields - gross exam
f. Ears
• Position of ears: Observe from front and draw line from inner canthi to
occiput
• Tympanic membranes
• Hearing - Gross assessment only usually
g. Nose
• Nasal septum
• Mucosa (color, polyps)
• Sinus tenderness
• Discharge
h. Mouth and Throat
• Lips (colors, fissures)
• Buccal mucosa (color, vesicles, moist or dry)
• Tongue (color, papillae, position, tremors)
• Teeth and gums (number, condition)
• Palate (intact, arch)
• Tonsils (size, color, exudates)
• Posterior pharyngeal wall (color, lymph hyperplasia, bulging)
• Gag reflex
i. Neck
• Thyroid
• Trachea position
• Masses (cysts, nodes)
• Presence or absence of nuchal rigidity
j. Lungs/Thorax
• Inspection
• Pattern of breathing
Abdominal breathing is normal in infants
Period breathing is normal in infants (pause < 15 seconds)
• Respiratory rate
• Use of accessory muscles: retraction location, degree/flaring
• Chest wall configuration
• Auscultation
• Equality of breath sounds
• Rales, wheezes, rhonchi
• Upper airway noise
• Percussion and palpation often not possible and rarely helpful
k. Cardiovascular
• Auscultation
• Rhythm
• Murmurs
• Quality of heart sounds
• Pulses
• Quality in upper and lower extremities
L. Abdomen
• Inspection
• Shape
Infants usually have protuberant abdomens
Becomes more scaphoid as child matures
• Umbilicus (infection, hernias)
• Muscular integrity (diasthasis recti)
• Auscultation
• Palpation
• Tenderness - avoid tender area until end of exam
• Liver, spleen, kidneys: May be palpable in normal newborn
• Rebound, guarding: Have child blow up belly to touch your hand
M. Musculoskeletal
• Back
• Sacral dimple
• Kyphosis, lordosis or scoliosis
• Joints (motion, stability, swelling, tenderness)
• Muscles
• Extremities: Deformity, Symmetry, Edema and Clubbing
• Gait
• In-toeing, out-toeing
• Bow legs, knock knee: “Physiologic” bowing is frequently seen under 2
years of age and will spontaneously resolve
• Limp
• Hips: Ortolani’s and Barlow’s signs
N. Neurologic - most accomplished through observation alone
• Cranial nerves
• Sensation
• Cerebellum
• Muscle tone and strength
• Reflexes: Deep Tendon Reflex, Superficial (abdominal and cremasteric),
Neonatal primitive
O. GU
• External genitalia
• Hernias and Hydrocoeles
• Almost all hernias are indirect
• Can gently palpate; do not poke finger into the inguinal canal
• Cryptorchidism
• Distinguish from hyper-retractile testis
• Most will spontaneously descend by several months of life
• Tanner staging in adolescents
• Rectal and pelvic exam not done routinely
Self-assessment 4.5
• Enumerate sites for measuring body temperature.
• Describe any 3 differences in physical examination of a child and adult.
4.7 Beliefs that affect Child health
Learning activity 4.7
Discuss different beliefs in your community that may affect the child health
It is observed that traditional healthcare practices and cultural beliefs have a
significant place and are widely used in all societies. Traditional cultural practices
reflect values and beliefs held by members of a community for periods often
spanning generations. Every social grouping in the world has specific traditional
cultural practices and beliefs, some of which are beneficial to all members, while
others are harmful to a specific group, such as children and pregnant women.
Health beliefs are what people believe about their health, what they think constitute
their health, what they consider the cause of their illness, and ways to overcome
their illness. These beliefs are culturally determined and all come together to form
larger health belief systems.
A. Cultural practices affect children’s and families’ conceptions of health, as well
as children social development, attitudes towards health problems they experience
conception of illness, reactions to illness and therapy.
Children learn their beliefs, values, capabilities, knowledge and skills from
their families and their culture. Furthermore, culture plays an important role in
socialization and development of children. Cultural background holds a significant
place in children’s social and emotional development, as well as improvement of
their motor and cognitive skills.
B. Religion
Along with cultural values, concepts of religion and spirituality hold a significant
place in lives of the individual and society. Although the terms ‘spirituality’ and
‘’religion’ are often used alternately, spirituality is inclusive of the concept of religion.
Religion is a factor that affects life style of the society and conception of health and
illness.
Religion is a concept that may affect individuals’ and society’s philosophy of life,
conceptions of health and illness, types of food consumed, rituals of birth and death,
and healthcare practices. Societies are found to use various religious practices
in care and treatment. Religious practices may have various effects on children’s
social and moral development. Healthcare practices based on religious and spiritual
values may play a significant role in shaping children’s and family’s lifestyle and
may have a great impact on children’s health. Various religions and sects are able
to affect children’s health and care practices, nutrition, and medical practices.
Concepts affected by culture

C. Geographical region
Child’s and family’s cultural values, as well as their environment of habitation result
in various differences in their conception and expression of health, illness, pain,
and their reflection to healthcare practices.
For example, it was observed in some rural areas in Africa that food items such
as eggs and meat were limited due to the fear that children may turn to thieves,
witches or sorcerers. It was detected that, in certain societies, there are differences
in individuals’ conception and attribution of meaning to verbal and non-verbal
communication.
Self-assessment 4.7
Discuss 2 concepts of culture and the way they can affect child’s health.

4.8 Practices that affect Child health
Learning activity 4.8

1. Describe what you are seeing on the above picture and discuss different
traditional practices that affect child health in your community
2. What is the impact of those practices to the child health?

Traditional practices
It is observed that individuals resort to traditional healthcare practices before
professional practices of care. It is noted that, in certain cultures the patients are
treated by individuals who are named traditional physicians or medicine man and
who are believed to possess divine Powers to cure illnesses.
It is observed that traditional healthcare practices and cultural beliefs have a
significant place and are widely used in all societies. According to current medical
knowledge, traditional methods applied to the child may be classified as practices
that adversely affect the child’s health and practices that have no adverse effect
on the child’s health. Among practices that may adversely affect the child’s health
are attitudes such as delaying breastfeeding for a certain time after childbirth, not
feeding the newborn with colostrum, coating the newborn with salt, placing soil
under the baby, and wrapping the baby tightly to make its legs grow straight. On
the other hand, practices such as placing a yellow kerchief on the baby’s face to
prevent newborn jaundice, to dress the baby with red-colored clothing, praying,
placing an evil eye talisman in the baby’s room are characterized as having no
adverse effect on the child’s health but may nevertheless be efficient in comforting
the family.
Health is influenced by culture which is a dynamic factor as well as biological
and environmental factors. Health practices are the outcome of health beliefs
generally originated from the culture of individual. Cultural practices of families
are directly related with the child health. Cultural practices affect children’s and
families’ conceptions of health, as well as children’s social development, attitudes
towards health problems they experience, conception of illness, reaction to illness
and therapy. There exist different practices that affect the child health. These are
named differently in Rwanda depending on the region. These includes Milk teeth
extraction (gukura ibyinyo), Uvulectomy (guca ikirimi), Tonsilectomy (guca
ibirato), Extracting millet (gukura uburo).
Milk teeth extraction (Gukura ibyinyo)
Normally the development of deciduous teeth begins while the baby is in utero and
about sixth weeks gestation, the first buds of primary teeth appear in the baby’s
jaw. The lower teeth are formed first followed by the upper anterior teeth. At birth
the baby has a full set of 20 primary teeth (10 in upper jaw, 10 in lower jaw) hidden
within the gums. Crown formation of the milk canine tooth in the upper jaw (maxilla)
is complete 9 months and the crown formation of a deciduous canine tooth in the
lower jaw (mandible)is complete between 8 and 9 months after birth.
Milk teeth extraction is a process of gouging out an infant’s healthy baby canine buds
imbedded underneath the gums, using unsterile tools such as a hot or sharpened
nail, a bicycle spoke or knitting needle, with no anesthesia. It is a dangerous and
sometimes fatal traditional practice. Milk teeth extraction believed to cure a tooth
disease known as Ibyinyo. In reality, this so-called disease is the natural teething
stage that all babies go through, beginning at around 6 months of age. Teething
in babies causes mouth pain, fever and sometimes even vomiting or diarrhea,
prematurely extracting the teeth is not a cure, and causes serious permanent
damage of the child.
Uvulectomy (Guca ikirimi)
Uvulectomy consists of cutting the uvula which has a function of blocking the passage
into the nasal cavity when swallowing so that the foods or fluids do not enter the
nasal passages. The uvula also involves in articulation of voice to form sounds of
speech. When uvulectomy is performed, there is likelihood of an infant developing
the conditions of hypernasal speech known as velopharyngeal insufficiency (VPI)
and/or nasal regurgitation (entering of food into the nasal cavity).
Tonsilectomy (gukata ibirato)
It consists of cutting the baby’s tonsils.
Extracting millet (gukura uburo)
It consists of skin cuts that are performed on chest wall of some children claimed to
be the remedy for chest infections in infants.
A. Complications of traditional practices
All of those mentioned above traditional practices have different complications such
as loss of blood that may lead to shock later on Anaemia, blood infections, tetanus,
HIV/AIDS (because the materials used are not sterilized), facial disfigurement and
can be fatal. The underlying permanent tooth buds can be damaged or eradicated,
causing malformations and long-term crowding in the anterior region of the maxilla
and mandible.
B. Prevention
The prevention of traditional practices involves a multidisciplinary team. This
goes beyond changing particular beliefs and behaviors within communities and
societies: it is about fundamental social change. There is need of increased, access
especially for poor and vulnerable people, to all essential services, including health
and education, social welfare and legal services. The community needs a sound
understanding of the importance of religion, faith and other belief systems: how
they can support work to end traditional practices that are harmful to children.
Conclusion
Nurses should be cautious about the children’s and families’ cultural beliefs’ and
practices’ reflections on the child’s health. In this context, the individual should be
conceived in spiritual and psychosocial aspects from birth to death and holistic care
should be provided
Self-assessment 4.8
1. Discuss the complications of traditional practices that affect child health.
2. What is your role in the prevention of traditional practices that affect the
child health?
End unit assessment 4
1. What is health Promotion?
2. Which children should you monitor growth?
3. What does the psychosexual development theory of Sigmund Freud say
about the development of personality which is different from what was
said by other theorists?
4. Describe different types of nutritional assessment
5. Describe the elements assessed during the pediatric physical
assessment.
UNIT 5:PREVENTION OF DISEASES IN CHILDREN
Key unit competence: Provide disease prevention services to children.
Introductory activity 5
Observe the following images illustrating different measures used to prevent
diseases in children.

From the pictures shown above,
a) What do you think that the associate nurse from image A is doing
to the child?
b) What have you observed from the image B?
c) What do you think that the child from image C is doing?
d) What do you think to be the use of image D?
e) What do you think as the advantages of performing that activity
from image E?
f) What do you think that the children from image F are doing?
g) What have you observed from the image G?
h) What do you observe from the image H?
i) What do you oberved from image I ?
j) What have you observed from image J?
5.1 Preventive measures for common childhood illnesses
Learning activity 5.1
A years ago, X District was one of the first to implement vaccination program in
southern province, Rwanda. Health care providers, community health workers
were trained and followed up for proper program implementation and, during
follow-up visits, availability of vaccines and materials at the community level and
health facilities were improved. But during monthly report from health facilities,
they noticed increased cases of pneumonia and diarrhoea among children
between 2 months -9months however no actions was taken on tracing dropouts
for vaccination due to lack of clear guidelines. During the review meeting a
month ago, the in charge of health canter reported that there is reduction in
number of children attending vaccination service. Then, recommendations were
made to start implementing the tracing of dropouts whenever possible in order to
increase the impact of the strategy and decrease the incidence of the diseases.
Some health facilities set up advanced strategy of vaccination to facilitate those
who are far from health centres. District health management team leader who
participated in the review meeting decided to start implementing tracing of
children immunization dropout by engaging CHWs.
Read the case scenario described above and think about answers to the following
questions:
a. What do you think can have been the cause of the incidence of increased
cases of pneumonia and diarrhoea among children as mentioned in the
scenario?
b. What intervention do you think that can be done to prevent the diseases
mentioned in scenario?
c. What do you think to be the cause of different childhood illnesses?

Learning activity 5.1

Globally, infectious diseases, including pneumonia, diarrhea, malaria
and sepsis remain the leading causes of death for children 1 month to 5 years of age.
Access to basic lifesaving interventions such as adequate nutrition, vaccinations,
and treatment for common childhood diseases can save many children’s lives.
Disease prevention is an important part of maintaining the child’s good health.
Disease prevention, understood as specific, population-based and individual
based interventions for prevention, aiming to minimize the burden of diseases and
associated risk factors. While different childhood illnesses are caused by a variety
of parasites, viruses, and bacteria, a lot of common childhood illnesses tend to
spread.
It is the most cost-effective health intervention. A set of practice guidelines for
different service levels were created by the World Health Organization (WHO),
which include vaccination.
Vaccination is the term used for getting a vaccine that is, actually getting the
injection or taking an oral vaccine dose. Immunization refers to the process of both
getting the vaccine and becoming immune to the disease following vaccination.
Primary prevention refers to actions aimed at reducing the incidence of diseases
in children; these actions include the provision of information on behavioural and
medical health risks, nutritional and food supplementation; oral and dental hygiene
education, clinical preventive services such as vaccination
Secondary prevention deals with early detection and treatment of diseases.
This comprises activities such as evidence-based screening programs for early
detection of diseases or for prevention of congenital malformations; preventive
drug therapies of proven effectiveness when administered.
Different measures used to prevent the childhood illnesses:
• Vaccinations: All recommended childhood vaccines are scientifically proven
to be safe and effective.
• Washing hands regularly: Getting children into the habit of washing their
hands is one of the most powerful ways to prevent illness. Encourage them to
wash their hands before and after eating, after using the washroom, and after
coming home from playing outside or in a public area.
• Covering mouth and noses when coughing and sneezing: Teach children
to help prevent the spread of illness by covering mouth and noses while
coughing and sneezing with a tissue or elbow. Tell them to remember to wash
hands after.
• Disinfection of toys, electronics, and communal objects: Bacteria and
parasites can survive on some surfaces for many days. Use alcohol wipes
or rubbing alcohol to clean favourite toys, tablets, phones, doorknobs, and
any other commonly touched household object. Wash bath towels and bed
sheets regularly.
• Eating healthy and exercise regularly: Following a healthy diet and
exercising are powerful ways to boost the immune system
• Starting good habits early: Explain early and often why good hygiene
matters. Integrate good hygiene habits into daily routines and don’t forget to
tell the children when they’ve done a good job.

Self-assessment 5.1
1. Define the term vaccination?
2. Differentiate the word vaccination and immunisation?
3. What are the actions aimed at minimising the incidence of the diseases
in children?

5.2 Principles of early child hood development
Learning activity 5.2

Early Childhood development starts from conception until the age of 5 years which
means that it starts when a woman conceives and the foetus starts growing in the
womb. When the baby is born, there is specific needs for effective growth and
development.
During this process a child progresses from dependency on their parents/guardians
to increasing independence. Child development is strongly influenced by genetic
factors (genes passed on from their parents) and events during prenatal life. It is
also influenced by environmental facts and the child’s learning capacity.
Child development can be actively enhanced through targeted therapeutic
intervention and the ‘just right’ home-based practice, recommended by Occupational
Therapists and Speech Therapists.
What does child development include?
Child development covers the full scope of skills that a child masters over their life
span including development in:
• Cognition: The ability to learn and problem solve
• Social interaction and emotional regulation: Interacting with others and
mastering self-control
• Speech and Language: Understanding and using language, reading and
communicating
• Physical skills: The fine motor (finger) skills and gross motor (whole body)
skills
• Sensory awareness: The registration of sensory information for use
Why is child development important?

Observing and monitoring child development is an important tool to ensure that
children meet their ‘developmental milestones’. Developmental milestones (a
‘loose’ list of developmental skills that believed to be mastered at roughly the same
time for all children but that are far from exact) act as a useful guideline of ideal
development.
By checking a child’s developmental progress at particular age markers against
these arbitrary time frames, it allows a ‘check in’ to ensure that the child is roughly
‘on track’ for their age. If not, this checking of developmental milestones can be
helpful in the early detection of any hiccups in development. This ‘check’ is usually
carried out through child/mother services and Pediatricians as infants and toddlers,
and later through preschool and school term skills assessments.
The earliest possible detection (and early intervention treatment if appropriate)
of developmental challenges can be helpful in minimizing the impact these
developmental hiccups can have on a child’s skill development and subsequently
their confidence, or serve as an indicator of a possible future diagnosis.
Developmental milestone checklists or charts are used as a guide as to what
is ‘normal’ for a particular age range and can be used to highlight any areas in
which a child might be delayed. However, it is important to be aware that while
child development has a predictable sequence, all children are unique in their
developmental journey and the times frames that they meet the many developmental
milestones
Problems in Child Development:
Problems in child development can arise due to: genetics, prenatal circumstances,
the presence of a specific diagnosis or medical factors, and/or the lack of opportunity
or exposure to helpful stimuli. Specific assessment by the best fit professional (which
may initially be the general practitioner or Pediatrician, and then Occupational
Therapist, Speech Therapist, Psychologist and/or Physiotherapist) can provide
clarity about the developmental issues and extent of concern as well as can help to
formulate a plan to overcome the challenge(s). As the process of child development
involves multiple skills developing simultaneously, there may then be benefit in
consulting multiple professionals.
Overcoming the developmental challenges is crucial to maximizing the ease and
speed of development, minimizing the gap that occur between a child’s ability and
those of their same aged peers, the confidence of the child as well as the frustration
that can be encountered by the child’s parents and/or care-givers.
Principles of child development
1. Child growth and development are interrelated
In order to understand this principle, it is first necessary to distinguish
between “growth” and “development”. All organisms including the humans
increase in size as they grow older. Their responsive behaviors also increase in
number as time passes on and life situations vary. This is an index of quantitative
change and is called growth.
The term growth is used in purely physical sense. It generally refers to an increase
in size, length, height and weight. Changes in the quantitative aspects come into
the domain of growth.
Development implies improvement in functioning and behaviour and hence brings
qualitative changes which are difficult to be measured directly. It indicates changes
in the quality or character rather than in quantitative aspects. These qualitative
changes accumulate to form a noticeable change of behaviour pattern a qualitative
change from earlier to the present set of behaviour, which is termed development
a noticeable difference in the pattern of the same behaviour will be marked at this
stage.
The growth and developmental process starts at the prenatal stage when a single
celled organism at conception grows and develops to a highly complex body
structure along with variety of functions. The process by which it takes place is
known as development. Growth continues after the baby is born up to maturational
limit while development continues throughout life.

