Acknowledgements Introduction How HIV and AIDS affect young children Preventing HIV infection in young children Diagnosis, treatment and care Issues for health workers Selected resources Glossary Appendix 1 Appendix 2

	3.1 Diagnosis and testing of infected children Diagnosis Clinical signs and symptoms HIV counselling and testing Birth to 6 Months Issues to consider in testing children for HIV Diagnostic tests
	3.2 Treatment and care Basic care and support needs for all children - with and without HIV Prevention, treatment and supportive care at home Preventing transmission of HIV at home Helping children to stay well Nutrition and children with HIV and AIDS Feeding and illness Safe preparation of food Taking care of common conditions How to give oral rehydration salts (ORS) solution How to make gentian violet solution Giving medicines to children Management of common infections at primary care level Clinical follow-up Referral and treatment Immunisation: protecting against common childhood infections Palliative care in terminal HIV/AIDS Drugs for treatment of children with HIV and AIDS
	3.3 Affected children What can health workers do? Child rights and HIV and AIDS Community-based support programme Strategies for dealing with children orphaned by HIV and AIDS

This Section describes how HIV and AIDS affects children's health and issues related to diagnosis in young children. It provides a practical overview of management and care for children with HIV and AIDS at community and primary care levels, including prevention, supportive care, treatment of common illnesses and referral. Finally, it discusses care for children affected by HIV and AIDS.

3.1 Diagnosis and testing of infected children

Key Points    Many HIV-infected children die from common childhood illnesses. Diagnosis of HIV in young children is often based on clinical signs. However, clinical diagnosis is difficult. Where available, an HIV test can confirm the clinical diagnosis. Counselling for family members and children should precede and follow any diagnostic tests.

HIV infection is a chronic condition which ranges from no symptoms to AIDS.

Infections in HIV-positive children are usually caused by the same pathogens as in HIV-negative children, but tend to be more frequent with repeated infections more common. Children with HIV also have a greater risk of pulmonary tuberculosis. However, infections in HIV-positive children can sometimes be caused by more unusual opportunistic infections which respond poorly to treatment. 

In general, the management of specific conditions in HIV-infected children is similar to that in other children. Many HIV-infected children die from common childhood illnesses, rather than from AIDS. Most of these deaths are preventable by early diagnosis and correct management of childhood infection. Ensuring that all children get the best practical treatment for common illnesses is the best way of caring for children with HIV.

Although some children with HIV stay well for many years, especially if they receive good nutrition, treatment and care, some become sick and develop HIV disease and AIDS-related symptoms soon after HIV infection. These children may get sick more quickly than adults who can be free of symptoms for many years. This is possibly because an infant's immune system is not fully developed and is less able to fight the virus. 

Children may also die more quickly than adults after becoming infected with HIV. Worldwide, about half the infected infants will die before the age of five years. 

Children with HIV infection in developing countries become ill and die more rapidly than those in industrialised countries, because of lack of appropriate treatment and care, poor nutrition and infectious diseases to which they are very vulnerable. In Zambia, for example, nearly half of infected children die before the age of two, and in one Ugandan study two-thirds had died by the age of three.
 
Diagnosis 
HIV in infants and young children is diagnosed on the basis of clinical signs confirmed by diagnostic testing. In many countries, clinical diagnosis alone is used because laboratory testing is expensive or not available, and because HIV antibody testing - the most commonly used method - does not give a true picture of a child's HIV status before the age of 15-18 months. A definitive diagnosis of HIV, if it is made at all, is most likely to be made at referral level.
 
Clinical signs and symptoms 
The clinical expression of HIV infection in children is highly variable. A proportion of HIV-positive children develop severe HIV-related symptoms in the first year of life; these signs are associated with high mortality. Other HIV-positive children may remain asymptomatic or mildly symptomatic for more than a year and may survive for many years.

In developing countries, children with HIV often have the same illnesses as children without HIV infection and, like children without HIV, are killed by common infections such as diarrhoea, measles and respiratory infections. 

This makes clinical diagnosis of children with HIV difficult and, without access to laboratory testing, health workers may not be able to distinguish HIV-positive children from other children. 

However, unlike other children, infants and children with HIV infection may have:
  

	common illnesses that are more severe, more frequent and more persistent
	recurrent serious systemic bacterial infections
	opportunistic infections.

HIV-positive children have symptoms which include failure to thrive, wasting, weight loss, persistent and recurrent diarrhoea, repeated attacks of oral thrush, otitis media and skin rashes, recurrent fever and delayed development. 

