◄UNIT 5:PREVENTION OF DISEASES IN CHILDRENTopic 7►

UNIT6:CHILD HEALTH CARE

  • UNIT6:CHILD HEALTH CARE

    Key Unit Competence
    Provide care to children

    6.0 Introductory activity

    6.1 Introduction to Integrated Management of Childhood 

    Illnesses (IMCI)

    Learning activity 6.1

    Children are not small adults and they face multiple diseases that affect their 
    health. In developing countries, there is a high burden of diseases affecting 
    under five children requiring early detection of those diseases and management.
    Based on your clinical exposure and meeting patients of different ages, what 
    should be prioritized when managing sick young children in low resource 

    settings?

    Since the 1970s, the estimated annual number of deaths among children less than 
    5 years old has decreased by almost a third. This reduction, however, has been 
    very uneven. And in some countries rates of childhood mortality are increasing. 
    In 1998, more than 50 countries still had childhood mortality rates of over 100 per 
    1000 live births. Altogether more than 10 million children die each year in developing 

    countries before they reach their fifth birthday. Seven in ten of these deaths are due 

    to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, 
    or malnutrition and often to a combination of these conditions.
    Limited supplies and equipment, combined with an irregular flow of patients, 
    leave health care providers at first-level facilities with few opportunities to practice 
    complicated clinical procedures. Instead, they must often rely on history and signs 
    and symptoms to determine a course of management that makes the best use of 
    available resources.
    Providing quality care to sick children in these conditions is a serious challenge. 
    In response to this challenge, WHO and UNICEF developed a strategy known as 
    Integrated Management of Childhood Illness (IMCI). Although the major stimulus 
    for IMCI came from the needs of curative care, the strategy combines improved 
    management of childhood illness with aspects of nutrition, immunization, and other 
    important disease prevention and health promotion elements. 
    The objectives are to reduce deaths and the frequency and severity of illness and 
    disability and to contribute to improved growth and development.
    Below are principles of IMCI:
    • All sick young infants up to two months must be assessed for bacterial 
    infection/jaundice and major symptoms of diarrhea
    • All sick children 2months to 5 years must be examined for general danger 
    signs which indicate the need for referral or admission to a hospital
    • All young infants and child 2months-5years of age must be routinely assessed 
    for nutritional status and immunization status, feeding problems and 
    other potential problems.
    Integrated Management of Childhood Illnesses (IMCI) is:
    • not necessarily dependent on the use of sophisticated and expensive 
    technologies
    • a more integrated approach to managing sick children 
    • move beyond addressing single diseases to addressing the overall health 
    and well-being of the child
    • careful and systematic assessment of common symptoms and specific clinical 
    signs to guide rational and effective actions
    • integrates management of most common childhood problems (pneumonia, 
    diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and 
    anemia, ear problems)
    • includes preventive interventions 
    • adjusts curative interventions to the capacity and functions of the health 
    system (evidence-based syndromic approach)

    • involves family members and the community in the health care process

    Due to its appropriateness, the IMCI facilitates the accurate identification at 
    first contact, appropriate combined treatment of all major illnesses, speeds 
    –up referral of the severely ill child and improves the quality of care of sick 

    children at the first referral level.

    Self- assessment activity 6

    1. Describe three (3) principles of IMCI.

    2. What are the major facilitators of IMCI in low resource settings?

    6.2 Components of Integrated Management of Childhood 

    Illnesses (IMCI)

    Learning activity 6.2

    In your opinion, what should be the involvement of families and community 
    during the patient care?
    Integrated Management of Childhood Illnesses (IMCI) is meant to move along the 
    two tracks of the health systems and community, respectively while promoting the 
    establishment of strong links between the two with much emphasis on capacity 
    building. Its aim is to reduce preventable mortality, minimize illness and disability 
    and promote healthy growth and development of children under 5 years of age.
    To improve access and quality of care for newborns and children in primary health 
    care services, WHO and UNICEF designed the IMCI strategy.
    IMCI is a strategy that has three components which are:
    1. Improvements in the case-management skills of health staff through the 
    provision of locally adapted guidelines on IMCI and through activities to 
    promote their use
    2. Improvements in the health system required for effective management of 
    childhood illness
    3. Improvements in family and community practices
    The aim is to strengthen prevention and management of common childhood illnesses 
    in the newborn period, and support children’s healthy growth and development.

    6.2.1 Improvement health workers skills

    This refers to clinical and communication skills and covers both pre-service 

    education and in-service training in the case management of sick children.

    IMCI case management requires a well-defined set of knowledge and skills to 
    accurately assess, classify, and treat ill children and, thereby, reduce mortality 

    and reduce disabilities.

    a. Case management process

    The health worker assesses a child by checking first for danger signs, asking 
    questions about common conditions (cough or difficult breathing, diarrhea, fever, and 
    ear problems), examining the child, and checking the nutrition, immunization 

    status and assesses also the child for other health problems.

    After classification, the health worker identifies specific treatments and develops 
    an integrated treatment plan for each child. If a child requires urgent referral, the 
    health worker gives essential treatment before the patient is transferred. If a child 

    needs treatment at home, the health worker gives the first dose of drugs to the child

    The health worker provides practical treatment instructions, and advice on how to 
    give oral drugs, feeding, fluids during illness, how to treat local infections at home 
    and advises the caretaker on follow-up care to recognize signs that indicate that the 

    child should return immediately to the health facility.

    If a child is underweight, provides counselling to solve feeding problems, including 
    assessment of breastfeeding practices and follow up on immunization schedule 

    and if necessary, reassesses the child for new problems.

    b. Assessing danger signs in children using IMCI strategy
    In IMCI all children are assessed for the following danger signs:
    • lethargic or unconscious
    • Convulsing now
    • History of convulsions
    • Vomiting everything.
    • Not able to drink or breastfeed
    If a child has any of these danger signs, he/she should be managed quickly and if 
    necessary refer after giving him/her pre- referral treatment.

    c. Main symptoms
    After the danger signs, children are then assessed for four main symptoms. These 
    are:
    • Cough and difficult breathing
    • Diarrhea
    • Fever

    • Ear problem

    6.2.2 Improvement of health systems

    Improving health systems to deliver IMCI concerns policy, planning and management, 
    financing, organization of work and distribution of tasks at health facilities, human 
    resources, availability of drugs and supplies, referral, monitoring and health 
    information system, supervision, evaluation and research. It is an umbrella which 
    covers human resources and their capacity. 

    6.2.3 Improvement of family and community practices

    The community component of the Integrated Management of Childhood Illness 
    (IMCI) strategy addresses family and community child care practices. The family 
    and the community where children live play a major role in child health and 
    development. There is a longstanding need to involve the family and community 
    actively and plan and implement child care interventions in both the health system 
    and the community in parallel. There are 12 key family and community practices 
    related to child health and development, that if properly promoted and adopted by 
    the targeted communities, would potentially contribute to improving child survival, 

    growth and development.

    These includes:
    • Breastfeeding feeding: the baby should breastfeed exclusively for at least 
    up to 6 months to improve their immunity and reduce resistance to infection.
    • Complementary feeding: From 6 months of age, other feeds may be 
    introduced like freshly prepared energy and nutrients rich complementary 
    foods combined with breastfeeding can be continued up to 2 years or longer.
    • Micronutrients: Ensure that children receive adequate amounts of 
    micronutrients (vitamin A, iron and zinc, in particular). 
    • Hygiene: Children’s faeces should be properly disposed, and wash hands 
    after defecation before preparing meals and before feeding children.
    • Immunization: children’s schedule of immunization should be respected 
    (complete a full course of immunizations example: BCG, DPT, OPV and 

    measles).

    • Malaria: Protect children in malaria-endemic areas, by ensuring that they 
    sleep under insecticide-treated mosquito nets
    • Psychosocial development. Promote mental and social development of 
    children and stimulating environment (talking, playing, dancing,)
    • Home care for illness. Continue to feed and offer more fluids, including 
    breastmilk, to children when they are sick. 
    • Home treatment for infections. Give sick children appropriate home 
    treatment for infections. 
    • Care-seeking. Recognize when sick children need treatment outside the 
    home and seek care from appropriate providers. 
    • Compliance with advice. Follow the health worker’s advice about treatment, 
    follow-up and referral. 
    • Antenatal care. Ensure that every pregnant woman has adequate antenatal 
    care. This includes having at least four antenatal visits with an appropriate 
    health care provider and receiving the recommended doses of the tetanus 

    toxoid vaccination.

    In addition, IMCI incorporates a strong component of prevention and health 
    promotion as an integral part of care. thus, among other benefits, it helps increase 
    vaccination coverage and improve knowledge and home-care practices for 

    children under five, subsequently contributing to growth and healthy development.

    Key requirements for IMCI strategy

    • The adoption of a national policy and standards on an integrated approach to 
    child health and development.
    • Regular review and updating of IMCI clinical guidelines with adaptation to the 
    country’s epidemiology, medicines and commodities, relevant policies, and 
    local foods and language used by the population.
    • Improving quality of care in primary health facilities by training, mentoring and 
    support supervision of health workers in integrated assessment, treatment 
    and effective counseling of caregivers.
    • Ensuring availability of the essential medicines, laboratory tests and key 
    equipment for prevention and case management.
    • Strengthening referral pathways and improving quality of care in hospitals for 
    management of severely ill children referred from the outpatient clinics.
    • Empowering families and communities to prevent disease, seek timely care 
    from qualified health care providers for illness, provide adequate home care 
    for sick children, and support children’s healthy growth and development. 

