Shills that Save Lives
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ASHA Module 7
Shills
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Focus on Child Health and Nutrition
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Contents
PART A: Child Health & Nutrition
1.
2.
3.
4.
5.
6.
7.
Infant and Young Child Feeding
Assessment of Malnutrition
Update on Immunisation
Assessing the Sick Child
Assessing and Classifying Fever
Management of Diarrhoeal Disease
Management of Acute Respiratory Infection (ARI)
5
7
14
18
20
22
24
29
PART B: Women's Reproductive Health
33
1. Safe Abortion
2. Family Planning
3. Reproductive Tract Infections (RTIs) and
Sexually Transmitted Infections (STIs)
35
38
PART C: Newborn Health
47
1. High Risk Assessment and Management of Low Birth
Weight/Pre-Term Babies
2. Breastfeeding Low Birth Weight/Pre-Term babies
3. Asphyxia Diagnosis and Management
4. Neonatal Sepsis: Diagnosis and Management
49
51
52
54
PART D: Introduction to Infectious Diseases
57
Malaria
Tuberculosis
59
63
Annexes
67
44
Contents 3
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About this booh
The sixth and seventh modules cover areas whose content is already
familiar to the ASHA. In addition, this module includes the development
of specific competencies in healthcare for mothers and children. It is thus,
intended to serve as a refresher module, building on existing knowledge
and the development of new skills in the area of maternal and child health.
ASHAs that are newly recruited into the programme, could directly
start with Module 5, 6 and 7. This module is also designed to serve as a
reading material for ASHAs, and is therefore, to be given to each ASHA.
A companion communication kit for the ASHA to use when she conducts
home visits and village meetings has also been developed. There is also a
manual for trainers with training aids to use during the training of ASHA.
The training plan envisages a total of 20 to 24 days of residential training, to
impart the skills that these two modules are teaching.
Acknowledgements
The sections on maternal and newborn care are excerpted from the SEARCH
Manual on 'How to Train ASHA in Home-Based Newborn Care' and
SEARCH developed ASHA Reading Material on Home-Based Newborn Care.
Thanks are due to Members of the National ASHA Mentoring Group, United
Nations Children's Fund (UNICEF), Breastfeeding Promotion Network of
India (BPNI), the Public Health Resource Network (PHRN), and the training,
maternal and child health and malaria divisions of the ministry for providing
extensive feedback, and also HLFPPT for providing information on Nischay
Kit. The Integrated Management of Neonatal Childhood Illnesses (IMNCI)
package is also incorporated into these modules.
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Child Health & Nutrition
1. Infant and Young Child Feeding
Objectives of the session
By the end of the session, the ASHA will learn about:
' • J Communicate essential messages for prevention of malnutrition, advice on
feeding and on prevention of illness, and on access to health and nutrition
services.
( • i Analyse the causes of malnutrition in a specific child - the role of feeding
practices, role of illnesses, of familial and economic factors and of access to
services.
i • J Counsel families to prevent malnutrition and to reverse malnutrition in
children below five years.
One-third of the world's undernourished children live in India. About 46%
of the children below three years in India are underweight. This means
that roughly one out of two children weigh less than they should for their
age. Under nutrition in early child hood is associated with poor academic
performance, reduced work capacity, and poor health and nutrition status
through childhood, adolescence and adulthood.
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Facts about Malnutrition in Young Children
• Malnutrition increases susceptibility to disease. Malnutrition is one of the
contributory factors to over half of all child deaths.
tt;
•
Malnutrition is highly related to poverty. Poor families have less money to
spend to get the quantity and variety of food, they find it more difficult to
get healthcare and also there is less time for child care.
•
Counselling can help the family in making the right choices on using
their scarce resources to feed their children and protect them from
malnutrition.
®
Families are more comfortable when issues of feeding are discussed in
their homes. Also at the home, not only the mother, but the father and the
grandparents of the child, all become part of the dialogue.
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Child Health & Nutrition 7
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It is easier to prevent a child from slipping into malnutrition than to
reverse it once it is severely underweight. Hence, the focus should be on
counselling every family with a young child below one year of age, because
it is this time, especially in the age of 6 to 18 months that most children
become malnourished.
Recognising Malnutrition
It is difficult to recognise malnutrition just by looking at a child. Only very
severe cases would show obvious signs of weakness or wasting by which time
it is too late. Most children look normal but their height and weight when
measured is less than expected for their age. It is therefore essential to weigh
every child monthly, so as to detect malnutrition in time. Depending on the
weight the child can be classified as mild, moderate or servely underweight.
Sick children need special attention. However, families of all children especially
children below two should be counselled on feeding the child so as to prevent
malnutrition.
Six Important Messages For Preventing Child Malnutrition
1. Exclusive Breastfeeding: Till the age of six months, give only breast milk;
not even water should be added.
2. Complementary Feeding: At the age of six months, add other foods.
Breastfeeding alone is not enough, though it is good to continue
breastfeeding for at least one to two years more. There are five things to
remember about complementary feeding:
(i) Consistency: Initially the food has to be soft and mashed. But later,
anything that adults eat can be given to the child, with less spices. Do
not dilute food. Keep it as thick as possible, for e.g. "give daal not daal
ka pani'.
(ii) Quantity: Gradually increase the amount of such foods. Till at about
one year, the child gets almost half as much nutrition as the mother.
(iii) Frequency: The amount of complementary foods given should be equal
to about half what the adult needs in terms of nutrients. But since the
child's stomach is small, this amount has to be distributed into four to
five, even six feeds per day.
(iv) Density: The food also has to be energy dense, low in volume, high in
energy, therefore, add some oil or fats to the food. Family could add a
spoon of it to every roti/every meal. Whatever edible oil is available in
the house is sufficient.
(v) Variety: Add protective foods - green leafy vegetables. The rale is that the
greener it is, or the more red it is the more its protective quality. Similarly
meat, eggs, fish are liked by children and very nutritive and protective.
3
8T' Simple Shills that Save Lives
Feeding during the illness: Give as much as the child will take; do not
reduce the quantity of food. After the illness, to catch up with growth, add
an extra-feed. Recurrent illness is a major cause of malnutrition.
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Prevent illness: Recurrent illness is a major cause of malnutrition. There are
six important things to remember which could prevent illness:
(a) Handwashing: before feeding the child, before preparing the child's
food, and after cleaning up the child who has passed stools. This is the
single most useful measure to prevent recurrent diarrhoea.
(b) Drinking water to be boiled. Though useful for everyone, it is of
particular importance to the malnourished child with recurrent diarrhoea.
(c) Full immunisation of the child: Tuberculosis, diphtheria, pertussis and
measles are all prevented by immunisation and are the diseases that cause
severe malnutrition. In malnourished children, these diseases are more
common and life threatening, than in normal children.
(d) Vitamin A: To be given along with measles vaccine in the ninth month
and then repeated once every six months till five years of age. This too
reduces infections and night blindness, all of which is more common in
malnourished children.
(e) Avoid persons with infections, especially with a cough and cold picking
up the child, and handling the child, or even coming near the child during
the illness. This does not apply to mother, but even she should be more
rigorous in handwashing and more careful in handling the baby.
(f) Preventing Malaria: In districts with malaria the baby should sleep under
an insecticide treated bed net. Malaria too is a major cause of malnutrition.
I
You should encourage parents and other family members to spend time with
the child as it matters a lot. Time has to be spent in feeding the child. Time has
I
to be spent in playing and talking with the child. Such children eat and absorb
food better.
5
Access to health services
♦ Access to health services makes for prompt treatment of illness.
On the very first day of the illness, if you help the mother decide
on whether it is a minor illness for which home remedy would be
adequate, or to be reffrered to a doctor, such a decision would save
lives. Early treatment would prevent malnutrition.
♦
6
Access to contraceptive services is important. If the age of mother is
less than 19, or the gap between two children is less than three years,
there is a much higher chance of the children being malnourished.
Access to anganwadi services
♦ The anganwadi provides a food supplement for the child up to the
age of 5. This could be a cooked meal, or in the form of take - home
rations. Malnourished children are to be given additional food
supplements. For children below the age of two, take - home rations
Child Health 8 Nutrition
are to be given. Even pregnant women and lactating mothers up to six
months are entitled to get food supplements in the anganwadi centres.
♦
Weighing the baby and informing the family of the level of
malnutrition is another important anganwadi service.
♦
The anganwadi is also the site where the Village Health and Nutrition
Day (VHND) is conducted. The ANM visits every month and the
child is given immunisation. Vitamin A, paediatric iron tablets.
Oral Rehydration Salts (ORS) packets or drugs needed for illness
management.
Note
Wasted expenditure on unnecessary services is also an issue. Families tend
to spend a lot oF money in commercial health foods which are very costly.
This money is better spent in buying cheap, lower cost locally available
nutritious foods. Tonics and health drinks are also a waste for the poor family.
Unnecessary and costly treatments by local doctors for the recurrent bouts
of diarrhoea and minor colds and coughs could also be a drain. One of the
I
important services that you can perform is in making people aware that such
expenditures are unnecessary.
Counselling on Malnutrition
All the above messages are important for managing malnutrition also. But
there are too many points to list out and the family members may not register
it. Also, many of the messages may not be applicable to that particular child, or
may not be possible for that family. For these reasons, we have to do it in two
steps - first an analysis of why a child is malnourished and once we have an
understanding of this, then a dialogue with the family to see what can be done.
For an analysis, we need to know the Following:
J
•
What is the nutritional status of child - is it normal, underweight,
moderately underweight or severely underweight?
•
What is the child being fed as compared to what needs to be given?
•
What is the recent history of child's illness, and whether enough has been
done to treat it promptly and to prevent further illness?
•
What is the family's access to the three key services? (ICDS, Health
Services and Public Distribution Services)
Shill in Eliciting Information
There is a skill of asking each question so as to get the right information.
What the child is being Fed
•
Simple Skills that Save Lives
Ask specifically what was fed in the last one day, starting from now and
recalling backwards, till the previous day
Things to notice: how many feedings in a day, how much in each feed, whether
the child's food included pulses, vegetables, oil.
9
Ask specifically about protective foods which are not given daily.
•
Ask about feeding during illness.
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Illness and treatment
®
Ask whether the child fell ill during past six months (ask specifically about
diarrhoea, fever, cold and cough). Start with most recent illness, and then
ask them to recall backwards -,z before this when was he/she sick? etc.
•
What actions did the family take during illness? Which provider did they
go to?
•
What difficulties did the family face in accessing healthcare and how
much did it cost?
•
What are the likely inessential services or expenditures which they are
getting into?
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Access to anganwadi services
•
Is the child taken regularly every month to the Anganwadi Centre (AWC)
for weighing? Have they seen the growth curve?
•
Is the family availing of food supplements from the anganwadi, is it
regular, reliable and of variety needed and reasonable quality?
Shill in Analysis
Based upon the replies to these questions, you will form an understanding of
the multiple causes of malnutrition in that specific child. It is never one factor.
I
Given below are examples of understanding that ASHA formed
in two children:
Banu was a nine month old girl with moderate malnutrition. She is being
breastfed and only this month was started on complementary food. She eats
rice and dal from her parents' plate while they are eating, once at about 10.00
am and then about 6.00 p.m. She had diarrhoea once, one month ago, but no
other illness. You gave her ORS and she became alright with it. She does not go
to the anganwadi or get rations from there. Her immunisation is on schedule.
Rafay is an 18 month old boy who is severely underweight. He has no odema,
but there is some wasting. He cannot go to the hospital because his mother
-
cannot leave her younger child and she also has to go to work as she is
the only earning member. Rafay is not being breastfed, but gets to eat roti,
dal and vegetables. He eats about half a roti or one roti thrice a day. But his
mother complains that he does not eat a lot and has very poor appetite.
He has frequent episodes of respiratory infection but no other illness. His
immunisation schedule is complete.
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Child Health & Nutrition tji
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it is many. Do not jump immediately to some point
and start giving your advice. Ask all the questions,
listen to the replies fully, think about it and then
only give your advice.
Discuss what measures are needed in each case and how this is to be
conveyed?
Shill of Counselling
How to give advice
• First praise the mother for how well she is coping with the child and
reinforce the good practices she is following. Praise must always precede
any other advice.
•
Then deliver each message as needed for that child in the form of a
suggestion and ask whether they could implement it. Dialogue with the
family explaining why the step is needed and how they could achieve
it. If they are convinced, they would agree. If not convinced or unable to
agree, move on to the next message. It takes more than one visit and one
dialogue for families to agree, even if it was possible.
