This classification is given if a child has any one of the following symptoms: visible severe wasting, severe pallor, clouding of the cornea, or edema of both feet. Such children are given vitamin A and an urgent referral to hospital.


This classification is based on the presence of one of the following: low weight-for-age, foamy patches on the white of the eye, or pallor. Children in this category will have their feeding assessed, using one set of questions for infants age 1 week to 2 months, and another set for those 2 months to 5 years. For the younger groups, questions are asked about whether there is difficulty in feeding and the frequency of breastfeeding and consumption of other foods and drinks. Breastfeeding is further assessed by observing the attachment and suckling effectiveness of infants during a 4-minute period for infants who have not fed for at least an hour. For the older infants, the mother is asked questions about breastfeeding frequency and diurnal patterns; type, frequency, amounts, and providers of other foods and feeding techniques; and any changes in feeding as a result of illness. The mother's answers are compared with a set of “Feeding Recommendations during Sickness and Health” that are intended for all children up to 5 years, and referred to as the “Food Box.” The “Food Box” provides basic information on how and what the child should be fed from the ages of 0–4 months, 4–6 months, 6–12 months, 12 months–2 years, and 2 years and older. The mother then is counseled as appropriate using the “Counsel the Mother” chart.

Administration of vitamin A and counseling on the use of foods rich in vitamin A are recommended for children with foamy patches on the eye. For children with pallor, medicinal iron is given for 14 days; after this period the mother is asked to return to obtain sufficient iron to last up to 2 months. (If pallor still exists at 2 months, the child is referred for assessment.) An oral antimalarial drug is advised in high malaria areas, and mebendazole, a broad-spectrum antiparasitic agent, is recommended for children older than 2 years who have not had a dose in the prior 6 months. For children with low weight-for-age or pallor, the mother is asked to return with her child in 14 days. At that time the child is reweighed, weight gain is calculated, and feeding is reassessed. If weight gain has been inadequate or the child has lost weight, or if the child has a feeding problem, the mother is counseled about problems found by the health worker, who again refers to the “Food Box” and the “Counsel the Mother” charts. The mother is asked again to return with her child in 14 days or is referred. If weight gain is good, the mother is encouraged to continue.

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