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Foreword
"IMNCI" is an integrated strategy which deals with a number of priority health problems
resulting in major cause of mortality and morbidity in under five children. Children
brought to health facilities are often found suffering from more than one morbid condition,making a single diagnosis impossible. These children require a combined therapy for
successful treatment. In IMNCI efforts have been made to focus on the child as a whole,
rather than on a single disease or condition fostering holistic approach to child health and
development.
Majority of the patients attending the outpatient departments (OPD) in our hospitals are
children. Problems seen in the OPD clinics are typical of what most health professional
graduates will come across later in their careers. Developing core knowledge and skill in
outpatient paediatrics is essential for undergraduate students as part of their basic
education.
IMNCI pre service training has already been introduced in undergraduate curriculum,
referring to the process of developing the practice of standardized protocol-based
management of the most common medical conditions that afflict children. Introducing this
in medical and paramedical education, before graduates enter service, will lend a hand to
their real life situation
This Handbook on IMNCI is a training module for pre service training for medical
students to develop knowledge, master skills before graduation & to empower future
health care providers in relevant decision making. It focuses on approach to the sick child
in an integrated manner, considering the child as a whole and not just for the illness he/she
has been brought. The "STUDENT'S HANDBOOK IMNCI" adopts a uniform presentation while dealing with different subjects consisting of an overview of the
integrated case management; assessment and classification of the sick child; identifying
treatment priorities; appropriate treatment; knowledge on communications and counseling
skills and follow up of sick child. It emphasizes assessment of growth, nutrition,
immunization status and primary and underlying illnesses. The coverage umbrella is
expanded to provide guidelines to include the most vulnerable period in the child's life by
being adapted to local needs. IMCI offers a strategy for improving the state of children in
Bhutan. This approach could help the country in achieving the Millennium Development
Goals of reducing the under-five mortality.
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Acknowledgement
Reviewing committee
1. Dr. K. P. Tshering, Pediatrician, Head of Paediatric Department , JDWNRH2. Dr. Drupthob Sonam, Medical Superintendent, JDWNRH3. Dr. H. P. Chhetri, Pediatrician, Military Hospital, Lungtenphu4. Dr. P. Bhandari, Pediatrician, ERRH, Mongar5. Dr. Shukhrat Rakhimdjanov, Health Specialist, UNICEF Country Office, Bhutan6. Dr. Ripa Chakma, Lecturer, RIHS7. Ms. Deki Pem, Lecturer, RIHS8. Mr. Thukten Tshering, Chief Pharmacist, JDWNRH9. Mr. Tandin Dorji, CPO, CDD, DoPH, MoH10. Mr. Kaka, PO, EMTDD, DMS, MoH11. Mr. Sonam Zangpo, Sr. PO, IMNCI-ARI/CDD, DoPH
12. Mrs. Yeshi Chhoden, Program Assistant, UNICEF Country Office, Bhutan13. Dr. Pelden Wangchuk, MO, Damphu Hospital, Tsirang14. Dr. Kinley Wangdi, Medical Superintendent, Phunstholing General Hospital,
Chuka
Proof reading and edited by:Dr. Ripa Chakma, Lecturer, RIHS
Ms. Deki Pem, Lecturer, RIHS
Formatting:
Ms Karma Sonam, Assistant Information Technology officer
Produced by: IMNCI-ARI/CCD Program
Department of Public Health
Ministry of Health, Thimphu
Financial and Technical Support:UNICEF Country Office
2011
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Contents
1 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ................................ 1
1.1 Introduction ........................................................................................................... 1
1.2 RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TOCASE MANAGEMENT ........................................................................................... 2
1.3 COMPONENTS OF THE INTEGRATED APPROACH .................................... 3
1.4 THE PRINCIPLES OF INTEGRATED CARE ................................................... 3
1.5 THE IMNCI CASE MANAGEMENT PROCESS ............................................... 4
2 OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO YEARS 7
2.1 LEARNING OBJECTIVES .................................................................................. 7
2.2 ASSESSMENT OF SICK CHILDREN ................................................................ 7
2.2.1 History taking- COMMUNICATING WITH THE PARENTS OR
CAREGIVER ................................................................................................................ 8
2.2.2 CHECKING FOR GENERAL DANGER SIGNS ........................................... 9
2.2.3 CHECKING MAIN SYMPTOMS ................................................................. 11
2.2.3.1 COUGH OR DIFFICULT BREATHING .................................................. 11
2.2.3.2 Diarrhoea ...................................................................................................... 14
2.2.3.3 FEVER ........................................................................................................ 21
2.2.3.4 EAR PROBLEMS ....................................................................................... 28
2.2.4 CHECKING NUTRITIONAL STATUS - MALNUTRITION AND
ANAEMIA ...................................................................................................... 32
2.2.5 CHECKING IMMUNIZATION, VITAMIN A and DEWORMING STATUS
39
2.2.6 ASSESSING THE CHILD'S FEEDING ........................................................ 41
2.2.7 ASSESSING OTHER PROBLEMS ............................................................... 44
2.3 identify treatments FOR SICK CHILDREN....................................................... 45
2.3.1 REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS ............. 45
2.3.2 TREATMENT IN OUTPATIENT CLINICS ................................................. 48
2.3.2.1 ORAL DRUGS ........................................................................................... 48
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2.3.2.2 TREATMENT OF LOCAL INFECTIONS ........................................... 53
2.3.2.3 COUNSElLING A MOTHER OR CAREGIVER ...................................... 58
CHAPTER 3 ....................................................................................................................... 62
3 OUTPATIENT Management of SICK Young Infants Up to 2 Months ..................... 62
3.1 Learning Objectives ............................................................................................ 62
3.2 ASSESSMENT OF sick YOUNG INFANTS .................................................... 62
3.2.1 Classification of very severe disease............................................................... 65
3.2.2 Check for jaundice. ......................................................................................... 66
3.2.3 DIARRHOEA ................................................................................................. 68
3.2.4 FEEDING PROBLEMS OR LOW WEIGHT ................................................ 70
3.2.5 CHECKING IMMUNIZATION STATUS .................................................... 72
3.2.6 ASSESSING OTHER PROBLEMS ............................................................... 73
3.3 Treatment Procedures for SICK Infants .............................................................. 75
3.3.1 REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS ........................... 75
3.3.2 TREATMENT IN OUTPATIENT CLINICS ................................................. 77
3.3.2.1 ORAL DRUGS ........................................................................................... 77
3.3.2.2 COUNSELLING A Mother or Caregiver ................................................... 78
3.3.2.3 FOLLOW-UP CARE .................................................................................. 84
3.4 Recording forms ..........................................................................................................85
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CHAPTER 1
1 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
1.1 INTRODUCTION
Although, globally under-five (U5) mortality has decreased by almost a third since the
1970s, this reduction has not been evenly distributed throughout the world. According to the
2005 World Health Report , globally mortality rates in children under 5 years of age fell
throughout the later part of the 20 th century: from 146 per 1000 live births in 1970 to 88 in
2003. Towards the turn of the millennium, however, the overall downward trend started to
falter in some parts of the world. Mortality in U5 children in low- to middle-income
countries is still very high.1Every year more than 10 million children in these countries die
before they reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory
infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition and often to a
combination of these conditions.
In Bhutan, Infant Mortality Rate continues to be high at 40/1000 live births and Under Five
Mortality Rate at 60/1000 live births per year. One out of nearly 16 children die before
reaching the age of five years. Most of this mortality is in the first four weeks of life.
Major health problems in Bhutan
Acute respiratory infection
Diarrhoeal diseases
Under-nutrition is common among children
Tuberculosis and malaria are the other major health problems.