•
Then point out any harmful or wasteful practices, explaining why you
say so.
•
Arrange for a follow-up visit to see how many practices have changed and
to further reinforce the messages. Each family with a malnourished child
needs to be met about once or twice a month.
•
Arrange for mother and child to meet the ANM or the doctor as required.
Such a visit is required in the following circumstances:
♦
Any child who is severely underweight. If, in addition, there are
danger signs, admission in a facility which manages such children
would be desirable.
♦
Any child who is underweight, who does not gain weight even after a
few months of trying to follow the advice.
♦
Any child who is underweight, who has fever, or chronic cough or
persistent anaemia.
Even if the family is not going to see the doctor or ANM, do inform the
Anganwadi Worker (AWW) and the ANM so that they can follow-up too.
This work is equally their work also.
How you should NOT give advice
Do not prescribe advice without dialogue—just telling families what to do
would not help...
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Simple Shills that Save Lives
Do not give very broad and what can be perceived as zinsutlting' advice like
- "you must take care of your child, or you must keep the child clean, or you
must give nutritious food etc."
Anaemia in the Young Child
Anaemia is important to diagnose because it commonly comes along with
malnutrition. It may be a cause of poor appetite. Blood testing is essential,
but even in its absence based on observation of pallor alone, treatment can be
started.
Looking for Anaemia in Children
Unusual paleness (Pallor) of the skin of the soles or palms is a sign of
anaemia.
•
To see if the child has anaemia, look at the skin of the child's palm. Hold
the child's palm open by grasping it gently from side to side.
•
Do not stretch the fingers backward. This may cause pallor.
•
Compare the child's palm with your own palm and the palm of other
children. If the skin is paler than of others, the child has pallor.
Treatment for anaemia is to give one tablet of paediatric iron daily. And also
give one tablet of Albendazole for deworming once in six months. For a child
less than two years, give half a tablet of Albendazole (Refer Annexure 6). Iron
rich foods as discussed for the mother (Book 6) are also needed for the young
child. If anaemia does not improve, the child must be referred to a doctor for
more complete blood tests and treatment.
Feed 4 to 6
times/day (i
Don't Dilute
unnecessarily
'Not daal water
butDaal'.
Add Fats
and Oils.
Start at
six months
Red and Greens
The greener- the
redder the better.
Continue feeding
during illness and
extra feed after!
Milk, Eggs, Meat & Fish.
Children Love it:
and its good for health
7
2. Assessment oFMalnutrition
Objectives of the session
By the end of the session, the ASHA will learn about:
Know signs of malnutrition in a sick child.
Be able to classify grades of malnutrition.
to plot weight for age on a growth chart.
ALL sick children should be assessed for signs suggesting malnutrition.
Look and Feel:
i • Look for visible severe wasting.
! •
Look for oedema of both feet.
•
Determine grade of malnutrition by plotting weight for age (with AWW).
Identifying Visible Severe Wasting
• A child with visible severe wasting is very thin, has no fat, and looks like
skin and bones. Some children are thin but do not have visible severe
wasting. This assessment step helps you in identifying the children with
visible severe wasting who need urgent treatment and referral to a hospital.
•
To look for visible severe wasting, remove the child's clothes. Look for severe
wasting of the muscles of the shoulders, arms, buttocks and legs. Look at the
child from the side to see if the fat of the buttocks is missing. When wasting is
extreme, there are many folds of skin on the buttocks and thigh.
•
The face of a child with visible severe wasting may still look normal. The
child's abdomen may be large or distended.
•
Look and feel to determine if the child has swelling of both feet. Use your
thumb to press gently for a few seconds on the upper surface of each foot.
The child has oedema if a dent remains in the child's foot when you lift
your thumb.
Determine Grade of Malnutrition
The AWW uses a growth monitoring chart for every child. Every child in the
village should be weighed and his/her weight plotted on the growth chart.
There is a separate chart for boys and for girls under the age of five years.
♦
How to plot weight for age and identify malnutrition:
• The left hand vertical line is the measure of the child's weight.
•
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Simple Shills that Save Lives
The bottom line of the chart shows the child's age in months.
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•
Find the point on the chart where the line for the child's weight meets the
line for the child's age.
Decide where the point is in relation to the curves:
• If the point is below the bottom most (-3SD) curve, the child is severely
underweight.
•
If the point is between 2nd and 3rd curve or exactly on the 3rd curve, the
child is moderately underweight.
•
If the point is on or above the curve marked zero or between the curve
zero and -2SD (second curve) or exactly on the 2nd curve, then the child is
normal.
Community Level Care for a Malnourished Child
All children who are underweight, should receive the following:
1. Nutritional counselling as discussed earlier
2. Prompt treatment for all illnesses
3. Periodic weight measurement to ensure weight gain and detect worsening
early.
(a) De-worming tabs (Albendazole): Half tablet of albendazole for a child less
than two years old and one tablet for all children above two.
(see Annexure-6)
(b) Paediatric Iron and Folic Acid Tablets: Daily one for three months.
(c) A dose of Vitamin A: If this has not been given.
Remember:
Those children who are moderately underweight, should
be taken to a 24X7 PHC or higher facility for a medical
consultation. Children who are severely malnourished need
prompt hospitalisation in a centre which manages such
children. This is often the District Hospital.
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Child Health & Nutrition
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3. Update on Immunisation
This session has already been covered in the ASHA Module 2. Thus, this is
only a recapitulation.
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Objectives of the session
By the end of the session, the ASHA will learn about:
-S'.
Learn the skill of beneficiary track:ing: listing the names and knowing
when the next dose is due.
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y'• T Learn the skill of ensuring that the child's immunisation record is
updated.
Learn which children are at risk of being excluded from the programme
and how to ensure complete coverage.
National Immunisation Schedule
At the time of birth
At 6 weeks
(within the first 24 hrs)
AT 10 wee!hs At 14 weeks
At 9-12
BCG
DPT
DPT
DPT
Measles
Ora] Polio
Oral Polio
j Oral Polio
Oral Polio
Oral Polio
Booster Doses
Tetanus Toxoid is to be given at 10 years of age and again at 16 years of age.
Vitamin A is to be given at 9 months along with the booster and then every
six months thereafter till the fifth year of life, i.e is the 18th, 24th, 30th, 36th
month and so on till the 60th month.
Role of ASHA in Immunisation
(a) Make a list of pregnant women, newborns and
children up to two years eligible for different vaccines.
(b) Visit all families once in six months at least to update
this list. After every immunisation session (VHND)
update both the village register and the child's health
card. Learn how to fill this village health register and
child health card. You must be able to do this and
teach this on your own.
(c) Ensure that immunisation is discussed during every
home visit in homes where there is a child under one
year of age.
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(d) Remind mother when the immunisation is due and
alert her to the date when the VHND is being held.
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Village Health and
Nutrition Day
(e) If needed, escort the mother and baby to the
VHND on the date when the vaccine is due.
This is important for families who do not access
services such as those from poor and marginalised
communities.
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(f) Ensure that first dose of BCG and oral polio is given
soon after the baby is born.
(g) Mobilising children for VHND:
(i) Find out from the ANM when her next visit is due. If ASHA has her
mobile number, confirm it on previous or same day.
I
(ii) You must ensure that poorest and most distant households receives
special attention to access the service.
(iii) Some children are more likely to be left out than others. This includes
physically or mentally challenged children, children of migrant
families, children belonging to families considered of Tower status'
or different from the majority of the village. Such children and such
families are said to be 'marginalised'. They need your special attention
and assistance.
(iv) Some hamlets or urban slums/basti have neither ANM or Anganwadi
centre/worker taking care of their health needs. As an immediate step
to address the issue. This needs to be corrected. As an immediate step,
a women representative of the hamlet/slum can be included into the
'village health and sanitation committee'.
(v) The village health plan should help identify hamlets and communities
that are under-serviced. We will learn about village health plans in a
later module.
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Child Health & Nutrition jg.
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4. Assessing the Sick Child
Common illnesses in the young child could include: diarrhoea, cough and
cold, and fever. Each of these conditions will be discussed in the following
chapters. However, before you begin to learn about each specific illness, you
need to know about the danger signs in a child.
Objectives of the session
By the end of the session, the ASHA will learn about:
• ) How to identify general danger signs among sick children.
L •:J Be able to recognise symptoms of common illnesses.
Enable prompt referral.
What are danger signs?
Danger signs indicate serious illness. These can occur in many illnesses. Some
danger signs may occur without any relationship to the type of illness. For
example fever, diarrhoea, pneumonia, meningitis or malaria can all produce
lethargy or unconsciousness. These illnesses can also make the child so sick
that the child is not able to drink any fluids. These are called general danger
signs. The presence of even one general danger sign is enough to indicate
a severe disease. A danger sign calls for immediate referral. Where signs of
common illness like cold and cough, fever, and diarrhoea are present without
any of the danger signs, and where there is no doctor, you could provide
some home-based care to the child and keep a watch for signs that indicate
the need for referral.
What are the questions to be ashed when seeing a sick child?
Every child who is seen for an illness should be checked for the presence of
the following general danger signs:
• Not able to drink or breastfeed
• Vomits everything
• Has convulsions
• Is lethargic or unconscious.
How to assess a sick child for danger signs?
Step 1: ASK: Is the child able to drink or breastfeed?
A child has the sign "not able to drink or
breastfeed" if the child is not able to suck or
swallow when offered a drink or breast milk. If
the mother says that the child is not able to drink
or breastfeed, ask her to describe what happens
when she offers the child something to drink. For
2$ Simple Shills that Save Lives
example, is the child able to take fluid into his mouth and swallow it? If you
are not sure about the mother's answer, ask her to offer the child a drink of
clean water or breast milk. Look to see if the child is swallowing the water
or breast milk. A child who is breastfed may have difficulty sucking when
his nose is blocked. If the child's nose is blocked, clear it. If the child can
breastfeed after his nose is cleared, the child does not have the danger sign.
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Step 2: ASK: Does the child vomit everything?
A child who is not able to hold anything down at all has the sign “vomits
everything." What goes down comes back up. A child who vomits
everything will not be able to hold down food, fluids or oral drugs. A child
who vomits several times but can hold down some fluids does not have this
general danger sign.
Step 3: ASK: Has the child had convulsions?
Ask the mother questions on whether the child has
suffered from convulsions (local term) or not.
Step 4: LOOK: See if the child is lethargic or
unconscious.
iI
The lethargic child is sleepy when the child should be awake. A child who
stares blankly and does not appear to notice what is happening around is
also lethargic.
I
The unconscious child does not waken at all. This child does not respond to
touch, loud noise or pain.
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Step 5: Ensure that the child is referred to a PHC/CHC immediately.
fip1
Remember:
All sick children must be assessed for general danger
v signs.
A child who has even one general danger sign has a
severe problem. Refer this child urgently to hospital.
Complete the rest of the assessment and any pre-referral
treatment immediately so that referral is not delayed.
I
If child has diarrhoea, cough and/or cold, or fever, without any of the
danger signs, the next three chapters describe how to proceed.
§
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Child Health & Nutrition
5. Assessing and Classifying Fever
Objectives of the Session
■. -J
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By the end of the session, the ASHA will learn about:
How to assess the child for fever.
gik.■
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Identify signs for which urgent referral is required.
r
.
) Start the first line of treatment before referral.
st
Fever is a common problem among young children. A child with fever may have
malaria or another disease such as simple cough or cold or other viral infection.
ASK: Does the child have fever?
Ask the mother if the child has fever. To check
temperature, place the thermometer in the armpit
for 2 minutes.
If you do not have a thermometer, place your hand
on the tummy of the child to decide if the child
feels hot to touch.
1 ■ i
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Fever is present if the mother is sure that her child
has had fever, measured by the thermometer, or
if you have determined that the child feels hot to
touch.
ASK: For how long? If more than seven days, has fever
been present every day?
Ask the mother how long the child has had fever. If the fever
has been present every day for more than seven days, refer this
child for further assessment.
LOOK or FEEL for stiff neck.
A child with fever and stiff neck may have meningitis. A
child with meningitis needs urgent treatment with injectable
antibiotics and referral to a hospital.
I jML
While you talk with the mother during the assessment, look
to see if the child moves and bends his neck easily as he looks
around. If the child is moving and bending his neck, he does not
have a stiff neck.
