IMNCI Facilitator Guide Health Worker 2023

INTEGRATED MANAGEMENT OF
NEONATAL AND CHILDHOOD

ILLNESS (IMNCI)
FACILITATOR GUIDE FOR

HEALTH WORKERS
Child Health Division
Ministry of Health & Family Welfare
Government of India
2023
Ministry of Health and Family Welfare
Government of India
INTEGRATED MANAGEMENT OF
NEONATAL AND CHILDHOOD
ILLNESS (IMNCI)
FACILITATOR GUIDE FOR

HEALTH WORKERS
2023
MESSAGE
I am pleased to note that the Ministry of Health and Family Welfare has developed the
revised version of Integrated Management of Neonatal and Childhood Illness (IMNCI) and
developed Facility Based Care of Sick Children as an update of “Facility Based Integrated
Management of Neonatal and Childhood Illness (F-IMNCI)” training package which are
being released.
National Health Policy (NHP) 2017 provides a framework to strengthen healthcare system
for attaining Universal Health Coverage (UHC) and work on Government’s philosophy of
‘Sabka Sath Sabka Vikas’. Our flagship programme ‘Ayushman Bharat’ is working towards
attainment of UHC as one of the key targets under Sustainable Development Goals. Under
this UHC, we are committed to provide appropriate healthcare to newborns and children
across the country. Our progress has been steady, despite the COVID-19 pandemic and we
are making all efforts to improve children’s survival.
There’s a continuous need for upskilling and revising training packages, based on recent
challenges and new evidence. The training packages developed by the Ministry of Health
and Family Welfare are a right step in this direction towards addressing comprehensive
management of newborns and sick children in outpatient as well as in-patient settings.
These will be helpful in setting up better standards of care in public health facilities for our
newborns and children and will help us ensure that each child gets a better start to life and is
provided an equal opportunity to survive and thrive.
I extend my best wishes to everyone.
Integrated Management of Neonatal and Childhood Illness (IMNCI)

Facilitator Guide for Health Workers
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Date: 15.11.2023
Place: New Delhi

FOREWORD
The Ministry of Health and Family Welfare, Government of India has implemented a
number of policies and programmes aimed at ensuring universal access to health coverage
and reducing child and neonatal mortality. Our country has made sizeable gains in last one
decade in Child Mortality and reach to 32 per 1000 Live births in the year 2020. Under
National Health Policy (NHP) 2017, the country has set-up ambitious targets of Under 5
Mortality i.e. 23 per 1000 Live births by 2025 and our team is closely working with States/
UTs to achieve these targets in given time frame.
To fulfill the role of providing quality healthcare services for newborns and children, Ministry
of Health and Family Welfare, Government of India has developed training package for
comprehensive management of illness in newborns and under-five children with distinct
outpatient and inpatient components. These target the capacity building needs of pediatricians,
medical officers, nurses and peripheral health workers and provide knowledge and skills of
high order required for management of common conditions that lead to maximum morbidity
and mortality among children in our country.
I would like to express my heartfelt appreciation to all those who contributed to the preparation
of these documents. I am sure that these packages will help in equipping our healthcare
providers with knowledge and skill to deliver newborn and child health services with quality,
all across the country.
With best wishes!

PREFACE
The Government of India is committed to achieve goals under National Population Policy (2017) and bring
down Neonatal Mortality Rate to 16 and Under Five Mortality Rate to 23 by 2025, which are well beyond
the Sustainable Development Goals (SDGs) set for 2030. Newborn and Child health are the central pillars
in the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH+N) strategy.
Inter-linkages between various RMNCAH+N life cycle stages have a significant impact on the mortality and
morbidity of children.
The Child Health Division of the Ministry, with support from technical experts and development partners
has revised Facility Based Integrated Neonatal and Childhood Illness (F-IMNCI) developed in the year 2009,
with updated algorithms and improved training methodology and presented it in a pictorial format which
also serves as a job-aid. The F-IMNCI training package has been divided into two packages of “Integrated
Management of Newborn and Child Illnesses (IMNCI)” – for outpatient management of both young infants
(0-2 months) and children up to five years of age and new package titled, “Facility Based Care of Sick Children”
– focusing on appropriate inpatient management of major causes of childhood mortality beyond neonatal
age from one month to 59 months old children with common illnesses, like pneumonia, diarrhoea, malaria,
meningitis, and severe malnutrition. The training duration has been reduced to make it more practical.
The package emphasizes on the skill imparting techniques by the facilitators and ensures uniform messaging
across all the levels. With this revised training package, we hope that the training will be more hands-on and
the entire training experience will be enhanced, leading to better learning outcomes. I urge the States and UTs
to take this package up to scale and universalize it by the end of 2024-25.
I am hopeful that by adopting this revised training package, the trainers along with service providers will
feel more confident in carrying on with their roles and responsibilities. I would also like to place on record
my appreciation for the hard work and untiring efforts put in by the Child Health Division in revising and
developing the training package. I assure the States and UTs full support, of my team, in taking this important
initiative forward.

ACKNOWLEDGEMENT
India has witnessed a huge transformation in the scenario of children’s health evident by
faster reduction in child mortality over the last decade as compared to global rates. This
has been made possible by India’s continued investments in health systems which are
being strengthened further in the wake of threats posed by COVID-19 pandemic through
improvement of physical infrastructure and training of health care providers to equip them
with suitable skill sets at different levels of care, to deliver quality newborn and child health
services.
The Facility Based Integrated Neonatal and Childhood Illness (FIMNCI) package was first
launched in India in the year 2009 guiding appropriate inpatient management of major
causes of childhood mortality, which has now been bifurcated into two packages based on
outpatient and inpatient management:
1. Integrated Management of Newborn and Child Illnesses (IMNCI)- for outpatient

management of both young infants (0-2 months) and children up to five years of age with
two separate chart booklets for healthcare workers (ANM) and Physicians to be covered over
five days.
Cont’d on next page

2. New package titled, “Facility Based Care of Sick Children” - focuses on providing appropriate
inpatient management of major causes of childhood mortality beyond neonatal age i.e. one
month to 59 months old children with common illnesses, like- pneumonia, diarrhoea, malaria,
meningitis, and severe malnutrition also taught over five days.
Other major differences are:
I. Facility based approach dissociated from IMNCI; management is now linked to Emergency
signs
II. New chapters added on management of children with shock, management of children
presenting with lethargy, unconsciousness or convulsions, supportive care
III. National Guidelines for pediatric management of COVID-19, Malaria, Dengue and
Tuberculosis included
IV. Training videos developed by KSCH, Lady Hardinge Medical College
These training packages are a culmination of the work initiated by my previous colleagues Dr
Ajay Khera, Ex-Commissioner (MCH); Dr P K Prabhakar, Ex Joint Commissioner (CH) and
Dr. Sumita Ghosh, Ex- Additional Commissioner (Child Health), I convey my sincere gratitude
for their vision. I would also like to thank Prof. (Dr) Praveen Kumar, Kalawati Saran Children’s
Hospital (KSCH), New Delhi and his team who worked very hard to develop and revise this
package. I also want to acknowledge the contribution of Dr. Ashfaq Bhat (NIPI), Dr. Deepti
Agarwal (WHO-India), Vishal Kataria (MoHFW) and Vaibhav Rastogi (MoHFW) who had
worked together with KSCH to refine this package further with the support of Academicians,
Experts, State Child Health Officers, Development Partners (NIPI, WHO, UNICEF, USAID,
IPE Global, PATH) and also supported the pilot testing.
The Child Health Division will provide all the necessary support to the States and UTs to roll
out these training packages at the earliest and contribute towards further improving children’s
health and survival. I wish you the very best for your efforts and look forward to your continued
support as we move together on the mission to improve the quality of life of children and attain
the national health goals.
(Dr. Shobhna Gupta)

LIST OF CONTRIBUTORS
MOHFW
• Ms L S Changsan, Additional Secretary & Mission Director (NHM), MoHFW

• Dr P Ashok Babu, Joint Secretary (RCH), MoHFW
• Dr Shobhna Gupta, Deputy Commissioner & In-charge (Child Health), MoHFW
• Vishal Kataria, National Technical Consultant (CH), MoHFW
• Dr Vaibhav Rastogi, Lead Consultant (CH), MoHFW
• Dr Kapil Joshi, Senior Consultant (CH), MoHFW
• Sharad Singh, Lead Consultant (CH), MoHFW
• Sumitra Dhal Samanta, Senior Consultant (CH), MoHFW
Experts
• Dr A K Jaiswal, Patna Medical College, Bihar

• Dr Anju Seth, Lady Hardinge Medical College, New Delhi
• Dr Dipangkar Hazarika, NHM Assam
• Dr Harish Chellani, VMMC & Safdarjung Hospital, New Delhi
• Dr Inderdeep Kaur, NHM Punjab
• Dr Jagdish Chandra, ESI Hospital, Basaidarapur , Delhi
• Dr Jyotsna Shrivastava, Gandhi Medical College, Bhopal, MP
• Dr Kamal Kumar Singhal, Lady Hardinge Medical College, New Delhi
• Dr Mala Kumar, King George’s Medical College, Lucknow, UP
• Dr Mallesh Kariyappa, Vanivilas Hospital & BMC, Bangalore
• Dr Praveen Kumar, Lady Hardinge Medical College, New Delhi
• Dr Rani Gera, VMMC & Safdarjung Hospital, New Delhi
• Dr Rajesh Mehta, Delhi
• Dr Satinder Aneja, Sharda University, UP
• Dr Shalu Gupta, Lady Hardinge Medical College, New Delhi
• Ms Shivani Rohatgi, Lady Hardinge Medical College & KSCH, Delhi University, New Delhi
• Dr Soumya Tiwari, Lady Hardinge Medical College, New Delhi
• Dr Sumita Ghosh, Ex-Additional Commissioner & In-charge (Child Health), MoHFW
• Dr Varinder Singh, Lady Hardinge Medical College, New Delhi
• Dr Virendra Kumar, Maulana Azad Medical College, New Delhi
• Dr Viswas Chhapola, Lady Hardinge Medical College, New Delhi
• Dr Younis Mushtaq, NHM Jammu & Kashmir
Development Partners
• Dr Ashfaq Bhat, NIPI

• Dr Deepti Agrawal, WHO – India
• Dr Harish Kumar, IPE Global
• Dr Nimisha Goel, NIPI
• Dr Rajat Khanna, NIPI
• Dr Sachin Gupta, USAID – India
• Dr V K Anand, Save the Children
• Dr Vandana Bhatia, UNICEF - India
• Dr Vivek Singh, UNICEF – India
CONTENTS
SECTION 1
1. Introduction to this facilitator guide 17
SECTION 2
2. Introduction to training & materials used 29
SECTION 3
3. Assess & classify young infant for possible serious bacterial infection/jaundice 33
SECTION 4
4. Assess & classify young infant for diarrhoea 41
SECTION 5
5. Check for feeding problem and low weight for age 43
SECTION 6
6. Assess any other problem, immunization status and development supportive practices 47
SECTION 7
7. Identify treatment 48
SECTION 8
8. Treat the young infant 50
SECTION 9
9. Assess & classify the sick child for general danger signs and
cough or difficult breathing 63
SECTION10
10. Assess and classify diarrhoea 67
SECTION11
11. Assess and classify fever 71
SECTION12
12. Check for malnutrition 73
SECTION13
13. Check for anemia 75
SECTION14
14. Check the child’s immunization, prophylactic vitamin A, iron-folic acid supplementation,
deworming status & assess other problems, assess the mother/caregiver’s development
supportive practices and counsel the mother about her own health 76
SECTION15
15. Review exercises 77
SECTION16
16. Identify treatment 82
SECTION17
17. Treat the child 83
SECTION18
18. Follow-up visits & follow-up care 107
ANNEXURES 19
19.1. Checklist for Monitoring Clinical Sessions (Sick Young Infants Aged up to 2 months) 109
19.2. Checklist for Monitoring Clinical Sessions (Sick Child Aged and months up to 5 years)110
19.3. Group Checklist for Clinical Signs (Sick Young Infants Aged upto 2 months) 111
19.4. Group Checklist for Clinical Signs (Sick Child Aged 2 months upto 5 years) 112
SECTION
INTRODUCTION TO THIS
1 FACILITATOR GUIDE
1.1 HOW DOES THIS COURSE DIFFER FROM OTHER TRAINING

COURSES?

01 The material in the course is not presented by lecture. Instead, each participant
is given an instructional booklet, called module for training of health workers,
that has the basic information to be learned. Information is also provided
through demonstrations, photographs and videos.

02 T he module is designed to help each participant develop specific skills necessary
for case management of sick children. Participants develop these skills as they
read the module, observe live and video demonstrations, and practice skills
through video exercises, group discussions, oral drills, or role plays.

03 After practicing skills in the module, participants practice the skills in a real
clinical setting, with supervision to ensure correct patient care.

04 Each participant works at his/her own speed.
1.2 ROLE AND RESPONSIBILITIES OF A FACILITATOR

Who is a FACILITATOR?
A facilitator is a person who helps the participants learn the skills presented in the course. The
facilitator spends much of his time in discussions with participants, either individually or in small
groups. For facilitators to give enough attention to each participant, a ratio of one facilitator to 6
participants is desired. In your assignment to teach this course, YOU are a facilitator.
As a facilitator, you need to be very familiar with the material being taught. It is your job to give
explanations, do demonstrations, answer questions, talk with participants about their answers to
exercises, conduct role plays, lead group discussions, organize and supervise clinical practice in
outpatient clinics, home visits and generally give participants any help they need to successfully
complete the course. You are not expected to teach the content of the course through formal lectures.
(Nor is this a good idea, even if this is the teaching method to which you are most accustomed).
Integrated Management of Neonatal and Childhood Illness (IMNCI) 17

What, then, DOES a FACILITATOR do?
As a facilitator, you do 3 basic things:
1. You INSTRUCT:
- Make sure that each participant understands how to work through the materials and what he
is expected to do in each module and each exercise.
- Answer the participant’s questions as they occur.
- Explain any information that the participant finds confusing, and help him understand the
main purpose of each exercise.
- Lead group activities, such as group discussions, oral drills, video exercises and role plays,
to ensure that learning objectives are met.
- Promptly assess each participant’s work and give correct answers.
- Discuss with the participant how s/he obtained his answers in order to identify any
weaknesses in the participant’s skills or understanding.
- Provide additional explanations or practice to improve skills and understanding.
- Help the participant to understand how to use skills taught in the course in his own clinic.
- Explain what to do in each clinical practice session.
- Model good clinical skills, including communication skills, during clinical practice sessions.
- Give guidance and feedback as needed during clinical practice sessions.
2. You MOTIVATE:
- Compliment the participant on his correct answers, improvements or progress.
- Make sure that there are no major obstacles to learning (such as too much noise or not
enough light).
3. You MANAGE:
- Plan ahead and obtain all supplies needed each day, so that they are in the classroom or
taken to the clinic when needed.
- Make sure that movements from classroom to clinic and back are efficient.
- Monitor the progress of each participant.
How do you do these things?

• Show enthusiasm for the topics covered in the course and for the work that the participants are
doing.
• Be attentive to each participant’s questions and needs. Encourage the participants to come to you
at any time with questions or comments. Be available during scheduled times.
• Watch the participants as they work, and offer individual help if you see a participant looking
troubled, staring into space, not writing answers, or not turning pages. These are clues that the
participant may need help.
• Promote a friendly, cooperative relationship. Respond positively to questions (by saying, for
example, “Yes, I see what you mean,” or “That is a good question”). Listen to the questions and
try to address the participant’s concerns, rather than rapidly giving the “correct” answer.
• Always take enough time with each participant to answer his questions completely (that is, so
that both you and the participant are satisfied).
18 Integrated Management of Neonatal and Childhood Illness (IMNCI)

What NOT to do...
• During times scheduled for course activities, do not work on other projects or discuss matters
not related to the course.
• In discussions with participants, avoid using facial expressions or making comments that could
cause participants to feel embarrassed.
• Do not call on participants one by one as in a traditional classroom, with an awkward silence
when a participant does not know the answer. Instead, ask questions during individual feedback.
• Do not lecture about the information that participants are about to read. Give only the introductory
explanations that are suggested in the Facilitator Guide. If you give too much information too
early, it may confuse participants. Let them read it for themselves in the modules.
Do not review text paragraph by paragraph. (This is boring and suggests that participants cannot
read for themselves). As necessary, review the highlights of the text during individual feedback or
group discussions.
• Avoid being too much of a showman. Enthusiasm (and keeping the participants awake) is great,
but learning is most important. Keep watching to ensure that participants are understanding the
materials. Difficult points may require you to slow down and work carefully with individuals.
• Do not be condescending. In other words, do not treat participants as if they are children. They
are adults.
• Do not talk too much. Encourage the participants to talk.
• Do not be shy, nervous or worried about what to say. This Facilitator Guide will help you
remember what to say. Just use it!
How can this FACILITATOR GUIDE help you?

This Facilitator Guide will help you teach the course module, including the video segments and
assist you with clinical practice sessions. This Facilitator Guide includes the following:
• a list of the procedures to complete the module, highlighting the type of feedback to be given
after each exercise guidelines for the procedures. These guidelines describe:
- how to do demonstrations, role plays, and group discussions,
- supplies needed for these activities,
- how to conduct the video exercises,
- how to conduct oral drills,
- points to make in group discussions or individual feedback.
• answer sheets (or possible answers) for most exercises
• a place to write down points to make in addition to those listed in the guidelines
To prepare yourself for the module, you should:

• read the module and work on the exercises,
• read in this Facilitator Guide all the information provided about the module,
• plan exactly how the work on the module will be done and what major points to make,
• collect any necessary supplies for exercises in the module, and prepare for any demonstrations
or role plays,

• think about sections that participants might find difficult and questions they may ask,
• plan ways to help with difficult sections and answer possible questions,
• think about the skills taught in the module and how they can be applied in participants’ own
facilities,
• ask participants questions that will encourage them to think about using the skills in their
facilities. Questions are suggested in appropriate places in the Facilitator Guide.
1.3 Checklist of instructional materials needed in each small group
ITEM NEEDED NUMBER NEEDED

Facilitator Guide for Module 1 for each facilitator
Sets of participant’s module, photograph booklet,
chart booklet, Mid-Upper Arm Circumference 1 set for each facilitator and 1 set for each
(MUAC) tape and Mother and Child Protection participant
(MCP) card
Facilitator will inform you where yoursmall
Laptop, projector, copy of photograph book
group will view the video.
Set of 4 Case Management Poster (Large version-
2 sets for each small group
to display on the wall)
Recording Forms (for exercises in module & for
10 for each participant plus some extras
clinical practice)
Group Checklist of Clinical Signs Observed 1 per group
Statement Cards (Page 101-102 from this module) 1 set for each participant
1.4 Checklist of Supplies Needed for Class Room Sessions

Supplies needed for each person include:
* name tag and holder * felt tip pen
* paper/ notebook * highlighter
* ball point pen * 2 pencils
* eraser * sharpner
Supplies needed for each group include:

* paper clips
* pencil sharpener
* stapler and staple pins
* flipchart pad and markers OR blackboard and chalk, folder or large envelope to collect
answer sheets
In addition, certain exercises require special supplies such as drugs, ORS packets, or a baby doll.
These supplies are listed in the guidelines for each activity. Be sure to review the guidelines and
collect the supplies needed before these activities.

1.5 Facilitator Techniques
A. Techniques for Motivating Participants
I. Encourage Interaction
1. During the first day, you will talk individually with each participant several times (for
example, during individual feedback). If you are friendly and helpful during these first
interactions, it is likely that the participants (a) will overcome their shyness; (b) will
realize that you want to talk with them; and (c) will interact with you more openly and
productively throughout the course.
2. L
ook carefully at each participant’s work (including answers to short-answer exercises).
Check to see if participants are having any problems, even if they do not ask for help. If
you show interest and give each participant undivided attention, the participants will feel
more compelled to do the work. Also, if the participants know that someone is interested
in what they are doing, they are more likely to ask for help when they need it.
3. Be available to the participants at all times.
II. Keep Participants Involved in Discussions

4. F
requently ask questions of participants to check their understanding and to keep them
actively thinking and participating. Questions that begin with “what,” “why,” or “how”
require more than just a few words to answer. Avoid questions that can be answered with
a simple “yes” or “no.”
fter asking a question, PAUSE. Give participants time to think and volunteer a response.
A
A common mistake is to ask a question and then answer it yourself. If no one answers
your question, rephrasing it can help to break the tension of silence. But do not do this
repeatedly. Some silence is productive.
5. A
cknowledge all participants responses with a comment, a “thank you” or a definite nod.
This will make the participants feel valued and encourage participation. If you think a
participant has missed the point, ask for clarification, or ask if another participant has a
suggestion. If a participant feels his comment is ridiculed or ignored, he may withdraw
from the discussion entirely or not speak voluntarily again.
6. A
nswer participants questions willingly, and encourage participants to ask questions
when they have them rather than to hold the questions until a later time.
7. D
o not feel compelled to answer every question yourself. Depending on the situation,
you may turn the question back to the participant or invite other participants to respond.
You may need to discuss the question with the another facilitator before answering. Be
prepared to say “I don’t know but I’ll try to find out.”
8. U
se names when you call on participants to speak, and when you give them credit or
thanks. Use the speaker’s name when you refer back to a previous comment.
9. A
lways maintain eye contact with the participants so everyone feels included. Be careful
not to always look at the same participants. Looking at a participant for a few seconds
will often prompt a reply, even from a shy participant.