Every day, millions of parents seek health care for their sick children, taking them tohospitals, health centres, pharmacists, doctors, and traditional healers. Surveys reveal that
many sick children are not properly assessed and treated by these health care providers, and
that their parents are poorly advised.2 At first-level health facilities in low-income countries,
diagnostic supports such as X-ray and laboratory services are minimal or non-existent, and
drugs and equipment are often scarce. Limited supplies and equipment and lack of awareness
of parents make it difficult for the health care provider to practice complicated clinical
procedure. Instead, they often rely on history and signs and symptoms to determine themanagement.
Providing quality care to sick children in these situations is a
serious challenge. Experience and scientific evidence show
that improvements in child health are not necessarily
dependent on the use of sophisticated and expensive
technologies, on the other hand effective strategies based on
holistic approach is sufficient to address the common illness
1. World Health Organization. World health report 2005 Make every mother and child count. Geneva, WHO, 2005.
2 World Health Organization. Report of the Division of Child Health and Development 1996-1997. Geneva, WHO, 1998.
Improvements in child healthare not necessarily dependenton the use of sophisticated and
expensive technologies.
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of under five children.
1.2 RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TOCASE MANAGEMENT
Many well-known prevention and treatment strategies undertaken separately have already
proven effective for saving young lives. Childhood vaccinations have successfully reduced
deaths from vaccine preventable diseases. Oral rehydration therapy has contributed to a
major reduction in diarrhoea deaths. Effective antibiotics have saved millions of children
with pneumonia. Prompt treatment
of malaria has saved a lot of lives.
Even modest improvements in
breastfeeding practices have reduced
childhood deaths. These
interventions were not integrated.
While each of these interventions
has shown great success, accumulating evidence suggests that a more integrated approach in
management of sick children is needed to achieve better outcomes. Child health programmes
need to move beyond single diseases to address the overall health and well being of the child.
Because many children present with overlapping signs and symptoms of diseases, a single
diagnosis may not be feasible or appropriate. This is especially true for first-level health
facilities where examinations involve few instruments, little or no laboratory tests, and no X-
ray.
To address the illness of under five children as a whole, the World Health Organization
(WHO), in collaboration with UNICEF and many other agencies, institutions and
individuals, developed and introduced a strategy known as the Integrated Management of
Neonatal and Childhood Illness (IMNCI). Although the major reason for developing the
IMNCI strategy stemmed from the needs of curative care, the strategy also addresses aspects
of nutrition, immunization, and other important elements of disease prevention and health
promotion.
The objectives of the strategy are to reduce death, the frequency and severity of illness and
disability, and to contribute to improved growth and development.
IMNCI as a key strategy for Improving child health
Management of
sick children
Nutrition immunization Other disease prevention
Promotion of growth and
development
A more integrated approach to managing sickchildren is needed to achieve better outcomes.
Child health programmes need to move beyondaddressing single diseases to addressing the
overall health and well being of the child.
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The IMNCI clinical guidelines target children less than 5 years old, the age group that bears
the highest burden of deaths from common childhood diseases. It is an evidence-based,
syndromic approach to case management that supports the rational, effective and affordable
use of drugs and diagnostic tools. The approach can be used to determine the:
Health problem(s) the child may have;
Severity of the child’s condition
Actions that can be taken to care for the child (e.g. refer the child immediately).
It may be mentioned that along with treatment the health status of the children can be
improved by proper counselling of the parents on:
Appropriate feeding practices
Bringing the sick child to the health centres as soon as symptoms arise, without anydelay
A critical example of the need for timely care is Africa, where approximately 80 percent of
childhood deaths occur at home, before the child has any contact with a health facility. 3
1.3 COMPONENTS OF THE INTEGRATED APPROACH
The IMNCI strategy includes both preventive and curative interventions. The aim of the
strategy is to improve health care practices in health facilities, the health system
(infrastructure and health care delivery) and at home. The core of the strategy is integrated
case management of the most common childhood problems with a focus on the most
common causes of death. It does not include management of trauma and other acuteemergencies due to accidents.
The strategy includes three main components
Improvements in the case-management skills of health care providers.
Improvements in the overall health system required for effective management ofchildhood illness.
Improvements in family and community health care practices.
1.4 THE PRINCIPLES OF INTEGRATED CARE
The IMNCI guidelines are based on the following principles:
All sick children must be examined for “general danger signs” which indicate theneed for immediate referral or admission to a BHU/hospital.
All sick children must be routinely assessed for major symptoms (for children age2 months up to 5 years: cough or difficult breathing, diarrhoea, fever, ear problems;
3 Oluwole D et al. Management of childhood illness in Africa. British medical journal, 1999, 320:594-595.
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for young infants up to 2 months: very severe disease, diarrhoea, jaundice and
feeding.
They must also be routinely assessed for nutritional and immunization status,
feeding problems and other problems
Assess Vitamin A supplementation and de-worming status for children age 2 monthsup to 5 years.
Only a limited number of carefully selected clinical signs are used, based onevidence of their sensitivity and specificity to detect disease.4 These signs were
selected considering the conditions and realities of first-level health facilities.
A combination of individual signs leads to a child’s classification(s) rather than adiagnosis. Classification(s) indicate the severity of condition(s). They call for
specific actions based on whether the child:
a. Should be urgently referred to higher level of care.
b. Requires specific treatments (such as antibiotics or anti-malarial treatment), OR
c. May be safely managed at home.
The classifications are colour coded: “pink” suggests hospital referral or admission ,
“yellow” indicates need for initiation of treatment, and “green” calls for home treatment.
The IMNCI guidelines address most, but not all of the major reasons for which asick child is brought to a clinic. A child coming with chronic problems or less
common illnesses may require special care. The guidelines do not describe themanagement of trauma or other acute emergencies due to accidents or injuries.
IMNCI management procedures use a limited number of essential drugs andencourage active participation of caregivers in the treatment of children.
An essential component of the IMNCI guidelines is the counsell ing of caregivers
about home care, including counselling about feeding, fluids and when to return to
the health facility.
1.5 THE IMNCI CASE MANAGEMENT PROCESS
As the disease burden, clinical signs and symptoms vary at different age groups, imnciguidelines recommend case management procedure based on 2 age categories
Young infants aged up to 2 months
Children aged 2 months up to 5 years
4 Sensitivity and specificity measure the diagnostic performance of a clinical sign compared with that of the gold standard, which bydefinition has a sensitivity of 100% and a specificity of 100%. Sensitivity measures the proportion or percentage of those with the
disease who are correctly identified by the sign. In other words, it measures how sensitive the sign is in detecting the disease.
(Sensitivity = true positives / [true positives + false negatives]) Specificity measures the proportion of those without the disease who
are correctly called free of the disease by using the sign. (Specificity = true negatives / [true negatives + false positives])
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The case management of a sick child brought to a first-level health facility includes a number
of important elements.
At Outpatient Health Facility
Assessment
Classification and identification of treatment
Referral, treatment of the child or counselling of the child’s caregiver (depending onthe classification(s) identified).
Follow-up care
At Referral Health Facility
Rapid screening of sick children for emergency sign as soon as they arrive in healthfacility , following Emergency Triage Assessment and Treatment (ETAT)
Follow up care
At Home
Teaching mothers or other caregiver how to give oral drugs and treat local infections.
Counselling mothers or other caregivers about:
a. Food and fluids
b. Give oral drugs at home
c. Treat local infections at home
d. When to return
e. Her own health
Course method and materials
In addition to this handbook –“Students’ Handbook on IMNCI”, a chart booklet thatsummarizes the steps in case management. The same information is shown on 5 wall charts.
The first three charts are for management of the sick child age 2 months up to 5 years and thetwo other charts- for management of the sick young infant age up to 2 months.
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CHAPTER 2
2 OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5YEARS
2.1 LEARNING OBJECTIVES
This section of the handbook will describe and allow the students to practice the following
skills:
Asking the mother/caregiver about the child’s problem.