If you did not see any movement, or if you are not sure, draw
the child's attention to his umbilicus or toes. For example, you
can shine a flashlight on his toes or umbilicus or tickle his toes
to encourage the child to look down. Look to see if the child can
bend his neck when he looks down at his umbilicus or toes.
i
Simple Shills that Save Lives
Table for Classifying Fever
Any general danger sign
Very
Give first dose of Cotrimoxazole.
or
severe
Give first dose of antimalarial, after making a smear.
stiff neck
febrile
Give one dose of Paracetamol to bring the high fever down.
Danger signs:
disease
Refer URGENTLY to hospital.
Malaria
Give first dose of anti-malarial, after making a smear.
•
Not able to drink or
•
Vomits everything
•
Has convulsions
•
Is lethargic or
breastfeed
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unconscious
Fever (by history or feels
hot) in a malarial area.
Give one dose of paracetamol to bring the high fever down.
Advise extra fluids, continue feeding and advise about danger signs.
Follow up in two days if fever persists
If fever is present every day for more than seven days, refer the child.
Remember:
Do not assess for fever if the child does not have fever.
If fever has been present everyday for seven days or
more, refer to hospital.
Remember to classify a child with fever who has a
general danger sign as very Severe Febrile disease.
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•
If fever is high, one can do Tepid water sponging' to lower the fever.
Learn how to do this.
•
If fever is high, and child is above 2 months of age you can give
paracetamol, (see Annexure-6)
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Child Health & Nutrition 23
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6. Management of Diarrhoeal Disease
8
Objectives of the session
By the end of the session, the ASHA will learn about:
Be able to diagnose dehydration and ascertain if referral is required.
Learn the skill of preparing and demonstrating ORS use to the mother/care1
X
fQj Learn the skill of counselling the mother for feeding during diarrhoeal epis*
Prevention of Diarrhoea
Good hygiene practices and use of safe drinking
water also protect against diarrhoea. Hands
should be thoroughly washed with soap and
water after defecating and after contact with
faeces, and before touching or preparing food or
feeding children.
To prevent diarrhoea, all faeces, including those
of infants and young children, should be disposed of in a latrine or toilet or
buried. If there is no toilet or latrine, adults and children should defecate
away from houses, paths, water supplies and places where children play.
Faeces should then be buried under a layer of soil. Human and animal faeces
should be kept away from water sources. In communities without toilets
or latrines, the community should consider joining together to build such
facilities. Households can be encouraged to build their own toilet.
Step 1: Identifying the nature of diarrhoea
•
Duration: Ask the mother if her child has diarrhoea. Passing stools more
than three times a day is diarrhoea. Usually it is watery.
•
If the mother says the child has diarrhoea: Ask for how long the child has
had diarrhoea. If the diarrhoea is of 14 days or more duration, the child has
severe persistent diarrhoea. This child should be referred to hospital.
•
Passing Blood: Ask if there is blood in the stools. The child who is passing
blood in the stools has dysentery. This child also needs referral. But one
can start treatment at home also, especially if the access to a doctor is not
immediately possible. The child should be treated with Cotrimoxazole at
home (dosage as Annexure 6) and the mother should be advised home care.
Step 2: Assess every child with diarrhoea for dehydration.
44 Simple Shills that Save Lives
•
Look at the child's general condition. Is the child lethargic or unconscious?
Is the child restless and irritable?
•
Look for sunken eyes.
sti
9
Ask the mother to offer the child some water in a cup or spoon. Watch
the child drink. Is the child not able to drink or is drinking poorly? Is the
drinking eagerly, thirsty?
•
A child is not able to drink if he is not able to suck or swallow when
offered a drink. A child may not be able to drink because he is lethargic or
unconscious.
•
A child is drinking poorly if the child is weak and cannot drink without
help. He may be able to swallow only if fluid is put in his mouth.
•
A child has the sign drinking eagerly, thirsty if it is clear that the child
wants to drink. Look to see if the child reaches out for the cup or spoon
when you offer him water. When the water is taken away, see if the child
is unhappy because he wants to drink more.
•
If the child takes a drink only with encouragement and does not want to
drink more, he does not have the sign "drinking eagerly, thirsty."
•
PINCH the skin of the abdomen. Does it go back: Very slowly (longer than
2 seconds)? Slowly?
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Step 3: How to Classify Diarrhoea
Two of the following signs:
• Refer URGENTLY to hospital with
• Lethargic or unconscious
Severe
mother giving frequent sips of ORS/
i • Sunhen eyes
Dehydration
fluids on the way.
• Not able to drinh or drinking poorly
-
• Shin pinch goes bach very slowly.
Two of the following signs:
• Give fluid and food for some
• Restless, irritable
Some
• Sunhen eyes
Dehydration
• Follow-up in 2 days if not improving.
No Dehydration
• Give fluid and food to treat diarrhoea
dehydration (Plan B).
• Drinhs eagerly, thirsty
• Shin pinch goes bach slowly.
I Not enough signs to classify as some or
severe dehydration.
at home (Plan A).
Passing urine normally.
Diarrhoea for 14 days or more.
• Follow-up in 2 days if not improving.
Severe
I Persistent
| Diarrhoea
Blood in the stool. Some or severe
Dysentery
dehydration.
No Dehydration
• Refer to hospital.
f
Referral if possible.
• Or give Cotrimoxazole for 5 days, (see
Annexure 6 for dosage)
’ • Follow-up in 2 days.
2
Child Health & Nutrition ^
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Managing Diarrhoea at home
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Making OR5
Do a demonstration of preparation of ORS
Cl
\
(a)
Wash your hands
with soap
(b)
Pour all the ORS powder
into a container having
capacity of 1 litre
(c)
Measure 1 litre of drinking
water (boiled & cooled) &
pour it in a container
(d)
Stir well until the
powder is mixed
thoroughly
Nowadays, one litre plastic water bo les are available and can be used to measure the
correct quantity of water.
If the ORS packet is not available, teach the mother how to make home-made
ORS: For one glass (200 ml) of water, add a pinch of salt and a spoon of sugar.
(See in the diagram how a pinch of salt is taken with three fi ngers and how
a spoon of sugar is measured). Alternatively one litre of water with 50 gm of
sugar (8 spoons) and 5 gm (a teaspoon) of salt. Juice of half a lime can be
squeezed in. Taste to see that it is not too salty or too sugary It should taste of
tears. Spoon is taken as 5 ml. Measure this amount and ensure it comes to 5 ml.
Vkx
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Water
1 litre
Sugar
Water
Note: Discard ORS fluid if it is kept for more than 24 hrs.
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Simple Skills that Save Lives
Salt
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Plan A: IF the child has diarrhoea but no dehydration:
• If the child is still being breastfed, the mother is to be encouraged to
continue breastfeeding, longer at each feed.
•
^7
If passing frequent watery stools:
For a child less than six months of age, give ORS and clean, preferably boiled
water, in addition to breast milk. No other fluid or food to be added.
If the child is older than six months and not being exclusively breastfed, give
ORS solution and home available fluids. Fluids that are available at home
include soups, green coconut water, rice or pulse-based drinks, porridge, lime
juice with salt and sugar.
y■
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How much ORS to give?: In addition to the usual fluid intake; give
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♦
If the child is up to two months of age:" five spoonfuls after every
loose stool
♦
If the child is more than two months of age and less than two years,
give about half a cup after every loose stool (100 ml).
♦
Older children can have up to one cup (200 ml) after every stool.
I
Tips to help the mother:
♦ Give frequent small sips from the cup.
♦
If the child vomits, wait for 10 minutes.
♦
Then continue but more slowly.
♦
Continue giving extra fluids until the diarrhoea stops.
♦
Continue feeding/breastfeeding whenever the child wants.
Need for referral:You should counsel the mother to call you immediately
if the:
If
Child becomes sicker.
♦
Not able to drink or breastfeed.
♦
Drinks poorly.
♦
Develops a fever.
r
Has blood in the stool.
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Child Health & Nutrition @
A
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Plan B: If the child has diarrhoea and some dehydration
Determine the amount of ORS over a four hour period
Age
Up to 4 months
■
; Weight
[Amount of ORS in ml
<6hg
I 200-400 ml
4 months up to
Hmomh.
| 6 <10 hg
10< 12 kg
; 12 to 19 kg
400-700 ml
700- 900 ml
! 900-1400 ml
5
7
. . I3..
■ Amount in cups of 200 ml each [2
12 months up to
to
■
5 years
If the child wants more ORS than shown, encourage the mother to give it.
For infants under six months who are not breastfed, also give 100-200 ml
clean water during this period.
After four hours:
•
Re-assess the child and classify for dehydration (as in table above)
•
Select the appropriate plan (A or B) to continue treatment.
•
Begin feeding the child.
Leave two packets of ORS with the mother for further use.
Treating with Cotrimoxazole
The type of tablets used, adult or paediatric and the amount given per day
and the number of times per day and the number of days is given - all four
aspects have to be learnt. (Please see Annexure -6)
Remember:
Classify all cases of diarrhoea for dehydration. In
addition also classify as severe persistent diarrhoea if
duration is 14 days or more and dysentery if there is
blood in stool.
•
•
•
•
•
Children with signs of severe dehydration should be referred to
hospital.
Children with severe persistent diarrhoea should be referred to
hospital.
Children with dysentery could be treated with medicine at home. If
they have high fever or look unwell, they should be referred.
Children with some dehydration should be rehydrated with ORS.
Children who are not dehydrated and have diarrhoea of less than
14 days duration should be managed at home.
Where is ORS Available: Part of drug kit, available in the Sub-Centre; PHC.
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jj-j Simple Shills that Save Lives
7. Management of Acute Respiratory Infection (ARI)
I
Objectives of the session
By the end of the session, the ASHA will learn about:
i
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Be able to diagnose ARI through measuring fever, observing chest
indrawing, and breath counting.
11
✓Ax
fiS) Be able to manage mild and moderate ARI with Contrimoxazole.
Diagnose and refer the severe cases.
Step 1: Identifying the signs of ARI
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Ask the mother if the child has cough or difficult breathing. If the mother
says that the child has cough or difficult breathing, ask for the duration. A
child who has had cough, even if mild, for more than 30 days, needs to be
referred to hospital for further assessment. Any cough with fever for more
than three days should also be referred.
Step 2: Look for chest indrawing
Chest indrawing in a child with cough or difficult breathing indicates that the
child has pneumonia.
In a child less than one year, in normal breathing, the whole chest wall (upper
and lower) and the abdomen move OUT when the young infant breathes IN.
When chest indrawing is present, the lower chest wall goes IN when the young
infant breathes IN.
In children less than one year of age, mild chest indrawing can occur. But in
children more than one year of age, mild chest indrawing is NOT normal.
I
A child with any chest indrawing should be referred to the hospital.
Count the breaths in one minute.
Count the breaths the child takes in one minute as ASHA has learnt earlier.
Decide whether the child has normal breathing or fast breathing.
If the child's age is
Thechild has Fast breathing if you count
2 months up to 12 months:
50 breaths per minute or more
12 months up to 5 years:
40 breaths per minute or more
I
Note. The child who is exactly 12 months old has fast breathing if you count
40 breaths per minute or more.
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Child Health & Nutrition 29
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Classify Cough or Difficult Breathing
Here is the classification table for cough or difficult breathing.
Signs/Symptoms
Status
Any general danger Severe Pneumonia or
sign or
Very Severe Disease
Chest indrawing
Fast breathing
Pneumonia
• Give first dose of Cotrimoxazole.
• Refer URGENTLY to hospital.
• Give Cotrimoxazole for 5 days. (2 Paediatric tablets twice
daily for a child from 2 up to 12 months and 3 tablets twice
daily for a child from 12 months up to 5 years.
• Follow-up in 2 days.
♦ If improving, advise home care and tablets to continue.
♦ If no improvement, insist on referral.
No signs of
Cough or Cold
pneumonia or very
• Advise home care for cough or cold.
• If coughing for more than 30 days, refer for assessment.
severe disease
Remember:
•
A child with any danger sign or chest indrawing has
SEVERE PNEUMONIA OR VERY SEVERE DISEASE
and needs urgent referral to hospital.
A child who has no general danger signs and no chest
indrawing but has fast breathing has PNEUMONIA.
This child should be treated with medicine at home.
A child who has no general danger signs, no chest indrawing and
no fast breathing has NO PNEUMONIA, COUGH OR COLD.. The
mother of this child should be advised how to give home care.
Shills Checklist: Counting Respirations
30 Simple Shills that Save Lives
1.
Wait for the child to be quiet and calm.
2.
Remove your wrist watch and hold it in one hand, close to the baby's
abdomen.
