CARE OF CHILD AGED 2 MONTHS TO 5 YEARS >> Part 1: Assess and classify child

Part 1: Assess and classify child

In this part of the training you will learn how to assess a sick child and classify the child's illness. You will also learn how to interact
with the child's mother or other caregiver who brings the child to you. From here on, when you see the word "mother" you should
understand this is a short way of saying "mother or other caregiver".
The assess and classify part of the training is divided into following units:
 Ask the mother about the child's problems
 Check for general danger signs
 Assess main symptoms:
o Cough or difficulty breathing
o Diarrhoea
o Fever
o Ear problem
 Check for HIV infection
 Check for acute malnutrition and anaemia
 Check immunization,vitamin A, and deworming status
 Assess other problems including mouth and gum conditions
When learning how to assess and classify a sick child you will use the IMCI recording form. Its purpose is to help you record information
collected about the child's signs and symptoms when you do exercises and when you see children during clinical practice sessions.
Each training unit in this part will provide you with examples of how to fill in relevant parts of the recording form.

There are two sides to the form. The front side is similar to the ASSESS &CLASSIFY chart. The other side of the form has spaces for
you to use when you plan the child's treatment. In this module, however, you will use the front side only. You will learn how to use the
reverse side when you will work with part of this training called Identify treatment".

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Key steps: Ask the mother about the child's problems

Some simple techniques will help you to be more effective when you see the mother and her sick child.
Greet the mother appropriately without hurrying and ask her to sit with her child.
Try to:
 avoid using words that suggest judgement of the mother and baby such as "wrong" or "bad"
 sit so that your head is level with the mother's head
 look at the mother and pay attention as she speaks
 remove barriers (table or notes) between you and the mother
 make the mother feel that you have time to listen to her.
Look to see if the child's weight, length or height and temperature have been recorded. If not, wait until later when you assess
and classify the child's main symptoms. Then weigh the child and measure the child's length or height and temperature.
Do not undress or disturb the child at this stage.
Ask the mother what the child's problems are. An important reason for asking this question is to start communicating well with the
mother. Good communication helps to reassure the mother that her child will receive good care. Later in the visit, you will need to teach
and advise the mother about caring for her child at home. It will be easier for you to do so if you have good communication with the
mother from the beginning of the visit.

Find out if this is an initial or follow-up visit for the problem.

 If this is the child's initial visit for a particular episode of an illness or problem, then you will need to use the IMCI case-
management procedure to assess and classify the child.
 If the child was seen a few days ago for the same illness, this is a follow-up visit. The purpose of a follow-up visit, is to find out
if the treatment given during the initial visit has helped the child. If the child is not improving or is getting worse after a few
days, you will need to refer the child to a hospital or change the child's treatment. You will learn how to carry out a follow-up
visit later in the training.
Use good communication skills
 Listen carefully to what the mother tells you. This will show her that you are taking her concerns seriously.
 Use words the mother understands. If she does not understand the questions you ask her, she cannot give the information
you need to assess and classify the child correctly.
 Give the mother time to answer the questions. For example, she may need time to decide if the sign you asked about is
present.
 Ask additional questions when the mother is not sure about her answer. When you ask about a main symptom or related
sign, the mother may not be sure if it is present. Ask her additional questions to help her give clearer answers.

Always check ALL sick children for general danger signs.

General danger signs are:
 the child is not able to drink or breastfeed
 the child vomits everything
  the child has had convulsions during the present illness or has convulsions now
 the child is lethargic or unconscious
A child with a general danger sign has a serious problem. All children with a general danger sign need urgent referral to hospital.