    Three major determinants of effective implementation

    • Political leadership to ensure an enabling environment
    • Strengthened health systems based on empowerment, recognized, motivated, 
    supplied and supported frontline health workers
    • Empowered communities that can hold systems accountable and utilize IMCI 

    services

    Self- assessment activity 6.2

    1. Mention three components of IMCI Strategy.

    2. Discuss the major determinants of effective implementation of IMCI.

    6.3 Specific assessment of children under five years

    Learning activity 6.3


    WHO have developed a series of IMCI charts which show the sequence of the steps 
    and provide information that will help to apply IMCI case management guidelines 
    according to the age of the child.
    Describes how to assess and classify sick children so that signs of disease are not 
    overlooked. According to the chart, you should ask the mother about the child’s 
    problem and check the child for general danger signs. Then ask about the four main 
    symptoms: cough or difficult breathing, diarrhea, fever and ear problem. A child 
    who has one or more of the main symptoms could have a serious illness. When 

    a main symptom is present, ask additional questions to help classify the illness. 

    Check the child for malnutrition and anemia. Also check the child’s immunization
    status and assess other problems the mother has mentioned.
    6.3.1 Assess the child for danger signs
    Record what the mother tells you about the child’s problems by using good 

    communication skills


    Table 6.1: Classification of danger signs in children
    Check ALL sick children for general danger signs. A general danger sign is present 
    if:
    • the child is not able to drink or breastfeed
    • the child vomits everything
    • the child has had convulsions

    • the child is lethargic or unconscious.

    A child with a general danger sign has a serious problem. Most children with a 
    general danger sign need URGENT referral to hospital. They may need lifesaving 
    treatment with injectable antibiotics, oxygen or other treatments which may not be 
    available in health center. 
    Complete the rest of the assessment immediately.
    When you check for general danger signs:
    ASK: Is the child able to drink or breastfeed?
    A child has the sign “not able to drink or breastfeed” if the child is not able to suck 

    or swallow when offered a drink or breastmilk

    When you ask the mother if the child is able to drink, make sure that she 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, 
    is the child able to take fluid into his 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 breastmilk. 
    Look to see if the child is swallowing the water or breastmilk.
    A child who is breastfed may have difficulty sucking when his nose is blocked. If the 
    child’s nose is blocked, clear it. If the child can breastfeed after his 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 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.
    When you ask the question, use words the mother understands. Give her time to 
    answer. If the mother is 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 if each time the child swallows’ food or fluids, does the child vomit? If you are 
    not sure of the mother’s answers, ask her to offer the child a drink. See if the child 

    vomits.

    ASK: Has the child had convulsions?
    Ask the mother if the child has had convulsions during this current illness.
    LOOK: See if the child is lethargic or unconscious.
    A lethargic child is not awake and alert when he should be. He is drowsy and does 
    not show interest in what is happening around him. Often the lethargic child does 
    not look at his mother or watch your face when you talk. The child may stare blankly 
    and appear not to notice what is going on around him.
    An unconscious child cannot be wakened. He does not respond when he 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.
    Note: If the child is sleeping and has cough or difficult breathing, count the number 
    of breaths first before you try to wake the child.
    If the child has a general danger sign, complete the rest of the assessment 
    immediately. This child has a severe problem. There must be no delay in his 
    treatment

    6.3.2 Assess the child for main symptoms

    Ask the mother about the four main symptoms: cough or difficulty in breathing, 
    diarrhea, fever and ear problems.
    a. COUGH OR DIFFICULT IN BREATHING
    Respiratory infections can occur in any part of the respiratory tract such as the 
    nose, throat, larynx, trachea, air passages or lungs. A child with cough or difficult 
    breathing may have pneumonia or another severe respiratory infection. Pneumonia 
    is an infection of the lungs. Both bacteria and viruses can cause pneumonia. In 
    developing countries, pneumonia is often due to bacteria. The most common are 
    Streptococcus pneumoniae and Hemophilus influenzae. Children with bacterial 
    pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).
    There are many children who come to the health center with less serious respiratory 
    infections. Most children with cough or difficult breathing have only a mild infection. 
    For example, a child who has a cold may cough because nasal discharge drips 
    down the back of the throat. Or, the child may have a viral infection of the bronchi 
    called bronchitis. These children are not seriously ill. They do not need treatment 
    with antibiotics. Their families can treat them at home.
    Health care providers need to identify the few, very sick children with cough or 
    difficult breathing who need treatment with antibiotics. checking for these two 
    clinical signs: fast breathing and chest indrawing.
    When children develop pneumonia, their lungs become stiff. One of the body’s 
    responses to stiff lungs and hypoxia (too little oxygen) is fast breathing.
    When the pneumonia becomes more severe, the lungs become even stiffer. Chest 
    indrawing may develop. Chest indrawing is a sign of severe pneumonia.
    ASSESS COUGH OR DIFFICULT BREATHING
    A child with cough or difficult breathing is assessed for:
    How long the child has had cough or difficult breathing?
    • Fast breathing
    • Chest indrawing

    • Stridor in a calm child.

    STEPS FOR ASSESSING A CHILD FOR COUGH OR DIFFICULT BREATHING
    For ALL sick children, ask about cough or difficult breathing.

    ASK: Does the child have cough or difficult breathing?

    “Difficult breathing” is 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.”
    If the mother answers NO, look to see if you think the child has cough or difficult 
    breathing. If the child does not have cough or difficult breathing, ask about the next 
    main symptom, diarrhea. Do not assess the child further for signs related to cough 
    or difficult breathing.

    If the mother answers YES, ask the next question.

    ASK: For how long?

    A child who has had cough or difficult breathing for more than 30 days has a chronic 
    cough. This may be a sign of tuberculosis, asthma, whooping cough or another 
    problem.
    COUNT the breaths in one minute.
    Normal breathing rates are higher in children age 2 months up to 12 months than 
    in children age 12 months up to 5 years. For this reason, the cut-off for identifying 
    fast breathing is higher in children 2 months up to 12 months than in children age 
    12 months up to 5 years


    Note:     The child who is exactly 12 months old has fast breathing if you count 40 
    breaths per minute or more.
    LOOK for chest indrawing.

    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. Any chest indrawing, even if it is not severe, is an 

    indicator of severe pneumonia in a child age 2 months up to 5 years

    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. 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. Then listen for 
    stridor. Put your ear near the child’s mouth because stridor can be difficult to hear.
    Sometimes you will hear a wet noise if the nose is blocked. Clear the nose, and 
    listen again. A child who is not very ill may have stridor only when he is crying or 
    upset. Be sure to look and listen for stridor when the child is calm.
    You may hear a wheezing noise when the child breathes OUT. This is not stridor.
    b. DIARRHEA
    Diarrhea is passage of frequent loose or watery stools. Mothers usually know when 
    their children have diarrhea. Diarrhea is common in children especially in those 
    between 6 months and 2 years of age. It is more common in children under 6 
    months who are drinking cow’s milk or infant feeding formulas more so if they are 
    bottle-fed.
    Frequent passing of normal stool is not diarrhea. The number of stools normally 
    passed in a day varies with the diet and age of the child. In many regions’ diarrhea 
    is defined as 3 or more loose or watery stools in a 24-hour period.
    What are the Types of Diarrhea?
    Most diarrheas which cause dehydration are loose or watery. If an episode of 
    diarrhea lasts less than 14 days, it is acute diarrhea. Acute watery diarrhea causes 
    dehydration and contributes to malnutrition. The death of an infant with acute 
    diarrhea is usually due to dehydration.
    If the diarrhea lasts 14 days or more, it is persistent diarrhea. Up to 20% of episodes 
    of diarrhea become persistent. Persistent diarrhea often causes nutritional problems 
    and contributes to deaths in children.
    Diarrhea with blood in the stool, with or without mucus, is called dysentery. The 
    most common cause of dysentery is Shigella bacteria. Amoebic dysentery is not 
    common in young children.
    ASSESS DIARRHOEA
    A child with diarrhea is assessed for:
    • how long the child has had diarrhea
    • blood in the stool to determine if the child has dysentery, and for

    • signs of dehydration.

    Ask about diarrhea in ALL children:

    ASK: Does the child have diarrhea?

    If the mother answers NO, ask about the next main symptom, fever. You do not 
    need to assess the child further for signs related to diarrhea.
    If the mother answers YES, or if the mother said earlier that diarrhea was the 
    reason for coming to the clinic, record her answer. Then assess the child for signs 

    of dehydration, persistent diarrhea and dysentery.

    ASK: For how long?

    Diarrhea which lasts 14 days or more is persistent diarrhea. Give the mother time 
    to answer the question. She may need time to recall the exact number of days.

    ASK: Is there blood in the stool?

    Ask the mother if she has seen blood in the stools at any time during this episode 

    of diarrhea. Next, check for signs of dehydration.

    LOOK and FEEL for the following signs:
    LOOK at the child’s general condition. Is the child lethargic or unconscious? 

    restless and irritable?

    When you checked for general danger signs, you checked to see if the child was 
    Lethargic or unconscious. If the child is lethargic or unconscious, he has a general 
    danger sign. Remember to use this general danger sign when you classify the 

    child’s diarrhea. Look to see if the child is restless and irritable.

    LOOK for sunken eyes.

    Note: In a severely malnourished child who is visibly wasted (that is, who has 
    marasmus), the eyes may always look sunken, even if the child is not dehydrated. 
    Even though sunken eyes is less reliable in a visibly wasted child, still use the sign 

    to classify the child’s dehydration.

    OFFER the child fluid. Is the child not able to drink or drinking poorly? 

    drinking eagerly, thirsty?

    Ask the mother to offer the child some water in a cup or spoon. Watch the child 
    drink.
    A child is not able to drink if he is not able to suck or swallow when offered a drink. 
    A child may not be able to drink because he is lethargic or unconscious.
    A child is drinking poorly if the child is weak and cannot drink without help. He may 

    be able to swallow only if fluid is put in his mouth.

    A child has the sign drinking eagerly, thirsty if it is clear that the child wants to 
    drink. Look to see if the child reaches out for the cup or spoon when you offer him 
    water. When the water is taken away, see if the child is unhappy because he wants 
    to drink more.
    If the child takes a drink only with encouragement and does not want to drink more, 

    he does not have the sign “drinking eagerly, thirsty.”

    PINCH the skin of the abdomen. Does it go back: Very slowly (longer than 2 

    seconds)? Slowly?