III. Keep the Session Focused and Lively
10. Keep your presentations lively:
- Present information conversationally rather than read it.
- Speak clearly. Vary the pitch and speed of your voice.
- Use examples from your own experience, and ask participants for examples from
their experience.
11. Write key ideas on a flipchart as they are offered. (This is a good way to acknowledge
responses. The speaker will know his suggestion has been heard and will appreciate
having it recorded for the entire group to see).
When recording ideas on a flipchart, use the participant’s own words if possible. If you
must be briefer, paraphrase the idea and check it with the participant before writing it.
You want to be sure the participant feels you understood and recorded his idea accurately.
Do not turn your back to the group for long periods as you write.
12. At the beginning of a discussion, write the main question on the flipchart. This will help
participants stay on the subject. When needed, walk to the flipchart and point to the
question.
araphrase and summarize frequently to keep participants focused. Ask participants for
P
clarification of statements as needed. Also, encourage other participants to ask a speaker
to repeat or clarify his statement.
Restate the original question to the group to get them focused on the main issue again. If
you feel someone will resist getting back on track, first pause to get the group’s attention,
tell them they have gone astray, and then restate the original question.
o not let several participants talk at once. When this occurs, stop the talkers and assign
D
an order for speaking (For example, say “Let’s hear Madhu’s comment first, then Satish’s,
then Kamla’s”). People usually will not interrupt if they know they will have a turn to
talk.
Thank participants whose comments are brief and to the point.
13. Try to encourage quieter participants to talk. Ask to hear from a participant in the group
who has not spoken before, or walk toward someone to focus attention on him and make
him feel he is being asked to talk.
B. Manage any Problems

14. Some participants may talk too much. Here are some suggestions on how to handle an
overly talkative participant:
- Do not call on this person first after asking a question
- After a participant has gone on for some time say, “You have had an opportunity to express
your views. Let’s hear what some of the other participants have to say on this point.”
Then rephrase the question and invite other participants to respond, or call on someone
else immediately by saying, “Champa, you had your hand up a few minutes ago.”

- When the participant pauses, break in quickly and ask to hear from another member
of the group or ask a question of the group, such as, “What do the rest of you think
about this point?”
- Record the participant’s main idea on the flipchart. As he continues to talk about the
idea, point to it on the flipchart and say, “Thank you, we have already covered your
suggestion.” Then ask the group for another idea.
- Do not ask the talkative participant any more questions. If he answers all the questions
directed to the group, ask for an answer from another individual specifically or from
a specific subgroup. (For example, ask, “Does anyone on this side of the table have
an idea?”).
15. Try to identify participants who have difficulty understanding or speaking the course
language. Speak slowly and distinctly so you can be more easily understood and
encourage the participant in his efforts to communicate.
iscuss with the co-facilitator any language problems which seriously impair the ability
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of a participant to understand the written material or the discussions. It may be possible
to arrange help for the participant.
iscuss disruptive participants with your co-facilitator. (The facilitator may be able to
D
discuss matters privately with the disruptive individual).
C. Reinforce Participants Efforts

16. As a facilitator, you will have your own style of interacting with participants. However,
a few techniques for reinforcing participants efforts include:
- avoiding use of facial expressions or comments that could cause participants to feel
embarrassed,
- sitting or bending down to be on the same level as the participant when talking to
him,
- answering questions thoughtfully, rather than hurriedly,
- encouraging participants to speak to you by allowing them time,
- appearing interested, saying “That’s a good question/suggestion.”
17. Reinforce participants who:

- try hard
- ask for an explanation of a confusing point
- do a good job on an exercise
- participate in group discussions
- help other participants (without distracting them by talking at length about irrelevant
matters).

D. Techniques for Relating information given in the Modules to Participants’ Jobs
1. Discuss the use of these case management procedures in participants’ own clinics. The
guidelines for giving feedback on certain exercises suggest specific questions to ask. (For
example, in Identify Treatment, ask where the participant can refer children with severe
classifications; in Treat the Child, ask what fluids will be recommended for Plan A, and ask
whether he dispensed drugs to mothers; in Follow-up, ask whether mothers will bring a child
back for follow-up). Be sure to ask these questions and listen to the participant’s answers.
This will help participants begin to think about how to apply what they are learning.
2. Reinforce participants who discuss or ask questions about using these case management
procedures by acknowledging and responding to their concerns.
E. Techniques for Assisting Co-facilitators

1. Spend some time with the co-facilitator when assignments are first made. Exchange
information about prior teaching experiences and individual strengths, weaknesses and
preferences. Agree on roles and responsibilities and how you can work together as a team.
2. Assist one another in providing individual feedback and conducting group discussions. For
example, one facilitator may lead a group discussion, and the other may record the important
ideas on the flipchart. The second facilitator could also check the Facilitator Guide and add
any points that have been omitted.
3. Each day, review the teaching activities that will occur the next day (such as role plays,
demonstrations and drills), and agree who will prepare the demonstration, lead the drill, play
each role, collect the supplies, etc.
4. Work together on each section of the module rather than taking turns having sole responsibility
for a module.
F. Techniques for facilitating learning from the module when participants are
working
- Look available, interested and ready to help.
-
Watch the participants as they work, and offer individual help if you see a participant
looking troubled, staring into space, not writing answers, or not turning pages. These are
clues that the participant may need help.
- Encourage participants to ask you questions whenever they would like some help.
-
If important issues or questions arise when you are talking with an individual, make note
of them to discuss later with the entire group.
-
If a question arises which you feel you cannot answer adequately, obtain assistance as soon
as possible from another facilitator.
-
Review the points in this Facilitator Guide so you will be prepared to discuss the next
exercise with the participants.
I. When Providing Individual Feedback:

• Before giving individual feedback, refer to the appropriate notes in this guide to remind
yourself of the major points to make.
• Compare the participant’s answers to the answer sheet provided. If the answer sheet is labelled
“Possible Answers,” the participant’s answers do not need to match exactly, but should be
reasonable. If exact answers are provided, be sure the participant’s answers match.

• If the participant’s answer to any exercise is incorrect or is unreasonable, ask the participant
questions to determine why the error was made. There may be many reasons for an incorrect
answer. For example, a participant may not understand the question, may not understand certain
terms used in the exercise, may use different procedures at his clinic, may have overlooked some
information about a case, or may not understand a basic process being taught.
• Once you have identified the reason(s) for the incorrect answer to the exercise, help the participant
correct the problem. For example, you may only need to clarify the instructions. On the other
hand, if the participant has difficulty understanding the process itself, you might try using a
specific case example to show step-by-step how the case management sections are used. After
the participant understands the process that was difficult, ask him to work the exercise or part of
the exercise again.
Summarize, or ask the participant to summarize, what was done in the exercise and why.
Emphasize that it is most important to learn and remember the process demonstrated by the
exercise. Give the participant a copy of the answer sheet, if one is provided.
• Always reinforce the participant for good work by (for example):
- commenting on his understanding,
- showing enthusiasm for ideas for application of the skill in his work,
- telling the participant that you enjoy discussing exercises with him,
- letting the participant know that his hard work is appreciated.
II. When Leading a Group Discussion:

• Plan to conduct the group discussion at a time when you are sure that all participants will have
completed the preceding work. Wait to announce this time until most participants are ready, so
that others will not hurry.
• Before beginning the discussion, refer to the appropriate notes in this guide to remind yourself
of the purpose of the discussion and the major points to make.
• Always begin the group discussion by telling the participants the purpose of the discussion.
• In a discussion often there is no single correct answer that needs to be agreed on. Just be sure the
conclusions of the group are reasonable and that all participants understand how the conclusions
were reached.
• Try to get most of the group members involved in the discussion. Record key ideas on a flipchart
as they are offered. Keep your participation to a minimum, but ask questions to keep the
discussion active and on track.
• Always summarize, or ask a participant to summarize, what was discussed in the exercise. Give
participants a copy of the answer sheet, if one is provided.
• Reinforce the participants for their good work by (for example):
- praising them for the list they compiled,
- commenting on their understanding of the exercise,
- commenting on their creative or useful suggestions for using the skills on the job,
- praising them for their ability to work together as a group.

III. When Coordinating a Role Play:
• Before the role play, refer to the appropriate notes in this guide to remind yourself about the
purpose of the role play, roles to be assigned, background information, and major points to make
in the group discussion afterwards.
• As participants come to you for instructions before the role play,
- assign roles. At first, select individuals who are outgoing rather than shy, perhaps by asking
for volunteers. If necessary, a facilitator may be a model for the group by acting in an early
role play.
- give role play participants any props needed, for example, a baby doll, drugs.
- give role play participants any background information needed. (There is usually some
information for the “mother” which can be photocopied or clipped from this guide).
- suggest that role play participants speak loudly.
- allow preparation time for role play participants.
• When everyone is ready, arrange seating/placement of individuals involved. Have the “mother”
and “doctor” stand or sit apart from the rest of the group, where everyone can see them.
• Begin by introducing the players in their roles and stating the purpose or situation. For example,
you may need to describe the age of the child, assessment results, and any treatment already
given.
• Interrupt if the players are having tremendous difficulty or have strayed from the purpose of the
role play.
• When the role play is finished, thank the players. Ensure that feedback offered by the rest of the
group is supportive. First discuss things done well. Then discuss things that could be improved.
• Try to get all group members involved in discussion after the role play. In many cases, there are
questions given in the module to help structure the discussion.
• Ask participants to summarize what they learned from the role play.
1.6. CLINICAL PRACTICE
Objectives
Clinical practice is an essential part of the OUTPATIENT MANAGEMENT OF NEONATAL AND
CHILDHOOD ILLNESS course. The course provides daily practice in using case management skills
so that participants can perform them proficiently when they return to their own clinics. Participants
learn about the skills by reading information in the modules or seeing demonstrations on video. They
then use the information by doing written exercises or case studies. Finally, and most importantly,
in clinical practice, participants practice using their skills with real sick children and young infants.
General Objectives:
During clinical practice sessions, participants will:

• see examples of signs of illness in real children.
• see demonstrations of how to manage sick young infants and children.
• practice assessing, classifying and treating sick young infants and children and counselling
mothers about food, fluids, and when to return.
• receive feedback about how well they have performed the skill and guidance about how to
strengthen particular skills.
• gain experience and confidence in using the skills as described in the chart booklet.

Outpatient sessions take place in outpatient clinics and inpatients. Each small group of participants
work in outpatient clinics and /or inpatients each day and is supervised by its facilitators. The focus
of these sessions is to provide practice of the case management process with young infants and sick
children.
In the Outpatient Sessions, participants will:

• See sick children and young infants brought to the clinic by their mothers.
• Practice assessing and classifying sick children and young infants according to the ASSESS &
CLASSIFY charts.
• Practice identifying the child’s treatment using the “Identify Treatment” column on the ASSESS
& CLASSIFY charts.
• Practice treating sick children and young infants according to the TREAT THE YOUNG INFANT
AND COUNSEL THE MOTHER charts.
• Practice counseling mothers about feeding and fluid recommendations, development supportive
practices and when to return according to the COUNSEL THE MOTHER chart.
• Practice using good communication skills when assessing, treating and counseling mothers of
sick children and young infants.
In the Inpatient Clinical Practice Sessions, the focus of the inpatient sessions is to practice
assessing and classifying clinical signs, especially signs of severe illness. During inpatient sessions,
participants will:
• See as many examples as possible of signs of severe classifications from the ASSESS & CLASSIFY
THE SICK YOUNG INFANT and ASSESS & CLASSIFY THE SICK CHILD AGE 2 MONTHS
UPTO 5 YEARS sections, including signs not frequently seen.
• Practice assessing and classifying sick children and young infants according to the job-aid,
focusing especially on the assessment of general danger signs, other signs of severe illness, and
signs which are particularly difficult to assess (for example, chest indrawing and skin pinch).
• Practice helping mothers to correct positioning and attachment.
Participants practice the case management steps as part of a case management process. The clinical
practice skills are presented in the order they are being learned in the modules. In each clinical
session, participants use the skills they have learned upto and including that day’s session. This
allows participants to gain experience and confidence in performing skills introduced in earlier
sessions.
To ensure that participants receive as much guidance as possible in mastering the clinical skills,
the outpatient facilitator and inpatient instructor give particular attention and feedback to the new
skill being practiced that day. If any participant has difficulty with a specific skill, the facilitator or
inpatient instructor continues working with the participant on that skill in subsequent sessions until
the participant can perform the skill with confidence.

Role of Facilitator During Clinical Sessions
The role of the facilitator during outpatient sessions is to:

1. Do all necessary preparations for carrying out the outpatient sessions.
2. Explain the session objectives and make sure the participants know what to do during each
outpatient session.
3. Demonstrate the case management skills described on the charts. Demonstrate the skills exactly
as participants should do them when they return to their own clinics.
4. Observe the participants progress throughout the outpatient sessions and provide feedback and
guidance as needed.
5. Be available to answer questions during the outpatient sessions.
6. Lead discussions to summarize and monitor the participants’ performance.
7. Complete the Checklist for Monitoring Outpatient Sessions to record participants performance
and the cases managed.
(There should be 1 facilitator for every group of 6 to 8 participants.)
1.7. SCHEDULE OF SESSIONS FOR TRAINING
Classroom Sessions Clinical Sessions

Day 1 -
Complete assessment of young infant
Day 2 Day 2
Complete Identify Treatment, Inpatient Session:
Treatment and counseling Assess and classify young infant for Possible Serious
Bacterial Infection (Hospital)
Day 3 Day 3
Start sick child and read complete assessment of Complete assessment, identify treatment and counsel
a sick child for breastfeeding (Hospital)
Day 4 Day 4
Complete treatment and counsel for feeding and Assess and classify children for cough, fever, or
development supportive practice diarrhoea or malnutrition. (Hospital)
Day 5 Day 5
Follow up, record filling and future planning Complete assessment treatment and counseling
(Community)

SECTION
INTRODUCTION TO TRAINING &

2 MATERIALS USED
2.1 Introduction
About 60% of the infant mortality occurs in the first month of life and 2/3 of these occur in the first
week of life. The important causes of deaths amongst young infants are infections and many of
these babies are low birth weight infants. In young children under five years, cough, diarrhoea and
fever are the important causes of death. The health workers in India provides care to most of these
children. There is a need to train the health workers in the basic skills and skills of communication.
The objectives of this training course are:

• To train the health workers in technical skills in:
- Early referral of seriously ill children and young infants
- Provide home care to young infants
- Treating children with dehydration by ORS solution; and
- Treating children with pneumonia and young infants with local bacterial infection
• To train the health worker in communication skills in:
- Advising the mother on feeding infants and children and development support care
- Keeping young infants warm
- Giving fluids
- Relieving cough by home remedies
- Observing child for selected signs for follow-up and timely consultation
2.2 Training package

The training package comprises of the participant’s Training Module, Chart Booklet, Facilitator
Guide, Videos and Photographs.
1. Training Module: The Participant’s Training Module includes Management of Young Infants
aged upto 2 months and Management of Sick Children aged 2 months upto 5 years. It has
simple descriptions to help the health workers in managing young infants with possible serious
bacterial infection, diarrhoea, feeding problems and provide home care to young infants. It also
provides guidelines to manage children aged 2 months upto 5 years with cough, diarrhoea, fever
or malnutrition. It contains sections, which will help the participant correctly assess, classify and
treat these children.
2. Chart Booklet: It includes the ASSESS and CLASSIFY section. It includes dose of amoxycillin
and injection gentamycin, guidance on use of ORS, keeping young infants warm and feeding
advice and key signs of illness the mother must know.
3. MCP Card: Consists of reminder about the key signs of illness, foods to give the child,
immunization, early childhood development and guidance on home care.
4. Facilitator Guide: Includes a step-by-step description to be used by the facilitators so that the
health workers are encouraged to learn the key points the participant’s module and they become
competent in using the job-aid.
5. Videos: The video demonstrates the key signs the health workers are expected to learn.
6. Photographs

2.3 Introduction of Yourself and Participants
If participants do not know you or do not know each other, introduce yourself as a facilitator of this
course and write your name on the blackboard or flipchart. As the participants introduce themselves,
write their names on the blackboard or flipchart. Leave the list of names in a place where everyone
can see it to help you and the participants learn each other’s names.
Administrative tasks
There may be some administrative tasks or announcements that you should address. For example,
you may need to explain the arrangements that have been made for lunches, the daily transportation
of participants from their lodging to the course, or payment of per diem.
Explanation of your role as Facilitator
Explain to participants that, as facilitator (and along with your co-facilitator, if you have one), your
role throughout this course will be to:
• guide them through the course activities
• answer questions as they arise or find the answer if you do not know
• clarify information they find confusing
• give individual feedback on exercises, where indicated
• lead group discussions, drills, video exercises and role plays
• prepare them for each clinical session (explain what they will do and what to take) in outpatient
sessions, demonstrate tasks
• observe and help them as needed during their practice in outpatient sessions.
2.4 Introduce the participant’s Training Module

Introduce the participant’s Training Module and tell the participants that there are two parts of this
course:
• Management of young infants aged upto 2 months (0 to 59 days old)
• Management of sick children 2 months upto 5 years (2 to 59 months)
Each part of the course has a participant’s module and a colour-coded management chart booklet.
Participant read Section -1 ‘Introduction’ in the Training Module

2.5 Conduct a brief Group Discussion
The objective of the group discussion is to identify the most common childhood health problems
responsible for high mortality.
In order to initiate discussion on the subject, ask following questions to ascertain participants’
perspective:
• How many sick children under the age of 5 years did you see in last 1 week?
• How many deliveries took place in your area during the last week?
• How long after the delivery you came to know about it?
• Any child death in last 1 month, and what age?
• Where do sick newborns go for treatment?
Ask the participants to identify the causes of infant and child mortality in their region. At the end of
the discussion emphasize that:
• Infections are responsible for a large proportion of deaths in infants under 2 months and many
of these babies are low birth weight infants.
• Pneumonia, diarrhoea and undernutrition are responsible for a sizeable number of deaths in
children under 5 years.
• Most cases of pneumonia, diarrhoea and undernutrition are treatable by the health worker.
• Mothers and caretakers have a very important role in preventing these deaths. During the
discussion, ask the health worker to relate their experience on some these common problems.
2.6 Review the topics of Young Infant Module

• Participants complete reading Section 1.
• Review the objectives of this young infant module:
- Assess and classify young infants for possible serious bacterial infection/
jaundice,
- Assess for diarrhoea,
- Assess and classify for feeding problem and low weight for age,
- Assess and classify the young infant’s immunization status,
- Assess other problems,
- Assess the mother/caregiver’s development supportive practices & counsel for
practices to support child’s development using MCP card,
- Counsel the mother about her own health,
- Provide treatment and refer when required,
- Correct breastfeeding problems,
- Advise the mother on home care to young infant,
- Follow-up care.

2.7 Introduce the colour-coded management chart booklet
Tell the participants that the management section includes:
• Assess and classify section
• Treat the young infant or child
• Counsel the mother section
Point out that the Assess and Classify section has three columns:
“Assess” column lists what signs and symptoms to check and how to do it.
“Classify as” helps in classifying each illness the young infant or child has.
“Identify Treatment”section lists appropriate treatment decisions for each classification.
Also tell the participants that the job-aid is organized in three different colors (Pink, Yellow and
Green):
• Pink colour- indicate severe illness. Children with a severe illness must be referred to a hospital
or sent to the doctor as advised in the guide.
• Yellow colour- means the disease should be treated with medicine at home and home care
advice to the mother.
• Green colour – means the disease can be treated with home care without the use of medicines.
Stress that the three basic steps in case management of a sick child are- Assessment, Classification
and Identify Treatment.