Examples of quantitative change would be height, weight, or body temperature
(growth). For Qualitative change examples would be going from crawling to walking
stage or beginning to talk using words from a babbling stage(development).
Types of child growth:
• Physical growth (Height, Weight, head & chest circumference)
• Physiological growth (vital signs).
2. Child development proceeds from General to specific
As the child develops, his behaviour becomes more and more intricate and
complex leading towards specificity. In the beginning his behaviour remains mass
and undifferentiated a general response to all stimuli. But gradually they get
differentiated and specific response is elicited to specific stimulus.
For example, the child at birth expresses only three kinds of behaviour. They lie
and rest on the bed, they sleep and they cry when they are hungry. The baby again
cries when he is uncomfortable due to bed-wetting or something else disturbing
him. Gradually this crying response becomes time specific when he is hungry at
intervals. His crying responses due to uncomfortable feeling becomes different
from the earlier ones due to the presence of an unfamiliar face or remaining alone
in the bed and so on, thus indicating this awareness of making different responses
to different stimuli.
3. Child development proceeds directionally:
“The cephalo-caudal” principle refers to the fact that development (as well as growth)
always proceeds directionally from head to foot. This principle demonstrated in
physical growth simply by comparing the changes that take place in the comparative
sizes of different parts of the body.
At birth baby’s heads are large in comparison to the rest of their bodies. As children
grow older, the rate of growth increases in the lower extremities of the body. As this
occurs, the head gradually begins to look smaller in relation to the rest of the body.
4. Child development continues throughout life:
Development is more or less a continuous process with spurts at some stages. The
changes that are controlled by the developmental process are orderly and tend to
occur in an unvarying sequence. Therefore, the major changes are, more or less,
predictable. Everybody can be expected to sit before standing, to stand before
walking. Since development is continuous, what happens at one stage influences
all subsequent stages. People change as a result of maturation and experience.

5. Child development is individualised: Each child is unique the most
important principles of development are individual differences. There is no
fixed rate of development. That all children will learn to walk is universal, but
the time at which each child takes his/ her first step may vary.
Self-assessment 5.2
1) Outline the principles of child development.
2) Outline types of growth
3) Explain the term cephalo-caudal.
5.3 Types of child development
Learning activity 5.3
Read the case scenario below and answer questions below
Katia, a three-years-old little girl attends kindergarten where she has numerous
friends. She usually sings to her mum songs that are taught by her teacher. Her
weight is 17 kilograms. She is average size compared to the other children in
her class and has very good posture (physically fit) compared to her colleagues.
She is able to ride a bike with training wheels, loves jumping, likes playing with
her friends, love to help self-bath, feeds herself with a small spoon and fork.
She can zip, unzip and button her coat without assistance. She draws circle and
heart shapes. She is able to twist and partially braid her doll’s hair.
a. What do you think about Katia’s memory?
b. According to your understanding what do you think about her motor
skills?
c. What indicates Katia’s social emotional skill from the scenario?
As infants grow and reach early childhood, they become more aware of how
the world works and have a better understanding of what, where, how, and why
through the following types of development:

1. Cognitive and intellectual development in children: It is the development
of the skills and knowledge that help them understand their environment. It’s
the evolution of their thought process - how they process information, think,
determine right from wrong, make decisions, solve problems, learn new
things and how they perceive the world around them. Examples: thinking,
remembering, counting or identifying shapes.
Brain growth is part of cognitive development. The child’s brain develops in infancy
and early childhood so does their capacity to remember. The child memory plays a
huge significant role in a child’s socio-emotional and cognitive functioning.
The human brain is not fully developed at birth. That is the reason we can’t
remember being a baby, yet we can remember every line from our favourite teen
movie or song. It is due to the way brain develops, and more specifically, how
memory system develops from child hood, through adolescence and adulthood.
While the development of memory (short & long-term) is most evident in the first
2-5 years of a children’s life, their memory continues to develop well until adulthood.
Moreover, not all parts of the brain develop at the same time. In fact, the brain isn’t
fully developed until age of 25.
There are many ways to help promote children’s cognitive development. This can
literally start immediately after birth. The more engagement and interaction with
children, the more opportunities to them to develop the necessary cognitive skills
and abilities. As with adults, every child is different. For example, some will have
excellent memories; others may have weaker memory and skills but may show
strength in logic and reasoning instead.
2. Gross motor skills
Gross Motor skills refer to the physical skills needed to make large body movements
i.e. the large muscles, specifically the head, neck, arms, and legs. It’s the
movement of arms, legs or torso in a coordinated and controlled way.
The first example of a child developing gross motor skills is at around 3-4 months
when he raises his head when pulled into a sitting position, followed by him rolling
over. Examples are crawling, jumping or running.
Each stage of gross motor skill development leads to the next, as they strengthen
the necessary muscles and bones to help them progress from rolling over to sitting,
crawling, standing, walking, running, hopping, etc. Some gross motor skills also
require eye-hand coordination skills such as throwing, catching, kicking,
riding a scooter or a bike
Children use our gross motor skills literally all the time, whether sitting down or
standing up or lying in bed, every time of moving or change positions, it’s by using
gross motor movements. Balance, body strength and body awareness are all part
of gross motor development. Here are a few other examples of everyday activities
require gross motor skills
3. Fine motor skills
Fine motors refer to the physical skills needed to make small movements i.e.
the small muscles, specifically their hands and fingers. Fine motor skills start
developing almost at birth as they grasp reflexively, followed a few months later
when they place their fingers in their mouth, and by 6 months old, when they begin
to grasp at objects.

Fine motor skills involve more precision to perform than gross motor skills
and requires a number of independent skills (like hand-eye coordination, hand
control, body awareness, and patience) to work together to perform the task at
hand do things like play with toys, dress themselves, feed themselves, draw
and write are examples of fine motor skills.

Young children need time to practice their fine motor movement every day. Whether
they’re picking up something to eat or trying to pull up the zipper on their jacket,
it might be tempting (and far quicker) to take over and do it ourselves, especially
when we’re in a rush, but we must remember that these are all essential activities
for fine motor development.
Fine motor skill development is an originator to developing good handwriting
skills. The more opportunities a child has to pick up small objects (pincer grip),
and manipulate and exercise the small muscles in the palm of his hand, the better
control and strength he’ll have later on, when colouring, cutting and forming letters.
4. Speech and language
The development of speech and language refers to the skills children use to
understand and communicate with others. Language development helps a child to
communicate what they want and how they feel. It is also crucial to their thought
process; problem-solving, and forming relationships with others.

It is a critical part of child development and most of the foundations speech refers to
the making of sounds that become words. At around 2 months, babies first start
fussing, and at 6 months they generally start babbling - this is them learning
how to make the sounds which will eventually form words. It’s the physical act of
talking, even if we don’t understand what they’re saying.

Language, on the other hand, is the use of words (spoken or written), gestures
to communicate and understand others. Language refers to any form of
communication, be it verbal or nonverbal. Young children might not be forming
full sentences yet, or even speaking coherently, but don’t overlook their ability to
communicate. They can communicate their emotions and feelings through sound,
facial expressions, gestures and actions. Smiling, crying, shouting, laughing,
throwing things, pointing, and even throwing bad temper are just a few ways they
are attempting to communicate with you.

Language development is located down in the first 12 months of baby’s life and
develops at a rapid rate, especially between the ages of 2-5. Most children will have
learned the basics by age 6.
5. Social and emotional skills
These refer to a child’s ability to interact with others, to understand and
manage feelings and emotions. Examples of socioemotional skills are empathy,
sympathy, recognizing and expressing feelings, and the ability to relate to
others.
These skills begin in early childhood – from birth, as they interact with their
caregivers and form emotional attachments - and will continue growing throughout
adulthood. Babies show signs of socioemotional growth by smiling when he/she
sees you, waving goodbye when someone leaves, sharing his toys with his sibling,
even showing anxiety around strangers (around 7-9 months) or tantrums (around
age 2). The positive and negative reactions are all a normal part of their emotional
growth.
Healthy socioemotional skills will help the child to form and maintain positive
relationships, self-confidence, develop self-awareness and awareness of others
and their feelings, manage stress and anxiety.
Self-assessment 5.3
1. Outline types of child development.
2. Explain cognitive and intellectual development in children.
3. Explain by giving examples on social and emotional skills.
5.4 Factors influencing the child development
Learning activity 5.4
Read the case scenario and answer questions below
Kaliza is 4years old firstborn of her family living in village. Her mother is a
housewife and her father is a farmer where they live in small house with 2 goats
and 2 rabbits. The child Kaliza did not start the nursery school yet because she
doesn’t speak well, is not able to feed herself, and cannot dress or undress
herself. She is fairly walking but can’t run, she is physically unstable when
looking at her. Her mother reported that community health worker measured her
and said that the child is not growing well. She also says that Kaliza is just lazy
as she is a girl. she added that her baby delayed even to sit and crawling just
like her younger sister. She claimed that her child does not like eating vegetables
and fruits. She does not like to play with other children (neighbours of her age)
because they live far from them.
a. What do you think about Kaliza’s condition?
b. What do you think that can cause the child in scenario delayed
speaking, walking?
Child development refers to the sequence of physical, language, thought and
emotional changes that occur in a child from birth to the beginning of adulthood.
During this process a child progresses from dependency on their parents/guardians
to increasing independence.
Child development is strongly influenced by a wide variety of factors throughout his/
her life. These factors influence a child both in positive ways that can enhance their
development and in negative ways that can compromise the child’s developmental
outcomes.
These factors include:
Genetics: children inherit much genetically aside from physical appearance, like
eye and hair colour, skin tone, nose shape, as well as height and body build. They
also inherit things like attitude an extent, inherit traits like intelligence, abilities, and
attitude. While all kids are special and have amazing potential, some children are
also more naturally gifted or excel more than others at certain things. Whether it be
at sports or academics, some kids pick things up much faster or more easily than
others. Not everyone is destined to be a pro tennis player (in fact, few are). Not
every child learns at the same pace or has the same capability to acquire or retain
or understand information.
Health & nutrition: Health attributes are passed through the genes, some viruses,
diseases, and disabilities can be developed as a result of external factors including
(but not limited to) our environment. Good health can include access to quality
healthcare, vaccinations, medicines, a toxin-free environment, clean water and air.
Nutrition (balanced diet) plays a significant part in children’s growth and development
as it affects not just their health but also strength, growth, and energy levels, which
can adversely affect learning. Providing children with a balanced diet from birth is
essential for their growth and development. When children face with health and
nutrition issues can lead them to developmental delay. Developmental delays
can reduce a child’s ability to communicate, learn, be mobile, live independently,
make decisions and care for themselves
Gender: A side from the biological differences between boys and girls, gender
expectations and social norms can also influence a child’s development. More
often, without realizing it, the perceived gender roles can influence the way in
which parenting children can have profound effects on their children’s thoughts,
behaviours, and actions.
Parents unwittingly expose their children to different environments or opportunities.
For example, being roughhouse with boys, but be gentler with girls, and therefore
potentially exposing boys more to the use of gross motor skills at an earlier age.

Environment: children’s living physical and social environment also plays a big
role in influencing their development positively or negatively. Access to suitable
housing, health care, education and recreation facilities, clean air and water can
influence a child directly through their own health well-being and opportunities
afforded to them, as well as indirectly by affecting their caregivers’ emotional and
physical well-being.

It’s important for the child to have access to and live in a stress-free environment.
Children plays, toys, and interaction with others help stimulating both mental
and physical aspects. The social relationships that children have can be hugely
impactful. The quality of their interactions with others determines their intellectual,
social, and emotional development.

Family: Family is almost certainly the most important factor in child development. In
early childhood especially, parents are the ones who spend the most time with their
children and sometimes influence the way they act, think and behave. Children’s

social, emotional, and even physical development are very dependent on familial
related opportunities including the strength of familial bond.
The interaction with children (how often) can be hugely significant. Parents are
important people in their little lives, and children depend on them for everything
(nourishment, security, warmth, comfort, attention, stimulation, and, most importantly,
love and affection). If children feel safe, they can take risks, ask questions, make
mistakes, and learn to trust, share their feelings, and grow well.
Self-assessment 5.4
1. Explain how can genetic influence child’s development?
2. List factors influencing child development, it can be positively or negatively.
5.5 Promotion of child health
Learning activity 5.5
Observe the images below and reflect to them.
a. How do you understand health promotion?
b. What do you think about image C and D?
c. What do you think about images A?
The World Health Organization defines health promotion as the process of enabling
people to increase control over, and to improve, their health. Health promotion
moves beyond a focus on individual behaviour towards a wide range of social and
environmental interventions. Health promotion’s purpose is to positively influence
the healthy behaviour of people and societies as well as the living and working
conditions that impact their health.

Health promotion focuses on improving and protecting the health of different
populations and communities, including children and their families. Health promotion
programs aim to reduce health disparities and improve health outcomes. Programs
that focus on improving the health and well-being of children in early childhood may
be implemented in homes, childcare settings, and other community-based settings.
Health in childhood determines health throughout life and into the next generation.
“Ill health or harmful lifestyle choices in childhood can lead to ill health throughout
life, which creates health, financial and social burdens for countries today and
tomorrow”

The above quote illustrates just how important the promotion of children’s health
is. Child health promotion focuses upon the enhancement of children and young
people’s overall health and well-being.

Child health promotion tips

The child health promotion activities include but not limited to the following activities:
• Growth monitoring
• Immunization program.
• Promotion of access to and participation in school feeding (healthy foods and
drinks at schools)
• Controlling food quantity and quality (foods and drinks) outside school feeding
• Offering leisure’s and sport activities to children (celebrations and events).
• Providing and ensuring access to safe water.
• Education on nutrition in classes, school day, and in after-school programs for
example, through school gardens and farm-to-school activities.
The center for disease control notes that programs that focus on influencing and
modifying certain health behaviors and outcomes from an early age can greatly
impact health outcomes later in life. Some of these programs include a focus on:
• Childhood obesity, especially programs in early childhood education settings
• Healthy food options and nutrition
• Physical activity like exercises
• Chronic disease in childhood prevention
Oral health
• Healthy sleep habits
• Prevention of drug use among children
• Access to age-appropriate screening tests for development, hearing, and
vision
• Childhood trauma and adverse childhood experiences (ACEs) prevention
Typical activities for health promotion, disease prevention, and wellness
programs include:
Communication: Raising awareness about healthy behaviours for the general
public. Examples of communication strategies include public service announcements,
health fairs, mass media campaigns, and newsletters.
Education: Empowering behaviour change educations, communications and
actions through increased knowledge. Examples of health education strategies
include courses, trainings, and support groups.

Policies, systems and environment improvement: Making systematic changes
– through improved laws, rules, and regulations (policy), functional organizational
components (systems), and economic, social, or physical environment to encourage,
make available, and enable healthy choices

Nursing roles in child health promotion

The backbone of the nursing profession has always been recognized as that of a
caring profession and one that excels in disease prevention and health promotion.
Nurses are strong advocates for patients because they direct the health care
system.

The nursing roles in child health promotion and disease prevention are:
Health educator: Nurses spend the most time with the patients and provide
anticipatory guidance about immunizations, nutrition, dietary, medications, and
safety.

Nurses are consistently working to prevent illnesses such as heart disease, stroke,
diabetes, and obstructive pulmonary disease; they do this through a variation of
tactics that include education, risk factor prevention, and the monitoring of safety
hazards either in the workplace, community, or home. Helping patients to potentially
receive preventative services such as counselling, screenings, and precautionary
procedures or medications. Nurses can impassion those to engage in healthy
lifestyles through education, mentorship, and leadership.

Nurses are able to perform health promotion tasks by enhancing the quality of life
for all people through assessment of individual and community needs, education,
identification of resources, evaluation and implementation of programs to help
reduce premature deaths.
Nurses provide the practical guidance on everyday health issues such as preventing
obesity, dental health, skin care and prevention of diseases and infections.
Nurses explore the best practice for nursing children with chronic illnesses such
as asthma, cancer, diabetes and disabilities, and gives guidance on promoting the
health of adolescents looking at issues of sexual health, smoking, drugs and alcohol.
Each chapter discusses key health promotion messages, relevant government
policy and health promotion
Self-assessment 5.5
1. Briefly explain nursing roles in child health promotion.
2. Centre for disease control notes that programs that focus on influencing
and modifying certain health behaviours among children for better health,
list at least 5 programs.
5.6 Developmental monitoring and screening
Learning activity 5.6
During community outreach, an associate nurse student found in one of the
visited families, a child called Cyiza who was dirty and lying in his bed. The
neighbour told that his parents do not care for him because he is still lying down
while other children of 3years of the same age can run and go to school. Cyiza
cannot get up and just know to say da and articulate other strange sounds.
a) What do you think about the situation of Iriza?
b) What do you think about parents attitudes towards this child ?
c) What should the associate nurse and parents do to help their child?
d) According to the age of the child in wich category can you classify the child
Cyiza?
Overview of child health development
Child health and development depends closely to experiences rooted from early
years of child’s life. Children including those with special health care needs, grow
healthy when all skills are timely acquired and grow up where their social, emotional
and educational needs are met. Positive parenting practices play an important role
in child’s healthy development. Therefore, parents should help their child stay
healthy, be safe, and be successful in many areas such as emotional, behavioral,

cognitive, and social by responding to children in a predictable way, showing
warmth and sensitivity, having routines and household rules, sharing books and
talking with children, supporting health and safety, using appropriate discipline
without harshness. Proper nutrition, exercise, and sleep have valuable impact on
child development.
Monitoring of development is critical for two reasons: First, new circumstances
(e.g., medical illness, family or environmental disruption, or injuries) may interfere
with development. Second, as children develop, they gain new categories of skills
that are difficult to assess at earlier stages (e.g., one cannot usually detect isolated
language delays in children younger than 18 to 24 months, the period at which
children begin to develop language skills). In 2006, the American Academy of
Pediatrics (AAP) published guidelines recommending developmental surveillance
at every child visit, as well as additional periodic developmental screening using a
standardized test at the 9, 18, and 30 months old.
Stages of child development
a. New-born refers to the stage immediately after birth until 1 month.
b. Infant is a child in the period from 1 month until 12 months.
c. Toddler stage is from 12 months until approximately 3 years.
d. Early childhood or Pre-schooler are children in 3- to 6-year-olds.
e. School-age children are 6 to 12 years old.
f. Adolescence begins around 12 or 13 to adulthood
Self-assessment 5.6
1. When can you argue that a child is growing or developing well?
2. What should do parents to help their child stay healthy, safe, and be
successful in many areas regarding?
3. Monitoring of development is critical for two reasons. Why?

5.7. Developmental monitoring
Learning activity 1.4

These pictures are showing developmental monitoring of a child
a. Which domain do you think it explicates the A.
b. Which domain do you think it explicates the B.
c. Which domain do you think it explicates the C.
Developmental monitoring is checking whether a child reaches the skills and
behaviours that are expected by his or her age or those of likelihood. It is something
parents and other caregivers can do, on a regular and ongoing basis. Developmental
monitoring provides important information about a child’s developmental health.
Using CDC’s developmental milestone checklists makes the monitoring easy. The
associate nurse, nurse and other child caretakers play a vital role in identifying
children at risk for developmental disabilities and in referring them for appropriate
early intervention services.