In addition, they may not respond so well to standard treatment and are also more likely to suffer from recurrent or serious bacterial infections with life-threatening conditions such as septicaemia, meningitis and abscess. 

Signs 
The following signs are less common in children without HIV: 
  

	recurrent infection - more than two severe episodes of a bacterial and/or viral infection (pneumonia, meningitis, sepsis, cellulitis) in the past 12 months
	oral thrush - the presence of white plaques (spots) inside the mouth. After the neonatal period, the presence of oral thrush without previous antibiotic treatment or lasting more than 30 days despite treatment, is highly suggestive of HIV infection
	herpes zoster - also known as shingles, a skin condition characterised by a painful
	rash with blisters confined to one part of the body
	chronic otitis media - ear discharge lasting 14 days or more
	chronic parotitis - the presence of swollen glands just in front of the ear for 14 days or more. There mayor may not be any associated pain or fever and the swelling may be on one or both sides
	generalised lymphadenopathy - the presence of enlarged lymph nodes without any apparent underlying cause
	persistent and/or recurrent fever - fever (over 38°C) lasting for seven days or more,
	or occurring more than once over a period of seven days
	neurologic problems - development delays, failure to reach developmental milestones.

The following two signs are common in non-HIV-infected children as well as in HIV-positive children: 
 

	persistent diarrhoea - diarrhoea lasting 14 days or more
	failure to thrive - a marked downward change in expected growth as indicated on the child's growth card.

Conditions specific for HIV infection in children 
The following conditions are known to be very specific to HIV -infected children. However, diagnosis of these conditions is difficult with limited diagnostic facilities.
  

	Pneumocystic carinii pneumonia (PCP) - a diagnosis of PCP should be made in a child who has severe or very severe pneumonia and filling up of the small spaces in the lungs revealed by chest x-ray. The possibility of PCP should also be considered in children known or suspected to have HIV with ordinary pneumonia but who are not responding to treatment.
	Oesophageal candidiasis - the child may have difficulty or pain while vomiting or swallowing, reluctance to take food, salivation, crying during feeding and weight loss. The condition may occur with or without evidence of oral thrush. If oral thrush is not found, other causes of painful swallowing (such as cytomegalovirus, herpes simplex, lymphoma, carcinoma and, rarely, Kaposi sarcoma) may have to be ruled out, usually at a higher referral level.
	Lymphoid interstitial pneumonitis - the diagnosis of lymphoid interstitial pneumonitis (LIP) is difficult. In general it requires confirmation by a chest x-ray. The child is often asymptomatic in the early stages but may later have a cough, with or without difficulty breathing and signs of hypoxaemia such as finger clubbing.
	Kaposi sarcoma - this is rare in children. Diagnosis needs to be confirmed by skin biopsy.

 
There are problems with using clinical symptoms as the basis for diagnosis of HIV in children. 
  

	Clinical diagnosis is difficult, because many of the signs are common in children whether they are infected with HIV or not. For example, children with tuberculosis who do not have HIV fail to gain weight, have intermittent fever and chronic cough. Children with HIV who do not have TB have the same symptoms.
	The clinical criteria therefore lack specificity (some children may be diagnosed as infected when they are not) and sensitivity (some children who are infected may not be diagnosed as having HIV).
	The emphasis on chronic illness means that acute illnesses, which also contribute to death in infants and young children with HIV, may be missed.
	Some illnesses are more difficult to diagnose in children with HIV. For example, children with HIV who have tuberculosis may be tuberculin test negative because their immune system is not functioning well, and may have different symptoms such as fever without a cough.

 
HIV counselling and testing 
If the child's HIV status is not known, but there are reasons to suspect HIV infection (based on clinical signs or diagnoses in the family), WHO and UNAIDS recommend that the child should be tested for HIV where possible. Although maternal antibodies interfere with conventional serological testing under the age of 15 months, if the child is suspected to have HIV on clinical grounds, WHO suggests that both the mother and child should be tested to rule out other HIV-associated and potentially treatable clinical problems such as tuberculosis. In addition, if it is known that the mother became infected after delivery, the presence of antibodies in the first year of life are indicative of HIV infection in the infant. 
 