SECTION
ASSESS & CLASSIFY YOUNG INFANT

3 FOR POSSIBLE SERIOUS BACTERIAL
INFECTION / JAUNDICE
In this section the participants will learn to identify the signs of possible serious bacterial infection,
jaundice in a young infant.
3.0 Participants read Section 2 ‘Assess and Classify the Sick Young Infant’
through ‘Determine if this is Initial or Follow up visit’.
3.1 Group Discussion on Steps of Effective Communication
Stress that good communication goes a long way in better management of cases as mothers come
out with the problems only when they open up.
Highlight that both verbal and non-verbal communication skills need to be practiced for better
proficiency.
Ask participants to contribute a point as to how should one behave while talking with mothers and
make a list for use during the clinical practice and role-plays.
Listening and Learning Skills Non-Verbal skills

• Use helpful non-verbal skills • Pay attention
• Ask open questions • Keep your head level
• Use responses and gestures which show interest • Remove barriers
• Reflect back what the mother says • Take time
• Empathize: show that you understand how she feels • Touch appropriately
• Avoids words which sound judgmental
Participants read ‘Assess Young Infant for Possible Serious Bacterial Infection / Jaundice’.
3.2 CONDUCT A DRILL: CHECK FOR SIGNS OF POSSIBLE SERIOUS
BACTERIAL INFECTION
To conduct this drill:

1. Gather the participants together and tell them you will conduct a drill. During the drill, they will
review the steps “checking for possible serious bacterial infection”
2. Explain the procedures for doing the drill. Tell participants:
• This is not a test. The drill is an opportunity for participants to practice recalling information
a Health Worker needs to use when assessing and classifying young infants.
• Call on individual participants one at a time to answer the questions. You will usually call
on them in order, going around the table. If a participant is unable to answer, go to the next
person and ask the question again.
• Participants should wait to be called on and should be prepared to answer as quickly as they
can. This will help keep the drill lively.

3. Ask if participants have any questions about the drill.
4. Allow participants to review the assessment steps for a few minutes before the drill begins.
Participants should review the steps for checking for Possible Serious Bacterial Infection.
5. Tell the participants they may refer to the chart booklet during the drill, but they should try to
answer the question without looking at or reading from the chart booklet.
6. Illustrate what they will be doing in the drill by asking a question from the other facilitator.
Begin by asking “How do you decide if the young infant has had convulsions?”
7. Answer is that by asking the mother if the young infant has had convulsions.
8. Use local words for convulsions.
9. Start the drill by asking the first question. Call on a particular participant to provide the answer.
He should answer as quickly as he can. Then ask the next question and call on another participant
to answer. If a participant gives an incorrect answer, ask the next participant if he can answer.
10. Continue the drill until all the participants can answer correctly.
QUESTIONS ANSWERS
An infant age less than 2 months. What - Ask: Is there any difficulty in feeding?
question is asked as the first step for checking - Ask: Has the infant had convulsions?
for possible serious bacterial infection?
How do you decide if the young infant has:
- Fast breathing? - If breathing rate is more than 60(second count)
- Movement only when stimulated or no - If the infant is awake but has no spontaneous
movement movements, gently stimulate the young infant.
- If the infant moves only when stimulated and
then stops moving, or does not move even when
stimulated
How do you decide if the young infant has:
- Has fever Axillary temperature >37.50C OR feels hot to touch
- Has low body temperature Axillary temperature <35.50C OR feels cold to touch
How do you recognize severe chest The lower chest wall goes in when the child breathes
indrawing? IN. This should happen all the time for chest
indrawing to be present.
What should you do if you are not sure that If there is any doubt, ask the mother to change the
chest indrawing is present? young infant’s position. If the lower chest wall does
not go in when the young infant breathes IN, the
young infant does not have chest indrawing.
Chest indrawing is present most of the No, because chest indrawing should always be
time but not present all the time. Will you present to be considered positive.
consider this as chest indrawing?
A young infant has chest indrawing when he No, because chest indrawing can appear in a normal
is breastfeeding. Is chest indrawing present? baby if he is breastfeeding.
A young infant 1-month-old has a nose No, nose block can produce false chest indrawing. It
block. Health Worker sees chest indrawing. should be cleared before deciding if chest indrawing
Is it considered to be present or not? is present or not.

DRILL: REVIEW CHECKING FOR POSSIBLE SERIOUS BACTERIAL
INFECTION
articipants read through “Classify the Young Infant for Possible Serious Bacterial Infection
P
/ Jaundice’
3.3 DEMONSTRATION: Introduce the classification tables and how to classify Young Infant
for Possible Serious Bacterial Infection/Jaundice
When all participants have read section Assess Possible Serious Bacterial Infection/Jaundice. Ask
participants to gather for a demonstration.
Materials needed:
Project the Classification Table -Possible Bacterial Serious Infection/Jaundice.
To conduct the demonstration:

Ask if there are any questions about recognizing signs for assessing a young infant such as: count
the number of breaths in one minute, look for chest indrawing.
When there are no further questions, tell participants that the purpose of the demonstration is to
introduce the classification tables for possible serious bacterial Infection / jaundice and how to use
them to classify a sick young infant for possible serious bacterial Infection/Jaundice. Depending on
the combination of the young infant’s signs and symptoms, the young infant is classified in either
the pink, yellow, or green row.
Pink classification: POSSIBLE SERIOUS BACTERIAL INFECTION

OR
Yellow classification: LOCAL BACTERIAL INFECTION
OR
Green classification: INFECTION UNLIKELY
Here is the classification table for possible serious bacterial infection / Jaundice.
1. Look at the pink (or top) rows.
Does the young infant have any of the signs of possible serious bacterial infection?
If the young infant has any of the signs of possible serious bacterial infection, select the severe
classification, POSSIBLE SERIOUS BACTERIAL INFECTION.
2. If the young infant does not have the severe classifications, look at the yellow rows.
This young infant does not have a severe classification. Is the umbilicus red or draining pus?
Does the young infant have skin pustules?
3. If the young infant does not have any signs of bacterial infection, look at the green row.
Whenever you use a classification table, start with the top row. In each classification table, a
young infant receives classifications in one colour only. If the infant has signs from more than
one row, always select the more serious classification.

Remember:
• All young infants must be assessed for possible serious bacterial infection
• A young infant who has even one sign of possible serious bacterial infection has the
classification Possible Serious Bacterial Infection (pink classification). Refer this young
infant promptly to hospital.
• A young infant who has no sign of Possible Serious Bacterial Infection but has signs of local
bacterial infection has the classification Local Bacterial Infection (Yellow classification). This
young infant can be treated at home with medicines.
• A young child who has no signs of serious or local bacterial infection has the classification
Infection Unlikely (Green classification). The caretaker of this young infant should be advised
to give proper home care.
• If the infant has jaundice, choose an additional classification from the jaundice classification
table.
• If the infant has signs in the pink row for jaundice, classify as SEVERE JAUNDICE. If the
infant has none of the signs in the pink row, but has the sign in the yellow row, classify him
as JAUNDICE. If the infant has no signs of jaundice from pink or yellow row, classify him
as NO JAUNDICE.
When all discussion is complete, tell the participants that they will now watch a video-1.
3.4.1 Video demonstration – Assessing for Possible Serious Bacterial Infection

When all the participants are ready, arrange for them to move to where the video exercise will be
shown. Make sure they bring their modules and chart booklet.
Show the video exercise (Video-1 on Assess very severe disease):

Tell participants that they will watch a demonstration of how to assess a young infant for possible
bacterial infection. The video will show examples of abnormal signs.
Ask if participants have any questions before you start the video. When there are no additional
questions, start the video.
Show the video. Follow the instructions given in the video. Pause the video and give explanations
or discuss what the participants are seeing as needed to be sure the participants understand how to
assess these signs.
At the end of the video, lead a short discussion. If the participants are not clear about the assessment
of any signs, rewind the video and show the relevant portions again.
Important points to emphasize about the assessment in this video are:

• It is particularly difficult to count breathing rate in a young infant because of irregular breathing.
Repeat count, which is 60 or more.
Now show them Video 2 on counting respiratory rate and Video 3 on looking for chest
indrawing.

3.5 DEMONSTRATION: Introduce the recording form
Materials needed to do this demonstration: Laptop and projector
• Blank Recording Form (infant <2 months)
When all the participants are ready, introduce the form by briefly mentioning each part of the form
and its purpose. Use enlarged recording form, to help participants see each part as you refer to it.
For example:
“This is a recording form. Its purpose is to help you record information collected about the infant’s
signs and symptoms when you do exercises in the module and when you see infants during clinical
practice sessions.
There are 2 sides to the form. The front side is similar to the ASSESS & CLASSIFY section. The
other side of the form has spaces for you to use when you plan the infant’s treatment. In this module,
however, you will use the front side only. You will learn how to use the reverse side later in the course.
Look at the top of the front side of the form (Point to each space as you say). There are spaces for
writing:
• the infant’s name, age and temperature.
• the mother’s answer about the infant’s problems.
• whether this is an initial visit or follow-up visit.
Look at how the recording form is arranged. Notice that:

• the form is divided into 2 columns: (Point to each column as you mention it) one is for “Assess”
and the other is for “Classify.” These two columns relate to the Assess and Classify columns on
the ASSESS & CLASSIFY poster.
• Point to the relevant columns on the poster and then on the Recording Form to show their
correspondence.
Look at the Assess column. It shows the assessment steps for assessing the infant’s signs and
symptoms.
Here is the Assess column on the recording form where you record any signs and symptoms that you
find are present.
Here on the form is where you will record information about (point as you say the name) possible
serious bacterial infection, diarrhoea, feeding problem, malnutrition and anemia. You can see that
the assessment steps under the main symptom on the chart booklet are the same as on this form.
There is also a section for recording information about the infant’s immunization status.
• There is a ‘Classify’ column in the chart booklet, and a ‘Classify’ column in the recording form.
You record the infant’s classification in the column of the recording form.
• When you use the recording rorm to do exercises in this course or when you are working with
sick children during clinical sessions.
• circling any sign that is present, like this (circle a sign on the recording form). If the infant does
not have a sign, you do not need to circle anything.

• ticking Yes if a main symptom is present or No if it is not present. (point to the Yes/No blanks
after each symptom assessment question on the enlargement.)
• writing specific information in spaces such as the one for recording the number of breaths per
minute (point to where this numbers is written) or the number of days a sign or symptom has
been present (point to the “for how long?” question in the diarrhoea section).
Writing the classification of the main symptom
As you work through the exercises in this module, you will only see the part of the form for the main
symptoms and signs you have learned.
At the end of the demonstration, ask if there are any questions.
3.6 Practice Exercises on Assessment and Classification for Possible Serious

Bacterial Infection
Ask the participants to keep their recording forms and pen ready. Slowly read out the case history
and/or write it out on a flip chart or blackboard. Explain that they should tell a facilitator when they
have completed their work on the exercises, and that the facilitator will, discuss their answers with
them individually.
Case 1: Rekha
Rekha is 20 days old female. She has a breathing rate of 66 per minute, moves only when stimulated.
Since she has two signs present in the pink classification box and none in the yellow classification
box. So, you will select the pink classification - POSSIBLE SERIOUS BACTERIAL INFECTION.
What is the correct classification? Possible Serious Bacterial Infection
Case 2: Amit
Amit is 45 days old male. He has skin pustules over his skin on the abdomen. He has no signs in the
pink classification box. Has one sign in the yellow classification box, so you will select the yellow
box classification – LOCAL BACTERIAL INFECTION
What is the correct classification? Local Bacterial Infection
Case 3: Meena
Meena is 15 days old female. She feels hot to touch, has no movements even when stimulated and
has pus draining from the umbilicus.
She has two signs in the pink classification box and one sign in the yellow classification box.
She has signs in both the classification boxes but you have to choose only one classification
for possible serious bacterial infection. Whenever you use a classification table, start with the
top row. In each classification table, a young infant receives classifications in one colour only.
If the infant has signs from more than one row, always select the more serious classification. So, you
will select the classification from the pink box- POSSIBLE SERIOUS BACTERIAL INFECTION.
Classify Meena? Possible Serious Bacterial Infection

3.7 Conduct Group discussion of photographs of a young infant’s umbilicus and
skin pustules
Talk about each of the first 3 photographs, pointing out or having participants point out and tell
how they recognize the signs.
For each photograph, ask a participant to explain what they see in the photograph. Discuss as
necessary so that participant understands how to recognize an infected umbilicus.
Photograph 1: Normal umbilicus in a newborn

Photograph 2: This is an umbilicus with redness extending to the skin of the abdomen
Photograph 6: This infant has skin pustules.
Now ask the participants to write their answers for photographs 3-5.
Umbilicus Normal Redness or draining pus

Photograph 3 √
Photograph 4 √
Photograph 5 √ (pus)

SECTION
ASSESS & CLASSIFY YOUNG INFANT FOR

4 DIARRHOEA
In this section the participants will learn:

• What questions are to be asked to a mother for a child with diarrhoea
• How to assess and classify a child who is having diarrhoea
4.1
Participants read ‘Assess Young Infant for Diarrhoea’ through ‘Classify
Young Infant for Diarrhoea’
4.2 DEMONSTRATION: Classify Dehydration

When all the participants have read through Assess and Classify Diarrhoea, gather the participants
together for a short demonstration.
Materials needed: Laptop and projector

• Blank Recording Form
• Classification table - Dehydration
To conduct this demonstration:

1. Briefly review with participants the steps for classifying Possible serious bacterial infection.
2. Introduce the enlarged classification table for diarrhoea. Explain that classifying diarrhoea is
slightly different than classifying Possible serious bacterial infection.
• All young infants with diarrhoea are classified for dehydration. There are two pink classification
box in the classification table for the signs of SEVERE and SOME DEHYDRATION which
means that infants classified with either of the conditions will require urgent referral after giving
first dose of antibiotics. To select a classification for dehydration, the young infants must have
two or more of the signs in either of the pink classification box. One sign is not enough to select
a classification. If the young infant has only one sign in a classification box, look at the next
classification box.
• If the young infant does not have enough signs to classify severe or some dehydration, select the
green (third) classification box and classify the infant as NO DEHYDRATION.
4.3 Conduct Video -4 Exercise:

Show the Video-4 on assessing dehydration. Tell the participants that they will:
• See examples of children with diarrhoea who have signs of dehydration
• Watch a demonstration of a diarrhoea assessment and how to classify dehydration; and
• Do an exercise to practice recognizing skin pinch

4.4 Exercise: Assess and classify for diarrhoea
Case 1: Neera
Neera is 7 weeks old female. Her weight is 3.0 kg. Her temperature is 37°C. Her mother has brought
her because she has diarrhoea. The health worker first assesses her for signs of possible serious
bacterial infection. The mother says that Neera has not had convulsions. The health worker counts
her breathing and finds she is breathing 58 breaths per minute. She was sleeping in her mother’s
arms but woke up when her mother unwrapped her. She has slight chest indrawing. Her umbilicus
is not red or no draining pus. There are no pustules. She is crying and moving her arms and legs.
When the health worker asks the mother about Neera’s diarrhoea, the mother replies that it began 3
days ago. Neera is still crying. She stopped once when her mother put her to the breast. She began
crying again when she stopped breastfeeding. Her eyes look normal, not sunken. When the skin of
her abdomen is pinched, it goes back slowly. What is her classification?
Some dehydration, AS THE SIGNS PRESENT ARE Irritability and Skin pinch goes back slowly.

SECTION
CHECK FOR FEEDING PROBLEM AND

5 LOW WEIGHT FOR AGE
In this section the participants will learn

• To assess feeding in the young infant
• To classify feeding problem and low weight for age
5.1 Participants read “Check for Feeding problem & Low Weight for age”
5.2 Participants read ‘Assess Breast feeding’ and ‘Classify for Feeding Problems’
5.3 Conduct Video Demonstration (Video 5 on assessing breastfeeding)
EXERCISE – Part I: Check for Feeding Problem
• Tell participants that they will see a demonstration of assessing feeding. In particular, they will
see how to assess breastfeeding. Point to the enlargement and review the steps of assessing
breastfeeding.
• The video will show examples of the signs of good and poor attachment and effective and
ineffective suckling.
• At the end of the video, lead a short discussion. If participants are not clear about the assessment
of any signs, rewind the video and show the relevant portions again.
Important points to emphasize in the discussion are:
• The four signs of good attachment (point to these on the enlargement as you review them).
• An infant who is well attached does not cause any pain or discomfort to the breast. Good
attachment allows the infant to suckle effectively. Signs of effective suckling are:
- The infant suckles with slow deep sucks.
- An infant who is suckling effectively may pause sometimes and then start suckling again.
• An infant who is suckling effectively may pause sometimes and then start suckling again.
Remember that the mother should allow her baby to finish the feed and release the breast himself.
A baby who has been suckling effectively will be satisfied after a breastfeed.
5.4 Conduct Group Discussion of Photographs on Breast feeding Assessment.

Project the photographs on the screen.
• Talk about each of the photographs (13-21), pointing out or having participants point out and tell
how they can see each sign of good or poor attachment. Participants should write responses of
each photograph in their module.

Photographs 13-21: Assessment of breastfeeding
Photo Signs of Good Attachment Assessment Comments

Chin Mouth Lower Lip More Areola
Touching Wide Turned Showing Above
Breast Open Outward
13 Yes Yes Yes Yes Good attachment
(almost)
14 No No Yes No (equal above Not well attached
and below)
15 Yes No No Yes Not well attached Lower lip
turned in
16 No No No No Not well attached Cheeks
pulled in
17 Yes Yes Yes Cannot see Good attachment
18 No No Yes No (equal above Not well attached
and below)
(almost)
21 Yes No No No (more below) Not well attached Lower lip
turned in
Photographs 22 and 23: White patches (thrush) in the mouth of an infant.
5.5 DEMONSTRATION: Classify Feeding Problem & Low Weight for Age
Materials needed: Laptop and projector

• Blank Recording Form
• Classification Table – Feeding Problem & Low Weight for Age
To conduct this demonstration:

• Briefly review with participants the steps for classifying Feeding Problem & low weight for age
• Display the enlarged section of the poster:
• Tell participants that there are three sections in this table, The second and third rows deal with
assessing feeding.
• Look at the top row.
• A young infant with weight less than 1800 gm in infants less then 7 days/ weight for age <-3SD
in infants 7-59 days old (Red on MCP card) has the signs Very Low Weight.
• A young infant with weight between 1800 to 2500 gm or weight for age <-2SD (Yellow on MCP
card) will be classified as Feeding Problem and/ or Low Weight.
• Now assess for breastfeeding.
- If the infant is not breastfed at all, do not assess breastfeeding.
- If the infant has a serious problem requiring urgent referral to a hospital, do not assess
breastfeeding. In these situations, classify the feeding based on the information that you have
already.

• Observe a breastfeed. Low weight-for-age is often due to low birth weight. Low birth weight
infants are particularly likely to have a problem with breastfeeding.
• Remember that the mother should allow her baby to finish the feed and release the breast himself.
A baby who has been suckling effectively will be satisfied after a breastfeed.
• A young infant with no signs in the Pink classification box and is having any of the signs,
breast or nipple problem or not well attached to breast or not suckling effectively or less than 8
breastfeeds in 24 hours or received other foods or drinks or thrush, has the classification feeding
problem and/or low weight.
• If a young infant has no other signs of inadequate feeding, has the classification no feeding
problem.
•
REMEMBER:
At least one classification needs to be picked in all Young Infants
Home Visits for Young Infants

Tell the participants that they can play an important role in improving the new born care in their
area by educating the community and counselling the mother about home care of a young infant
and children. This is possible only if home visits are conducted and families provided guidance in
looking after these young infants.
Keep track of all births in the area so that they learn about a birth within 24 hours. Perform the first
home visit at the earliest, preferably on the day of birth. Before going for the home visit, ensure that
they have the following with them:
• Weighing scale (use the one available at the Anganwadi)
• Chart booklet
• Recording form and a pen
At the first visit, perform the following tasks:

Greet the family and ask the mother if she and her baby are well
When you see the mother and her new born infant, introduce yourself to the family and greet them
appropriately. Ask if the new born is well to open a dialog with the family.
If the mother is unable to answer because she is in pain or is tired or sleepy, ask another family
member who is taking care of the baby.
Communicate the purpose of home visits to the mother and the family
Tell the family that the purpose of your visit is to help them provide essential newborn care to
keep the baby healthy and growing well. Explain to them that this is possible through exclusive
breastfeeding, keeping the baby warm, taking care of the cord and early recognition and treatment
of any illness. Tell the family that you will check if the baby is well. Also inform the family that you
will visit again several times over the next 4 weeks.

