Who/Fch/Cah/00.40 Distr.: General Original: English

8/14/2019 Who/Fch/Cah/00.40 Distr.: General Original: English

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IMCIIntegratedManagement ofChildhoodIllness

WHO/FCH/CAH/00.40DISTR.: GENERAL

ORIGINAL: ENGLISH

2001

World Health OrganizationDepartment of Child and Adolescent Healthand Development (CAH)

MODEL CHAPTER

FOR TEXTBOOKS


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World Health Organization, 2001

This document is not a formal publication of the World Health Organization (WHO),and all right s are reserved by t he Organization. The document may, however, be freely reviewed,abstracted, reproduced and translated, in part or in whole, but not for sale nor for usein conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.Designed by minimum graphicsPrinted in France


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Contents

Integrated Management of Childhood Illness 1

The inequities of child health 1

Rationale for an evidence-based syndromic approach to case management 2

Components of the integrated approach 3

The principles of integrated care 3Adapting the guidelines to a countrys situation 4

The IMCI case management process 4

Outpatient health facility 4

Referral health facility 4

Appropriate home management 4

Outpatient management of children age 2 months up to 5 years 6

Assessment of sick children 6

History taking communicating with the caretaker 6Checking for general danger signs 6

Checking main symptoms 7

Cough or difficult breathing 7

Diarrhoea 9

Fever 12

Ear problems 15

Checking nutritional statusmalnutrition and anaemia 15

Assessing the childs feeding 17Checking immunization status 17

Assessing other problems 18

Treatment procedures for sick children 18

Referral of children age 2 months up to 5 years 18

Treatment in outpatient clinics 19

Oral drugs 19

Treatment of local infections 23

Counselling a mother or caretaker 23

Follow-up care 25

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w 1

The inequities of child healthAlthough the annual number of deaths amongchildren less than 5 years old has decreased byalmost a third since the 1970s, this reduction hasnot been evenly distributed throughout the world.According to the 1999 World Health Report , chil-dren in low- to middle-income countries are 10times more likely to die before reaching age 5 thanchildren living in the industrialised world. In 1998,more than 50 countries still had childhood mor-tality rates of over 100 per 1,000 live births. 1

Every year more than 10 million children in thesecountries die before they reach their fifth birth-day. Seven in 10 of these deaths are due to acuterespiratory infections (mostly pneumonia), diar-rhoea, measles, malaria, or malnutritionand

often to a combination of these conditions (Fig-ure 1).

Projections based on the 1996 analysis The Global Burden of Disease 2 indicate that these conditionswill continue to be major contributors to childdeaths through the year 2020 unless significantlygreater efforts are made to control them.

Infant and childhood mortality are sensitive indi-cators of inequity and poverty. It is no surprise tofind that the children who are most commonly andseverely ill, who are malnourished and who aremost likely to die of their illness are those of themost vulnerable and underprivileged populationsof low-income countries. However, even withinmiddle-income and so-called industrialised coun-tries, there are often neglected geographical areaswhere childhood mortality remains high. Millionsof children in these areas are often caught in thevicious cycle of poverty and ill healthpovertyleads to ill health and ill health breeds poverty.

Quality of care is another important indicator of inequities in child health. Every day, millions of parents seek health care for their sick children, tak-ing them to hospitals, health centres, pharmacists,doctors, and traditional healers. Surveys reveal thatmany sick children are not properly assessed andtreated by these health providers, and that theirparents are poorly advised. 3 At first-level healthfacilities in low-income countries, diagnostic sup-ports such as radiology and laboratory services areminimal or non-existent, and drugs and equipmentare often scarce. Limited supplies and equipment,combined with an irregular flow of patients, leavedoctors at this level with few opportunities to prac-tise complicated clinical procedures. Instead, theyoften rely on history and signs and symptoms todetermine a course of management that makes thebest use of available resources.

Providing quality care to sick children in theseconditions is a serious challenge. Yet how can thissituation be reversed? Experience and scientific

Integrated Management of Childhood Illness

1 World Health Organization. World health report 1999 making a difference . Geneva, WHO, 1999.

2 Murray CJL and Lopez AD. The global burden of disease: acomprehensive assessment of mortality and disability from dis-eases injures, and risk factors in 1990 and projected to 2020 .

Geneva, World Health Organization, 1996.3 World Health Organization. Report of the Division of Child

Health and Development 19961997 . Geneva, WHO, 1998.

Figure 1. Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999

Malaria7%

Measles8%

Diarrhoea15%

Pneumonia19%

Other28%

Perinatal20%

HIV/AIDS3%

Malnutrition54%


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2 w IMCI: MODEL CHAPTER FOR TEXTBOOKS

evidence show thatimprovements in childhealth are not neces-

sarily dependent onthe use of sophisti-cated and expensivetechnologies, butrather on effectivestrategies that are

based on a holistic approach, are available to themajority of those in need, and which take into ac-count the capacity and structure of health systems,as well as traditions and beliefs in the community.

Rationale for an evidence-basedsyndromic approach to case managementMany well-known prevention and treatment strat-egies have already proven effective for saving younglives. Childhood vaccinations have successfullyreduced deaths due to measles. Oral rehydrationtherapy has contributed to a major reduction indiarrhoea deaths. Effective antibiotics have savedmillions of children with pneumonia. Prompt treat-

ment of malaria hasallowed more childrento recover and leadhealthy lives. Evenmodest improvementsin breastfeeding prac-tices have reducedchildhood deaths.

While each of theseinterventions hasshown great success,accumulating evi-dence suggests that amore integrated ap-proach to managingsick children is needed

to achieve better outcomes. Child health pro-grammes need to move beyond single diseases toaddressing the overall health and well-being of thechild. Because many children present with over-lapping signs and symptoms of diseases, a singlediagnosis can be difficult, and may not be feasibleor appropriate. This is especially true for first-levelhealth facilities where examinations involve few

instruments, little or no laboratory tests, and noX-ray.

During the mid-1990s, the World Health Organi-zation (WHO), in collaboration with UNICEF andmany other agencies, institutions and individuals,

responded to this challenge by developing a strat-egy known as the Integrated Management of Child-hood Illness (IMCI). Although the major reasonfor developing the IMCI strategy stemmed fromthe needs of curative care, the strategy also ad-dresses aspects of nutrition, immunization, andother important elements of disease prevention andhealth promotion. The objectives of the strategyare to reduce death and the frequency and sever-ity of illness and disability, and to contribute toimproved growth and development.

The IMCI clinical guidelines target children lessthan 5 years oldthe age group that bears the high-est burden of deaths from common childhood dis-eases (Figure 2).

The guidelines take an evidence-based, syndromicapproach to case management that supports therational, effective and affordable use of drugs and

Improvementsin child health are

not necessarily

dependent on theuse of sophisticated

and expensivetechnologies.

A more integratedapproach to

managing sick children is needed to

achieve betteroutcomes.

Child healthprogrammes need to

move beyondaddressing single

diseases to address-ing the overall health

and well-being of the child.

Percentage of deaths occurring among:Children 0 4 years All other age groups

54%

ARI

79%

85% 89%

Malaria

Diarrhoea Measles

4 Adapted from Murray and Lopez, 1996.

Figure 2. Proportion of Global Burden of Selected DiseasesBorne by Children Under 5 Years (Estimated, Year 2000)4


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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS w 3

diagnostic tools. Evidence-based medicine stressesthe importance of evaluation of evidence fromclinical research and cautions against the use of

intuition, unsystematic clinical experience, anduntested pathophysiologic reasoning for medicaldecision-making. 5 In situations where laboratorysupport and clinical resources are limited, thesyndromic approach is a more realistic and cost-effective way to manage patients. Careful and sys-tematic assessment of common symptoms andwell-selected clinical signs provides sufficient in-formation to guide rational and effective actions.

An evidence-based syndromic approach can beused to determine the:

s Health problem(s) the child may have;s Severity of the childs condition;

s Actions that can be taken to care for the child(e.g. refer the child immediately, manage withavailable resources, or manage at home).

In addition, IMCI promotes:

s Adjustment of the curative interventions to thecapacity and functions of the health system; and

s Active involvement of family members and the

community in the health care process.Parents, if correctlyinformed and coun-selled, can play animportant role in im-proving the healthstatus of their childrenby following the advicegiven by a health careprovider, by applyingappropriate feeding

practices and by bring-ing sick children to a

doctor as soon as symptoms arise. A critical ex-ample of the need for timely care is Africa, whereapproximately 80 percent of childhood deaths oc-cur at home, before the child has any contact witha health facility. 6

Components of the integrated approachThe IMCI strategy includes both preventive andcurative interventions that aim to improve prac-tices in health facilities, the health system and athome. At the core of the strategy is integrated casemanagement of the most common childhood prob-lems with a focus on the most common causes of death.

