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Integrated Management of Childhood Illness for High HIV Settings. Geneva: World Health Organization; 2008.

Cover of Integrated Management of Childhood Illness for High HIV Settings

Integrated Management of Childhood Illness for High HIV Settings.

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CHILD AGED 2 MONTHS UP TO 5 YEARS ASSESS AND CLASSIFY THE SICK CHILD

Assess and classify the sick child aged 2 months up to 5 years

Assess, Classify and Identify Treatment

Ask the mother what the child’s problems are Determine whether this is an initial or follow-up visit for this problem. If follow-up visit, use the follow-up instructions on TREAT THE CHILD chart if initial visit, assess the child as follows:

Check for general danger signs

ASK:
  • Is the child able to drink or breastfeed?
  • Does the child vomit everything?
  • Has the child had convulsions?
LOOK:
  • See if the child is lethargic or unconscious.
  • Is the child convulsing now?

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so that referral is not delayed.

Then ask about main symptoms

Flowchart Icon

Flowchart (PDF, 121K)

Then check for malnutrition and anaemia

Flowchart Icon

Flowchart (PDF, 63K)

Then check for HIV infection*

Flowchart Icon

Flowchart (PDF, 72K)

Then check the child’s immunization, vitamin a and deworming status

IMMUNIZATION SCHEDULE: Follow national guidelines
AgeVACCINEHIV-EXPOSEDHIV-INF ECTED
BirthBCGOPV-0BCG*NO BCG
6 weeksDPT+HIB-1OPV-1Hep B1SameSame
10 weeksDPT+HIB-2OPV-2Hep B2SameSame
14 weeksDPT+HIB-3OPV-3Hep B3SameSame
9 monthsMeasles**Measles at 6 monthsSame***
Repeat at or after 9 monthsSame***
*

BCG should NOT be given any time after birth to infants known to be HIV infected or born to HIV infected women and HIV status unknown but who have signs or reported symptoms suggestive of HIV infection.

**

Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunisation activities as early as one month following the first dose.

***

Measles vaccine is NOT given if child is severely immunocompromised due to HIV infection.

VITAMIN A PROPHYLAXIS

Give every child a dose of Vitamin A every six months from the age of 6 months. Record the dose on the child’s card.

Same protocol for HIV-exposed and infected children.

ROUTINE WORM TREATMENT

Give every child mebendazole every 6 months from the age of one year. Record the dose on the child’s card.

Same protocol for HIV exposed and infected children.

Make sure child with any general danger sign is referred after first dose of an appropriate antibiotic and other urgent treatments.

Assess other problems

Assess, classify and treat skin and mouth conditions

Mouth ulcer or gum problems
SIGNSCLASSIFY AS:TREATMENTS:
  • Deep or extensive ulcers of mouth or gums or
  • Not able to eat
SEVERE GUM OR MOUTH INFECTION
  • Refer URGENTLY to hospital
  • If possible, give first dose acyclovir pre-referral.
  • Start metronidazole if referral not possible.
  • If child is on antiretroviral therapy this may be a drug reaction so refer to second level for assessment.
  • Ulcers of mouth or gums
GUM/MOUTH ULCERS
  • Show mother how to clean the ulcers with saline or peroxide or sodium bicarbonate.
  • If lips or anterior gums involved, give acyclovir, if possible. If not possible, refer.
  • If child receiving cotrimoxazole or antiretroviral drugs or isoniazid (INH) prophylaxis (for TB) within the last month, this may be a drug rash, especially of the child also has a skin rash, so refer.
  • Provide pain relief.
  • Follow up in 7 days.

WHO Paediatric Clinical Staging for HIV1

Only for confirmed HIV infected children. Determine the clinical stage by assessing the child’s signs and symptoms. Look at the classification for each stage and decide which is the highest stage applicable to the child – where one or more of the child’s symptoms are represented.

WHO Paediatric Clinical Stage 1 AsymptomaticWHO Paediatric Clinical Stage 2 Mild DiseaseWHO Paediatric Clinical Stage 3 Moderate DiseaseWHO Paediatric Clinical Stage 4 Severe Disease (AIDS)
Growth--Moderate unexplained malnutrition not responding to standard therapySevere unexplained wasting/ stunting/ Severe malnutrition not responding to standard therapy
Symptoms/signsNo symptoms or only:
  • Persistent generalized lymphadenopathy
  • Enlarged liver and/or spleen
  • Enlarged parotid
  • Skin conditions (prurigo, seborrhoeic dermatitis, extensive molluscum contagiosum or warts, fungal nail infections, herpes zoster)
  • Mouth conditions (recurrent mouth ulcerations, angular cheilitis, lineal gingival Erythema)
  • Recurrent or chronic RTI (sinusitis, ear infections, otorrhoea)
  • Oral thrush (outside neonatal period)
  • Oral hairy leukoplakia
  • Unexplained and unresponsive to standard therapy:
    -

    Diarrhoea >14 days

    -

    Fever>1 month

    -

    Thrombocytopenia* (<50,000/mm3 for > 1 month)

    -

    Neutropenia* (<500/mm3 for 1 month)

    -

    Anaemia for >1 month (haemoglobin < 8 gm)*

  • Recurrent severe bacterial pneumonia
  • Pulmonary TB
  • Lymph node TB
  • Symptomatic LIP*
  • Acute necrotizing ulcerative gingivitis/ periodontitis
  • Chronic HIV associated lung disease including bronchiectasis*
  • Oesophageal thrush
  • More than one month of herpes simplex ulcerations
  • Severe multiple or recurrent bacterial infections > 2 episodes in a year (not including pneumonia)
  • Pneumocystis pneumonia (PCP)*
  • Kaposi’s sarcoma
  • Extrapulmonary tuberculosis
  • Toxoplasma brain abscess*
  • Cryptococcal meningitis*
  • Acquired HIV-associated rectal fistula
  • HIV encephalopathy*
ARV TherapyIndicated:
  • All infants below 12 mo irrespective of CD4
  • 12–35 mo and CD4 ≤ 20% (or ≤750 cells)
  • 36–59 mo and CD4≤20% (or ≤ 350 cells)
  • 5 yrs and CD4 ≤15% (<200 cells/mm3)
Indicated:
Same as stage I		ART is indicated:
  • Child is over 12 months—usually regardless of CD4 but if LIP/TB/ oral hairy leukoplakia—ART
Initiation may be delayed if CD4 above age related threshold for advanced or severe immunodeficiency		ART is indicated:
Irrespective of the CD4 count, and should be started as soon as possible.
If HIV infection is NOT confirmed in infants<18 months, presumptive diagnosis of severe HIV disease can be made on the basis of **:
  • HIV antibody positive
AND
  • One of the following:
    -

    AIDS defining condition OR

    -

    Symptomatic with two or more of :

    -

    Oral thrush

    -

    Severe pneumonia

    -

    Severe sepsis

*

conditions requiring diagnosis by a doctor or medical officer – should be referred for appropriate diagnosis and treatment.

**

in a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated.

HIV testing for the exposed child

RECOMMEND HIV testing for:

  • All children born to an HIV positive mother
  • All sick children with symptomatic suspected HIV infection
  • All children brought for child health service in a generalized epidemic setting

For children >18 months, a positive HIV antibody test result means the child is infected.

For HIV exposed children <18 months of age,

  • If PCR or other virological test is available, test from 6 weeks of age
    • A positive result means the child is infected
    • A negative result means the child is not infected, but could become infected if they are still breast feeding.
  • If PCR or other virological test not available, use HIV antibody test
    • A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected.

If PCR or other virological test is not available, use HIV antibody test.

If the child becomes sick, recommend HIV antibody test.

If the child remains well, recommend HIV antibody test at 9–12 months.

If child >12 months has not yet been tested, recommend HIV antibody test.

Interpreting the HIV antibody test results in a child < 18 months of age
Test resultHIV antibody test is positiveHIV antibody test is negative
Not breastfeeding or not breastfed in last 6 weeksHIV exposed and /or HIV infected
Manage as if they could be infected. Repeat test at 18 months		HIV negative
Child is not HIV infected
Breast feedingHIV exposed and /or HIV infected
Manage as if they could be infected. Re peat test at 18 months or once breast-feeding has been discontinued for more than 6 weeks		Child can still be infected by breast-feeding. Repeat test once breast feeding has been discontinued for more than 6 weeks.

1. The older the child is the more likely the HIV antibody is due to their own infection and not due to maternal antibody.

2. Very exceptionally a very severely sick child who is HIV infected will have HIV antibody test results that are negative. If the clini-cal picture strongly suggests HIV, then virological testing will be needed.

Footnotes

1

Note that these are interim recommendations and may be subject to change.

Copyright © 2008, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK144144
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