3.
Lift up the baby's shirt so you can see the full breath; the abdomen rising
and falling equals one breath.
4.
Count the child's breathing for one minute.
5.
Record the number of breaths in a minute.
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Home Management for Common Cold or Cough
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•
Keep the young child warm and away from the draught.
•
If the child's nose is blocked and this is interfering with feeding, clean the
nose by putting in nose drops (boiled and cooled glass of water mixed
with pinch of salt) and by cleaning the nose with a soft cotton wick.
•
Breastfeed frequently and for longer period at each feed. Exclusively
breastfeed for six months.
•
Child should continue to be given normal diet during cough and cold.
This is important as this will prevent malnutrition and also help the child
to recover from illness.
•
In case the child is not able to take the normal quantities of food, s/he
should be given small quantities of food frequently.
•
Child can also be given foods of thicker consistency such as khichari,
dalia, sooji or rice in milk, idli etc..
•
Small quantities of oil/ghee should be added to the food to provide extra
energy.
•
After the illness, at least one extra meal should be given to the child for at
least a week to help the child in speedy recovery.
•
Give increased amounts of fluids.
•
Give extra fluids (as much as the child will take), such as dal soup,
vegetable soup, plain clean water or other locally available fluids.
•
Always feed from a cup or spoon. Never use a bottle.
For babies over six months of age, soothe the throat and relieve the cough
with a safe home-made cough remedy (made into a tea) such as:
•
Sugar, ginger, lemon, tulsi leaves or mint.
•
Sonf, elaichi, ginger.
Any other local practice that is soothing and is not unpleasant or harmful
could also be encouraged, for example the application of luke-warm mustard
oil. Colds are self-limiting.
Note: If the child is sleeping and has cough or difficult breathing, count the
number of breaths first before you try to wake the child.
Child Health & Nutrition
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Women's
Reproductive
Health
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Women's Reproductive Health
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1. Safe Abortion’
Objectives of the session
By the end of the session, the ASHA will leam about:
Be able to advise on method, based on duration of pregnancy.
Understand the risks of unsafe abortions, and know where safe abortion
services are available in her area.
T T
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{(•y Help women in need of such services to access safe abortion services.
Be able to identify signs of post abortal complications and advise
appropriate referral.
Counsel for appropriate contraception after the abortion.
I
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A woman seeks abortion because:
• She does not want more children and has not used a contraceptive method
properly or the method failed.
•
A pregnancy can endanger her life.
•
She has no partner who will help support child.
•
She got pregnant after rape.
•
The child will be bom with serious birth defects.
When a woman is faced with an unwanted pregnancy, she should be able to
get a safe abortion.
Legality: In India, abortions are legal up to 20 weeks. They are legal only if
done by a qualified practitioner. Up to 12 weeks, one doctor can do it. After
12 weeks, two doctors need to sign the consent form. Abortion services are
free in all government hospitals. Women over 18 do not need anyone else to
sign a consent form.
i
This chapter has been covered in Books 2 and 3, and is intended to serve as a refresher.
Women's Reproductive Health
I i
Safety: Abortion is very safe if done by an experienced health worker. In India,
only a doctor can perform an abortion, and this should be done under clean
conditions, and with proper instruments.
Abortion is often difficult to get because, there are not enough service providers
and facilities. Those providers who do provide abortion services may charge a
lot of money or not even be legal providers of safe abortion services.
If you are helping someone decide about an abortion
She needs respectful advice and friendly support. Do not tell anyone else, not
even her family members, about her decision unless she wants others to know.
Abortion is unsafe when it is done:
• By someone who has not been trained to do it.
•
With the wrong instruments or medicines.
•
Under unclean conditions.
The later in pregnancy the abortion is undertaken, the more risky it becomes.
Methods: All these methods can only be done by a trained,
legal provider
•
Medical Abortion: This can be done only in very early pregnancies less
than seven weeks or 49 days after last missed period. The woman is
advised to take tablets, but this should be prescribed by and supervised by
a legal provider.
•
Manual Vacuum Aspiration: This
method involves the woman staying in
the health facility for a few hours. It can
be done up to eight weeks of pregnancy.
•
Dilatation and curettage (D and C): This
method can be done up to 12 weeks of
pregnancy. It is associated with a higher risk of complications.
Post-abortion care
You should advise women
• To avoid sex or putting anything in the vagina for at least five days after the
abortion.
1
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5
Simple Shills that Save Lives
•
Drink plenty of fluids for faster recovery.
•
Some bleeding from vagina for up to two weeks is normal, but it should be
light. Next monthly period will be after 4-6 weeks.
•
That the risk of pregnancy exists as soon as intercourse is resumed regardless
of monthly period. Therefore a contraceptive should be used.
Post-abortion complications
Warning signs for which you should advise immediate referral:
• Heavy bleeding
• High fever
• Severe pain in the abdomen
• Fainting and confusion
yr/
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y
• Foul smelling discharge from the vagina.
Tashs for you to be involved in are:
•
Counselling women who want abortion service or need more information
to take a decision. Find out the nearest legal and safe public and private
providers of such care.
•
Visit the mother at home on Days 3 and 7 after the abortion.
•
Providing information on the signs of complications and the need for
immediate referral.
•
Motivating the woman for use of contraception after the abortion.
V.
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SCT’
Women's Reproductive Health 3^
1
2. Family Planning
The main focus of the chapter2 is to provide ASHA with skills such as
understanding contraceptive needs of the community, enabling them to make
an informed choice, and ensuring access to contraceptive services. She will
also learn the skill of maintaining and updating the list of eligible couples in
her community in the Health Register.
I
Objectives of the session
By the end of the session, the ASHA will learn about:
Be able to develop line lists of eligible couples for identification and
follow-up.
i
Understand the side-effects of the methods to counsel the woman to
continue with the method or seek appropriate assistance.
Be able to assess which methods are suitable for couples/individuals
based on their marital status, number of children, child bearing intentions,
and the mother's health status, and counsel for method use based on
informed choice.
Be able to counsel for delay in age of marriage, delay in age of first child
bearing and in child spacing.
I
Provide contraceptive services like: (i) Condoms, (ii) Emergency
Contraceptive Pills (ECP), and (iii) Re-supply of Oral Contraceptive Pills
(OCP), and maintain sufficient stocks and client records.
u•
Provide information on where, when and how to access other methods
(sterilisation. Intra Uterine Contraceptive Device (IUCD), starting the use
of OCP) and provide information on compensation for sterilisation and
IUCD services and family planning insurance scheme.
Assist ANM in follow-up of contraceptive users.
Identify side-effects and user problems in contraceptive users and counsel
and refer appropriately.
Help poor families access contraception.
i
2 Family Planning has been covered in Books 1 and 2 in some detail. Book 1 also provides
an understanding of the menstruation-fertility links. This chapter is intended to serve as a
refresher, and builds on the ASHA's existing knowledge.
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SB Simple Skills that Save Lives
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Women's Needs for Family Planning
Different women and couples have different needs for contraception. When
you counsel a woman on family planning, you should keep in mind the
following:
•
Marital status:
♦ Unmarried: condoms or pills or emergency pills
♦ Newly married and wanting to delay the first child: condoms or pills
•
Just delivered (postpartum) or just had an abortion (post-abortal):
condoms, pills, IUCD (after six weeks), injectables (currently not available
in the public sector, but being used in the private sector)
•
Wanting to space children: condoms, pills, IUCD, injectables.
•
Not wanting more children: Long acting (10) IUCD and sterilisation for
the man or the woman.
I
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!
Types of Family Planning Methods and Information on Side-Effects
I
i
The Pill
If a woman takes birth control pills every day, pills will protect her from
pregnancy for the entire monthly cycle. These pills are called Mala N or Mala
D. Pills should be provided to those women who are specifically advised by
the doctor. However, since you are required to dispense these, it is important
for you to know a few important facts.
Taking pills may be dangerous for women with the following signs:
• Woman has jaundice, recognised by yellow skin and eyes.
•
Woman has ever had signs of a stroke, paralysis or heart disease.
•
Woman has ever had a blood clot in the veins of her legs.
•
If the woman smokes and is over 35 years old.
•
Has high blood pressure (more than 140/90).
If the woman has any of the problems listed above, the doctor would then
counsel her to use a method other than the pills.
TV
J
Side-effects of pills
■
The pills contain the same chemicals that a woman's body makes when she is
pregnant. So she may have the following side-effects:
• Nausea
Headaches
•
Swelling of legs
•
Changes in monthly period.
Side-effects often get better after the first 2 or 3 months. If they do not, and
they are annoying or worrying her, you should advise the woman to see an
ANM or doctor.
5*
03
Women's Reproductive Health ^9.
k.
Pills should not be advised for women who are breastfeeding.
OCP are available in your drug kit, and at the Sub-Centre, Primary Health
Centre (PHC) and Community Health Centre (CHC).
Emergency Contraceptive Pills
ASHA does not start women on a pill, but could provide follow-up once
it is started. These are for emergency use, when the couple has not used a
contraceptive and have had unprotected sex. It can also be used in instances
of rape, or accidental breaking of the condom. The woman must take the
pill as soon as possible after unprotected sex. The pills are effective within
12- 24 hours of intercourse. The pills will not work if the woman has already
become pregnant from having sex more than three days earlier. These pills
are available in your drug kit, at the Sub-Centre, PHC and CHC. These pills
are to be used only as an emergency method and you should advise users to
shift to regular methods of family planning.
Condom: The condom is a narrow bag of thin rubber that the man wears on
his penis during sex. Because the man's semen stays in the bag, the sperm
cannot enter the woman's body, and she cannot get pregnant. The condom is
a useful device to be used as a contraceptive and to protect against Sexually
Transmitted Infections (STIs) and HIV. It is also useful for couples where the
male is a migrant and returns home for short durations.
I
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Men most often buy condoms from shops. Since you have a supply of
condoms in your drug kit, women may feel more confident in approaching
you to obtain condoms.
The Intrauterine Contraceptive Device (IUCD, Copper-T, the Loop)
The IUCD is a small object or device that is inserted into the uterus and
prevents the man's sperm from fertilising the woman's egg. The IUCD can
stay in the uterus for up to 10 years. The most common lUCDs are made of
copper.
Remember:
a
►► A condom is to be used every time the woman has a
sexual encounter to prevent from pregnancy, STIs
and HIV.
►► A condom is to be used only once. A condom that has
been used before is more likely to break.
►► Condoms are to be kept in a cool, dry place away from
sunlight. Condoms that are from old or torn package are
more likely to break.
1
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5w
4b Simple Shills that Save Lives
-M '
Who should not use an IUCD?
You should not counsel IUCD use if the woman:
•
Has never been pregnant.
•
Has anaemia (Low Hb).
•
Is in danger of getting a Sexually Transmitted Infection. (This includes any
woman who has more than one partner, or whose partner may have other
sex partners.)
•
Has ever had an infection in her tubes or uterus, or an infection after
giving birth or having an abortion.
•
Has had a pregnancy in her tubes.
•
Has a lot of bleeding and pain during monthly bleeding.
Common side-effects: The woman may have some light bleeding during the
first week after getting an IUCD. Some women also have longer, heavier and
more painful monthly bleeding, but this usually stops after the first three
months.
I
I
I
Who should insert an IUCD: An IUCD must be inserted by a trained
Auxiliary Nurse Midwife (ANM), nurse or a doctor after doing a pelvic
(internal) examination. The best time to have the IUCD inserted is during the
monthly bleeding/period. After childbirth, it is best to wait six weeks for the
uterus to return to its normal size and shape before getting an IUCD.
What to watch for: Occasionally an IUCD will slip out of place. If this
happens, it will not be effective in preventing pregnancy, so it is important for
the woman to learn to check her IUCD to make sure it is still in place. Most
lUCDs have 2 thread-like strings attached which hang down into the vagina.
The mother should be counselled to check the strings after each monthly
bleeding to make sure the IUCD is in place.
I
Teaching a woman to check the IUD strings
•
Wash hands.
•
Squat down and reach as Far as she can into the vagina with two Fingers.
Feel For the IUD strings, but do not pull them.
•
Take Fingers out and wash her hands again.
Sterilisation (the operation when the couple wants no
more children)
• Since these operations are permanent, they are only good
for those women or men who are certain that they do not
want any more children.
Bi
■^7Z......
13
S’
C3
Women's Reproductive Health
L
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I
•
To have one of these operations, the woman must go to a PHC or CHC.
The surgery is fast and safe, and does not cause side-effects.