The strategy includes three main components:

s Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on integrated managementof childhood illness and activities to promote

their use;s Improvements in the overall health system re-

quired for effective management of childhoodillness;

s Improvements in family and community healthcare practices.

The principles of integrated careThe IMCI guidelines are based on the followingprinciples:

s All sick children must be examined for gen-eral danger signs which indicate the needfor immediate referral or admission to a hospi-tal.

s All sick children must be routinely assessed for major symptoms (for children age 2months up to 5 years: cough or difficult breath-ing, diarrhoea, fever, ear problems; for younginfants age 1 week up to 2 months: bacterialinfection and diarrhoea). They must also be rou-

tinely assessed for nutritional and immuni-zation status, feeding problems, and other

potential problems .

s Only a limited number of carefully-selected clinical signs are used, based on evidence of their sensitivity and specificity 7 to detect disease.

5 Chessare JB. Teaching clinical decision-making to pediatricresidents in an era of managed care. Paediatrics , 1998, 101

(4 Pt): 7627666 Oluwole D et al. Management of childhood illness in Africa.

British medical journal , 1999, 320:594595.

Careful andsystematic

assessment of common symptoms

and well-selectedspecific clinical signs

provide sufficientinformation to guiderational and effective

actions.

7 Sensitivity and specificity measure the diagnostic perform-ance of a clinical sign compared with that of the gold stand-ard, which by definition has a sensitivity of 100% and aspecificity of 100%. Sensitivity measures the proportion orpercentage of those with the disease who are correctly iden-tified by the sign. In other words, it measures how sensitive

the sign is in detecting the disease. (Sensitivity = true posi-tives / [true positives + false negatives]) Specificity measuresthe proportion of those without the disease who are correctlycalled free of the disease by using the sign. (Specificity =true negatives / [true negatives + false positives])


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These signs were selected considering the con-ditions and realities of first-level health facili-ties.

s A combination of individual signs leads to achilds classification(s) rather than a diag-nosis . Classification(s) indicate the severity of condition(s). They call for specific actions basedon whether the child (a) should be urgentlyreferred to another level of care, (b) requiresspecific treatments (such as antibiotics or anti-malarial treatment), or (c) may be safely man-aged at home. The classifications are colour coded : pink suggests hospital referral or ad-mission, yellow indicates initiation of treat-

ment, and green calls for home treatment.s The IMCI guidelines address most, but not

all, of the major reasons a sick child isbrought to a clinic . A child returning withchronic problems or less common illnesses mayrequire special care. The guidelines do not de-scribe the management of trauma or other acuteemergencies due to accidents or injuries.

s IMCI management procedures use a limited number of essential drugs and encourageactive participation of caretakers in the

treatment of children.

s An essential component of the IMCI guidelinesis the counselling of caretakers about homemanagement, including counselling about feed-ing, fluids and when to return to a health facil-ity.

Adapting the guidelines to a countryssituationThe underlying principles of the IMCI guidelinesare constant. However, in each country the IMCIclinical guidelines should be adapted to:

s Cover the most serious childhood illnesses typi-cally seen at first-level health facilities;

s Make the guidelines consistent with nationaltreatment guidelines and other policies; and

s Make IMCI implementation feasible throughthe health system and by families caring for theirchildren at home.

Adaptation of the IMCI guidelines normally is co-ordinated by a national health regulating body (e.g.,

Ministry of Health) and incorporates decisionscarefully made by national health experts. For thisreason, some clinical signs and details of clinical

procedures described below may differ from thoseused in a particular country. The principles usedfor management of sick children, however, are fullyapplicable in all situations.

The IMCI case management processThe case management of a sick child brought to afirst-level health facility includes a number of im-portant elements (see Figure 3).

Outpatient health facility s Assessment;

s Classification and identification of treatment;

s Referral, treatment or counselling of the childscaretaker (depending on the classification(s)identified);

s Follow-up care.

Referral health facility s Emergency triage assessment and treatment

(ETAT);

s Diagnosis, treatment and monitoring of patientprogress.

Appropriate home management s Teaching the mother or other caretaker how to

give oral drugs and treat local infections at home;

s Counselling the mother or other caretaker aboutfood (feeding recommendations, feeding prob-lems); fluids; when to return to the health facil-ity; and her own health.

Depending on a childs age, various clinical signsand symptoms have different degrees of reliabilityand diagnostic value and importance. Therefore,the IMCI guidelines recommend case managementprocedures based on two age categories:

s Children age 2 months up to 5 years

s Young infants age 1 week up to 2 months


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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS w 5

Figure 3. IMCI case management in the outpatient health facility, first-level referral facility and at home for the sick child from age 2 months up to 5 years

THE INTEGRATED CASE MANAGEMENT PROCESS

OUTPATIENT HEALTH FACILITY

Check for DANGER SIGNSq Convulsions

q Lethargy/unconsciousnessq Inability to drink/breastfeed

q Vomiting

Assess MAIN SYMPTOMSq Cough/diff iculty breathing

q Diarrhoeaq Fever

q Ear problems

Assess NUTRITION and IMMUNIZATION STATUSand POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS

CLASSIFY CONDITIONS andIDENTIFY TREATMENT ACTIONS

According to colour-coded treatment

GREENHome management

HOMECaretaker is counselled on:

q Home treatment(s)q Feeding and fluids

q When to return immediatelyq Follow-up

PINKUrgent referral

OUTPATIENTHEALTH FACILITY

q Pre-referral treatmentsq Advise parents

q Refer child

YELLOWTreatment at outpatient

health facility

OUTPATIENTHEALTH FACILITY

q Treat local infectionq Give oral drugs

q Advise and teach caretakerq Follow-up

REFERRAL FACILITY q Emergency Triage and

Treatment (ETAT)q Diagnosisq Treatment

q Monitoring and Follow-up


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Outpatient management of childrenage 2 months up to 5 years

s Use words the caretaker understands.Try to use local words and avoid medicalterminology.

s Give the caretaker time to answer ques-tions. S/he may need time to reflect and decideif a clinical sign is present.

s Ask additional questions when the care-taker is not sure about the answer. A care-taker may not be sure if a symptom or clinicalsign is present. Ask additional questions to helpher/him give clear answers.

Checking for general danger signs

A sick child brought to an outpatient facility may

have signs that clearly indicate a specific problem.For example, a child may present with chest in-drawing and cyanosis, which indicate severe pneu-monia. However, some children may present withserious, non-specific signs called general dangersigns that do not point to a particular diagnosis.For example, a child who is lethargic or uncon-scious may have meningitis, severe pneumonia,cerebral malaria or another severe disease. Greatcare should be taken to ensure that these generaldanger signs are not overlooked because they sug-

gest that a child is severely ill and needs urgentattention.

Assessment of sick childrenThe assessment procedure for this age group in-cludes a number of important steps that must betaken by the health care provider, including: (1)history taking and communicating with the care-taker about the childs problem; (2) checking forgeneral danger signs; (3) checking main symptoms;(4) checking nutritional status; (5) assessing thechilds feeding; (6) checking immunization status;and (7) assessing other problems.

History taking communicating withthe caretaker

It is critical to communicate effectively with the

childs mother or caretaker. Good communicationtechniques and an integrated assessment are re-quired to ensure that common problems or signsof disease or malnutrit ion are not overlooked. Us-ing good communication helps to reassure themother or caretaker that the child will receive goodcare. In addition, the success of home treatmentdepends on how well the mother or caretakerknows how to give the treatment and understandsits importance.

The steps to good communication are:

s Listen carefully to what the caretaker says.This will show her/him that you take their con-cerns seriously.

History takingGeneral danger signs

Main symptomsCough or difficult breathing

DiarrhoeaFever

Ear problemsNutritional status

Immunization statusOther problems

ASSESSMENT OF SICK CHILD

6 w

History taking

General danger signsMain symptoms

Cough or difficult breathingDiarrhoea

FeverEar problems

Nutritional statusImmunization status

Other problemsASSESSMENT OF SICK CHILD


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The following danger signs should be rou-tinely checked in all children.

s The child has had convulsions during the

present illness . Convulsions may be the resultof fever. In this instance, they do little harm be-yond frightening the mother. On the other hand,

convulsions may beassociated with menin-gitis, cerebral malariaor other life-threaten-ing conditions. Allchildren who have hadconvulsions during thepresent illness should

be considered seri-ously ill.

s The child is unconscious or lethargic . Anunconscious child is likely to be seriously ill. Alethargic child, who is awake but does not takeany notice of his or her surroundings or doesnot respond normally to sounds or movement,may also be very sick. These signs may be asso-ciated with many conditions.

s 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 mothers evidencefor this, but observe while she tries to breastfeedor to give the child something to drink.

s The child vomits everything . The vomitingitself may be a sign of serious illness, but it isalso important to note because such a child willnot be able to take medication or fluids for re-hydration.