Physical developmental delays

Physical developmental delay is when a child is not able to do activities or basic
movements such as rolling over, sitting without support, or walking that other
children of their age are doing. Developmental delay can be a sign of a serious
health condition and it’s important to seek early care for adequate and timely
interventions. Parents and other caregivers are the most important to identifying
any deviation from normal basing on specific behavioral and skills features and
termed as developmental milestones.
Figure 5.3: a child with getting up problems ring the History Taking of a Child wit
All young children need both developmental monitoring and developmental
screening to help parents and child’s health care providers, teachers, and other
care takers know if child’s development is on normal progress.
Developmental monitoring involves using information obtained from the history
taking, physical examination, and developmental screening tests to assess
development on an ongoing basis.
History Taking
The following information should be elicited:
Parental concerns regarding the child’s development.
Parental concerns regarding the child’s language development, articulation,
fine motor skills, or global development are likely to be associated with true
developmental delays.
Parental concerns about behavior or personal–social skills are associated with
developmental delays in some cases.
• Risk factors for developmental disabilities
Prenatal
Maternal illness, infection, or malnutrition, maternal exposure to toxins, teratogens,
alcohol, illicit drugs, anticonvulsants, antineoplastic, or anticoagulants drugs,
decreased fetal movements, intrauterine growth retardation, family history of
deafness, blindness, or mental retardation, chromosomal abnormalities
Perinatal: Asphyxia: Apgar scores of 0–3 at 5 min, prematurity, low birth weight,
abnormal presentation.
Postnatal: Meningitis, encephalitis, seizure disorder, hyperbilirubinemia: bilirubin
>25 mg/dl in full-term infant, severe chronic illness, central nervous system trauma,
child abuse. and neglect
Family history
Consanguinity may cause chronic condition of the kidney may be associated with
Attainment of developmental milestones
Developmental milestones (how a child plays, learns, speaks, acts, or moves)
are behaviours or skills most children can do by a certain age. All young children
need both developmental monitoring and developmental screening to help parents,
child’s health care provider, teachers, and other providers to know if the child’s
development is on track
At 2 months
Social/emotional milestones
When spoken to or picked up, the child calms down and responds by looking at the
face of the instructor, demonstrating happiness to someone who walk up to her or
smile at her/him.
Language/communication milestones: Regarding this milestone, the infant only
makes sounds other than crying or reacts to loud sounds
Cognitive milestones (learning, thinking, problem-solving: At 2 months, the
child watches the movement of the person who is coming or going as and can
observe a toy for several seconds.
Movement/physical development milestones: At this age the infant holds head
up when on tummy, moves both arms and both legs and opens hands briefly
At 4months
Social/emotional milestones: At this age the child smiles on his own to get
someone’s attention or chuckles (not yet a full laugh) when you try to make her
laugh; looks at you, moves, or makes sounds to get or keep your attention. Knows
familiar people; likes to look at self in a mirror and laughs.
Language/communication milestones: Regarding language or communication,
a 4months child makes sounds like “oooo”, “aahh” (cooing). Makes sounds back
to respond and turns the head towards the sound of a voice. Takes turns making
sounds with you. Blows “raspberries” (sticks tongue out and blows) and makes
squealing noises.
Cognitive milestones (learning, thinking, problem-solving: Learning, thinking
and problem solving are observed when the child is hungry specific cues such as
opening mouth when she sees breast or bottle. Also he or she looks at his hands
attentively. Puts things in her mouth to explore them. Reaches to grab a toy he
wants and Closes lips to show she doesn’t want more food
Movement/physical development milestones: At this age, the child is able to
hold his head steady without support. He can hold a toy put in his hand and uses
arm to swing at toys. Brings hands to mouth and when lied in prone position, he /
she is able to push up onto elbows/forearms. Rolls from tummy to back. Leans on
hands to support himself when sitting
At 6 months
Social/emotional milestones: Social or emotional milestones are important cues
that display the child development; an infant at this age will be able to recognize
familiar people; Likes to look at self in a mirror and laughs
Language/communication milestones: Takes turns making sounds with you.
Blows “raspberries” (sticks tongue out and blows) Makes squealing noises.
Cognitive milestones (learning, thinking, problem-solving: The child explores
objects by his or her mouth. Reaches to grab a toy he wants and closes lips to show
she or his no longer hungry or does not want
Movement/physical development milestones: Physical development by 6
months is characterized by active movement of the limb where the enfant rolls from
the abdomen to back. Leans on hands to support himself when sitting
By 9 months
Social/emotional milestone: By this age most of babies are shy, clingy, or fearful
around strangers; Recognize their name when called. They are able to express
their emotions by facial expression (happy or unhappy)
Language/communication milestones: Child at 9 months’ lifts arms up to show
that she/he want to be picked up by a loved one and makes a lot of different sounds
like “mamamama” and “bababababa
Cognitive milestones (learning, thinking, problem-solving): The child shows
learning process by trying to identify objects when dropped out of sight (like his
spoon or toy). Bangs two things together
Movement/physical development milestones: The physical development occurs
progressively; thus the baby first tries to get to a sitting position by herself and end
by sitting without any support. This movement progress involves also the use of
upper and lower limbs. Thus the child will move things from one hand to her other
hand or uses fingers to “rake” food towards himself
By one year

Social/emotional milestones: The young infant has observed adult person doing
and in the future he will try to help in adult activity (washing clothes and other
activities)
Language/communication milestones: Communication skills are acquired
progressively; from sounds other than crying observed early, the one-year-old
baby can understand adult orders and respond accordingly. The infant will know
to say good bye, should call a parent “mama” or “dada” or another special name,
distinguish an order from adult person and responds accordingly ex: a no and the
child ceases what he or she was doing!
Cognitive milestones (learning, thinking, problem-solving): The learning
process is present at each state of child growing, we observed at the previous
state from where the child tried to identify objects when dropped out of sight (like
his spoon or toy) and bangs two things together thus by one year, the baby knows
to put something in a container, like a bean in a cup. Looks for things he sees you
hide, like a toy under a blanket
Movement/physical development milestones: Physical development involves
also limbs and the baby manage to stand; walking, holding on to furniture drinks
from a cup without a lid, as you hold it. For further progress, by one year the baby
picks things up between thumb and pointer finger, like small bits of food.
BY 15 months
Social/emotional milestones: By 15 months the baby copies other children while
playing, like taking toys out of a container when another child does, identify and
shows her / his objet of choice. He/she is also able to express their emotion by
clapping hand or he/she cuddles you.
Language/communication milestones: Language progresses as the baby grows
up; two words besides “mama” or “dada,” are acquired like “ba” for ball or “da” for
dog. Recognize a familiar object when you name it; Follows directions given with
both a gesture and words. For example, he/she gives you a toy when you hold out
your hand and say, “Give me the toy.” Points to ask for something or to get help
Cognitive milestones (learning, thinking, problem-solving): Learning at
this stage is characterized by baby’s progress in identifying objects and tries its
appropriate use. Phone to hear, cup put towards the mouth. Stacks at least two
small objects, like blocks
Movement/physical development milestones: By this age the infant takes a few
steps on his own and for taking some food the enfant feels easy to use fingers to
feed herself
By 18 months
Social/emotional milestones: By 18 months walks away by his or her own but
the immature child invents opportunities that make him closer to someone who
should help in need by: a. Showing something interesting, b. Putting hands out to
be washed, c. Reading with an adult, d. Helping in dressing him by pushing arm
through sleeve or lifting up foot
Language/communication milestones: By 18 years the communication skills
improve and besides “mama “or dada” three or more words are added. Responds
appropriately when asked to give something”
Cognitive milestones (learning, thinking, problem-solving): Learning process
at this age is characterized by baby’s imitation adult activities. She/he wants to
sweep and perform activity in in a simple and appropriate way or plays with toys,
like pushing a toy car in a simple direction.
Movement/physical development milestones: The child gets to a sitting position
by herself and without support. Upper limbs also progress and the infant is able
to change objects from one hand to her other hand or use fingers to “rake” food
towards himself
2 years
Social/emotional milestones: At 2 years the emotion of the child is characterized
by a bit of empathy towards others. The baby identifies negative emotions from
others. Such as when you are hurt or upset or pausing or looking sad when
someone is crying. Looks at your face to see how to react in a new situation
Language/Communication milestones: Communication at this age improves
and the baby is able to identify things in a book when you ask, like “where is the
chair? Language also progresses and at least two words together, like “More milk”
can be spelled. Some parts of the body are known and the infant can show at least
two body parts. Uses more gestures than just waving and pointing, like blowing a
kiss or nodding yes
Cognitive Milestones (learning, thinking, problem-solving): The process of
learning is multi steps; by 2 years the baby holds something in one hand while
using the other hand; for example, holding a container and taking the lid off, tries to
use switches, knobs, or buttons on a toy, plays with more than one toy at the same
time, like putting toy food on a toy plate.
Movement/Physical development milestones: By 2 years limbs structures have
progressively developed, the child exhibits some advanced and strong movements
such as kicking a ball, running after it and he or she is able to walk up a few stairs
with or without help. Eats with a spoon
By 30 months
Social/emotional milestones: At this age, the child shows some cues of socialism
and he/ she is interested by playing in group with other children. Wants his/her
progress to be noticed by others by saying “Look at me!
Language/communication milestones: Language progress increases gradually
and the child is now able to articulate about 50 words; says two or more words
together, with one action word; knows to pick an object from a book when it is asked
to show it or to name the object. Says words like “I,” “me,” or “we”
Cognitive milestones (learning, thinking, problem-solving): The infant has
learned from his/ her caregivers and at this age he shows his maturity or problem
solving by playing in nurturing his doll. When an object is left at a high level he will
try to reach it by climbing or standing on a stool. Follows two-step instructions like
“Put the toy down and close the door.” He is able to identify or pick a desired color
at least one.
Movement/physical development milestones: Physical development increases
with the age but also with a certain degree of maturity. Thus the child opens things
by twisting them or turning doorknobs to open it or unscrewing lids. Can undress off
alone, Jumps off with both feet. Open and turns off a book.
By 3 years
Social/emotional milestones: The child has familiarized with people around him
and does not like to be left alone or with strange ones. Within ten minutes after you
leave her, he has forgotten and will join others to play with.
Language/communication milestones: By 3 years, conversation is eased
using at least two back-and-forth exchanges. Use why questions to discover an
environment or a cibled one by asking “who,” “what,” “where,” or “why” questions,
like “Where is mommy/daddy?”. The infant is able to interpret an action on a picture
cg:” drawing”, “smiling.” Says first name, when asked. Wants other to appreciate
him or her by good spelling of words
Cognitive milestones (learning, thinking, problem-solving): Learning by 3
years old is marked by correct imitation or strong compliance to adult orders or
advices. Thus a 3 years old child is able imitate a work showed by a caretaker. Ex:
Draws a circle, when you show him how. Fear of hot objects as told.
Movement/physical development mile stones: A 3 years old infant is able to tie
thinks together and has acquired some self-care abilities such as dressing skills or
eating by himself using appropriate kitchen utensils.
4 years
Social/emotional milestones: By 4 years old the child plays simulations that
imitate a desired profession, playing as a teacher or barking like a dog to provoke
fear in likelihood. However, he likes to be a helper comforting or protecting those
in danger. The child identifies respectful areas for applicable behavior! (church, vs
market)
Language/communication milestones: At this age the child is able to articulate
sentences with four or more words from a song or a story. Talks about at least one
thing that happened during his day, like “I played soccer.” And Answers simple
questions like “What is a coat for?” or “What is a crayon for?”
Cognitive milestones (learning, thinking, problem-solving): The child knows to
draw a person and can name at least 3 parts. He /She is able to identify few colors.
At this age he can tell a story in appropriate order.
Movement/physical development milestones: A 4 years old child catches a
large ball most of the time or holds crayon or pencil between fingers and thumb
(not a fist). Can unbutton some button. Finally serves food or pours water by him or
herself. Unbuttons some buttons
5years
Social/Emotional Milestones: The child does continue adapting to the social
environment; respects pre-established rules and can even take a role within a play.
Sings, dances, or acts for you. Does simple chores at home, like matching socks or
clearing the table after eating
Language/Communication Milestones: Development involve improved
communication where the infant is able to tell a story she heard or made up with at
least two events. For example, a cat was stuck in a tree and a firefighter saved it
• Answers simple questions about a book or story after you read or tell it to him
• Keeps a conversation going with more than three back-and-forth exchanges
• Uses or recognizes simple rhymes (bat-cat, ball-tall)
Cognitive milestones (learning, thinking, problem-solving): Counts to 10,
Names some numbers between 1 and 5 when you point to them, uses words about
time, like “yesterday,” “tomorrow,” “morning,” or “night”, Pays attention for 5 to 10
minutes during activities. For example, during story time or making arts and crafts
(screen time does not count), Writes some letters in her name, names some letters
when you point to them.
Movement/Physical Development Milestones: Buttons some buttons, Hops on
one foot.
Physical examination
Head Circumference: A small head circumference may indicate abnormalities in
brain growth that place a child at risk for developmental disabilities. A large head
circumference may be a sign of hydrocephalus, a genetic syndrome, or a metabolic
storage disease. However, before assuming pathology in a child, one should
measure the head sizes of parents as a small or large head circumference may be
a family trait.
Congenital anomalies or dysmorphic features: Congenital anomalies or
dysmorphic features are associated with many genetic syndromes that may cause
mental retardation or learning disabilities.
Dermal lesions of neuro-cutaneous Syndromes
Approximately 50% of patients with dermal lesions have mental retardation or are
at risk for hearing loss and learning disabilities.
Muscle tone: Hypertonia may be a sign of cerebral palsy (CP), but in the first
year of their life, children with isolated increases in muscle tone should not be
diagnosed with CP as they may outgrow the problem. Hypertonia occurs in infants
with neuromuscular disorders or injury to the brain or spinal cord. Rarely, hypertonia
is the only sign of a metabolic disorder (e.g., peroxisomal disorders, acid maltase
deficiency). Hypotonia also occurs in some chromosomal disorders, such as Down
syndrome, so obtaining a karyotype should be considered if the child is dysmorphic
and hypotonic
• Primitive Reflexes
Asymmetries of primitive reflexes may help identify hemiplegia or other nerve
injuries. Persistence of primitive reflexes beyond the time of usual disappearance
or an obligate response may be signs of CP.
Self-assessment 5.7
a. What does mean developmental monitoring?
b. What elements do help in developmental monitoring?
c. What does mean developmental milestones?
5.8 Developmental screening
Learning activity 5.8

Developmental screening refers to assessing the child development through exams
and with using appropriate tools. For developmental and behavioral screening, it
is done using formal questionnaires or checklists asking questions about a child’s
development, including language, movement, thinking, behavior, and emotions.
Developmental screening can be done by skilled care providers such as a doctor
or nurse, but also by other professionals in healthcare, early childhood education,
community, or school settings. This screening is more formal than developmental
monitoring but it is most of the time done only when there is a concern from parent
or health care provider. According to AAP, periodic developmental screening should
be a part of routine visits for all children even if there is not a known concern.
Importance of developmental screening
The first step to connecting young children with early intervention services is
effective, periodic developmental screening. Children with special health care
needs are more likely to have developmental delays and disabilities than their
peers, therefore the child should be early assessed for developmental issues in
order to provide timely and adequate intervention services. Appropriate and early
interventions to infants and toddlers with developmental delays and disabilities
must include their families for positive and sustainable results.
Screening includes also the use of parent reports and screening tools. Parental
concerns are highly accurate in identifying developmental problems. In some
studies, up to 80% of parental concerns have been found as accurate.
Signs of developmental delay

Table 5.1: Signs of developmental delays
At every visit the following elements must be considered:
• Eliciting and addressing parents’ concerns at each visit
• Viewing milestones at each visit
• Identifying and addressing psychosocial risk and resilience factors
• Using a general screen that is validated and accurate at 9, 18, 24 – 30 months
and at each subsequent visit
Hearing assessment screening: Universal hearing screening during the newborn
period is recommended because screening limited to infants with risk factors for
hearing identifies only half of infants with significant hearing impairment.
Risk factors for hearing impairment: Family history of deafness, congenital
TORCH infections: toxoplasmosis, other infections, rubella, cytomegalovirus,
and herpes simplex, Congenital malformation of the head and neck, Prematurity
(< 1,500 g at birth), Extended stay in neonatal intensive care unit (>48 hrs.),
Hyperbilirubinemia requiring exchange transfusion, Meningitis or encephalitis,
anoxia.
Vision assessment: The detection of amblyopia is the most important reason for
early vision screening as early detection can prevent vision loss in the “neglected”
eye. Newborns should be able to fixate on a face; by 1 to 2 months of age, infants
should be able to follow an object horizontally across their visual field.
Development screening tests
General Development

Ages 0–5 Years: Ages and Stages Questionnaires: The Ages and Stages
Questionnaires is a series of parent-completed questionnaires that assess the
domains of communication, gross motor, fine motor, problem solving and personal
adaptive skills.

Ages 0–8 Years: Parents’ Evaluation of Developmental Status (PEDS):
This parent-completed questionnaire elicits parental concerns about aspects of
the child’s development and behavior. Based on the response of the parents to
questions, an algorithm guides the clinician in determining whether the child needs
referral, additional screening, or continued surveillance. Additional information on
this test is available at www.pedstest.com

Autism spectrum disorder (ASD) : The AAP(American association of paediatrician)
recommends that all children should be screened for autism spectrum disorder
(ASD) during regular well-child visits at 18 months, 24 months. Autism, or autism
spectrum disorder (ASD), refers to a broad range of conditions characterized
by challenges with social skills, repetitive behaviours, speech and nonverbal
communication.