Birth to 6 Months    A few babies with HIV are small at birth and fail to thrive. Many develop symptoms at about three or four months of age. These symptoms may include severe bacterial infections (such as meningitis, severe skin infections or itchy rashes, pneumonia), swollen lymph glands in the neck or under the armpits, swollen stomach (because of enlarged liver or spleen), failure to thrive, and fungal infections, especially oral thrush. Babies may also cry constantly or be irritable. Six months to 15 months  Growth faltering, often with illnesses such as malaria, diarrhoea or ear infections (otitis media), is common. Persistent diarrhoea and respiratory (cough) and lung (pneumonia) infections may also be frequent. Babies may also be slow to crawl or unable to sit. Over 15 months  In addition to the symptoms in children aged 6-15 months, those aged over 15 months may also have itchy rash (eczema), swollen glands, chronic cough and persistent oral thrush. They may be slow to start walking or talking. Upper respiratory infections may become chronic and otitis media may develop into mastoiditis.

Issues to consider in testing children for HIV     Antibody testing an infant before the age of 15 months will only provide information about the HIV status of the mother. If other methods (such as polymerase chain reaction - PCR) are available for testing the child, ask whether the parents want to know the child's HIV status or is it the health worker that wishes to know. Are pre-and post-test counselling available to the mother and other family members to help them understand the implications of testing the child and to make an informed decision? Testing the child should never be used as a means of indirectly testing the mother. Are staff available who have the training and skills to counsel parents if their child is discovered to have HIV? If a child is found to be positive, will this help the child to get the special care and attention he or she needs? For example, will infections which could become serious such as diarrhoea or pneumonia be identified and treated more quickly? Is there a danger of discrimination against the infant if he or she is diagnosed as HIV infected? Will it help parents to know why the child is frequently sick? Will it prevent them spending money and time seeking a cure? Is there a danger that, if they do not know the child has HIV, they may believe that immunisation or ORS do not work and may fail to give these to their other children? Will knowing the child's HIV status change your advice to parents about care of the child including preventing infections and seeking help promptly from a health worker if the child becomes sick? Is it possible to refer the mother and child for support and counselling or to a community care programme?  Because diagnosis of HIV in a child probably means that the mother also has HIV infection, and possibly also the father, what implications will this have for the family?

An HIV test can confirm the clinical diagnosis, alert the health worker and parents to HIV-related problems, and discuss prevention of mother-to-child transmission (including where possible prevention using antiretrovirals). If the child does have HIV, the parents and child will know why the child is frequently sick, and parents will know how to manage the child. In theory the child can also be referred to appropriate facilities, for support, counselling and treatment or for home-based care. However, health workers need to decide whether testing the child and discovering that he or she has HIV infection provides any benefits, and what impact a positive test result would have on the mother and other members of the family. Issues to be considered are included in the box above. 

In settings where there is no access to HIV testing, health workers must assess the possibility that the child has HIV on the basis of clinical signs and symptoms. They should also remember that treatment and care of common infections is the same in all children, regardless of HIV status, but that they should be alert for children who respond poorly to standard treatment or have frequent or more severe infections. 

Counselling both before and after testing is essential. HIV counselling should take account of the child as part of a family, including the psychological implications of HIV for the child, mother, father and other family members. Counselling requires time and needs to be done by knowledgeable staff. Staff at first referral level may not have sufficient experience to provide counselling. If the first level health worker is not doing the counselling, the reason for referral to counselling should be discussed with the parent. 

HIV counselling is indicated in the following situations, if a child: 
  

	has an unknown HIV status and presents with clinical and/or epidemiological risk factors
	is known to be HIV positive and is responding poorly to treatment or needs further investigations
	is known to be HIV positive and has responded well to treatment prior to discharge and referral to a community-based care programme for psychosocial support.

In children with an unknown HIV status:
  

	manage emergency conditions if present (the treatment is the same for HIV-infected and uninfected children)
	manage other associated conditions
	decide if you will do the counselling or need to refer the child
	if a health worker is doing the counselling, then he or she needs to make time for the counselling session, and the following should be considered during the counselling session:   reason for considering HIV infection  HIV transmission routes in children, prevention of transmission in a family setting  management and follow-up issues  risk factors for illness  immunisation and HIV  breastfeeding and HIV  how the HIV test is done the implications of a positive result in the child and /or parents.

In children who are known to be HIV positive and respond poorly to treatment or need further investigations, the following discussions should form part of the counselling sessions: 
  

	the parents' understanding of HIV infection
	management and follow-up
	risk factors for illness
	immunisation and HIV
	the need to refer to a higher level.

