SUMMARY NOTES.

IMCI/ETAT UNIT CODE:NRS-2/005

• PRE REQUISITE: Communication Skills, Anatomy and
Physiology, Fundamentals of Nursing,
Pharmacology I, Pharmacology II, Basic Nutrition
• CORE REQUISITE: Pediatric Nursing
• PURPOSE: The student will acquire knowledge on IMCI
strategy, develop skills and attitudes to enable him/her to
promote health, prevent illness and manage children less than
5 years suffering from common childhood diseases.
 UNIT CONTENT
: How to apply
- Pediatric Emergency Triage, Assessment and Treatment
(ETAT), principles in management of childhood illnesses and
Integrated Management of Childhood Illnesses (IMCI)
Assess, classify and manage a young infant with:
• cough and difficulty in breathing
• very severe disease
• fever
• diarrhea
• ear problems
• malnutrition
• HIV/AIDS
• meningitis
• jaundice
• eye infection.
Resuscitate a sick young infant; Check for:
• A feeding problem.
• Low weight or low birth weight.
• Young infant and mother’s HIV status.
• Teach the mother to treat local infections at home
• INSTRUCTIONAL METHODOLOGY: Probing questions, Lecture,
Brain storming, Small questions, discussion,
Assignments, Self-directed studies and Video Shows
• TEACHING MATERIALS: models, Charts, Videos, Computers,
Textbooks, ICATT
• MEANS OF EVALUATION: C.A.T. SandEnd of block examination
• REFERENCE MATERIAL:
• Ministry of health IMCI module book
• Ministry of health 2017 basic pediatric protocol 4th edition
 • World health organization2014 IMCI chart booklet.

INTRODUCTION

• Children are not just little adults!!

• An adult gives you the history directly – a child needs his parents to
relay the history

• Adult somatic growth is complete – a child’s growth is constantly

changing in predictable ways.
• An adult has completed all stages of development – a child’s
development and age are integrally related and impact all aspects of
her physical and emotional states.
DIFFERENCES BETWEEN PAEDIATRIC HISTORY AND ADULT HISTORY.
• Content Differences
– Prenatal and birth history
– Developmental history I'm
– Social history of family
– Environmental risks
– Immunization history
• Parent as Historian
– Parent’s interpretation of signs, symptoms
• Children above the age of 4 may be able to provide some of their
own history .
• Reliability of parents’ observations varies.
• Adjust wording of questions - “When did you first notice Johnny was
limping”? instead of “When did Johnny’s hip pain start”?
 –Observation of parent-child interactions
• Distractions to parents may interfere with history taking .
• Quality of relationship.
–Parental behaviors/emotions are important.
• Parental guilt -nonjudgmental/reassurance.
Outline of the Pediatric History
• Chief Complaint.
– Brief statement of primary problem (including duration) that caused
family to seek medical attention.
• History of Present Illness
 – Initial statement identifying the historian, that person’s relationship to
patient and their reliability.
– Age, sex, race, and other important identifying information about
patient.
– Concise chronological account of the illness, including any previous
treatment with full description of symptoms.
• Past Medical History
– Major medical illnesses.
– Major surgical illnesses-list operations and dates.
– Trauma-fractures, lacerations .
– Previous hospital admissions with dates and diagnoses.
 – Current medications.
– Known allergies (not just drugs) .
• Immunization status - be specific, not just up to date.
• Pregnancy and Birth History.
– Maternal health during pregnancy: bleeding, trauma, hypertension,
fevers, infectious illnesses, medications, drugs, alcohol, smoking,
rupture of membranes.
– Gestational age at delivery.
– Labor and delivery - length of labor, fetal distress, type of delivery
(vaginal, cesarean section), use of forceps, anesthesia, breech delivery.
 – Neonatal period - Apgar scores, breathing problems, use of oxygen,
need for intensive care, hyperbilirubinemia, birth injuries, feeding
problems, length of stay, birth weight.
• Developmental History
– Ages at which milestones were achieved and current developmental
abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st
word, toilet training, riding tricycle, etc. (see developmental charts)
– School-present grade, specific problems, interaction with peers
– Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares
etc.
• Feeding History
– Breast or bottle fed, types of formula, frequency and amount, reasons
for any changes in formula
– Solids - when introduced, problems created by specific types
– Fluoride use
• Family History
– Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer,
abnormal bleeding, allergy and asthma, epilepsy
– Mental retardation, congenital anomalies, chromosomal problems,
growth problems, ethnic background
• Social
 – Living situation and conditions - daycare, safety issues
– Composition of family
– Occupation of parents

Review of Systems:

• Weight - recent changes, weight at birth.