Common signs of autism: Avoiding eye contact. Delayed speech and
communication skills. Reliance on rules and routines. Being upset by relatively
minor changes. Unexpected reactions to sounds, tastes, sights, touch and smells.
Difficulty understanding other people’s emotions.
Self-assessment 5.8
1. State signs of developmental delay at 18 months.
2. Briefly explain autism
3. list signs of autism
5.9 Immunisation according to expanded program of
immunisation
Learning activity 5.9

Today every country in the world has a national immunization programme.
Vaccines are viewed as one of the safest, most cost-effective, successful public
health interventions to prevent deaths and improve lives.
a. How do you understand by term immunization?
b. When a vaccine introduced into the body, it produces protection from
a specific disease, according to your understanding what is the name
for that protection?
c. Every country has immunization programme, what do you think about
its aim?
Vaccination is the intervention used to prevent or eradicate childhood diseases. It is
the most cost-effective health intervention. A set of practice guidelines for different
service levels were created by the World Health Organization (WHO), which
include vaccine monitoring, immunization techniques, cold chain management and
reporting systems.
EPI (Expanded Program on Immunization) covers vaccination services implemented
in order to ensure the immunization of all vulnerable age groups by preventively
reaching out to them before they contract and develop infectious diseases. This
program aims to control, and eventually eradicate these infections with a special
focus on decreasing the incidence of these infectious diseases and its associated
deaths.
Immunization activities are fully integrated into routine health services within each
health Facilities. These are key terms that explains interchangeable words used in
immunization activity.
Immunity: Protection from an infectious disease. If you are immune to a disease,
you can be exposed to it without becoming infected.
Vaccine: A preparation that is used to stimulate the body’s immune response
against diseases. Vaccines are usually administered through needle injections, but
some can be administered by mouth or sprayed into the nose.
Vaccination: The act of introducing a vaccine into the body to produce protection
from a specific disease.
Immunization: A process by which a person becomes protected against a disease
through vaccination.
There are two types of immunity: active and passive.
Active Immunity results when exposure to a disease organism triggers the immune
system to produce antibodies to that disease. Active immunity can be acquired
through natural immunity or vaccine-induced immunity.
Natural immunity: acquired from exposure to the disease organism through
infection with the actual disease.
Vaccine-induced immunity: acquired through the introduction of a killed or
weakened form of the disease organism through vaccination. if an immune person
comes into contact with that disease in the future, their immune system will recognize
it and immediately produce the antibodies needed to fight it. Active immunity is
long-lasting, and sometimes life-long.

Passive immunity is provided when a person is given antibodies to a disease rather
than producing them through his or her own immune system.
Vaccines types and mechanism of action
They exist live-attenuated vaccines, inactivated vaccines, subunit, recombinant,
conjugate, and polysaccharide vaccines, toxoid vaccines, mRNA vaccines and
Viral vector vaccines
Live-attenuated vaccines: Live-attenuated vaccines inject a live version of the
germ or virus that causes a disease into the body. Although the germ is a live
specimen, it is a weakened version that does not cause any symptoms of infection
as it is unable to reproduce once it is in the body. The types of diseases that liveattenuated
vaccines are used for include: Measles and rubella (MR combined
vaccine) and rotavirus
Inactivated vaccines: An inactivated vaccine uses a strain of a bacteria or virus
that has been killed with heat or chemicals. This dead version of the virus or bacteria
is then injected into the body. Inactivated vaccines are the earliest type of vaccine
to be produced, and they do not trigger an immune response that is as strong as
that triggered by live-attenuated vaccines. The types of diseases that inactivated
vaccines are used for include: Hepatitis A and Polio
Subunit, recombinant, conjugate, and polysaccharide vaccines: Subunit,
recombinant, conjugate, and polysaccharide vaccines use particular parts of
the germ or virus. They can trigger very strong immune responses in the body
because they use a specific part of the germ. These types of vaccines are used to
create immunity against the following diseases: Hib (Hemophilus influenza type b),
Hepatitis B, Human papillomavirus (HPV), cough, pneumococcal disease.
Toxoid vaccines: Toxoid vaccines use toxins created by the bacteria or virus to
create immunity to the specific parts of the bacteria or virus that cause disease, and
not the entire bacteria or virus. The immune response is focused on this specific
toxin. Toxoid vaccines do not offer lifelong immunity and need to be topped up over
time. Toxoid vaccines are used to create immunity against diphtheria and tetanus.
Viral vector vaccines: Viral vector vaccines modify another virus and use it as a
vector to deliver protection from the intended virus. Some of the viruses used as
vectors include adenovirus, influenza, measles virus and vesicular stomatitis virus
(VSV).
The Expanded Program on Immunization (EPI) plans to vaccinate children aged
0 to 15months, against: Tuberculosis, polio, diphtheria, Tetanus, Pertussis/
whooping cough, Hepatitis B, infections with haemophilus influenza type B,
pneumonia, measles, rubella and rotavirus infections.

The booster of measles vaccine is given at 15 months, but also 12-year-old
adolescent girls receive vaccine against human papillomavirus and tetanus vaccine
for pregnant women or women of childbearing age and the child also receives the
mosquito net impregnated during vaccination of MR at the age of 9 months.
Self-assessment 5.9
1. Explain types of immunity?
2. At what age of vaccination among children is extended?
3. What are the vaccinated diseases among children in Rwanda?
5.10 National expanded program of immunisation vaccine
Learning activity 5.10

The overall goal of the national EPI is to contribute to the improved well-being of
the Rwandan people through reduction of child morbidity and mortality through
vaccination of preventable diseases. Vaccination program to children in Rwanda
is comprised of three principal components: routine vaccination, supplemental
immunization activities, and surveillance for target diseases.

Table 5.2; Immunization schedule
NB: - It is necessary to respect the minimum interval of 28 days between 2 doses
of vaccines with multiples doses (DTP-HepB-Hib, OPV, Pneumo and Vaccine
Rotavirus).
It is strictly forbidden to administer another multi-dose vaccine before 28 days even
if the vaccination date coincides with weekends or public holidays.
For the HPV vaccine, 12-year-old adolescent girls should not receive the second
dose before 6 months from the first dose.
In Rwanda, the school approach has been chosen as the basic approach for
administering this vaccine, but 12-year-old girls who are out of school and those
who have not been privileged enough to receive the vaccine should benefit from it
at the health facility.
Vaccination for special cases: child who has never been in contact with the
vaccination service

Table 5.3: immunization schedule for special cases
NB: Systematically check the BCG scar in the child who presents for vaccination at
14 weeks, if no scar revaccinate.
For the premature baby, it is necessary to start the vaccination calendar right out of
the neonatology service.

Self-assessment 5.10
1. State the vaccines given at 6weeks
2. Explain how to administer BCG?
3. Explain how to administer MR vaccine at 9months and 15 months.
5.11 Behaviour change communication and social
mobilization
Learning activity 5.11

Communication of the key messages about immunization to a group
The community has a big role to play in making the decision to vaccinate the target
population.
An example of messages to pass on to parents during an immunization
session:
Every child needs to be protected against some vaccine-preventable diseases. Here
are the diseases that can be prevented by vaccination: Tuberculosis, Diphtheria,
Tetanus, Pertussis, Poliomyelitis, Measles, Rubella, Hepatitis B, a large proportion
of pneumonia, meningitis, severe diarrhoea with dehydration caused by rotavirus,
etc
The tetanus toxoid vaccine (VAT) for the pregnant woman protects the unborn baby.
Her mother needs two doses in the first pregnancy within 28 days, 6 months later
a third dose (VAT3), a year later a fourth dose (VAT4) and finally a year later a fifth
dose (VAT5). A mother, who has already received 5 doses of TT with the minimum
required interval between doses, is protected against tetanus for the rest of her
reproductive life and, as a result, will protect all the children who will be born from
her during the first month of their life against tetanus.
The immunization card is a very important tool for monitoring the health of the
child; it must be kept carefully and always present whenever the child reports to the
health worker.
4. Choose a method of communication that attracts the interest of the group:
storytelling, sketch, riddle, song, questions / answers, demonstration
5. Involve the group and Encourage parents to ask questions
• Against which disease is the child being vaccinated today?
• What are the possible side effects and how to do if they occur?
• What is the date of the next appointment?
• The need for the mother to keep the vaccination card
• Need to complete vaccination series
• How old is the child? (Check the date of birth of the child to determine if
the child is eligible for the rotavirus vaccine)
• I am giving your child vaccines: (quote them)
• They will help your child stay healthy
• The child may have fever and pain at the injection site. If the fever exceeds
two days, bring the child back to the nearest community health worker or
health facility.
• For measles, fever with a slight popular rash may appear within 6 to 12
days.
• For BCG, a small ulceration may develop followed by a scar and this in 1
to 2 months. If no scar within 3 months, bring the child back to revaccinate.
• Small health problems related to vaccination are much less serious than
if your child did not receive these vaccines.
• Bring your child back at 15 months old for reminder of measles vaccine.
• The need for the mother to keep the vaccination card.
1. Social mobilization
Social mobilization is the process of bringing together all possible inter-sectoral
partners and allies to participate in development programmes. It builds on the
contribution of technical experts, and emphasizes the capabilities and roles of
social allies and partners including community members. Social mobilisation aims
at empowering individuals and communities to identify their needs, their rights,
and their responsibilities, change their ideas and beliefs and organize the human,
material, financial and other resources required for socioeconomic development.
To lead a good social mobilization, the following factors are decisive:
• Obtain in due time a commitment from the politico-administrative
authorities (Cell and sector managers, mayors, ...)
• Solicit the participation of religious and community leaders (eg health
leaders, local elected officials ...). They usually know where, when, and
how to reach the population.
• Consider associations (Umugoroba w’ababyeyi, umuganda, Amarerero
(ECD), different clubs, etc.). They constitute a considerable resource on
knowledge of the local situation, and other diverse skills.
• Involve CHWs in the transmission of immunization messages at the
monthly meeting with CHWs and home visits.
• Make sure there is consistency in the contents of the messages.
Strategies to trace dropouts:
• Identify drop-outs and localise them in folders or vaccination register.
• Communicate the names of identified children to the community health worker
within their radius of action
• The community health worker, during home visits, retrieves these children
and brings them to the health center for immunization
• During the same visit, the community health worker registers newborns and
educates their mothers about their vaccination
• When monitoring children’s growth at the community level, the ASC should
check the immunization status of children and remind parents to respect
future appointments.
• Apply the vaccination policy to any contact : In case the mother brings her
child to the health center, ask him for a vaccination form, if the card is missing,
his mother receives an individual educational talk and vaccinate the child if
necessary or fix an appointement.
Preparation of the equipment for vaccination
i) Injection equipment and vaccines
• 5 ml syringes and needles to reconstitute RR vaccines
• 2 ml syringes and needles to reconstitute BCG.
• 0.5 ml auto-disable syringes for administration of DTP-HepB / Hib, RR,
vaccines, Pneumococcal-vaccine (PCV-13), Inactivated Polio Vaccine
(IPV), HPV and VAT vaccines
• 0.05ml BCG syringes
• The droppers for the polio vaccine and the rotarix vaccine if the dropper is
not incorporated in the bottle)
• Safety boxes (receptacles) and trash
• Cotton or gauze
• Prepare vaccines according to the expected target per session
• Clean water to clean the vaccine injection site (Never use alcohol or
disinfectants)
• Ice packs
• Vaccine carrier
• Freeze -Tags for monitoring the quality of vaccines
ii) Management tools and IEC materials
• Vaccination card (children, teenage girls aged 12 and pregnant women)
• Immunization registry for immunization of children, teenage girls aged 12
and pregnant women
• Calendar to determine dates of appointments (RDV)
• Scorecards for vaccination
• IEC message books
• Posters and brochures
iii)Other materials
• Tables, Chairs, Benches, Baby Scales, Panties, Height, MUAC, Scissors,
Kidney Basins, Pens, DVD and Television.
Stapes of a vaccination session
• Home
• Registration and Sorting
• Growth monitoring
• Group IEC
• Vaccination
To maintain the required temperature during the immunisation session :
• Open the vaccine carrier and place the vaccines on the clean table Vaccine
vials should never be placed on frozen ice packs during the immunization
session because some non-freezable vaccines may be frozen;
• Frozen accumulators must be thawed (packaged) before putting them in
vaccine carriers for vaccine transport
• Avoid taking the ice packs out of the vaccine carrier during the immunization
session; this may increase the temperature inside the vaccine carrier and
thus expose the vaccines to temperatures above + 8 ° C.
• Always keep the vaccine carrier in the shade and closed
Recommendations:
• When DTP-HepB-Hib, PCV-13, Rotarix and tetanus (VAT) vaccines are
kept at too low temperatures (ie below 0 ° C where they freeze), they can
no longer be considered as effective. They are damaged and must be
thrown away.
• Do not place hot accumulators next to the vaccines.
• Do not load multiple syringes with vaccines in advance before
administration.

Self-assessment 5.11
1. State at least four strategies to trace dropout
2. List materials needed during vaccination session
3. When DTP-HepB-Hib, PCV-13, Rotarix and tetanus (VAT) vaccines are
kept at too low temperatures (below 0 ° C where they freeze), what will
happen and what to do?
5.12 Vaccination cold chain
Learning activity 5.12

Observe the images below and reflect on it.
Cold chain is system for storing and transporting vaccines in a potent state (within
an acceptable temperature range) from the manufacturer to users.
The cold chain is the system used for keeping and distributing vaccines in good
conditions. It takes a chain of precisely coordinated events in temperature-controlled
environments to store, manage and transport these life-saving products.
Vaccines must be continuously stored in a limited temperature range from the
time they are manufactured until the moment of vaccination. This is because
temperatures that are too high or too low can cause the vaccine to lose its potency
(its ability to protect against disease). Once a vaccine loses its potency, it cannot
be regained or restored.
The cold chain guidelines recommend the following: the vaccine storage
should be maintained in the temperature range of 2–8°C, the use of
minimum/maximum thermometers, temperature charts, and the shake test.
The cold chain consists of a series of storage and transport links, all designed to
keep vaccines within an acceptable range until it reaches the user.
Vaccines are sensitive to heat and freezing and must be kept at the correct
temperature from the time they are manufactured until they are used.
The cold chain equipment
Different levels within the health care system need different equipment for
transporting and storing vaccines and diluents at the correct temperature.
• Primary vaccine stores: need cold or freezers rooms, freezers, refrigerators,
cold boxes and sometimes refrigerator trucks for transportation.
• Intermediate vaccine stores: depending on their size and capacity need cold
and freezer rooms, and/or freezers, refrigerators and cold boxes.
• Health facilities: need refrigerators with freezing compartments, cold boxes
and vaccine carriers.
Cold chain monitoring equipment
The purpose of cold chain monitoring equipment is to keep track of the temperature
to which vaccines and diluents are exposed during transportation and storage
The different monitors are: Vaccine vial monitors, Vaccine cold chain monitor
card, Thermometers and Freeze indicator
Vaccine Cold Chain Monitor Card
A vaccine cold chain monitor is a card with an indicator strip that changes the
colour when the vaccines are exposed to temperatures too high. The vaccine cold
chain card is used to estimate the length of time that vaccine has been exposed
to high temperatures. Manufacturers pack these monitors with vaccines supplied
by WHO and UNICEF.Usually used for large shipments of vaccines. Same card
should remain with same batch.
Maintaining cold boxes and vaccine carriers
Must be dried after their use. If left wet with closed lids, they become moldy and the
seal will be affected. Store them with the lid open when not used, if possible. Don’t
store them outside under the sunlight, it can cause cracks and reduce the efficiency
of the cold box.
WARNING:
• Never shake the bulbs (not to heat them),
• Never exceed the amount of solvent recommended for dilution of the vaccine
• Regularly use solvents from vaccines of the same manufacturer and same
period
• Avoid freezing vaccine diluents At the service delivery level, diluents should
be kept in refrigerators
• The dilution syringe and the dropper must be used for each vial.
• Use clean water when cleaning the vaccine injection site.
• Do not use the cold accumulators on the table during the immunization
session; they stay at the vaccine doors to keep the correct temperature.
• Read the expiry date of the vaccine on the vial.
• If the date is exceeded, discard the bottle. Similarly, if the label has fallen and
is not found, discard the bottle;
• For liquid vaccines: OPV, IPV, VAT, DTP-HepB-Hib, Pneumo, Rotavirus
Vaccine and HPV; It must be reassured that vaccines are not frozen before
administering them.
Administration of the vaccine:
To avoid suffocation, do not direct the vaccine to the bottom of the mouth (to the
throat); rather direct the vaccine to the cheeks (lateral of the mouth).This vaccine
should be administered orally to children aged 6-14 weeks for the 1st dose and
children 24 weeks or less for the remaining two doses with a minimum interval of 4
weeks between doses.
Caution: If, for some reason, an incomplete dose is administered (for example, the
child has spat or regurgitated part of the vaccine), replacement of the dose is not
indicated. The child

Self-assessment 5.12
1. List the different monitors used in cold chain monitoring
2. Use true or false
If, for some reason an incomplete dose is administered
(for example, the child has spat or regurgitated part of the vaccine).
a) Replacement of the dose is indicated.
b) replacement of the dose is not indicated.
c) Replace the dose next month.
d) Replace the dose after 1week.
3. The child who comes for vaccination suffering from …. Does not receive
oral vaccines.
a) Malaria
b) Headache
c) Diarrhoea
d) cough

who comes to the session suffering from diarrhea does not receive oral vaccines.
End Unit assessment 5
Multiple choice questions
1. Which statement defines Primary prevention?
a. Refers to the actions aimed for early detection and treatment of the
disease.
b. Refers to actions aimed at reducing the incidence of diseases in children
c. Simply means immunisation.
d. Refers to the actions aimed at sensitisation.
2. Which of the following statements that define (s) the immunization circle?
a. Refers to the process of becoming immune to the disease.
b. Refers to the process of getting vaccination.
c. Refers to the process of both getting the vaccine and becoming immune to
the disease following vaccination.
d. Refers to the action of vaccinating the population.
3. The increase in size, length, height and weight refers to one of the
following term.
a. Development
b. Growth
c. Cognitive milestone
d. Communication milestone
4. The improvement in the body functioning and behaviour refers also to one
of the following elements.
a. Development
b. Growth
c. Cognitive milestone
d. Communication milestone
5. One of the following principle refers to the fact that development (as well
as growth) always proceeds direc¬tionally from head to foot.
a. Integration
b. Individual difference
c. Interrelation
d. Cephalo-caudal
6. Choose the correct features that are associated with many genetic
syndromes that may cause mental retardation or learning disabilities. a)
Congenital anomalies
a. Congenital anomalies
b. Head circumference
c. Dermal Lesions of neuro-cutaneous Syndromes
d. Muscle tone problems
7. The Expanded Program on immunization (EPI) plans to vaccinate children
aged 0 to 15 months, against the following diseases except:
a. Tuberculosis
b. Polio,
c. Diabetes mellitus
d. Tetanus
8. One of these types of immunity results when exposure to a disease
organism triggers the immune system to produce antibodies to that
disease and this can be acquired through natural immunity or vaccineinduced immunity.
a. Passive immunity
b. Active Immunity
c. Innate immunity
d. Immunodeficiency
9. One of these types of immunity is provided when a person is given
antibodies to a disease rather than producing them through his or her
own immune system.
a. Passive immunity
b. Active Immunity
c. Innate immunity
d. Immunodeficiency
10. These are the preventive measures used to prevent the childhood
illnesses except:
a. Getting the vaccinations
b. Washing the hands regularly
c. Eat healthy and exercise regularly
d. Receiving the medication due to the disease that the child is suffering from.