Checking general danger signs.
Asking the mother/caregiver about the four main symptoms:
cough or difficult breathing
diarrhoea
fever
ear problem
When a main symptom is present:
assessing the child further for signs related to the main symptom.
classifying the illness according to the signs which are present or absent.
Checking for signs of malnutrition and anaemia and classifying the child’s nutritionalstatus.
Checking the child’s immunization status and deciding if the child needs anyimmunization today.
Assessing other problems.
2.2 ASSESSMENT OF SICK CHILDREN
The assessment procedure for this age group includes a number of important steps that must
be taken by the health care provider, including: (1) Asking the mother/caregiver about the
child’s problem; (2) checking for general danger signs; (3) checking four main symptoms;(4) checking nutritional status; (5) assessing the child’s feeding; (6) checking immunizationstatus; Vit-A, de-worming status, and (7) assessing other problems.
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2.2.1 HISTORY TAKING- COMMUNICATING WITH THE PARENTS ORCAREGIVER
It is critical to communicate effectively with the child's mother or caregiver. Goodcommunication techniques and an integrated assessment are required to ensure that common
problems or signs of disease or malnutrition are not overlooked. Using good communication
helps to reassure the mother or caregiver that the child will receive appropriate care. In
addition, the success of home treatment depends on how well the mother or caregiver knows
how to give the treatment and understands its importance.
The steps of good communication:
Listen carefully to what the parents or caregiver says:
This will show them that you take their concerns seriously.
Use words the caregiver understands:
Try to use local words and avoid medical terminology
Give the caregiver time to answer questions:
Asking mother about the child’s problem
General Danger Signs
Main Symptoms
Cough or Difficult Breathing
Diarrhoea
Fever
Ear Problems
Nutritional Status
Immunization Status
Vitamin A-Status
De-worming
Feeding Assessment
Other Problems
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S/he may need time to reflect and decide if a clinical sign is present.
Ask additional questions when the caregiver is not sure about the answer:
A caregiver may not be sure if a symptom or clinical sign is present. Ask additional
questions to help her/him to give clear answers.
2.2.2 CHECKING FOR GENERAL DANGER SIGNS
General danger signs indicate signs that may or may not be specific for a particular illness,however they are serious conditions. For example, a child with general danger signs may
have meningitis, encephalitis, septicaemia, Dengue shock syndrome, severe pneumonia,
cerebral malaria or another severe disease. Great care should be taken to ensure that these
general danger signs are not overlooked because they suggest that a child is severely ill and
needs urgent attention.
The following danger signs should be routinely checked in all children.
1. The child is unable to drink or breastfeed. A child may be unable to drink either because s/he is too weak or because s/he cannot swallow. Do not rely completely on the
mother's statement for this, but observe while she tries to breastfeed or to give the child
something to drink.
2. The child vomits everything. This means that the child vomits everything (like food,drink, medicine) whatever offered. It is important to note because such a child will not be
able to take medication or fluids for re-hydration.
3. The child has had convulsions during the present illness . Convulsions may beassociated with meningitis, cerebral malaria or other life-threatening conditions or with
minor illness like fever. All children who have had convulsions should be considered
seriously ill because the more serious causes of convulsions cannot be ruled out without
investigations done in a hospital.
4. The child is unconscious or lethargic. An unconscious child does not respond to any
stimuli (sound or movement of limbs). A lethargic child responds a little to stimuli, but
DANGER
INABILITY TO DRINK
SIGNS
CONVULSIONS
OR BREASTFEED
VOMITS EVERYTHING
EVERYTHING
LETHARGY UNCONSCIOUSNESS LETHARGY
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does not take any notice of his or her surroundings. These signs may be associated with
many serious conditions.
If a child has one or more of these signs, s/he must be considered seriously ill and will
almost always need referral. In order to start treatment for severe illnesses without delay, thechild should be quickly assessed for the most important causes of serious illness — acuterespiratory infection (ARI), diarrhoea, and fever (especially associated with malaria and
measles). A rapid assessment of nutritional status is also essential, as malnutrition could also
contribute to death.
Example: Top part of a recording form with General Danger Signs
CASE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5 F. The health
worker asked, “What are the child’s problems?” The mother said “ Phuntsho has been
coughing for 6 days, and she is having trouble breathing.” This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that Phuntsho is able to drink. She has not been vomiting. She did not have convulsions during
this illness. The health worker asked, “does Phuntsho seem unusually sleepy?” The mother
said, “Yes”. The health worker clapped his hands. He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not watch his face. She stared blankly and appeared not to notice what was going
on around her.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name of the health facility: Thinleygang BHU Date: 1/1/2011
Child’s Name: Phuntsho Age/sex: 18 months/F Weight: 11.5 kg Temperature 99.50 C/F
ASK: What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
LETHARGIC or UNCONSCIOUS
VOMITS EVERYTHING
CONVULSIONS
General danger sign present?
Yes √ No __
Remember to use danger sign when
selecting classifications
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2.2.3 CHECKING MAIN SYMPTOMS
After checking for general danger signs, the health care provider must check four main
symptoms: (1) cough or difficult breathing; (2) diarrhoea; (3) fever; and (4) ear problems.
The first three symptoms are included because they often result in death. Ear problems are
included because they are considered one of the main causes of hearing loss and sometimes it
may give rise to CNS infections like Meningitis and brain abscess.
COUGH OR DIFFICULT BREATHING
A child presenting with cough or difficult breathing may suffer from pneumonia or other
serious respiratory infection.
CLINICAL ASSESSMENT
Three key clinical signs are used to assess a sick child with cough or difficult breathing:
Respir atory rate , which distinguishes children who have pneumonia from those whodo not;
Chest indrawing , which indicates severe pneumonia; and
Stridor , which indicates upper air-way obstruction and require hospital admission.
High respiratory rate or fast breathing is the single most sensitive and specific among
clinical signs of Pneumonia in under-five children. Even crepitation on auscultation by an
expert is less sensitive as a single sign than fast breathing.
Cut-off rates for fast breathing depend on the child’s age. Normal breathing rates are higherin children age 2 months up to 12 months than in children age 12 months up to 5 years.
Chest in-drawing, defined as the inward movement of the lower chest wall with inspiration,
is a useful indicator of severe pneumonia. It is more specific than “inter -costal in drawing,”which involves the soft tissue between the ribs without involvement of the bony structure of
the chest wall.5 Chest in-drawing should only be considered present if it is consistently
present in a calm child . Agitation, a blocked nose or breastfeeding can cause temporary chest
in-drawing.
5 Mulholland EK et al. Standardized diagnosis of pneumonia in developing countries. Pediatric infectious disease journal, 1992,
11:77-81.
Child’s Age Cut-off Rate for Fast Breathing
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
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Stridor is a harsh sound heard during inspiration {breathes in} due to obstruction of upper
airway.
Calm children, who have stridor should be referred. Wheeze is a musical sound heard during
expirations. Wheezing sound is most often associated with asthma and bronchiolitis. At thislevel, no distinction can be made between children with bronchiolitis and those with
pneumonia.
Note: I f wheezing and either f ast breathing or chest indrawing: Give a trial of rapid
acting inhaled bronchodilator for up to thr ee times 20 minu tes apart. Count the breaths
and look for chest indrawing again, and then classi fy.
CLASSIFICATION OF COUGH OR DIFFICULT BREATHING
Based on a combination of the above clinical signs, children presenting with cough or
difficult breathing can be classified into three categories:
1. Children who have either a general danger sign or chest indrawing or stridor.
Children in this group are most likely to have infection with invasive bacterial organisms and
diseases which may be life threatening. This warrants the use of injectable antibiotics and
early referral.
Any general danger
sign or
Chest indrawing or
Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an appropriate
antibiotic.