    Note: In a child with marasmus (severe malnutrition), the skin may go back slowly 
    even if the child is not dehydrated. In an overweight child, or a child with edema, 
    the skin may go back immediately even if the child is dehydrated. Even though skin 

    pinch is less reliable in these children, still use it to classify the child’s dehydration.

    c. FEVER 

    A child with fever may have malaria, measles or another severe disease. Or, a child 
    with fever may have a simple cough or cold or other viral infection.
    MALARIA
    Malaria is caused by four species of plasmodia transmitted through the bite of a 
    female anopheles’ mosquitoes, the dangerous one being Plasmodium falciparum. 
    The most common species is Plasmodium vivax. Fever is the main symptom of 
    malaria. It can be present all the time or go away and return at regular intervals. 
    Other signs of malaria are shivering, sweating and vomiting. Signs of malaria can 
    overlap with signs of other illnesses. For example, a child may have malaria and 
    cough with fast breathing, a sign of pneumonia. This child needs treatment for both 
    falciparum malaria and pneumonia. Children with malaria may also have diarrhea. 
    They need an antimalarial and treatment for the diarrhea.
    In areas with very high malaria transmission, malaria is a major cause of death 
    in children. A case of uncomplicated malaria can develop into severe malaria as 
    soon as 24 hours after the fever first appears. Severe malaria is malaria with 
    complications such as cerebral malaria or severe anemia. The child can die if he 
    does not receive urgent treatment.
    Deciding Malaria Risk: To classify and treat children with fever, you must know 
    the malaria risk in your area. The National Anti-Malaria Program classifies areas as 
    high or low malaria risk areas.
    MEASLES: Fever and a generalized rash are the main signs of measles. Measles 
    is highly infectious. Maternal antibody protects young infants against measles for 
    about 6 months. Then the protection gradually disappears. Most cases occur in 
    children between 6 months and 2 years of age. Overcrowding and poor housing 

    increase the risk of measles occurring early.

    Measles is caused by a virus. It infects the skin and the layer of cells that line the 
    lung, gut, eye, mouth and throat. The measles virus damages the immune system 
    for many weeks after the onset of measles. This leaves the child at risk for other 
    infections.
    Complications of measles occur in about 30% of all cases. 
    • diarrhea (including dysentery and persistent diarrhea)
    • pneumonia
    • stridor
    • mouth ulcers
    • ear infection and
    • severe eye infection (which may lead to corneal ulceration and blindness).
    Encephalitis occurs in about one in one thousand cases. A child with encephalitis 
    may have general danger sign such as convulsions or lethargic or unconscious.
    Measles contributes to malnutrition because it causes diarrhea, high fever and 
    mouth ulcers. These problems interfere with feeding. Malnourished children are 
    more likely to have severe complications due to measles. This is especially true for 
    children who are deficient in vitamin A. One in ten severely malnourished children 
    with measles may die. For this reason, it is very important to help the mother to 
    continue to feed her child during measles.

    ASSESS FEVER

    Decide the malaria risk (high or low).
    Then assess a child with fever for:
    • how long the child has had fever
    • history of measles
    • stiff neck
    • bulging fontanelle
    • runny nose
    • signs suggesting measles -- which are generalized rash and one of these: 
    cough, runny nose, or red eyes.
    • if the child has measles now or within the last 3 months, assess for signs of 
    measles complications which are: mouth ulcers, pus draining from the eye 

    and clouding of the cornea.

    ASK: Does the child have fever?

    Check to see if the child has a history of fever, feels hot or has a temperature of 
    37.5o or above.
    The child has a history of fever if the child has had any fever with this illness. Use 
    words for “fever” that the mother understands. Make sure the mother understands 
    what fever is. For example, ask the mother if the child’s body has felt hot. Feel the 
    child’s abdomen or axilla and determine if the child feels hot.
    Look to see if the child’s temperature was measured today and recorded on the 
    child’s chart. If the child has a temperature of 37.5oC or above, the child has fever. 
    If the child’s temperature has not been measured, and you have a thermometer, 

    measure the child’s temperature.

    

    If the child does not have fever (by history, feels hot or temperature 37.5oC or 
    above), ask about the next main symptom, ear problem.
    If the child has fever (by history, feels hot or temperature 37.5oC or above), assess 
    the child for additional signs related to fever. Assess the child’s fever even if the 
    child does not have a temperature of 37.5oC or above or does not feel hot now. 

    History of fever is enough to assess the child for fever

    DECIDE Malaria Risk: high or low

    Decide if the malaria risk is high or low. You will use this information when you 
    classify the child’s fever.
    ASK: For how long? If more than 7 days, has fever been present every day?

    Ask the mother how long the child has had fever. If the fever has been present for 
    more than 7 days, ask if the fever has been present every day

    Most fevers due to viral illnesses go away within a few days. A fever which has been 
    present every day for more than 7 days can mean that the child has a more severe 

    disease such as typhoid fever. Refer this child for further assessment.

    ASK: Has the child had measles within the last 3 months?
    Measles damages the child’s immune system and leaves the child at risk for other 
    infections for many weeks.
    A child with fever and a history of measles within the last 3 months may have an 
    infection due to complications of measles such as an eye infection.
    LOOK or FEEL for stiff neck.
    A child with fever and stiff neck may have meningitis. A child with meningitis needs 
    urgent treatment with injectable antibiotics and referral to a hospital.
    While you talk with the mother during the assessment, look to see if the child moves 
    and bends his neck easily as he looks around. If the child is moving and bending his 

    neck, he does not have a stiff neck.

    Figure 6.2: Assessing for neck stiffness

    If you did not see any movement, or if you are not sure, draw the child’s attention 
    to his umbilicus or toes. For example, you can shine a flashlight on his toes or 
    umbilicus or tickle his toes to encourage the child to look down. Look to see if the 
    child can bend his neck when he looks down at his umbilicus or toes.
    If you still have not seen the child bend his neck himself, ask the mother to help you 
    lie the child on his back. Lean over the child, gently support his back and shoulders 
    with one hand. With the other hand, hold his head. Then carefully bend the head 
    forward toward his chest. If the neck bends easily, the child does not have stiff neck. 
    If the neck feels stiff and there is resistance to bending, the child has a stiff neck. 

    Often a child with a stiff neck will cry when you try to bend the neck.

    FEEL for bulging fontanelle
    The fontanelle is open for most of the period of infancy before it is closed by the 
    growth of the surrounding bones. If the fontanelle is open, feel for bulging fontanelle 
    just as you did for young infants.
    LOOK for runny nose.
    A runny nose in a child with fever may mean that the child has a common cold. If 
    the child has a runny nose, ask the mother if the child has had a runny nose only 
    with this illness. If she is not sure, ask questions to find out if it is an acute or chronic 
    runny nose.
    When malaria risk is low, a child with fever and a runny nose does not need an 
    antimalarial. This child’s fever is probably due to the common cold.
    LOOK for signs suggesting MEASLES.
    Assess a child with fever to see if there are signs suggesting measles. Look for a 
    generalized rash and for one of the following signs: cough, runny nose, or red eyes.
    Generalized rash
    In measles, a red rash begins behind the ears and on the neck. It spreads to the 
    face. During the next day, the rash spreads to the rest of the body, arms and legs. 
    After 4 to 5 days, the rash starts to fade and the skin may peel. Some children 
    with severe infection may have more rash spread over more of the body. The rash 
    becomes more discolored (dark brown or blackish), and there is more peeling of 
    the skin.
    A measles rash does not have vesicles (blisters) or pustules. The rash does 
    not itch. Do not confuse measles with other common childhood rashes such as 
    chicken pox, scabies or heat rash. (The chicken pox rash is a generalized rash with 
    vesicles. Scabies occurs on the hands, feet, ankles, elbows, buttocks and axilla. 
    It also itches. Heat rash can be a generalized rash with small bumps and vesicles 
    which itch. A child with heat rash is not sick.) You can recognize measles more 
    easily during times when other cases of measles are occurring in your community.
    Cough, Runny Nose, or Red Eyes
    To classify a child as having measles, the child with fever must have a generalized 
    rash AND one of the following signs: cough, runny nose, or red eyes. The child has 
    “red eyes” if there is redness in the white part of the eye. In a healthy eye, the white 
    part of the eye is clearly white and not discolored.
    If the child has MEASLES now or within the last 3 months: Look to see if the 
    child has mouth or eye complications. Other complications of measles such as 
    stridor in a calm child, pneumonia, and diarrhea are assessed earlier; malnutrition 

    and ear infection are assessed later.

    LOOK for mouth ulcers. Are they deep and extensive?

    Look inside the child’s mouth for mouth ulcers. Ulcers are painful open sores on the 
    inside of the mouth and lips or the tongue. They may be red or have white coating 
    on them. In severe cases, they are deep and extensive. When present, mouth 
    ulcers make it difficult for the child with measles to drink or eat.
    Mouth ulcers are different than the small spots called Koplik spots. Koplik spots 
    occur in the mouth inside the cheek during early stages of the measles infection. 
    Koplik spots are small, irregular, bright red spots with a white spot in the center. 
    They do not interfere with drinking or eating. They do not need treatment.

    LOOK for pus draining from the eye.
    Pus draining from the eye is a sign of conjunctivitis. Conjunctivitis is an infection 
    of the conjunctiva, the inside surface of the eyelid and the white part of the eye. If 
    you do not see pus draining from the eye, look for pus on the conjunctiva or on the 
    eyelids.
    Often the pus forms a crust when the child is sleeping and seals the eye shut. It can 
    be gently opened with clean hands. Wash your hands after examining the eye of 
    any child with pus draining from the eye.

    LOOK for clouding of the cornea.