SECTION B: SHORT ANSWER QUESTIONS AND TRUE OR FALSE
11. The combined vaccine against diphtheria, tetanus and pertussis
(whooping cough) and the vaccine against poliomyelitis cause sudden
infant death syndrome.
12. Vaccines have several damaging and long-term side-effects that are yet
unknown. Vaccination can even be fatal.
13. Better hygiene and sanitation will make diseases disappear and vaccines
are not necessary.
14. It is better to be immunized through disease than through vaccines.
15. It is necessary to take children for vaccination as it is the most useful way
of preventing childhood illnesses.
SHORT ANSWER QUESTIONS
16. Explain how do vaccines work?
17. State at list 5 activities to trace dropout of immunisation.
GROWTH MONITORING CHART BY WHO
UNIT6:CHILD HEALTH CARE
Key Unit Competence
Provide care to children
6.0 Introductory activity
6.1 Introduction to Integrated Management of Childhood
Illnesses (IMCI)
Learning activity 6.1
Children are not small adults and they face multiple diseases that affect their
health. In developing countries, there is a high burden of diseases affecting
under five children requiring early detection of those diseases and management.
Based on your clinical exposure and meeting patients of different ages, what
should be prioritized when managing sick young children in low resource
settings?
Since the 1970s, the estimated annual number of deaths among children less than
5 years old has decreased by almost a third. This reduction, however, has been
very uneven. And in some countries rates of childhood mortality are increasing.
In 1998, more than 50 countries still had childhood mortality rates of over 100 per
1000 live births. Altogether more than 10 million children die each year in developing
countries before they reach their fifth birthday. Seven in ten of these deaths are due
to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria,
or malnutrition and often to a combination of these conditions.
Limited supplies and equipment, combined with an irregular flow of patients,
leave health care providers at first-level facilities with few opportunities to practice
complicated clinical procedures. Instead, they must often rely on history and signs
and symptoms to determine a course of management that makes the best use of
available resources.
Providing quality care to sick children in these conditions is a serious challenge.
In response to this challenge, WHO and UNICEF developed a strategy known as
Integrated Management of Childhood Illness (IMCI). Although the major stimulus
for IMCI came from the needs of curative care, the strategy combines improved
management of childhood illness with aspects of nutrition, immunization, and other
important disease prevention and health promotion elements.
The objectives are to reduce deaths and the frequency and severity of illness and
disability and to contribute to improved growth and development.
Below are principles of IMCI:
• All sick young infants up to two months must be assessed for bacterial
infection/jaundice and major symptoms of diarrhea
• All sick children 2months to 5 years must be examined for general danger
signs which indicate the need for referral or admission to a hospital
• All young infants and child 2months-5years of age must be routinely assessed
for nutritional status and immunization status, feeding problems and
other potential problems.
Integrated Management of Childhood Illnesses (IMCI) is:
• not necessarily dependent on the use of sophisticated and expensive
technologies
• a more integrated approach to managing sick children
• move beyond addressing single diseases to addressing the overall health
and well-being of the child
• careful and systematic assessment of common symptoms and specific clinical
signs to guide rational and effective actions
• integrates management of most common childhood problems (pneumonia,
diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and
anemia, ear problems)
• includes preventive interventions
• adjusts curative interventions to the capacity and functions of the health
system (evidence-based syndromic approach)
• involves family members and the community in the health care process
Due to its appropriateness, the IMCI facilitates the accurate identification at
first contact, appropriate combined treatment of all major illnesses, speeds
–up referral of the severely ill child and improves the quality of care of sick
children at the first referral level.
Self- assessment activity 6
1. Describe three (3) principles of IMCI.
2. What are the major facilitators of IMCI in low resource settings?
6.2 Components of Integrated Management of Childhood
Illnesses (IMCI)
Learning activity 6.2
In your opinion, what should be the involvement of families and community
during the patient care?
Integrated Management of Childhood Illnesses (IMCI) is meant to move along the
two tracks of the health systems and community, respectively while promoting the
establishment of strong links between the two with much emphasis on capacity
building. Its aim is to reduce preventable mortality, minimize illness and disability
and promote healthy growth and development of children under 5 years of age.
To improve access and quality of care for newborns and children in primary health
care services, WHO and UNICEF designed the IMCI strategy.
IMCI is a strategy that has three components which are:
1. Improvements in the case-management skills of health staff through the
provision of locally adapted guidelines on IMCI and through activities to
promote their use
2. Improvements in the health system required for effective management of
childhood illness
3. Improvements in family and community practices
The aim is to strengthen prevention and management of common childhood illnesses
in the newborn period, and support children’s healthy growth and development.
6.2.1 Improvement health workers skills
This refers to clinical and communication skills and covers both pre-service
education and in-service training in the case management of sick children.
IMCI case management requires a well-defined set of knowledge and skills to
accurately assess, classify, and treat ill children and, thereby, reduce mortality
and reduce disabilities.
a. Case management process
The health worker assesses a child by checking first for danger signs, asking
questions about common conditions (cough or difficult breathing, diarrhea, fever, and
ear problems), examining the child, and checking the nutrition, immunization
status and assesses also the child for other health problems.
After classification, the health worker identifies specific treatments and develops
an integrated treatment plan for each child. If a child requires urgent referral, the
health worker gives essential treatment before the patient is transferred. If a child
needs treatment at home, the health worker gives the first dose of drugs to the child
The health worker provides practical treatment instructions, and advice on how to
give oral drugs, feeding, fluids during illness, how to treat local infections at home
and advises the caretaker on follow-up care to recognize signs that indicate that the
child should return immediately to the health facility.
If a child is underweight, provides counselling to solve feeding problems, including
assessment of breastfeeding practices and follow up on immunization schedule
and if necessary, reassesses the child for new problems.
b. Assessing danger signs in children using IMCI strategy
In IMCI all children are assessed for the following danger signs:
• lethargic or unconscious
• Convulsing now
• History of convulsions
• Vomiting everything.
• Not able to drink or breastfeed
If a child has any of these danger signs, he/she should be managed quickly and if
necessary refer after giving him/her pre- referral treatment.

c. Main symptoms
After the danger signs, children are then assessed for four main symptoms. These
are:
• Cough and difficult breathing
• Diarrhea
• Fever
• Ear problem
6.2.2 Improvement of health systems

Improving health systems to deliver IMCI concerns policy, planning and management,
financing, organization of work and distribution of tasks at health facilities, human
resources, availability of drugs and supplies, referral, monitoring and health
information system, supervision, evaluation and research. It is an umbrella which
covers human resources and their capacity.

6.2.3 Improvement of family and community practices

The community component of the Integrated Management of Childhood Illness
(IMCI) strategy addresses family and community child care practices. The family
and the community where children live play a major role in child health and
development. There is a longstanding need to involve the family and community
actively and plan and implement child care interventions in both the health system
and the community in parallel. There are 12 key family and community practices
related to child health and development, that if properly promoted and adopted by
the targeted communities, would potentially contribute to improving child survival,
growth and development.
These includes:
• Breastfeeding feeding: the baby should breastfeed exclusively for at least
up to 6 months to improve their immunity and reduce resistance to infection.
• Complementary feeding: From 6 months of age, other feeds may be
introduced like freshly prepared energy and nutrients rich complementary
foods combined with breastfeeding can be continued up to 2 years or longer.
• Micronutrients: Ensure that children receive adequate amounts of
micronutrients (vitamin A, iron and zinc, in particular).
• Hygiene: Children’s faeces should be properly disposed, and wash hands
after defecation before preparing meals and before feeding children.
• Immunization: children’s schedule of immunization should be respected
(complete a full course of immunizations example: BCG, DPT, OPV and
measles).
• Malaria: Protect children in malaria-endemic areas, by ensuring that they
sleep under insecticide-treated mosquito nets
• Psychosocial development. Promote mental and social development of
children and stimulating environment (talking, playing, dancing,)
• Home care for illness. Continue to feed and offer more fluids, including
breastmilk, to children when they are sick.
• Home treatment for infections. Give sick children appropriate home
treatment for infections.
• Care-seeking. Recognize when sick children need treatment outside the
home and seek care from appropriate providers.
• Compliance with advice. Follow the health worker’s advice about treatment,
follow-up and referral.
• Antenatal care. Ensure that every pregnant woman has adequate antenatal
care. This includes having at least four antenatal visits with an appropriate
health care provider and receiving the recommended doses of the tetanus
toxoid vaccination.
In addition, IMCI incorporates a strong component of prevention and health
promotion as an integral part of care. thus, among other benefits, it helps increase
vaccination coverage and improve knowledge and home-care practices for
children under five, subsequently contributing to growth and healthy development.
Key requirements for IMCI strategy

• The adoption of a national policy and standards on an integrated approach to
child health and development.
• Regular review and updating of IMCI clinical guidelines with adaptation to the
country’s epidemiology, medicines and commodities, relevant policies, and
local foods and language used by the population.
• Improving quality of care in primary health facilities by training, mentoring and
support supervision of health workers in integrated assessment, treatment
and effective counseling of caregivers.
• Ensuring availability of the essential medicines, laboratory tests and key
equipment for prevention and case management.
• Strengthening referral pathways and improving quality of care in hospitals for
management of severely ill children referred from the outpatient clinics.
• Empowering families and communities to prevent disease, seek timely care
from qualified health care providers for illness, provide adequate home care
for sick children, and support children’s healthy growth and development.

Three major determinants of effective implementation
• Political leadership to ensure an enabling environment
• Strengthened health systems based on empowerment, recognized, motivated,
supplied and supported frontline health workers
• Empowered communities that can hold systems accountable and utilize IMCI
services
Self- assessment activity 6.2
1. Mention three components of IMCI Strategy.
2. Discuss the major determinants of effective implementation of IMCI.
6.3 Specific assessment of children under five years
Learning activity 6.3

WHO have developed a series of IMCI charts which show the sequence of the steps
and provide information that will help to apply IMCI case management guidelines
according to the age of the child.
Describes how to assess and classify sick children so that signs of disease are not
overlooked. According to the chart, you should ask the mother about the child’s
problem and check the child for general danger signs. Then ask about the four main
symptoms: cough or difficult breathing, diarrhea, fever and ear problem. A child
who has one or more of the main symptoms could have a serious illness. When
a main symptom is present, ask additional questions to help classify the illness.
Check the child for malnutrition and anemia. Also check the child’s immunization
status and assess other problems the mother has mentioned.
6.3.1 Assess the child for danger signs
Record what the mother tells you about the child’s problems by using good
communication skills

Table 6.1: Classification of danger signs in children
Check ALL sick children for general danger signs. A general danger sign is present
if:
• the child is not able to drink or breastfeed
• the child vomits everything
• the child has had convulsions
• the child is lethargic or unconscious.
A child with a general danger sign has a serious problem. Most children with a
general danger sign need URGENT referral to hospital. They may need lifesaving
treatment with injectable antibiotics, oxygen or other treatments which may not be
available in health center.
Complete the rest of the assessment immediately.
When you check for general danger signs:
ASK: Is the child able to drink or breastfeed?
A child has the sign “not able to drink or breastfeed” if the child is not able to suck
or swallow when offered a drink or breastmilk
When you ask the mother if the child is able to drink, make sure that she understands
the question. If she says that the child is not able to drink or breastfeed, ask her to
describe what happens when she offers the child something to drink. For example,
is the child able to take fluid into his mouth and swallow it? If you are not sure about
the mother’s answer, ask her to offer the child a drink of clean water or breastmilk.
Look to see if the child is swallowing the water or breastmilk.
A child who is breastfed may have difficulty sucking when his nose is blocked. If the
child’s nose is blocked, clear it. If the child can breastfeed after his nose is cleared,
the child does not have the danger sign, “not able to drink or breastfeed.”
ASK: Does the child vomit everything?
A child who is not able to hold anything down at all has the sign “vomits everything.”
What goes down comes back up. A child who vomits everything will not be able to
hold down food, fluids or oral drugs. A child who vomits several times but can hold
down some fluids does not have this general danger sign.
When you ask the question, use words the mother understands. Give her time to
answer. If the mother is not sure if the child is vomiting everything, help her to make
her answer clear. For example, ask the mother how often the child vomits. Also
ask if each time the child swallows’ food or fluids, does the child vomit? If you are
not sure of the mother’s answers, ask her to offer the child a drink. See if the child
vomits.
ASK: Has the child had convulsions?
Ask the mother if the child has had convulsions during this current illness.
LOOK: See if the child is lethargic or unconscious.
A lethargic child is not awake and alert when he should be. He is drowsy and does
not show interest in what is happening around him. Often the lethargic child does
not look at his mother or watch your face when you talk. The child may stare blankly
and appear not to notice what is going on around him.
An unconscious child cannot be wakened. He does not respond when he is touched,
shaken or spoken to.
Ask the mother if the child seems unusually sleepy or if she cannot wake the child.
Look to see if the child wakens when the mother talks or shakes the child or when
you clap your hands.
Note: If the child is sleeping and has cough or difficult breathing, count the number
of breaths first before you try to wake the child.
If the child has a general danger sign, complete the rest of the assessment
immediately. This child has a severe problem. There must be no delay in his
treatment
6.3.2 Assess the child for main symptoms
Ask the mother about the four main symptoms: cough or difficulty in breathing,
diarrhea, fever and ear problems.
a. COUGH OR DIFFICULT IN BREATHING
Respiratory infections can occur in any part of the respiratory tract such as the
nose, throat, larynx, trachea, air passages or lungs. A child with cough or difficult
breathing may have pneumonia or another severe respiratory infection. Pneumonia
is an infection of the lungs. Both bacteria and viruses can cause pneumonia. In
developing countries, pneumonia is often due to bacteria. The most common are
Streptococcus pneumoniae and Hemophilus influenzae. Children with bacterial
pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).
There are many children who come to the health center with less serious respiratory
infections. Most children with cough or difficult breathing have only a mild infection.
For example, a child who has a cold may cough because nasal discharge drips
down the back of the throat. Or, the child may have a viral infection of the bronchi
called bronchitis. These children are not seriously ill. They do not need treatment
with antibiotics. Their families can treat them at home.
Health care providers need to identify the few, very sick children with cough or
difficult breathing who need treatment with antibiotics. checking for these two
clinical signs: fast breathing and chest indrawing.
When children develop pneumonia, their lungs become stiff. One of the body’s
responses to stiff lungs and hypoxia (too little oxygen) is fast breathing.
When the pneumonia becomes more severe, the lungs become even stiffer. Chest
indrawing may develop. Chest indrawing is a sign of severe pneumonia.
ASSESS COUGH OR DIFFICULT BREATHING
A child with cough or difficult breathing is assessed for:
How long the child has had cough or difficult breathing?
• Fast breathing
• Chest indrawing
• Stridor in a calm child.
STEPS FOR ASSESSING A CHILD FOR COUGH OR DIFFICULT BREATHING
For ALL sick children, ask about cough or difficult breathing.
ASK: Does the child have cough or difficult breathing?
“Difficult breathing” is any unusual pattern of breathing. Mothers describe this
in different ways. They may say that their child’s breathing is “fast” or “noisy” or
“interrupted.”
If the mother answers NO, look to see if you think the child has cough or difficult
breathing. If the child does not have cough or difficult breathing, ask about the next
main symptom, diarrhea. Do not assess the child further for signs related to cough
or difficult breathing.

If the mother answers YES, ask the next question.
ASK: For how long?
A child who has had cough or difficult breathing for more than 30 days has a chronic
cough. This may be a sign of tuberculosis, asthma, whooping cough or another
problem.
COUNT the breaths in one minute.
Normal breathing rates are higher in children age 2 months up to 12 months than
in children age 12 months up to 5 years. For this reason, the cut-off for identifying
fast breathing is higher in children 2 months up to 12 months than in children age
12 months up to 5 years

Note: The child who is exactly 12 months old has fast breathing if you count 40
breaths per minute or more.
LOOK for chest indrawing.