Treat the child to prevent low blood
sugar.
Refer URGENTLY to hospital.*
Children who have fast breathing, as defined by WHO, in about 80 percent cases, can be
detected as children with pneumonia. They can be treated with oral antibiotics at home.
Treatment on this classification has been shown effective to reduce mortality.
Fast breathing.PNEUMONIA
Give an appropriate antibiotic for 5 days.
Soothe the throat and relieve the cough with asafe remedy.
If coughing more than 3 weeks or if havingrecurrent wheezing refer for assessment forTB or asthma.
Advise mother when to return immediately.
Follow-up in 2 days.
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2. Children who have cough or cold but no signs of Pneumonia or very severe disease, donot require antibiotics. Such children may require a safe remedy to relieve cough. A child
with cough and cold normally improves in one or two weeks. However, a child withchronic cough (more than 30 days) needs to be further assessed (and, if needed, referred)
to exclude tuberculosis, asthma, whooping cough or other problem.
Note: An tibioti c should not be used routinely for cough or cold, as it neither shor ten
EXAMPLE: Top part of recording form with the main symptom cough or difficult
breathing.
CASE : Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5 F. The healthworker asked, “What are the child’s problems?” The mother said “ Phuntsho has been
coughing for 6 days, and she is having trouble breathing.” This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that
Phuntsho is able to drink. She has not been vomiting. She did not have convulsions during
this illness. The health worker asked, “does Phuntsho seem unusually sleepy?” The mother
said, “Yes”. The health worker clapped his hands. He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not watch his face. She stared blankly and appeared not to notice what was going
on around her.
The health worker asked the mother to lift Phuntsho’s shirt. He then counted the number ofbreaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in drawing. He did not hear stridor or wheeze.
No signs of pneumonia
or very severe disease. NOPNEUMONIA:
COUGH OR
COLD
If coughing more than 30 days referfor assessment.
Soothe the throat and relieve the cough witha safe remedy.
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
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MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name of the health facility: Thinleygang BHU Date: 1/1/2011
Child’s Name: Phuntsho Age/sex: 18 months/F Weight: 11.5 kg Temperature 99.50 C/F
ASK: What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
LETHARGIC or UNCONSCIOUS
VOMITS EVERYTHING
CONVULSIONS
General danger sign
present?
Yes _ No _____
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes √ No_
For how long? 6 Days * Count the breaths in one minute.
* 41 breaths per minute. fast breathing
* Look for chest indrawing.
* Look and listen for stridor.
Severe pneumonia
or very severe
Disease
DIARRHOEA
A child presenting with diarrhoea should first be assessed for general danger signs and thechild's caregiver should be asked if the child has cough or difficult breathing.
Diarrhoea is the next symptom that should be routinely checked in every chi ld brought to the
clinic. A child with diarrhoea may have three potentially lethal conditions: (1) acute watery
diarrhoea (including cholera); (2) dysentery (bloody diarrhoea); and (3) persistent diarrhoea
(diarrhoea that lasts 14 days or more). All children with diarrhoea should be assessed for: (a)
signs of dehydration; (b) how long the child has had diarrhoea; and (c) blood in the stool to
determine if the child has dysentery.
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CLINICAL ASSESSMENT
A number of clinical signs are used to assess the degree of dehydration.
1. Child’s general condition. Depending on the degree of dehydration, a child withdiarrhoea may be lethargic or unconscious (this is also a general danger sign) or look
restless/irritable. Only children who cannot be consoled and calmed should be considered
restless or irritable.
2. Sunken eyes. The eyes of a dehydrated child may look sunken. In a severelymalnourished child who is visibly wasted (that is, who has marasmus), the eyes may
always look sunken, even if the child is not dehydrated. Even though the sign “sunkeneyes” is less reliable in a visibly wasted child, it can still be used to classify the child’sdehydration.
3. Child’s reaction when offered to drink . A child is considered not able to drink if s/he isnot able to take fluid in his/her mouth and swallow it. For example, a child may not be
able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the
child is weak and cannot drink without help. S/he may be able to swallow only if fluid is
put in his/her mouth.
A child has the sign of drinking eagerly, thirsty if it is clear that the child wants to drink
more. Notice if the child reaches out for the cup or spoon when you offer him/her water.
When the water is taken away, see if the child is unhappy because s/he wants to drink more.
If the child takes a drink only with encouragement and does not want to drink more, s/he
does not have the sign “drinking eagerly,thirsty”.
4. Elasticity of skin .
Check elasticity of skin by skin pinch.
When released, the skin pinch goes
back (a) very slowly (longer than 2
seconds), (b) slowly (skin stays up even
for a brief instant), or (c) immediately.
In a child with marasmus (severe
malnutrition), the skin may go back
slowly even if the child is not
dehydrated.
In an overweight child, or a child with oedema, the skin may go back immediately even if the
child is dehydrated.
After the child is assessed for dehydration, the caregiver of a child with diarrhoea should be
asked how long the child has had diarrhoea and whether there is blood in the stool. This
will allow identification of children with persistent diarrhoea and dysentery respectively.
CLASSIFICATION OF DEHYDRATION
Based on a combination of the above clinical signs, children presenting with diarrhoea
are classified into three categories:
Standard Procedures for Skin Pinch
Locate the area on the child's abdomen halfwaybetween the umbilicus and the side of the abdomen;
then pinch the skin using the thumb and the radialside of the index finger.
The hand should be placed so that when the skin ispinched, the fold of skin will be in a line up and downthe child's body and not across the child's body.
It is important to firmly pick up all of the layers ofskin and the tissue under them for one second andthen release it.
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1. Children with severe dehydration will be presenting with two or more of the followingsigns: lethargic or unconscious, sunken eyes, not able to drink or drinking poorly and
skin pinch goes back very slowly. These children may have a fluid deficit equalling or
greater than 10 percent of their body weight.
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or
drinking poorly
Skin pinch goes back veryslowly.
SEVERE
DEHYDRATION
If child has no other severe
classification:
Give fluid for severe dehydration
(Plan C). OR
If child also has another severe
classification:
Refer URGENTLY to hospital
with mother giving frequent sips
of ORS on the way.
Advise the mother to continue
breastfeeding
If child is 2 years or older and there
is cholera in patient’s area, give
antibiotic for cholera.
2. Children with some dehydration will be presenting with two of the following signs:restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly. These
children may have a fluid deficit equalling 5 to 10 percent of their body weight.
3. Children not having enough signs to be classified as some or severe dehydration , will be classified as No Dehydration .These children may have fluid deficit of
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Persistent diarrhoea almost never occurs in
infants who are exclusively breast-fed.
Note:
1. Antibiotics should not be used routinely for treatment of diarrhoea. Most diarrhoealepisodes are self-limiting and caused by agents for which antibiotics are not required,
except Cholera.
2. Anti-diarrhoeal agents - including anti-motility agents (e.g., loperamide, codeine,diphenoxylate with atropine, and tincture of opium), adsorbents (e.g., kaolin), Bismuth
subsalicylate and charcoal - do not provide practical benefits for children with diarrhoea,
and some may have dangerous side effects. These drugs should never be given to
children with diarrhoea.
Classification of Persistent Diarrhoea
Persistent diarrhoea is an episode of
diarrhoea, with or without blood, which
begins acutely and lasts at least 14 days or more.
Persistent diarrhoea is usually associated with weight loss and often with serious non-
intestinal infections. Many children with persistent diarrhoea are malnourished and they are
at increased risk of death.
Note: Persistent diarrhoea almost never occurs in infants who are exclusively breast-fed.
Many children with diarrhoea for 14 days or more should be classified based on the presence
or absence of any dehydration:
1. Children with persistent diarrhoea who have any degree of dehydration should be
classified as Severe Persistent diarrhoea and should be managed in the hospital as theyrequire special treatment
Not enough signs toclassify as some or
severe dehydration NO
DEHYDRATION
Give fluid, zinc and food to treat diarrhoeaat home (Plan A).