If a child has one or more of these signs, s/hemust be considered seriously ill and will almostalways need referral. In order to start treatmentfor severe illnesses without delay, the child shouldbe quickly assessed for the most important causesof serious illness and deathacute respiratory in-fection (ARI), diarrhoea, and fever (especiallyassociated with malaria and measles). A rapidassessment of nutritional status is also essential,as malnutrition is another main cause of death.

Checking main symptomsAfter checking for general danger signs, the healthcare provider must check for main symptoms. The

generic IMCI clinical guidelines suggest the fol-lowing four: (1) cough or difficult breathing; (2)diarrhoea; (3) fever; and (4) ear problems.

The first three symptoms are included because theyoften result in death. Ear problems are includedbecause they are considered one of the main causesof childhood disability in low- and middle-incomecountries.

Cough or difficult breathing

A child presenting with cough or difficult breath-ing should first be assessed for general danger signs.This child may have pneumonia or another severerespiratory infection. After checking for dangersigns, it is essential to ask the childs caretaker aboutthis main symptom.

Clinical assessment

Three key clinical signs are used to assess a sickchild with cough or difficult breathing:

s Respiratory rate , which distinguishes children

who have pneumonia from those who do not;s Lower chest wall indrawing , which indicates

severe pneumonia; and

s Stridor , which indicates those with severe pneu-monia who require hospital admission.

No single clinical sign has a better combination of sensitivity and specificity to detect pneumonia inchildren under 5 than respiratory rate, specifi-cally fast breathing . Even auscultation by anexpert is less sensitive as a single sign.

Cut-off rates for fast breathing (the point at whichfast breathing is considered to be fast) depend onthe childs age. Normal breathing rates are higher

OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS w 7

DANGER

SIGNS

LETHARGY UNCONSCIOUSNESS

INABILITY TO DRINK

OR BREASTFEED

V O M I T I N G

C O N V U L S I O N S History taking

General danger signs


DiarrhoeaFever



ASSESSMENT OF SICK C

HILD


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in children age 2 months up to 12 months than inchildren age 12 months up to 5 years.

Childs 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

Note: The specificity of respiratory rate for de-tecting pneumonia depends on the prevalenceof bacterial pneumonia among the population.In areas with high levels of viral pneumonia, res-piratory rate has relatively modest specificity.Nevertheless, even if the use of respiratory rateleads to some overtreatment, this will still besmall compared with the current use of anti-biotics for all children with an ARI, as occurs inmany clinics.

Lower chest wall indrawing , defined as the in-ward movement of the bony structure of the chestwall with inspiration, is a useful indicator of se-vere pneumonia. It is more specific than inter-costal indrawing, which concerns the soft tissuebetween the ribs without involvement of the bonystructure of the chest wall. 8 Chest indrawing shouldonly be considered present if it is consistently present in a calm child . Agitation, a blocked nose orbreastfeeding can all cause temporary chestindrawing.

Stridor is a harsh noise made when the child in-hales (breathes in ). Children who have stridorwhen calm have a substantial risk of obstructionand should be referred. Some children with mildcroup have stridor only when crying or agitated.This should not be the basis for indiscriminatereferral. Sometimes a wheezing noise is heard whenthe child exhales (breathes out ). This is not stri-dor. A wheezing sound is most often associatedwith asthma. Experience suggests that even whereasthma rates are high, mortality from asthma isrelatively uncommon. In some cases, especiallywhen a child has wheezing when exhaling, the fi-nal decision on presence or absence of fast breath-ing can be made after a test with a rapid actingbronchodilator (if available). At this level, no dis-tinction is made between children with bronchi-olitis and those with pneumonia.

Classification of cough or difficult breathing

Based on a combination of the above clinical signs,children presenting with cough or difficult breath-

ing can be classified into three categories:s Those who require referral for possible severe

pneumonia or very severe disease.

This group includes children with any generaldanger sign, or lower chest indrawing or stridorwhen calm. Children with severe pneumonia orvery severe diseasemost likely will have invasivebacterial organisms and diseases that may belife-threatening. This warrants the use of inject-able antibiotics.

q Any general danger sign or SEVERE PNEUMONIAq Chest indrawing or ORq Stridor in calm child VERY SEVERE DISEASE

s Those who require antibiotics as outpatientsbecause they are highly likely to have bacterialpneumonia.

This group includes all children with fast respi-ratory rate for age. Fast breathing, as defined

by WHO, detects about 80 percent of childrenwith pneumonia who need antibiotic treatment.Treatment based on this classification has beenshown to reduce mortality. 9

q Fast breathing PNEUMONIA

s Those who simply have a cough or coldand do notrequire antibiotics.

Such children may require a safe remedy to a

relieve cough. A child with cough and cold nor-mally improves in one or two weeks. However,a child with chronic cough (more than 30 days)needs to be further assessed (and, if needed, re-ferred) to exclude tuberculosis, asthma, whoop-ing cough or another problem.

q No signs of pneumonia NO PNEUMONIA:or very severe disease COUGH OR COLD

9 Sazawal S, Black RE. Meta-analysis of intervention trials oncase management of pneumonia in community settings.Lancet , 1992, 340(8818):528533.

8 Mulholland EK et al. Standardized diagnosis of pneumoniain developing countries. Pediatric infectious disease journal ,1992, 11:7781.


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Diarrhoea

A child presenting with diarrhoea should first beassessed for general danger signs and the childscaretaker should be asked if the child has cough ordifficult breathing.

Diarrhoea is the next symptom that should be rou-tinely checked in every child brought to the clinic.A child with diarrhoea may have three potentiallylethal conditions: (1) acute watery diarrhoea (in-cluding cholera); (2) dysentery (bloody diarrhoea);and (3) persistent diarrhoea (diarrhoea that lastsmore than 14 days). All children with diarrhoeashould 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 hasdysentery.

Clinical assessment

All children with diarrhoea should be checked todetermine the duration of diarrhoea, if blood ispresent in the stool and if dehydration is present.A number of clinical signs are used to determinethe level of dehydration:

Childs general condition . Depending on the de-gree of dehydration, a child with diarrhoea may belethargic or unconscious (this is also a general dan-ger sign) or look restless/irritable. Only childrenwho cannot be consoled and calmed should beconsidered restless or irritable.

Sunken eyes . The eyes of a dehydrated child maylook sunken . In a severely malnourished child whois visibly wasted (that is, who has marasmus), theeyes 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 canstill be used to classify the childs dehydration.

Childs reaction when offered to drink . A childis not able to drink if s/he is not able to take fluid inhis/her mouth and swallow it. For example, a child

may not be able to drink because s/he is lethargicor unconscious. A child is drinking poorly if the childis weak and cannot drink without help. S/he maybe able to swallow only if fluid is put in his/hermouth. A child has the sign drinking eagerly, thirstyif it is clear that the child wants to drink. Notice if the child reaches out for the cup or spoon whenyou offer him/her water. When the water is takenaway, see if the child is unhappy because s/he wantsto drink more. If the child takes a drink only withencouragement and does not want to drink more,s/he does not have the sign drinking eagerly,thirsty.

Elasticity of skin . Check elasticity of skin usingthe skin pinch test. When released, the skin pinchgoes back either very slowly (longer than 2 seconds),or slowly (skin stays up even for a brief instant), orimmediately . In a child with marasmus (severe mal-nutrition), the skin may go back slowly even if thechild is not dehydrated. In an overweight child, ora child with oedema, the skin may go back imme-diately even if the child is dehydrated.

After the child is assessed for dehydration, the care-taker of a child with diarrhoea should be askedhow long the child has had diarrhoea and if thereis blood in the stool. This will allow identificationof children with persistent diarrhoea and dysen-tery.

Classification of dehydration

Based on a combination of the above clinical signs,children presenting with diarrhoea are classifiedinto three categories:


Standard procedures for skin pinch tests Locate the area on the childs abdomen halfway

between the umbilicus and the side of theabdomen; then pinch the skin using the thumband first finger.

s The hand should be placed so that when the skinis pinched, the fold of skin will be in a line upand down the childs body and not across thechilds body.

s It is important to firmly pick up all of the layersof skin and the tissue under them for one

second and then release it.

History taking



FeverEar problems


Other problemsASSESSMENT OF SICK CHIL

D


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s Those who have severe dehydration and whorequire immediate IV infusion, nasogastric ororal fluid replacement according to the WHO

treatment guidelines described in Plan C (seefigure 4 under treatment procedures).

Patients have severe dehydration if they have afluid deficit equalling greater than 10 percentof their body weight. A child is severely dehy-drated if he/she has any combination of two of the following signs: is lethargic or unconscious,is not able to drink or is drinking poorly, hassunken eyes, or a skin pinch goes back veryslowly.