For chest indrawing to be present, it must be clearly visible and present all the
time. If you only see chest indrawing when the child is crying or feeding, the child
does not have chest indrawing. Any chest indrawing, even if it is not severe, is an
indicator of severe pneumonia in a child age 2 months up to 5 years
LOOK and LISTEN for stridor.
Stridor is a harsh noise made when the child breathes IN. Stridor happens when
there is a swelling of the larynx, trachea or epiglottis. This swelling interferes with
air entering the lungs. It can be life-threatening when the swelling causes the child’s
airway to be blocked. A child who has stridor when calm has a dangerous condition.
To look and listen for stridor, look to see when the child breathes IN. Then listen for
stridor. Put your ear near the child’s mouth because stridor can be difficult to hear.
Sometimes you will hear a wet noise if the nose is blocked. Clear the nose, and
listen again. A child who is not very ill may have stridor only when he is crying or
upset. Be sure to look and listen for stridor when the child is calm.
You may hear a wheezing noise when the child breathes OUT. This is not stridor.
b. DIARRHEA
Diarrhea is passage of frequent loose or watery stools. Mothers usually know when
their children have diarrhea. Diarrhea is common in children especially in those
between 6 months and 2 years of age. It is more common in children under 6
months who are drinking cow’s milk or infant feeding formulas more so if they are
bottle-fed.
Frequent passing of normal stool is not diarrhea. The number of stools normally
passed in a day varies with the diet and age of the child. In many regions’ diarrhea
is defined as 3 or more loose or watery stools in a 24-hour period.
What are the Types of Diarrhea?
Most diarrheas which cause dehydration are loose or watery. If an episode of
diarrhea lasts less than 14 days, it is acute diarrhea. Acute watery diarrhea causes
dehydration and contributes to malnutrition. The death of an infant with acute
diarrhea is usually due to dehydration.
If the diarrhea lasts 14 days or more, it is persistent diarrhea. Up to 20% of episodes
of diarrhea become persistent. Persistent diarrhea often causes nutritional problems
and contributes to deaths in children.
Diarrhea with blood in the stool, with or without mucus, is called dysentery. The
most common cause of dysentery is Shigella bacteria. Amoebic dysentery is not
common in young children.
ASSESS DIARRHOEA
A child with diarrhea is assessed for:
• how long the child has had diarrhea
• blood in the stool to determine if the child has dysentery, and for
• signs of dehydration.
Ask about diarrhea in ALL children:
ASK: Does the child have diarrhea?
If the mother answers NO, ask about the next main symptom, fever. You do not
need to assess the child further for signs related to diarrhea.
If the mother answers YES, or if the mother said earlier that diarrhea was the
reason for coming to the clinic, record her answer. Then assess the child for signs
of dehydration, persistent diarrhea and dysentery.
ASK: For how long?
Diarrhea which lasts 14 days or more is persistent diarrhea. Give the mother time
to answer the question. She may need time to recall the exact number of days.
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 diarrhea. Next, check for signs of dehydration.
LOOK and FEEL for the following signs:
LOOK at the child’s general condition. Is the child lethargic or unconscious?
restless and irritable?
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 diarrhea. Look to see if the child is restless and irritable.
LOOK for sunken eyes.
Note: In a severely malnourished child who is visibly wasted (that is, who has
marasmus), the eyes may always look sunken, even if the child is not dehydrated.
Even though sunken eyes is less reliable in a visibly wasted child, still use the sign
to classify the child’s dehydration.
OFFER the child fluid. Is the child not able to drink or drinking poorly?
drinking eagerly, thirsty?
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, 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.”
PINCH the skin of the abdomen. Does it go back: Very slowly (longer than 2
seconds)? Slowly?
Note: In a child with marasmus (severe malnutrition), the skin may go back slowly
even if the child is not dehydrated. In an overweight child, or a child with edema,
the skin may go back immediately even if the child is dehydrated. Even though skin
pinch is less reliable in these children, still use it to classify the child’s dehydration.
c. FEVER
A child with fever may have malaria, measles or another severe disease. Or, a child
with fever may have a simple cough or cold or other viral infection.
MALARIA
Malaria is caused by four species of plasmodia transmitted through the bite of a
female anopheles’ mosquitoes, the dangerous one being Plasmodium falciparum.
The most common species is Plasmodium vivax. Fever is the main symptom of
malaria. It can be present all the time or go away and return at regular intervals.
Other signs of malaria are shivering, sweating and vomiting. Signs of malaria can
overlap with signs of other illnesses. For example, a child may have malaria and
cough with fast breathing, a sign of pneumonia. This child needs treatment for both
falciparum malaria and pneumonia. Children with malaria may also have diarrhea.
They need an antimalarial and treatment for the diarrhea.
In areas with very high malaria transmission, malaria is a major cause of death
in children. A case of uncomplicated malaria can develop into severe malaria as
soon as 24 hours after the fever first appears. Severe malaria is malaria with
complications such as cerebral malaria or severe anemia. The child can die if he
does not receive urgent treatment.
Deciding Malaria Risk: To classify and treat children with fever, you must know
the malaria risk in your area. The National Anti-Malaria Program classifies areas as
high or low malaria risk areas.
MEASLES: Fever and a generalized rash are the main signs of measles. Measles
is highly infectious. Maternal antibody protects young infants against measles for
about 6 months. Then the protection gradually disappears. Most cases occur in
children between 6 months and 2 years of age. Overcrowding and poor housing
increase the risk of measles occurring early.
Measles is caused by a virus. It infects the skin and the layer of cells that line the
lung, gut, eye, mouth and throat. The measles virus damages the immune system
for many weeks after the onset of measles. This leaves the child at risk for other
infections.
Complications of measles occur in about 30% of all cases.
• diarrhea (including dysentery and persistent diarrhea)
• pneumonia
• stridor
• mouth ulcers
• ear infection and
• severe eye infection (which may lead to corneal ulceration and blindness).
Encephalitis occurs in about one in one thousand cases. A child with encephalitis
may have general danger sign such as convulsions or lethargic or unconscious.
Measles contributes to malnutrition because it causes diarrhea, high fever and
mouth ulcers. These problems interfere with feeding. Malnourished children are
more likely to have severe complications due to measles. This is especially true for
children who are deficient in vitamin A. One in ten severely malnourished children
with measles may die. For this reason, it is very important to help the mother to
continue to feed her child during measles.

ASSESS FEVER
Decide the malaria risk (high or low).
Then assess a child with fever for:
• how long the child has had fever
• history of measles
• stiff neck
• bulging fontanelle
• runny nose
• signs suggesting measles -- which are generalized rash and one of these:
cough, runny nose, or red eyes.
• if the child has measles now or within the last 3 months, assess for signs of
measles complications which are: mouth ulcers, pus draining from the eye
and clouding of the cornea.
ASK: Does the child have fever?

Check to see if the child has a history of fever, feels hot or has a temperature of
37.5o or above.
The child has a history of fever if the child has had any fever with this illness. Use
words for “fever” that the mother understands. Make sure the mother understands
what fever is. For example, ask the mother if the child’s body has felt hot. Feel the
child’s abdomen or axilla and determine if the child feels hot.
Look to see if the child’s temperature was measured today and recorded on the
child’s chart. If the child has a temperature of 37.5oC or above, the child has fever.
If the child’s temperature has not been measured, and you have a thermometer,
measure the child’s temperature.

If the child does not have fever (by history, feels hot or temperature 37.5oC or
above), ask about the next main symptom, ear problem.
If the child has fever (by history, feels hot or temperature 37.5oC or above), assess
the child for additional signs related to fever. Assess the child’s fever even if the
child does not have a temperature of 37.5oC or above or does not feel hot now.
History of fever is enough to assess the child for fever
DECIDE Malaria Risk: high or low
Decide if the malaria risk is high or low. You will use this information when you
classify the child’s fever.
ASK: For how long? If more than 7 days, has fever been present every day?

Ask the mother how long the child has had fever. If the fever has been present for
more than 7 days, ask if the fever has been present every day

Most fevers due to viral illnesses go away within a few days. A fever which has been
present every day for more than 7 days can mean that the child has a more severe
disease such as typhoid fever. Refer this child for further assessment.
ASK: Has the child had measles within the last 3 months?
Measles damages the child’s immune system and leaves the child at risk for other
infections for many weeks.
A child with fever and a history of measles within the last 3 months may have an
infection due to complications of measles such as an eye infection.
LOOK or FEEL for stiff neck.
A child with fever and stiff neck may have meningitis. A child with meningitis needs
urgent treatment with injectable antibiotics and referral to a hospital.
While you talk with the mother during the assessment, look to see if the child moves
and bends his neck easily as he looks around. If the child is moving and bending his
neck, he does not have a stiff neck.
Figure 6.2: Assessing for neck stiffness
If you did not see any movement, or if you are not sure, draw the child’s attention
to his umbilicus or toes. For example, you can shine a flashlight on his toes or
umbilicus or tickle his toes to encourage the child to look down. Look to see if the
child can bend his neck when he looks down at his umbilicus or toes.
If you still have not seen the child bend his neck himself, ask the mother to help you
lie the child on his back. Lean over the child, gently support his back and shoulders
with one hand. With the other hand, hold his head. Then carefully bend the head
forward toward his chest. If the neck bends easily, the child does not have stiff neck.
If the neck feels stiff and there is resistance to bending, the child has a stiff neck.
Often a child with a stiff neck will cry when you try to bend the neck.
FEEL for bulging fontanelle
The fontanelle is open for most of the period of infancy before it is closed by the
growth of the surrounding bones. If the fontanelle is open, feel for bulging fontanelle
just as you did for young infants.
LOOK for runny nose.
A runny nose in a child with fever may mean that the child has a common cold. If
the child has a runny nose, ask the mother if the child has had a runny nose only
with this illness. If she is not sure, ask questions to find out if it is an acute or chronic
runny nose.
When malaria risk is low, a child with fever and a runny nose does not need an
antimalarial. This child’s fever is probably due to the common cold.
LOOK for signs suggesting MEASLES.
Assess a child with fever to see if there are signs suggesting measles. Look for a
generalized rash and for one of the following signs: cough, runny nose, or red eyes.
Generalized rash
In measles, a red rash begins behind the ears and on the neck. It spreads to the
face. During the next day, the rash spreads to the rest of the body, arms and legs.
After 4 to 5 days, the rash starts to fade and the skin may peel. Some children
with severe infection may have more rash spread over more of the body. The rash
becomes more discolored (dark brown or blackish), and there is more peeling of
the skin.
A measles rash does not have vesicles (blisters) or pustules. The rash does
not itch. Do not confuse measles with other common childhood rashes such as
chicken pox, scabies or heat rash. (The chicken pox rash is a generalized rash with
vesicles. Scabies occurs on the hands, feet, ankles, elbows, buttocks and axilla.
It also itches. Heat rash can be a generalized rash with small bumps and vesicles
which itch. A child with heat rash is not sick.) You can recognize measles more
easily during times when other cases of measles are occurring in your community.
Cough, Runny Nose, or Red Eyes
To classify a child as having measles, the child with fever must have a generalized
rash AND one of the following signs: cough, runny nose, or red eyes. The child has
“red eyes” if there is redness in the white part of the eye. In a healthy eye, the white
part of the eye is clearly white and not discolored.
If the child has MEASLES now or within the last 3 months: Look to see if the
child has mouth or eye complications. Other complications of measles such as
stridor in a calm child, pneumonia, and diarrhea are assessed earlier; malnutrition
and ear infection are assessed later.
LOOK for mouth ulcers. Are they deep and extensive?

Look inside the child’s mouth for mouth ulcers. Ulcers are painful open sores on the
inside of the mouth and lips or the tongue. They may be red or have white coating
on them. In severe cases, they are deep and extensive. When present, mouth
ulcers make it difficult for the child with measles to drink or eat.
Mouth ulcers are different than the small spots called Koplik spots. Koplik spots
occur in the mouth inside the cheek during early stages of the measles infection.
Koplik spots are small, irregular, bright red spots with a white spot in the center.
They do not interfere with drinking or eating. They do not need treatment.

LOOK for pus draining from the eye.
Pus draining from the eye is a sign of conjunctivitis. Conjunctivitis is an infection
of the conjunctiva, the inside surface of the eyelid and the white part of the eye. If
you do not see pus draining from the eye, look for pus on the conjunctiva or on the
eyelids.
Often the pus forms a crust when the child is sleeping and seals the eye shut. It can
be gently opened with clean hands. Wash your hands after examining the eye of
any child with pus draining from the eye.

LOOK for clouding of the cornea.

The cornea is usually clear. When clouding of the cornea is present, there is a
hazy area in the cornea. Look carefully at the cornea for clouding. The cornea may
appear clouded or hazy. The clouding may occur in one or both eyes.
Corneal clouding is a dangerous condition. The corneal clouding may be due
to vitamin A deficiency which has been made worse by measles. If the corneal
clouding is not treated, the cornea can ulcerate and cause blindness. A child with
clouding of the cornea needs urgent treatment with vitamin A.
A child with corneal clouding may keep his eyes tightly shut when exposed to light.
The light may cause irritation and pain to the child’s eyes. To check the child’s eye,
wait for the child to open his eye. Or, gently pull down the lower eyelid to look for
clouding.
If there is clouding of the cornea, ask the mother how long the clouding has been
present. If the mother is certain that clouding has been there for some time, ask if
the clouding has already been assessed and treated at the hospital. If it has, you
do not need to refer this child again for corneal clouding.
d. EAR PROBLEMS
A child with an ear problem may have an ear infection.
When a child has an ear infection, pus collects behind the ear drum and causes
pain and often fever. If the infection is not treated, the ear drum may burst. The
pus discharges, and the child feels less pain. The fever and other symptoms may
stop, but the child suffers from poor hearing because the ear drum has a hole in it.
Usually the ear drum heals by itself. At other times the discharge continues, the ear
drum does not heal, and the child becomes deaf in that ear.
Sometimes the infection can spread from the ear to the bone behind the ear (the
mastoid) causing mastoiditis. Infection can also spread from the ear to the brain
causing meningitis. These are severe diseases. They need urgent attention and
referral.
Ear infections rarely cause death. However, they cause many days of illness in
children. Ear infections are the main cause of deafness in developing countries,
and deafness causes learning problems in school. The ASSESS & CLASSIFY
chart helps you identify ear problems due to ear infection.
ASSESS EAR PROBLEM
A child with ear problem is assessed for:
• ear pain
• ear discharge and
• if discharge is present, how long the child has had discharge, and
• tender swelling behind the ear, a sign of mastoiditis.
ASK: Does the child have an ear problem?
If the mother answers NO, record her answer. Do not assess the child for ear
problem. Then check for malnutrition and anaemia.
If the mother answers YES, ask the next question:
ASK: Does the child have ear pain?
Ear pain can mean that the child has an ear infection. If the mother is not sure that
the child has ear pain, ask if the child has been irritable and rubbing his ear.
ASK: Is there ear discharge? If yes, for how long?
Ear discharge is also a sign of infection. When asking about ear discharge, use
words the mother understands.
If the child has had ear discharge, ask for how long. Give her time to answer the
question. She may need to remember when the discharge started.
You will classify and treat the ear problem depending on how long the ear discharge
has been present.
• An ear discharge that has been present for 2 weeks or more is treated as a
chronic ear infection. An ear discharge that has been present for less than 2
weeks is treated as an acute ear infection.
You do not need more accurate information about how long the discharge has been
present.
LOOK for pus draining from the ear.
Pus draining from the ear is a sign of infection, even if the child no longer has any
pain. Look inside the child’s ear to see if pus is draining from the ear.
FEEL for tender swelling behind the ear.
Feel behind both ears. Compare them and decide if there is tender swelling of the
mastoid bone. In infants, the swelling may be above the ear.
Both tenderness and swelling must be present to classify mastoiditis, a deep
infection in the mastoid bone. Do not confuse this swelling of the bone with swollen
lymph nodes.
Self- assessment activity 6.3
1. Enumerate three danger signs that a child may present using IMCI
Strategy.
2. What are the four main symptoms assessed using IMCI Strategy?
6.4. General assessment of children under five years
Learning activity 6.4

When the main symptom is present, assess the child further for signs related to
main symptom and classify the illness according to the signs which are present or
absent.
Check for signs of malnutrition and anemia and classify the child’s nutritional
status.
Check HIV status and classify, check the child’s immunization status and decide
if the child needs any immunizations and assess any other problems.
6.4.1 Check for malnutrition
Check all sick children for signs suggesting malnutrition.
A mother may bring her child to clinic because the child has an acute illness. The
child may not have specific complaints that point to malnutrition. A sick child can be
malnourished, but the doctor or the child’s family may not notice the problem.
A child with malnutrition has a higher risk of many types of disease and death. Even
children with mild and moderate malnutrition have an increased risk of death.
Identifying children with malnutrition and treating them can help prevent many
severe diseases and death. Some malnutrition cases can be treated at home.
Severe cases need referral to hospital for special feeding or specific treatment of a
disease contributing to malnutrition (such as tuberculosis).
Causes of Malnutrition: There are several causes of malnutrition. They may vary
from country to country. One type of malnutrition is protein-energy malnutrition.
Protein-energy malnutrition develops when the child is not getting enough energy
or protein from his food to meet his nutritional needs. A child who has had frequent
illnesses can also develop protein- energy malnutrition. The child’s appetite
decreases, and the food that the child eats is not used efficiently. When the child
has protein-energy malnutrition:
• The child may become severely wasted, a sign of marasmus.
• The child may develop oedema, a sign of kwashiorkor.
• The child may not grow well and become stunted (too short).
A child whose diet lacks recommended amounts of essential vitamins and
minerals can develop malnutrition. The child may not be eating enough of the
recommended amounts of specific vitamins (such as vitamin A) or minerals (such
as iron). Not eating foods that contain vitamin A can result in vitamin A deficiency. A
child with vitamin A deficiency is at risk of death from measles and diarrhoea. The
child is also at risk of blindness.
ASSESS FOR MALNUTRITION
LOOK for visible severe wasting.
A child with visible severe wasting has marasmus, a form of severe malnutrition. A
child has this sign if he is very thin, has no fat, and looks like skin and bones. Some
children are thin but do not have visible severe wasting.
To look for visible severe wasting, remove the child’s clothes. Look for severe
wasting of the muscles of the shoulders, arms, buttocks and legs. Look to see if
the outline of the child’s ribs is easily seen. Look at the child’s hips. They may look
small when you compare them with the chest and abdomen. Look at the child from
the side to see if the fat of the buttocks is missing. When wasting is extreme, there
are many folds of skin on the buttocks and thigh. It looks as if the child is wearing
baggy pants.

The face of a child with visible severe wasting may still look normal. The child’s
abdomen may be large or distended.
LOOK and FEEL for oedema of both feet
A child with oedema of both feet may have kwashiorkor, another form of severe
malnutrition. Oedema is when an unusually large amount of fluid gathers in the
child’s tissues. The tissues become filled with the fluid and look swollen or puffed
up.
Look and feel to determine if the child has oedema of both feet. Use your thumb to
press gently for a few seconds on the top side of each foot. The child has oedema
if a dent remains in the child’s foot when you lift your thumb.
Determine weight for age.
Determine the weight for age as you did for the young infant. See separate WHO
growth charts for boys and girls. Decide if the point is above, on, or below the bottom
curve.
• If the point is below the bottom curve, the child is severely underweight for
age.
• If the point is above or on the -3 SD line (bottom line), the child is not severely
underweight.
• If the point is above or on the bottom curve, but below -2 SD line, the child is
moderately underweight for age.
• If the point is above or on the -2 SD line, the child is not moderately underweight.
EXAMPLE: A male child is 26 months old and weighs 8.0 kilograms. Determine the
child’s weight for age and plot on the growth chart. See the response on the chart
below
Figure 6.4: WHO weight for age chart
6.4.2 Check for anaemia
Check all sick children for signs suggesting anaemia.
A mother may bring her child to clinic because the child has an acute illness. The
child may not have specific complaints that point to anaemia. Most children with
anaemia can be treated at home. Severe cases need referral to hospital for blood
transfusion.
Causes of Anaemia: Not eating foods rich in iron can lead to iron deficiency
and anaemia. Anaemia is a reduced number of red cells or a reduced amount of
haemoglobin in each red cell. A child can also develop anaemia as a result of:
• Infections
• Parasites such as hookworm or whipworm. They can cause blood loss from
the gut and lead to anaemia.
• Malaria which can destroy red cells rapidly. Children can develop anaemia if
they have had repeated episodes of malaria or if the malaria was inadequately
treated.
The anaemia may develop slowly. Often, anaemia in these children is due to both
malnutrition and malaria.
ASSESS FOR ANAEMIA
Here is the box from the “Assess” column on the ASSESS & CLASSIFY chart. It
describes how to assess a child for malnutrition and anaemia.

LOOK for palmar pallor.

Pallor is unusual paleness of the skin. It is a sign of anaemia.
To see if the child has palmar pallor, look at the skin of the child’s palm. Hold the
child’s palm open by grasping it gently from the side. Do not stretch the fingers
backwards. This may cause pallor by blocking the blood supply.