Advise mother when to returnimmediately.
Follow-up in 5 days if not improving.
Dehydration present SEVERE PERSISTENTDIARRHOEA
Treat dehydration beforereferral unless the child has
another severeclassification.
Refer to hospital.
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2. Children with persistent diarrhoea who have no signs of dehydration should be classifiedas Persistent diarrhoea and can be managed in the outpatient clinic initially, however if
required, they also needs to be managed at hospital.
Proper feeding is the most important aspect of treatment for most children with persistent
diarrhoea. The goals of nutritional therapy are to:
a. Provide a sufficient intake of energy, protein, vitamins and minerals to facilitate therepair process in the damaged gut mucosa and to improve nutritional status;
b. Avoid giving foods or drinks that may aggravate diarrhoea;
c. Reduce the amount of animal milk [or lactose] in the diet, for those who are not breast-fed.
d. Ensure adequate food intake during convalescence to correct any malnutrition.
Routine treatment of persistent diarrhoea with antimicrobials is not effective. Some children,however, have non-intestinal or intestinal infections that require specific antimicrobial
therapy. The persistent diarrhoea of such children will not improve until these infections are
diagnosed and treated correctly.
CLASSIFICATION OF DYSENTERY
The mother or caregiver of a child with diarrhoea should be asked if there is blood in the
stool.
A child is classified as having DYSENTERY if the mother or caregiver reports blood in the
child’s stool.
It is not necessary to examine the stool or perform laboratory tests to diagnose dysentery.
Stool culture, to detect pathogenic bacteria, is rarely possible. Moreover, at least two days
are required to obtain the results of a culture.
About 10 percent of all diarrhoeal episodes in children under five years are due to dysentery, butthese cause up to 15 percent of all diarrhoeal deaths.
No dehydration PERSISTENT
DIARRHOEA Advise the mother on feeding a child
who has:PERSISTENT DIARRHOEA.
Give multivitamins/minerals and zincfor 10 days
Follow-up in 5 days.
Treat for 5 days with an oralantibiotic recommended for
Shigella in your area.
Follow-up in 2 days.
Blood in the stool DYSENTERY
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Bloody diarrhoea in young children is usually a sign of invasive enteric infection that carries
a substantial risk of serious morbidity and death. About 10 percent of all diarrhoea episodes
in under-5 children are due to dysentery, but these cause up to 15 percent of all diarrhoeal
deaths.6
Dysentery is especially severe in infants and in children who (a) are malnourished (b)
Develop clinically evident dehydration during their illness and (c) are not breast-fed. It also
has a more harmful effect on nutritional status than acute watery diarrhoea. Dysentery occurs
with increased frequency and severity in children who have measles or have had measles in
the preceding month, and diarrhoeal episodes that begin with dysentery are more likely to
become persistent than those that start without blood in the stool.
All children with dysentery (bloody diarrhoea) should be treated promptly with an antibiotic
effective against Shigella because: (a) bloody diarrhoea in children under 5 is caused more
frequently by Shigella than by any other pathogen; (b) shigellosis is more likely to result in
complications and death if effective antimicrobial therapy is not begun promptly; and (c)early treatment of shigellosis with an effective antibiotic substantially reduces the risk of
severe morbidity or death.
Example: Top part of the recording form with the main symptom diarrhoea.
CASE : Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5F. The health
worker asked, “What are the child’s problems?” The mother said “ Phuntsho has been
coughing for 6 days, and she is having trouble breathing.” This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that
Phuntsho is able to drink. She has not been vomiting. She did not have convulsions duringthis illness. The health worker asked, “does Phuntsho seem unusually sleepy?” The mother
said, “Yes”. The health worker clapped his hands. He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not watch his face. She stared blankly and appeared not to notice what was going
on around her.
The health worker asked the mother to lift Phuntsho’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in-drawing. He did not hear stridor or wheeze.
The health worker asked,” Does the child have diarrhoea?” The mother said, “Yes for 3days.” There was no blood in the stool. Phuntsho’s eyes looked sunken. The health worker
asked, “Do you notice anyt hing different about Phuntsho’s eyes?” The mother said, “Yes”.
He gave the mother some clean water in a cup and asked her to offer it to Phuntsho. When
offered, Phuntsho would not drink. When pinched, the skin of Phuntsho’s abdomen went
back slowly.
6 Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1 ISBN 92 4 1592330
Geneva, World Health Organization, 2005
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MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name of the health facility: Thinleygang BHU Date: 1/1/2011
Child’s Name: Phuntsho Age/sex: 18 months/F Weight: 11.5 kg Temperature 99.50 C/F
ASK: What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
LETHARGIC or UNCONSCIOUS
VOMITS EVERYTHING
General danger sign
present?
Yes No _
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes √ No_
For how long? 6 Days * Count the breaths in one minute.
*_41_ breaths per minute. Fast breathing
* Look for chest indrawing.
* Look and listen for stridor .
Severe pneumonia or
very severe Disease
DOES THE CHILD HAVE DIARRHOEA? Yes No _____
For how long? 3 Days Look at the general condition
Is there blood in the stool? Is the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Pinch the skin of the abdomen. Does it go back: Very slowly (
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FEVER
All sick children should be checked for fever. Fever is a very common condition and is often
the main reason for bringing children to the health centre. It may be caused by minor
infections, but may also be the most obvious sign of a life-threatening illness, particularly
malaria, especially lethal malaria ( P. falciparum), or other severe infections, includingmeningitis, typhoid fever, or measles. When diagnostic facility is limited, it is important first
to identify those children who need urgent referral with appropriate pre-referral treatment
(antimalarial or antibacterial).
Clinical Assessment
Body temperature should be checked in all sick children brought to an outpatient clinic.
Children are considered to have fever if their body temperature is above 99.5°F (axillary). In
the absence of a thermometer, children are considered to have fever if they feel hot. Fever
may also be considered if the mother gives a history of fever.
A child presenting with fever should be assessed for:
I. Stif f neck : A stiff neck is a sign of meningitis. If the child is conscious and alert,check stiffness by asking the child to bend his/her neck to look down or by very
gently bending the child’s head forward. It should move normally.
II. Runny nose : means watery secretion from nose which occurs usually due to commoncold.
Duration of fever . Most fevers due to viral illnesses go away within few days. A fever that
has been present every day for more than seven days indicates that the child has a more
severe disease such as typhoid fever.
Malaria: Malaria is one of the major public health problems in Bhutan. Out of 20 districts,
10 of them have seasonal transmission (population 234,630) and malaria outbreaks are an
annual feature causing high morbidity and mortality in the affected population. Five districts
are endemic (population 234,633) adjoining the international borders with the state of West
Bengal and Assam on the Indian side.
Note: Risk of malaria and other endemic infections in situations where routine microscopy is
not available or the results may be delayed, the risk of malaria transmission must be defined.
The World Health Organization (WHO) has proposed definitions of malaria risk settings for
countries and areas with risk of malaria caused by P. falciparum. A high malaria risk setting
is defined as a situation in which more than 5 percent of cases of febrile disease in children
age 2 to 59 months are malarial disease. A low malarial risk setting is a situation where
fewer than 5 percent of cases of febrile disease in children age 2 to 59 months are malarial
disease, but in which the risk is not negligible. If malaria does not normally occur in the area,
the setting is considered to have no malaria risk . In low/no malaria risk area, travelling to a
high risk zone within 1 month – should be considered as high risk for malaria.
Other endemic infections with a public health importance in the area, (e.g. dengue
haemorrhagic fever or relapsing fever), should also be considered. In such situations, the
national health authorities normally adapt the IMNCI clinical guidelines locally.