• Skin and Lymph - rashes, adenopathy, lumps, bruising and bleeding,
pigmentation changes.
• Headaches, concussions, unusual head shape, strabismus, conjunctivitis,
visual problems, hearing, ear infections, draining ears, cold and sore
throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis,
caries.
• Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, chest
pain, palpitations.
• Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum,
hemoptysis, TB

• GI - stool color and character, diarrhea, constipation, vomiting,

hematemesis, jaundice, abdominal pain, colic, appetite.

• GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of

urinary stream, polyuria, previous infections, facial edema.
• Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or
weakness, injuries, gait changes.
• Allergy - urticarial, hay fever, allergic rhinitis, asthma, eczema, drug
reactions.
 Integrated Management of Childhood illness.
(IMCI)
23

Definition
• Is the integrated strategy that combines and links together existing
child health programs?

• Is an evidenced based, syndrome approach to case management

that supports the rational, effective and affordable use of drugs and
diagnostic tools.

• A joint WHO/UNICEF initiative since 1992.Currently focused on first

level health facilities
 OBJECTIVES OF IMCI

• To reduce significantly mortality and morbidity associated with the

major cause of diseases in children

• To promote improved growth and development of children under 5

years of age.
PRINCIPLES OF IMCI CASE MANAGEMENT

• All sick children aged up to 5 years are examined for general danger
signs and all sick young infants are examined for very severe
disease. These signs indicate immediate referral or admission to
hospital
• The children and infants are then assessed for main symptoms. For
older children, the main symptoms include:
cough or difficulty breathing, diarrhea, fever and ear infection. For young
children, local bacterial infection, diarrhea and jaundice. All sick children
are routinely assessed for nutritional and immunization and deworming
status and other problems.
• Only a limited number of clinical signs are used.
• A combination of individual signs leads to a child’s classification
within one or more symptom groups rather than a diagnosis.
• IMCI management procedures use limited number of essential drugs
and encourage active participation of caretakers in the treatment of
children.
• Counseling of caretakers on home care, correct feeding and giving of
fluids, and when to return to clinic is an essential component of
IMCI

Essential IMCI Drugs at Health

Facilities(IMCI RECOMMENDED DRUGS)
• Artemether/Lumefantrine
• Amodiaquine Tabs (200mg)
• Quinine (inj.) (vials) (600mg/2ml)
• Amoxycillin Tabs (250mg)/syrup 250 mg or
125/5 ml
• Chloramphenicol (inj) 1g vials
• Chloramphenicol syrup (600ml bottles)
125mg/5mls
• Gentamicin (vials (80mg/2ml)
• Crystalline penicillin 100,000 units vials
• ORS 500ml sachet
• Hartmann’s solution 500ml bottles
• Nalidixic acid (250mg tabs)
• Metronidazole (200mg tabs)
• Erythromycin (250mg tabs)
• Mebendazole 500 mg tabs
• Iron 200mg
• Cotrimoxazole (80mg:400mg)
• Folic Acid tabs (5mg)
• Paracetamol tabs (500mg)
• Gentian Violet
• Mycostatin (20ml)
• Diazepam – vials
• 10% glucose ½ litre bottle
• Salbutamol (tabs) 2mg
 • Salbutamol inhaler
• Salbutamol nebulization solution (50ml bottle)
• Vitamin A (capsules) soft gelatmous 100,000 and 200,000 units
• Essential Non pharmaceuticals

INTRODUCTION
- 70% of children under five years die from pneumonia, diarrhea, malaria,
measles and malnutrition.

- There are feasible and effective ways health workers can care for children
with these illness and prevent most of the deaths.
- WHO and UNICEF uses updated technical findings to describe management
of these illness in a set of combined guidelines instead of using separate
guidelines for each illness.

• IMCI helps a health worker to quickly consider all of child’s symptoms

and not overlook any problem.