    The cornea is usually clear. When clouding of the cornea is present, there is a 
    hazy area in the cornea. Look carefully at the cornea for clouding. The cornea may 
    appear clouded or hazy. The clouding may occur in one or both eyes.
    Corneal clouding is a dangerous condition. The corneal clouding may be due 
    to vitamin A deficiency which has been made worse by measles. If the corneal 
    clouding is not treated, the cornea can ulcerate and cause blindness. A child with 
    clouding of the cornea needs urgent treatment with vitamin A.
    A child with corneal clouding may keep his eyes tightly shut when exposed to light. 
    The light may cause irritation and pain to the child’s eyes. To check the child’s eye, 
    wait for the child to open his eye. Or, gently pull down the lower eyelid to look for 
    clouding.
    If there is clouding of the cornea, ask the mother how long the clouding has been 
    present. If the mother is certain that clouding has been there for some time, ask if 
    the clouding has already been assessed and treated at the hospital. If it has, you 

    do not need to refer this child again for corneal clouding.

    d. EAR PROBLEMS

    A child with an ear problem may have an ear infection.
    When a child has an ear infection, pus collects behind the ear drum and causes 
    pain and often fever. If the infection is not treated, the ear drum may burst. The 
    pus discharges, and the child feels less pain. The fever and other symptoms may 
    stop, but the child suffers from poor hearing because the ear drum has a hole in it. 
    Usually the ear drum heals by itself. At other times the discharge continues, the ear 
    drum does not heal, and the child becomes deaf in that ear.
    Sometimes the infection can spread from the ear to the bone behind the ear (the 
    mastoid) causing mastoiditis. Infection can also spread from the ear to the brain 
    causing meningitis. These are severe diseases. They need urgent attention and 
    referral.
    Ear infections rarely cause death. However, they cause many days of illness in 
    children. Ear infections are the main cause of deafness in developing countries, 
    and deafness causes learning problems in school. The ASSESS & CLASSIFY
    chart helps you identify ear problems due to ear infection.

    ASSESS EAR PROBLEM

    A child with ear problem is assessed for:
    • ear pain
    • ear discharge and
    • if discharge is present, how long the child has had discharge, and
    • tender swelling behind the ear, a sign of mastoiditis.
    ASK: Does the child have an ear problem?
    If the mother answers NO, record her answer. Do not assess the child for ear 
    problem. Then check for malnutrition and anaemia.
    If the mother answers YES, ask the next question:
    ASK: Does the child have ear pain?
    Ear pain can mean that the child has an ear infection. If the mother is not sure that 
    the child has ear pain, ask if the child has been irritable and rubbing his ear.
    ASK: Is there ear discharge? If yes, for how long?
    Ear discharge is also a sign of infection. When asking about ear discharge, use 
    words the mother understands.
    If the child has had ear discharge, ask for how long. Give her time to answer the 
    question. She may need to remember when the discharge started.
    You will classify and treat the ear problem depending on how long the ear discharge 
    has been present.
    • An ear discharge that has been present for 2 weeks or more is treated as a 
    chronic ear infection. An ear discharge that has been present for less than 2 
    weeks is treated as an acute ear infection.
    You do not need more accurate information about how long the discharge has been 
    present.
    LOOK for pus draining from the ear.
    Pus draining from the ear is a sign of infection, even if the child no longer has any 
    pain. Look inside the child’s ear to see if pus is draining from the ear.
    FEEL for tender swelling behind the ear.
    Feel behind both ears. Compare them and decide if there is tender swelling of the 
    mastoid bone. In infants, the swelling may be above the ear.
    Both tenderness and swelling must be present to classify mastoiditis, a deep 
    infection in the mastoid bone. Do not confuse this swelling of the bone with swollen 

    lymph nodes.

    Self- assessment activity 6.3

    1. Enumerate three danger signs that a child may present using IMCI 
    Strategy.

    2. What are the four main symptoms assessed using IMCI Strategy?

    6.4. General assessment of children under five years

    Learning activity 6.4


    When the main symptom is present, assess the child further for signs related to 

    main symptom and classify the illness according to the signs which are present or 

    absent.

    Check for signs of malnutrition and anemia and classify the child’s nutritional 
    status. 
    Check HIV status and classify, check the child’s immunization status and decide 

    if the child needs any immunizations and assess any other problems.

    6.4.1 Check for malnutrition

    Check all sick children for signs suggesting malnutrition.
    A mother may bring her child to clinic because the child has an acute illness. The 
    child may not have specific complaints that point to malnutrition. A sick child can be 
    malnourished, but the doctor or the child’s family may not notice the problem.
    A child with malnutrition has a higher risk of many types of disease and death. Even 
    children with mild and moderate malnutrition have an increased risk of death.
    Identifying children with malnutrition and treating them can help prevent many 
    severe diseases and death. Some malnutrition cases can be treated at home. 
    Severe cases need referral to hospital for special feeding or specific treatment of a 

    disease contributing to malnutrition (such as tuberculosis).

    Causes of Malnutrition: There are several causes of malnutrition. They may vary 
    from country to country. One type of malnutrition is protein-energy malnutrition. 

    Protein-energy malnutrition develops when the child is not getting enough energy 

    or protein from his food to meet his nutritional needs. A child who has had frequent 
    illnesses can also develop protein- energy malnutrition. The child’s appetite 
    decreases, and the food that the child eats is not used efficiently. When the child 
    has protein-energy malnutrition:
    • The child may become severely wasted, a sign of marasmus.
    • The child may develop oedema, a sign of kwashiorkor.
    • The child may not grow well and become stunted (too short).

    A child whose diet lacks recommended amounts of essential vitamins and 

    minerals can develop malnutrition. The child may not be eating enough of the 
    recommended amounts of specific vitamins (such as vitamin A) or minerals (such 
    as iron). Not eating foods that contain vitamin A can result in vitamin A deficiency. A 
    child with vitamin A deficiency is at risk of death from measles and diarrhoea. The 

    child is also at risk of blindness.

    ASSESS FOR MALNUTRITION

    LOOK for visible severe wasting.

    A child with visible severe wasting has marasmus, a form of severe malnutrition. A 
    child has this sign if he is very thin, has no fat, and looks like skin and bones. Some 
    children are thin but do not have visible severe wasting.
    To look for visible severe wasting, remove the child’s clothes. Look for severe 
    wasting of the muscles of the shoulders, arms, buttocks and legs. Look to see if 
    the outline of the child’s ribs is easily seen. Look at the child’s hips. They may look 
    small when you compare them with the chest and abdomen. Look at the child from 
    the side to see if the fat of the buttocks is missing. When wasting is extreme, there 
    are many folds of skin on the buttocks and thigh. It looks as if the child is wearing 

    baggy pants.


    The face of a child with visible severe wasting may still look normal. The child’s 
    abdomen may be large or distended.
    LOOK and FEEL for oedema of both feet
    A child with oedema of both feet may have kwashiorkor, another form of severe 
    malnutrition. Oedema is when an unusually large amount of fluid gathers in the 
    child’s tissues. The tissues become filled with the fluid and look swollen or puffed 
    up.
    Look and feel to determine if the child has oedema of both feet. Use your thumb to 
    press gently for a few seconds on the top side of each foot. The child has oedema 
    if a dent remains in the child’s foot when you lift your thumb.
    Determine weight for age.
    Determine the weight for age as you did for the young infant. See separate WHO 
    growth charts for boys and girls. Decide if the point is above, on, or below the bottom 
    curve.
    • If the point is below the bottom curve, the child is severely underweight for 
    age.
    • If the point is above or on the -3 SD line (bottom line), the child is not severely 
    underweight.
    • If the point is above or on the bottom curve, but below -2 SD line, the child is 
    moderately underweight for age.
    • If the point is above or on the -2 SD line, the child is not moderately underweight.
    EXAMPLE: A male child is 26 months old and weighs 8.0 kilograms. Determine the 
    child’s weight for age and plot on the growth chart. See the response on the chart 

    below

    Figure 6.4: WHO weight for age chart

    6.4.2 Check for anaemia

    Check all sick children for signs suggesting anaemia.
    A mother may bring her child to clinic because the child has an acute illness. The 
    child may not have specific complaints that point to anaemia. Most children with 
    anaemia can be treated at home. Severe cases need referral to hospital for blood 

    transfusion.

    Causes of Anaemia: Not eating foods rich in iron can lead to iron deficiency 
    and anaemia. Anaemia is a reduced number of red cells or a reduced amount of 
    haemoglobin in each red cell. A child can also develop anaemia as a result of:
    • Infections
    • Parasites such as hookworm or whipworm. They can cause blood loss from 
    the gut and lead to anaemia.
    • Malaria which can destroy red cells rapidly. Children can develop anaemia if 
    they have had repeated episodes of malaria or if the malaria was inadequately 
    treated. 
    The anaemia may develop slowly. Often, anaemia in these children is due to both 

    malnutrition and malaria.

    ASSESS FOR ANAEMIA
    Here is the box from the “Assess” column on the ASSESS & CLASSIFY chart. It 
    describes how to assess a child for malnutrition and anaemia.

    LOOK for palmar pallor.

    Pallor is unusual paleness of the skin. It is a sign of anaemia.
    To see if the child has palmar pallor, look at the skin of the child’s palm. Hold the 
    child’s palm open by grasping it gently from the side. Do not stretch the fingers 
    backwards. This may cause pallor by blocking the blood supply.

    6.4.3 Check the child’s immunization, prophylactic vitamin a & 
    iron-folic acid supplementation status

    Immunization, prophylactic vitamin A and iron-folic acid supplementation status 
    should be assessed in ALL sick children.
    CHECK THE CHILD’S IMMUNIZATION STATUS
    Check the immunization status for ALL sick children. Have they received all the 
    immunizations recommended for their age? Do they need any immunizations 
    today?
    Use the National Recommended Immunization Schedule when you check the 
    child’s immunization status. Look at the ASSESS & CLASSIFY chart and locate 
    the recommended immunization schedule. Refer to it as you read how to check a 

    child’s immunization status.