In children who are known to be HIV positive and respond well to treatment prior to discharge and referral to a community-based care programme for psychosocial support, the following discussions should form part of the counselling session: 
  

	the reason for referral to a community-based care programme
	management and follow-up
	risk factors for illness
	immunisation and HIV.

Diagnostic tests 
There are several diagnostic methods for detecting HIV in infants and young children, including testing for HIV antibodies, viral culture and polymerase chain reaction (PCR) testing.

HIV antibody testing 
 

Antibody testing is the most common and widely available method for diagnosing HIV. An HIV test - usually an ELISA (enzyme-linked immunosorbent assay) test - detects antibodies to HIV in the blood. These antibodies are produced by the body's immune system in response to infection with the virus. If there are no antibodies, the person is antibody negative (seronegative or HIV negative). In adults, the test may be negative if they have only recently been infected because it can take up to three months from the time of infection before antibodies are produced. This is called the 'window period'.

In infants and young children, antibody testing is more complicated. This is because a child is born with his or her mother's antibodies which can remain in the child's body until about 12-15 months of age. Hence, during the first 15 months of life, an antibody test cannot show a difference between maternal antibodies and those produced by the baby. It is only possible to tell whether or not a baby is infected once his or her own immune system takes over and the maternal antibody is gone.

Other diagnostic methods 
These methods look for the presence of the virus itself rather than the body's reaction to it. Virus culture from blood or body fluid or PCR can detect whether or not an infant is infected with HIV in most cases by the age of about three months. 

But these methods are expensive, require sophisticated facilities and expertise, and are not usually available in developing countries.

3.2 Treatment and care

Key Points    Good care and treatment improves the quality of life for children with HIV. Providing supportive care at home may be less expensive for the family and more familiar and happier for the child. Providing regular, nutritious food helps the child grow and fight off infections. Children with HIV are not sick all the time and should lead as normal a life as possible.

 

Most HIV-related illness in children is caused by common infections that can be prevented and cared for at home or treated at a health centre. Early recognition and treatment of common illnesses can also prevent the development of more serious infections, reducing hospital admissions and demand on health services. This section therefore focuses on:     prevention, treatment and supportive care at home  management of common infections at primary care level  referral of more serious illnesses and children who fail to respond to standard treatment.    Good care and treatment can improve the quality of life and life expectancy for children with HIV. Most early deaths are preventable with good management. But in many settings, health services are unable to provide the ongoing care that children with HIV and AIDS need at health facilities.

Some countries have adopted a 'continuum of care' approach. This covers a range of services including counselling and testing, clinical treatment, and community - and home-based care. Care is provided at different levels and at different times according to need. The key to improving quality of life for children with HIV is early entry into the continuum of care. 

In Zambia for example, a number of different 'entry points' are used to ensure that those who need care are identified, including blood transfusion services, traditional healers, NGOs, counselling and testing facilities, and community-based home care programmes. Care is provided at different levels, according to severity of illness, and whether the child can be looked after at home or needs to be admitted. Steps are taken to make sure that proper care can be provided after discharge from a health facility. 

Basic care and support needs for all children - with and without HIV     Nutrition - safe weaning and nutritious food Care -  consistent parenting, security and love Recreation - something and someone to play with Education - parents and caregivers need information about looking after children when they are ill Prevention of illness - immunisation, good hygiene and a safe environment Appropriate management of illness - treatment of supportive care for common infections.

Prevention, treatment and supportive care at home 
 

Caring for children with HIV at home has several advantages:     good basic care can be given at home  sick children are usually happier at home in a familiar environment and surrounded by their family and friends  it is usually less expensive for families to care for a sick child at home, with fewer hospital bills and transport costs carers can more easily meet other family responsibilities. No family will have a health worker with them all the time to help with the care of a sick child. Families are important members of the health team and health workers need to teach them about HIV and home care.

Families need to know how HIV is transmitted and not transmitted, what they can do to prevent transmission of HIV and other infections and to keep their child well, how to recognise and take care of common illnesses, and when a child is more seriously ill and needs to be taken to a health facility.

As a health worker, think about who needs to know about home care and what they need to know. Talk to them about caring for the child at home. Find out what they already know. Let them ask questions and answer their questions. Check that they understand what to do and that they have the time and resources to care for the child. Help them to identify other people who can help them and provide support. 