• There is also counseling to mothers and other care givers on importance

of seeking care for a sick child before a child becomes extremely sick and
follow up visits.
 CASE MANAGEMENT PROCESS.
1. Assess the child or Young infant
2. Classify the illness
3. Identify Treatment
4. Treat the child
5. Counsel the mother
6. Give follow-up care
PURPOSE OF IMCI
1. Assess signs and symptoms of illness, nutrition, immunization and
Vitamin A supplementation status
2. Classify the illness
3. Identifying Treatment for the child’s classification of illness and deciding
on referral
4. Giving important pre-referral medication
5. Providing Treatments in the clinic.
eg. Vit.A, ORS, DRUGS.
6.Teaching mothers to give specific treatment at home .eg. oral antibiotics
7. Counselling the mother on feeding and return dates
8.Reassessing during follow up and providing appropriate care.

• NB:Most classification tables have 3 rows colored pink, yellow or Green

depending on the seriousness of the child’s illness.
 Assess and Classify the Sick Child Aged 2 months
up to 5 years
• This describes how to assess and classify sick children so that signs of
diseases are not overlooked.

• According to the chart, the mother is asked about the child’s problems
and he/she is examined for general danger signs.

• Four main symptoms are considered;

- Cough and Difficult in breathing
- Diarrhea
- Fever
- Ear Problem
 A child with one or more of the main symptoms could have a serious illness.
Children with HIV may be ill more often and illness may be more severe.

Skills to be learnt include:

• Asking the mother what the child’s problem is • Checking for General
danger signs.

• Asking the mother about the four main symptom.

• When a main symptom is present, assess the child further for signs related
to the main symptoms, classifying illness according to signs present.

• Checking for signs of malnutrition and anemia and classifying a child’s

nutrition status.
• Checking the child for symptomatic HIV infection.

• Checking the childs’ immunisation status and Vit.A implementation status.

• Asking any other problem.

1. ASK THE MOTHER WHAT THE CHILDS PROBLEM ARE:

- A child may be brought to the clinic because it is sick, well child
visits,immunisations and treatment of injuries

- IMCI Charts are not to be used on a well child brought for immunization or
for a child with any injury or burn.
-When you see a mother and the sick child - Greet the mother
appropriately.
 -Ask the mother what the child’s problem and ensure you have good
communication skills.
-Determine if it is an initial visit or follow up visit for the problem.
2) CHECK FOR GENERAL DANGER SIGN
A danger sign is present if:
-A child is not able to feed /breastfeed

- The child vomits everything

- The child has had convulsions or is convulsing now.
- The child is lethargic or unconsciousness.
NB: Most children with a General danger sign needs urgent referral to the
hospital.
3.ASSESS AND CLASSIFY COUGH OR DIFFICULT IN BREATHING
A child with cough and difficult in breathing may have pneumonia or another
severe respiratory infection.
Two clinical signs suggesting pneumonia are:- fast breathing and chest in
drawing.

• A child with difficult breathing is assessed for:

- How long the child has had cough or difficulty in breathing

-Fast beathing;2/12-1 year-more than 50 breaths per min,1yr-5 yr-More
than 40 breaths per min.
-Chest in drawing
-Stridor in a calm child
-Wheeze
 CLASSIFY COUGH AND DIFFICULT IN BREATHING
• The three possible classification for this are:-

- Severe pneumonia or Very severe Disease

-Pneumonia
-No pneumonia
MANAGEMENT.

• SEVERE PNEUMONIA OR VERY SEVERE DISEASE

- A child with chest in drawing usually has severe pneumonia or it may have
another serious acute lower respiratory infection. eg. bronchiolitis,
pertussis or wheezing problem.
- Chest in drawing develops when lungs become stiff and the child needs
more effort to breath and the breathing may become slowed.

- It may be the only sign of severe pneumonia

- Chest in drawing is also an entry sign for suspected symptomatic HIV

infection.

• The child need urgent referral to a hospital for treatment. eg. Oxygen and
I.V. antibiotics.

• Before referral, administer appropriate antibiotic to prevent pneumonia

from worsening.

• Also treat other serious bacteria infection .eg. sepsis and meningitis

• Treat the child to prevent low blood sugar.