Two of the following signs:q Lethargic or unconsciousq Sunken eyes SEVEREq Not able to drink or DEHYDRATION

drinking poorlyq Skin pinch goes back

very slowly

s Those who have some dehydration and whorequire active oral treatment with ORS solutionaccording to WHO treatment guidelinesdescribed in Plan B (see figure 5 under treat-ment procedures).

Children who have any combination of the fol-lowing two signs are included in this group: rest-less/irritable, sunken eyes, drinks eagerly/thirsty,skin pinch goes back slowly. Children with somedehydration have a fluid deficit equalling 5 to10 percent of their body weight. This classifica-tion includes both mild and moderatedehydration, which are descriptive terms usedin most paediatric textbooks.

Two of the following signs:q Restless, irritableq Sunken eyes SOMEq Drinks eagerly, thirsty DEHYDRATIONq Skin pinch goes back

slowly

s Those children with diarrhoea who have nodehydration.

Patients with diarrhoea but no signs of dehy-dration usually have a fluid deficit, but equal to

less than 5 percent of their body weight.Although these children lack distinct signs of dehydration, they should be given more fluid

than usual to prevent dehydration from devel-oping as specified in WHO Treatment Plan A(see figure 5 under treatment procedures).

Not enough signs to classify as NOsome or severe dehydration DEHYDRATION

Note: Antibiotics should not be used routinelyfor treatment of diarrhoea. Most diarrhoealepisodes are caused by agents for which anti-microbials are not effective, e.g., viruses, or by

bacteria that must first be cultured to determinetheir sensitivity to antimicrobials. A culture,however, is costly and requires several days toreceive the test results. Moreover, most labora-tories are unable to detect many of the impor-tant bacterial causes of diarrhoea.

Note: Anti-diarrhoeal drugsincluding anti-motility agents (e.g., loperamide, diphenoxylate,codeine, tincture of opium), adsorbents (e.g.,kaolin, attapulgite, smectite), live bacterialcultures (e.g., Lactobacillus, Streptococcus

faecium), and charcoal do not provide prac-tical benefits for children with acute diarrhoea,and some may have dangerous side effects. Thesedrugs should never be given to children less than5 years old.

Classification of persistent diarrhoea

Persistent diarrhoea is an episode of diarrhoea, withor without blood,which begins acutely

and lasts at least 14days. It accounts forup to 15 percent of allepisodes of diarrhoeabut is associated with30 to 50 percent of deaths. 10 Persistent di-arrhoea is usually asso-ciated with weight loss and often with seriousnon-intestinal infections. Many children who de-velop persistent diarrhoea are malnourished,

10 Black RE. Persistent diarrhea in children in developing coun-tries. Pediatric infectious diseases journal , 1993, 12:751761

Persistent diarrhoeaaccounts for up to15 percent of all

episodes of diarrhoea but is

associated with 30 to50 percent of deaths.


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greatly increasing the risk of death. Persistent di-arrhoea almost never occurs in infants who areexclusively breast-fed.

All children with diarrhoea for 14 days or moreshould be classified based on the presence orabsence of any dehydration:

s Children with severe persistent diarrhoeawho alsohave any degree of dehydration require specialtreatment and should not be managed at theoutpatient health facility.

Referral to a hospital is required. As a rule, treat-ment of dehydration should be initiated first,unless there is another severe classification.

q Dehydration present SEVERE PERSISTENTDIARRHOEA

s Children with persistent diarrhoea and no signs of dehydration can be safely managed in the out-patient clinic, at least initially.

Proper feeding is the most important aspect of treatment for most children with persistent di-arrhoea. The goals of nutritional therapy are to:(a) temporarily reduce the amount of animalmilk (or lactose) in the diet; (b) provide a suffi-cient intake of energy, protein, vitamins andminerals to facilitate the repair process in thedamaged gut mucus and improve nutritionalstatus; (c) avoid giving foods or drinks that mayaggravate the diarrhoea; and (d) ensure adequatefood intake during convalescence to correct anymalnutrition.

Routine treatment of persistent diarrhoea withantimicrobials is not effective. Some children,however, have non-intestinal (or intestinal) in-fections that require specific antimicrobialtherapy. The persistent diarrhoea of such chil-dren will not improve until these infections arediagnosed and treated correctly.

q No dehydrat ion PERSISTENT DIARRHOEA

Classification of dysentery

The mother or caretaker of a child with diarrhoeashould be asked if there is blood in the stool.

s A child is classified as having dysentery if themother or caretaker reports blood in the childsstool.

q Blood in the stool DYSENTERY

It is not necessary to examine the stool or performlaboratory tests to diagnose dysentery. Stoolculture, to detect pathogenic bacteria, is rarely pos-sible. Moreover, at least two days are required toobtain the results of a culture. Although dysen-tery is often described as a syndrome of bloodydiarrhoea with fever, abdominal cramps, rectal painand mucoid stools, these features do not alwaysaccompany bloody di-arrhoea, nor do theynecessarily define itsaetiology or determineappropriate treatment.

Bloody diarrhoea inyoung children is usu-ally a sign of invasiveenteric infection thatcarries a substantialrisk of serious morbid-ity and death. About 10 percent of all diarrhoeaepisodes in children under 5 years old aredysenteric, but these cause up to 15 percent of alldiarrhoeal deaths. 11

Dysentery is especially severe in infants and in chil-dren who are undernourished, who develop clini-cally-evident dehydration during their illness, orwho are not breast-fed. It also has a more harmfuleffect on nutritional status than acute watery diar-rhoea. Dysentery occurs with increased frequencyand severity in children who have measles or havehad measles in the preceding month, anddiarrhoeal episodes that begin with dysentery aremore likely to become persistent than those thatstart without blood in the stool.

All children with dysentery (bloody diarrhoea)should be treated promptly with an antibiotic ef-fective against Shigella because: (a) bloody diar-rhoea in children under 5 is caused much morefrequently by Shigella than by any other pathogen;(b) shigellosis is more likely than other causes of


About 10 percent of all diarrhoea

episodes in childrenunder 5 years old aredysenteric, but these

cause up to 15percent of all

diarrhoeal deaths.

11 The management of bloody diarrhoea in young children . Docu-ment WHO/CDD/94.9 Geneva, World Health Organization,1994


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diarrhoea to result in complications and death if effective antimicrobial therapy is not begunpromptly; and (c) early treatment of shigellosis with

an effective antibiotic substantially reduces the riskof severe morbidity or death.

Fever

All sick children should be checked for fever.Fever is a very common condition and is often themain reason for bringing children to the health cen-tre. It may be caused by minor infections, but mayalso be the most obvious sign of a life-threatening

illness, particularly malaria (especially lethal ma-laria P. falciparum ), or other severe infections, in-cluding meningitis, typhoid fever, or measles. Whendiagnostic capacity is limited, it is important firstto identify those children who need urgent refer-ral with appropriate pre-referral treatment (anti-malarial or antibacterial).

Clinical assessment

Body temperature should be checked in all sick

children brought to an outpatient clinic. Childrenare considered to have fever if their body tempera-ture is above 37.5 C axillary (38 C rectal). In theabsence of a thermometer, children are consideredto have fever if they feel hot. Fever also may berecognised based on a history of fever.

A child presenting with fever should be assessedfor:

Stiff neck . A stiff neck may be a sign of meningi-tis, cerebral malaria or another very severe febriledisease. If the child is conscious and alert, checkstuffiness by tickling the feet, asking the child tobend his/her neck to look down or by very gently

bending the childs head forward. It should movefreely.

Risk of malaria and other endemic infections .

In situations where routine microscopy is not avail-able or the results may be delayed, the risk of ma-laria transmission must be defined. The WorldHealth Organization (WHO) has proposed defi-nitions of malaria risk settings for countries andareas with risk of malaria caused by P. falciparum .A high malaria risk setting is defined as a situationin which more than 5 percent of cases of febriledisease in children age 2 to 59 months aremalarial disease. A low malarial risk setting is a situ-ation where fewer than 5 percent of cases of

febrile disease in children age 2 to 59 months aremalarial disease, but in which the risk is not negli-gible. If malaria transmission does not normallyoccur in the area, and imported malaria is uncom-mon, the setting is considered to have no malariarisk . Malaria risk can vary by season. The nationalmalaria control programme normally definesareas of malaria risk in a country.

If other endemic infections with public health im-portance for children under 5 are present in thearea (e.g., dengue haemorrhagic fever or relapsing

fever), their risk should be also considered. In suchsituations, the national health authorities normallyadapt the IMCI clinical guidelines locally.

Runny nose . When malaria risk is low, a child withfever and a runny nose does not need an antima-larial. This childs fever is probably due to a com-mon cold.

Duration of fever . Most fevers due to viral ill-nesses go away within a few days. A fever that hasbeen present every day for more than five days canmean that the child has a more severe disease such

as typhoid fever. If the fever has been present formore than five days, it is important to checkwhether the fever has been present every day.

Measles . Considering the high risk of complica-tions and death due to measles, children with fe-ver should be assessed for signs of current orprevious measles (within the last three months).Measles deaths occur from pneumonia andlarynigotracheitis (67 percent), diarrhoea (25 per-cent), measles alone, and a few from encephalitis.Other complications (usually nonfatal) include

conjunctivitis, otitis media, and mouth ulcers. Sig-nificant disability can result from measles includ-ing blindness, severe malnutrition, chronic lung



Diarrhoea

FeverEar problemsNutritional status




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disease (bronchiectasis and recurrent infection),and neurologic dysfunction. 12

Detection of acute (current) 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 occurrenceof measles within the last three months (recentmeasles). Despite great success in improving im-munization coverage in many countries, substan-tial numbers of measles cases and deaths continueto occur. Although the vaccine should be given at9 months of age, immunization often does not takeplace (because of false contraindications, lack of vaccine, or failure of a cold chain), or is delayed.

In addition, many measles cases occur early in achilds life (between 6 and 8 months of age), espe-cially in urban and refugee populations.

If the child has measles currently or within the lastthree months, s/he should be assessed for possiblecomplications. Measles damages the epithelial sur-faces and the immune system, and lowers vitaminA levels. This results in increased susceptibility toinfections caused by pneumococcus, gram-nega-tive bacteria, and adenovirus. Recrudescence of herpes virus, Candida, and malaria can also occur

during measles infection. It is important to checkevery child with recent or current measles for pos-sible mouth or eye complications. Other possiblecomplications such as pneumonia, stridor in a calmchild, diarrhoea, malnutrition and ear infection areassessed in relevant sections of the IMCI clinicalguidelines.

Before classifying fever, check for obvious causesof fever (e.g. ear pain, burn, abscess, etc.).

Classification of fever

s All children with fever and any general dangersign or stiff neck are classified as having verysevere febrile diseaseand should be urgently re-ferred to a hospital after pre-referral treatmentwith antibiotics (the same choice as for severepneumonia or very severe disease).

Note : In areas where malaria P.falcipar um ispresent, such children should also receive a pre-referral dose of an antimalarial (intramuscularquinine).

q Any danger sign or VERY SEVEREq Stiff neck FEBRILE DISEASE

Further classifications will depend on the level of malaria risk in the area.

s In a high malaria risk area or season, chil-dren with fever and no general danger sign orstiff neck should be classified as having malaria.

Presumptive treatment for malaria should begiven to all children who present with fever inthe clinic, or who have a history of fever duringthis illness. Although a substantial number of children will be treated for malaria when in factthey have another febrile illness, presumptivetreatment for malaria is justified in this categorygiven the high rate of malaria risk and the pos-sibility that another illness might cause the ma-laria infection to progress. This recommendationis intended to maximise sensitivity, ensuring thatas many true cases as possible receive properantimalarial treatment. 13

q Fever (by history or feelshot or temperature MALARIA37.5 Cor above)

s In a low malaria risk area or season, childrenwith fever (or history of fever) and no generaldanger sign or stiff neck are classified as havingmalariaand given an antimalarial only if they haveno runny nose (a sign of ARI), no measles, andno other obvious cause of fever (pneumonia,sore throat, etc.).

Evidence of another infection lowers the prob-

ability that the childs illness is due to malaria.Therefore, children in a low malaria risk areaor season, who have evidence of another infec-tion, should not be given an antimalarial.

q NO runny nose andNO measles and MALARIANO other causes of fever


12 World Health Organization. Technical basis for the case man-agement of measles . Document WHO/EPI/95. Geneva, WHO,1995.

13 Management of uncomplicated malaria and the use of antima-larial drugs for the protection of travellers . Report of an infor-

mal consultation, Geneva, 1821 September 1995. Geneva,World Health Organization, 1997 (unpublished documentWHO/MAL/96.1075 Rev 1 1997; available on request fromDivision of Control of Tropical Diseases (CTD)).


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Classification of measles

All children with fever should be checked for signsof current or recent measles (within the last three

months) and measles complications.s Severe complicated measlesis present when a child

with measles displays any general danger sign,or has severe stomatitis with deep and exten-sive mouth ulcers or severe eye complications,such as clouding of the cornea. These childrenshould be urgently referred to a hospital.

q Any danger sign; orq Clouding of cornea or SEVERE COMPLICATEDq Deep or extensive MEASLES

mouth ulcers

s Children with less severe measles complications,such as pus draining from the eye (a sign of con-junctivitis) or non-deep and non-extensivemouth ulcers, are classified as measles with eye ormouth complications. These children can be safelytreated at the outpatient facility. This treatmentincludes oral vitamin A, tetracycline ointmentfor children with pus draining from the eye, andgentian violet for children with mouth ulcers.

Children classified with pneumonia, diarrhoeaor ear infection AND measles with eye or mouthcomplications should be treated for the otherclassification(s) AND given a vitamin A treat-ment regimen. Because measles depresses theimmune system, these children may be also re-ferred to hospital for treatment.

q Pus draining from the MEASLES WITHeye or EYE OR MOUTH

q

Mouth ulcers COMPLICATIONS

s If no signs of measles complications have beenfound after a complete examination, a child isclassified as having measles. These children canbe effectively and safely managed at home withvitamin A treatment.

q Measles now or within MEASLESthe last three months

s In a low malaria risk area or season, childrenwith runny nose, measles or clinical signs of otherpossible causes of fever are classified as having

fevermalaria unlikely. These children need follow-up. If their fever lasts more than five days, theyshould be referred for further assessment to de-termine causes of prolonged pyrexia. If possi-ble, in low malaria risk settings, a simple malarialaboratory test is highly advisable.

q Runny nose PRESENT orq Measles PRESENT or FEVER q Other causes of fever MALARIA UNLIKELY

PRESENT

s In a no malaria risk area or season, anattempt should be made to distinguish cases of possible bacterial infection, which require anti-biotic treatment, from cases of non-complicatedviral infection. Presence of a runny nose in suchsituations has no or very little diagnostic value.

When there are obvious causes of fever present such as pneumonia, ear infection, or sore throat

children could be classified as having possiblebacterial infectionand treated accordingly.

q Obvious causes of fever POSSIBLE BACTERIALINFECTION

s In a no malaria risk area or season, if no clini-cal signs of obvious infection are found, theworking classification becomes uncomplicatedfever.

Such children should be followed up in two daysand assessed further. As in other situations, all

children with fever lasting more than five daysshould be referred for further assessment.

q NO obvious causes UNCOMPLICATED FEVERof fever

Note : Children with high fever, defined as anaxillary temperature greater than 39.5 C or arectal greater than 39 C, should be given asingle dose of paracetamol to combat hyper-thermia.


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Ear problems

Ear problems are the next condition that shouldbe checked in all children brought to the outpa-tient health facility. A child presenting with an earproblem should first be assessed for general dan-ger signs, cough or difficult breathing, diarrhoeaand fever. A child with an ear problem may havean ear infection. Although ear infections rarelycause death, they are the main cause of deafnessin low-income areas, which in turn leads to learn-ing problems .

Clinical assessment When otoscopy is not available, look for the fol-lowing simple clinical signs:

Tender swelling behind the ear . The most seri-ous complication of an ear infection is a deep in-fection in the mastoid bone. It usually manifestswith tender swelling behind one of the childs ears.In infants, this tender swelling also may be abovethe ear. When both tenderness and swelling arepresent, the sign is considered positive and shouldnot be mistaken for swollen lymph nodes.

Ear pain . In the early stages of acute otitis, a childmay have ear pain, which usually causes the childto become irritable and rub the ear frequently.

Ear discharge or pus . This is another importantsign of an ear infection. When a mother repor ts anear discharge, the health care provider should checkfor pus drainage from the ears and find out howlong the discharge has been present.