Some projects have provided simple home kits - which include, for example, items such as soap, bleach, vaseline and ORS packets - to help families to care for children with HIV and AIDS.
 
Preventing transmission of HIV at home 
There is very little risk that carers will acquire HIV from looking after a child with HIV or AIDS, provided that they follow certain simple rules. 

These include minimising contact with blood and body fluids, being careful with sharp instruments and covering open cuts and wounds. Bed linen and clothing soiled with faeces or blood should be washed carefully with hot water and soap and handled as little as possible.
 
Helping children to stay well 
The following are some of the most important things that parents can do to prevent illness and help their children to stay well, whether or not a child has HIV infection.
 
Hygiene 
  

	Make sure the home is clean.
	Prepare food and drink, including formula, hygienically with boiled water and clean utensils.
	Wash hands with soap (or ashes) before preparing and giving food to the child, after using the toilet and after changing soiled bedding or clothes, and before giving medicines.
	Teach young children to wash their hands frequently, especially after using the toilet and before eating.
	Keep the child away from animal and human faeces, and keep areas where children playas clean as possible.
	Brush the child's teeth until he or she can do it.
	Wash the Child's bed linen, towels and clothes with hot water and soap. Keep separate from other household laundry if blood or faeces are on them, avoid touching blood or faeces by rinsing off first and then wash items in hot soapy water and dry in the sun. Wash hands after handling soiled articles.
	Avoid spitting (this spreads TB) or spit into a container.
	Cover your mouth when coughing or sneezing.
	Dispose of waste, in a pit latrine or by burying or burning.

Health care 
  

	Look out for symptoms of illness, especially cough, fever, fast or difficult breathing, loss of appetite or poor weight gain, diarrhoea, and vomiting, and treat these or seek treatment as soon as possible.
	Make sure the child is immunised (but not with live vaccines if he or she has symptomatic HIV, see page 37).
	Avoid common infections, for example by keeping a child away from others who have pneumonia, tuberculosis and measles. Young children should not, if possible, sleep in the same room as an adult suspected of having TB disease.
	Parents can help protect a child against malaria by making sure he or she sleeps under a bednet, preferably one impregnated with insecticide, by using coils and repellents to keep mosquitoes out of the home, and by draining pools of water that may be mosquito breeding areas.
	Check the mouth for sores and thrush and treat these promptly.

Nutrition and general care 
  

	Give regular nutritious food to help the child grow and fight off infections.
	Make sure the child gets enough sleep and rest.
	Treat the child like other children. Children with HIV are not sick all the time and should lead as normal a life as possible, including playing with other children.

 
Nutrition and children with HIV and AIDS 
 

Children with HIV often lose weight or fail to thrive and grow. Repeated episodes of diarrhoea and other infections often result in loss of appetite and further weight loss. Special efforts are needed to make sure that they do not become severely malnourished. Malnourished children are more vulnerable to infection and the problem is made worse in those with HIV who are already at greater risk of infection.  It is therefore very important that children with HIV eat a good diet, to help them resist and fight off infections. They particularly need to get enough vitamin A in their diet because it helps to protect against diarrhoea and respiratory infections.

A good diet includes:
 
Energy-rich foods such as maize, rice, millet porridge, bread, cassava, plantain or yam. These provide the main part of the meal and most of the energy. Sugar, animal fats, coconuts, nuts and vegetable oil are a concentrated source of energy.

Body-building foods such as meat, chicken, fish, eggs, dairy produce, nuts and beans. These foods contain protein and micronutrients such as iron, zinc, calcium and some vitamins.

Vitamin-rich foods such as dark green leafy vegetables and orange and yellow fruits. 

Family foods can be made more nutritious and easy to eat. For example, porridge can be made more energy-rich by adding vegetable oil or nuts or adding mashed pulses, vegetables, milk, fruit juice or coconut milk. Fermenting or malting can make foods such as porridge more nutritious and easier to swallow. 
 
Feeding and illness 
Children who are sick often lose their appetite. They need to be encouraged to eat small meals more frequently than usual, made with foods they like. Giving lemon juice in warm water or ginger drink can help reduce nausea. Unsweetened yoghurt and fermented foods like sour porridge are good for candida (oral thrush). 

Children with diarrhoea should be given well cooked local staples that can be easily digested in a soft mashed form and with added energy. Rice, barley, bananas and sweet potatoes are good staples. Foods rich in potassium, such as spinach, bananas, coconut water, avocado, should be given to replace potassium losses during diarrhoea. Refined, canned or junk foods should be avoided because they are less nutritious. Steaming or stir are good cooking methods because they do not remove as much of the nutrients from food as other methods. Spicy or fatty foods should also be avoided as these can worsen nausea. 