• Incase of convulsions, manage airway and give diazepam.

• Check the child for suspected symptomatic HIV infection.

Drugs used in Severe pneumonia

• 1ST LINE: Benzyl penicillin 50 000iu/Kg QID • - 2ND Line: Ceftazidime 90-
150mg/kg/day or - Ceftriaxone 50-75 mg/kg/day OD.
VERY SEVERE PNEUMONIA

• Benzyl penicillin and Gentamicin 5mg/Kg I.M

b) Give a bronchodilator
If wheezing, give a bronchodilator if available
c) Treat fever-give paracetamol 6 hourly.
d)Manage fluids carefully
-Give fluids with caution to avoid overloading
-Encourage child to drink
-Avoid NGT if child is in respiratory distress
e) Manage Airway
-Clear blocked nostrils
-Help a child to cough up secretions
f) Keep the infant warm
TREAT WHEEZING

• Use a bronchodilator to treat wheezing

• Asses child after 30 minutes

ASSESS TREAT CHILD<1 YR
Chest in drawing +other -Nebulise using rapid acting
danger sign +wheeze bronchodilator
-First dose of Antibiotic
-Refer immediately
Fast breathing + -Oral bronchodilators
wheeze -Oral antibiotics
-Send home on treatment
-Follow up in 2/7
TREAT CHILD>1YR
-Nebulise using rapid acting
bronchodilator
-Assess after 30 minutes
-Give oral prednisolone -
Give first dose of antibiotic
and refer immediately
-Oral bronchodilators
-Oral antibiotics
-Send home on treatment
-Follow up in 2/7
No fast breathing; -Oral bronchodilators Oral bronchodilators
wheeze only -Send home on treatment -Send home on treatment

ORAL BRONCHODILATORS
• Salbutamol inhaler in spacer 2 puffs in 10 minutes.

• Subcutaneous epinephrine 0.01ml/Kg

• Nebulizer salbutamol <1 yr0.5ml in 2.0ml of sterile water >1 yr1.0mls in

2.0 mls of sterile water

• If not improved,IV Aminophylline 5mg/kg given slowly over 20 minutes

• Monitor vital signs.

 ORAL SALBUTAMOL TDS FOR 5 DAYS
AGE 2MG TABS 4MG TABS SYRUP

2/12-12/12 ½ ¼ 2.5mls

1yr-5yr 1 ½ 5.0mls

PNEUMONIA
• A child with fast breathing and no danger sign is classified as having
pneumonia
TREATMENT

- Give an appropriate antibiotic

- Give vitamin A

- Teach the mother to give antibiotics at home - Advice her on when to

return.

DRUGS
a) Give antibiotic treatment
i) Mild chest in drawing and no respiratory
distress, administer oral Amoxycillin. See the child daily and if no
improvement give I.M. Xpen.
 COTRIMOXAZOLE AMOXYCILLIN

AGE/WT 480 mg tabs 120mg tabs syrup 250mg Syrup

capsule 125mg/5ml
2/12-12/12 ½ tab 2 5mls 1/2 5 mls
4-10kg

1year-5 yrs 1tab 3tabs 7.5 mls 1 10mls

10-19kgs
 No pneumonia, cough or cold
• There is no need for an antibiotic

• Advice the mother on good home care of the child using the home
remedy.eg. warm beverages

• In case of a chronic cough, refer the child to hospital for further

assessment.
ASSESS AND CLASSIFY DIARRHOEA

Diarrhea is the passing of 3 or more watery stools in a 24 hour

period.
• Common in babies under 6 months on formula feeds or cows’
milk.
• TYPES OF DIARRHOEA
a) Acute Diarrhea
-Lasts less than 14 days -Causes dehydration
- Leads to malnutrition
b) Persistent diarrhea
-Lasts more than 14 days
- Causes nutritional problems
-Contributes to death in children
-Found mainly in HIV infections
• Child with diarrhea is assessed for:
- Duration of diarrhea
-Presence of blood in stool
-Signs of dehydration
ASSESS DIARRHEA

- General condition
- Abnormally sleepy-Lethargic/unconsciousness
- Restless or irritable
- Sunken eyes
- Assess for blood in stools
 • Observe the child as he drinks