•
The services for sterilisation are provided on certain days in these centres.
You must know the nearest site where this service is available and on
what days.
•
When needed, the ASHA could accompany the woman to the facility for
the tubectomy procedure. Often because of the case overload,
<
quality of
services is not assured and the ASHA should help the woman receive
good quality care. Accompanying is desirable, but not mendatory.
The operation for the man (Vasectomy)
A vasectomy is a simple operation, with only a small puncture
to block the tubes that carry the sperm. It takes only a few
minutes to do. The operation does not change a man's ability
to have sex or to feel sexual pleasure. He still ejaculates
semen but there are no sperm in the semen. The couple must
be
advised—to
------------> use condoms or other contraceptives for 90 days following
vasectomy.
The operation for the woman (Tubectomy)
A tubal ligation is a slightly more difficult operation than a
vasectomy, but it is still very safe. It takes about 30 minutes.
A trained doctor makes a small cut in the woman's abdomen,
and then cuts or ties the tubes that carry the egg to the womb.
The woman can have the operation within seven days of the
start of the menstrual cycle, 24 hours after delivery, or six weeks after the
delivery.
L
Important
Sterilisation and pills do not protect against STIs and Human Immuno-deficiency
Virus (HIV). So, for protection from STIs and HIV, a condom should be used
during every sexual intercourse, if the woman is at risk of contracting them.
u
Simple Shills that Save Lives
I
/
The following diagram describes the levels of service for various contraceptives:
I
I
Village Level: ASHAs and VHNDs
________________
■_________________ ______
IEC for Family
Counselling
Re-supply of Oral
Dispense Condoms
Referral
Follow-up for
Planning
on Choice of
Contraceptives
& Emergency Pills
for IUCD &
contraceptive
Method
Pills
(ECPs)
Sterilisation
acceptors
, IEC forFarhily
Planning
C unseliing
Choice of
or
oiceof
‘
Method
Sub-Centre
Chech-ups for "Provision of
new clients
IUDs, Oral
new clients
IUDs, Oral
interested
Pills, ECPs &
&
interested in
in
Pills,ECPs
xOral
-uqi iPills
iijo k&J
Condoms
Condoms
lUCDs
.UCDs
investigation '
of family
______
Referrai for
Support.
sterilisation Itraining and
panning
resupplyof
problems
CBDs
■
I
PHC and Higher Health Centres
IEC for Family
Method
Check-ups for
Provision of
Investigation of
Planning
Counselling
new clients
sterilisation
family planning
and resupply of
interested in
services, IUDs
problems
Sub-centres and
sterilisation
Oral Pills, ECPs
services
& Condoms
Support, training
CBDs
•i
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I
I
Women's Reproductive Health
I
3. Reproductive Tract Infections (RTIs) and
Sexually Transmitted Infections (STIs)
Objective of the session
By the end of the session, the ASHA will learn about:
| Understand RTI/STI and HIV/AIDS3; prevention, management and
J .reatment,
5) Be able to counsel women on protection from RTI/STI and HIV/AIDS.
g U1
,
,
., f. f„Kneandtreament:
j) Be able to gutde „ome„ to appropriate tachoea tor lesbng and treatntent
Is white discharge normal?
•
Some amount of white discharge is normal. It is the vagina's way of
cleansing itself.
•
The amount of discharge varies during different phases of the menstrual
cycle. During the fertile period it is wet and slippery, and clear.
•
During pregnancy, the discharge increases in amount.
•
Discharge that is bad smelling (smell of menstrual blood, fishy odour),
white lumpy discharge (curd, coloured greenish, yellowish, reddish,
bloody), accompanied by itching, a rash, sores, burning urination, and
lower abdominal pain, pain during intercourse is indicative of RTI or STI.
•
A change in colour and odour is an alert to the women of a possible
infection. In addition, if there is itching or burning, there is high
possibility of an infection.
•
Discharge is also indicative of certain hormonal problems or even cancer.
What are STIs?
STIs are infections that are passed from an infected person to another during
sexual intercourse. Mothers can pass on STIs to babies during the delivery
process.
Most STIs are RTIs. However a few like Hepatitis-B and HIV are STIs but not
RTIs. Many Reproductive Tract Infections are Sexually Transmitted Infections.
However many other Reproductive Tract Infections are contracted by other
means e.g. post childbirth or abortion or from GI infections.
Why are STIs serious problem for women?
u
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Simple Shills that Save Lives
•
Because the infected semen stays longer inside a women's body.
•
The entire genital tract in women is hidden, therefore, the infection stays
inside for a longer time and is silent for longer.
3 This section has also been covered in Book 3. Thus, this session is expected to serve as a
refresher course.
1
•
It is harder for a woman to protect herself from STIs, because she
unable to negotiate with the male partner to use a condom.
often
What are the consequences of STIs?
STIs can cause:
• infertility in men and women;
•
babies to be bom too early, too small or blind; and
•
long lasting pain in lower abdomen, or even cancer.
•
Death from severe infection or AIDS
1
What are the signs of RTIs?
Signs of RTIs include:
• Abnormal discharge
•
Lower abdominal pain
•
Rash, Swelling in the groin or sore in genital area.
I
However, these signs manifest very late. It is best to be aware that a woman
can be at risk for an STI if:
• Husband has signs of an STI.
•
Either the man or woman has more than one sexual partner.
•
In some occupations which require long period of travel and where the
men engage in casual sex.
I
I
I
Tashs for ASHA to be involved in are:
• Counsel women at risk on preventive measures.
•
18
Counsel women with symptoms of RTI/STI to go to the health facility for
treatment. All 24X7 PHCs or higher facilities are equipped and skilled to
provide necessary care.
•
Take the course of medicine fully (all courses are for a week or ten days).
You should motivate the woman to complete the course of medicines. Not
completing the course of medicines makes the bacteria resistant and can
cause a worse infection that does not respond to drugs the next time.
•
Ensure that the husband also gets treated.
•
Counsel a women to abstain from sexual activity during the period of
treatment.
•
If the husband is known to indulge in extra-marital relationships, counsel
the woman to avoid having unprotected sex.
i
Where to get treatment for RTI/STI
• All drugs for STI treatment are available free of cost from PHC upwards.
•
ANM and the PHC doctor can provide treatment.
CD
Women's Reproductive Health
For cure of STIs, medicines are necessary, but for relief you could
advice the woman to:
•
Sit in a pan of clean, warm water for 15 minutes. Add lemon juice to the water.
•
Do not have sex until she feels better.
•
Try to wear cotton next to the shin.
•
Wash undergarments every day.
•
Pour clean water on genitals after passing urine.
•
Medicines should also be provided for the partner.
•
If repeated STIs occur, testing can be done at District Hospital for Below
Poverty people Line (BPL), free for others.
HIV and AIDS
You can increase awareness on HIV and AIDS: On its transmission, its
prevention and services available. You can also help in reducing myths and
misconception as well as stigma and discrimination associated with it. Know
the following:
I
•
HIV is transmitted through: a) having unprotected sex (sex without condom);
b) receiving HIV infected blood or blood products; c) using/sharing
unsterilised needles or lancets; and d) from HIV infected mother to her baby.
•
It does not spread through any other mode such as kissing and touching,
holding hands, mosquito bites, sharing clothes, or through saliva, nose
fluids, tears.
•
Who is at higher risk: Commercial Sex Workers (CSWs), Injecting Drug
Users (IDUs), Men who have Sex with Men (MSM), migrant labourers,
persons with multiple sexual partners, babies born to mothers who are HIV
infected, and persons with other STIs.
•
Persons with HIV are at greater risk of getting Tuberculosis. Every 1 in 20
persons suffering from TB in India is also HIV infected.
•
HIV can be prevented by using condom during sexual intercourse
(protected sex), using safe blood (when blood transfusions are necessary)
from blood bank of government hospitals or recognised hospitals only,
using sterilised needles/avoid sharing of needles, and by avoiding sex with
multiple partners.
•
HIV testing and management facility is available in the District Hospital free
of cost. Treatment services for AIDS are available in some district hospitals
or in the main government hospital in the big cities.
V'
"
You should encourage persons at high risk to go for HIV test. If women who
are at high risk become pregnant, they must be motivated to gets tested,
as timely treatment may prevent transmission of HIV from HIV infected
mother to baby.
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Simple Shills that Save Lives
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Newborn
Health
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Newborn Health
1. High Risk Assessment and Management of Low Birth
Weight/Pre-Term Babies
Identifying a high risk baby and what to do?
Objectives of the session
By the end of the session, the ASHA will learn about:
I
which babies „eat high „sk.
Diagnose and refer high risk children.
I
Counsel the mother on how to breastfeed a pre-term/Low Birth Weight
(LBW) newton
I
D Teach mothers to express milk and feed such babies using a bowl
or spoon.
v
Guidelines for ASHA on identifying a high risk baby
•
Birth weight less than 2000 gm.
•
Pre-term (delivery which happens when mother is 8 months and 14 days
pregnant or less).
•
Baby not taking feeds on Day 1.
I
If you were not present at the time of delivery and your first visit to the
newborn is delayed, then the newborn is to be weighed on the day of your
first visit. In such cases, using the following table, determine whether the
baby is high risk or not:
Day on which baby is
weighed for the first
time
Dtagnosis
s?
'Ya'' t''
I High Risk Baby
1 to 14 days
Less than 2 kg
15 to 21 days
Less than 2 kg 100 gm
j 22 to 27 days
[ 28th day
Less than
i L=.
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£High Risk Baby
I High Risk Baby
Less than 2 kg 300 gm
| High Risk Baby
In
1
Newborn Health 49
Guidance that you should give to the family
•
Keep the baby clothed from the very first day. In winter, cover the baby with a
blanket.
•
Do not bathe a baby until its weight is 2000 gm.
•
Ensure that mother's nails are cut and that her hands are washed every time
the baby is breastfed.
•
After returning from the toilet, all family members must wash their hands with
soap before touching the baby.
•
High risk babies should be breastfed after every two hours.
•
If baby is not suckling milh, squeeze the breast milh in a small bowl and then
feed the baby with a spoon.
•
The weight of high risk babies should improve every week from second week.
If this does not happen, counsel them to consult you.
•
Ash them to call you immediately if the baby develops any of the following:
All limbs become limp, stops feeding, has chest indrawing, has fever, and is
cold to touch.
What should you do if the baby is at high risk?
@ Simple Shills that Save Lives
•
Increase the number of home visits after delivery from 5 to 13.
•
A daily visit, if possible, for the first week.
•
Once every three days until the baby is 28 days old, and if the baby is
improving once on the 42nd day.
•
Weigh babies on Day 7,15, 21, 28, 42. Babies who weigh less than 2300
gm on the 28th day have a higher risk of dying. If the baby is not gaining
weight, refer the baby to the hospital.
•
Explain the high risk issues to the parents and family (see box above).
•
Provide specific care as per the problem but in general, keep the baby
warm and breastfeed more often every two hours.
•
For poor breastfeeding, observe the mother breastfeeding. Ensure proper
latch on and positioning. Encourage the mother so that she is motivated
to feed the baby well. Counsel the mother that she should not give other
liquids or feeds.
•
If on Day 28 the weight is less than 2300 gm or weight gain in 28 days is
less than 300 gm, then you should continue to visit once a week in the
2nd month and take the weight every day.
•
Fill home visit form for high risk baby (See Annexe 1 for the form)
2, Breastfeeding Low Birth Weight/Pre-Term babies
Advantages of breast milk for LBW and pre-term Babies
•
Has the right nutrients for the pre-term/LBW baby
•
Pre-term babies need more protein and a mother who has delivered
pre-term has more breast milk.
•
Is easily digestible.
•
Contains factors to fight infection (small babies are more vulnerable
to disease).
•
Breastfeeding keeps the baby close to the mother and therefore, warm.
This protects the pre-term baby from cold (Hypothermia), which can lead
to infection.
Key Messages
For small babies who can suckle
• Try the underarm hold for more support or the alternate underarm hold.
•
If sleeping, wake baby every 2-3 hours for breastfeeding by rubbing a
damp cloth over its face.
For babies who are not able to suckle:
•
Babies less than 1500 gm may not be able to breastfeed in the beginning.
•
Express milk by applying gentle pressure over entire breast and collect
milk in a clean bowl.
•
Express milk every 2-3 hours to keep the milk supply up.
•
Put baby to breast and allow her to lick the nipple, and try to suckle.
•
Once the baby is able to suckle, she should be put to the breast as often as
possible to stimulate milk production.
•
Continue feeding with the spoon as well until the baby is getting its milk
requirements directly from the breast.
I
How much to give?
r
I
•
For a LBW baby: For first day 60 ml/kg body weight.
•
Add 20 ml/kg body weight until baby is taking 200 ml per day.
•
Divide the total into 8-12 feeds (every 2-3 hours).
•
Colostrum can be kept for up to 12 hours at room temperature.
•
Mature milk (after first 72 hours) can be kept for 6-8 hours at room temperature.
•
Continue until baby can be fully breastfed.
§
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Newborn Health ■’Sf
k
3. Asphyxia Diagnosis and Management
r-:.1
Objective of the session
By the end of the session, the ASHA will learn about:
|
F
Identify signs of asphyxia in the newborn.
Support and if necessary, manage asphyxia in the newborn.
What is Asphyxia?
A baby having any one of the following symptoms at the time of birth is
asphyxiated:
•
•
•
•
No cry
Weal? cry
No breathing
Weal? breathing.
If a baby has asphyxia, it is an Emergency. A life can be saved or lost in these
five minutes. If you are present at the time of birth, and there is no doctor or
nurse, you should try to help to manage the baby. However, in many such
newborns, your efforts may not make enough difference and you should not
feel bad or blame yourself for this.
Consequences of Asphyxia
Immediate (at birth)
•
Baby is born dead (stillbirth)
•
Dies at once or within a few days
•
Unable to suckle.
Long term
If the baby survives, it may have:
Mental retardation
•
Epilepsy (seizures and fits)
•
Spasticity (difficulty walking or moving arms and hands).
These signs warn of asphyxia during labour
1. Prolonged or difficult labour
2. Ruptured membranes with little fluid (dry delivery)
3. Green or yellow colour thick amniotic fluid
u
52- Simple Shills that Save Lives
4. Cord comes out first or cord is wound tightly around the neck
1 IO
5. Pre-term labour (delivery taking place less than 8 months 14 days of pregnancy)
6. Baby being born in a position in which the head does not come out first.
Asphyxia Action Tree
You must know the signs during labour that may indicate asphyxia at birth.
In this module, ASHA will learn to manage asphyxia using a mucus extractor.
During labour: History given by mother about the nature of water;
and the breaking of bag of water
Water is thick, yellow or green
Water is clear
4,
Clear the month of baby with gauze
|
piece as soon as head is seen
T
IMMEDIATELY AFTER BIRTH:
1. Note the time of birth and start counting time
2. Immediately dry the baby cover with cloth
AT 30 SECONDS
1
1
Baby crying well
no cry. no breath or weak breathing
Not asphyxiated
asphyxiated
3. Cut and tie the cord
3. Place baby in position with head slightly
extended
4. Cover the baby with dry cloth
4. Place a folded cloth under baby's shoulders to
heep the head slightly extended
5. Place baby near mother
5. Immediately clean the month with mucus
extractor. If the baby does not breathe, suction
I-
the throat. If baby still doesn't breathe, suction
the nose with mucus extractor
If the baby does not cry, start immediately to
!
I
ventilate (in less than one minute from birth) use
bag & mash (40 times per minute). If the baby
starts to cry or breathe STOP
6. Start breastfeeding
6. If no cry or breathe continue ventilating if
possible, call for help
AT 10 MINUTES, if no breathing-baby is dead if
baby gasping continues for 5 more minutes AT
15 MINUTES if no breathing, baby is dead
n
Newborn Health 53
i
I
Ir
4. Neonatal Sepsis: Diagnosis and Management
obj ectives of the Session
"
By the end of the session, the ASHA will learn about:
® Know key signs and symptoms of
Know how to prevent sepsis.
■
i • i
■ v ■
J Teach parents and family how to recognise
high
risk
signs.
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SOs&F''
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k. Identify children who have sepsis.
"Sepsis" means infection. In newborn babies, "sepsis" refers to any serious
infection in the baby whether in the lungs, brain or blood.
i
I
How common is sepsis and how serious?
•
In rural India, one out of every ten newborns
develops sepsis.
•
Sepsis in the first month of life is very serious, and
is the most common killer of newborns in the first
month of life.
•
Without treatment, many babies with sepsis will die;
with treatment, most babies will get better, live and grow up normally.
J
Causes of neonatal sepsis
•
Mother has infection during pregnancy or delivery.
•
Unclean techniques during delivery (poor handwashing, use of unclean
blade or cord ties) can cause sepsis.
•
Cord becomes infected from unclean cutting or putting dirty things on it
•
Baby is weak; born pre-term or with LBW (less than 2000 gm)
•
Baby becomes weak from poor feeding practices; not giving breast milk
early and exclusively.
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Simple Skills that Save Lives
.1 il: •
•
Baby becomes weak — exposed to the cold after delivery.
•
Baby comes into contact with someone who has an infection: mother,
family members, or ASHA
u
Can sepsis be prevented? Yes, if the following are observed fcarefully
•
Good hygiene: frequent handwashing; clean instruments during delivery;
clean clothes
•
Keeping the baby warm during the cold season
•
Breastfeeding (early initiation and on demand, and exclusive)
•
Keeping the umbilical cord clean and dry
Information about danger signs to parents: You should teach the parents
that if any of the following signs develop, you should be called immediately
or the baby should be taken at once for referral.
•
Limbs become limp
•
Stops feeding
•
Has chest indrawing
Has fever
•
Is cold to touch.
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Management of sepsis
Sepsis treatment: Two antibiotics are used: Cotrimoxazole and Gentamicin
You can start the treatment of sepsis by giving Cotrimoxazole:
Cotrimaxozole syrup two times a day is to be given:
♦ Vt teaspoon twice a day for seven days if baby is full term.
♦
teaspoon twice a day for ten days if baby is pre-term.
•
Gentamicin injection is to be given once a day. You can refer the parents to
the nearest PHC where there is a doctor available.
•
If parents are reluctant or are unable to go, you can request the ANM to
help them.
When to refer the baby
I
•
Baby has breastfeeding problems and is not solved by ASHA's
Counselling and home management.
•
Baby has danger signs:
♦
Not responding - after antibiotic treatment for 24 hours.
♦
Becomes yellow (jaundice) on first day or jaundice persists after 14 days.
♦
Bleeding from nose, mouth or anus.
♦
Convulsions.
♦
Body temperature of baby continues to remain less that 95 degree F
even after re-warming the baby for 24 hours.
♦
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Tetanus (stiffness after the fourth day), unable to suckle or open mouth.
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Introduction
to Infectious
Diseases
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introduction to Infectious Diseases
Community Level Care for Malaria in Areas where Malaria is endemic
Objectives of the session
By the end of the session, the ASHA will learn about:
Understand and be able to communicate key facts about malaria and its
prevention.
Making a blood smear and testing blood using a rapid diagnostic test for malaria,
j Managing fever in the young child- when to suspect malaria, how and when to
test, when to refer, when and what to treat.
\ • j Understanding spread of TB and methods of diagnosis.
Supporting treatment of TB and follow-up with patients.
Malaria
Malaria is an infection caused by parasite (microorganism) called
Plasmodium. This is transmitted by the female anopheles mosquito. There are
two types of malaria: Vivax and Falciparum. Vivax is not very dangerous but
falciparum malaria can cause damage to the brain, liver and lungs.
How does it spread?: When the mosquito bits an infected person, the parasite
enters the mosquito's stomach. It multiplies in the insect's stomach and then
when it bites another person, the parasite enters the blood of the person along
with the insect's saliva and infects him/her .
Signs and Symptoms
•
The patient can have fever, high shivering and sweating, which can occur
on alternate days (in Vivax type of malaria) and every day at a certain
time with Falciparum type infection.
•
Sometimes the patient has continuous fever, malaise, and headache.
•
Malaria affects more frequently and more severely children below five
years, pregnant women, or patients who are already ill.
•
Falciparum malaria can affect the brain: causing clouding of
consciousness, fits, or paralysis leading to death.
Introduction to Infectious Diseases 59
Who is at higher risk?: In areas where malaria is highly prevalent, pregnant
mothers and malnourished children are at greater risk.
How to suspect malaria: Any person living in a malaria affected area, who
develops fever must be suspected as having malaria. If fever is with chills and
rigor and headache, it is even more likely.
How to confirm: There are two ways of confirming malaria:
•
Using the Rapid Diagnostic Test (RDT) kit the patient's blood can be tested
for malaria (Please see Annexe 4). If the test is positive then the patient
has malaria.
•
You should also make a blood smear. (Please see Annexe 5). The parasite
can be seen in the blood smear Sometimes the blood smears can be
negative, and a repeat smear is required.
RDT and Smears are to be taken before starting treatment. All ASHAs
working in a block with a high incidence of malaria need to be trained for
taking smears for malaria.
Treating Malaria
1. Give paracetamol for fever. Also sponging with warm water to bring
down temperature when needed.
2. If RDT is positive for malaria- Give chloroquine or Artesunate
Combination treatment (ACT) drug as recommended. (Annexe 7) The
dose of the drug depends of the age group. The exact dosage schedule is
given in Annexe 6. Nowadays the recommendation is to treat for malaria
only if the test is positive. If the test is not available, or cannot be done, it
is permissible to give a course of chloroquine. This would still be needed
in many areas.
3. If despite treatment fever does not begin to come down within two or
three days, or persists even after a week, referral becomes mandatory.
Referral to ANM or doctor is necessary if there is no response and fever continues
or if patient becomes delirious.
ill
-
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6p Simple Shills that Save Lives
\
Prevention of Malaria
Mosquitoes thrive in warm and wet climates. There
are many types of mosquitoes, but only very few of
them transmit the disease. The mosquito that transmits
malaria is called Anopheles and it bites almost
exclusively at night. It does not bite during the day.
That is why sleeping under a bed net is a good way of
preventing bites. The mosquito that spreads malaria
breeds in clean water. That is why during rainy season,
where water collects, this forms a good breeding place
for mosquitoes.
Ways of controlling malaria: There are two ways:
Do not allow mosquitoes to multiply:
•
Spraying insecticide where mosquitoes sit when they
come to bite inside the houses.
•
Drying up breeding pits.
•
Not allowing water to stagnate- pouring a spoon of
oil over the water surface in small collections. This is
enough to kill the mosquito larvae.
,
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•
Enable cultivation of Gambusia fish in ponds and
wells- these eat up the mosquito larvae. Also remove
the grass from banks of pond. Larvae find it difficult
to breed if there is no vegetation and the pond edges
are vertical.
•
Water in drains and canals should not be allowed to remain stagnant in
one place and it should be flushed and cleaned once in a week.
Do not allow mosquitoes to bite
•
Clothes that cover the body, like full sleeved shirts.
•
Mosquito nets treated with
insecticides so that infected
mosquitoes do not reach the sleeping
person. The mosquitoes coming in
contact with the net may die later.
•
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Use of mosquito repellent, e.g.
burning neem leaves to drive
mosquitoes away.
The Role of ASH A in Prevention and Management of Malaria
i.
During house visits and in the village meetings you should inform
the community about malaria, how to prevent it and what to do for
fever. You should also inform the community of the services you can
provide for malaria and request that for any case of fever you should be
contacted.
ii.
Encourage and help the village health and sanitation committee and the
women's groups or other community organisations to take appropriate
collective action to prevent malaria in that area.
iii.
Where possible, ask those with fever, who you suspect of having malaria
to go to the primary health centre. You should facilitate this. It is only if
the patient cannot go the same day, that you should take on the task of
diagnosis and treatment of the suspected patient with malaria till such
time as the qualified service provider is accessed.
g
o
Introduction to Infectious Diseases
w
iv.
All fever cases that approach you and are unable to go to the primary
health centre within a day, should be screened using RDT and blood
slides. Fever cases which turn out to be RDT positive should be provided
treatment immediately. You should store the positive RDT along with the
blood slide for Quality Assurance (QA) check at a later date. For cases
which are RDT negative, you should send blood slides to the laboratory.
For those with a positive result, you can treat the cases following the
drug regimen in which you are trained.
v.
All fever cases should be given paracetamol and fever managed as per
the guidelines. The persons who test positive for malaria would be
given with either chloroquine drug or ACT drugs (depending on the
instructions in that area) followed by primaquine for radical treatment.
vi.
Whenever you do a blood test or give a drug you should make a record
of it in your diary. You should, provide the information during the
monthly ASHA review meeting to the ANM or to your supervisor.
If payment is being made for this work, you may be also required to
maintain a register.