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Measles. Considering the high risk of complications and death due to measles, children withfever should be assessed for signs of current or previous measles (within the last three
months). Measles infections cause serious immunodeficiency and deaths usually occur from pneumonia (67 percent), diarrhoea (25 percent), larynigotracheitis and encephalitis. Other
complications (usually non-fatal) include conjunctivitis, otitis media, and mouth ulcers.
Significant disability can result from measles e.g. xeropthalmia including blindness, severe
malnutrition, chronic lung disease (bronchiectasis and recurrent infection), and flare up of
TB and neurological dysfunction.7
Detection of measles is based on fever with a generalised rash, plus at least one of the
following signs: red eyes, runny nose, or cough.
The mother should be asked about the occurrence of measles within the last three months.
Despite great success in improving immunization coverage in many countries, substantial
numbers of measles cases and deaths continue to occur. Although the vaccine should be
given at 9 months of age, immunization often does not take place or delayed because of false
contraindications, lack of vaccine, failure of a cold chain or lack of awareness.
CLASSIFICATION OF FEVER : BEFORE GOING FOR THE CLASSIFICATION, THE FIRSTCONSIDERATION NEEDS TO BE DONE, WHETHER THE CHILD IS COMING FROM THE HIGH, LOW OR
NO MALARIA RISK AREA.
If the malaria risk in the local area is low or no ask:
Have you traveled with the child outside this area?
If yes, have you been to a malarious area in the last 30 days?
Reclassify the malaria risk as high if there has been travel to a malarious area in thelast 30 days.
The child may have acquired malaria during travel. Many mothers will know whether thearea where they traveled has malaria transmission. If a mother does not know or is not sure,
ask about the area and use your own knowledge of whether the area has malaria. If you are
still not sure, assume the malaria risk is high.
1. Child from high malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY SEVERE
FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral treatment
with antibiotics (the same choice as for severe pneumonia or very severe disease). But as the
risk of Falciparum malaria is high, such children should also receive a pre-referral dose of an
anti-malarial.
7 World Health Organization. Technical basis for the case management of measles. Document WHO/EPI/95. Geneva, WHO, 1995.
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Children with fever but no general danger sign or stiff neck should be classified as
having MALARIA.
Treat the child classified as having MALARIA with an antimalarial after the MP slide is
positive for PFR or PV.
2. Child from Low Malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY
SEVERE FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral
treatment with antibiotics (the same choice as for severe pneumonia or very severe disease).
But as the risk of Falciparum malaria is high, such children should also receive a pre-referral
dose of an anti-malarial.
Give quinine for severe malaria (first dose)
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
Give one dose of paracetamol in clinic for high
fever (38.5°C or above).
Refer URGENTLY to hospital.
Any danger sign or
stiff neck
VERY SEVERE
FEBRILE
DISEASE
Give quinine for severe malaria(first dose)
Give first dose of an appropriateantibiotic.
Treat the child to prevent low blood sugar.
Any danger sign or
stiff neck
VERY SEVERE FEBRILE
DISEASE
Fever (by historyor feels hot ortemperature37.5°C*corabove)
MALARIA
Make MP slide
If PFR +ve admit and treat accordingly
o If PV+ treat accordingly
Give one dose of paracetamol in cl in icfor hi gh fever (38.5°C or above).
Advise mother when to returnimmediately.
Follow-up in 2 days if fever persists.
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Children with fever (or history of fever) having neither general danger sign nor stiff neck or
no runny nose (a sign of ARI), no measles, and no other obvious cause of fever (pneumonia,
sore throat, etc.) are classified as malaria. They should be treated at outpatient clinic with an
oral anti-malarial and paracetamol.
Children with runny nose, measles or clinical signs of other possible infection are classified
as having Fever — Malaria Unlikely. These children need follow-up. If their fever lasts for
more than seven days, they should be referred for further assessment to determine causes of
prolonged fever.
Evidence of another infection lowers the probability that the child's illness is due to malaria.
Therefore, children in low malaria risk area, which have evidence of another infection,should not be given an anti-malarial.
Note: Children with high fever, defined as an axillary temperature greater than 100°F should
be given a single dose of paracetamol to combat hyperthermia.
3. Child from No Malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY
SEVERE FEBRILE DISEASE and should be referred urgently to a hospital after pre-
referral treatment with antibiotics (the same choice as for severe pneumonia or very severe
disease).
Runny nose presentor
Measles present
Other causes offever present
FEVER-
MALARIA
UNLIKELY
Give one dose of paracetamol in clinic forhigh fever (38.5°C or above).
Advise mother when to return immediately.
Follow-up in 2 days if fever persists.
If fever is present every day for more than 7days, refer for assessment.
NO runny noseand
NO measlesand
NO othercauses of fever
MALARIA
Make MP slide
o If PFR +ve admit and treat accordingly
o If PV+ treat accordingly.
Give one dose of paracetamol in clinic for high fever (38.5°C or above).
Advise mother when to return immediately.
Follow-up in 2 days if fever persists.
If fever is resent ever da for more than 7 da s,
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All other cases of fever are classified as Fever No Malaria and treated for the respective
cause.
CLASSIFICATION OF MEASLES
All children with fever should be checked for signs of measles and measles complications.
1. Severe complicated measles: when a child with measles displays any general danger signor deep and extensive mouth ulcers or clouding of the cornea, they should be classified as
severe measles. These children should be urgently referred to a hospital with a pre-
referral treatment.
Give first dose of an appropriateantibiotic.
Treat the child to prevent low blood sugar.
Give one dose of paracetamol inclinic for high fever (38.5°C orabove).
Refer URGENTLY to hospital .
Any danger sign or
stiff neck
VERY SEVERE FEBRILE
DISEASE
Give one dose of paracetamol in clinic for highfever (38.5°C or above).
Treat Other Causes of fever
Follow-up in 2 days if fever persists.
If fever is present every day for more than 7da s, refer for assessment.
Any fever
FEVER-NO
MALARIA
Give Vitamin A.
Give first dose of an appropriateantibiotic.
If clouding of the cornea or pusdraining from the eye, apply
chloromycetine eye ointment.
Refer URGENTLY to hospital.
Any danger sign or
Clouding of cornea or
Deep or extensivemouth ulcers
Severe complicated
measles
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2. Measles with eye or mouth complications: Children with less severe measlescomplications, such as pus draining from the eye (a sign of conjunctivitis) or non-deep
and non-extensive mouth ulcers, are classified as measles with eye or mouth
complications. These children can be safely treated at the outpatient facility. The
treatment includes oral vitamin A, tetracycline ointment for children with pus drainingfrom the eye, and gentian violet for children with mouth ulcers.
3. Measles: If no signs of measles complications have been found after a completeassessment, a child is classified as having Measles. These children can be effectively and
safely managed at home with vitamin A treatment.
EXAMPLE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.6 0 F. The
health worker asked, “What are the child’s problems?” The mother said “ Phuntsho has been
coughing for 6 days, and she is having trouble breathing. “ This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that
Phuntsho is able to drink. She has not been vomiting. She has not had convulsions during
this illness. The health worker asked.” Does Phuntsho seem unusually sleepy?” The mother said, “Yes.” The health worker clapped his hands, He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not look into his face. She stared blankly and appeared not to notice what was
going on around her.
The health worker asked the mother to lift Phuntsho’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in drawing. He did not hear strido or wheeze.
The health worker asked, “Does the child have diarrhoea?” The mother said, “Y es” , for 3
days.” There was no blood in the stool. Phuntsho’s eyes looked sunken. The health worker
asked “Do you notice anything different about Phuntsho’s eyes?” The mother said, “Yes”.
Pus drainingfrom the eye or
Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
Give Vitamin A.
I f pus drain ing fr om the eye, treateye infection with chloromycetine
eye oin tment.