• Assess if the child drinks –Normally

- eagerly/Thirsty

- Weakly
• Pinch the skin of the abdomen;
- Does it go back very slowly.
- Goes back slowly.
- Goes back normally.
 CLASSIFY DIARRHOEA.
CLASSIFY DEHYDRATION IN ACUTE DIARRHOEA
1. Severe dehydration
2. Some dehydration
3. No dehydration
CLASSIFY PERSISTENT DIARRHEA AS:
1.Severe persistent diarrhea
2.Persistent diarrhea
• Presence of blood in stool is classified as dysentry.
 ≥ 14
day
 MANAGEMENT OF DIARRHOEA/GE
• Antibiotics are NOT indicated unless there is dysentery or persistent
diarrhea and proven amoebiasis or giardiasis.

• All cases should receive zinc sulphate.

• Manage nutrition of the child

• Pharmacological management-antibiotics used only when the diseases

associated with diarrhea are confirmed.
MANAGEMENT OF DEHYDRATION
Management of severe dehydration
PLAN C: TREAT SEVERE DEHYDRATION IN THE CLINIC
 - Give Ringers lactate in divided doses as follows

- Give 30mls/Kg in 1 hour if child is below 1 year and over ½ hour if above 1
year.

- Another alternative is 70 ml/kg of Ringers lactate in 5 hours for under 1

year and over 21/2 hours for above one year

- Reassess at least hourly, after every 3-6 hours, reclassify as severe, some or
no dehydration.
• Another alternative is use of NGT where 100mls/Kg of ORS is given over
6 hours.
 PLAN B; TREAT SOME DEHYDRATION WITH ORS
-It includes an initial treatment period of 4 hours in the clinic
Give ORS 75mls/Kg over a period of 4 hours

- After four hours, reassess and classify the child for dehydration and
choose appropriate plan to continue with.
PLAN A: TREAT DIARRHEA AT HOME

- This is for treatment of a child who has diarrhea but no

dehydration.

- Three rules apply in home treatment.

- Give extra fluid
- Continue breast feeding
 - Give ORS 10mls/Kg after every loose stool
- Return for follow up
SEVERE PERSISTENT DIARRHOEA

• Treat dehydration using appropriate fluid plan. ie. plan C

• Advice mother to feed the child frequently

• Give vitamins and minerals

• Identify and treat infections

• Monitor the child

 Assigment
• MARY , 11 MONTHS OLD, WEIGH S 8 KG .HE COMES TO THE CLINIC TODAY
BECAUSE HE HAD DIARRHOEA. HE HAS NO BLOOD IN THE STOOL . HE IS
IRRITABLE. HIS EYES ARE SUNKEN.THE HEALTH WORKER OFFERS THE CHILD
FLUID , AND THE CHILD DRINKS EAGERLY . WHEN THE HEALTH WORKER
PINCHES THE SKIN OF THE ABDOMEN , IT GOES BACK SLOWLY. ASSESS AND
CLASSIFY JOELS ILLNESS.
 ASSESS AND CLASSIFY FEVER
• A child with fever may have malaria, measles, or a simple cough, cold, viral
infections or a very severe disease.
• MALARIA

- It’s a protozoa infection caused by plasmodium species especially

P.falciparum.

- It’s a major public health problem in Kenya

- It has two epidemiological situations

a) Stable Malaria
-Occurs in high rainfall areas within lake basins or coastal strips.
-These are also known as High malaria risk areas.
-Nearly all populations have the parasite in most parts of the year
especially children and pregnant women

b) Unstable Malaria
-Is seasonal and follows rainfall pattern.
- Becomes epidemic with prolonged rainfall
- All ages are affected and can develop severe disease
-Areas affected are Low Malaria Risk areas.
 ASSESS FOR FEVER
• Does the child feel hot or temperature of 37.5◦c • Then ask:
- For how long,
-If more than 7 days, has fever been present everyday?
-Has the child had measles within the last 3 months

• Look and feel for stiff neck

• Look for runny nose

• Look for signs of Measles

- Generalised rash and

 - One of these: cough, runny nose or red eyes.
• If the child has measles now or within the last three months
-Look for mouth ulcers
- Look for pus draining from the eye -Look for clouding of
the cornea.
  Give first dose of quinine (under medical
* Any VERY supervision or if a hospital is not
general SEVERE accessible within 4 hours.
danger FEBRILE  Give first dose of an appropriate
sign or DISEAS antibiotic.
* Stiff neck
. E/  Treat the child to prevent low blood
MALARIA sugar.
 Give one dose of paracetamol in health
( 0C or above).
centerfor high fever37.5
 Send a blood smear with the patient.
 Refer URGENTLY to hospital.
  Treat the child with an oral antimalarial .