6.4.3 Check the child’s immunization, prophylactic vitamin a &
iron-folic acid supplementation status

Immunization, prophylactic vitamin A and iron-folic acid supplementation status
should be assessed in ALL sick children.
CHECK THE CHILD’S IMMUNIZATION STATUS
Check the immunization status for ALL sick children. Have they received all the
immunizations recommended for their age? Do they need any immunizations
today?
Use the National Recommended Immunization Schedule when you check the
child’s immunization status. Look at the ASSESS & CLASSIFY chart and locate
the recommended immunization schedule. Refer to it as you read how to check a
child’s immunization status.
Give the recommended vaccine when the child is the appropriate age for each
dose. All children should receive all the recommended immunizations before their
first birthday. If the child does not come for an immunization at the recommended
age, give the necessary immunizations any time after the child reaches that age.
Give the remaining doses at least 4 weeks apart. You do not need to repeat the
whole schedule.
CHECK THE CHILD’S PROPHYLACTIC VITAMIN A SUPPLEMENTATION STATUS
Vitamin A is an essential micronutrient and is necessary for vision, integrity of
membrane structures, the normal functioning of body cells, growth and development.
A child with vitamin A deficiency is at a risk of death from measles and diarrhea.
The child is also at risk of blindness. The National Vitamin A Prophylaxis Program
recommends 9 doses of vitamin A at 9, 18, 24, 30, 36, 42, 48, 54 and 60 months
of age

Give the recommended dose of vitamin A when the child is the appropriate age for
each dose. In case a child more than 9 months of age has not received a dose of
vitamin A in last 6 months, give a dose as per the dosage schedule according to
age of the child.
CHECK THE CHILD’S PROPHYLACTIC IRON-FOLIC ACID SUPPLEMENTATION
STATUS
Anaemia is a reduced number of red cells or a reduced amount of haemoglobin in
each red cell. Not eating foods rich in iron can lead to iron deficiency and anaemia.
A child can also develop anaemia as a result of various systemic infections,
malaria, or infestation with hookworm or whipworm. Prophylactic supplementation
of iron folic acid for 100 days in a year is recommended under the National Anaemia
Prophylaxis Programme.
6.4.4 Assess children for HIV
HIV testing is RECOMMENDED for all children with unknown HIV status especially
those to HIV-positive mothers.
Since the ASSESS & CLASSIFY chart does not address all of a sick child’s problems,
you will now assess other problems the mother told you about. For example, she
may have said the child has a skin infection, itching or swollen neck glands. Or you
may have observed another problem during the assessment. Identify and treat any
other problems according to your training, experience and clinic policy. Refer the
child for any other problem you cannot manage in clinic.
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after
first dose of an appropriate antibiotic and other urgent treatments.
EXCEPTION: Rehydration of the child according to Plan C may resolve danger
signs so that referral is no longer needed.
This note reminds you that a child with any general danger sign needs urgent
treatment and referral. It is possible, though uncommon, that a child may have a
general danger sign, but may not have a severe classification for any of the main
symptoms.
Self-assessment 6.4
1. If a child has pallor of the palms when performing your assessment, what
does it indicate.
2. In a table format, describe the Rwanda national immunisation calendar.
6.5 Assessment of children aged below 2 months
Learning activity 6.5
A 20 days’ sick infant is brought to the health post by her mother complaining for
inability to breastfeed and change of the infant’s skin colour. From your previous
knowledge and experiences, what questions would you ask the mother to explore
more the problem?
For all sick young infants aged below 2 months, they must be checked for possible
bacterial infection/jaundice, feeding problems, immunization status and verify if the
infant has diarrhea. Mothers are to be taught how to keep their infant warm, teach
correct position and encourage for exclusive breastfeeding, advise on home care
of young infant, recognition of illness in newborn, appropriate referral, and advice
mother to return immediately if danger signs present.
Ask the mother what the young infant’s problems are. Determine if this is an initial
or follow-up visit for these problems. If this is a follow-up visit, you should manage
the infant according to the special instructions for a follow-up visit as found in IMCI
charts of assessment and management.
SUMMARY OF “ASSESS AND CLASSIFY”

Young infants have special characteristics that must be considered when classifying
their illnesses. They can become sick and die very quickly from serious bacterial
infections. They frequently have only general signs such as few movements, fever,
or low body temperature. Mild chest indrawing is normal in young infants because
their chest wall is soft.
The chart is not used for a sick newborn, that is a young infant who is less
than 1 week of age. In the first week of life, newborn infants are often sick from
conditions related to labour and delivery, or have conditions which require special
management. Newborns may be suffering from asphyxia, sepsis from premature
ruptured membranes or other intrauterine infection, or birth trauma. Or they may
have trouble breathing due to immature lungs. Jaundice also requires special
management in the first week of life. For all these reasons, management of a sick
newborn is somewhat different from caring for a young infant age 1 week up to 2
months.
The steps for assessing and caring for a sick young infant are:
• Check for signs of possible bacterial infection. Then classify the young infant
based on the clinical signs found.
• Ask about diarrhoea. If the infant has diarrhoea, assess for related signs.
Classify the young infant for dehydration. Also classify for persistent diarrhoea
and dysentery if present.
• Check for feeding problem or low weight. This may include assessing
breastfeeding. Then classify feeding.
• Check the young infant’s immunization status.
• Assess any other problems.
If you find a reason that a young infant needs urgent referral, you should continue
the assessment.
6.5.1. How to check a young infant for possible bacterial
infection

Table 6.5: Checking for bacterial infection in children
This assessment step is done for every sick young infant. In this step you are
looking for signs of bacterial infection, especially a serious infection. A young infant
can become sick and die very quickly from serious bacterial infections such as
pneumonia, sepsis and meningitis.
It is important to assess the signs in the order on the chart, and to keep the young
infant calm. The young infant must be calm and may be asleep while you assess
the first four signs, that is, count breathing and look for chest indrawing, nasal
flaring and grunting.
To assess the next few signs, you will pick up the infant and then undress him,
look at the skin all over his body and measure his temperature. By this time, he will
probably be awake. Then you can see if he is lethargic or unconscious and observe
his movements.
Check for possible bacterial infection in ALL young infants.
ASK: HAS THE INFANT HAD CONVULSIONS?
Ask the mother this question.
LOOK: COUNT THE BREATHS IN ONE MINUTE. REPEAT THE COUNT IF
ELEVATED
Count the breathing rate as you would in an older infant or young child. Young infants
usually breathe faster than older infants and young children. The breathing rate of a
healthy young infant is commonly more than 50 breaths per minute. Therefore, 60
breaths per minute or more is the cut off used to identify fast breathing in a young
infant.
If the first count is 60 breaths or more, repeat the count. This is important because the
breathing rate of a young infant is often irregular. The young infant will occasionally
stop breathing for a few seconds, followed by a period of faster breathing. If the
second count is also 60 breaths or more, the young infant has fast breathing.
LOOK FOR SEVERE CHEST INDRAWING
Look for chest indrawing as you would look for chest indrawing in an older infant
or young child. However, mild chest indrawing is normal in a young infant because
the chest wall is soft. Severe chest indrawing is very deep and easy to see. Severe
chest indrawing is a sign of pneumonia and is serious in a young infant.
LOOK FOR NASAL FLARING

LOOK AND LISTEN FOR GRUNTING
Grunting is the soft, short sounds a young infant makes when breathing out.
Grunting occurs when an infant is having trouble breathing.
LOOK AND FEEL FOR BULGING FONTANELLE
The fontanelle is the soft spot on the top of the young infant’s head, where the
bones of the head have not formed completely. Hold the young infant in an upright
position. The infant must not be crying. Then look at and feel the fontanelle. If the
fontanelle is bulging rather than flat, this may mean the young infant has meningitis.
LOOK FOR PUS DRAINING FROM THE EAR
Pus draining from the ear is a sign of infection. Look inside the infant’s ear to see if
pus is draining from the ear.
LOOK AT THE UMBILICUS—IS IT RED OR DRAINING PUS? DOES THE
REDNESS EXTEND TO THE SKIN?
There may be some redness of the end of the umbilicus or the umbilicus may be
draining pus. (The cord usually drops from the umbilicus by one week of age.)
How far down the umbilicus the redness extends determines the severity of the
infection? If the redness extends to the skin of the abdominal wall, it is a serious
infection.
FEEL: MEASURE TEMPERATURE (OR FEEL FOR FEVER OR LOW BODY
TEMPERATURE)
Fever (axillary temperature more than 37.5 °C or rectal temperature more than 38
°C) is uncommon in the first two months of life. If a young infant has fever, this may
mean the infant has a serious bacterial infection. In addition, fever may be the only
sign of a serious bacterial infection. Young infants can also respond to infection by
dropping their body temperature to below 35.5 °C (36 °C rectal temperature). Low
body temperature is called hypothermia. If you do not have a thermometer, feel the
infant’s stomach or axilla (underarm) and determine if it feels hot or unusually cool.
LOOK FOR SKIN PUSTULES. ARE THERE MANY OR SEVERE PUSTULES?
Examine the skin on the entire body. Skin pustules are red spots or blisters that
contain pus. If you see pustules, is it just a few pustules or are there many? A
severe pustule is large or has redness extending beyond the pustule. Many or
severe pustules indicate a serious infection.

LOOK: SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS

Young infants often sleep most of the time, and this is not a sign of illness. Even
when awake, a healthy young infant will usually not watch his mother and a health
worker while they talk, as an older infant or young child would.
A lethargic young infant is not awake and alert when he should be. He may be
drowsy and may not stay awake after a disturbance. If a young infant does not
wake up during the assessment, ask the mother to wake him. Look to see if the
child wakens when the mother talks or gently shakes the child or when you clap
your hands. See if he stays awake.
An unconscious young infant cannot be wakened at all. He does not respond when
he is touched or spoken to.
LOOK AT THE YOUNG INFANT’S MOVEMENTS. ARE THEY LESS THAN
NORMAL?
A young infant who is awake will normally move his arms or legs or turn his head
several times in a minute if you watch him closely. Observe the infant’s movements
while you do the assessment.
6.5.2. How to classify possible bacterial infection
Classify all sick young infants for bacterial infection. Compare the infant’s signs
to signs listed on the color-coded table and choose the appropriate classification.
There are two possible classifications for bacterial infection: POSSIBLE SERIOUS
BACTERIAL INFECTION and LOCAL BACTERIAL INFECTION.

Self-assessment 6.5
Compare and show in a tabulated format the signs of a serious bacterial infections
and local bacterial infection in sick children below 2 months and propose the
appropriate treatment using IMCI strategy.
6.6. Assessment of children aged from 2 months to 5
years
Learning activity 6.6
A 48 months old child was admitted to the hospital for having bacterial infection.
He looks to be afraid of facility’s environment and healthcare team. What
strategies will the nurse use to get permission from the child and administer
injectable medication as prescribed?
A mother or other caretaker brings a sick child to the clinic for a particular problem
or symptom. If you only assess the child for that particular problem or symptom, you
might overlook other signs of disease. The child might have pneumonia, diarrhoea,
malaria, measles, or malnutrition. These diseases can cause death or disability in
young children if they are not treated.
There should be recognition of illness and risk, prevention and management of iron
and vitamin A deficiency, counselling on feeding for all children under 2 years and
counselling on feeding for malnourished children.
The chart ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5
YEARS describes how to assess and classify sick children so that signs of disease
are not overlooked. The chart then helps you to identify the appropriate treatments
for each classification. According to the chart, you should ask the mother about the
child’s problem and check the child for general danger signs. Then ask about the
four main symptoms: cough or difficult breathing, diarrhoea, fever and ear problem.
A child who has one or more of the main symptoms could have a serious illness.
When a main symptom is present, ask additional questions to help classify the
illness and identify appropriate treatment(s). Check the child for malnutrition and
anaemia. Also check the child’s immunization status and assess other problems that
the mother has mentioned. The next several chapters will describe these activities.
For every child that is brought to the clinic:
SUMMARY ON EFFECTIVE COMMUNICATION FOR SICK CHILDREN
• Active listening
• Empathizing with the child’s point of view
• Developing trusting relationships
• Understanding non-verbal communication
• Building rapport
• Explaining, summarizing and providing information
• Giving feedback in clear way
• Understanding and explaining the boundaries of confidentiality
Self-assessment 6.6
What are key points to consider for effective communication when caring for sick
children.
6.7. Management of the child with COUGH OR DIFFICULT
BREATHING using IMCI strategy
Learning activity 6.7

CLASSIFY COUGH OR DIFFICULT BREATHING
There are three possible classifications for a child with cough or difficult breathing.
They are:
• Severe pneumonia or very severe disease or
• Pneumonia or
• No pneumonia: cough or cold
DESCRIPTION OF EACH CLASSIFICATION FOR COUGH OR DIFFICULT
BREATHING.
• Severe pneumonia or very severe disease
A child with cough or difficult breathing and with any of the following signs: any
general danger sign, chest indrawing or stridor in a calm child -- is classified as
having SEVERE PNEUMONIA OR VERY SEVERE DISEASE.
A child with chest indrawing usually has severe pneumonia. Or the child may have
another serious acute lower respiratory infection such as bronchiolitis, pertussis, or
a wheezing problem. Chest indrawing develops when the lungs become stiff. The
effort the child needs to breathe in is much greater than normal.
A child with chest indrawing has a higher risk of death from pneumonia than the
child who has fast breathing and no chest indrawing. If the child is tired, and if the
effort the child needs to expand the stiff lungs is too great, the child’s breathing
slows down. Therefore, a child with chest indrawing may not have fast breathing.
Chest indrawing may be the child’s only sign of severe pneumonia.
Treatment
In developing countries, bacteria cause most cases of pneumonia. These cases
need treatment with antibiotics. Viruses also cause pneumonia. But there is no
reliable way to find out if the child has bacterial pneumonia or viral pneumonia.
Therefore, whenever a child shows signs of pneumonia, give the child an appropriate
antibiotic.
A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE
is seriously ill. He needs urgent referral to a hospital for treatments such as oxygen,
a bronchodilator or injectable antibiotics. Before the child leaves your clinic, give
the first dose of injectable chloramphenicol (if not possible give oral amoxicillin). The
antibiotic helps prevent severe pneumonia from becoming worse. It also helps treat
other serious bacterial infections such as sepsis or meningitis.
• Pneumonia
A child with cough or difficult breathing who has fast breathing and no general
danger signs, no chest indrawing and no stridor when calm is classified as having
PNEUMONIA.
Treatment
Treat PNEUMONIA with oral amoxycillin. If amoxycillin is not available give oral
cotrimoxazole. Show the mother how to give the antibiotic. Advise her when to
return for follow-up and when to return immediately.
• No pneumonia: cough or cold
A child with cough or difficult breathing who has no general danger signs, no chest
indrawing, no stridor when calm and no fast breathing is classified as having NO
PNEUMONIA: COUGH OR COLD.
Treatment
A child with NO PNEUMONIA: COUGH OR COLD does not need an antibiotic.
The antibiotic will not relieve the child’s symptoms. It will not prevent the cold from
developing into pneumonia. But the mother brought her child to the clinic because
she is concerned about her child’s illness. Give the mother advice about good home
care. Teach her to soothe the throat and relieve the cough with a safe remedy such
as warm tea with sugar. Advise the mother to watch for fast or difficult breathing and
to return if either one develops.
A child with a cold normally improves in one to two weeks. However, a child who
has a chronic cough (a cough lasting more than 30 days) may have tuberculosis,
asthma, whooping cough or another problem.
Table 6.5: Classification of cough or difficult breathing
Self-assessment 6.7
You receive a 46 months old child in consultation at the health center with cough
for the past 4 days. On assessment, you notice a respiratory rate of 42 breaths
per minute with chest indrawing and fast breathing but blood smear shows
HIV negative. Please make a classification of this child and identify related
management basing on IMCI strategy.
6.8 Management of the child with DIARRHEA using
IMCI strategy
Learning activity 6.8

a. Describewhat you see on the picture above.
b. What are the dangers of drinking from an open tap.
There are three classification tables for classifying diarrhea.
• All children with diarrhea are classified for dehydration.
• If the child has had diarrhea for 14 days or more, classify the child for persistent
diarrhea.
• If the child has blood in the stool, classify the child for dysentery.
STEPS FOR ASSESSING A CHILD WITH DIARRHEA
Classify dehydration
There are three possible classifications of dehydration in a child with diarrhea:
• severe dehydration
• some dehydration
• no dehydration
To classify the child’s dehydration, begin with the red (or top) row.
If two or more of the signs in the red row are present, classify the child as having
SEVERE DEHYDRATION.
If two or more of the signs are not present in the red row, look at the yellow (or
middle) row. If two or more of the signs are present in the yellow row, classify the
child as having SOME DEHYDRATION.
If two or more of the signs are not present in the red row or yellow row, classify
the child as having NO DEHYDRATION. This child does not have enough signs to
be classified as having SEVERE/ SOME DEHYDRATION. Some of these children
may have one sign of dehydration or have lost fluids without showing signs.
Here is a description of each classification for dehydration:
SEVERE DEHYDRATION
If the child has two of the following signs: lethargic or unconscious, sunken eyes,
not able to drink or drinking poorly, skin pinch goes back very slowly, classify
the dehydration as SEVERE DEHYDRATION.
Treatment
Any child with dehydration needs extra fluids. A child classified with SEVERE
DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids.
SOME DEHYDRATION
If the child does not have signs of SEVERE DEHYDRATION, Does the child have
signs of SOME DEHYDRATION?
If the child has two or more of the following signs: restless/ irritable, sunken eyes,
drinks eagerly, thirsty, skin pinch goes back slowly then classify the child’s
dehydration as SOME DEHYDRATION.
Treatment
A child who has SOME DEHYDRATION needs fluid and foods. 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. Children
with some dehydration are also given daily dose of zinc supplement for 14 days.
Zinc should be given as soon as the child can eat and has successfully completed
4 hours of rehydration.
NO DEHYDRATION
A child who does not have two or more signs in either the red or yellow row is
classified as having NO DEHYDRATION.
Treatment
This child needs extra fluid to prevent dehydration. A child who has NO
DEHYDRATION needs home treatment. The 3 rules of home treatment are:
1. Give extra fluid
2. Give zinc supplement daily for 14 days. The first tablet should be given in
the health center, demonstrating to the mother how to dissolve it in water
or breastmilk, if necessary.
3. Continue feeding
4. When to return.
“Plan A: Treat Diarrhea at Home” describes what fluids to teach the mother to use
and how much she should give. A child with NO DEHYDRATION also needs zinc
supplement, food and the mother needs advice about when to return to the clinic.
Feeding recommendations and information about when to return are on the chart
COUNSEL THE MOTHER
CLASSIFY PERSISTENT DIARRHOEA
After you classify the child’s dehydration, classify the child for persistent diarrhea if
the child has had diarrhea for 14 days or more.
There are two classifications for persistent diarrhea:
• Severe persistent diarrhea
• Persistent diarrhea
SEVERE PERSISTENT DIARRHOEA
If a child has had diarrhea for 14 days or more and also has some or severe
dehydration, classify the child’s illness as SEVERE PERSISTENT DIARRHOEA.
Treatment
Children with diarrhea lasting 14 days or more who are also dehydrated need
referral to hospital. These children need special attention to help prevent loss of
fluid. They may also need a change in diet. They may need laboratory tests of stool
samples to identify the cause of the diarrhea. Treat the child’s dehydration before
referral unless the child has another severe classification. Treatment of dehydration
in children with severe disease can be difficult. These children should be treated in
a hospital.
PERSISTENT DIARRHOEA
A child who has had diarrhea for 14 days or more and who has no signs of dehydration
is classified as having PERSISTENT DIARRHOEA.
Treatment
Special feeding is the most important treatment for persistent diarrhea. Children
with persistent diarrhea are also given single dose of vitamin A and a daily dose of
zinc sulphate for 14 days.
CLASSIFY DYSENTERY
There is only one classification for dysentery: Classify a child with diarrhea and
blood in the stool as having DYSENTERY.
Treatment
Treat the child’s dehydration. Also give ciprofloxacin for Shigella because:
• Shigella cause about 60% of dysentery cases seen in clinics.
• Shigella cause nearly all cases of life-threatening dysentery.
Finding the actual cause of the dysentery requires a stool culture. It can take at
least 2 days to obtain the laboratory test results.