If mouth ulcers, treat with gentianviolet.
Follow-up in 2 days.
Measles now or within
the last 3 monthsMeasles Give Vitamin A
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“He gave the mother some clean water in a cup and asked her to offer it to Phuntsho. When
offered the cup, Phuntsho would not drink. When pinched, the skin of Phuntsho’s abdomen
went back slowly.
Because Phuntsho’s temperature is 98.6
0
F and she feels hot, the health worker assessed Phuntsho further for signs related to fever. The mother said Phuntsho’s fever began 2 days
ago. The risk of malaria is low. Phuntsho has not had measles within the last 3 months, and
there are no signs suggesting measles. She does not have stiff neck. The health worker
noticed that Phuntsho has a runny nose.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name of the health facility: Thinleygang BHU Date: 1/1/2011
Child’s Name: Phuntsho Age/sex: 18 months/F Weight: 11.5 kg Temperature 99.50 C/F
ASK : What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING
CONVULSIONS
General danger sign
present?
Yes No _
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes No_
For how long? __6_ Days * Count the breaths in one minute.
*_41_ breaths per minute. Fast breathing
* Look for chest indrawing.
* Look and listen for stridor.
Severe pneumonia
or very severe
Disease
DOES THE CHILD HAVE DIARRHOEA? Yes
No _____For how long? 3 Days Look at the general condition
Is there blood in the stool? Is the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Severe
Dehydration
LETHARGIC or UNCONSCIOUS
Not able to drink or drinkin
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Drinking eagerly, thirsty
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds or
DOES THE CHILD HAVE FEVER? Yes _ No ____ (by history/feels hot or temp.
more than 99.5 F)
Decide Malaria Risk: High Low No
If Low or No than ask: Have you travelled outside this area?
If yes, have you been in a malarious area during last 30 days?
* For how long? 2 Days * Look or feel for stiff neck
* If more than 7 days, has fever * Look for Runny nose
been present every day? Look for signs of MEASLES:
* Has the child had measles * Generalized rash and
within the last 3 months? * One of these: cough, runny nose, or red eyes
If the child has measles now * Look for mouth ulcers
Or within the last 3 months: * If yes, are they deep and extensive?
* Look for pus draining from the eye.
* Look for clouding of the cornea.
Very severe Febrile
Disease
EAR PROBLEMS
Ear problems are the next condition that should be checked in all children brought to the
outpatient health facility. A child presenting with an ear problem should first be assessed for
general danger signs, cough or difficult breathing, diarrhoea and fever. A child with an ear
problem may have an ear infection. Although ear infections rarely cause death, they are the
main cause of deafness in low-income areas, which in turn leads to learning problems. Ear
infection also may cause meningitis as a complication.
CLINICAL ASSESSMENT
If there is an ear problem, look for the following simple clinical signs:
Tender swell ing behind the ear . The most serious complication of an ear infection is an
infection in the mastoid bone. It usually manifests with tender swelling behind the child’sears.
Ear pain . In the early stages of acute ear infection, a child may have ear pain, which usually
causes the child to become irritable and rub the ear frequently.
Ear discharge of pus . This is another important sign of an ear infection. When a mother
reports an ear discharge, the health care provider should check for pus draining from the ears
Slowl ?
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and find out how long the discharge has been present.
Classification of Ear Problems
Based on the simple clinical signs above, the child’s condition can be classified in thefollowing ways:
Children presenting with tenderness and swelling (behind the ear) of the mastoid bone are classified as having MASTOIDITIS and should immediately be referred to the
hospital for treatment, after giving a pre-referral treatment with a dose of antibiotic
and a single dose of Paracetamol for pain.
Children with ear pain or ear discharge (or pus) for fewer than 14 days are classified as
having ACUTE EAR INFECTION and should be treated for five days with the same first-line
antibiotic as for pneumonia.
Children with ear discharge (or pus) for 14 days or more, are classified as CHRONICEAR INFECTION. Generally, antibiotics are not recommended because they are
expensive and their efficacy is not proven, however dry the ear by wicking andfollow-up in 5 days is recommended.
Tender swelling behind the earMASTOIDITIS
Give first dose of an appropriate
antibiotic.
Give first dose of paracetamol for pain.
Refer URGENTLY to hospital.
Ear pain or
Pus is seen draining fromthe ear and discharge isreported for less than 14
days
Acute ear infection
Give an antibiotic for 5 days.
Give paracetamol for pain.
Dry the ear by wicking.
Follow-up in 5 days.
Dry the ear by wicking.
Treat with topicalciprofloxacin ear drops for14 days
Follow up in 5 days.
Pus is seen draining from the earand discharge is reported for 14
days or more.CHRONIC EAR
INFECTION
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Children having neither pain nor discharge (pus) draining from the ear, are classified as
NO EAR INFECTION and do not require any specific treatment.
Example: Ear problem section of the case recording form:
Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.6
0
F. The healthworker asked, “What are the child’s problems?” The mother said “Phuntsho has been
coughing for 6 days, and she is having trouble breathing. “ This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that Phuntsho is able to drink. She has not been vomiting. She has not had convulsions during
this illness. The health worker asked.” Does Phuntsho seem unusually sleepy?” The mother
said, “Yes.” The health worker clapped his hands, He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not look into his face. She stared blankly and appeared not to notice what was
going on around her.
The health worker asked the mother to lift Phuntsho’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in drawing. He did not hear stridor or wheeze.
The health worker asked, “Does the child have diarrhoea?” The mother said, “Y es” , for 3
days.” There was no blood in the stool. Phuntsho’s eyes looked sunken. The health worker
asked “Do you notice anything different about Phuntsho’s eyes?” The mother said, “Yes”.
“He gave the mother some clean water in a cup and asked her to offer it to Phuntsho. When
offered the cup, Phuntsho would not drink. When pinched, the skin of Phuntsho’s abdomen
went back slowly.
Because Phuntsho’s temperature is 98.6 0 F and she feels hot, the health worker assessed
Phuntsho further for signs related to fever. The mother said Phuntsho’s fever began 2 days
ago. The risk of malaria is low. Phuntsho has not had measles within the last 3 months, and
there are no signs suggesting measles. She does not have stiff neck. The health worker
noticed that Phuntsho has a runny nose.
Next the health worker asked about Phuntsho’s ear problem. The mother said she is sure that
Phuntsho has ear pain. She cries most of the night because her ear hurt. There has not been
ear discharge. The health worker did not see any pus draining from her ear, health worker
felt behind the child’s ears and found no tender swelling.
No ear pain andno pus seen draining from the
ear . NO EAR INFECTION No additional treatment.
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MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name of the health facility: Thinleygang BHU Date: 1/1/2011
Child’s Name: Phuntsho Age/sex: 18 months/F Weight: 11.5 kg Temperature 99.50 C/F
ASK: What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __
Assess (circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING
CONVULSIONS
General danger sign
present?
Yes No _
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes No_
For how long? __6_ Days * Count the breaths in one minute.
*_41_ breaths per minute. Fast breathing
* Look for chest indrawing.
* Look and listen for stridor.
Severe pneumonia
or very severe
Disease
DOES THE CHILD HAVE DIARRHOEA? Yes No _____
For how long? 3 Days Look at the general condition
Is there blood in the stool? Is the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Drinking eagerly, thirsty
Pinch the skin of the abdomen. Does
it go back: Very slowly (longer than
2 seconds) or slowly?
Severe
Dehydration
LETHARGIC or UNCONSCIOUS
Not able to drink or drinking
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DOES THE CHILD HAVE FEVER? Yes _ No ____ (by history/feels hot or temp.
more than 99.5 F)
Decide Malaria Risk: High Low No
If Low or No than ask: Have you travelled outside this area?
If yes, have you been in a malarious area during last 30 days?