Check for signs of Possible Serious Bacterial Infection
Use the ASSESS AND CLASSIFY THE YOUNG INFANT chart as you have learnt earlier.
Ask if the newborn has diarrhoea
Diarrhoea is not a problem in the first week of life. If the mother says that her baby has diarrhoea,
reassure her. (At home visit after 1 week of age, assess and classify for diarrhoea if the mother says
that the young infant has diarrhoea).
Check for feeding problem
Use the ASSESS AND CLASSIFY THE YOUNG INFANT chart as you have learnt earlier.
Record weight and decide the schedule of subsequent home visits
The schedule of subsequent visits is based on birth weight. The recommended schedule for home
visits is outlined below:
All babies 3, 7 days

Low birth weight babies (weight less 3, 7, 14, 21, 28 and 42 days
than 2.5 kg)

SECTION
ASSESS ANY OTHER PROBLEM,
6 IMMUNIZATION STATUS AND
DEVELOPMENT SUPPORTIVE PRACTICES
Participants read ‘Assess any other problem’ and ‘Check Immunization status’, ‘Assess the mother/
caregiver’s development supportive practices and counsel for practices to support child development
using MCP card.
Case 1: Neera
Neera is 7 weeks old female. Her weight is 3.0 kg. Her temperature is 37°C. Her mother has brought
her because she has diarrhoea. The health worker first assesses her for signs of possible serious
bacterial infection. The mother says that Neera has not had convulsions. The health worker counts
her breaths and finds she is breathing 58 breaths per minute. She was sleeping in her mother’s arms
but awoke when her mother unwrapped her. She has slight chest indrawing. Her umbilicus is not red
or no draining pus. There are no pustules.
She is crying and moving her arms and legs. When the health worker asks the mother about Neera’s
diarrhoea, the mother replies that it began 3 days ago. Neera is still crying. She stopped once when
her mother put her to the breast. She began crying again when she stopped breastfeeding. Her eyes
look normal, not sunken. When the skin of her abdomen is pinched, it goes back slowly.
The mother says that she has no difficulty feeding her. She breastfeeds about 5 times in 24 hours. She
gives her cow’s milk 3 times by bottle for last 10 days. The worker uses the weight-for-age chart and
determines that Neera has very low weight.
Answer
Since Neera’s mother is feeding less than 8 times in 24 hours and is taking other foods or drinks, there
is feeding problem. However there is an indication for urgent referral so breastfeeding assessment
was not done.

SECTION
7 IDENTIFY TREATMENT
7.0 Participants complete reading section ‘Identify treatment’
Briefly introduce the section by explaining that it describes the final step on the ASSESS & CLASSIFY
section: “Identify Treatment.”
7.1 Demonstration: How to identify treatment and using back of recording form
Conduct a demonstration on identifying treatment. Illustrate it with some examples. Pointing to

the poster, explain how to read across the poster from each classification to the list of treatments
needed. Point to the treatments listed for POSSIBLE SERIOUS BACTERIAL INFECTION and
read them aloud (or have a participant read them aloud). Point to the treatments listed for diarrhoea
with NO DEHYDRATION and read them aloud (or have a participant read them aloud). Ask a
participant to point to the classification SOME DEHYDRATION. Then ask that participant to read
aloud the treatments.
Explain that severe classifications usually require referral to a hospital.
Explain what is meant by “hospital”: a health facility with inpatient beds and supplies and
expertise to treat a sick child.
Explain that this section does not describe how to do the treatments, but simply how to identify
which treatments are needed. Participants will learn how to do the treatments in the section Treat
the Young Infant.
7.2 Exercises on Identify Treatment
In this exercise you will decide whether or not urgent referral is needed. Tick the appropriate answer.
1. Sarla is an 11-day-old girl. She has the classification:

LOCAL BACTERIAL INFECTION
NO FEEDING PROBLEM
Does Sarla need urgent referral? YES NO 

Identify the treatment she needs:
• Give oral amoxycillin twice daily for 5 days
• Teach mother to treat local infections at home
• Advise Mother to Give Home Care to the Young Infant
• Advise the Mother to Return Immediately if the Young Infant has any Danger Signs:
• Follow up in 2 days

2. Neena is a 6-week-old girl. She has the classification:
POSSIBLE SERIOUS BACTERIAL INFECTION
Does Neena need urgent referral? YES  NO
What is the pre-referral treatment that she needs?

• Give first dose of oral amoxycillin and intramuscular gentamicin.
• Treat to prevent low blood sugar.
• Advise the mother how to keep the young infant warm on the way to the hospital.
• Refer URGENTLY to hospital
3. Hanif is a 7-day-old boy. He has the classification:

Diarrhoea with NO DEHYDRATION and
FEEDING PROBLEM
Does Hanif need urgent referral? YES NO. 
4. Habib is a 19-day-old boy. He has:

LOCAL BACTERIAL INFECTION
POSSIBLE SERIOUS BACTERIAL INFECTION
Does Habib need urgent referral? YES  NO

SECTION
8 TREAT THE YOUNG INFANT
8.0 Introduce the section

State briefly that it will teach health workers how to use the TREAT section. The chart booklet
contains information on how to provide treatment to sick young infant and how to teach the mother
to continue providing treatment at home.
The TREAT section is organized into several main sections. As you mention a section, point to it on
the poster. The sections are:
• Give oral amoxycillin and IM gentamicin
• Treat the young infant to prevent low blood sugar
• Teach the mother how to keep young infant with low weight warm at home
• Teach the mother to give oral drugs at home
• Teach the mother to treat local infections at home (skin and umbilical infection & thrush)
• Teach correct positioning and attachment for breastfeeding
• Teach the mother to treat breast and nipple problems
• Teach the mother to express breastmilk and feed with a cup and spoon (donor humar milk/
animal milk)
• Teach mother/caregiver where there is no prospects of breastfeeding or has to give replacement
feeds temporarily
• Advise mother to give home care
• Counsel the mother about her own health
• Assess the mother /caregiver development supportive practices
• Advise the mother to return immediately if the young infant has any danger signs
This section will teach how to give the treatment described in each section.

8.1 Discuss giving pre-referral gentamicin
Dosage: 5-7.5 mg/kg/day

Discuss as given in the section.
• Route of administration: intramuscular
• Site of Injection: Antero-lateral aspect of the thigh
Preparation: Prefer to use 20 mg/ ml strength (may be prepared by adding 2 ml sterile water in 80
mg/ 2 ml vial i.e. total volume 4 ml giving strength of 20 mg/ml).
Choose the dose from the row of the table that is closest to the infant’s age and weight.
Storage: Gentamicin is a heat stable drug and can be maintained at room temperature. There is no
need for refrigerator/cold chain maintenance for the storage of the drug.
• Syringe and needle: 1 ml disposable syringe with 23 Gauge needle should be used. Alternatively,
insulin syringe could be used. Auto disposable syringes provided for immunization should not
be used because of varying dosage marking.
• Duration of treatment: Total duration of treatment is 7 days. In cases of follow up treatment, the
health worker may follow the advice as per the discharge ticket/ doctor’s prescription.
8.2. ROLE PLAY – Counselling a mother for referral

Give the “mother” the situation described below. Remind her that she may make up additional
realistic information that fits the situation if necessary.
After the role play, use questions to lead a group discussion.
Role Play - Description for Sharad’s Mother
You have a 3-week-old son named Sharad weighing 3 kg. He has difficulty in breathing. Thehealth
worker has already explained to you that Sharad needs urgent referral.
You are timid with the health worker and do not volunteer information unless asked. You have
come a long way to the clinic and you are tired. You are reluctant to go to the hospital because
transportation is difficult for you as you have no money and your husband is away at work. You
are also concerned about where to leave your 2-year-old elder daughter, if you were to go away
to the hospital. You also have concerns about how to manage yourself in a large hospital in a
large city.

Role Play Instructions
Health workers: Explain the need for referral to Sharad’s mother and give her instructions. Discuss
any problems she may have about going to the hospital. Assume that the hospital is about an hour
away and that transportation is similar to what is available in your own area. If you have a telephone
in your own clinic, assume that one is available in the role play.
Observers:
Tell them to watch the role play. Be prepared to comment on what was done well and what could
be improved. Be prepared to answer the questions:
Questions:
Is this mother likely to go to the hospital? Why or why not?
Has she been given all the necessary instructions? If not, what information was missing?
Discussion on common problems in referral

After the role play lead a discussion on common problems in referral. Information in the following
table can be used to relate to the role play as well as general discussion.
Problems Possible solutions

Mother is not convinced about seriousness Explain what harm can occur if the treatment is delayed. Give
of the illness examples of children with similar disease who suffered from
complications or died because of delay of even a few hours
in taking to the referral facility.
Mother is scared of the treatment andtests Tell the mother what to expect. Explain that the treatment is
carried out in the hospital. for helping the child get better. The injections, IV and tests do
cause some pain but are not harmful for the child.
Family does not have faith in the services Give examples of children who have recovered from their
provided by the referral centre. They illness as a result of timely referral. Emphasize that the purpose
have heard of a of a bad outcome in other of referral is to provide the best treatment for the child.
children.
The family have heard that the hospital Tell the mother that you are providing a referral card which
staff are rude. will help the family get priority treatment. Explain that it is
worthwhile to bear some inconvenience resulting from hospital
treatment and staying in a strange unfamiliar place because
the child will be cured.
The family is worried about large expenses Discuss with the mother what expenses are likely to occur and
from hospital admission,transport and how the family may be able to arrange these to meet the situation.
expenses on food. Some hardship is going to occur but this is worth the trouble since
it involves the well-being of the child.
The family is worried about who willlook Discuss the possibility of another member of the household
after the other children while themother doing this job. Suggest that neighbours or relatives may be
and the child are gone to the hospital. approached for help during this crisis situation.
The mother wonders why the treatment Explain that you can treat most of the diseases but not all of
cannot be provided by you. them. If the disease requires IV fluids, oxygen or medicines by
injection then hospital treatment is the best. Clarify that it is not
possible for you to do certain tests on the child. They are carried
out only in hospitals.

8.3. Participants read through ‘Teach mother how to keep young infant with low
weight warm at home’
8.4. Participants read through ‘Treat the young infant through steps of giving oral
drugs’
Demonstration on selecting amount of drug for pre referral treatment of Sharad.
Group Discussion: How to give oral drugs at home
Summarize: Emphasize the following points about giving oral drugs at home
• Determine the appropriate drugs and dosage for the infant’s age or weight.
• Tell the mother the reason for giving the drug to the infant.
• Demonstrate on how to measure a dose.
• Watch the mother’s practice for measuring a dose by herself.
• Ask the mother to give the first dose to her infant.
• Explain carefully how to give the drug, then label and pack the drug.
• Explain that all the oral drug tablets or syrups must be used to finish the course of treatment,
even if the infant gets better.
• Check the mother’s understanding before she leaves the clinic.
8.5 Conduct Drill: Asking good checking questions
Rephrase the following questions as Examples of possible CHECKING

good checking questions QUESTIONS
• Will you give your infant the Syrup as we • When will you give your infant the Syrup?
discussed? • How much of the syrup will you give as one dose?
• You should breastfeed your infant when he has • How will you feed your infant when he has
diarrhoea, correct? diarrhoea?
• When should you breastfeed him?
• Do you know how to give your infant 2.5 ml • Show me how you will give 2.5 ml amoxycillin
amoxycillin syrup? syrup to your infant.
• When will you give the amoxycillin syrup?
• Do you know how to apply gentian violet paint • How will you apply gentian violet paint?
to your infant? • How often will you apply gentian violet paint?
• Can you take your infant to the hospital? • Who will take your infant to the hospital?
• How will you travel with your infant to the
hospital?
• Will you return for a follow-up visit? • When will you return for a follow-up visit?
• Do you know when to return?

8.6 DEMONSTRATION: Warm the Young Infant using skin-to-skin contact
(Kangaroo Mother Care)
Material Needed:
• Laptop and projector
• Section: Warm the Young Infant Using Skin-to-Skin Contact (Kangaroo Mother Care)
• A Baby Doll
8.6.1. Review the steps written in the section.

• Provide privacy to the mother. If mother is not available, skin-to-skin contact may be
provided by the father or any other adult.
• Request the mother to sit or recline comfortably.
• Undress the baby gently, except for cap, nappy and socks.
• Place the baby prone on mother’s chest in an upright and extended posture, between her breasts,
in skin-to-skin contact; turn baby’s head to one side to keep airways clear
• Cover the baby with mother’s blouse, ‘pallu’ or gown; wrap the baby-mother duo with an added
blanket or shawl.
• Breastfeed the baby frequently.
• If possible, warm the room (>25oC) with a heating device.
• Skin-to-skin contact is the most practical, preferred method of warming a hypothermic infant in
a primary health care facility.
8.7. Participants read ‘Teach the mother to Treat Local Infections at Home’
through ‘Treatment of Diarrhoea - Plan A’
Highlight that ORS Should be used only when stools are watery and other home available fluids
should not be used in young infants.
8.8. Participants read ‘Counsel the Mother of a Young Infant with the Classification
‘Feeding Problem or low weight’ through ‘Common Breastfeeding Problems and
Possible Solutions’

8.9. Video-6 demonstration of how to teach correct positioning and attachment
for breastfeeding- EXERCISE- Part I
When all the participants are ready, arrange for them to move to where the video will be shown.
Make sure they bring their modules.
To show the video demonstration:

• Tell participants that they will watch a demonstration of helping a mother to improve positioning
and attachment for breastfeeding.
• Ask if participants have any questions before you start the video. When there are no additional
• At the end of the video, lead a short discussion. Ask participants to look at the box, “Teach
Correct Positioning and Attachment for Breastfeeding.” Explain that the video showed exactly
these steps. Then make the following points:
- Good positioning is important for good attachment. A baby who is well positioned can
take a good mouthful of breast. (As you speak, point to the steps on the enlargement).
- Review the four steps to help her position the infant.
- When you explain to a mother how to position and attach her infant, let her do as much
as possible herself.
- Then review the 3 steps to help the infant to attach.
- Check for signs of good attachment and effective suckling. It may take several attempts
before the mother and baby are able to achieve good attachment.
- If participants are not clear about the steps, rewind the video and show it again.
8.10 Group discussion of photographs-Recognizing signs of good positioning

Display the enlargement of “Teach Correct Positioning and Attachment for Breastfeeding” from
24-29.
For each photograph, ask a participant to explain the signs of good or poor position (such as baby’s
body is twisted away from mother). After the photograph has been assessed, ask a participant what
he would advise this woman to do differently to improve her baby’s position (for example, hold
the baby closer to her body, with the baby’s head and body straight). During this discussion, have
the participants continually refer to the enlargement (or to the box on the YOUNG INFANT section,
“Teach Correct Positioning and Attachment for Breastfeeding”) so that they repeat and learn all the
correct steps.

Photographs 24-29: Assessment of correct positioning and attachment
Photo Signs of Good Positioning Comments onAttachment

Infant’s Head and Infant’s Supporting
Head Body Body Infant’s Whole
and Body Facing Close to Body
Straight Breast Mother’s
24 Yes Yes Yes Yes
25 Yes Yes Yes Yes
26 No-neck No No-turned No Not well attached: mouth
turned, so away from not wide open, lower lip
not straight mother’s not turned out, areola equal
with body body above and below
27 No No-body No-body No-only neck Not well attached: mouth
turned away not close and shoulders not wide open, lower lip
supported not turned out, more areola
below than above
28 Yes Yes Yes-very Yes Good attachment: chin
close touching breast
29 No-head No-body No-not No-only neck Not well attached: mouth not
and neck turned close and shoulders wide open
twisted away supported
and bent
forward,
not straight
with body
8.11 Conduct role play to stress the basic steps of communication when counselling
the mother.
Objective
The objective of the role play is to learn the different steps of communication which include the
following:
• Asking the mother important questions and listening to her response
• Identifying what she is doing right and where she is making mistakes
• Praising her when appropriate
• Advising the mother using simple language and giving relevant advice
• Solving her problems
• Check mothers understanding by asking selected questions
•
Description for the mother
This is a scripted role play about Manu, a 1-month-old infant who is being breastfed but whose
mother feels that the breast milk is not enough. She is giving some water and tea to Manu since she
feels that the child should get used to foods and fluids other than breast milk.

Description for the Health Worker
• The facilitator should demonstrate the role of the health worker

• It is necessary to read the script carefully and, as much as possible, learn it before the role play.
• Use a baby doll as a prop.
• For the participants not playing the roles, write the communication skills on flip chart or
blackboard before the role play:
ASK AND LISTEN

PRAISE
ADVISE
CHECK UNDERSTANDING
Ask participants to identify the feeding problems discussed in the role play. Determine if they can
identify and illustrate the steps and skills of communication.
Feeding problems, which should be summarized in this role play, are:
• low frequency of breast feeding;

• water and tea given to the child; and,
• the child not getting breastfeed when the mother goes out to work.
Summarize the role play

Emphasize that, at this stage that participants need not worry about the technical aspects of counselling
but they should be convinced that talking to mothers is important and they should become familiar
with the steps of communication. While summarizing the role play, lay stress that it is important to
ask the mother questions, and listen to her response, praise her for what she is doing right, then
advise her on important aspects. She may have some problems which must be solved, and finally,
it is necessary to ask some checking questions to be sure that she has understood and is willing to
follow the advice.
SCRIPT FOR DEMONSTRATION ROLE PLAY
Health Worker: I will like to know about Manu’s feeding. What do you feed Manu?
Ask, listen
Mother: I give him breastfeeds about 4-5 times per day.
Health Worker: It is very nice that you are breastfeeding Manu. Breastmilk is the best food for the
Praise baby at this age. However, babies at this age should be given breastfeeds at least 8
Advise times in the day and night. Why are you not breastfeeding Manu more often?
Ask, listen
Mother: I would like to feed him more often but I am working outside the home for about
6-7 hours per day and my breast milk does not seem to be sufficient.

Health Worker: One reason why breast milk is not enough is that the baby does not get the
Advise breastfeed at frequent intervals, that is whenever the baby wants it. If you feed the
Ask, listen baby at more frequent intervals (whenever the baby wants to feed), your milk supply
will be better. Is it possible for you to take Manu with you so that you are able to
feed the baby whenever he is hungry?
Mother: I think it is a good idea to take Manu along to work. I will try to follow your
suggestions, and see if I can breastfeed him more often.
Health Worker: I am very happy that you will be able to take Manu along to work. Do you give
Praise anything else to Manu besides breast milk?
Ask, listen
Mother: Yes, Manu is given some water and some tea in between breastfeeds. This way
Manu is not hungry.
Health Worker: Giving other things at this age spoils all the protection that breastfeeds provide.
Praise If you give other things, then the supply of breast milk becomes less. Therefore, you
Ask, listen should not give water or tea or any other food. I suggest that as soon as you are able
to feed Manu breast milk more often, you can stop tea and water. So, how many
times will you breastfeed Manu?
Mother: I will give him breastfeed at least 8 times during the day and night.
Health Worker: That is very good. You should breastfeed Manu during the day as well as
Praise at night. How often will you put Manu to breast?
Advise
Ask, listen
Mother: I will feed him whenever he appears hungry at least 8 times during the day and
night.
Health Worker: That is very good. I request you to come back if you find any difficulty in breast-
Praise feeding Manu.
8.12. Participants read ‘Advise Mother to give Home Care’, ‘Counsel mother
about her own health’, ‘Assess the mother/ caregiver for development supportive
practices’ and ‘Follow- up care’.
Advise the mother and the family on home care
Exclusive breastfeeding
Ask the mother if she has already put the infant to the breast. If the mother has already started
breastfeeding, praise the mother for starting the breastfeeding. If the mother has not yet started
breastfeeding, prepare her to put the infant to the breast. Talk to the mother and answer any questions
about breastfeeding that she may have.
Emphasize the importance of exclusive breastfeeding and counsel her against giving any other
foods or fluids other than breast milk. Remember to tell her that no extra water is required for an
exclusively breastfed baby even if in hot weather. There is always enough water in breast milk to
protect the baby from getting dehydrated.

How to keep the baby warm?
As in the TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER chart.
When to seek care

As in TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER chart.
Advise the mother and the family on new-born care practices

Counsel mother for her own health
Use information provided in the chart booklet.

Umbilical cord care
Check if the cord is oozing blood because it has not been tied properly. If not tied properly, tie it again
with a thread that has been boiled in water for at least 15 minutes. See if anything has been applied
to the cord. If nothing has been applied, praise the mother and the family. Otherwise emphasize the
importance of not applying anything on the cord and keeping the cord dry.
Bathing the infant

While the baby needs to be kept clean, discourage the mother from giving bath to the baby during
the first day after birth. The mother or the birth attendant can clean the baby by wiping with a soft
moist cloth. When the baby is given a bath, bathing should be done quickly in a warm room, using
warm water.
Low birth weight infants should not be given a bath. Instead, clean the baby with a soft, clean cloth
soaked in lukewarm water.
Hand washing
The mother should wash hands with soap and water after cleaning the baby every time it passes
stools.
Before you leave the house, tell the family that you will visit again as per schedule. However, the
family can contact you for help in case they think the young infant has a problem.
SUBSEQUENT HOME VISITS

Follow the instructions given above for the first home visit at the subsequent visits also. All neonates
regain birth weight in 7-14 days. If baby has not gained birth weight by day-14 of life, assess
breastfeeding and identify cause.
At the last scheduled home visit, ensure that you advise the mother to continue exclusive breastfeeding
upto 6 months and go for BCG, Rotavirus-1, fIPV-1, PCV-1, OPV and Hepatitis B immunization at
6 weeks of age.