Self-assessment 6.8
A mother brought a 36 months old child to the health post complaining of diarrhea
since the last 15 days. You make an assessment and do not notice any danger
sign or sign of dehydration. Asking for the history, blood was not reported to be in
the stool. Classify and identify appropriate management of this child using IMCI
strategy.
6.9 Management of the child with FEVER using IMCI
strategy
Learning activity 6.9

• Describe what you see on the picture above.
• With your experience in previous clinical placement, what is the range of
normal temperature for children.
If the child has fever and no signs of measles, classify the child for fever only.
If the child has signs of both fever and measles, classify the child for fever and for
measles.
There are two fever classification tables on the ASSESS & CLASSIFY chart. One
is for classifying fever when the risk of malaria is high. The other is for classifying
fever when the risk of malaria is low. To classify fever, you must know if the malaria
risk is high or low.
Then you select the appropriate classification table.
HIGH MALARIA RISK:
There are two possible classifications of fever when the malaria risk is high.
• very severe febrile disease
• malaria
VERY SEVERE FEBRILE DISEASE (High Malaria Risk)
If the child with fever has any general danger sign, bulging fontanelle or a stiff neck,
classify the child as having VERY SEVERE FEBRILE DISEASE.
Treatment
A child with fever and any general danger sign or stiff neck may have meningitis,
severe malaria (including cerebral malaria) or sepsis. It is not possible to distinguish
between these severe diseases without laboratory tests. A child classified as having
VERY SEVERE FEBRILE DISEASE needs urgent treatment and referral. Before
referring urgently, you will give several treatments for the possible severe diseases.
Give the child an injection of quinine for malaria after RDT/ making a blood
smear. Also give first dose of injectable chloramphenicol (If not possible give oral
amoxycillin) for meningitis or other severe bacterial infection. You should also treat
the child to prevent low blood sugar. Also give paracetamol if there is a high fever.
MALARIA (High Malaria Risk)
If a general danger sign or stiff neck is not present, look at the yellow row. Because
the child has a fever (by history, feels hot, or temperature 37.5oC or above) in a
high malaria risk area, classify the child as having MALARIA.
When the risk of malaria is high, the chance is also high that the child’s fever is due
to malaria.
Treatment
Give Oral antimalarials for high malaria risk areas according to the National Anti Malaria Program policy.
• If smear or RDT is positive for P. falciparum give
Artesunate, Sulpha- pyrimethamine, and Primaquine on day 1; and
Artesunate on Day 2 and Day 3.
• If smear is positive for P. vivax give chloroquine for 3 days and primaquine
for 14 days.
• If both RDT and blood smear is negative or not available, give chloroquine
for 3 days.
Give paracetamol to a child with high fever (axillary temperature of 38.5oC or
above). Most viral infections last less than a week. A fever that persists every day
for more than 7 days may be a sign of typhoid fever or other severe disease. If
the child’s fever has persisted every day for more than 7 days, refer the child for
additional assessment.
FOR LOW MALARIA RISK
If risk of malaria in your area is low, use the Low Malaria Risk classification table.
There are three possible classifications of fever in a child with low malaria risk.
• Very severe febrile disease
• Malaria
• Fever - malaria unlikely
VERY SEVERE FEBRILE DISEASE (Low Malaria Risk)
If the child with fever has any general danger sign, bulging fontanelle or a stiff neck,
classify the child as having VERY SEVERE FEBRILE DISEASE.
Treatment
Manage the child on the same lines as VERY SEVERE FEBRILE DISEASE in High
Malaria Risk areas.
MALARIA (Low Malaria Risk)
If a general danger sign or stiff neck or bulging fontanelle is not present, look at
the yellow row. If there is no runny nose, no measles and no other cause of fever
(pneumonia, cough or cold, dysentery, diarrhea, skin infection) in a low malaria risk
area, classify the child as having MALARIA.
Treatment
Give oral antimalarials for low malaria risk areas according to the National AntiMalaria Program policy.
• If smear is positive for P. falciparum with Chloroquine and Primaquine on
day 1 and Chloroquine alone on Day 2 and Day 3.
• If smear is positive for P. vivax give Chloroquine for 3 days along with
Primaquine for 14 days.
• If smear is negative or not available, give chloroquine for 3 days.
Give one dose of paracetamol in clinic for high fever (temperature 38.5°C or above).
FEVER-MALARIA UNLIKELY (Low Malaria Risk)
If a general danger sign or stiff neck or bulging fontanelle is not present, and Runny
nose or Measles or Other cause of fever is PRESENT in a low malaria risk area,
classify the child as having FEVER - MALARIA UNLIKELY.
Treatment
Give one dose of paracetamol in clinic for high fever (temperature 38.5°C or above),
and 3 additional doses for use at home for high fever. If fever is present every day
for more than 7 days, refer for assessment.
CLASSIFY MEASLES
A child who has the main symptom “fever” and measles now (or within the last 3
months) is classified both for fever and for measles. First you must classify the
child’s fever. Next you classify measles.
If the child has no signs suggesting measles, or has not had measles within the
last three months, do not classify measles. Ask about the next main symptom, ear
problem.
There are three possible classifications of measles:
• severe complicated measles
• measles with eye or mouth complications
• measles
The table for classifying measles if present now or within the last 3 months is shown
as follows:
SEVERE COMPLICATED MEASLES
If the child has any general danger sign, clouding of cornea, or deep or extensive
mouth ulcers, classify the child as having SEVERE COMPLICATED MEASLES.
This child needs urgent treatment and referral to hospital.
Children with measles may have other serious complications of measles. These
include stridor in a calm child, severe pneumonia, severe dehydration, or severe
malnutrition. You assess and classify these signs in other parts of the assessment.
Their treatments are appropriate for the child with measles.
Treatment
Some complications are due to bacterial infections. Others are due to the measles
virus which causes damage to the respiratory and intestinal tracts. Vitamin A
deficiency contributes to some of the complications such as corneal ulcer. Any
vitamin A deficiency is made worse by the measles infection. Measles complications
can lead to severe disease and death.
All children with SEVERE COMPLICATED MEASLES should receive urgent
treatment. Treat the child with first dose of vitamin A. Also give the first dose of
injectable chloramphenicol (if not possible give oral amoxycillin) before referring
the child.
If there is clouding of the cornea, or pus draining from the eye, apply tetracycline
ointment. If it is not treated, corneal clouding can result in blindness. Ask the
mother if the clouding has been present for some time. Find out if it was assessed
and treated at the hospital. If it was, you do not need to refer the child again for this
eye sign.
MEASLES WITH EYE OR MOUTH COMPLICATIONS
If the child has pus draining from the eye or mouth ulcers which are not deep
or extensive, classify the child as having MEASLES WITH EYE OR MOUTH
COMPLICATIONS. A child with this classification does not need referral.
You assess and classify the child for other complications of measles (pneumonia,
diarrhea, ear infection and malnutrition) in other parts of this assessment. Their
treatments are appropriate for the child with measles.
Treatment
Identifying and treating measles complications early in the infection can prevent
many deaths. Give two doses of Vitamin A (Give first dose in clinic and give mother
one dose to give at home the next day.). It will help correct any vitamin A deficiency
and decrease the severity of the complications. Teach the mother to treat the child’s
eye infection or mouth ulcers at home. Treating mouth ulcers helps the child to
more quickly resume normal feeding.
MEASLES
A child with measles now or within the last 3 months and with none of the
complications listed in the pink or yellow rows is classified as having MEASLES.
Give the child vitamin A to help prevent measles complications.
All children with measles should receive two doses of Vitamin A
Self-assessment 6.9
A 6 months old infant was brought to the consultation by her mother complaining
of hot skin on touch and crying through the last night. She also added that his
brother recovered from malaria 2 weeks ago. On assessment, the child has a
temperature of 38.5°C. A negative test of malaria was confirmed. Classify and
identify the appropriate management of this child using IMCI strategy.
6.10 Management of the child with EAR PROBLEM using
IMCI strategy
Learning activity 6.10
A child of 24 months was brought by his mother in consultation complaining of
the child crying persistently throughout the night. On examination you discovered
that there was a pus discharge from ear, and swollen behind the ear with pain
to touch.
As a student in senior six, what can you do to assist this child.
There are four classifications for ear problem:
• mastoiditis
• acute ear infection
• chronic ear infection
• no ear infection
MASTOIDITIS
If a child has tender swelling behind the ear, classify the child as having MASTOIDITIS.
Treatmen
Refer urgently to hospital. This child needs treatment with injectable antibiotics.
He may also need surgery. Before the child leaves for hospital, give the first dose
of injectable chloramphenicol (if not possible, give oral amoxycillin). Also give one
dose of paracetamol if the child is in pain.
ACUTE EAR INFECTION
If you see pus draining from the ear and discharge has been present for less
than two weeks, or if there is ear pain, classify the child’s illness as ACUTE EAR
INFECTION.
Treatment
A child with an ACUTE EAR INFECTION should be given oral amoxycillin for 5 days.
If amoxycillin is not available give cotrimoxazole for 5 days. Antibiotics for treating
pneumonia are effective against the bacteria that cause most ear infections. Give
paracetamol to relieve the ear pain (or high fever). If pus is draining from the ear,
dry the ear by wicking.
CHRONIC EAR INFECTION
If you see pus draining from the ear and discharge has been present for two weeks
or more, classify the child’s illness as CHRONIC EAR INFECTION.
Treatment
Most bacteria that cause CHRONIC EAR INFECTION are different from those
which cause acute ear infections. For this reason, oral antibiotics are not usually
effective against chronic infections. Do not give repeated courses of antibiotics for
a draining ear.
The most important and effective treatment for CHRONIC EAR INFECTION is to
keep the ear dry by wicking. Teach the mother how to dry the ear by wicking. Also
give topical quinolone ear drops for two weeks.
NO EAR INFECTION
If there is no ear pain and no pus is seen draining from the ear, the child’s illness is
classified as NO EAR INFECTION. The child needs no additional treatment.
Table 6.8: Classification of ear problem
Self-assessment 6.10
A child of 24 months was received in consultation complaining of crying guarding
the left side of jaw and pus discharge from the left side of the ear for 8 days.
Classify and identify the treatment for this child using IMCI strategy.
6.11 Management of the child with NUTRITIONAL
PROBLEM AND ANEMIA using IMCI strategy
Learning activity 6.11

CLASSIFY NUTRITIONAL STATUS
There are three classifications for a child’s nutritional status. They are:
• Severe malnutrition
• Very low weight
• Not very low weight
SEVERE MALNUTRITION
If the child has visible severe wasting or oedema of both feet, classify the child as
having SEVERE MALNUTRITION
Treatment
Children classified as having SEVERE MALNUTRITION are at risk of death from
pneumonia, diarrhoea, measles, and other severe diseases. These children need
urgent referral to hospital where their treatment can be carefully monitored. They
may need special feeding and antibiotics. Before the child leaves for hospital, give
the child a single dose of vitamin A. Prevent low blood sugar, while referral is being
organized initiate active treatment for hypothermia and keep the child warm on the
way to hospital.
VERY LOW WEIGHT
If the child is severely underweight for age, classify the child as having VERY LOW
WEIGHT
Treatment
A child classified as having VERY LOW WEIGHT has a higher risk of severe
disease. Assess the child’s feeding and counsel the mother about feeding her
child according to the recommendations in the FOOD box on the COUNSEL THE
MOTHER chart.
Advise the mother to return for follow-up in 1 month.
NOT VERY LOW WEIGHT
If the child is Not Severely Underweight, classify the child as having NOT VERY
LOW WEIGHT.
Treatment
If the child is less than 2 years of age, assess the child’s feeding. Counsel the
mother about feeding her child according to the recommendations in the FOOD box
on the COUNSEL THE MOTHER chart. Children less than 2 years of age have a
higher risk of feeding problems and malnutrition than older children.
CLASSIFY ANAEMIA
There are three classifications for a child’s anaemia. They are:
• Severe anaemia
• Anaemia
• No anaemia
SEVERE ANAEMIA
If the child has severe palmar pallor, classify the child as having SEVERE ANAEMIA
Treatment
Children classified as having SEVERE ANAEMIA are at risk of death due to chronic
hypoxaemia or congestive cardiac failure. These children need urgent referral to
hospital because they may need blood transfusions and their treatment can be
carefully monitored.
ANAEMIA
If the child has some palmar pallor, classify the child as having ANAEMIA.
Treatment
A child with some palmar pallor may have anaemia. Treat the child with iron folic
acid. Advise the mother to return for follow-up in 14 days.
NO ANAEMIA
If the child has no palmar pallor, classify the child as having NO ANAEMIA.
Treatment
Give prophylactic iron folic acid for a total of 100 days in a year after a child has
recovered from acute illness, if child is 6 months of age or older and has not received
prophylactic iron folic acid for 100 days in last one year.
Table 6.10: Classification of anemia
Self-assessment 6.11
You receive a 40 months old child in consultation presenting some pallor in the
palm of arms. No danger signs or any other abnormality is found. Classify and
identify the treatment for this child using IMCI strategy.
6.12 Management of the child with HIV using IMCI
strategy
Learning activity 6.12
What are the most common Sexually Transmitted Infections that a mother
may transmit to the unborn fetus?

For HIV exposed children 18 months or older, a positive HIV antibody test result
means the child is infected.
For HIV exposed children less than 18 months of age:
• If PCR or other virological test is available, test from 4 - 6 weeks of age.
– A positive result means the child is infected.
– A negative result means the child is not infected, but could become infected
if they are still breast feeding.
• If PCR or other virological test is not available, use HIV antibody test. A
positive result is consistent with the fact that the child has been exposed to
HIV, but does not tell us if the child is definitely infected.
Self-assessment 6.12
Describe the classification of HIV status using IMCI strategy
6.13 Follow up care using IMCI strategy
Learning activity 6.13
Following a nursing intervention for a sick child, it is important to assess the
progress of the treatment given. Discuss its related rationale.
At a follow-up visit you can see if the child is improving on the drug or other treatment
that was prescribed:
• Care for the child who returns for follow-up using all the boxes that match the
child’s previous classifications.
• If the child has any new problem, assess, classify and treat the new problem
as on the ASSESS AND CLASSIFY chart.
Self-assessment 6.13
Explain the follow up care of a child that visited the health center 3 days ago
suffering from pneumonia.
End unit assessment
1. What is the importance of IMCI?
2. List danger signs that should be assessed in children following IMCI
strategy.
3. Enumerate main symptoms of pediatric illness following IMCI strategy.
4. Mention three signs that indicate a child with protein energy malnutrition.
5. A father brought a child of 20 months at health center, whose mother died
while giving birth to baby, the baby has been given cow milk from birth
because their social economic status did not allow them to buy formula
for baby, the baby does not like to eat and is still taking cow milk. The
father mentioned also that the baby had malaria when he was 7 months,
11 months and 2 weeks ago he had another episode of malaria. The baby
is now very weak, has skin pallor.
a. What would be the problem of the child?
b. What are possible causes?
6. A mother brings her child to the health center complaining that the child
has been passing loose watery stools with no blood stains for the past
10 days, the physical assessment the child looks weak with sunken eyes
and shows signs of dehydration.
a. What are the common ways that infants may get diarrhea?
b. judge what a child with diarrhea may be assessed
c. how would you classify this type of diarrhea?
7. What signs will you based on to classify a child as having severe
pneumonia or very severe disease?
8. What signs will you based on to diagnose severe dehydration in children?
describe the treatment that will be provided to the child
9. What are the four main classifications of ear problem in children
10. Explain how a child with dysentery may be classified
11. Describe how to identify severe wasting in an infant
12. Mention the complications that a child with vitamin A deficiency may
develop.
References
WHO, U., & Hopkins, J. (2018). Family Planning: Global Handbook for Providers.
World Health Organization, USAID and Johns Hopkins University. http://www.
unfpa. org/public/publications/pid/397.
Kloser, N. jayn., & Hatfield, N. T. (2010). Introductory Maternity and Pediatric
Nursing. China. Edition 2
Resources, T. A. (2018). Comprehensive Sexuality eduction ,. A REFERENCE
BOOK FOR SECONDARY SCHOOL TEACHERS 1(May). Rwanda Education
Board (REB) United Nations Population Fund (UNFPA)
Yacobson, I., Christopherson, K., & Michaelides, T. (2012). Facts For Family
Planning .
Planning, F. (2020). Family Planning: rights and empowerment principles for family
planning.
WHO, U., & Hopkins, J. (2018). Family Planning: Global Handbook for Providers.
World Health Organization, USAID and Johns Hopkins University. http://www.
Unfpa. Org/public/publications/pid /397.
Kloser, N. jayn., & Hatfield, N. T. (2010). Introductory Maternity and Pediatric
Nursing. China. Edition 2
Resources, T. A. (2018). Comprehensive Sexuality eduction ,. A REFERENCE
BOOK FOR SECONDARY SCHOOL TEACHERS 1(May). Rwanda Education
Board (REB) United Nations Population Fund (UNFPA)
Yacobson, I., Christopherson, K., & Michaelides, T. (2012). Facts For Family
Planning .
Planning, F. (2020). Family Planning: rights and empowerment principles for family
planning.
Long, S.S., Prober, C.G. and Fischer, M., 2022. Principles and practice of pediatric
infectious diseases E-Book. Elsevier Health Sciences.
Magesa, E., Sankombo, M. and Nakakuwa, F., 2021. Effectiveness of rotavirus
vaccine in the prevention of diarrhoeal diseases among children under age five
years in Kavango East and West Regions, Namibia. Journal of Public Health in
Africa, 12(1).
Esposito, S., Jones, M.H., Feleszko, W., Martell, J.A.O., Falup-Pecurariu, O., Geppe,
N., Martinón-Torres, F., Shen, K.L., Roth, M. and Principi, N., 2020. Prevention
of new respiratory episodes in children with recurrent respiratory infections: an
expert consensus statement from the world association of infectious diseases and
immunological disorders (WAidid). Microorganisms, 8(11), p.1810.
Topic 7
Topic 8
Topic 9
Topic 10

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