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vii. Transport of slides and obtaining the result of the test: The
slides collected by you should be delivered to the sub
centre by you or by anyone whom you request, on a day to
day basis. These slides should then be transported to the
PHC lab preferably twice a week, or less by the MPW (M)
and if not, the MPW (F). The results should be conveyed to
you by the MPW (M) and if not the MPW (F).
viii. If there is a pregnant woman in a high malaria area, you
should facilitate her getting a insecticide treated bed net
at the time of the first antenatal care check up and follow
up to see that she uses it. After delivery you should ensure
that the baby from the time of birth also sleeps under an
insecticide treated bed-net.
If a pregnant woman gets high fever and chills, ensure that she is taken to
see a doctor. You could start Chloroquine or ACT immediately if there is a
delay in seeing a doctor.. Do NOT give primaquine to a pregnant woman
or a child below one year of age.
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62 Simple Shills that Save Lives
Tuberculosis
/
Tuberculosis (TB) is a highly infectious bacterial disease caused by a germ
(Mycobacterium tuberculosis). TB can affect any part of the body. When it affects
the lungs, it is called pulmonary TB. The commonest form of TB is pulmonary
TB. It affects over 2 million people in India. TB in any other part of the body
(i.e. other than lungs) is called extra-pulmonary TB.
How does TB spread?
TB germs usually spread through tiny droplets in the air, when a patient with
pulmonary tuberculosis coughs or sneezes. When these droplets are inhaled
by a healthy person, s/he gets infected with TB. This infected person will have
a 10% lifetime risk of developing TB. Spread of disease is increased in poorly
ventilated houses where many people live close together or in high dust areas
like mines and quarries. An undernourished or malnourished patient is also
at a high risk of contracting and dying of TB. Both drugs and nourishment are
needed to achieve a cure in such persons. Children can also get both forms of TB.
When should TB be suspected?
The symptoms of pulmonary TB are:
• Cough with sputum for two weeks or more
I
•
Pain in chest
•
Sometimes the presence of blood stained sputum (haemoptysis) with
symptoms like:
♦ Rise in evening temperature
♦
Night sweats
♦
Loss of weight
♦
Loss of appetite.
A person with cough for two weeks or more is a suspect for TB and should be
referred to a PHC/CHC/DH for the confirmation of diagnosis.
How to diagnose TB?
Sputum examination is the main tool for diagnosing pulmonary TB.
I .
The diagnosis is made when the germ is present in the sputum of the
patient. At least two sputum samples have to be tested (one
of which has to be collected first thing in the morning at the
patient's home and the other at the health facility). A receptacle
for collection of sputum at home is given to the patient at the
microscopy centre at the health facility). The two samples
should be collected for examination preferably within 24 hours.
The sputum is stained by a special dye and examined under a
11
microscope by trained personnel.
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Introduction to Infectious Diseases 63
The person is said to be a TB patient if the germ is detected in both or one of
the two samples. Patients who are sputum negative for germs but who still
exhibit disease symptoms should be referred to the Medical Officer (MO) who
may order other investigations like an X-ray of the lungs.
Diagnosis of TB must be done by a Medical Officer.
What is DOTS?
DOTS programme is "Directly Observed Treatment" in which a health
worker or another trained person who is not a family member, watches as the
patient swallows the anti-TB medicines in her presence.
What is'Cure'?
A patient who is initially sputum smear-positive and who has completed
treatment and had negative sputum smears on two occasions, one of which
was at the end of treatment, is declared a 'cured' patient.
Treatment and Management of TB
• Diagnosis of TB is done through X-ray, sputum examination.
•
All patients who have TB need to be treated with anti-TB drugs which can
take up to six or nine months.
•
The current approach is through Directly Observed Treatment, Short
Course (DOTS).
•
Patients must take the drugs regularly and not stop before the specified
period even if they feel better.
Prevention of TB
• BCG vaccination of children can prevent TB
among small children. BCG is given at birth.
•
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Simple Shills that Save Lives
•
Finding cases and ensuring compliance with
treatment is important.
•
Improve living conditions.
•
ASHA should discuss TB during health
communication sessions
•
ASHA should encourage old people and
those who are vulnerable with cough for
over one month to visit a doctor.
ASHA could serve as a DOTS provider in her village and ensure
compliance with treatment.
Your Role in the Treatment Phase
• You could serve as the DOTS provider in your village
and ensure compliance.
•
Since the treatment is of long duration, the ASHA has
a key role in motivating the patient to complete the
treatment and prevent them from stopping midway or
drop out.
•
Recognising the side-effects of the drugs (Annexe 8)
and knowing how to deal with side-effects of drugs
and making sure of drug availability at the health
facility will help you to do this more effectively.
•
Encourage the patient to take sufficient nutrition
during treatment and moderate rest at least for the first
two months.
•
The family of the patient should be counselled to take precautions at
home especially for children and elder persons who can contract the
I
disease quickly.
•
The patient must eat and drink from a separate set of utensils which
should be washed separately. When coughing, the patient must put a
protective clean cloth over his mouth to prevent spread of droplets or
leave the house and cough in a nearby open space. The cloth should be
washed in hot water or with disinfectant thoroughly on a regular basis.
•
The patient should not have close contact with spouse, children and
infants and the elderly within the family at least for two months after
starting treatment. Simple hygiene precautions will help in preventing
transmission of TB within the family.
•
You must keep a watch on the other family members to detect early signs
of TB in the members and if necessary, get them examined from time to
time.
•
Ensure BCG vaccination of children at birth. This can help prevent TB
among small children.
•
TB is also a stigmatising disease. Confidentiality of patient identity must
be maintained.
•
Awareness of TB related symptoms and the approach to achieving a cure
through self-reporting for examination must be stressed at community
gatherings as also the importance of good nutrition and taking of
complete treatment.
§
s
Introduction to Infectious Diseases
I
•
Relapse of TB in patients who have had previous treatment is possible.
Many times, such patients are considered as new patients. The record of
previous treatment should be made known to the health facility where the
patient presents for re-treatment so that a different drug regimen may be
prescribed.
Precautions for Anti-TB Treatment among Pregnant Women
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•
Women in child bearing age should be counselled to avoid pregnancy
while on anti-TB treatment and at least six months after.
•
The effect of oral contraceptives is reduced by medicines and hence, other
methods of contraception should be advocated.
•
One of the TB drugs. Streptomycin, should not be given in the first
trimester of pregnancy.
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Annexe 1: Home Visit Form for the High Risk Baby
Homevisitfor
Ash/Examine
Da^F ASHA's visit
Dav
Day 2
Dav33
Day
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Action Take
A. Ash Mother
IF less than 4 times or
No. of times mother take full
if meals not full, advise
meal in 24 hrs
Y/N
mother to do so
t
Bleeding: How many pads are
Y/N
If more than 5 pads, refer
mother to hospital
changed in a day
During the cold season is the
Yes/No/
Yes/No/
Yes/No/
Yes/No/
Yes/No/
Yes/No/
baby being hept warm (near
NA
NA
NA
NA
NA
NA
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Advise the mother to do
so, if not being done
mother,2 clothed and wrapped
properly)
Is the baby being fed properly
Advise the mother to do
so, if not being done
(whenever hungry or at least
I
7-8 times in 24 hrs)
Is baby crying incessantly or
passing urine less than 6 times
a day
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
_____
Advise mother to feed the
baby after every 2 hours
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B. Examination of Mother
Temperature up to 102
degree F (38.9 degree Ci
Temperature: Measure and
record
treat with paracetamol, and
if the temperature is above
i it, refer to hospital)
Foul-smelling discharge and
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
hospital
fever more than 100 degree F
(37.8 degree C)
Is mother speaking abnormally
Yes/No
Yes/No
~--------------Yes/No
Yes/No
Yes/No
___________________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
-
If yes, take action
for breast feeding
management
milk to be less
Cracked nipples/painful and/or
i
If yes, refer the mother to
hospital
or having fits?
Mother has no milk since
delivery or if perceives breast
If yes, refer the mother to
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
engorged breast
If yes, take action
for breast feeding
management
I
Action Take
C. Examination of Baby
Are the eyes swollen or with pus
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
If yes, ask mother to put
tetracycline ointment in
baby's eyes twice a day, for
Five days
Weight (on day 7,15, 28 and 42)
Yes/No
If weight gain every week
after first week is less than
100 gm, then take action
(for breastfeeding)
1
Temperature: Measure and
If baby's temperature
Record
is more than 99 degree
Yes/No
Fahrenheit (37.2 degree
Celsius), treat with
Paracetamol
If it is between 95.1 97
degree Fahrenheit (35.1-36.1
degree Celsius), ash mother
to feed baby frequently,
heep the baby warm.
If temperature of baby
is less than 95 degree F
(35 degree Celsius), do
!
hypothermia management
Shin:
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Treat with gentian violet
Yes/No
and observe for signs of
Pus Filled pustules
Cracks or redness on the shin
sepsis
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Keep baby clean and dry
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
If it is on the First day or
Yes/No
i fold (thigh/Axilla /Buttoch)
Yellowness in eyes or shin:
beyond 14th day, then it is
Jaundice
abnormal jaundice. Refer
the baby to hospital
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Give health education to the mother on day 2
Yes/No
Give high risk baby information sheet on day 2
Yes/No
Give danger sign information sheet to parents on Day
2- Yes/No
ASHA Module 7
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D. Sepsis Diagnosis: Chech now for the following signs of sepsis: If sign is present mention - Yes, if it is absent mention - No
Record the observations on Day 1 from the first examination of newborn form
Date of ASHA's visit
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Action by the ASHA
Supervisory
Chech
Consider the first three signs as criteria for
All limbs limp
Yes/No
diagnosing sepsis only if the sign was absent
previously and then it newly developed
If at least two criteria are present on the
same day, diagnose as sepsis, and proceed
Feeding less/Stopped
Cry weah/stopped
---------------------------------- ...
Distended abdomen or mother
with sepsis management (using sepsis
management form)
says 'baby vomits often'
keep a watch and call ASHA
tough' or baby's temperature
If only one sign is present, visit every day
to check appearance of another sign.
Meanwhile provide management for the
>99 degree F (37.2 degree C)
Chest in-drawing
L
Pus on umbilicus
Total number of criteria present
Yes/
No
existing problem
Yes/
No
Yes/
No
Yes/
No
Yes/
No
Yes/
No
Which management of sepsis was accepted by the family? (Circle the correct answer)
1. No treatment
2. Referral
Yes/No
Even if no sign is observed, ash the mother to
Mother says ‘baby is cold to
Is it Sepsis
Yes/No
3. Treatment by ASHA
4. Other treatment (specify)
(See the box at the bottom)
Yes/No
Yes/No
Yes/No
IF treated by ASHA, Fill the sepsis management form.
I
•
For Feeding problem, provide breast Feeding management.
•
For only chest in-drawing treat with cotra syrup
•
For the pus on umbilicus, treat with gentian violet paint
•
For hypothermia, provide hypothermia management
•
For fever, provide fever management
i
If the baby's weight on 28th day is less than 2300 grams or weight gain over
birth weight is less than 300 grams, continue to visit baby in 2nd month.
Record the observations on the home visit form.
|
i
Supervisor's note: Incomplete work/Incorrect work/ incorrect record/in
correct record
Name of ASHA:
Date:
Name of trainer/Facilitator
I
I
Annexes
J
Annexe 2: Instruction on Use of Mucus Extractor
! 1.
-
Place the baby in the proper position, dry
and cover with a folded towel under its
shoulders. The baby's head should be
slightly extended.
2. Take the mucus extractor out of sterile
1
wrapper.
3.
Place tube with the mouth piece in your
mouth. Hold the other tube in your hand at
least 1 hand's length from the tip.
| 4.
| 2.
cries and breathes normally, stop. If not,
proceed with the next step.
Insert the tube no further than your index
finger into the baby's throat, and gently
such out any secretions. If baby cries and
breathes normally, stop. If not, proceed with
the next step.
——
2. Remove clear tubing from baby's throat and
mouth and place tip into one nostril and
gently such. Repeat with other nostril.
3.
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Simple Skills that Save Lives
I
Place finger length of clear tubing in baby's
mouth and such for a few seconds, moving
tip around mouth to dear secretions. If baby
When resuscitation is finished, dispose of
mucus extractor (do not reuse).
4
Annexe 3: Shill Checklist: Using Bag and Mash
Descnpdons
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Place the baby in proper position,
1.
dry and cover with a folded towel
under the baby's shoulders. The
baby's head should be slightly
extended
I---------------------------------------—
“
Place the mash with bag
1 2.
attached over infant's mouth
and nose, and try to make an
airtight seal.