After illness it is important that children eat more to help them recover and build up their strength. A simple rule is to give an extra meal a day until the child has reached the same weight as before the illness.

Safe preparation of food 
 

Clean food preparation and storage can reduce the risk of infections, especially diarrhoea. Food should be cooked until it is thoroughly heated and bubbles. Cooked food should not be stored for more than 24 hours and any food that has been kept for more than two hours should be thoroughly reheated. Food and water should be stored in clean covered containers.  Boiled and cooled water should be used to wash fruits and vegetables, and for cooking and drinking.  Wash hands with soap and water before preparing and cooking food or feeding a child.

 
 
Taking care of common conditions 

Fever 
  

	A child has fever if he or she has a high body temperature (above 37.5°C).
	Remove unnecessary clothing and blankets.
	Put the child in the fresh air, preferably where there is a breeze.
	Make sure the child drinks plenty of fluids because fever can make him or her dehydrated.
	If the child has high fever (more than 38.5°C), give paracetamol to reduce the fever.
	The child should be taken to a health centre if the fever continues for more than three
	days. If the child also has a cough and is losing weight, has a stiff neck, severe pain or sudden diarrhoea or convulsions, or there is malaria in the area, he or she should be brought sooner.

 
Diarrhoea 
  

	A child has diarrhoea if he or she passes more than three loose stools in a day.
	Diarrhoea can cause dehydration because of the loss of fluids and body salts.
	Dehydration is dangerous in infants and small children.
	Treating diarrhoea at home involves three important actions:   - giving the child more fluids to drink than usual,    - continuing to feed the child, and    - seeking care when needed.
	Parents should bring the child to a health centre if there is blood in the stools, if after three days there are still many watery stools, if the child vomits repeatedly, eats or drinks poorly, has fever, or is very thirsty.
	Additional fluids should be safe and include, as well as plain water, those which contain salt, such as ORS, salted soup, such as carrot soup, salted rice water.
	Other good home drinks for children with diarrhoea are green coconut water, yoghurt drinks, unsweetened tea, unsweetened fresh fruit juice, and water in which a cereal such as rice has been cooked.
	Medicines are not necessary for most children with diarrhoea.

How to give oral rehydration salts (ORS) solution     A cup is the best method because it allows the fluid to be given in small steady amounts which reduces vomiting. About one teaspoon every two or three minutes is a useful guide. Older children can drink on their own from a cup. Plastic droppers are more difficult to keep clean and free of germs. Carers need to be patient and persistent when giving ORS. If a child refuses to take any more fluid after a time, it usually means that he or she has had enough. A child under two years needs about 50-100mI (between a quarter and half a cup) of fluid after each loose stool. Older children require about 100-200ml (half to one cup) of fluid after each loose stool.

Skin problems 
  

	Skin problems include rashes, itching, painful sores and abscesses.
	Cleaning the skin with soap and water and keeping it dry between washing can prevent most common skin problems. Salty water can be used as a disinfectant.
	Carers should try to stop young children from scratching if possible as this can cause infection. Keeping the nails short and clean helps. Carers can also try putting gloves over the child's hands. The irritation and itching can be reduced by cooling the skin with water or by fanning it,
	by applying calamine lotion and by not letting the child get too hot.
	If the skin is very dry, washing with soap and water can make it worse. Oils or creams, such as vaseline, glycerine or vegetable or plant oil (for example, coconut oil) can be used instead.
	Avoid perfumed oils, soap and lotion as these may irritate the skin.
	Children in nappies and those with diarrhoea need careful skin care. To prevent sores and rashes, leave the baby's bottom exposed to the air as much as possible, wash the baby's bottom between nappy changes with warm water, and use a barrier cream such as zinc and castor oil. Leaving the baby in wet nappies or cloths causes rashes and sores.
	Potassium permanganate solution makes a good antiseptic for soaking infected sores. Add a pinch of crystals to a litre of clean water.

Shingles 
  

	Shingles begins as a painful rash with blisters and healing takes several weeks.
	Apply calamine lotion twice a day to relieve pain and itching, and promote healing.
	Keep sores dry and relieve pain with paracetamol.
	Bathe in salt water or apply gentian violet to prevent infection.

Bed sores