* Blood  Give one dose of paracetamol in health center

smear MALARIA
for high fever (37.5 0C or above).
(+)
 Advise mother when to return immediately.
If blood
 Follow-up in 2 days if fever persists.
smear
not  If fever is present every day for more than 7
done: days, refer for assessment.
* NO runny
nose,
and
* NO
measles,
and
* NO other
causes
of fever
 THEN ASK: Does the Child have Fever?

severe
HEMORRHAGIC immediately.
60
hemorrhagic fever

61
 NB: To classify and treat fever, one must know the malaria risk in
the area.
There is high malaria risk if most of the fever cases are due to
malaria
There is low malaria risk if less than 5% of fever cases are due to
malaria.
• MEASLES

- The main signs of measles are fever and generalized rash.

- It is highly infectious especially in overcrowded areas.

- Etiology- caused by a virus

 - It infects the skin and layers of the cells lining the lungs,
gut,eye,mouth and throat. There is also damage to the
immune system.
• Complications include
-Diarrhea
-Pneumonia
-Mouth ulcers
-Ear infections
-Severe eye infection and blindness.
Leads to malnutrition secondary to diarrhoea and mouth ulcers.
SEVERE FEBRILE DISEASE

• Give antibiotic and ant malaria treatment

- Treat for meningitis and Malaria
- Meningitis-I.M Cef and benzyl penicillin QID. Give high doses.
Treat for 10 days
-Malaria-Give quinine, if not available, oral antimalarial.
-Manage fluids carefully
NB: Very severe febrile disease with stiff neck and bulging
fontanelle,restrict fluids.
• Treat fever using paracetamol

• Paediatric paracetamol doses

 NB: Fever alone is not a reason to give antibiotic except in young
infant aged less than 2 months.
TREATMENT OF UNCOMPLICATED MALARIA
1ST Line-Artemether Lumefantrine:Dosing scheduled for AL
 TREATMENT OF SEVERE MALARIA
• IV or IM QUININE

• Loading dose,20 mg/Kg. Over three hours

• Maintenance dose 10mg/Kg

• Switch to oral quinine after the child improves at 10mg/kg/day.

 ANTIBIOTICS
- MENINGITIS
Give penicillin and ceftriaxone
-Benzyl Penicillin 100 000i.u/Kg in 4 divided doses
-Ceftriaxone 100/kg 12 hourly
DIAZEPAM FOR CONVULSIONS
Main treatment for recurrent convulsions

• Give 0.5mg/Kg diazepam solution per rectal

• Check blood sugar levels and manage appropriately.5mls/Kg of 10%

Dextrose
• Repeat diazepam in 10 minutes

• Give Oxygen if available and refer

• Check ABC after the fit

• Check airway and clear

TREAT CHILD FOR HYPOGLYCAEMIA

• Ask the mother to breastfeed if the child can breastfeed

• Give EBM if the child can swallow but unable to breastfeed

• If unable to swallow, give Dextrose 10%(10mls/Kg)

I.V. slowly
• Keep the child warm

• Refer urgently

• Grace is 4 months old. She weighs 5.5kg. Her temperature is 38.0C.

