The discharge process of all children should include:
correct timing of discharge from hospital
counselling the mother on treatment and feeding the child at home
ensuring that the child's vaccination status and record card are up to date
communicating with the health worker who referred the child or who will be responsible for follow-up care
giving instructions on when to return to hospital for follow-up and on symptoms and signs indicating the need to return urgently
assisting the family with special support, e.g. providing equipment for a child with a disability or linking with community support organizations for children with HIV/AIDS.
12.1. Timing of discharge from hospital
In general, in the management of acute infections, a child can be considered ready for discharge after the clinical condition has improved markedly (afebrile, alert, eating and sleeping normally), and oral treatment has been started.
A decision on when to discharge should be made on an individual basis, taking into consideration factors such as:
the family's home circumstances and how much support is available to care for the child
the staff's judgement of the likelihood that the treatment course will be completed at home
the staff's judgement of the likelihood that the family will return immediately to hospital if the child's condition worsens.
The timing of discharge of a child with severe acute malnutrition is particularly important and is discussed in Chapter 7. In each case, the family should be given as much warning as possible of the discharge date, so that appropriate arrangements can be made to support the child at home.
If the family removes the child prematurely against the advice of the hospital staff, counsel the mother on how to continue treatment at home, and encourage her to bring the child for follow-up after 1–2 days and to make contact with the local health worker for help in the follow-up care of the child.
12.2. Counselling
Mother's card
A simple, pictorial card reminding the mother of home care instructions, when to return for follow-up care and the signs indicating the need to return immediately to the hospital can be given to each mother. This card will help her to remember the appropriate foods and fluids and when to return to the health worker.
Appropriate cards should be available as part of national IMCI guidelines. If they are available, use them; if not, see Annex 6 for a reference to an example.
When reviewing the mother's card with the mother:
Hold the card so that she can easily see the pictures, or allow her to hold it herself.
Point to the pictures as you talk, and explain each one; this will help her to remember what the pictures represent.
Mark the information that is relevant to the mother. For example, put circles around the feeding advice for the child's age and around the signs to return immediately. If the child has diarrhoea, tick the appropriate fluid(s) to be given. Record the date for the next vaccination.
Watch to see if the mother looks worried or puzzled. If so, encourage questions.
Ask the mother to tell you in her own words what she should do at home. Encourage her to use the card to help her remember.
Give her the card to take home. Suggest that she show it to other family members. (If you do not have a large enough supply of cards to give to every mother, keep several in the clinic to show to mothers.)
Provide an effective interpreter if language is a barrier.
12.3. Nutrition counselling
For HIV counselling, see section 8.4.
Identifying feeding problems
First, identify any feeding problems that have not been fully resolved.
Ask the following questions:
Compare the child's actual feeding with the recommended guidelines for feeding a child of that age (see section 10.1.2). Identify any differences, and list these as feeding problems.
In addition, consider:
Advise the mother how to overcome the problems and how to feed the child.
Refer to local feeding recommendations for children of different ages. These recommendations should include details of locally appropriate energy-rich and nutrient-rich complementary foods.
Even when specific feeding problems are not found, praise the mother for what she does well. Give her advice that promotes:
Examples of nutritionally adequate diets (see Chart 15 in the WHO manual Management of the child with a serious infection or severe malnutrition could be printed on the reverse of a locally adapted mother's card.
12.4. Home treatment
Use words the mother understands.
Use teaching aids that are familiar (e.g. common containers for mixing ORS).
Allow the mother to practise what she must do, e.g. preparing ORS solution or giving an oral medication, and encourage her to ask questions.
Give advice in a helpful, constructive manner, praising the mother for correct answers or good practice.
Teaching mothers is not just giving instructions. It should include:
- –
Give information. Explain to the mother how to give treatment, e.g. preparing ORS, giving an oral antibiotic or applying eye ointment.
- –
Show an example. Demonstrate to the mother how to give the treatment.
- –
Let her practice. Ask the mother to prepare the medicine or give the treatment while you watch. Help her as needed, so that she does it correctly.
- –
Check her understanding. Ask the mother to repeat the instructions in her own words, or ask her questions to see that she has understood correctly.
12.5. Checking the mother's health
If the mother is sick, provide treatment for her, and help to arrange follow-up at a first-level clinic close to her home. Check the mother's nutritional status, and give any appropriate counselling. Check the mother's immunization status, and, if needed, give her tetanus toxoid. Make sure the mother has access to family planning and birth spacing and counselling about preventing sexually transmitted and HIV infections. If the child has TB, the mother and other members of the family should have a chest X-ray and a Mantoux test. Make sure the mother knows where to have them, and explain why they are needed.