Classification of ear problemsBased on the simple clinical signs above, the childscondition can be classified in the following ways:

s Children presenting with tenderness and swell-ing of the mastoid bone are classified as havingmastoiditisand should be referred to the hospital

for treatment. Before referral, these children firstshould receive a dose of antibiotic and a singledose of paracetamol for pain.

q Tender swelling behind MASTOIDITISthe ear

s Children with ear pain or ear discharge (or pus)for fewer than 14 days are classified as havingacute ear infectionand should be treated for fivedays with the same first-line antibiotic as for

pneumonia.

q Ear discharge for fewerthan 14 days or ACUTE EAR INFECTION

q Ear pain

s If there is ear discharge (or pus) for more then14 days, the childs classification is chronic earinfection. Dry the ear by wicking. Generally,antibiotics are not recommended because theyare expensive and their efficacy is not proven.

q Ear discharge for more CHRONICEAR INFECTIONthan 14 days

s If no signs of ear infection are found, childrenare classified as having no ear infectionand do notrequire any specific treatment.

q NO ear pain and NO eardischarge seen draining NO EAR INFECTION

from the ear

Checking nutritional statusmalnutritionand anaemiaAfter assessing for general danger signs and thefour main symptoms, all children should be as-sessed for malnutrition and anaemia. There are twomain reasons for routine assessment of nutritionalstatus in sick children: (1) to identify children withsevere malnutrition who are at increased risk of mortality and need urgent referral to provide ac-tive treatment; and (2) to identify children with


History taking



FeverEar problems


Other problemsASSESSMENT OF SICK CHILD


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sub-optimal growth resulting from ongoing defi-cits in dietary intake plus repeated episodes of

infection (stunting), and who may benefit fromnutritional counselling and resolution of feedingproblems. All children also should be assessed foranaemia.

Clinical assessment

Because reliable height boards are difficult to findin most outpatient health facilities, nutritionalstatus should be assessed by looking and feelingfor the following clinical signs:

Visible severe wasting . This is defined as severewasting of the shoulders, arms, buttocks, and legs,with ribs easily seen, and indicates presence of

marasmus.Oedema of both feet . The presence of oedema(accumulation of fluid) in both feet may signalkwashiorkor. Children with oedema of both feetmay have other diseases like nephrotic syndrome,however, there is no need to differentiate theseother conditions in the outpatient settings becausereferral is necessary in any case.

Weight for age . When height boards are not avail-able in outpatient settings, a weight for age indica-tor (a standard WHO or national growth chart)

helps to identify children with low (Z score lessthan 2) or very low (Z score less than 3) weightfor age who are at increased risk of infection andpoor growth and development.

Palmar pallor . Although this clinical sign is lessspecific than many other clinical signs included inIMCI guidelines, it can allow doctors to identifysick children with severe anaemia often caused by

vv

1This line shows the childs weight:

8.0 kg

v

2This line shows the childs age:

27 months

3This is the point where the lines

for age and weight meet.Because the point isbelow the

bottom curve, the child is very lowweight for age.


Main symptoms


FeverEar problems


Other problemsASSESSMENT OF SIC

K CHILD


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malaria infection. Where feasible, the specificity of anaemia diagnosis may be greatly increased byusing a simple laboratory test (e.g., the Hb test).

Classification of nutritional status and anaemia

Using a combination of the simple clinical signsabove, a health care provider can classify childrenin one of the following categories:

s Children with severe malnutrition or severe anaemia(exhibiting visible severe wasting, or severe pal-mar pallor or oedema of both feet) are at highrisk of death from various severe diseases andneed urgent referral to a hospital where their

treatment (special feeding, anti-biotics or bloodtransfusions, etc.) can be carefully monitored.

q Visible severe wasting or SEVEREq Severe palmar pallor or MALNUTRITIONq Oedema of both feet OR SEVERE ANAEMIA

s Children with anaemia or low (or very low) weightforage also have a higher risk of severe disease andshould be assessed for feeding problems. Thisassessment should identify common, importantproblems with feeding that feasibly can becorrected if the caretaker is provided effectivecounselling and acceptable feeding recommen-dations based on the childs age.

When children are classified as having anaemiathey should be treated with oral iron. Duringtreatment, the child should be seen every twoweeks (follow-up), at which time an additional14 days of iron treatment is given. If there is noresponse in pallor after two months, the childshould be referred to the hospital for furtherassessment. Iron is not given to children withsevere malnutrition who will be referred. Inareas where there is evidence that hookworm,whipworm, and ascaris are the main causes andcontributors to anaemia and malnutrition, regu-lar deworming with mebendazole every four tosix months is recommended. Mebendazole is in-expensive and safe in young children.

q Some palmar pallor or ANAEMIA ORq (Very) low weight (VERY) LOW WEIGHT

for age

s Children who are not low (or very low) weightfor age and who show no other signs of malnu-trition are classified as having no anaemia and not

very low weight. Because children less than 2 yearsold have a higher risk of feeding problems andmalnutrition than older children do, their feed-ing should be assessed. If problems are identi-fied, the mother needs to be counselled aboutfeeding her child according to the recommendednational IMCI clinical guidelines (see follow-ing section).

q NOT (very) low weight NO ANAEMIAfor age and no other AND NOT (VERY)signs of malnutrition LOW WEIGHT

Assessing the childs feedingAll children less than 2 years old and all chil-dren classified as anaemia or low (or very low) weightneed to be assessed for feeding.

Feeding assessmentincludes questioningthe mother or care-

taker about: (1)breastfeeding fre-quency and nightfeeds; (2) types of complimentary foodsor fluids, frequency of feeding and whether feed-ing is active; and (3) feeding patterns during thecurrent illness. The mother or caretaker should begiven appropriate advice to help overcome anyfeeding problems found (for more details, refer tothe section on counselling the mother or caretaker).

Checking immunization status


All children underage 2 should have a

feeding assessment,even if they have a

normal Z-score.



DiarrhoeaFever





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The immunization status of every sick child brought to a health facility should be checked. Ill-ness is not a contraindication to immunization. In

practice, sick children may be even more in needof protection provided by immunization than wellchildren. A vaccines ability to protect is notdiminished in sick children.

As a rule, there are only four common situationsthat are contraindications to immunization of sickchildren:

s Children who are being referred urgently tothe hospital should not be immunized. There isno medical contraindication, but if the child dies,the vaccine may be incorrectly blamed for the

death.

s Live vaccines (BCG, measles, polio, yellow fe-ver) should not be given to children withimmunodeficiency diseases, or to children whoare immunosuppressed due to malignant dis-ease, therapy with immunosuppressive agentsor irradiation. However, all the vaccines, includ-ing BCG and yellow fever, can be given to chil-dren who have, or are suspected of having, HIVinfection but are not yet symptomatic.

s DPT2 / DPT3should not be givento children who havehad convulsions orshock within threedays of a previousdose of DPT. DTcan be administeredinstead of DPT.

s DPT should not be given to children withrecurrent convulsions or another active neuro-logical disease of the central nervous system. DTcan be administered instead of DPT.

Assessing other problemsThe IMCI clinical guidelines focus on five mainsymptoms. In addition, the assessment steps withineach main symptom take into account several othercommon problems. For example, conditions suchas meningitis, sepsis, tuberculosis, conjunctivitis,and different causes of fever such as ear infectionand sore throat are routinely assessed within theIMCI case management process. If the guidelinesare correctly applied, children with these condi-

tions will receive presumptive treatment or urgentreferral.

Nevertheless, health care providers still need toconsider other causes of severe or acute illness. Itis important to address the childs other complaintsand to ask questions about the caretakers health(usually, the mothers). Depending on a specificcountrys situation, other unique questions maybe raised. For example, in countries where vita-min A deficiency is a problem, sick child encoun-ters should be used as an opportunity to updatevitamin A supplementation.

Treatment procedures for sick childrenIMCI classifications are not necessarily specificdiagnoses, but they indicate what action needs tobe taken. In the IMCI guidelines, all classificationsare colour coded: pink calls for hospital referral oradmission, yellow for initiation of treatment, andgreen means that the child can be sent home withcareful advice on when to return. After comple-tion of the assessment and classification procedure,the next step is to identify treatment.

Referral of children age 2 months up to 5 years All infants and children with a severe classification (pink) are referred to a hospital assoon as assessment is completed and necessary pre-referral treatment is administered. Conditionsrequiring urgent referral are listed in Figure 4.

Note : If a child only has severe dehydration andno other severe classification, and IV infusion isavailable in the outpatient clinic, an attemptshould be made to rehydrate the sick child.

Illness is not acontraindication to

immunization.A vaccines ability to

protect is notdiminished in sick

children.


Main symptoms


FeverEar problems


Other problemsASSESSMENT OF SIC

K CHILD


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The referral note should include:s Name and age of the child;

s Date and time of referral;

s Description of the childs problems;

s Reason for referral (symptoms and signs lead-ing to severe classification);

s Treatment that has been given;

s Any other information that the referral healthfacility needs to know in order to care for thechild, such as earlier treatment of the illness orany immunizations needed.

Successful referral of severely ill children to thehospital depends on effective counselling of thecaretaker. If s/he does not accept referral, avail-

able options (to treat the child by repeated clinicor home visits) should be considered. If the care-taker accepts referral, s/he should be given a short,clear referral note, and should get information onwhat to do during referral transport, particularlyif the hospital is distant.