She is in the health center today because she has diarrhea. She
does not have any General Danger Signs. She is not coughing and
does not have difficult breathing. Assess and classify Grace illness.
ASSESS AND CLASSIFY EAR PROBLEM

Assess for: -Ear pain

- Ear discharge and duration

- Tender swelling behind the ear-Mastoiditis

ASSESS CLASSIFY MANAGEMENT

TENDER MASTOIDITIS UURGENT REFERRAL

SWELLING
BEHIND THE CLASSIFICATION ADMINISTER FIRST DOSE OF APPROPRIATE
ANTIBIOTICS
EAR ADMINISTER PARACETAMOL FOR PAIN
SURGERY

PUS DRAINS ACUTE EAR INFECTION ADMINISTER ORAL ANTIBIOTICS

FROM THE Acute PARACETAMOL FOR PAIN
EAR< 14 DAYS WICKING TO DRY THE EAR
EAR PAIN

PUS DRAINS CHRONIC EAR INFECTION WICKING TO DRY THE EAR

FROM THE EAR DON’T GIVE REPEATED COURSES OF
FOR MORE ANTIBIOTIC
THAN 14 DAYS

OR
NO EAR NO EAR INFECTION NO TREATMENT NEEDED
INFECTION
 MASTOIDITIS

• Give IM benzyl penicillin

• Treatment for 10 days

• Switch to oral CAF 25mg/kg QID after 3-5 days.

 ASSESS FOR MALNUTRITION AND ANAEMIA
NB: Growth faltering and very low weight is an entry sign for
suspected HIV infection.
Visible severe wasting SEVERE Urgent referral
Severe pal mar pallor MALNUTRITION/SEVERE Special feeding
Edema of both feet ANEMIA Antibiotic Treatment
Weight below very low Vitamin A
weight curve Treat to prevent low blood
sugar
Some pal mar pallor ANEMIA/VERY LOW WEIGHT -Administer Iron
Very low weight for age -Administer Ant malarias in
high risk areas
-Mebendazole for
Hookworms/Whip worms
-Advice follow up in 2/52 for
palmar pallor and 1/12 for
very low weight
No pallor NO ANEMIA/NOT VERY LOW -Assess childs feeding and
No signs of malnutrition WEIGHT. advice on proper feeding
-Administer Mebendazole if
child is >2 years
 ASSESS FOR SUSPECTED SYMPTOMATIC HIV
INFECTION
• Assess for Symptomatic HIV Infection.

• 3 or more of he following:
-Enlargement of lymph nodes of neck,axilla or groin
-Oral thrush
-Growth faltering
-Fast breathing/chest in drawing
-TB in any of the parents in the last 5 years
-2 or more episodes of persistent diarrhea (lasting more than 14
days).
Any 3 of the following SUSPECTED SYMPTOMATIC HIV
-Enlargement of lymph INFECTION
nodes of
neck,axilla or groin
-Oral thrush
-Growth faltering
-Fast breathing/chest in
drawing
-TB in any of the parents in
the
last 5 years
-2 or more episodes of
diarrhea
lasting more than 14 days.
 Less than three of the above NO SUSPECTED SYMPTOMATIC HIV
INFECTION

CHECK FOR IMMUNISATION STATUS

AND VIT A SUPPLEMENTATION STATUS
• Use recommended immunization schedule

• Give recommended vaccine if the child is due.

• NB:CONTRAINDICATIONS TO IMMUNISATIONS
1. Do not give BCG and Yellow fever vaccine to a child known to
have Symptomatic HIV infection
2. Do not give Pentavalent 2 and 3 to a child who has had convulsion
or shock within 3 days of the recent dose.
3. Do not give Pentavalent to a child with recurrent convulsion or
another neurological disease.

• Children with diarrhea due for OPV should receive it but should
return in 4 weeks for an extra OPV dose

• If a child is going to be referred, do not immunize the child

before referal.The hospital staff should make the decision about
immunizing the child once admitted.
WHO/UNICEF Recommendations for HIV Infected Children
Vaccine Asymptomatic Symptomatic Optimal timing of
HIV HIV immunization

BCG Yes No Birth

 DPT Yes Yes 6, 10, 14 wks

PCV 10 Yes Yes 6, 10, 14 wks

OPV* Yes Yes 0, 6, 10, 14 wks

Measles Yes Yes 6 and 9 months

Hepatitis B & HiB Yes Yes 6, 10, 14 wks

Yellow fever Yes No** 9 months

* IPV an alternative for children with symptomatic HIV

** Pending further studies.
 114

ASSESS ANY OTHER PROBLEM THE CHILD HAS.

• Since ASSESS and CLASSIFY does not address all of the sick Childs'
problems, you will now assess other problems the mother told
you about. She may have said the child has skin infection, itching
or swollen lymph nodes.