    Give the recommended vaccine when the child is the appropriate age for each 
    dose. All children should receive all the recommended immunizations before their 
    first birthday. If the child does not come for an immunization at the recommended 
    age, give the necessary immunizations any time after the child reaches that age. 
    Give the remaining doses at least 4 weeks apart. You do not need to repeat the 
    whole schedule.
    CHECK THE CHILD’S PROPHYLACTIC VITAMIN A SUPPLEMENTATION STATUS
    Vitamin A is an essential micronutrient and is necessary for vision, integrity of 
    membrane structures, the normal functioning of body cells, growth and development. 
    A child with vitamin A deficiency is at a risk of death from measles and diarrhea. 
    The child is also at risk of blindness. The National Vitamin A Prophylaxis Program 
    recommends 9 doses of vitamin A at 9, 18, 24, 30, 36, 42, 48, 54 and 60 months 

    of age

     

    Give the recommended dose of vitamin A when the child is the appropriate age for 
    each dose. In case a child more than 9 months of age has not received a dose of 
    vitamin A in last 6 months, give a dose as per the dosage schedule according to 
    age of the child.

    CHECK THE CHILD’S PROPHYLACTIC IRON-FOLIC ACID SUPPLEMENTATION 

    STATUS

    Anaemia is a reduced number of red cells or a reduced amount of haemoglobin in 
    each red cell. Not eating foods rich in iron can lead to iron deficiency and anaemia. 
    A child can also develop anaemia as a result of various systemic infections, 
    malaria, or infestation with hookworm or whipworm. Prophylactic supplementation 
    of iron folic acid for 100 days in a year is recommended under the National Anaemia 

    Prophylaxis Programme.

    6.4.4 Assess children for HIV

    HIV testing is RECOMMENDED for all children with unknown HIV status especially 
    those to HIV-positive mothers.

    Since the ASSESS & CLASSIFY chart does not address all of a sick child’s problems, 
    you will now assess other problems the mother told you about. For example, she 
    may have said the child has a skin infection, itching or swollen neck glands. Or you 
    may have observed another problem during the assessment. Identify and treat any 
    other problems according to your training, experience and clinic policy. Refer the 
    child for any other problem you cannot manage in clinic.
    MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after 
    first dose of an appropriate antibiotic and other urgent treatments.
    EXCEPTION: Rehydration of the child according to Plan C may resolve danger 
    signs so that referral is no longer needed.
    This note reminds you that a child with any general danger sign needs urgent 
    treatment and referral. It is possible, though uncommon, that a child may have a 
    general danger sign, but may not have a severe classification for any of the main 

    symptoms.

    Self-assessment 6.4

    1. If a child has pallor of the palms when performing your assessment, what 
    does it indicate.

    2. In a table format, describe the Rwanda national immunisation calendar.

    6.5 Assessment of children aged below 2 months 

    Learning activity 6.5

    A 20 days’ sick infant is brought to the health post by her mother complaining for 
    inability to breastfeed and change of the infant’s skin colour. From your previous 
    knowledge and experiences, what questions would you ask the mother to explore 
    more the problem?
    For all sick young infants aged below 2 months, they must be checked for possible 
    bacterial infection/jaundice, feeding problems, immunization status and verify if the 
    infant has diarrhea. Mothers are to be taught how to keep their infant warm, teach 
    correct position and encourage for exclusive breastfeeding, advise on home care 
    of young infant, recognition of illness in newborn, appropriate referral, and advice 
    mother to return immediately if danger signs present. 
    Ask the mother what the young infant’s problems are. Determine if this is an initial 
    or follow-up visit for these problems. If this is a follow-up visit, you should manage 
    the infant according to the special instructions for a follow-up visit as found in IMCI 

    charts of assessment and management.

    SUMMARY OF “ASSESS AND CLASSIFY”


    Young infants have special characteristics that must be considered when classifying 
    their illnesses. They can become sick and die very quickly from serious bacterial 
    infections. They frequently have only general signs such as few movements, fever, 
    or low body temperature. Mild chest indrawing is normal in young infants because 
    their chest wall is soft.
    The chart is not used for a sick newborn, that is a young infant who is less 
    than 1 week of age. In the first week of life, newborn infants are often sick from 
    conditions related to labour and delivery, or have conditions which require special 
    management. Newborns may be suffering from asphyxia, sepsis from premature 
    ruptured membranes or other intrauterine infection, or birth trauma. Or they may 
    have trouble breathing due to immature lungs. Jaundice also requires special 
    management in the first week of life. For all these reasons, management of a sick 
    newborn is somewhat different from caring for a young infant age 1 week up to 2 
    months.
    The steps for assessing and caring for a sick young infant are:
    • Check for signs of possible bacterial infection. Then classify the young infant 
    based on the clinical signs found.
    • Ask about diarrhoea. If the infant has diarrhoea, assess for related signs. 
    Classify the young infant for dehydration. Also classify for persistent diarrhoea 
    and dysentery if present.
    • Check for feeding problem or low weight. This may include assessing 
    breastfeeding. Then classify feeding.
    • Check the young infant’s immunization status.
    • Assess any other problems.
    If you find a reason that a young infant needs urgent referral, you should continue 

    the assessment. 

    6.5.1. How to check a young infant for possible bacterial 

    infection

      

    Table 6.5: Checking for bacterial infection in children

    This assessment step is done for every sick young infant. In this step you are 
    looking for signs of bacterial infection, especially a serious infection. A young infant 
    can become sick and die very quickly from serious bacterial infections such as 
    pneumonia, sepsis and meningitis.
    It is important to assess the signs in the order on the chart, and to keep the young 
    infant calm. The young infant must be calm and may be asleep while you assess 
    the first four signs, that is, count breathing and look for chest indrawing, nasal 

    flaring and grunting.

    To assess the next few signs, you will pick up the infant and then undress him, 
    look at the skin all over his body and measure his temperature. By this time, he will 
    probably be awake. Then you can see if he is lethargic or unconscious and observe 
    his movements.
    Check for possible bacterial infection in ALL young infants.
    ASK: HAS THE INFANT HAD CONVULSIONS?
    Ask the mother this question.
    LOOK: COUNT THE BREATHS IN ONE MINUTE. REPEAT THE COUNT IF 
    ELEVATED
    Count the breathing rate as you would in an older infant or young child. Young infants 
    usually breathe faster than older infants and young children. The breathing rate of a 
    healthy young infant is commonly more than 50 breaths per minute. Therefore, 60 
    breaths per minute or more is the cut off used to identify fast breathing in a young 
    infant.
    If the first count is 60 breaths or more, repeat the count. This is important because the 
    breathing rate of a young infant is often irregular. The young infant will occasionally 
    stop breathing for a few seconds, followed by a period of faster breathing. If the 
    second count is also 60 breaths or more, the young infant has fast breathing.
    LOOK FOR SEVERE CHEST INDRAWING
    Look for chest indrawing as you would look for chest indrawing in an older infant 
    or young child. However, mild chest indrawing is normal in a young infant because 
    the chest wall is soft. Severe chest indrawing is very deep and easy to see. Severe 
    chest indrawing is a sign of pneumonia and is serious in a young infant.

    LOOK FOR NASAL FLARING


    LOOK AND LISTEN FOR GRUNTING
    Grunting is the soft, short sounds a young infant makes when breathing out. 
    Grunting occurs when an infant is having trouble breathing.
    LOOK AND FEEL FOR BULGING FONTANELLE
    The fontanelle is the soft spot on the top of the young infant’s head, where the 
    bones of the head have not formed completely. Hold the young infant in an upright 
    position. The infant must not be crying. Then look at and feel the fontanelle. If the 
    fontanelle is bulging rather than flat, this may mean the young infant has meningitis.
    LOOK FOR PUS DRAINING FROM THE EAR
    Pus draining from the ear is a sign of infection. Look inside the infant’s ear to see if 
    pus is draining from the ear.
    LOOK AT THE UMBILICUS—IS IT RED OR DRAINING PUS? DOES THE 
    REDNESS EXTEND TO THE SKIN?
    There may be some redness of the end of the umbilicus or the umbilicus may be 
    draining pus. (The cord usually drops from the umbilicus by one week of age.) 
    How far down the umbilicus the redness extends determines the severity of the 
    infection? If the redness extends to the skin of the abdominal wall, it is a serious 
    infection.
    FEEL: MEASURE TEMPERATURE (OR FEEL FOR FEVER OR LOW BODY 
    TEMPERATURE)
    Fever (axillary temperature more than 37.5 °C or rectal temperature more than 38 
    °C) is uncommon in the first two months of life. If a young infant has fever, this may 
    mean the infant has a serious bacterial infection. In addition, fever may be the only 
    sign of a serious bacterial infection. Young infants can also respond to infection by 
    dropping their body temperature to below 35.5 °C (36 °C rectal temperature). Low 
    body temperature is called hypothermia. If you do not have a thermometer, feel the 
    infant’s stomach or axilla (underarm) and determine if it feels hot or unusually cool.
    LOOK FOR SKIN PUSTULES. ARE THERE MANY OR SEVERE PUSTULES?
    Examine the skin on the entire body. Skin pustules are red spots or blisters that 
    contain pus. If you see pustules, is it just a few pustules or are there many? A 
    severe pustule is large or has redness extending beyond the pustule. Many or 
    severe pustules indicate a serious infection.

    LOOK: SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS

    Young infants often sleep most of the time, and this is not a sign of illness. Even 
    when awake, a healthy young infant will usually not watch his mother and a health 
    worker while they talk, as an older infant or young child would.

    A lethargic young infant is not awake and alert when he should be. He may be 

    drowsy and may not stay awake after a disturbance. If a young infant does not 
    wake up during the assessment, ask the mother to wake him. Look to see if the 
    child wakens when the mother talks or gently shakes the child or when you clap 
    your hands. See if he stays awake.
    An unconscious young infant cannot be wakened at all. He does not respond when 
    he is touched or spoken to.
    LOOK AT THE YOUNG INFANT’S MOVEMENTS. ARE THEY LESS THAN 
    NORMAL?
    A young infant who is awake will normally move his arms or legs or turn his head 
    several times in a minute if you watch him closely. Observe the infant’s movements 
    while you do the assessment.
    6.5.2. How to classify possible bacterial infection
    Classify all sick young infants for bacterial infection. Compare the infant’s signs 
    to signs listed on the color-coded table and choose the appropriate classification. 
    There are two possible classifications for bacterial infection: POSSIBLE SERIOUS 

    BACTERIAL INFECTION and LOCAL BACTERIAL INFECTION.