Role Play on Home Visit
There are 2 role plays to be conducted by the participants.
This exercise allows participants to practice the entire process covered in conducting the home
visits using the charts. Participants do the whole process using good communication skills and
using the assessment charts.
Highlights of role play 1, Rekha: 6-hour-old baby who is low weight has still not been put to
breasts but has been given pre lacteal feeds. Health worker must explain early initiation of breast
feeding and home care of a baby with low weight. This includes:
1. Advise mother how to keep the young infant with low weight or low body temperature warm at
home
2. Breastfeed frequently and for as long as the infant wants, day or night, during sickness &
healthy times
3. When to seek care for illness
Highlights of role play 2, Barkha: 7-day-old baby has normal weight and has a skin infection.
Mother is worried about transitional stools. Health worker must explain how to treat local infection
and reassure the mother.
Assign roles and conduct the role plays as follows:
1. Assign the role of health worker in each role play to a different participant. Encourage these
participants to take several minutes to review the relevant assessment chart. Tell them they
should be prepared for the mother to behave like a real mother, to ask questions, etc.
2. Assign the role of the mother in each role play to a different participant (If there are not enough
women, men can play the role of mothers). Give each mother a slip of paper describing the
situation, and her attitude. These slips of paper are provided below and on the next page of this
guide and may be photocopied or cut out. Tell the “mothers” that they may make up additional
realistic information that fits the situation if necessary. Help them prepare to play the role.
3. Conduct each role play. During the role play, observers should complete the sections of the
assessment charts printed in the module. They should be prepared to answer and discuss the
questions given in the module.
4. After each role play, lead a brief discussion. Ensure that positive comments are made as well as
suggestions for improvements (Note: If the health worker in the first role play does not properly
explain the recommendations for initiation of exclusive breast feeding, be sure to explain them
in this discussion).

Role Play 1 - Description for the mother
You are the mother of Rekha, a 6-hour-old baby who has low weight and has not been started on
breastfeeding yet. Now the health worker is going to ask you some questions, assess your baby
and advise you about home care and when to seek care for illness.
You are worried about Rekha, but you have little milk in your breasts. You are timid when talking
with the health worker, and you are hesitant to ask questions, even when you are confused. You
tend to answer the health worker very briefly so that he or she must ask further questions to get
the necessary information.
Rekha has not been given breast milk but your mother in-law has given some honey. If the health
worker advises you about breastfeeding convey your custom that breastfeeding is started only
after the arrival of the aunt (your husband’s sister) and she is expected today evening.
Role Play 2 - Description for the mother

You are the mother of Barkha, an 7-days-old girl who has normal weight and has skin pustules.
You are worried that baby passes several stools in a day after every feed but the stools do not or do
have separate water. Now the health worker is going to advise you the treatment of skin infection.
You are worried about Barkha and you want some medicine for loose stools. You tend to answer
the health worker very briefly so that he or she must ask further questions to get the necessary
information.
8.13 DRILL: Review of points of Advice for Mothers of Young Infants

Conduct this drill at a convenient time after this point in the module. If possible, do the drill before
the participants go to the last clinical session which should include counseling for mothers of young
infants.
Tell the participants that in this drill, they will review important points of advice for mothers of
infants, including
• improving positioning and attachment for breastfeeding
• home care
They may look at the YOUNG INFANT section if needed, but should try to learn these points so, they
can recall them from memory.
Ask the question in the left column. Participants should answer in turn. When a question has
several points in the answer, you may ask each participant to give one point of the answer. This
will move along smoothly and quickly if participants are setting in a circle or semi-circle and they
reply in order.

QUESTIONS ANSWERS
When advising a mother about Home Care for • Breastfeed frequently
a young infant, what are the five major points • Make sure the young infant stays warm
of advice? • Hand washing
• Not to apply anything on the cord
• When to return
What is the advice to give about •
Breastfeed frequently, as often and for as long as
breastfeeding? the infant wants, day and night, during sickness and
health
• Exclusive breastfeeding is best
• Do not use a bottle
What are the signs to teach a mother to return Return immediately with the infant if:
immediately with the young infant? • Breastfeeding or drinking poorly
• Becomes sicker
• Develops fever
• Fast breathing
• Difficult breathing
• Blood in stool
What is another reason that a mother may Return for a follow-up visit as scheduled. Return for
return with the young infant? immunization.
QUESTIONS ANSWERS
If a young infant has a feeding problem, In 2 days
when should the mother bring him back for
follow-up?
What advice would you give about keeping In cool weather, cover the infant’s head and feet and
the infant warm? dress the infant with extra clothing
What are the four signs of good attachment? • Chin touching breast
• Mouth wide open
• Lower lip turned outward
• More areola visible above than below the mouth
Describe effective suckling The infant takes slow, deep sucks, sometimes pausing
When you help a mother hold and position Show her how to hold the infant
her infant for breastfeeding, what are 4 points - with the infant’s head and body straight
to show her? - facing her breast, with infant’s nose opposite her
nipple
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and
shoulders
When the infant has attached, what Look for the signs of good attachment and effective
should you do? suckling
Again, what are the signs of good • Chin touching breast
attachment? • Mouth wide open
• Lower lip turned outward
• More areola visible above than below the mouth
If attachment or suckling is not good, • Ask the mother to take the infant off the breast.
what should you do? • Help the mother position and attach the infant again

SECTION
9 ASSESS AND CLASSIFY THE SICK CHILD

FOR GENERAL DANGER SIGNS AND
COUGH OR DIFFICULT BREATHING
9.1 DEMONSTRATION: “Introduce the Module and Steps of Assessment”
Material Needed:
• Laptop and projector
If the child is 2 months upto 5 years, select the appropriate section. “Upto 5 years” means the child
has not yet had his fifth birthday. (Be sure that participants understand “upto” means upto but not
including that age).
Stress the 3 basic steps which include the Assessment, Classification and Identify Treatment.
These 3 steps must be carried out in a sequence. First assess as recommended, then classify and
finally, choose treatment for conditions marked under classification.
The chart-booklet has 3 colors to guide treatment which the participants have already learnt
The purpose of this demonstration is how to assess and classify children according to the process
described on the chart-booklet ASSESS AND CLASSIFY SICK CHILDREN AGED 2 MONTHS
UPTO 5 YEARS. Tell them that by learning how to use the process shown on the chart-booklet,
participants will be able to identify signs of serious disease such as pneumonia, diarrhoea, malaria,
malnutrition and anemia.
• Tell participants that as for the young infant, this section also has three main sections. They are
indicated by three headings: Assess, Classify and Identify Treatment.
• Point to each heading and column. Explain that this module will teach participants how to
assess and classify. Later, they will learn how to identify treatment.
• Ask the mother about the child’s problem.
• Check for general danger signs.
• Ask the mother about the main symptoms:
- cough or difficulty in breathing
- diarrhoea
- fever
• When a main symptom is present:
- assess the child further for signs related to the main symptom.
- classify the illness according to the signs which are present or absent.
• Check for signs of malnutrition and anemia & classify the child’s nutritional status.
• Check the child’s immunization, vitamin A, deworming and prophylactic IFA status and
decide if the child needs any immunizations, deworming therapy, vitamin A and IFA.
• Assess any other problems.

9.2 Participants read ‘Check for General Danger Signs’.
9.3 Conduct Video-7 Exercise - ‘Check for General Danger Signs’
Show them the video and ask them to do the exercises mentioned in the video.
To conduct this video exercise:
Introduce the participants to the procedure for video exercises in this course. Explain that during
1.
the video exercises they will:
- see video demonstrations and exercises;
- do exercises and record their answers; and,
- check their own answers to exercises with those given on the video, the facilitator should
discuss the answers written by the participants and clarify any doubts.
Tell the participants that in the first part of the video, they will see examples of general danger
2.
signs. They will see a child who is:
- not able to drink or breast feed; and
- lethargic or unconscious.
Then the participants will do an exercise to practice deciding if the general danger sign “lethargic or
unconscious” is present in each child.
3. Next start the video. Because this is the first video exercise in the course, participants may not
be clear about how to proceed. During video exercise, watch the participants. If they are not
writing answers on the worksheets, encourage them to do so and explain how it should be done
if necessary. If they seem to be having difficulty, replay the exercise so they can see the exercise
again, develop an answer and write it on the worksheet.
PARTICIPANTS WATCH VIDEO-8
4. At the end of the exercise, stop the video. Ask if any participant had problems identifying the
sign “lethargic or unconscious”. Rewind the video to replay any exercise item or demonstration
that you think participants should see again. Emphasize points such as:
- Notice that a child who is lethargic may have his eyes open but is not alert or paying attention
to what is happening around him.
- Some normal young children sleep very soundly and need considerable shaking ora loud noise
to wake them. When they are awake, they are alert.
Is the child lethargic or unconscious?

YES NO
Child 1 
Child 2 
Child 3 
Child 4 

9.4. Participants read ‘Assess & Classify Cough or Difficulty in Breathing’
9.5. DEMONSTRATION: Classification for Cough or Difficulty in Breathing

Display enlarged section of poster or use chart booklet. Explain to participants as to how a
classification is selected.
There are 3 classifications available if a child has cough or difficult in breathing.
If child has a general danger sign or chest indrawing the classification is Severe pneumonia OR
very severe disease.
If a child does not have this classification, go down and see if the child has fast breathing. If yes,
select the classification pneumonia otherwise classify as no pneumonia:cough or cold.
In this box, there can be only one classification. For example, a child will not have severe
pneumonia & pneumonia together.
9.6 Conduct Video-9 Exercise – ‘Child with Cough or Difficult in Breathing’

Tell the participants that they will now:
• see a demonstration of how to count the number of breaths in a child in one minute
• practice counting the number of breaths a child takes in one minute and decide if fast breathing
is present
• see examples of looking for chest in drawing; and, fast breathing
• do a case study and practice assessing and classifying a sick child up through cough or difficult
breathing
Start the video and show the demonstration, exercises and case study for cough or difficult breathing.
If any participant has difficulty seeing the child’s breaths or counting them correctly, rewind the
video to that particular case and repeat the example. Show the participant where to look for and
count the breaths again.
Chest Indrawing
Note: Chest indrawing may be a difficult sign for participants to identify the first time. It may take
several trials for the participant to feel comfortable with this sign.
• If any participant has difficulty in identifying chest indrawing, repeat an example from the video.
Talk through with the participants where to look for chest indrawing, pointing to where the
chest wall goes in when the child breathes in.
• Some participants may need help determining when the child is breathing IN. Show an
example from the video. Point to where on the child’s chest the participant should be looking.
Each time the child breaths in, say “IN” to help the participant see clearly where to look and
what to look for.

It may be helpful to pause the video and ask a participant to point to the place where he would look
for chest indrawing. This will help you to check if participants are looking at the appropriate place
for identifying chest indrawing. Repeat the exercises on the video until you feel confident that the
participants understand where to look for chest indrawing and can identify the sign in each child
shown in this exercise.
For each of the children shown in the video, answer the question:
For each of the Does the child have

children shown fast breathing?
in the video-10,
Age Breaths per YES NO
answer the questions:
minute
Mano 4 years 65 
Wambai 6 months 66 
For each of the children shown

in the video-11, answer the Does the child have chest indrawing?
questions:
YES NO
Mary 
Jenna 
Ho 
Anna 
Lo 
Video Case Study

Box 1 page 66
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UPTO 5 YEARS
Name: Ben Age:____7 months Gender: Male Weight:__76 kg

kg _ kg Temperature: 38.5℃ Date:_13/02/2023__
ASK: What are the infant’s problems?_ cough for two weeks Initial visit?___√________ Follow up visit?___________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign present?

• NOT ABLE TO DRINK OR BREASTFEED Yes _______ No____√____
• LETHARGIC OR UNCONSCIOUS
• VOMITS EVERYTHING Remember to use danger sign when
• CONVULSIONS/ CONVULSING NOW selecting classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes___√___ No____
• For how long? __________ Days Severe Pneumonia
• Count the breaths in one minute_____ breaths
per minute.
• Look for chest indrawing Or
• Check oxygen saturation- <90%/≥90%
Fast breathing? Very Severe Disease
Box 2to be added after Josh page 68

Name:_ Josh Age: 6 months Gender: Male Weight: 6 kg Temperature: 38 ℃ Date:_13/02/2023__
ASK: What are the infant’s problems?_ Diarrhoea _ Initial visit?___√_____ Follow up visit?___________
66 Integrated
ASSESS Management
(Circle all of Neonatal and Childhood Illness (IMNCI)
signs present) CLASSIFY
Facilitator
CHECK Guide
FOR GENERAL for SIGNS
DANGER Health Workers General danger sign present?
SECTION
10 ASSESS AND CLASSIFY DIARRHOEA
10.1 Participants read ‘Assess and Classify Diarrhoea’

10.2 DEMONSTRATION: Classification for Diarrhoea
CLASSIFY DIARRHOEA
There is one classification table for classifying diarrhoea for dehydration.
• All children with diarrhoea are classified for dehydration.
• If the child has blood in the stool or diarrhoea for 14 or more days, s/he will be referred to the
hospital.
There are three possible classifications of dehydration in a child with diarrhoea:

• SEVERE DEHYDRATION
• SOME DEHYDRATION
• NO DEHYDRATION
To classify the child’s dehydration, begin with the Pink (or top) row.
• If two or more of the signs in the Pink row are present, classify the child as having SEVERE
DEHYDRATION.
• If two or more of the signs are not present in the pink row, look at the Yellow (or middle) row.
If two or more of the signs are present the Yellow row, classify the child as having SOME
DEHYDRATION.
• If two or more of the signs are not present in the Pink 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.
Classify all cases of diarrhoea for dehydration. In addition, also, classify dysentery if there is
blood in stool.
Emphasize following points:

• Children with signs of severe dehydration/ dysentery should be referred to hospital.
• Children with some dehydration should be rehydrated with ORS.
• Children who are not dehydrated and have no blood in stool should be managed at home.

10.3 Conduct Video Exercise: “Does the Child have Dehydration?”
Now show them the video on the skin pinch and ask them to do the exercise in the video.
Video 12-14 Exercise and Case Study - “Does the child have dehydration?”
To conduct this video exercise:
When all the participants are ready, arrange for participants to move to where the video exercise will
be shown. Make sure the participants bring their modules with them.
1. Tell participants that in this video exercise, they will:
- See examples of children with diarrhoea who have the signs of dehydration.
- Watch a demonstration of a diarrhoea assessment and how to classify dehydration.
Show Video-13 and 4: exercise and case study -
“Does the child have diarrhoea?”
1. Tell participants that in this video exercise, they will:
- See examples of children with diarrhoea who have the signs of dehydration.
- Watch a demonstration of a diarrhoea assessment and how to classify dehydration.
- Do an exercise to practice recognizing sunken eyes and slow or very slow skin pinch.
2. Explain that the participants should write answers to the exercises and case study. They check
their answers with those provided on the video.
3. At the end of each exercise, stop the video. If participants are having trouble identifying a
particular sign, rewind the video and show the exercise item again. Talk through the exercise item
and show the participants where to look to recognize the sign.
At the end of the video, conduct a short discussion. If participants had any particular difficulty,
provide guidance as needed. Emphasize points during the discussion such as:
- If you can see the tented skin even briefly after you release the skin, this is a slow skin pinch.
- A skin pinch which returns immediately is so quick that you cannot see the tented skin at all
after releasing it.
- Repeat the skin pinch if you are not sure. Make sure you are doing it in the right position.
Answers to Exercise
1. For each of the children shown, answer the question:
Show video-13 Does the child have sunken eyes?

YES NO
Child 1 
Child 2 
Child 3 
Child 4 
Child 5 
Child 6 

2. For each of the children shown, answer the question:
Show Video-4 Does the skin pinch go back:

Very slowly? Slowly? Immediately?
Child 1 
Child 2 
Child 3 
Child 4 
Child 5 
Box 1 page 66
10.4 PHOTOGRAPH EXERCISE ON SUNKEN EYES AND SKIN PINCH
Now show
Name: Benthe participants
Age:____7 months the photographs
Gender: Male on the
Weight:__7 kg projector.
_ kg Temperature: 38.5℃ Date:_13/02/2023__
Photograph 30: This child has sunken eyes.

ASK: What are the infant’s problems?_ cough for two weeks Initial visit?___√________ Follow up visit?___________
Photograph 31:all signsThe
ASSESS (Circle child’s skin pinch goes back very slowly.
present) CLASSIFY
Photograph 32: DANGER

CHECK FOR GENERAL The child
SIGNS has sunken eyes. General danger sign present?
• NOT ABLE TO DRINK OR BREASTFEED Yes _______ No____√____
Photograph 33:
•
•
LETHARGIC OR UNCONSCIOUS
VOMITS EVERYTHING
The child has sunken eyes. Remember to use danger sign when
CONVULSIONS/ CONVULSING NOW selecting classifications
Photograph 34: The child does not have sunkenYes__
eyes.
•
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? _√___ No____
Photograph 35:in one minute_____
The child Severe Pneumonia
breathshas sunken eyes.
• For how long? __________ Days
• Count the breaths
per minute.
• Look for chest indrawing Or
• Check oxygen saturation- <90%/≥90%
Photograph 36:
Fast breathing? The child’s skin pinch goes back very slowly. Very Severe Disease
Video-14 Case Study 2

Exercise:
Box 2to Josh bought
be added afterwith
Josh complaint
page 68 of diarhhoea
Name:_ Josh Age: 6 months Gender: Male Weight: 6 kg Temperature: 38 ℃ Date:_13/02/2023__
ASK: What are the infant’s problems?_ Diarrhoea _ Initial visit?___√_____ Follow up visit?___________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign present?

• NOT ABLE TO DRINK OR BREASTFEED Yes _______ No__√_
• LETHARGIC OR UNCONSCIOUS
• VOMITS EVERYTHING Remember to use danger sign when
• CONVULSIONS/ CONVULSING NOW selecting classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes__√_ No____
• For how long? __3_____ Days
• Count the breaths in one minute_ 56 breaths • Look for chest indrawing
per minute. • Check oxygen saturation- <90%/≥90% Pneumonia
Fast breathing?
DOES THE CHILD HAVE DIARRHOEA?

Yes___√ No____
• Look at the child’s general condition. Is the child:
For how long?__ 5 ___ Days?  Lethargic or unconscious?
•
 Restless and irritable? Severe Dehydration
Is there blood in stool?
• Look for sunken eyes
• Offer the child fluid. Is the child:
 Not able to drink or drinking poorly?
 Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back:
 Slowly?
 Very slowly (longer than 2 seconds)?

SECTION
11 ASSESS AND CLASSIFY FEVER
11.0 Participants read ‘Assess and Classify Fever’

11.1 DEMONSTRATION: Classification for Fever
There are 3 possible classifications of fever.

• VERY SEVERE FEBRILE DISEASE
• MALARIA/SUSPECTED MALARIA
• FEVER- MALARIA UNLIKELY
If the child with fever has any general danger sign or a stiff neck, classify the child as having VERY
SEVERE FEBRILE DISEASE.
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 37.5°0C or above), classify SUSPECTED MALARIA or
classify the child as having MALARIA, if RDT is positive.
All other cases of fever who do not have signs of very severe disease and/or RDT is either or not
available are classified as FEVER- MALARIA UNLIKELY as national programme discourages use
of antimalarial on empirical basis.
11. 2. Conduct Video-15 and 16 Exercise: “How to Assess a Child with Fever” and
“Does the Child have Stiff Neck?”
When all the participants are ready, arrange for them to move to where the video exercise will be
shown.
To conduct the video exercise:

1. Tell participants that during the video they will see examples of how to assess a child with fever
and child having stiff neck. They will do an exercise to practice identifying whether stiff neck is
present and do a case study to practice assessing and classifying a sick child up through fever.
2. Ask if participants have any questions before you start the video. When there are no additional
3. Assessing for stiff neck varies depending on the state of the child. You may not need to even
touch the child. If the child is alert and calm, you may be able to attract his attention and cause
him to look down. If you need to try to move the child’s neck, you saw in the video a position
which supports the child while gently bending the neck. It is hard to tell from a video whether
the child’s neck is stiff. When you do this step with a real child, you will feel the stiffness when
you try to bend the neck. You also saw the child cry from pain as the health worker tried to bend
the neck.