If during assessment you found presence of a general danger sign you should complete the rest of assessment immediately. If the
child is to be referred, you should give urgent pre-referral treatment.
Learning objectives: Check for general danger signs

At the end of this training unit you should know the:

 Clinical symptoms of general danger signs
 Actions to be taken when general danger signs are present

After completing the clinical practice relevant to this training unit, you should have the skills to:
 Use correct clinical procedures to check a child for general danger sign

Key steps: Check for general danger signs

See IMCI chart

CLINICAL ASSESSMENT
A sick child may have signs that clearly point to a disease.
For example, a child may present with cough and stridor when calm, which indicate severe pneumonia.
Some children may present with serious, non-specific signs that do not point to a particular disease.
For example, a child who is lethargic or unconscious may have meningitis, severe pneumonia, cerebral malaria or another severe
disease.
Great care should be taken to ensure that these general danger signs are not overlooked. General danger signs suggest that a child is
severely ill and needs urgent attention.

The following are general danger signs in young children:

 The child is not able to drink or breastfeed
 The child vomits everything
 The child has had convulsions during the present illness or has convulsions now
 The child is lethargic or unconscious

All sick children should be routinely checked for general danger signs
ASK: Is the child able to drink or breastfeed?

A child who is not able to suck or swallow when offered a drink or breast milk because he or she is too weak or cannot swallow has the
danger sign not able to drink or breastfeed.
 Ask the mother if the child is able to drink or breastfeed. Make sure that the mother understands the question. If she says that
the child is not able to drink or breastfeed, ask her to describe what happens when she offers the child something to drink. For
example ask: "Is the child able to take fluid into his or her mouth and swallow it?"
 If you are not sure about the mother's answer, ask her to offer the child a drink of clean water or breast milk. Look to see if the
child is swallowing the water or breast milk.
Remember: A child who is breastfed may have difficulty sucking when his or her nose is blocked. If the child's nose is blocked, clean it.
If the child can breastfeed after his or her nose is cleared, the child does not have the danger sign "not able to drink or breastfeed".
ASK: Does the child vomit everything?

A child who is not able to hold anything down at all has the danger sign "vomits everything." What goes down comes back up. A child
who vomits everything will not be able to hold down food, fluids or oral drugs. A child who vomits several times but can hold down some
fluids does not have this general danger sign.
 Ask the mother if the child vomits everything. When you ask the question, use words the mother understands.
 When you or the mother are not sure if the child is vomiting everything, help her to make her answer clear. For example, ask
the mother: "How often the child vomits? Also ask: "Each time the child swallows food or fluids, does the child vomit?"
 If you are still not sure of the mother's answers, ask her to offer the child a drink. See if the child vomits.
LOOK: Is the child having convulsions now?
ASK: Has the child had convulsions during the present illness?

During a convulsion, the child's arms and legs stiffen because the muscles are contracting. The child may lose consciousness or not be
able to respond to spoken directions.

Convulsions may be the result of fever. In this instance, they do little harm beyond frightening the mother. But convulsions may be
associated with meningitis, cerebral malaria or other life threatening conditions.

Convulsions considered a life threatening danger sign are:

 Any convulsions in children aged less than 6 months.
  More than one episode of convulsions during the present illness or convulsions lasting for more than 15 minutes in children
aged 6 months or more.
One episode of generalized convulsions during the current febrile illness in a child aged 6 months or more lasting for less than 15
minutes are considered simple febrile convulsions, NOT a general danger sign.
 Ask the mother if the child has had convulsions during this current illness. Use words the mother understands. For example,
the mother may know convulsions as "fits" or "spasms."
 Ask the mother of a child aged 6 months or more:
o How many times has the child had convulsionsduring this current illness?. Just once or more than once?
o How many minutes had the convulsions lasted? Has the child had the convulsions for a few minutes or for a long time
- more than 15 minutes?
LOOK: Is the child is unconscious or lethargic?