12.6. Checking immunization status
Ask to see the child's immunization card, and determine whether all the vaccinations recommended for the child's age have been given. Note any vaccinations the child still needs, and explain this to the mother. Give the vaccinations before the child leaves hospital, and record them on the card.
Recommended vaccination schedule
below lists WHO's international recommendations. National recommendations take account of local disease patterns.
Table 33Primary vaccination schedule for infants recommended in the Expanded Programme of Immunization
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| Vaccine | Age |
|---|
| Birth | 6 weeks | 10 weeks | 14 weeks | 9 months |
|---|
| BCG | | X | | | | |
| Polio | Oral polio vaccine | Xa | X | X | X | |
| Inactivated polio vaccine | | 8 weeks | | X | 5 months |
| DPT | | | X | X | X | |
| Hepatitis B | Option 1b | X | X | | X | |
| Option 2b | X | X | X | X | |
| H. influenzae type b | | X | X | X | | |
| Pneumococcal | Option 1 | | X | X | X | |
| Option 2 | | X | | X | X |
| Rotavirus | Rotarix | | X | X | | |
| Rota Teq | | X | X | X | |
| Yellow fever | | | | | | Xc |
| Measles | | | | | | Xd |
| Rubella | | | | | | X |
- a
In polio-endemic countries
- b
Option 1 is recommended in areas where perinatal transmission of hepatitis B virus is frequent (e.g. in South-East Asia). Option 2 may be used in areas where perinatal transmission is less frequent (e.g. in sub-Saharan Africa).
- c
In countries where yellow fever poses a risk
- d
In exceptional situations, where measles morbidity and mortality in infants < 9 months of age represent more than 15% of cases and deaths, give an extra dose of measles vaccine at 6 months of age. The scheduled dose should also be given as soon as possible after 9 months of age. The extra measles dose is also recommended for groups at high risk for death from measles, such as infants in refugee camps, infants admitted to hospitals, HIV-positive infants and infants affected by disasters and during outbreaks of measles.
A second opportunity to receive a dose of measles vaccine should be provided for all children. This may be done either as part of the routine schedule or in a campaign.
Contraindications
It is important to vaccinate all children, including those who are sick and malnourished, unless there are contraindications. There are only three contraindications to vaccination:
Do not give BCG or yellow fever vaccine to a child with symptomatic HIV infection or AIDS, but do give the other vaccines.
Do not give DPT-2 or -3 to a child who has had convulsions or shock within 3 days of the most recent dose.
Do not give DPT to a child with recurrent convulsions or an active disease of the central nervous system.
A child with diarrhoea who is due to receive oral polio vaccine should be given a dose, but this dose should not be counted in the schedule. Make a note on the child's immunization record that it coincided with diarrhoea, so that the health worker will give the child an extra dose.
12.7. Communicating with the first-level health worker
The first-level health worker who referred the child to hospital should receive information about the child's care in hospital, which should include:
diagnosis or diagnoses
treatment(s) given and duration of stay in hospital
response of the child to treatment
instructions given to the mother for follow-up treatment or other care at home
other matters for follow-up (e.g. vaccinations).
If the child has a health card, the above information can be recorded on it, and the mother should be asked to show it to the health worker. When there is no health card, these details should be recorded in a short note for the mother and health worker.
12.8. Providing follow-up care
Advise all mothers who are taking their children home after assessment in the hospital when to go to a health worker for follow-up care. Mothers may need to return to hospital:
for a follow-up visit within a specified number of days (e.g. when it is necessary to check progress or the response to an antibiotic)
if signs appear that suggest that the illness or injury (e.g. head injury) is worsening
for the child's next vaccination.
It is especially important to teach the mother the signs that indicate the need to return to hospital immediately. Guidance on the follow-up of specific clinical conditions is given in appropriate sections of this Pocket book.
Follow-up for feeding and nutritional problems
If a child has a feeding problem and changes in feeding have been recommended, follow up in 5 days to see whether the mother has made the changes, and give further counselling if needed.
If the child has anaemia, follow up in 14 days to give more oral iron.
If the child has a very low weight, additional follow-up is needed in 30 days, which involves weighing the child, reassessing feeding practices and giving further nutritional counselling.
When to return immediately
Advise the mother to return immediately if the child develops any of the following signs:
unable to drink or breastfeed
becomes sicker
develops a fever
signs of illness return after successful treatment in hospital
a cough or cold: fast or difficult breathing
diarrhoea: blood in stool or drinking poorly.
Next ‘well-child’ visit
Remind the mother about the child's next visit for vaccination, and record the date on the mother's card or the child's immunization record.