Answers to Exercise
For each of the children shown, answer the question:
Does the child have a stiff neck?

YES NO
Child 1 
Child 2 
Child 3 
Child 4 

SECTION
12 CHECK FOR MALNUTRITION
12.0. Participants read ‘Check for Malnutrition’
12.1. Photograph Exercise: Group Work followed by Group Feedback – ‘Visible

SevereWasting’, ‘Oedema of both feet’.
Show photographs from 67-70 on the projector and discuss about visible severe
wasting and oedema of both feet.
Photograph 67: This is an example of visible severe wasting. The child has small hips and thin
legs relative to the abdomen. Notice that there is still cheek fat on the child’s face.
Photograph 68: This is the same child as in photograph 67 showing loss of ribs fat.
Photograph 69: This is the same child as in photograph 67 showing folds of skin (“baggy pants”)
due to loss of buttock fat. Not all children with visible severe wasting have this
sign. It is an extreme sign.
Photograph 70: This child has Oedema of both feet.
Now look at photographs numbered 71 through 79. For each photograph, tick () whether the child
has visible severe wasting. Also look at photograph 79 and tick whether the child has Oedema of
both feet.
Does the child have visible severe wasting?

YES NO
Photograph 71 
Photograph 72 
Photograph 73 
Photograph 74 
Photograph 75 
Photograph 76 
Photograph 77 
Photograph 78 
Does the child have Oedema?
Yes No
Photograph 79 

12.2. DEMONSTRATION: Use the MUAC tape
Objectives
Participants will be able to:
• Use a color coded MUAC tape to measure the mid upper-arm circumference, to identify severely
malnourished children.
12.3. DEMONSTRATION: Classify Malnutrition
Use chart booklet for the demonstration
In this box one classification is to be definitely chosen whether child has any major symptom or not.
There are three classifications for a child’s nutritional status. They are:
• SEVERE ACUTE MALNUTRITION
• MODERATE ACUTE MALNUTRITION
• NO ACUTE MALNUTRITION
If the child has weight-for-length (WFL) or weight-for-height (WFH) <-3 SD score (Orange/Red
color on Mother and Child Protection card) or oedema of both feet, or MUAC <11.5 cm classify the
child as having SEVERE ACUTE MALNUTRITION
If the child has WFL or WFH <-2 SD (Yellow color on MCP card) and/or MUAC 11.5-12.4 cm
classify the child as having MODERATE ACUTE MALNUTRITION
If the child has WFL or WFH ≥-2SD score and MUAC ≥ 12.5 cm classify the child as having NO
ACUTE MALNUTRITION.

SECTION
13 CHECK FOR ANEMIA
13.0 Participants read ‘Check for Anemia’

13.1 DEMONSTRATION: Classify Anemia, use chart booklet for the demonstration
In this box one classification is to be definitely chosen whether child has any major symptom ornot.
There are three classifications for a child’s anemia.
They are:
• SEVERE ANEMIA
• ANEMIA
• NO ANEMIA
If the child has severe palmar pallor, classify the child as having SEVERE ANEMIA. If the child has
some palmar pallor, classify the child as having ANEMIA.
If the child has no palmar pallor, classify the child as having NO ANEMIA.
13.2 Conduct Photograph Exercise - Group Work followed by Group Feedback

‘Look for Palmar Pallor’
When all the participants are ready to do this exercise, gather the participants together. Project the
photos from 80-82 & discuss about palmar pallor.
Photograph 80: This child’s skin is normal. There is no palmar pallor.
Photograph 81a: The hands in this photograph are from two different children. The child on the
left has some palmar pallor.
Photograph 81b: The child on the right has no palmar pallor.
Photograph 82a: The hands in this photograph are from two different children. The child on the
left has no palmar pallor.
Photograph 82b: The child on the right has severe palmar pallor.
Now look at photographs numbered 83 through 88. For each photograph, tick () whether
the child has severe pallor, some pallor or no pallor.
Severe pallor Some pallor No pallor
Photograph 83 
Photograph 84 
Photograph 85a 
Photograph 85b 
Photograph 86 
Photograph 87 
Photograph 88 

SECTION
14 CHECK THE CHILD’S IMMUNIZATION,

PROPHYLACTIC VITAMIN A, IRON-
FOLIC ACID SUPPLEMENTATION, DEWORMING
STATUS & ASSESS OTHER PROBLEMS. ASSESS
THE MOTHER/CAREGIVER’S DEVELOPMENT
SUPPORTIVE PRACTICES AND COUNSEL THE
MOTHER ABOUT HER OWN HEALTH
14.1 Participants read ‘Check the Child’s Immunization, Prophylactic Vitamin

A IFA Supplementation, Deworming Status, Assess Other Problems. Assess the
Mother/Caregiver’s Development Supportive Practices and Counsel the Mother
About Her Own Health
14.2 Group Discussion

• Conduct a group discussion on other health problems. Ask participants to list common problems
they see. Write them on the flip chart. Emphasize that boils on the skin, scabies (‘kharish’), sore
eyes or pus draining from the ear are common. They do not cause death commonly. However,
they should be treated to reduce discomfort.
• Remind Health Workers that these were most probably taught to them in their earlier training.
These conditions should be recognized and treated accordingly. This course does not include
teaching their treatment.
• Review with the participants the Government’s immunization guidelines being used.
• Emphasize that all children should complete BCG, 3 doses of Pentavalent and Polio (oral and
injectable) and measles immunizations before 12 months age.
• BCG should be given, as soon as possible, in the first few weeks after the baby is born.
• The three doses of penta and polio should be given 1 month apart.
• Measles immunization is recommended at 9 months of age.
• Immunizations can be given even when the child is ill. (immunizations should not be given if the
child is to be referred to the hospital.
• An immunization record is very helpful in updating the immunization status and in avoiding
giving unnecessary immunization.
• Also give to prophylactic iron folic acid to a child twice weekly as per Anemia Mukt Bharat
guidelines if child is 6 months of age or older and has no acute illness.
• Give the recommended dose of Vitamin A/Albendazole when the child is of appropriate age.
• Talk about discussing other problems that mother might have told the health worker during the
interaction and how to address them based on their knowledge and experience. Also, emphasize
the importance of practices that support child’s development. Mothers/caretakers and other
family members should be assessed and counseled thoroughly for their involvement in child
development practices.
• Moreover, counsel the mothers about regular postnatal visits which is a good opportunity to
receive advice and care for herself and the child. Help her if she feels sick and counsel her to
eat well.

SECTION
15 REVIEW EXERCISES
15.1. Conduct Drill: Review of Cut-off for Determining Fast Breathing

This activity is optional. If you think that participants know this well, you may skip this.

Explain the procedures for doing the drill. Tell participants:
• This is not a test. The drill is an opportunity for participants to practice recalling information a
HEALTH WORKER needs to use when assessing and classifying sick children.
• Call on individual participants one at a time to answer the questions. You will usually call on
them in order, going around the table. If a participant cannot answer, go to the next person and
ask the question again.
• Participants should wait to be called on and should be prepared to answer as quickly as they can.
This will help keep the drill lively.
• Ask if participants have any questions about the drill.
• Tell the participants they may refer to the job-aid during the drill, but they should try to answer
the question without looking at or reading from the chart booklet.
Tell the participants that this drill will review the cutoffs for determining fast breathing in children.
Ask participants to enumerate the two age groups that you must keep in mind when determining fast
breathing and the respiratory rate threshold for each of the following:
• In infant <2 months, 60 breaths per minute or more is fast breathing.
• In infants 2 months up to 12 months, 50 breaths per minute or more is fast breathing.
• In children 12 months up to 5 years, 40 breaths per minute or more is fast breathing.
To explain how the drill will take place, ask the question from the co-facilitator, “What is the cut
off for fast breathing in a 6 months old child?” The answer is: The cut off for fast breathing is 50
or more per minute.

Then ask the questions in the left column. Participants should answer in turn.
QUESTIONS ANSWERS
WHAT IS FAST BREATHING IN AN INFANT OR
CHILD:
Age 4 weeks? 60 breaths per minute or more.
Age 6 weeks? 60 or more
Age 2 months? 50 or more
Age 3 years? 40 or more
Age 4 ½ months? 50 or more
Now, explain to the participants that you will tell the age of the child and breathing rate in one
minute. The participants will tell whether the breathing rate is fast or normal for age.
Begin the drill by asking your co-facilitator: The age of the child is 4 months, breathing rate is 52
times per minute. Is it fast breathing or normal? Answer: This child has fast breathing since the cut
off for fast breathing at this age is 50 or more per minute.
Ask a participant the first question and request him to provide the answer. The participant should
answer as quickly as possible. Proceed to the next question and call on another participant to answer.
If a participant gives an incorrect answer, ask the next participant if he can answer.

QUESTIONS ANSWERS
DOES THIS INFANT OR CHILD HAVE FAST BREATHING?
Age Breathing Rate

18 months 44 Yes
2 months 48 No
12 months 40 Yes
3 years 38 No
12 months 38 No
3 years 42 Yes
12 months 49 Yes
11 months 49 No
6 months 52 Yes
14 months 45 Yes
15.2. Review Classifying Signs of Illness

Tell the participants they will now practice classifying signs of illness. You will describe a child’s
signs and symptoms. Then call on a participant to select the appropriate classification. If you think
a participant needs additional practice, ask him to describe how s/he classified the child’s signs
according to the classification table. This would ensure that the participant is not getting a correct
answer by guess work.
Illustrate by giving an example. How would you classify a 10-month-old child who is lethargic, has
visible severe wasting and some palmar pallor. Go to the job-aid, mark out the circles in the “Signs”
section.
This child has very severe disease, severe acute malnutrition and anemia.

When all the participants are ready, begin the drill by asking the first question below:
QUESTION: How would you classify a 9-month old child with: ANSWER:
Cough AND not able to drink, has chest indrawing. VERY SEVERE
DISEASE OR SEVERE
PNEUMONIA
Cough AND breathing rate of 51 breaths per PNEUMONIA
minute and no signs of very serious
disease.
Cough AND breathing rate of 40 breaths per minute COUGH OR COLD
and no signs of very serious
disease.
Diarrhoea for 3 days AND blood in stool; child is drinking DEHYDRATION and
eagerly; skin pinch is slow. DYSENTERY
Diarrhoea for 3 days AND blood in stool; no signs of DYSENTERY;
DEHYDRATION. NO DEHYDRATION
Diarrhoea for 2 days AND no blood in stool; not lethargic or NO DEHYDRATION
unconscious; is able to drink normally;
skin pinch goes back immediately.
No cough and no diarrhoea visible severe wasting. SEVERE ACUTE
AND MALNUTRITION
No cough, no diarrhoea oedema of both feet. SEVERE ACUTE
AND MALNUTRITION
No cough, no diarrhoea severe pallor. SEVERE ANEMIA
AND
No cough, no diarrhoea does not have severe wasting, does ANEMIA
AND not have oedema but has some pallor.
No cough, no diarrhoea AND does not have severe wasting, does not MODERATE ACUTE
have oedema but MUAC 11.5-12.4 cm. MALNUTRITION
No cough, no diarrhoea, no MUAC ≥ 12.5 cm and does not have NO ACUTE

severe wasting, no oedema pallor. MALNUTRITION
of both feet AND
15.3. Conduct Drill: Identify the need for Immunization in Children
This activity is optional. If you think that participants know this well, you may skip this.
1. Make sure that participants are looking at the Immunization Section in the chart booklet page
number 11.
2. Write on the flip chart the age at which immunization should be given.
3. Illustrate by one example. Ask your Co-facilitator: “A child six months age with cough and cold
is brought to HEALTH WORKER. He has been given BCG, Penta-1 and Penta-2, OPV-1 and
OPV-2. What immunization should be given today?” Answer Penta-3 and OPV-3.
4. Start the drill by describing clearly and slowly the immunizations given and then asking
participants by turns what immunizations are required today.
5. Continue the drill until you are sure that all participants know the correct immunization
schedule.

Questions Answers
What immunizations would you advise today if:
The child is He/she has been given the following
immunizations
2 months old BCG OPV-1, Penta-1, Rota Virus-1,
fIPV –1, PCV –1
5 weeks old BCG OPV-0
4 months old BCG, OPV-1, Penta-1 Rota Virus-1, OPV-2, Penta-2 Rota Virus-2
fIPV –1, PCV –1
11 months old BCG, Penta-3, fIPV-2, RVV-3,PCV-2, MR-1 + JE-1 + PCV Booster,
OPV-3 fIPV-3
8 months old BCG, OPV-1, Penta-1 OPV-2, Penta-2, Rota Virus-2 and
fIPV-2
6 months old BCG, OPV 3 doses, Penta 3 doses , fIPV-2, No immunizations required
RVV-3 and PCV-2
7 months old BCG, OPV-1, 2, Penta-1, 2 OPV-3, Penta-3, fIPV-1, RVV-1,
PCV-1
5 months old OPV-1, 2, Penta-1, 2 BCG , OPV-3, Penta-3, fIPV-1,
RVV-1, PCV-1
10 months old BCG, OPV 3 doses, Penta 3 doses fIPV-2, MR-1, JE-1, fIPV and PCV
RVV-3, PCV-2 booster

SECTION
16 IDENTIFY TREATEMENT
16.0 Participants read ‘Identify Treatment’ through ‘Refer the Child’

16.0 Group Discussion – Pre-referral treatments
Discuss in the group various pre-referral treatments for severe illness before referring children.
• Give an Appropriate Antibiotic
• Treat the Child to Prevent Low Blood Sugar
• Advise Home Care for cough or cold
• Plan B: Treat Some Dehydration with ORS
• Teach the mother to give oral drugs at home
• Advice mother when to return to health worker

SECTION
17 TREAT THE CHILD
17.0 Read the section ‘Treat pneumonia with amoxycillin and gentamicin
17.1 Demonstration -- How to read a drug table
Purpose: To demonstrate how to read a drug table on the TREAT section, including selecting the
appropriate drug and determining the dose and schedule.
Materials: Laptop, projector. Give an Appropriate oral antibiotic from the TREAT section of
chart booklet.

a Display the section. Give an appropriate oral antibiotic. (or, ask participants to read the antibiotic
box in the chart booklet.) Point to the antibiotic box and tell participants that the box indicates
the following:
- Name of the drug and its formulation
- How much of the drug should be given (the dose)
- When the drug should be given (the schedule)
Then point out the lines that tell the name of the drug recommended for each classification of illness
(for example; PNEUMONIA, FEVER).
b. Name the antibiotic used in your area for pneumonia. Then tell participants that you will show
them how to use the box to determine how much antibiotic should be given to a child classified
as having PNEUMONIA.
c. Find the antibiotic in the antibiotic box. Point first to the antibiotic, then to the column that
specifies the different formulations of the antibiotic (e.g., adult tablet, paediatric tablet, or
syrup). Ask participants which formulation is used in their clinics. Point to the formulation that
is mentioned.
d. Point to the row where ages are listed. Explain the ages and weights in each row. Then find the
row for a 6-month-old child. Explain it is better to use the child’s weight, not age.
e. Determine the dose for a 6-month-old child who has SEVERE PNEUMONIA. First dose of
amoxycillin that a 6-month-old child should receive:
250 mg tablet or 5 ml (or 1 teaspoon) syrup-Tell participants about equivalent millilitre and
teaspoon measurements
f. Repeat the above demonstration for a 12 kg child with the same classification.
g. Give each participant the opportunity to try and read the antibiotic box. Ask one participant,
what drug would you give to a child classified as having PNEUMONIA?
Then have the participant point to the correct place on the antibiotic box where he would find the
answer.

17.2 DRILL: Determine the dose and schedule of amoxycillin and IM gentamicin
in the treatment of a child with pneumonia
Tell the participants that this drill will review how to determine the schedule and dose of amoxycillin
and IM gentamicin.
To conduct the drill:

a. Explain that this drill will help participants gain skill to determine the schedule and dose of
amoxycillin and IM gentamicin to be given to a sick child. This is an important skill. If the dose
is not correct, it may not help the child’s treatment. An overdose may be harmful. Be sure that
each participant consults the table during the drill. Do not let them guess as they are likely to
make mistakes.
b. Ask the participants if they have any questions before the drill begins. Answer all questions
thoroughly.
c. Give an example. Ask your Co-facilitator, “What is the dose of amoxycillin in a 9 months old
child with pneumonia?”
Answer 1 Paediatric tablet (125 mg) at every 12 hours.
d. Begin the drill. Ask the question in the left column. Refer to the appropriate column to check the
participant’s answer.
QUESTIONS#: AMOXICILLIN PEDIATRIC TABLET

WHAT DOSE OF AMOXICILLIN AND 25-30 mg/kg every 12 hrs
SCHEDULE WOULD YOU USE FOR:
A 12-month-old child classified as having pneumonia? 1
A 10-month-old child with cough classified as having 1
severe disease or severe pneumonia?
A 2-year-old child classified as having pneumonia? 1½
A 3-month-old child classified as having pneumonia? ½
A 20-month-old child classified as having pneumonia? 1½
A 10-month-old child with only cough and cold, no Nil
pneumonia?
# Please refer page number 12 of chart-booklet
17.3 Participants read ‘Treat Diarrhoea with dehydration with Oral Rehydration
Salt (ORS) Solution (Plan B)’
17.4 DRILL: Determine amounts of ORS solution to be given during the first 4
hours for Treatment of Children with Dehydration
Tell the participants that this drill will provide practice in determining the approximate amount of
ORS solution to be given to a child who has diarrhoea and some dehydration.

Materials needed for this drill:
• Participant’s module/chart booklet. Consult the table which shows ORS solution amounts to be
given according to age of the child.
To conduct the drill:
a. Ask the participants to look at the instructions for giving ORS solution to children with
dehydration. Tell the participants they can refer to the table during the drill. Discourage them
from relying on memory since this can lead to mistakes.
b. Tell the participants that you will state the ages of children with signs of dehydration. You will
then call on individual participants to state how much ORS solution should be given. Tell the
participants that this drill is practice for them to quickly and correctly determine the approximate
amounts of ORS to give to dehydrated children. To keep the drill lively, encourage the participants
to wait to be called on and be prepared to answer as quickly as they can.
c. Ask if there are any questions. Answer all questions thoroughly.
d. Start the drill by giving an example. Ask your Co-facilitator: “How much ORS is to be given to
a 1-year-old child with diarrhoea and dehydration?” The answer is 700-900 ml, i.e., 5-6 cups.
For this drill, consider that one cup provides 150 ml fluid.
e. Begin the drill. State the age for the first child. Call on a participant to tell you the range or the
calculated amount of ORS solution to give to that child during the first 4 hours.
f. Praise a participant for a correct answer. If a participant gives an incorrect answer, ask the next
participant to answer. If you feel that one or more participants do not understand, pause to
explain. Then resume the drill.
g. Keep the drill moving at a quick pace. Repeat the list of questions or make up new ones if
you believe participants need more practice. The drill ends when you are convinced that all
participants are skilled and comfortable determining amounts of fluid needed in 4 hours.
AGE Of A SICK CHILD# Number of Cups*

3 years old 7
4 months old 3
5 months old 3
10 months old 3
1½ years old 5
4 years old 7
15 months old 5
1 year old 5
2 months old 2
7 months old 3
8 months old 3
18 months old 5
4½ years old 7
3 months old 2
# Please refer Page No. 14 of the Chart Booklet.
*One cup provides 150 ml fluid. Adjust this volume according to the volume of ORS that local cups provide.
Tell the participants that the above amounts are only a guide. If a child wants more or less ORS solution,
give him what he wants.

17.5 DEMONSTRATION - Preparation of ORS solution
Objectives:
• To demonstrate steps of preparing ORS solution.
• To discuss precautions to be observed while preparing ORS solution.
Supplies:
• Measuring jar (1 litre)
• ORS packets (1000 ml preparation)
• Spoon
• Bowl
• A big container to dissolve ORS
• Clean water
Steps:
• Gather all the participants around the table. Make sure that every participant can clearly see the
demonstration.
• Wash your hands with soap and water.
• Pour all the ORS powder from one packet into a clean container.
• Measure 1000 ml of clean water.
• Pour water into the container. Mix well until the powder is completely dissolved.
• Taste the solution so you know how it tastes. Ask all the participants to taste the solution.
• Illustrate the steps on the pictures in the participant’s module (page number 104).
• Discuss the precautions to be observed while preparing ORS:
- Cleanliness (hands, container, etc)
- Correct measurement of water (1000 ml).
- Clean water
• Mixing it well.
- Taste the solution.
- Keep it for not more than 24 hours after preparation and throw away the unused solution.
- Dissolve a new ORS packet for giving to the child.
- Give it only by a spoon, frequently (once every minute).
- If one litre measure is not available, suggest a suitable alternative.
- Make sure that the participants understand the importance of correct measurement.
• Ask one of the participants to repeat the steps.
• Request one participant to do return demonstration in case the participants need more practice.