An unconscious or lethargic child is likely to be seriously ill. These signs may be associated with many conditions.
A lethargic child is not awake and alert when he or she should be. The child is drowsy and does not take any notice of his or her
surroundings or does not respond normally to sounds or movement. Often the lethargic child does not look at his or her mother or
watch your face when you talk. The child may stare blankly and appear not to notice what is going on around him or her.
An unconscious child cannot be wakened. The child does not respond when he or she is touched, shaken or spoken to.
 Ask the mother if the child seems unusually sleepy or if she cannot wake the child.
 Look to see if the child wakens when the mother talks or shakes the child or when you clap your hands.
Remember: If the child is sleeping and has a cough or has difficulty breathing, count the number of breaths per minute first before you
try to wake the child.
CLASSIFICATION
 A child who is not able to drink or breastfeed, or vomits everything, or has had convulsions during the present illness or has
convulsions now, or is lethargic or unconscious or is not able to drink or breastfeed has a danger sign and is classified as
VERY SEVERE DISEASE

• Any general danger sign VERY SEVERE DISEASE

Treatment. A child classified as VERY SEVERE DISEASE has a severe problem and needs URGENT attention. There must be no
delay in treatment. Give diazepam if the child is convulsing now. Quickly complete the assessment. In the next training units you will
learn how to assess the child. Based on the assessment give any pre-referral treatment needed immediately. In the Treat the child
section of this training you will learn how to identify treatments and give urgent pre-referral treatments. Before the child leaves, give the
child breast milk or sugar water to treat or prevent low blood sugar and advise the mother how to keep her child warm on the way to
hospital.

NOTE: Remember that simple febrile convulsions (one episode of generalized convulsions during the current febrile illness in a child
aged 6 months or more lasting for less than 15 minutes) are NOT a general danger sign. Assess, treat, and follow up the child
according to the IMCI guidelines. You will learn later in this training that this will include managing fever and looking for its cause.

All sick children should be routinely checked for general danger signs
 If you have found during the assessment that the child has a general danger sign, complete the assessment
IMMEDIATELY.
 Remember that a child with any general danger sign has a severe problem. There must be NO DELAY IN
TREATMENT.
Barbara
Barbara is 5 months old. She weighs 5.3 kg. She is 57 cm in length. Her temperature is 38.5°C. Her family brings her to the clinic
because she had convulsions. She also feels hot and has cough for 2 days her mother says.
The girl is able to drink, has not vomited does not have convulsions now, and is not lethargic or unconscious.

What would you do next? (Tick the correct answer or answers.)

Ask the mother how many times has the child had convulsions during this current illness

Very good, this is not the correct answer.

Ask the mother for how many minutes had the convulsions lasted

Very good, this is not the correct answer.

Classify the child as VERY SEVERE DISEASE

Very good, this is the correct answer. Explanation: Any convulsions in children aged less than 6 months are considered a life
threatening general danger sign.

Baster is a 2-year-old boy. He weighs 12 kg and his height is 87 cm. His temperature is 39.5°C. He was brought to the clinic because
he had convulsions this morning. He has fever and diarrhoea since yesterday his mother says.

What would you do next? (Tick the correct answer or answers.)

Ask the mother how many times has the child had convulsions during this current illness
Very good, this is one of the correct answers.

Ask the mother for how many minutes had the convulsions lasted
Very good, this is one of the correct answers.

Classify the child as VERY SEVERE DISEASE

Very good, this is not one of the correct answers.

Baster
Baster is a 2-year-old boy. He weighs 12 kg and his height is 87 cm. His temperature is 39.5°C. He was brought to the clinic because
he had convulsions this morning.
The health worker asked “How many times has Baster had the convulsions during this current illness?” The mother said, “Just once this
morning.” Then the health worker asked, “Has Baster had the convulsions for a few minutes or for a long time - more than 15 minutes?”
The mother said: “The convulsions seemed to last for a long time but may be it was not more than 5 minutes.”
The boy is able to drink, has not vomited does not have convulsions now, and is not lethargic or unconscious.

Would you classify the child as VERY SEVERE DISEASE?