    Self-assessment 6.5

    Compare and show in a tabulated format the signs of a serious bacterial infections 
    and local bacterial infection in sick children below 2 months and propose the 

    appropriate treatment using IMCI strategy.

    6.6. Assessment of children aged from 2 months to 5 

    years

    Learning activity 6.6

    A 48 months old child was admitted to the hospital for having bacterial infection. 
    He looks to be afraid of facility’s environment and healthcare team. What 
    strategies will the nurse use to get permission from the child and administer 

    injectable medication as prescribed?

    A mother or other caretaker brings a sick child to the clinic for a particular problem 
    or symptom. If you only assess the child for that particular problem or symptom, you 
    might overlook other signs of disease. The child might have pneumonia, diarrhoea, 
    malaria, measles, or malnutrition. These diseases can cause death or disability in 
    young children if they are not treated.
    There should be recognition of illness and risk, prevention and management of iron 
    and vitamin A deficiency, counselling on feeding for all children under 2 years and 
    counselling on feeding for malnourished children.
    The chart ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 
    YEARS describes how to assess and classify sick children so that signs of disease 
    are not overlooked. The chart then helps you to identify the appropriate treatments 
    for each classification. According to the chart, you should ask the mother about the 
    child’s problem and check the child for general danger signs. Then ask about the 
    four main symptoms: cough or difficult breathing, diarrhoea, fever and ear problem.
    A child who has one or more of the main symptoms could have a serious illness. 
    When a main symptom is present, ask additional questions to help classify the 
    illness and identify appropriate treatment(s). Check the child for malnutrition and 
    anaemia. Also check the child’s immunization status and assess other problems that 

    the mother has mentioned. The next several chapters will describe these activities.

    For every child that is brought to the clinic:

    SUMMARY ON EFFECTIVE COMMUNICATION FOR SICK CHILDREN
    • Active listening
    • Empathizing with the child’s point of view
    • Developing trusting relationships
    • Understanding non-verbal communication
    • Building rapport
    • Explaining, summarizing and providing information
    • Giving feedback in clear way

    • Understanding and explaining the boundaries of confidentiality

    Self-assessment 6.6

    What are key points to consider for effective communication when caring for sick 
    children.
    6.7. Management of the child with COUGH OR DIFFICULT 
    BREATHING using IMCI strategy
    Learning activity 6.7

    CLASSIFY COUGH OR DIFFICULT BREATHING

    There are three possible classifications for a child with cough or difficult breathing. 
    They are:
    • Severe pneumonia or very severe disease or
    • Pneumonia or

    • No pneumonia: cough or cold

    DESCRIPTION OF EACH CLASSIFICATION FOR COUGH OR DIFFICULT 
    BREATHING.
    • Severe pneumonia or very severe disease
    A child with cough or difficult breathing and with any of the following signs: any 
    general danger sign, chest indrawing or stridor in a calm child -- is classified as 
    having SEVERE PNEUMONIA OR VERY SEVERE DISEASE.
    A child with chest indrawing usually has severe pneumonia. 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 in is much greater than normal.
    A child with chest indrawing has a higher risk of death from pneumonia than the 
    child who has fast breathing and no chest indrawing. 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 severe pneumonia.
    Treatment
    In developing countries, bacteria cause most cases of pneumonia. These cases 
    need treatment with antibiotics. Viruses also cause pneumonia. But there is no 
    reliable way to find out if the child has bacterial pneumonia or viral pneumonia. 
    Therefore, whenever a child shows signs of pneumonia, give the child an appropriate 
    antibiotic.
    A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE 
    is seriously ill. He needs urgent referral to a hospital for treatments such as oxygen, 
    a bronchodilator or injectable antibiotics. Before the child leaves your clinic, give 
    the first dose of injectable chloramphenicol (if not possible give oral amoxicillin). The 
    antibiotic helps prevent severe pneumonia from becoming worse. It also helps treat 
    other serious bacterial infections such as sepsis or meningitis.
    • Pneumonia
    A child with cough or difficult breathing who has fast breathing and no general 
    danger signs, no chest indrawing and no stridor when calm is classified as having 
    PNEUMONIA.
    Treatment
    Treat PNEUMONIA with oral amoxycillin. If amoxycillin is not available give oral 
    cotrimoxazole. Show the mother how to give the antibiotic. Advise her when to 

    return for follow-up and when to return immediately.

    • No pneumonia: cough or cold
    A child with cough or difficult breathing who has no general danger signs, no chest 
    indrawing, no stridor when calm and no fast breathing is classified as having NO 
    PNEUMONIA: COUGH OR COLD.
    Treatment
    A child with NO PNEUMONIA: 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.
    A child with a cold normally improves in one to two weeks. However, a child who 
    has a chronic cough (a cough lasting more than 30 days) may have tuberculosis, 

    asthma, whooping cough or another problem. 

    Table 6.5: Classification of cough or difficult breathing

    Self-assessment 6.7

    You receive a 46 months old child in consultation at the health center with cough 
    for the past 4 days. On assessment, you notice a respiratory rate of 42 breaths 
    per minute with chest indrawing and fast breathing but blood smear shows 
    HIV negative. Please make a classification of this child and identify related 

    management basing on IMCI strategy.

    6.8 Management of the child with DIARRHEA using 

    IMCI strategy

    Learning activity 6.8


    a. Describewhat you see on the picture above.

    b. What are the dangers of drinking from an open tap.

    There are three classification tables for classifying diarrhea.
    • All children with diarrhea are classified for dehydration.
    • If the child has had diarrhea for 14 days or more, classify the child for persistent 
    diarrhea.

    • If the child has blood in the stool, classify the child for dysentery.

    STEPS FOR ASSESSING A CHILD WITH DIARRHEA

    Classify dehydration

    There are three possible classifications of dehydration in a child with diarrhea:
    • severe dehydration
    • some dehydration
    • no dehydration
    To classify the child’s dehydration, begin with the red (or top) row.
    If two or more of the signs in the red row are present, classify the child as having 
    SEVERE DEHYDRATION.
    If two or more of the signs are not present in the red row, look at the yellow (or 
    middle) row. If two or more of the signs are present in the yellow row, classify the 

    child as having SOME DEHYDRATION.

    If two or more of the signs are not present in the red row or yellow row, classify 
    the child as having NO DEHYDRATION. This child does not have enough signs to 
    be classified as having SEVERE/ SOME DEHYDRATION. Some of these children 
    may have one sign of dehydration or have lost fluids without showing signs.

    Here is a description of each classification for dehydration:

    SEVERE DEHYDRATION
    If the child has two of the following signs: lethargic or unconscious, sunken eyes, 
    not able to drink or drinking poorly, skin pinch goes back very slowly, classify 

    the dehydration as SEVERE DEHYDRATION.

    Treatment
    Any child with dehydration needs extra fluids. A child classified with SEVERE 
    DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids.
    SOME DEHYDRATION
    If the child does not have signs of SEVERE DEHYDRATION, Does the child have 
    signs of SOME DEHYDRATION?
    If the child has two or more of the following signs: restless/ irritable, sunken eyes, 
    drinks eagerly, thirsty, skin pinch goes back slowly then classify the child’s 

    dehydration as SOME DEHYDRATION.

    Treatment

    A child who has SOME DEHYDRATION needs fluid and foods. Treat the child with 
    ORS solution. In addition to fluid, the child with SOME DEHYDRATION needs food. 
    Breastfed children should continue breastfeeding. Other children should receive 
    their usual milk or some nutritious food after 4 hours of treatment with ORS. Children 
    with some dehydration are also given daily dose of zinc supplement for 14 days. 
    Zinc should be given as soon as the child can eat and has successfully completed 
    4 hours of rehydration.
    NO DEHYDRATION
    A child who does not have two or more signs in either the red or yellow row is 
    classified as having NO DEHYDRATION.
    Treatment
    This child needs extra fluid to prevent dehydration. A child who has NO 
    DEHYDRATION needs home treatment. The 3 rules of home treatment are:
    1. Give extra fluid
    2. Give zinc supplement daily for 14 days. The first tablet should be given in 
    the health center, demonstrating to the mother how to dissolve it in water 
    or breastmilk, if necessary.
    3. Continue feeding
    4. When to return.
    “Plan A: Treat Diarrhea at Home” describes what fluids to teach the mother to use 
    and how much she should give. A child with NO DEHYDRATION also needs zinc 
    supplement, food and the mother needs advice about when to return to the clinic. 
    Feeding recommendations and information about when to return are on the chart 

    COUNSEL THE MOTHER

    CLASSIFY PERSISTENT DIARRHOEA
    After you classify the child’s dehydration, classify the child for persistent diarrhea if 
    the child has had diarrhea for 14 days or more.
    There are two classifications for persistent diarrhea:
    • Severe persistent diarrhea
    • Persistent diarrhea

    SEVERE PERSISTENT DIARRHOEA

    If a child has had diarrhea for 14 days or more and also has some or severe 
    dehydration, classify the child’s illness as SEVERE PERSISTENT DIARRHOEA.
    Treatment
    Children with diarrhea lasting 14 days or more who are also dehydrated need 
    referral to hospital. These children need special attention to help prevent loss of 
    fluid. They may also need a change in diet. They may need laboratory tests of stool 
    samples to identify the cause of the diarrhea. Treat the child’s dehydration before 
    referral unless the child has another severe classification. Treatment of dehydration 
    in children with severe disease can be difficult. These children should be treated in 

    a hospital.

    PERSISTENT DIARRHOEA
    A child who has had diarrhea for 14 days or more and who has no signs of dehydration 

    is classified as having PERSISTENT DIARRHOEA.

    Treatment
    Special feeding is the most important treatment for persistent diarrhea. Children 
    with persistent diarrhea are also given single dose of vitamin A and a daily dose of 
    zinc sulphate for 14 days.
    CLASSIFY DYSENTERY
    There is only one classification for dysentery: Classify a child with diarrhea and 

    blood in the stool as having DYSENTERY.

    Treatment

    Treat the child’s dehydration. Also give ciprofloxacin for Shigella because:
    • Shigella cause about 60% of dysentery cases seen in clinics.
    • Shigella cause nearly all cases of life-threatening dysentery.
    Finding the actual cause of the dysentery requires a stool culture. It can take at 

    least 2 days to obtain the laboratory test results.


    Self-assessment 6.8

    A mother brought a 36 months old child to the health post complaining of diarrhea 
    since the last 15 days. You make an assessment and do not notice any danger 
    sign or sign of dehydration. Asking for the history, blood was not reported to be in 
    the stool. Classify and identify appropriate management of this child using IMCI 

    strategy.

    6.9 Management of the child with FEVER using IMCI 

    strategy

    Learning activity 6.9


    • Describe what you see on the picture above.
    • With your experience in previous clinical placement, what is the range of 
    normal temperature for children.
    If the child has fever and no signs of measles, classify the child for fever only.
    If the child has signs of both fever and measles, classify the child for fever and for 
    measles.
    There are two fever classification tables on the ASSESS & CLASSIFY chart. One 
    is for classifying fever when the risk of malaria is high. The other is for classifying 
    fever when the risk of malaria is low. To classify fever, you must know if the malaria 
    risk is high or low.
    Then you select the appropriate classification table.
     HIGH MALARIA RISK:
    There are two possible classifications of fever when the malaria risk is high.
    • very severe febrile disease
    • malaria
    VERY SEVERE FEBRILE DISEASE (High Malaria Risk)
    If the child with fever has any general danger sign, bulging fontanelle or a stiff neck, 

    classify the child as having VERY SEVERE FEBRILE DISEASE.

    Treatment

    A child with fever and any general danger sign or stiff neck may have meningitis, 
    severe malaria (including cerebral malaria) or sepsis. It is not possible to distinguish 
    between these severe diseases without laboratory tests. A child classified as having 
    VERY SEVERE FEBRILE DISEASE needs urgent treatment and referral. Before 
    referring urgently, you will give several treatments for the possible severe diseases. 
    Give the child an injection of quinine for malaria after RDT/ making a blood 
    smear. Also give first dose of injectable chloramphenicol (If not possible give oral 
    amoxycillin) for meningitis or other severe bacterial infection. You should also treat 
    the child to prevent low blood sugar. Also give paracetamol if there is a high fever.
    MALARIA (High Malaria Risk)
    If a general danger sign or stiff neck is not present, look at the yellow row. Because 
    the child has a fever (by history, feels hot, or temperature 37.5oC or above) in a 
    high malaria risk area, classify the child as having MALARIA.
    When the risk of malaria is high, the chance is also high that the child’s fever is due 
    to malaria.
    Treatment
    Give Oral antimalarials for high malaria risk areas according to the National Anti Malaria Program policy.
    • If smear or RDT is positive for P. falciparum give 
    Artesunate, Sulpha- pyrimethamine, and Primaquine on day 1; and 
    Artesunate on Day 2 and Day 3.
    • If smear is positive for P. vivax give chloroquine for 3 days and primaquine 
    for 14 days.
    • If both RDT and blood smear is negative or not available, give chloroquine 
    for 3 days.
    Give paracetamol to a child with high fever (axillary temperature of 38.5oC or 
    above). Most viral infections last less than a week. A fever that persists every day 
    for more than 7 days may be a sign of typhoid fever or other severe disease. If 
    the child’s fever has persisted every day for more than 7 days, refer the child for 
    additional assessment.
    FOR LOW MALARIA RISK
    If risk of malaria in your area is low, use the Low Malaria Risk classification table. 
    There are three possible classifications of fever in a child with low malaria risk.
    • Very severe febrile disease
    • Malaria

    • Fever - malaria unlikely

    VERY SEVERE FEBRILE DISEASE (Low Malaria Risk)
    If the child with fever has any general danger sign, bulging fontanelle or a stiff neck, 
    classify the child as having VERY SEVERE FEBRILE DISEASE.
    Treatment
    Manage the child on the same lines as VERY SEVERE FEBRILE DISEASE in High 
    Malaria Risk areas.
    MALARIA (Low Malaria Risk)
    If a general danger sign or stiff neck or bulging fontanelle is not present, look at 
    the yellow row. If there is no runny nose, no measles and no other cause of fever 
    (pneumonia, cough or cold, dysentery, diarrhea, skin infection) in a low malaria risk 
    area, classify the child as having MALARIA.
     Treatment
    Give oral antimalarials for low malaria risk areas according to the National AntiMalaria Program policy.
    • If smear is positive for P. falciparum with Chloroquine and Primaquine on 
    day 1 and Chloroquine alone on Day 2 and Day 3.
    • If smear is positive for P. vivax give Chloroquine for 3 days along with 
    Primaquine for 14 days.
    • If smear is negative or not available, give chloroquine for 3 days.
    Give one dose of paracetamol in clinic for high fever (temperature 38.5°C or above).
    FEVER-MALARIA UNLIKELY (Low Malaria Risk)
    If a general danger sign or stiff neck or bulging fontanelle is not present, and Runny 
    nose or Measles or Other cause of fever is PRESENT in a low malaria risk area, 
    classify the child as having FEVER - MALARIA UNLIKELY.
    Treatment
    Give one dose of paracetamol in clinic for high fever (temperature 38.5°C or above), 
    and 3 additional doses for use at home for high fever. If fever is present every day 
    for more than 7 days, refer for assessment.
    CLASSIFY MEASLES
    A child who has the main symptom “fever” and measles now (or within the last 3 
    months) is classified both for fever and for measles. First you must classify the 

    child’s fever. Next you classify measles.

    If the child has no signs suggesting measles, or has not had measles within the 
    last three months, do not classify measles. Ask about the next main symptom, ear 
    problem.
    There are three possible classifications of measles:
    • severe complicated measles
    • measles with eye or mouth complications
    • measles
    The table for classifying measles if present now or within the last 3 months is shown 

    as follows:

    SEVERE COMPLICATED MEASLES
    If the child has any general danger sign, clouding of cornea, or deep or extensive 
    mouth ulcers, classify the child as having SEVERE COMPLICATED MEASLES. 
    This child needs urgent treatment and referral to hospital.
    Children with measles may have other serious complications of measles. These 
    include stridor in a calm child, severe pneumonia, severe dehydration, or severe 
    malnutrition. You assess and classify these signs in other parts of the assessment. 

    Their treatments are appropriate for the child with measles.

    Treatment
    Some complications are due to bacterial infections. Others are due to the measles 
    virus which causes damage to the respiratory and intestinal tracts. Vitamin A 
    deficiency contributes to some of the complications such as corneal ulcer. Any 
    vitamin A deficiency is made worse by the measles infection. Measles complications 
    can lead to severe disease and death.
    All children with SEVERE COMPLICATED MEASLES should receive urgent 
    treatment. Treat the child with first dose of vitamin A. Also give the first dose of 
    injectable chloramphenicol (if not possible give oral amoxycillin) before referring 
    the child.
    If there is clouding of the cornea, or pus draining from the eye, apply tetracycline 
    ointment. If it is not treated, corneal clouding can result in blindness. Ask the 
    mother if the clouding has been present for some time. Find out if it was assessed 
    and treated at the hospital. If it was, you do not need to refer the child again for this 

    eye sign.

    MEASLES WITH EYE OR MOUTH COMPLICATIONS
    If the child has pus draining from the eye or mouth ulcers which are not deep 
    or extensive, classify the child as having MEASLES WITH EYE OR MOUTH 

    COMPLICATIONS. A child with this classification does not need referral.

    You assess and classify the child for other complications of measles (pneumonia, 
    diarrhea, ear infection and malnutrition) in other parts of this assessment. Their 
    treatments are appropriate for the child with measles.
    Treatment
    Identifying and treating measles complications early in the infection can prevent 
    many deaths. Give two doses of Vitamin A (Give first dose in clinic and give mother 
    one dose to give at home the next day.). It will help correct any vitamin A deficiency 
    and decrease the severity of the complications. Teach the mother to treat the child’s 
    eye infection or mouth ulcers at home. Treating mouth ulcers helps the child to 
    more quickly resume normal feeding.
    MEASLES
    A child with measles now or within the last 3 months and with none of the 
    complications listed in the pink or yellow rows is classified as having MEASLES. 
    Give the child vitamin A to help prevent measles complications.

    All children with measles should receive two doses of Vitamin A 

    Self-assessment 6.9

    A 6 months old infant was brought to the consultation by her mother complaining 
    of hot skin on touch and crying through the last night. She also added that his 
    brother recovered from malaria 2 weeks ago. On assessment, the child has a 
    temperature of 38.5°C. A negative test of malaria was confirmed. Classify and 

    identify the appropriate management of this child using IMCI strategy.

    6.10 Management of the child with EAR PROBLEM using 

    IMCI strategy

    Learning activity 6.10

    A child of 24 months was brought by his mother in consultation complaining of 
    the child crying persistently throughout the night. On examination you discovered 
    that there was a pus discharge from ear, and swollen behind the ear with pain 
    to touch. 

    As a student in senior six, what can you do to assist this child.

    There are four classifications for ear problem:
    • mastoiditis
    • acute ear infection
    • chronic ear infection

    • no ear infection

    MASTOIDITIS
    If a child has tender swelling behind the ear, classify the child as having MASTOIDITIS.

    Treatmen

    Refer urgently to hospital. This child needs treatment with injectable antibiotics. 
    He may also need surgery. Before the child leaves for hospital, give the first dose 
    of injectable chloramphenicol (if not possible, give oral amoxycillin). Also give one 
    dose of paracetamol if the child is in pain.
    ACUTE EAR INFECTION
    If you see pus draining from the ear and discharge has been present for less 
    than two weeks, or if there is ear pain, classify the child’s illness as ACUTE EAR 

    INFECTION.

    Treatment

    A child with an ACUTE EAR INFECTION should be given oral amoxycillin for 5 days. 
    If amoxycillin is not available give cotrimoxazole for 5 days. Antibiotics for treating 
    pneumonia are effective against the bacteria that cause most ear infections. Give 
    paracetamol to relieve the ear pain (or high fever). If pus is draining from the ear, 
    dry the ear by wicking.
    CHRONIC EAR INFECTION
    If you see pus draining from the ear and discharge has been present for two weeks 
    or more, classify the child’s illness as CHRONIC EAR INFECTION.
    Treatment
    Most bacteria that cause CHRONIC EAR INFECTION are different from those 
    which cause acute ear infections. For this reason, oral antibiotics are not usually 
    effective against chronic infections. Do not give repeated courses of antibiotics for 
    a draining ear.
    The most important and effective treatment for CHRONIC EAR INFECTION is to 
    keep the ear dry by wicking. Teach the mother how to dry the ear by wicking. Also 
    give topical quinolone ear drops for two weeks.
    NO EAR INFECTION
    If there is no ear pain and no pus is seen draining from the ear, the child’s illness is 

    classified as NO EAR INFECTION. The child needs no additional treatment.

    Table 6.8: Classification of ear problem

    Self-assessment 6.10

     A child of 24 months was received in consultation complaining of crying guarding 
    the left side of jaw and pus discharge from the left side of the ear for 8 days. 

    Classify and identify the treatment for this child using IMCI strategy.

    6.11 Management of the child with NUTRITIONAL 

    PROBLEM AND ANEMIA using IMCI strategy

    Learning activity 6.11


    CLASSIFY NUTRITIONAL STATUS
    There are three classifications for a child’s nutritional status. They are:
    • Severe malnutrition
    • Very low weight

    • Not very low weight

    SEVERE MALNUTRITION

    If the child has visible severe wasting or oedema of both feet, classify the child as 
    having SEVERE MALNUTRITION
    Treatment
    Children classified as having SEVERE MALNUTRITION are at risk of death from 
    pneumonia, diarrhoea, measles, and other severe diseases. These children need 
    urgent referral to hospital where their treatment can be carefully monitored. They 
    may need special feeding and antibiotics. Before the child leaves for hospital, give 
    the child a single dose of vitamin A. Prevent low blood sugar, while referral is being 
    organized initiate active treatment for hypothermia and keep the child warm on the 

    way to hospital.

    VERY LOW WEIGHT
    If the child is severely underweight for age, classify the child as having VERY LOW 
    WEIGHT
    Treatment
    A child classified as having VERY LOW WEIGHT has a higher risk of severe 
    disease. Assess the child’s feeding and counsel the mother about feeding her 
    child according to the recommendations in the FOOD box on the COUNSEL THE 
    MOTHER chart.
    Advise the mother to return for follow-up in 1 month.
    NOT VERY LOW WEIGHT
    If the child is Not Severely Underweight, classify the child as having NOT VERY 
    LOW WEIGHT.
    Treatment
    If the child is less than 2 years of age, assess the child’s feeding. Counsel the 
    mother about feeding her child according to the recommendations in the FOOD box 
    on the COUNSEL THE MOTHER chart. Children less than 2 years of age have a 

    higher risk of feeding problems and malnutrition than older children.

    CLASSIFY ANAEMIA
    There are three classifications for a child’s anaemia. They are:
    • Severe anaemia
    • Anaemia
    • No anaemia

    SEVERE ANAEMIA

    If the child has severe palmar pallor, classify the child as having SEVERE ANAEMIA
    Treatment
    Children classified as having SEVERE ANAEMIA are at risk of death due to chronic 
    hypoxaemia or congestive cardiac failure. These children need urgent referral to 
    hospital because they may need blood transfusions and their treatment can be 
    carefully monitored.
    ANAEMIA
    If the child has some palmar pallor, classify the child as having ANAEMIA.
    Treatment
    A child with some palmar pallor may have anaemia. Treat the child with iron folic 
    acid. Advise the mother to return for follow-up in 14 days.
    NO ANAEMIA
    If the child has no palmar pallor, classify the child as having NO ANAEMIA.
    Treatment
    Give prophylactic iron folic acid for a total of 100 days in a year after a child has 
    recovered from acute illness, if child is 6 months of age or older and has not received 

    prophylactic iron folic acid for 100 days in last one year.

    Table 6.10: Classification of anemia

    Self-assessment 6.11

    You receive a 40 months old child in consultation presenting some pallor in the 
    palm of arms. No danger signs or any other abnormality is found. Classify and 

    identify the treatment for this child using IMCI strategy.

    6.12 Management of the child with HIV using IMCI 

    strategy

    Learning activity 6.12

    What are the most common Sexually Transmitted Infections that a mother 

    may transmit to the unborn fetus?



    For HIV exposed children 18 months or older, a positive HIV antibody test result 
    means the child is infected.
    For HIV exposed children less than 18 months of age:
    • If PCR or other virological test is available, test from 4 - 6 weeks of age.
    – A positive result means the child is infected.
    – A negative result means the child is not infected, but could become infected 
    if they are still breast feeding.
    • If PCR or other virological test is not available, use HIV antibody test. A 
    positive result is consistent with the fact that the child has been exposed to 

    HIV, but does not tell us if the child is definitely infected.

    Self-assessment 6.12

    Describe the classification of HIV status using IMCI strategy

    6.13 Follow up care using IMCI strategy

    Learning activity 6.13

    Following a nursing intervention for a sick child, it is important to assess the 

    progress of the treatment given. Discuss its related rationale.

    At a follow-up visit you can see if the child is improving on the drug or other treatment 
    that was prescribed:
    • Care for the child who returns for follow-up using all the boxes that match the 
    child’s previous classifications.
    • If the child has any new problem, assess, classify and treat the new problem 

    as on the ASSESS AND CLASSIFY chart.

    Self-assessment 6.13

    Explain the follow up care of a child that visited the health center 3 days ago 

    suffering from pneumonia.

    End unit assessment

    1. What is the importance of IMCI?
    2. List danger signs that should be assessed in children following IMCI 
    strategy.
    3. Enumerate main symptoms of pediatric illness following IMCI strategy.
    4. Mention three signs that indicate a child with protein energy malnutrition.
    5. A father brought a child of 20 months at health center, whose mother died 
    while giving birth to baby, the baby has been given cow milk from birth 
    because their social economic status did not allow them to buy formula 
    for baby, the baby does not like to eat and is still taking cow milk. The 
    father mentioned also that the baby had malaria when he was 7 months, 
    11 months and 2 weeks ago he had another episode of malaria. The baby 
    is now very weak, has skin pallor.
    a. What would be the problem of the child?
    b. What are possible causes?
    6. A mother brings her child to the health center complaining that the child 
    has been passing loose watery stools with no blood stains for the past 
    10 days, the physical assessment the child looks weak with sunken eyes 
    and shows signs of dehydration.
    a. What are the common ways that infants may get diarrhea?
    b. judge what a child with diarrhea may be assessed
    c. how would you classify this type of diarrhea?
    7. What signs will you based on to classify a child as having severe 
    pneumonia or very severe disease?
    8. What signs will you based on to diagnose severe dehydration in children? 
    describe the treatment that will be provided to the child
    9. What are the four main classifications of ear problem in children
    10. Explain how a child with dysentery may be classified
    11. Describe how to identify severe wasting in an infant
    12. Mention the complications that a child with vitamin A deficiency may 

    develop.

    References

    WHO, U., & Hopkins, J. (2018). Family Planning: Global Handbook for Providers. 
    World Health Organization, USAID and Johns Hopkins University. http://www. 
    unfpa. org/public/publications/pid/397.
    Kloser, N. jayn., & Hatfield, N. T. (2010). Introductory Maternity and Pediatric 
    Nursing. China. Edition 2
    Resources, T. A. (2018). Comprehensive Sexuality eduction ,. A REFERENCE 
    BOOK FOR SECONDARY SCHOOL TEACHERS 1(May). Rwanda Education 
    Board (REB) United Nations Population Fund (UNFPA)
    Yacobson, I., Christopherson, K., & Michaelides, T. (2012). Facts For Family 
    Planning .
    Planning, F. (2020). Family Planning: rights and empowerment principles for family 
    planning.
    WHO, U., & Hopkins, J. (2018). Family Planning: Global Handbook for Providers. 
    World Health Organization, USAID and Johns Hopkins University. http://www. 
    Unfpa. Org/public/publications/pid /397.
    Kloser, N. jayn., & Hatfield, N. T. (2010). Introductory Maternity and Pediatric 
    Nursing. China. Edition 2
    Resources, T. A. (2018). Comprehensive Sexuality eduction ,. A REFERENCE 
    BOOK FOR SECONDARY SCHOOL TEACHERS 1(May). Rwanda Education 
    Board (REB) United Nations Population Fund (UNFPA)
    Yacobson, I., Christopherson, K., & Michaelides, T. (2012). Facts For Family 
    Planning .
    Planning, F. (2020). Family Planning: rights and empowerment principles for family 
    planning.
    Long, S.S., Prober, C.G. and Fischer, M., 2022. Principles and practice of pediatric 
    infectious diseases E-Book. Elsevier Health Sciences.
    Magesa, E., Sankombo, M. and Nakakuwa, F., 2021. Effectiveness of rotavirus 
    vaccine in the prevention of diarrhoeal diseases among children under age five 
    years in Kavango East and West Regions, Namibia. Journal of Public Health in 
    Africa, 12(1).
    Esposito, S., Jones, M.H., Feleszko, W., Martell, J.A.O., Falup-Pecurariu, O., Geppe, 
    N., Martinón-Torres, F., Shen, K.L., Roth, M. and Principi, N., 2020. Prevention 
    of new respiratory episodes in children with recurrent respiratory infections: an 
    expert consensus statement from the world association of infectious diseases and 

    immunological disorders (WAidid). Microorganisms, 8(11), p.1810.





    ◄UNIT 5:PREVENTION OF DISEASES IN CHILDRENTopic 7►