17.6 Participants read ‘Treat High Fever’ ‘Treat Anemia’ & give antimalarial as
per National Guidelines
17.7 Review the dose of Paracetamol, Iron folic acid and Antimalarial
17.8 Participants read ‘Home Care for Cough and Cold’
17.9 Group Discussion on Home Made Safe Cough Remedies’
Objectives:
1. To determine the locally available cough remedies being used by parents or grandmother or
others in the family for treating a child having cough or difficult in breathing.
2. To make HEALTH WORKERS aware that home made safe cough remedies are beneficial to a
child with cough.
3. To inform HEALTH WORKERS that cough medicines, which are available in the market, are
often harmful to a child having cough or difficult in breathing.
Issues to be raised:
1. Safe home remedies, e.g., sugar with water, tea, lemon water, tulsi water are good, because of
the following reasons:
- easily available;
- traditionally used for centuries without harmful effect;
- mothers/grandmothers have faith in them;
- cheap;
- these are sweet, the child will take it.
2. Cough mixtures, available in the market, can be harmful because of the following reasons:
- contain the medicine that makes the child drowsy (sleepy);
- the taste is not good and the child may vomit;
- costs money and is harmful;
- are not available in the village.
3. Some homemade remedies are not safe, e.g., preparation containing menthol are harmful.
Safe cough remedies are those cough remedies which do not produce harmful effects, i.e., do
not cause vomiting, do not produce drowsiness (sleepiness) and are easily available at home
without costing a lot.
17.10 Role Play - Advising Home Care for a Child with Cough or Difficult
Breathing: No Pneumonia
Objective:
To practice communication skills in advising home care in a child with cough or difficult breathing
with special emphasis on homemade cough remedy.

Case Scenario for the Mother
A mother brought her 7-month-old girl Tina who had cough for 4 days. The HEALTH WORKER assessed
Tina and found that she has no general danger sign, no chest indrawing and no fast breathing. The HEALTH
WORKER classified her as having NO PNEUMONIA: Cough or Cold. The HEALTH WORKER decided
to give HOME CARE to Tina. The mother has travelled 10 kms to reach the clinic. This is her first child
and she is worried that this cough may ‘become’ pneumonia. She wants the HEALTH WORKER to give
some medicine in a bottle which relieves the cough. Tina’s nose is blocked.
Give a copy of the description to both the persons performing the role play.
Use of Chart Booklet
The HEALTH WORKER consults the box Counsel the mother on Home Treatment for `cough
or cold’ (no pneumonia) on the chart booklet (Green box). She marks the section feed the child,
give increased fluids, soothe the throat and watch for signs to return quickly. The facilitator should
monitor the process of using the chart booklet.
Tips for the HEALTH WORKER

1. Praise the mother for having travelled so far to consult her.
2. Assure her that Tina does not have pneumonia and the cough will most probably not lead to
pneumonia if she follows the advise given to her.
3. Determine what she has given to treat cough in the past. Explains that cough medicines, though
available in the market, are not safe in children.
4. Discuss with her how to make a local safe cough remedy at home to soothe the throat. Checks
with her if she has all the ingredients available at home or within her village.
5. Determine whether the mother will be able to give the safe cough remedy.
6. Advise her and demonstrates how to clear the nose using saline nose drops (water in which salt
is dissolved - a medicine which can be prepared at home). This will also help the child eat well.
7. Explain all the signs on when to return immediately.
What the participants should check while watching the role play?
• Did the HEALTH WORKER praise the mother for bringing Tina?
• Was he/she able to convince the mother regarding the role of home-made safe cough remedy and
the harmful effects of most cough medicines purchased from the market?
• Did he/she ask the mother about the safe cough remedy used by her in the past at home?
• Did he/she explain how to clear the nose and how to prepare saline drops?
• Did the HEALTH WORKER explain to the mother regarding when to return immediately?
• Were the checking questions asked?
• Was the mother convinced and satisfied?

Summarize the Role Play
• Continue breastfeeding.
• Home made safe cough remedy should be given to soothe the throat. Discuss with the mother
1or 2 safe cough remedies which she can prepare at home.
• Increase fluids to loosen the secretions. This will help the child bring out secretions easily
while coughing.
• Clear the nose by using saline nose drops.
• Advise the mother about signs to observe and when to return immediately:
- Breathing becomes difficult
- Breathing becomes fast
- Difficulty in feeding
17.11 Participants read ‘Home Care for Diarrhoea with No Dehydration’

17.12 Conduct Group Discussion on “Home Available Fluids”.
Objectives:
1. To help the participants learn about the locally available fluids which can be given by the mother
at home to her child during diarrhoea.
2. To decide on a list of fluids not recommended during diarrhoea.
Points for Discussion

• Discuss the importance of giving home available fluids during diarrhoea.
• Ask the participants, one by one, to list the fluids which are commonly available at home in their
area.
• Discuss which fluids can be given during diarrhoea. Emphasize that the fluids selected should
not be too sweet, or spicy or salty.
• List fluids which should be avoided during diarrhoea. Discuss the reasons for avoiding these
fluids.
• Discuss the method of giving home available fluids.
Summarize Key Points

• Home available fluids are important to prevent dehydration during diarrhoea.
• Encourage the mother to give locally available fluids which she can afford and which are
readily available.
• Do not give fluids like aerated drinks, sweetened fruit, juices, spicy drinks, coffee, etc. These
can worsen the diarrhoea.
• NEVER DILUTE A FLUID. If you feel that a fluid is too strong, then after giving it, offer the
child plain clean water to drink.
• Give home available fluids by a cup or a spoon. Do not use a bottle.
• Give small quantities at frequent intervals.
• Continue to feed the child with foods as well.
• As far as possible, give a variety of fluids. This helps to balance out the salt and sugar intake.
• The presence of food in the home available fluid helps in its absorption.

Examples of home available fluids
Fluids to be given Fluids not to be given

• Rice Kanji (Mand, Peech) • Aerated drinks like Coke, Fanta,
• Vegetable etc.
• Buttermilk (dahi ki lassi) • Fruit juices (sweetened)
• Water • Coffee
_____________
• Lemon water with salt and _____________
Sugar (Shikanji) _____________
• Milk _____________
• Dal
_____________
_____________
_____________
Do not add any additional water to a fluid. If the HEALTH WORKER feels that fluid may be too
strong, ask the mother to give plain clean water after giving the fluid drink to the child. The practice
of dilution during illness should be discouraged.
17.13 Demonstration- How to Give Zinc
Dose of zinc
½ tablet per day (10 mg) for infants 2 months upto 6 months: to be dissolved in breast milk
1 tablet per day (20 mg) for children 6 months: to be dissolved in breast milk or plain water. Older
child can chew it directly
Duration of use
Start as soon as the diarrhoea begins i.e., from the first day and give for 14 days irrespective of when
the child recovers.
Why should zinc be given for 14 days?

• If given for 14 days it will replenish the zinc lost through stools. Improves appetite and weight
gain
• Prevents diarrhoea and pneumonia over the next 2 months
• Acts as a tonic after recovery from diarrhoea
Preparation of zinc
• Take a clean spoon, place 1 tablet (for infant, 6 months) on the spoon.
• Pour water carefully on the tablet taking care that the water does not reach the brim.
• Never dip the spoon with tablet into the water container.
• If the baby is <6 months and breastfed, tell mother to express milk first in the spoon and then add
½ tablet, discard the other ½. Be careful, while breaking the tablet into half, put pressure with
your thumb on the groove in the tablet. If two halves are not equal, break off the extra bit from
the larger half. Discard the remaining half.

• Shake the spoon slowly till the tablet dissolves completely. Take care that the solution does not
overflow. Do not use fingertip or any other material to dissolve the tablet.Tell the mother to
hold the child comfortably and ask her to feed the solution to the child.
• If there is any powder remaining in the spoon, let the child lick it or add little more water or
breast milk to dissolve it and then ask the mother to give it again.
Acceptability
The acceptability of these tablets is high; it has been tested in large number of children
Safety
• Zinc is totally safe beyond the neonatal period.
• No side effects are expected based on the multiple studies done by WHO and ICMR and
published in literature.
17.14 Role Play on the Advice regarding Home Treatment of Diarrhoea and No
Dehydration
Objective
The objective of this role play is to discuss with the mother, home care of a child with diarrhoea and
no dehydration.
The characters in this role play are the mother and a HEALTH WORKER.

Gopal is an 11-month-old male who is brought to the HEALTH WORKER with diarrhoea of 2
days duration. The HEALTH WORKER has examined Gopal and has found no dehydration. The
role play starts with the HEALTH WORKER explaining to the mother that Gopal does not have
dehydration and needs treatment at home. The mother is from a village. She is illiterate. The
family is poor and the earnings are made by daily wage labour. Gopal is the fourth child. Gopal
is continuing on breastfeeding and the mother thinks that the child is not fully satisfied with her
milk. She also gives him half diluted cow’s milk. Before Gopal got sick, he was getting two
teaspoons of porridge but this has been stopped ever since diarrhoea began. The mother wants the
HEALTH WORKER to give the child some medicine to cure the illness.

The HEALTH WORKER selects the box Counsel the Mother on Home Treatment for `Diarrhoea
- no dehydration’ (Green box) on the chart booklet, chooses the home available fluids in consultation
with the mother, marks out relevant portions of advice on breastfeeding, home available fluids, how
much to give (half cup per stool), how to give, to continue feeding and when to return. The facilitator
should monitor the process of using the chart booklet.

Tips for the HEALTH WORKER
• Praise the mother for bringing Gopal to him.
• Assure the mother that the child has no dehydration. Praise her for bringing the child early in
disease.
• Identify the fluids available at home.
• Encourage the mother to give home available fluids in amounts larger than given normally and
gives some idea about how much is to be given.
• Discourage the mother from diluting cow’s milk. Emphasizes that breast milk is good for Gopal
and it must be continued during diarrhoea.
• Give emphasis on continued feeding during the illness.
• Teach the mother signs of illness she should look for. If any of these signs are noted the mother
should bring back Gopal immediately Gopal immediately.
• Convinces the mother that medicines are not required.
What the observers of the role play should check while watching the role play?
• Did the HEALTH WORKER praise the mother for bringing Gopal to her?
• Has the HEALTH WORKER advised the correct home available fluids for giving to Gopal?
• Has the HEALTH WORKER answered the questions of the mother to her satisfaction?
• Was the HEALTH WORKER successful in correcting the feeding problems identified?
• Was any advise given for increasing the amounts of fluids?
• How well were the signs of illness taught?
• Was the mother convinced that medicines should not be given?
• Identify one checking question that was asked?
• What was done well in the role play?
• How could you improve the communication with the mother?

• Only home management is required in the treatment of child with diarrhoea and no dehydration.
• The 4 rules of home care are to give increased amount of fluids, give Zinc, to continue feeding
and observe for signs of when to return to the Health Worker.
• Medicines are generally not required in the treatment of diarrhoea with no dehydration.
• Home available fluids, which are safe, should be advised.
17.15 Participants read ‘Promote the Health of the Child’ through Identify
Feeding Problems”
17.16 DEMONSTRATION: Use of Feeding section

Explain how to use the COUNSEL THE MOTHER section. Point to the relevant sections of the
COUNSEL THE MOTHER section while outlining the tasks to be taught:
• Assess the child’s feeding.
• By comparing the child’s feeding to recommendations on the job-aid, identify feeding problems.

• Praise the mother for the tasks she is doing well and negotiate with the mother as to what she
will do to solve the feeding problem if any.
17.17. Role Play: Identifying Feeding Problems

Objectives:
• To practice asking questions to assess feeding.
• To identify correct feeding practices and important feeding problems.
Select one participant to play the role of the HEALTH WORKER and another to play the role of a
mother.
Description for the HEALTH WORKER

• You will use the questions listed to identify feeding problems.
• Presume that you have already assessed the child and given necessary treatment and advice.
Make sure that the problem of runny nose is discussed in home treatment.
• You may need to ask additional questions if the mother’s answers are unclear or incomplete.
• Feeding problems includes (a) not breastfeeding adequately; (b) refusal of “Dalia” during
illness; (c) the complementary food being “thin” and not energy rich; and, (d) giving sugar
water during the illness.
Give a copy of the description to both the persons performing the role play

The HEALTH WORKER should use the chart booklet to circle and write feeding practices and then
identify appropriate feeding recommendations by looking at the second box from the left. Ruby is
breastfed, circle that, but she is fed 4 times during day and night while she should be fed at least 8
times in 24 hours. She is given, in addition, thin Dalia. She is not taking it. Now circle systematically
good feeding practices - breastfeeding, not using a bottle. Identify and circle feeding problems - not
breastfeeding enough number of times, giving thin Dalia and giving sugar water. The facilitator
should monitor the correct use of the chart booklet.
Conduct the role play:

Participants not playing the roles should observe and note:
• Were all the questions on assessment of feeding identified?
• Which questions were missed?
• Was the mother praised for giving Ruby breastmilk and Dalia?
• Were any checking questions asked to clarify the mother’s answers?
• Did the HEALTH WORKER identify Ruby’s feeding problems?
After the role play, summarize:
• Review the answers that the mother gave to the feeding questions.
• List on the flip chart or chalk board correct feeding practices mentioned in the role play and
feeding problems discovered.

Good Feeding Practices Feeding Problems
• Breastfeeding Ruby • Breastfeeding not adequate
• Does not use a feeding bottle • Gives thin `Dalia’
• Giving `Dalia’ as complementary food • Started sugar water during illness
Discuss whether all the necessary questions were asked to the mother. If not, what additional
questions should have been asked? What might be the consequences of not asking these questions?
Discuss possible solutions for each feeding problem
Feeding Problems Possible Solutions

• Breastfeeding not • Ruby should continue to be breastfed during the illness
adequate • Increase the frequency of breastfeeding to at least 8 times
during day and night
• Mother must continue to breastfeed Ruby at night
• Gives thin `Dalia’ • Dalia should be thick in consistency. Add a little oil 1 teaspoon
to a cup. This will increase the energy of Dalia
• Dalia should be given about 2 times per day, as much as Ruby
will take. It should be given after the breastfeed
• Started sugar water during • Breastmilk has enough water in it. So, no extra water is needed
illness • Sugar water will reduce the success of breastfeeding.
Therefore, it should not be given
17.18 Drill: Review of Feeding Recommendations

QUESTIONS ANSWERS
A infant is 3 months old
Which column of the feeding recommendations The first (left-most) column

applies?
How often should this infant breastfeed? As often as the infant wants, day and night, at
least 8 times in 24 hours.
Should other food or fluid be given? No

A infant is 5 months old
Which column of the feeding recommendations The first (left-most) column

applies?
How often should the infant breastfeed? As often as the infant wants, at least 8 times in
24 hrs.
When should complementary foods be added? When the infant is 6 months of age

QUESTIONS ANSWERS
A infant is 6 months old and breastfed
Which column of the feeding recommendations The second column

applies?
How often should the infant breastfeed? As often as the infant wants
How much food be given? Start with 2-3 table spoons and
gradually increase to ½ cup
A child is 15 months old
Which column of the feeding recommendations The third column
applies?
How often should the child breastfeed? As often as the child wants
How often should complementary foods or family 3-4 times per day (3/4 cup) & snacks 1-2
foods be given and the amount per feed? times
A child is 10 months old and is not breastfed
Which column of the feeding recommendations The second column (from left)
applies?
What kinds of food should this child be given? Several participants may answer with local
complementary foods.
How many times per day and amount? 3-4 times per day (1/2 cup) & snacks 1-2
times
A child is 2 years old
Which column of the feeding recommendations The last (right-most) column

applies?
How often should family foods be given? At least 3 meals per day
How often should snacks be given between meals? Twice daily

A infant is 1 month old. She is breastfed about 6
times in 24 hours and receives no other milk.
Is this child breastfed often enough? No, the infant should be breastfed at least 8
times in 24 hours

QUESTIONS ANSWERS
A infant is 5 months old and is exclusively
breastfed (8 times in 24 hours)
Which column of the feeding The 1st column

recommendations applies ?
Should this baby be given complementary No

foods ?
A child is 3 years old. She eats 3 meals each
day with her family
Which column of the feeding The fourth column (right most)

recommendations applies?
How often should this child be given nutritious Twice daily

food between meals?
What are some examples of foods to give between Several participants may mention local foods
meals? listed on the chart booklet
An infant is 1 month old and is exclusively
breastfed. The weather is extremely hot and
dry
The mother asks if she should give her baby No. breastmilk contains all the water that the
clean water as well as breastmilk, since it is so baby needs.
hot. Should she?
17.19 Conduct Group Discussion on “Complementary foods available locally for

different age groups”
Objectives:
• To adapt the food box to local conditions for use by listing local complementary foods which
can be given to children.
• To discuss the important principles to be kept in mind while selecting complementary foods.
Points for Discussion

• Encourage the participants to list the foods which can be given at the following age:
- Birth upto 6 months
- 6 upto 9 months
- 9 upto 12 months
- 12 months upto 2 years
- 2 years and older
• Discuss in brief the contents or consistency of the foods recommended to ensure that these are
energy rich foods

• Encourage the participants to discuss cultural acceptability of the foods suggested for different
age groups among mothers.
• Discuss the important messages that a mother should know while giving food to the child.
Meeting nutritional needs as the child grows **

6 upto 9 months 9 up to 12 1 year up to 2 2 years and
months years older (up to 5
years)
Thick porridge; Greater variety Greater variety Greater
fruit and dark of fruit and dark of family foods variety
green vegetables, green vegetables, including, fruit of family
Food rich in Vitamin-A rich in vitamin and dark green foods,
and iron; and A and iron; and vegetables, rich including
animal-source animal-source in vitamin A and fruit and
foods (meat, fish, foods iron; and animal- dark green
eggs, and yoghurt source foods vegetables,
or other dairy rich in
products) vitamin A
and iron;
and animal-
source
foods
Quantity, how Start with 2-3 1/2 katori 3/4 katori (250 ml) 1katori
much ateach tablespoon and (250 ml) food (250 ml)
meal increase to 1/2
katori (250 ml)
Frequency,
how often
• Meals 2 to 3 meals 3 or 5 meals a 3 or 5 meals 3 or 4 meals a
a day day a day day
• Snacks 1 or 2 snacks 1 or 2 snacks 1 or 2 snacks 1 or 2 snacks
Consistency, Mashed, Mashed or finely Mashed or Prepared as

how prepared thick chopped; some chopped; some the family
for child to eat consistency chewable items items the child eats (with own
that stays on that the child can can hold serving)
spoon hold
** A good daily diet should be adequate in quantity and include an energy-rich food (for example,
thick cereal porridge with added oil); meat, fish, eggs, or pulses; and fruits and vegetables
*Active Feeding: The mother should be present when the child is fed. The portion for the child
should be separate from rest of the family members (including other children). After the child has
finished eating, some food should be left over in the plate/bowl.
17.20 Participants read ‘Give Feeding Advise According to Age’

17.21 Demonstration Role Play-Giving Feeding Advice using Good
Communication Skills
This demonstration role play gives participants a model of the entire process of feeding assessment,
identification of feeding problems and counselling.
Objective:
To practice counseling steps and communication skills in the following:
• asking questions to assess feeding;
• identifying correct feeding practices and important feeding problems;
• praising the mother when appropriate;
• advising the mother using simple language and giving only relevantadvice about feeding;
• checking the mother’s understanding.

• This is a scripted role play about Ashish, an 8-month-old child who has lost his appetite during
illness.
• Read your role (Ashish’s mother) carefully from the script.
Description for the HEALTH WORKER

• The facilitator should demonstrate the role of a HEALTH WORKER.
• Read the script carefully.
• Have the relevant section ready to use. A baby doll will be helpful as a prop.
For the participants not playing the roles, write communication skills on the flip chart or blackboard
before the role play:
- Ask, listen
- Praise, advise
- Check understanding
• To the left of the script, the communication skills being used are listed in italics. The co- facilitator
should stand near the flipchart or blackboard during the role play. Point to each skill as it is used
in the script. This will make participants aware of the skills being used.
• Ask participants to tell you what feeding problems were found.
• Feeding problems include:
- Ashish not feeding well during illness.
- Needs more varied complementary foods.
- He also needs one more serving per day.
• Was all of the relevant advice about feeding given? Identify specific advice which is considered
good.
• All relevant advice was given.

SCRIPT FOR DEMONSTRATION OF ROLE PLAY
Health Worker: Let’s talk about feeding Ashish. Do you breast feed him?
Ask, listen
Mother: Yes, I’m still breast feeding.