Urgent pre-referral treatments for children age 2 months upto 5 years (see Figure 4)

s Appropriate antibiotic

s Quinine (for severe malaria)

s Vitamin A

s Prevention of hypoglycemia with breastmilk orsugar water

s Oral antimalarial

sParacetamol for high fever (38.5

C or above)or pain

s Tetracycline eye ointment (if clouding of thecornea or pus draining from eye)

s ORS solution so that the mother can givefrequent sips on the way to the hospital

Note : The first four treatments above areurgent because they can prevent serious conse-quences such as progression of bacterial men-ingitis or cerebral malaria, corneal rupture dueto lack of vitamin A, or brain damage from lowblood sugar. The other listed treatments are alsoimportant to prevent worsening of the illness.

Non-urgent treatments , e.g., wicking a drain-ing ear or providing oral iron treatment, should bedeferred to avoid delaying referral or confusing the

caretaker.If a child does not need urgent referral, check tosee if the child needs non-urgent referral forfurther assessment; for example, for a cough thathas lasted more than 30 days, or for fever that haslasted five days or more. These referrals are not asurgent, and other necessary treatments may bedone before transporting for referral.

Treatment in outpatient clinics

The treatment associated with each non-referralclassification ( yellow and green ) is clearly spelledout in the IMCI guidelines. Treatment uses a mini-mum of affordable essential drugs (see Figure 5).

Oral drugs

Always start with a first-line drug. These areusually less expensive, more readily available in agiven country, and easier to administer. Give asecond-line drug (which are usually more expen-

sive and more difficult to obtain) only if a first-line drug is not available, or if the childs illnessdoes not respond to the first-line drug. The healthcare provider also needs to teach the mother orcaretaker how to give oral drugs at home.

s Oral antibiotics . The IMCI chart shows howmany days and how many times each day to givethe antibiotic. Most antibiotics should be givenfor five days. Only cholera cases receive anti-biotics for three days. The number of times togive the antibiotic each day varies (two, three or

four times per day). Determine the correct doseof antibiotic based on the childs weight. If thechilds weight is not available, use the childsage. Always check if the same antibiotic can beused for treatment of different classifications achild may have. For example, the same anti-biotic could be used to treat both pneumonia andacute ear infection .

s Oral antimalarials . Oral antimalarials vary bycountry. Chloroquine and sulfadoxine-pyrimethamine are the first-line and second-line

drugs used in many countries. Chloroquine isgiven for three days. The dose is reduced on thethird day unless the child weighs less than


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Figure 4. Urgent pre-referral treatments for the sick child from age 2 months up to 5 years

CLASSIFICATION TREATMENT

For all children before referral: Prevent low blood sugar by giving breastmilk or sugar water.

DANGER SIGNCONVULSIONS If the child is convulsing, give diazepam (10 mg/2 ml solution) in dose 0.1 ml/kg or paraldehyde indose 0.30.4 ml/ kg rectally; if convulsions continue after 10 minutes, give a second dose ofdiazepam rectally.

SEVERE PNEUMONIA OR Give first dose of an appropriate antibiotic. Two recommended choices are cotrimoxazole andVERY SEVERE DISEASE amoxicillin. If the child cannot take an oral antibiotic (children in shock or those who are vomiting

incessantly or are unconscious), give the first dose of int ramuscular chloramphenicol (40 mg/kg).Options for an intramuscular antibiotic for pre-referral use include benzylpenicillin and ceftriaxone.

VERY SEVERE FEBRILE DISEASEGive one dose of paracetamol for high fever (38.5Cor above).Give first dose of intramuscular quinine for severe malaria unless no malaria risk.Give first dose of an appropriate antibiotic.

SEVERE COMPLICATED MEASLESGive first dose of appropriate antibiotic.Give vitamin A.If there is clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment.

SEVERE DEHYDRATION WHO TREATMENT PLAN CIf there is no other severe classification, IV fluids should be given in the outpatient clinic according toWHO Treatment Plan C. Give 100 ml/kg IV fluids. Ringers lactate solution is the preferredcommercially available solution. Normal saline does not correct acidosis or replace potassium losses,but can be used. Plain glucose or dextrose solutions are not acceptable for the treatment ofsevere dehydration.

If IV infusion is not possible, urgent referral to the hospital for IV treatment is recommended.When referral takes more than 30 minutes, fluids should be given by nasogastric tube. If none ofthese are possible and the child can drink, ORS must be given by mouth.

Note: In areas where cholera cannot be excluded for patients less than 2 years old with severedehydration, antibiotics are recommended. Two recommended choices are cotrimoxazole andtetracycline.

SEVERE PERSISTENT DIARRHOEAIf there is no other severe classification, t reat dehydration before referral using WHO TreatmentPlan B for some dehydration and Plan Cfor severe dehydration. Then refer to hospital.

MASTOIDITIS Give first dose of an appropriate antibiotic. Two recommended choices are cotrimoxazole andamoxicillin. If the child cannot take an oral antibiotic (children in shock or those who are vomitingincessantly or who are unconscious), give the first dose of intramuscular chloramphenicol(40 mg/kg). Options for an intramuscular antibiotic for pre-referral use include benzylpenicillinand ceftriaxone.

Give first dose of paracetamol for pain.

SEVERE MALNUTRITION Give first dose of vitamin A.OR SEVERE ANAEMIA


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Figure 5. Treatment in the outpatient health facility of the sick child from age 2 months up to 5 years

CLASSIFICATION TREATMENT

PNEUMONIA Give appropriate antibiotic for five days.The choice of antibiotic is based on the fact that most childhood pneumonia of bacterial origin is dueto Streptococcus pneumoniae or Haemophilus influenzae. The treatment of non-severe pneumoniacan utilise a five-day course of either oral cotrimoxazole or amoxicillin. These two oral antibiot ics areusually effective treatment for these two bacteria, both are relatively inexpensive, widely available,and are on the essential drug list of most countries. [The advantages of cotrimoxazole are that it isused twice a day, is affordable and compliance is good. It has been shown that with a twice-dailydosing, compliance levels can reach 75 percent or higher. Amoxicillin is almost twice as expensive ascotrimoxazole and standard dosages are usually given three times a day. The compliance withthree-times-a-day dosing is about 60 percent or less.]Soothe the throat and relieve the cough with a safe remedy.

NO PNEUMONIA COUGH OR COLDSoothe the throat and relieve the cough with a safe remedy.

SOME DEHYDRATION WHO Treatment Plan BGive ini tial t reatment with ORS over a period of four hours. The approximate amount of ORS required(in ml) can be calculated by multiplying the childs weight (in kg) t imes 75; during these four hours,the mother slowly gives the recommended amount of ORS by spoonfuls or sips. Note: If the child isbreast-fed, breastfeeding should continue.

After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin;resuming feeding early is important to provide required amounts of potassium and glucose.When there are no signs of dehydration, the child is put on Plan A. If there is still some dehydration,Plan B should be repeated. If the child now has severe dehydration, the child should be put on Plan C.

NO DEHYDRATION WHO Treatment Plan APlan A focuses on the three rules of home treatment: give extra fluids, continue feeding, and advisethe caretaker when to return to the doctor (if the child develops blood in the stool, drinks poorly,becomes sicker, or is not better in three days).

Fluids should be given as soon as diarrhoea starts; the child should take as much as s/he wants.Correct home therapy can prevent dehydration in many cases. ORS may be used at home to preventdehydration. However, other fluids that are commonly available in the home may be less costly,more convenient and almost as effective. Most fluids that a child normally takes can also be used forhome therapy especially when given with food.

Recommended home fluid should be:

s Safe when given in large volumes. Very sweet tea, soft drinks, and sweetened fruit drinks should be avoided . These are often hyperosmolar owing to their high sugar content (less than300 mOsm/L). They can cause osmotic diarrhoea, worsening dehydration and hypenatremia.Also to be avoided are fluids with purgative action and stimulants (e.g., coffee, some medicinalteas or infusions).

s Easy to prepare. The recipe should be familiar and its preparation should not require much effortor time. The required ingredients and measuring utensils should be readily available andinexpensive.

s Acceptable. The fluid should be one that the mother is willing to give freely to a child withdiarrhoea and that the child will readily accept.

s Effective. Fluids that are safe are also effective. Most effective are fluids that containcarbohydrates and protein and some salt. However, nearly the same result is obtained when fluidsare given freely along with weaning foods that contain salt.


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PERSISTENT DIARRHOEA Encourage the mother to continue breastfeeding.

If yoghurt is available, give it in place of any animal milk usually taken by the child; yoghurt containsless lactose and is bett er tolerated. If animal milk must be given, limit it to 50 ml/ kg per day;greater amounts may aggravate the diarrhoea.If milk is given, mix it with the childs cereal and do not dilute the milk. At least half of the childsenergy intake should come from foods other than milk or milk products. Foods that are hyperosmolar(these are usually foods or drinks made very sweet by the addition of sucrose, such as soft drinks orcommercial fruit drinks) should be avoided. They can worsen diarrhoea.