• Identify and treat any other problems according to your training,

experience and clinic policy.
Assess, Classify and Treat the Sick
Young Infant Age 1 week up to 2
months
• To assess the young infant, Ask if the infant has had convulsions.
 •
look and feel for:
-Number of breaths in 1 minute

- Look for severe chest in drawing

- Look for nasal flaring

- Look for grunting and wheezing

- Look and feel for bulging Fontanelle.

- Look for pus draining from eyes and ears

- Look for pus draining from OR redness of the umbilicus

- Measure the Temperature

- Look for skin pustules

- Assess if infant is lethargic or unconscious.

- Look for movements.

CHECK FOR POSSIBLE BACTERIAL INFECTION
ASSESS FOR DIARRHEA

• Diarrhoea
• Blood in the stool
• Restless and irritable
• Sunken eyes
• Very slow skin pinch

THEN ASK: Does the young infant have diarrhea?

ASSESS FOR FEEDING PROBLEMS
CHECK IF AN INFANT HAS:

• Any difficulty feeding

• Is infant breastfeed

• Breastfeeding less than 8 times in 24 hours

• Taking other foods or fluids

• Low weight for age

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

 • Check immunization status of the infant.
• Assess any other problem the child has.
BREASTFEEDING PROBLEMS AND
SOLUTIONS
1. Difficult Breastfeeding
-Assess breastfeeding and breast problems
-Show mother on correct positioning and attachment
2. Use of feeding bottle
- Recommend reinstating breastfeeding if possible
-Recommend substituting bottle with cup and spoon.
-Show the mother how to feed the child with a cup.
 -Re emphasize hand washing.
3.Lack of Active feeding
-Counsel the mother feed the infant on demand
4. Child has Symptomatic HIV infection.
-Treat mouth sores quickly if present
-Ensure extra feeding when recovering from illness.
-Counsel on breastfeeding.

5.Not feeding well during illness

Counsel mother to :

• Clear blocked nostrils if they interferes with feeding

• Breast feeding more frequently and longer

• Encourage the child to eat as much as possible

• Give varied, soft, appetising enriched foods.

• Offer small frequent foods

• Check regularly for oral thrush.

• Follow up for feeding problems in 5/7 days.

REFERRAL OF A CHILD

• Cases when urgent referral is needed;

1. Severe pneumonia /Very severe disease
2. Severe Dehydration(if clinic can’t offer I.V. fluids)
3. Severe persistent diarrhea
4. Very severe febrile disease
5. Severe complicated measles
6. Mastoiditis
7. Severe malnutrition/Severe anemia
VITAMIN A

• Given to a child with severe malnutrition, measles,persistent diarrhea

and severe pneumonia

• Given in 2 doses for measles

• One dose given for other disease conditions if he had not received one
in the past one month.

• One dose given as per KEPI schedule.

 MULTI VITAMIN/MINERAL SUPPLEMENT
• Given to children with persistent diarrhea

• Given daily for two weeks

AGE/WEIGHT MULTIVITAMIN/MINERAL SUPPLEMENT
SYRUP

2/12-6/12 2.5 mls

4-8Kg

2yrs-5yrs 7.5mls
12-19Kg
 ETAT:TRIAGE OF SICK CHILDREN

• Emergency signs
1. Airway and Breathing:
 obstructed breathing,
 central cyanosis,
 severe respiratory distress,
 weak/absent breathing
2. Circulation

 Cold hands with;

 capillary refill> 3 seconds,

 weak and fast pulse,

 Slow( <60bpm) or absent pulse
3. Coma /convulsions/confusion in a child: AVPU=P’ or U’
4. Diarrhoea with sunken eyes= assessment and treatment for severe
dehydration
PRIORITY SIGNS IN A CHILD

• Tiny-sick infant aged less than 2 months

• Temperature very high > 39.5

• Trauma-major trauma

• Poisoning-mother reports poisoining

• Pallor-severe palmar pallor

 • Restless/irritable/Floppy

• Respiratory distress

• Referral-has an urgent referral letter

• Malnutrition-visible severe wasting

• Oedema of both feet

• Burns-severe burns
NB; Children having the above priority signs should be given priority in
the queue, weigh the baby, take baseline observations.

-END -