Health Worker: That’s very good. Breastmilk is still the best milk for Ashish.
Praise How often do you breast feed him each day?
Ask, listen
Mother: How often do you breastfeed him each day?
Health Worker: Do you also breastfeed at night?
Mother: Yes, if he wakes up and wants to.
Health Worker: Good. Keep breastfeeding as often as he wants.
Praise Tell me, are you giving Ashish any other foods or fluids besides breastmilk?
Ask, listen
Mother: Sometimes I give him cooked porridge, or banana mixed in curds.
Health Worker: Those are good choices. Who feeds the child & how often are these foods given?
Praise
Ask, listen
Mother: I myself feed Ashish whenever he seems hungry.
Health Worker: That is very good. Now tell me what is the amount you give and how many times a
day?
Mother: Usually ½ katori about 2 times a day.
Health Worker: Do you ever give Ashish a feeding bottle?
Mother: No, I don’t have one.
Health Worker: Good. It is much better to use a spoon or cup.
Praise Tell me, during this illness, has Ashish’s feeding changed?
Ask, listen
Mother: He still breastfeeds, but he has not been hungry for the porridge or curds.
Health Worker: Well, he’s probably just lost his appetite due to the fever most children do. Still,
Praise keep encouraging him to eat. Try giving him his favourite nutritious foods. Give him
Ask, listen small servings frequently. Have there been any other problems with feeding?
Mother: No, I don’t think so.
Health Worker: You said you were feeding Ashish porridge 2 times a day.
Advise At his age, he is ready to eat foods like cereal about 3 times
each day. Make sure the cereal is thick. Ashish is ready for some different foods too.
Try adding some mashed vegetables or beans to the cereal, or some very small bits
of meat or fish. Also add a little bit of oil for energy. Would this be possible for you
to do?
Mother: Yes, I think so.
Health Worker: Let me show you on this job-aid what Ashish needs. Since he’s 8 months old, he
Advise should get the foods in the proper amount included in this picture (mention some
local foods).
Mother: Yes, I think so.

Mother: Should I give him these foods now, while he is sick?
Health Worker: Try offering them. He might like the taste, and these are the best foods if he will eat
them. Offer the foods that he likes. And most importantly, keep breast feeding.
Mother: All right. I will try adding some more things to the cereal.
Health Worker: Good. What do you have that you will add?
Check
Understanding
Mother: I will add a little oil, and some mashed peas. Sometimes I can add vegetables or egg,
when I have them in my house.
Health Worker: Good. And how often will you try to feed Ashish these foods?
Check
Understanding
Mother: Three times each day.
Health Worker: That’s right. I am sure you will feed him well.
Praise

• Sick children often have poor appetite. They should be given their favourite foods, in small
amounts frequently.
• Adding oil and sugar to food helps to increase their strength. Children can get more energy
from these foods even if they consume small amounts.
• Increase frequency and duration of breastfeeding during illness.
• Discuss with the mother roughly the amounts that she would agree to give every time she
gives food.
17.22 Participants read assess the development support practices till exercise on
sensitivity and responsiveness
17.23 Card Game-Exercise True/False

Before exercise on sensitivity and responsiveness do an activity on Care for
the child’s development (true or false). Cut the following statements and let
participants write

STATEMENT CARDS
01 02
A mother does a better job The brain develops more

when she feels confident rapidly when the child first
about her activities to enters school than at any
provide care. other age.
03 04
The brain develops more rapidly
Young children
when thelearn
childmore A fatherschool
first enters should talk to his
by trying things out and child, even before the child
than at any other
copying others than by
age.
can speak.
being told what to do.
05 06
Before a child speaks,

the only way she
communicates is by crying. A baby can hear at birth.

07 08
A child should be scolded

A baby cannot see at birth. when he puts something
into his mouth.
09 10
A child drops things just to A child only begins to play

annoy his father and when he is old enough to
mother. play with other children
11 12
Children can learn by Talk to your child, but do

playing with pots and pans, not talk to a child while
cups, and spoons. breastfeeding.

Answer sheet with comments
Statement card True/False Comment

1. A mother does True Before a mother or other caregiver leaves, she should have a
a better job chance to practice any new play or communication activity.
when she feels Praise her for what she is able to do. Identify when she can
confident about practise again the next day, and how much time she can
her abilities to practise with her child.
provide care.
2. The brain False The brain develops most rapidly before birth and in the first
develops more two years of life. The efforts to provide good nutrition and help
rapidly when the child learn at this age will benefit thechild for her whole
the child first life.
enters school
than at any
other age.
3. Young children True Parents can guide, assist, and help while the child experiments.
learn more by
trying things out
and copying other
than by being told
what to do.
4. A father should True A child even can recognize his father’s voice before he/she
talk to his child, is born. By talking to a child, even before he/she speaks,
even before the the father prepares the child for speech and how people
child can speak. communicate. Children understand (receptive speech)
before they can speak.
5. Before a child False A young infant communicates by moving, reaching,
speaks, the touching. For example, a child communicates hunger by
only way she sucking his/her hands, shaping his/her mouth, turning to the
communicates is mother’s breast. Help caregivers see the child’s signs and
by crying. interpret them. Waiting until the child cries is distressful to
the child and to the caregiver.
6. A baby can True There is even evidence that a child hears before birth and
hear at birth. recognizes the voices of persons closest to them.
7. A baby cannot False The child can see at birth, although sight becomes more refined
see at birth. as the days go on. The child is most attracted to faces. Studies
show that a child can even begin to copy the faces of others
within 2 to 3 weeks. Some have found imitation even earlier,
within the first few days of life. Upto about the sixth week of
life, the child can only see things within about 12 inches of her
face. It is important to hold the him/her close for the child to see
your face.
8. A child should be False The child puts things in his/her mouth because the mouth is
scolded when he very sensitive. He/She learns hot and cold, smooth and rough
puts something through his/her mouth, as well as by his/her hands. Make
into his mouth. sure the objects are safe and clean.

9. A child drops False Dropping can be by accident. However, the child is also
things just to learning by trial: what happens (gravity), how long before there
annoy his father is a sound, how other persons react, etc.
and mother.
10. A child only A caregiver can begin to play with a child from birth. Children
begins to play False learn through play. Caregivers can play with a young infant with
when he is movements, touching, and attracting the attention and interest of
old enough to the child with simple noises and colourful objects.
play with other
children
11. Children can
learn by playing True Children do not need store bought toys. They can learn from
with pots and many household items.
pans, cups, and
spoons.
12. Talk to your
child, but do A mother can talk softly to a child and gently be
not talk to a False affectionate to a child who is breastfeeding without
child while distracting the child from feeding. It helps the mother
breastfeeding. become close to her child. The child is comforted by the
sounds and touch of themother.
Answers to exercise (Page No 121)
1. Deepti hears Rajat crying

“S”
2. Deepti picks up Rajat to soothe his crying
“R”
3. Deepti is giving Rajat a bath and notices a rash on his leg
“S”
4. Deepti sees Rajat watching the tree’s branches blowing in the wind
“S”
5. Deepti asks Rajat, “Do you see the wind blowing? The leaves are blowing!”
“R”
6. Deepti notices that Rajat is not feeding as much as usual
“S”
7. Deepti offers Rajat a food he likes to see if he will eat
“R”

17.24 Participants complete the section till follow up and do exercise
• Match the responses with the chart booklet.
• The facilitator will demonstrate some of these activities
Age Play activity Communication activity

Young • Provide ways for infant to see, hear, feel, move freely, • Look into baby’s eyes, and
infant, and touch you. talk to baby.
aged upto • Move colourful objects (e.g. ribbon bow) in front of • Smile and laugh with the
3 baby’s eyes to help the baby learn to follow and reach. baby.
months • Get conversations going by
copying the baby’s sounds
and gestures.
Infant, • Move colourful objects slowly in front of the infant’s • Smile and laugh with infant.
age 3 face and on the sides so that infant can move the face • Get a conversation going by
upto 6 with the movement of the object, help infant grab and copying the infant’s sounds
months hold objects. and gestures.
• Give infant a shaker, rattles or rings on a string. • Talk softly to infant and
• Give infant wooden spoon and other household objects respond.
to reach for, grab, and examine.
• Play with ball, rolling the ball back and forth.
Child, • Give child clean, safe household things to handle, bang, • Respond to your child’s
aged 6 and drop. sounds and interests.
upto 12 • Hide a child’s favourite toy under a cloth or box. See if • Call child’s name and see
months the child can find it. child respond.
• Place safe objects in front of the child so that child picks • Say Papa, Mama and Dada
them with thumb and finger to the child to encourage the
• Play peek-a-boo. child to repeat.
• Play tata and bye-bye with the child. • Tell child the name of things
• Help the child to stand up. and people.
• Play hand games, like bye-
bye.
Child, • Give child things to stack up, and to put into containers • Ask child simple questions.
aged 1 and take out. • Respond to child’s simple
year upto • Help the child to walk. questions and attempts to
2 years • Encourage the child when he/she imitates household talk
work. • Respond to child’s attempts
to talk. Show and talk about
nature, pictures, and things.
Child • Help child count, name, and compare things. • Encourage your child to
aged 2 • Show colours in the book and help the child recognize talk. Answer your child’s
years and them questions.
older • Make simple and safe toys (e.g. picture book), objects to • Engage the child in copying
sort (e.g. circles and squares, puzzle, doll). a straight line or a circle
• Encourage the child to imitate you to wash hands • Teach your child stories,
songs, and games.
• Talk about pictures or books.
• Engage the child in pointing
to body parts
• Encourage the child for
feeding self even though
some food is spilt

After the exercise, discuss bonding, attachment, sensitivity and responsiveness.
Summarize important concepts in child development
• Bonding between a mother and child
• Interactions between a child and caregivers (where caregivers are aware and sensitive to child,
and respond to needs)
• Communication between caregiver and child
• Creating ways for the child to play and develop skills (especially with homemade or inexpensive
items)
17.25 Group Discussion

Why should families play and communicate with the children?
Summarize
Finally, explain to the caregiver the importance of stimulating the child’s development. One of the
following reasons might be important to the child’s family:
• Play and communication, as well as good feeding, will help your child grow healthy and learn.
These activities are especially important in the first years of life.
• Play and communication activities help the brain to grow and make your child smart and
happy.
• Good care for the child’s development will help your child be ready to go to school and to
contribute one day to the family and community.
• Playing and communicating with your child will help build a strong relationship with your
child for life.

SECTION
18 FOLLOW UP VISITS AND

FOLLOW UP CARE
18.1 Participants read ‘Follow up Visits’ through ‘Follow up care’

18.2 Conduct a Drill on “When to Return for Follow up visit”
Question. Answer.
Pneumonia 2 days
Diarrhoea 5 days
Fever 2 days
Feeding problem 5 days
Moderate Acute Malnutrition 30 days
Anemia 14 days
Any other problem, if not improving 5 days
18. 3 Conduct a Drill on “When to return immediately”
a. Remind participants that, in addition to telling the mother about definite follow-up visits needed,
the health worker must teach her when to return immediately.
For example, if a child has pneumonia, the mother should be told to return in 2 days for follow-
up. She should also be told to return immediately, if the child:
- is not able to drink or breastfeed
- becomes sicker
- develops fever (unless the child already has a fever)
Point to the part of the job-aid where the signs to return immediately are listed
b. In this drill participants will practice saying the signs to return immediately for different cases.
Tell them that they may refer to the chart booklet as needed.
c. Read aloud the case’s classifications and follow-up times in the left column. (Unless specified
otherwise, assume that the child has NO ANEMIA AND NOT LOW WEIGHT FOR AGE and
no other classifications.) Ask each participant, in turn, to say the signs to return immediately
for a case.
Note: The signs “not able to drink or breastfeed” and “drinking poorly” are listed separately in the
answers to the drill. However, if a participant combines these signs for a child with diarrhoea, his
answer is correct. Explain that, in discussions with mothers of children with diarrhoea, it will be
simpler to say “drinking poorly,” which includes the sign “not able to drink or breastfeed.”

CASE SIGNS TO RETURN IMMEDIATELY
Not able to drink or breastfeed,
The child has PNEUMONIA and will be seen in 2
Becomes sicker,
days for follow-up. The child has no fever.
Develops fever
The child has NO PNEUMONIA: COUGH OR Becomes sicker,
COLD and Moderate Acute Malnutrition. She will Develops fever,
be seen again in 5 days about a feeding problem. Fast breathing,
Difficult breathing
Becomes sicker
The child has diarrhoea with NO DEHYDRATION.
Develops fever,
The mother has been told to come back in 5 days.
Blood in stool,
Drinking poorly
The child has fever and is classified as having Not able to drink or breastfeed,
MALARIA. He will be seen in 2 days for follow-up. Becomes sicker

SECTION
19 ANNEXURES
19.1 Checklist for Monitoring Clinical Sessions

This is an example of a monitoring checklist that has been completed. The facilitator has used a simple lettering
system to annotate the problems
SICK YOUNG INFANT AGED UPTO 2 MONTHS
Tick correct classification. Date:

Circle if any assessment or classification problems. Annotate below
Participant’s Initials
SICK YOUNG INFANT AGE (weeks)
POSSIBLE SERIOUS Possible serious bacterial
BACTERIAL infection OR very severe
INFECTION disease
Local bacterial infection
Infection Unlikely
Severe Jaundice
JAUNDICE Jaundice
No Jaundice
Severe dehydration
Some dehydration A
DIARRHOEA No Dehydration
Very low weight
FEEDING PROBLEM Feeding problem and/or low
OR LOW WEIGHT weight for age
FOR AGE
No feeding problem
Immunization status
CHECK AND ASSESS Other problems

Mother’s/ caregiver
development supportive
practices
IDENTIFY TREATMENT NEEDED
Tick treatments or counselling actually given
Circle, if any problem
Annotate below
Pre-referral treatment /Oral
drugs
Teach correct positioning,
attachment and feeding
problem
Teach mother how to express
breastmilk
Teach the mother to feed with
TREAT AND cup and spoon
COUNSEL Oral Thrush
Immunization
Development supportive
practices
About her own health
Follow-up care
SIGNS DEMONSTRATED IN ADDITIONALCHILDREN
PROBLEMS: A: WRONG ASSESSMENT OF SKIN PINCH

19.2 Checklist for Monitoring Clinical Sessions Date:
SICK CHILD – AGED 2 MONTHS UPTO 5 YEARS
Tick correct classification.
Circle if any assessment or classification problems. Annotate below
Participant’s Initials
SICK CHILD AGE (months)
GENERAL DANGER SIGNS
Severe Pneumonia OR
COUGH OR very severe disease
DIFFICULT Pneumonia
BREATHING No pneumonia: cough
& cold
Severe dehydration
DIARRHOEA Some dehydration
No Dehydration
Very severe febrile
disease
FEVER Malaria/ suspected
malaria
Fever-Malaria unlikely
Severe acute
malnutrition
MALNUTRITION Moderate acute
malnutrition
No acute malnutrition
Severe anemia
ANEMIA Anemia
No anemia
Immunization status
Feeding problems
CHECK AND ASSESS Other problems
Mother’s/ caregiver
development
supportive practices
IDENTIFY TREATMENT NEEDED
Tick treatments or counselling actually given. Circle, if any problem. Annotate below
Prereferral treatment
TREAT Oral Antibiotic
Plan B/ Plan A
Give advice on feeding
Feed of child
with severe acute
malnutrition or
moderate acute
malnutrition
COUNSEL
Immunization
Development
supportive practices
About her own health
Follow-up care
SIGNS DEMONSTRATED IN ADDITIONAL
CHILDREN

19.3 GROUP CHECKLIST FOR CLINICAL SIGNS (SICK YOUNG
INFANTS AGED UPTO 2 MONTHS)
Participants will monitor their own clinical practice experience by using their Recording Forms to
complete a Group Checklist of Clinical Signs.
A sample checklist is on the next two pages. The first page contains the signs to observe in young
infants age upto 2 months. The second page lists additional signs that are usually seen in children
age 2 months upto 5 years.
To use the group checklist:
1. Obtain or make an enlarged version of each page of the checklist and hang it on the wall of the
classroom. (You can copy it onto flipchart paper.)
2. When participants return to the classroom after clinical practice each day, they should indicate
the signs they have seen that day by writing their initials in the box for each sign. They should
indicate signs that they have seen in either the outpatient session or the inpatient session.
3. Each day they will add to the same checklist.
4. Monitor the Group Checklist to make sure that participants are seeing all of the signs.
• If you notice that participants have not seen many examples of a particular sign, take every
opportunity to show participants this sign when a child with the sign presents during an
outpatient session.
• Or, in facilitator meetings, talk with the inpatient instructor and discuss locating in the
inpatient ward a child or young infant with the sign the participants need to observe.
Note: These signs may also be observed in older infants and children age upto 5 years
Mild chest indrawing in Fast breathing in young Severe chest indrawing Convulsions
young infant (normal) infant inyoung infant
Movement only when No movement even Dehydration (Some or Cold To Touch

stimulated when stimulated Severe)
Red umbilicus or Skin pustules Palm and soles Yellow Thrush

draining pus
No attachment at all Not well attached to Good attachment Not suckling at all
breast
Not suckling effectively Suckling effectively Weight <1800 gm Breast or Nipple

problem

19.4 GROUP CHECKLIST FOR CLINICAL SIGNS (SICK CHILD AGED 2
MONTHS UPTO 5 YEARS)
Not able to drink or Vomits everything Lethargic or Fast breathing

breastfeed unconscious
Chest indrawing Restless and irritable Sunken eyes Drinking poorly
Drinking eagerly, thirsty Very slow skin pinch Slow skin pinch Stiff neck
Visible severe wasting/ Oedema of both feet Severe palmar pallor Some palmar pallor
MUAC<11.5cm


IMNCI Facilitator Guide Health Worker 2023

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INTEGRATED MANAGEMENT OF

NEONATAL AND CHILDHOOD

FACILITATOR GUIDE FOR

FACILITATOR GUIDE FOR

I extend my best wishes to everyone.

Integrated Management of Neonatal and Childhood Illness (IMNCI)

Integrated Management of Neonatal and Childhood Illness (IMNCI)

With best wishes!

Integrated Management of Neonatal and Childhood Illness (IMNCI)

Integrated Management of Neonatal and Childhood Illness (IMNCI)

1. Integrated Management of Newborn and Child Illnesses (IMNCI)- for outpatient

Cont’d on next page

Integrated Management of Neonatal and Childhood Illness (IMNCI)

Other major differences are:

(Dr. Shobhna Gupta)

• Ms L S Changsan, Additional Secretary & Mission Director (NHM), MoHFW

• Dr A K Jaiswal, Patna Medical College, Bihar

• Dr Ashfaq Bhat, NIPI

1.1 HOW DOES THIS COURSE DIFFER FROM OTHER TRAINING

1.2 ROLE AND RESPONSIBILITIES OF A FACILITATOR

Integrated Management of Neonatal and Childhood Illness (IMNCI) 17

How do you do these things?

18 Integrated Management of Neonatal and Childhood Illness (IMNCI)

How can this FACILITATOR GUIDE help you?

To prepare yourself for the module, you should:

Integrated Management of Neonatal and Childhood Illness (IMNCI) 19

1.3 Checklist of instructional materials needed in each small group

ITEM NEEDED NUMBER NEEDED

1.4 Checklist of Supplies Needed for Class Room Sessions

Supplies needed for each group include:

20 Integrated Management of Neonatal and Childhood Illness (IMNCI)

II. Keep Participants Involved in Discussions

Integrated Management of Neonatal and Childhood Illness (IMNCI) 21

B. Manage any Problems

22 Integrated Management of Neonatal and Childhood Illness (IMNCI)

C. Reinforce Participants Efforts

17. Reinforce participants who:

Integrated Management of Neonatal and Childhood Illness (IMNCI) 23

E. Techniques for Assisting Co-facilitators

I. When Providing Individual Feedback:

24 Integrated Management of Neonatal and Childhood Illness (IMNCI)

II. When Leading a Group Discussion:

Integrated Management of Neonatal and Childhood Illness (IMNCI) 25

1.6. CLINICAL PRACTICE

During clinical practice sessions, participants will:

26 Integrated Management of Neonatal and Childhood Illness (IMNCI)

In the Outpatient Sessions, participants will:

Integrated Management of Neonatal and Childhood Illness (IMNCI) 27

The role of the facilitator during outpatient sessions is to:

1.7. SCHEDULE OF SESSIONS FOR TRAINING

Classroom Sessions Clinical Sessions

28 Integrated Management of Neonatal and Childhood Illness (IMNCI)

INTRODUCTION TO TRAINING &

The objectives of this training course are:

2.2 Training package

Integrated Management of Neonatal and Childhood Illness (IMNCI) 29

Explanation of your role as Facilitator

2.4 Introduce the participant’s Training Module

3. Hanif is a 7-day-old boy. He has the classification: