IMNCI Students Handbook.pdf

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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


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




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.


Follow-up in 5 days if not improving.


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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


Treat for 5 days with an oralantibiotic recommended for

Shigella in your area.


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


illness.


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




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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VOMITS EVERYTHING

General danger sign

present?

Yes No _


Yes √ No_

For how long? 6 Days * Count the breaths in one minute.

*_41_ breaths per minute. Fast breathing


* 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.


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).



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).



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 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


If fever is present every day for more than 7da s, refer for assessment.

Any fever

FEVER-NO

MALARIA

Give Vitamin A.


If clouding of the cornea or pusdraining from the eye, apply

chloromycetine eye ointment.


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.


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.


but she did not look into his face. She stared blankly and appeared not to notice what was

going on around her.



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.


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.




ASK : What are the child’s problems? Cough, trouble breathing Initial visit? Follow-up visit? __




VOMITS EVERYTHING

CONVULSIONS

General danger sign

present?

Yes No _


Yes No_

For how long? __6_ Days * Count the breaths in one minute.




Severe pneumonia

or very severe

Disease

DOES THE CHILD HAVE DIARRHOEA? Yes

No _____For how long? 3 Days Look at the general condition






Severe

Dehydration


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.


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.


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


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.










“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




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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Assess (circle all signs present) CLASSIFY



VOMITS EVERYTHING

CONVULSIONS

General danger sign

present?

Yes No _


Yes No_

For how long? __6_ Days * Count the breaths in one minute.




Severe pneumonia

or very severe

Disease

DOES THE CHILD HAVE DIARRHOEA? Yes No _____

For how long? 3 Days Look at the general condition






Drinking eagerly, thirsty

Pinch the skin of the abdomen. Does

it go back: Very slowly (longer than

2 seconds) or slowly?

Severe

Dehydration


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


illness.


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.










“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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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

Documents

IMNCI Students Handbook.pdf