Food needs to be given in frequent, small meals, at least six times a day. All children with persistentdiarrhoea should receive supplementary multivitamins and minerals (copper, iron, magnesium, zinc)each day for two weeks.

DYSENTERY The four key elements of dysentery t reatment are:

s Antibioticss Fluidss Feedings Follow-up

Selection of an antibiotic is based on sensitivity patterns of strains of Shigella isolated in the area(nalidixic acid is the drug of choice in many areas). Recommended duration of treatment is five days.If after two days (during follow-up) there is no improvement, the antibiotic should be stopped anda different one used.

MALARIA Give an oral antimalarial drug. The selection of first-line and second-line treatment forP.falciparummalaria in endemic countries is an important decision made by health regulating authorities(e.g., Ministry of Health) based on information and technical advise provided by malaria controlprogrammes. Generic IMCI guidelines suggest that chloroquine is the first-line and sulfadoxine-pyrimethamine is the second-line antimalarial.

Give one dose of paracetamol for high fever (38.5 Cor above).

FEVERMALARIA UNLIKELY Give one dose of paracetamol for high fever (38.5 Cor above).POSSIBLE BACTERIAL INFECTIONTreat other obvious causes of fever.UNCOMPLICATED FEVER

MEASLES WITH EYE OR Give first dose of Vitamin A. If clouding of cornea or pus draining from the eye, apply tetracyclineMOUTH COMPLICATIONS eye ointment. If mouth ulcers, treat with gentian violet.

MEASLES CURRENTLY (OR WITHINGive first dose of Vitamin A.THE LAST 3 MONTHS)

ACUTE EAR INFECTION Give appropriate antibiotic for five days.Give one dose of paracetamol for pain.Dry the ear by wicking.

CHRONIC EAR INFECTION Dry the ear by wicking.

ANAEMIA OR LOW WEIGHT Assess the childs feeding and counsel the mother accordingly on feeding.If pallor is present: give iron; give oral antimalarial if high malaria risk. In areas where hookwormor whipworm is a problem, give mebendazole if t he child is 2 years or older and has not hada dose in the previous six months.

NO ANAEMIA AND NOT LOW WEIGHTIf the child is less than 2 years old, assess the childs feeding and counsel the mother accordinglyon feeding.


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Eye treatment for children being referredIf the child will be referred, and the child needstreatment with tetracycline eye ointment, cleanthe eye gently. Pull down the lower lid. Squirt thefirst dose of tetracycline eye ointment onto the

lower eyelid. The dose is about the size of a grainof rice.

10 kg. If this is a case, the child should be giventhe same dose on all three days.

s Paracetamol . If a child has a high fever, give

one dose of paracetamol in the clinic. If the childhas ear pain, give the mother enough paraceta-mol for one day, that is, four doses. Tell her togive one dose every six hours or until the earpain is gone.

s Iron . A child with anaemia needs iron. Givesyrup to the child under 12 months of age. If the child is 12 months or older, give iron tab-lets. Give the mother enough iron for 14 days.Tell her to give her child one dose daily for those14 days. Ask her to return for more iron in 14

days. Also tell her that the iron may make thechilds stools black.

Note : If a child with some pallor is receivingthe antimalarial sulfadoxine-pyrimethamine(Fansidar), do not give iron/folate tablets untila follow-up visit in two weeks. The iron/folatemay interfere with the action of the sulfadoxine-pyrimethamine that contains antifolate drugs.If an iron syrup does not contain folate, a childcan be given an iron syrup with sulfadoxine-pyrimethamine.

s Antihelminth drug . If hookworm or whip-worm is a problem in the area, an anaemic childwho is 2 years of age or older may needmebendazole. These infections contribute toanaemia because of iron loss through intestinalbleeding. Give 500 mg of mebendazole as asingle dose in the clinic.

s Vitamin A . Vitamin A is given to a child withmeasles or severe malnutrition . Vitamin A helpsresist the measles virus infection in the eye aswell as in the layer of cells that line the lung,gut, mouth and throat. It may also help theimmune system to prevent other infections.Vitamin A is available in capsule and syrup form.Use the childs age to determine the dose, andgive two doses. Give the first dose to the childin the clinic. Give the second dose to the motherto give her child the next day at home. Everydose of Vitamin A should be recorded becauseof danger of an overdose.

s Safe remedy for cough and cold . There is noevidence that commercial cough and cold rem-edies are any more effective than simple homeremedies in relieving a cough or soothing a sore

throat. Suppression of a cough is not desirablebecause cough is a physiological reflex to elimi-nate lower respiratory tract secretion. Breastmilk

alone is a good soothing remedy.

Treatment of local infections

If the child, age 2 months up to 5 years, has a localinfection, the mother or caretaker should be taughthow to treat the infection at home.

Instructions may be given about how to:

s Treat eye infection with tetracycline eye oint-ment;

s Dry the ear by wicking to treat ear infection;

s Treat mouth ulcers with gentian violet;

s Soothe the throat and relieve the cough with asafe remedy.

Counselling a mother or caretaker

A child who is seen at the clinic needs to continuetreatment, feeding and fluids at home. The childsmother or caretaker also needs to recognize whenthe child is not improving, or is becoming sicker.The success of home treatment depends on howwell the mother or caretaker knows how to give

treatment, understands its importance and knowswhen to return to a health care provider.

The steps to good communication were listed ear-lier. Some advice is simple; other advice requiresteaching the mother or caretaker how to do a task .When you teach a mother how to treat a child, usethree basic teaching steps: give information; showan example; let her practice.

When teaching the mother or caretaker: (1) usewords that s/he understands; (2) use teaching aidsthat are familiar; (3) give feedback when s/hepractices, praise what was done well and makecorrections; (4) allow more practice, if needed; and


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(5) encourage the mother or caretaker to ask ques-tions and then answer all questions. Finally, it isimportant to check the mothers or caretakers

understanding.The content of the actual advice will depend onthe childs condition and classifications. Below areessential elements that should be considered whencounselling a mother or caretaker:

s Advise to continue feeding and increase fluidsduring illness;

s Teach how to give oral drugs or to treat localinfection;

s Counsel to solve feeding problems (if any);

s Advise when to return.

Advise to continue feeding and increase fluids : The IMCI guidelines give feeding recom-mendations for different age groups. These feed-ing recommendations are appropriate both whenthe child is sick and when the child is healthy.During illness, childrens appetites and thirst maybe diminished. However, mothers and caretakersshould be counselled to increase fluids and tooffer the types of food recommended for the childsage, as often as recommended, even though a childmay take small amounts at each feeding. After ill-ness, good feeding helps make up for weight lossand helps prevent malnutrition. When the child iswell, good feeding helps prevent future illness.

Teach how to give oral drugs or to treat local infection at home : Simple steps should be fol-lowed when teaching a mother or caretaker howto give oral drugs or treat local infections. Thesesteps include: (1) determine the appropriate drugsand dosage for the childs age or weight; (2) tellthe mother or caretaker what the treatment is andwhy it should be given; (3) demonstrate how tomeasure a dose; (4) describe the treatment steps;(5) watch the mother or caretaker practise meas-uring a dose; (6) ask the mother or caretaker togive the dose to the child; (7) explain carefully how,and how often, to do the treatment at home; (8)explain that ALL oral drug tablets or syrups mustbe used to finish the course of treatment, even if the child gets better; (9) check the mothers or care-takers understanding.

Counsel to solve feeding problems (if any) :Based on the type of problems identified, it isimportant to give correct advice about the nutri-

tion of the young child both during and after ill-ness. Sound advice that promotes breastfeeding,improved weaning practices with locally appropri-ate energy- and nutrient-rich foods, and givingnutritious snacks to children 2 years or older, cancounter the adverse effect infections have onnutritional status. Specific and appropriate com-plementary foods should be recommended and thefrequency of feeding by age should be explainedclearly. Encourage exclusive breastfeeding for thefirst four months, and if possible, up to six months;discourage use of bottles for children of any age;and provide guidance on how to solve importantproblems with breastfeeding. The latter includesassessing the adequacy of attachment and suck-ling. Specific feeding recommendations should beprovided for children with persistent diarrhoea.Feeding counselling relevant to identified feedingproblems is described in the IMCI national feed-ing recommendations.

Advise when to return : Every mother or care-taker who is taking a sick child home needs to beadvised about when to return to a health facility.The health care provider should (a) teach signsthat mean to return immediately for further care;(b) advise when to return for a follow-up visit; and(c) schedule the next well-child or immunizationvisit.

The table below lists the specific times to advise amother or caretaker to return to a health facility.

A. IMMEDIATELY

Advise to return imme

Who/Fch/Cah/00.40 Distr.: General Original: English

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