YES

NO

Very good, this is the correct answer. Explanation: One episode of convulsions during the present illness lasting for less than 15
minutes in children aged 6 months or more is not considered a general danger sign.

Chin aged 4 years was brought to the clinic because he had convulsions when he woke up in the morning. The convulsions lasted for
about 5 minutes. He had another episode of convulsions on the way to the clinic. The second episode of convulsions was somewhat
shorter than the first episode.
Chin weighs 14 kg and his height is 103 cm. His temperature is 37°C. The boy is able to drink, has not vomited does not have
convulsions now, and is not lethargic or unconscious.

Would you classify the child as VERY SEVERE DISEASE?

YES
Very good, this is the correct answer. More than one episode of convulsions during the present illness is considered a general danger
sign.

Convulsions considered a life threatening danger sign are:

 Any convulsions in children aged less than 6 months.
 More than one episode of convulsions during the present illness or convulsions lasting for more than 15 minutes in children
aged 6 months or more.
One episode of generalized convulsions during the current febrile illness in a child aged 6 months or more lasting for less than 15
minutes are considered simple febrile convulsions, NOT a general danger sign.

Exercise 2 - Case study Salina

See IMCI chart

In this exercise you will assess a child for general danger signs.

Salina is 15 months old. She weighs 8.5 kg. She is 71 cm in length. Her temperature is 38.5°C.
The health worker asks, "What are the child's problems?" The mother says, "Salina has been coughing for 4 days, and she is not eating
well." This is Salina's initial visit for this problem.
The health worker checks Salina for general danger signs. He asks, "Is Salina able to drink or breastfeed?" The mother says, "No.
Salina does not want to breastfeed." The health worker gives Salina some water. She is too weak to lift her head. She is not able to
drink from a cup.
Next he asks the mother, "Is she vomiting?" The mother says, "No." The health worker sees that Salina does not have convulsions
now, so he asks, "Has she had convulsions?" The mother says, "No."
The health worker looks to see whether Salina is lethargic or unconscious. When the health worker and the mother are talking, Salina
watches them and looks around the room.

Aine is 3 years old. He weighs 14 kg. His height is 95 cm. His temperature is 38°C.
The health worker asks about the child's problems. Aine's parents say, "He is coughing and has ear pain." This is his initial visit for this
problem.
The health worker asks, "Is your child able to drink or breastfeed?" The parents answer, "Yes." "Does Aine vomit everything?" he asks.
The parents say, "No." The health worker asks, "Has he had convulsions?" They say, "No." The health worker looks at Aine. The
child sits calmly in his mother's lap and looks at the health worker.

Respiratory infections can occur in any part of the respiratory tract: the nose, throat, larynx, trachea, air passages or lungs.

You can see the main elements of a child respiratory system. If you have speakers you can hear different cough sounds when you
make a click with your computer mouse over mouth, larynx and trachea.

A child with a cough or difficulty breathing may have pneumonia or another severe respiratory infection. Pneumonia is an infection of
the lungs. Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).
Both bacteria and viruses can cause pneumonia. In low- and middle-income countries, pneumonia is often caused by bacteria. The
most common are:
 Streptococcus pneumoniae
 Haemophilus influenzae
Nevertheless many children are often brought to the clinic with less serious respiratory infections. Most children with a cough or
difficulty breathing have only a mild infection. These children are not seriously ill. They do not need treatment with antibiotics. Their
families can manage them at home.
CLINICAL ASSESSMENT
Difficulty breathing means any unusual pattern of breathing. Mothers describe this in different ways. They may say that their child's
breathing is "fast" or "noisy" or "interrupted." When you ask the mother if the child has a cough or difficulty breathing and the mother
answers "NO", see if you think the child has a cough or difficulty breathing.

A child with a cough or difficulty breathing is assessed for:

 How long the child has had a cough or difficulty breathing
 Fast breathing
 Chest indrawing
 Stridor
 Wheezing
ASK: For how long has the child had a cough or difficulty breathing?

A child who has had a cough or difficulty breathing for more than 2 weeks has a chronic cough. This may be a sign of tuberculosis,
asthma, whooping cough or another problem.
COUNT the breaths in one minute
 You must count the breaths the child takes in one minute to decide whether the child has fast breathing.
 The child must be quiet and calm when you watch and listen to his or her breathing.
 Cut-off rates for fast breathing (the point at which breathing is considered to be fast) depend on the child's age. Normal
breathing rates are higher in younger children.
Child's age: Fast breathing:

2 months up to 12 months 50 or more breaths per minute

12 months up to 5 years
40 or more breaths per minute

Note: A child who is exactly 12 months old has fast breathing if you count 40 or more breaths per minute.
Not another single clinical sign has a better combination of sensitivity and specificity to detect pneumonia in children under 5 years of age than re
sign.
LOOK for chest indrawing
Lower chest wall indrawing (the inward movement of the bony structure of the chest wall when the child breathes in) is an indicator of
pneumonia. It is more specific than intercostal indrawing, which concerns the soft tissue between the ribs without involvement of the
bony structure of the chest wall.
  If you did not lift the child's shirt when you counted the child's breaths, ask the mother to lift it now.
 Before you look for chest indrawing watch the child to determine when the child is breathing in and when the child is breathing
out.
 Look for chest indrawing when the child breathes in.
 Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes in when the child
breathes in.
Chest indrawing occurs when the effort the child needs to breathe in is much greater than normal. In normal breathing, the whole
chest wall (upper and lower) and the abdomen move out when the child breathes in. When chest indrawing is present, the lower
chest wall goes in when the child breathes in.
Note: For chest indrawing to be present, it must be clearly visible and present all the time. If you only see chest indrawing when the
child is crying or feeding, the child does not have chest indrawing.
If only the soft tissue between the ribs goes in when the child breathes in (intercostal indrawing or intercostal retraction), the child does
not have chest indrawing. In this assessment, chest indrawing means lower chest wall indrawing. It does not include intercostal
indrawing.
LOOK and LISTEN for stridor
Stridor is a harsh noise made when the child breathes in. Stridor happens when there is a swelling of the larynx, trachea or epiglottis.
These conditions are often called croup. This swelling interferes with air entering the lungs. It can be life-threatening when the swelling
causes the child's airway to be blocked. A child who has stridor when calm has a dangerous condition.
 To look and listen for stridor, look to see when the child breathes in.
 Listen for stridor when the child breathes in. Put your ear near the child's mouth because stridor can be difficult to hear.
 Sometimes you will hear a wet noise if the child's nose is blocked. Clear the nose, and listen again. A child who is not very ill
may have stridor only when crying or upset. Be sure to look and listen for stridor when the child is calm.

LOOK and LISTEN for wheezing

Wheezing is a soft musical noise made when the child is breathing out. Wheezing is caused by a narrowing of the air passages in the
lungs. Breathing out takes longer than normal and requires effort.
 Look and listen for wheezing when the child breathes out.
Hold your ear near the child's mouth because the wheezing noise can be difficult to hear. Sometimes so little air moves that there is no
noise. Look to see if the breathing out phase requires great effort and is longer than normal.

If wheezing and either fast breathing or chest indrawing:

 Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes apart. Count the breaths and look for
chest indrawing again, and then classify.
CLASSIFY THE CHILD'S COUGH OR DIFFICULTY BREATHING
Based on the clinical signs found during the clinical assessment, the child's condition can be classified into one of three categories
for: pre-referral treatment; specific treatment; or home care.

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

 A child with any general danger sign or stridor when calm is classified as having SEVERE PNEUMONIA OR VERY SEVERE
DISEASE.