* For how long? 2 Days * Look or feel for stiff neck
* If more than 7 days, has fever * Look for Runny nose
been present every day? Look for signs of MEASLES:
* Has the child had measles * Generalized rash and
within the last 3 months? *One of these: cough, runny nose, or red eyes
If the child has measles now * Look for mouth ulcers
Or within the last 3 months: * If yes, are they deep and extensive?
* Look for pus draining from the eye.
* Look for clouding of the cornea.
Very severe Febrile
Disease
DOES THE CHILD HAVE AN EAR PROBLEM? Yes_ __ No ___
* Is there ear pain? * Look for pus draining from the ear.
* Is there ear discharge? * Feel for tender swelling behind the ear.
If yes, for how long ? 1 Day
Acute Ear
Infection
2.2.4 CHECKING NUTRITIONAL STATUS - MALNUTRITION AND ANAEMIA
After assessing for general danger signs and the four main symptoms, al l children should be
assessed for malnutrition and anaemia.
There are two main reasons for routine assessment of nutritional status in sickchildren:
To identify children with severe malnutrition and/or severe anaemia who are at
increased risk of death and need urgent referral to provide active treatment; and
To identify children with sub-optimal growth.
CLINICAL ASSESSMENT
Because reliable length (infantometer)/height boards (stadiometer) are difficult to find in
most outpatient health facilities, nutritional status should be assessed by looking and feelingfor the following clinical signs:
Visible severe wasting. This means severe wasting of the shoulders, arms, buttocks, and legs
with easily seen ribs. It is usually assessed by looking at the buttock.
Palmar pallor. Although this clinical sign is less specific than many other clinical signs
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included in the IMNCI guidelines, it can allow health care providers to identify sick children
with severe anaemia. Where feasible, the specificity of anaemia diagnosis may be greatly
increased by using a simple laboratory test for Hb estimation.
To see if the child has palmar pallor, look at the skin of the child's palm. Hold the child's palm open by grasping it gently from the side. Do not stretch the fingers backwards. This
may cause pallor by blocking the blood supply. Compare the colour of the child's palm with
your own palm and with the palms of other children.
If the skin of the child's palm is pale, the child has some palmar pallor.
If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar
pallor.
Oedema of both feet. The presence of oedema in both feet may signal kwashiorkor. Children
with oedema of both feet may have other diseases like nephrotic syndrome. There is no need,
however, to differentiate these conditions in the outpatient settings or at the first level healthfacility because referral is necessary in both cases.
Weight for age. When length/height boards are not available in outpatient settings, a weight
for age (a standard WHO or national growth chart) helps to identify children with very low
(Z score less than – 3) weight for age that is at increased risk of infection and poor growthand development.
To determine weight for age:
1. Calculate the child’s age in months.
2. Weigh the child if he has not already been weighed today. Use a scale which you knowgives accurate weights. The child should wear light clothing when he is weighed.
Ask the mother to help remove any sweater or shoes.
3. Use the weight for age chart to determine weight for age.
Look at the left-hand axis to locate the line that shows the child's weight.
Look at the bottom axis of the chart to locate the line that shows the age in months.
Find the point on the chart where the line for the weight meets the line for the age.
4. Decide if the point is below the Very Low Weight for Age line, between the Very Lowand Low Weight for Age lines or above the Low Weight for Age line.
If the point is below the Very Low Weight for Age line, the child is very low weightfor age.
If the point is above or on the Very Low Weight for Age line and below the LowWeight for Age line, the child is low weight for age.
If the point is above or on the Low Weight for Age line, the child is not low weightfor age.
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WEIGHT FOR AGE CHART
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Classification of Nutritional Status and Anaemia
Using a combination of the simple clinical signs above, children can be classified in one of
the following categories:
Children with visible severe wasting, or Severe Palmar Pallor or oedema of both feetshould be classified as Severe malnutrition or Severe Anaemia and are at high risk of
death from various severe diseases. They need urgent referral to a hospital where
their treatment (special feeding, antibiotics or blood transfusions, etc.) can be
carefully monitored.
Children with very low weight for age should be classified as very low weight for age. They
also have a higher risk of severe disease and should be assessed for feeding problems. This
assessment should identify common, important feeding problems that can be corrected if
the caregiver is provided with appropriate counselling. When children are classified as
having ANAEMIA they should be treated with oral iron. During treatment, the child should
be seen every two weeks (follow-up), at which time an additional 14 days of iron treatment is
given. If there is no improvement in pallor after two weeks, the child should be referred tothe hospital for further assessment. Iron is not given to children with severe malnutrition who
will be referred.
Visible severe wastingor
Severe palmar pallor or
Oedema of both feet
SEVERE
MALNUTRITION OR
SEVERE ANAEMIA
Give Vitamin A if Visible SeverWasting and /or Oedema of both feet
present.
Refer URGENTLY to hospital .
Treat the child to prevent l ow blood
Assess the child’s feeding and counsel the mother onfeeding according to the FOOD box on the COUNSELTHE MOTHER chart.
If pallor:
Give iron.
If malaria high risk make smear and giveantimalarial if positive
Advice mother when to return immediately.
If pallor, follow up in 14 days.
If very low weight for age, follow up in 30 days.
Give ALBENDAZOLE if child is 15 months or olderand was not given a dose during 6 months.
Advice mother when to return immediately.
Some Palmar Pallor Or
Very low weight for
age
Anaemia Or
Very low
weight
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Children who are not very low weight for age and do not show other signs of malnutrition
including pallor are classified as having No anaemia and not very low weight . Because
children less than 2 years of age have a higher risk of feeding problems and malnutrition than
older children do, their feeding should be assessed. If problems are identified, the mother
needs to be counselled about feeding her child according to the recommendations of IMCIclinical guidelines.
Example: Malnutrition and Anaemia section of the case recording from.
Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.6 0 F. The healthworker asked, “What are the child’s problems?” The mother said “Phuntsho has been
coughing for 6 days, and she is having trouble breathing. “ This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that
Phuntsho is able to drink. She has not been vomiting. She has not had convulsions during
this illness. The health worker asked.” Does Phuntsho seem unusually sleepy?” The mother
said, “Yes.” The health worker clapped his hands, He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not look into his face. She stared blankly and appeared not to notice what was
going on around her.
The health worker asked the mother to lift Phuntsho’s shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in drawing. He did not hear stridor or wheeze.
The health worker asked, “Does the child have diarrhoea?” The mother said, “Y es” , for 3
days.” There was no blood in the stool. Phuntsho’s eyes looked sunken. The health worker
asked “Do you notice anything different about Phuntsho’s eyes?” The mother said, “Yes”.
“He gave the mother some clean water in a cup and asked her to offer it to Phuntsho. Whenoffered the cup, Phuntsho would not drink. When pinched, the skin of Phuntsho’s abdomen
went back slowly.
Because Phuntsho’s temperature is 98.6 0 F and she feels hot, the health worker assessed
Phuntsho further for signs related to fever. The mother said Phuntsho’s fever began 2 days
Not very low weight for ageand no sign of severe
malnutrition. NO ANAEMIA ANDNOT VERY
LOW WEIGHT
If child is less than 2 years old,assess the child’s feeding andcounsel the mother on feedingaccording to the feedingrecommendations.
If feeding problem, follow-up in5 days.
Advice mother when to returnimmediately.
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ago. The risk of malaria is low. Phuntsho has not had measles within the last 3 months, and
there are no signs suggesting measles. She does not have stiff neck. The health worker
noticed that Phuntsho has a runny nose.
Next the health worker asked about Phuntsho’s ear problem. The mother said she is sure that Phuntsho has ear pain. She cries most of the night because her ear hurt. There has not been
ear discharge. The health worker did not see any pus draining from her ear, health worker
felt behind the child’s ears and found no