Proper positioning of bag and mash
: 3.
Squeeze the bag
40 times per minute.
L
4.
Chech to see that the baby's chest rises with each ventilation
5.
If the chest is not rising
•
Reposition the baby's head and try again
•
Reposition the mash and chech that the seal does not allow
•
air to escape
Increase ventilation pressure by squeezing the bag harder
•
If there is too mucus, suction again
®
If chest is still not rising, remove bag from mash, place
I
mash over baby's mouth and nose and blow directly into
the mash
6.
r
After ventilating for one minute, stop and looh for
spontaneous cry or breathing. If not present, continue
ventilating
7.
Every two minutes or 80 breaths, chech for a few seconds
to see if the baby is responding. Is yes, stop. If no, continue.
8.
After 10 minutes of ventilation, if there is no gasping or
breathing, stop ventilation.
9.
When resuscitation is complete, wash the mash and valve
with soap and water, dry, and store in its bag.
Annexes@
i
ih
Annexe 4: Technique of Preparation of Blood Smear
For preparation of blood smears following items are required:
1. Clean glass slides
2. Disposable Lancet
3. Spirit or Cotton swab for cleaning the finger
4. Cotton
II
Sil
5. Clean piece of cotton cloth
Is
6. Lead pencil
After the patient information has been recorded on the appropriate form, the
blood films are made as under:
•
Take a clean glass slide free from grease and scratches
•
Clean the finger of the patient using a spirit swab
Take the following steps for preparation of the blood smear:
i. Select the second or third finger of the left hand
|
i
ii. The site of the puncture is the side of the ball of the finger, not
too close to the nail bed
iii. Allow the blood come up automatically. Do not squeeze the
finger.
iv. Hold the slide by its edges
v. The size of the blood drop is controlled better if the finger
touches the slides from below
I
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Simple Shills that Save Lives
vi. Touch the drop of blood with a clean slide, three'drops are
collected for preparing the thick smear.
vii. Touch another new drop of blood with the edge of a clean
slide for preparing the thin smear.
viii. Spread the drop of blood with the corner of another slide to
make a circle or a square about 1 cm
-d
ix. Bring the edge of the slide carrying the second drop of blood
to the surface of the first slide, wait until the blood spreads
along the whole edge
x. Holding it at an angle of about 45° push it forward with rapid
but not too brisk movement
xi. Write with a pencil the slide number on the thin film. Wait
until the thick film is dry. The thin film is always used as a label
to identify the patient.
Remember
•
The blood should not be excessively stirred. Spread gently in circular or
rectangular form with 3 to 6 movements.
•
The circular thick film should be about 1 cm (1/5 inch) in diameter.
•
Allow the thick film to dry with the slide in the flat, level position
protected from flies, dust and extensive heat.
•
Label the dry thin film with a soft lead pencil by writing in the thicker
portion of the film the blood slide number and date of collection
The lancet, cotton swab should be disposed off.
Annexes
Ii
Annexe 5: Technique for performing rapid diagnostic test
!
Materials in the Rapid Diagnostic Test Kit
1.
2.
Spirit (alcohol) swab (one for each patient)
Disposable Lancet (one for each patient)
3.
Capillary tube (one for each patient)
4.
5.
Test strip (one for each patient)
One multiple well plastic plate
6.
Test tube (one for each patient)
Buffer solution or reagent solution
7.
8.
Desiccant
Procedure
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-
•
Check that the test kit is within its expiry date. If not discard it. Read
the instructions of the test kit, as there may be minor variations in the
procedure between different kits. Place a small box, jar or bottle for trash
next to the kit.
•
Open a foil pouch and check that the desiccant inside it is still blue. If not,
discard the test.
•
Remove the test strip and the small glass tube or loop from the foil pouch
and place them on a clean dry surface.
•
Take out the buffer solution and the dropper. Place a new test tube in the
multiple well plate.
•
Clean a finger with the swab and let the skin dry completely in the air.
Prick finger on the side with a lancet. Place lancet in trash container. Let a
drop of blood come out on the skin.
•
Touch the tip of the glass tube or the loop to the blood drop on the finger
and let a small quantity of blood (a small drop) come up in the tube or the
loop.
•
Touch the tube or the loop to the test strip just below the arrow mark to
place the blood there. If there is a paper, where Plasmodium falciparum
is written, remove it and place the blood, where it was. Place tube/loop in
trash container.
•
Using the dropper, place 4 drops of buffer solution into a new test tube.
After this, place the test strip containing blood in the buffer solution with
the arrow pointing down. While waiting, a slide can be prepared.
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Simple Shills that Save Lives
•
Observe after 15 minutes - if any red line does not appear in the test strip
then the test strip is not working: discard it and use another one.
•
If a single red line appears, it is not falciparum malaria. If two red lines
appear, the test result is falciparum malaria.
•
The test should be read 15 to 20 minutes after blood was taken. Earlier or
later readings may lead to false results.
•
Place test strip and test tube in trash container. Make sure this contamer is
kept out of reach of children. When it is full, if in a village, bury it in the
ground, or send it with the MPW to the PHC for safe disposal.
Annexes ®
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Annexe 6: Drugs Dosage and Dispensing Schedule
Caution: Check the expiry date before dispensing the drug.
Cotrimoxazole
1 Tablet: Sulphamethoxazole 100mg + Trimethoprim 20mg
5ml or (1 tsp) Syrup: Sulphamethoxazole200mg+ Trimethoprim 40mg
Duration: To be given for 5 days
Frequency: Two times a day
seioaday
One fourth tsp (1.25ml)
Birth upto <1 months (<3kg)
| Twice a iay
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A
-
1 month up to 2months (3-4kg)
1 tab
1/4tsp (2.5ml)
2 months-12 months (4-10kgs)
2 tab
Full tsp (5ml)
12 months-5 yrs (10-19 kgs)
Stabs
2 full tsp (10ml)
i Twice a day
I
__________ I__
Twice a day |
Twice a day
|
■T
*Avoid cotrimoxazole in infants less than one month who are premature or jaundiced.
Side effects: Rarely nausea, vomiting, stomatitis, rashes, headache.
Caution: The dose is 5 to 8 mg/Kg of trimethoprim per day in two divided doses. Tablets come in 20 mg,
40 mg, 80 mg or sometimes 160 mg trimethoprim. Depending on what tablet is given to you, you would be
taught the number of tablets to be dispensed.
Albendazole
fdoseinaday
Age of the patient
I
<1 year
| 1-2 years
>2 years
Not to be given
i 400mg
_____ I_____
Vitab (Half)
400mg
Full tab
Side Effects: Rarely dizziness
Contraindicated in child less than 1 year and in pregnancy
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80 Simple Skills that Save Lives
Once a day
__ K”^)--
:—.———-----Once a day
.|——
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Iron and Folic Acid
Pediatric IFA=20mg elemental Iron
Duration: To be given for 14 days in anemic child and then reassess
Frequency: Once a day
■■■
■Hl
<4months
—i-------
d
On doctors advise
4 months - 12 months (Wt 6-10 Kg )
1 tab
Once a day*
1 yr-3 yrs (Wt 10-14 Kg)
1% tabs
Once a day*
&
I
Once a day*
2 tabs
3 yr - 5 yrs (Wt 14-19 Kg)
*Can be increased on doctor’s advise
Side Effects: Constipation
In
take doctors
advise
In case
case of
of diarrhea
pain abdomen
tablet to
be consumed after food
Paracetamol
1 tablet=500mg
Duration: To be given for 3 days only
Per kg dose of paracetamol=10-15 mg/kg/dose
Frequency: Maximum four times a day at an interval of six hours
mMM
HHHHHHHHH
2 months -3 years
: (Wt 4-14 kgs)
3yrs -5yrs
Max 4 times a day
!4tab (One fourth )
>
I
Max 4 times a day
1/2tab (Half)
7
(Wt 14-19 kgs)
F^7
^5 mg/5ml (Eachl ml contains 25 mg of paracetamol)
5ml or(1 tsp) Syrup=125
Per kg dose of paracetamol=10-15 mg/kg/dose
Duration: To be given for 3 days only
Frequency: Maximum four times a day at an interval of six hours
SB
Age
New Born<3kg
In ml
In teaspoon
1.25ml
1/4tsp (One fourth)
^^85
>1 year (>3kg-8kg)
1-3 yrs (>8-14 kgs)
>3 yrs >14 kgs
| 2.5ml
1/2tsp (Half)
5 ml
1 tsp (One)
7.5 ml
I1/?tsp (One and Half)
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Annexes
Annexe 7: Treatment Guidelines for ASHA
Age-specific Drug Schedules
I. Chloroquine tablets (150 mg base)
Age (m years)
Day 1
M
"
Tab Chloroqutne
|
1/2
I
1/2
1
1-4
5-8
: 9-14
r—---------j 15 8 above
I
3
Tab Chloroquine
TaUChloroqutne
_____________
| <1
|MKay -3
Day 2
L
4
1/4
i
1
1/2
2
3
1
p/2
4
2
2. Primaquine tablets (7.5 or 2.5 mg base)
w
Age (in years) ..
imac
OiflJ
1
f Tablet
■■■■■■
1
I
<1
Nil
1-4
7.5
5-8
15
9-14
30
15 8 above
45
Nil
1
r
2.5
1
5.0
2
4
10.0
4
6
15.0
6
2
f
* Primaquine is contraindicated in children under one year and pregnant women.
3. Artesunate 50 mg tablets + Sulfadoxine-Pyrimethamine 500 + 25 mg
tablets (ACT) combination
A
r
■
Age
(in
years)
/ •t
(number of tabs)*
<1 Year*
1-4 Yeas*
5-8 Year*
9-14 Year*
15 and above
-•ndP)
liiw
> * -T
.
er of tabs),
.
(i------
Ordp
K
7. K ,
AS
1/2
1/2
1/2
SP
1/4
Nil
Nil
AS
1
1
1
SP
1
Nil
Nil
2
2
2
SP
1,/2
Nil
Nil
AS
3
3
3
SP
2
Nil
Nil
AS
4
4
4
3
Nil
Nil
AS
SP
:
L
* till such time as age-wise blister packs are made available for all age groups
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Simple Shills that Save Lives
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Annexe 8: Side-effects of Common TB Drugs
Action to be taken
Drowsiness
Isoniazid (H)
Reassure patient
Red-orange
Rifampicin (R)
Reassure patient
Any oral medication
Reassure patient
urine/tears
Gastrointestinal
Give drugs with less water. Give
drugs over a longer period of
Upset
I
time. Do not give drugs on empty
stomach. If above fails.
consult MO regarding anti- emetic
if appropriate
Itching
____
Isoniazid (H)
Reassure patient
(other drugs also)
If severe, stop all drugs and refer
patentto MO
Refer to MO who will give
pyridoxine 100 mg/day symptoms
Burning in the
hands and feet
Isoniazid (H)
Joint pains
Pyrazinamide (Z)
If severe, refer patient for
| Impaired vision
Ethambutol (E)
evaluation
STOP treatment, refer patient for
Ringing in the ears
Streptomycin (S)
evaluation
STOP streptomycin, refer patient
Loss of hearing
subside
' ------Streptomycin (S)
Dizziness, loss of
forevaluation
Streptomycin (S)
STOP streptomycin, refer patient
forevaluation
balance
Jaundice
for evaluation
I STOP streptomycin, refer patient
Isoniazid (H)
STOP treatment, refer patient for
evaluation
Rifampicin (R)
Pyrazinamide (Z)
Acronyms1,
Acronyms
___ :_________ ______ _
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Simple Shills that Save Lives
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
AWW
Anganwadi Worker
AIDS
Acquired Immuno-deficiency Syndrome
ART
Anti-Retroviral Therapy
CHC
Community Health Centre
CSW
Commercial Sex Worker
DOT
Directly Observed Treatment (Short Course)
HIV
Human Immuno-deficiency Virus
HBNCC
Home-Based Newborn and Child Care
ICTC
Integrated Counselling and Testing Centre
ICDS
Integrated Child Development Services
IDU
Injecting Drug User
IUCD
Intra Uterine Contraceptive Device
IYCF
Infant and Young Child Feeding
MDT
Multi-Drug Therapy
PHC
Primary Health Centre
RTI
Reproductive Tract Infection
STI
Sexually Transmitted Infection
TB
Tuberculosis
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