SEVERE PNEUMONIA
• Any general danger sign
OR
• Stridor in calm child
VERY SEVERE DISEASE

Treatment. A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is seriously ill. He or she needs to be
urgently referred to a hospital for treatment, such as oxygen, a bronchodilator, or injectable antibiotics. Before the child leaves, give the
first dose of an appropriate antibiotic. The antibiotic helps prevent severe pneumonia from becoming worse. It also helps treat other
serious bacterial infections, such as sepsis or meningitis. In the Treat the child section of this training you will learn how to identify
treatment and give urgent pre-referral treatments.
PNEUMONIA
 A child with a cough or difficulty breathing who has chest indrawing or fast breathing and NO general danger signs and NO
stridor when calm is classified as having PNEUMONIA.

 Chest indrawing or
PNEUMONIA
 Fast breathing

If the child is wheezing and does NOT have a general danger sign or stridor, test the child for pneumonia by giving a rapid
acting bronchodilator. Watch the relevant video in the SEE part of this training unit for how to give a rapid acting bronchodilator. Wait
for 15 minutes and reassess the child. If there is still chest indrawing or fast breathing, repeat the test twice before classifying the child's
illness as pneumonia.

Treatment. A child with pneumonia needs treatment with amoxicillin. In the Treat the child section of this training you will learn how to
give amoxicillin and how to teach caregivers to treat the child at home.
A child with wheezing should receive inhaled bronchodilator for 5 days. A child who has a chronic cough (a cough lasting more than 2
weeks) may have tuberculosis, asthma, whooping cough or another problem. A child with a chronic cough needs to be referred to
hospital for further assessment.

A child with chest indrawing usually has a more severe pneumonia than a child with fast breathing and no chest indrawing. Or the child
may have another serious acute lower respiratory infection, such as bronchiolitis, pertussis, or a wheezing problem.

Chest indrawing develops when the lungs become stiff. The effort the child needs to breathe is much greater than normal. If the child is
tired, and if the effort the child needs to expand the stiff lungs is too great, the child's breathing slows down. Therefore, a child with
chest indrawing may not have fast breathing. Chest indrawing may be the child's only sign of pneumonia.

A child with chest indrawing has a higher risk of death from pneumonia than the child who has fast breathing and no chest indrawing.
Previously, when oral cotrimoxazole was recommended for the treatment of “fast breathing pneumonia” and injectable antibiotics were
recommended for “chest indrawing pneumonia”, two different classifications were needed. Present guidelines recommend treatment
with oral amoxicillin that is equivalent to injectable penicillin in cases of “chest indrawing pneumonia” as well as in "fast breathing
pneumonia", therefore a child with chest indrawing can be treated at home and may be classified as PNEUMONIA.

An exception is chest indrawing in an HIV infected or exposed child and chest indrawing in a child with severe acute
malnutrition. These children need to be urgently referred to a hospital for injectable antibiotics and other treatments.
COUGH OR COLD

 A child with cough or difficult breathing who has no general danger signs, no stridor when calm, no chest indrawing, and no
fast breathing is classified as having COUGH OR COLD.

• No signs of pneumonia or very severe disease COUGH OR COLD

Treatment. A child with COUGH OR COLD does not need an antibiotic. The antibiotic will not relieve the child's symptoms. It will not
prevent the cold from developing into pneumonia. But the mother brought her child to the clinic because she is concerned about her
child's illness. Give the mother advice about good home care. Teach her to soothe the throat and relieve the cough with a safe remedy
such as warm tea with sugar. Advise the mother to watch for fast or difficult breathing and to return if either one develops.
If the child is wheezing, give an inhaled bronchodilator or, if not available, oral salbutamol for 5 days. If the wheezing is recurrent, refer
the child for assessment.
.
A child with a cold normally improves in one to two weeks. But a child who has a chronic cough (a cough lasting more than two weeks)
may have tuberculosis, asthma, whooping cough or another problem. A child with a chronic cough needs to be referred to hospital for
further assessment