INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS MODULE 2: ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Transcription

1 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS MODULE 2: ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS SOUTH AFRICAN ADAPTATION 2009

2 TABLE OF CONTENTS INTRODUCTION... 3 LEARNING OBJECTIVES ASK THE MOTHER WHAT THE CHILD S PROBLEMS ARE GENERAL DANGER SIGNS ASSESS AND CLASSIFY COUGH OR DIFFICULT BREATHING Assess cough or difficult breathing Assess wheeze Classify cough or difficult breathing Classify wheeze ASSESS AND CLASSIFY DIARRHOEA Assess diarrhoea Classify diarrhoea Classify dehydration Classify persistent diarrhoea Classify dysentery ASSESS AND CLASSIFY FEVER Assess fever Assess for meningitis Assess for malaria Classify fever Classify meningitis Classify malaria Classify measles ASSESS AND CLASSIFY EAR PROBLEM Assess ear problem Classify ear problem CHECK FOR MALNUTRITION AND ANAEMIA Assess for malnutrition Assess for anaemia Classify malnutrition and anaemia Classify malnutrition Classify anaemia CONSIDER HIV INFECTION Assess the child s HIV test Classify the child s HIV test Assess the mother s HIV test and for features of HIV infection Classify the mother s HIV test and features for HIV infection CONSIDER TB Assess for TB Classify for TB CHECK THE CHILD S IMMUNIZATION STATUS ASSESS OTHER PROBLEMS ASK ABOUT THE MOTHER S HEALTH

3 INTRODUCTION A mother brings her 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, wheezing, diarrhoea, malaria, meningitis, or malnutrition. These diseases can cause death or disability in young children if they are not treated appropriately. The child may also have underlying HIV infection or TB; correct identification and management of these conditions are key to saving the lives of children in South Africa. 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. 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 or 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 every child for malnutrition and anaemia. Then check for possible HIV infection or TB. Also check the child s immunization status and assess any other problems the mother has mentioned. This means that every child will have a full assessment, and no serious illnesses will be missed in your busy clinic. The integrated process of assessing a child ensures that not only the main problem is addressed, but that any other illness or nutritional deficiency is detected and managed. The symptoms and signs are very well defined in this module. Many of them are already well-known to you, but the module helps you to identify them more accurately, and to use them to assess and classify common conditions in children. 3

4 LEARNING OBJECTIVES This module will describe and allow you to develop the following skills: Using an integrated approach Practicing triage Asking the mother about the child s problem. Checking for general danger signs. Asking the mother about the four main symptoms: cough or difficult breathing diarrhoea fever ear problem. When a main symptom is present: assessing the child further for signs related to the main symptom classifying the illness according to the signs which are present or absent. Checking for signs of malnutrition and anaemia in all children, and classifying the child s nutritional status. Checking for possible HIV infection based on HIV testing of the child and mother, and on symptoms and signs where the child has not been tested. Checking whether the child has been in contact with an adult with TB. If there is a TB contact or if the child has other conditions which may suggest TB, the child is assessed and classified for TB. Checking the child s immunization status and deciding if the child needs any immunizations today. Assessing any other problems, e.g. skin problems. Asking about the mother s health Your facilitator will tell you more about the ASSESS & CLASSIFY chart. 4

5 1. ASK THE MOTHER WHAT THE CHILD S PROBLEMS ARE A mother (or other family member such as the father, grandmother, sister or brother) usually brings a child to the clinic because the child is sick. But mothers also bring children for well-child visits, immunization sessions and for treatment of injuries. The steps on the ASSESS & CLASSIFY chart describe what you should do when a mother brings her child to the clinic because he is sick. The chart should not be used for a well child brought for immunization or for an injured child. When children arrive at the clinic, the clinic staff usually find out first what the reason is for the visit. The child must be weighed and the weight recorded accurately on the Road to Health Chart (RTHC). The temperature is measured and recorded on a patient card preferably on the inside of the child s RTHC. Then the mother and child see a health worker. If they have to wait they should be seated together with other children in a separate queue. It is important that any child who is seriously ill should be identified as soon as possible and should not be kept waiting, as this could put the child at risk. In order to prevent this from happening a trained member of the clinic staff should assess all waiting children for signs of serious illness and for any general danger signs (you will learn more about these later in this module). This should be done while the children are waiting in the queue so that seriously ill children are not overlooked and made to wait for a long time. This is known as rapid appraisal of all waiting children or triage and is an important part of the implementation of IMCI in any clinic. A child who has signs of serious illness or a general danger sign needs urgent attention. The assessment should be completed, any pre-referral treatment should be started and the child referred urgently. When you see the mother and her sick child: Greet the mother appropriately and ask her to sit with her child. You need to know the child s age so you can choose the right case management chart. Look at the child s record to find the child s age. If the child is age 2 months up to 5 years, assess and classify the child according to the steps on the ASSESS & CLASSIFY chart. If the child is younger than 2 months, assess and classify the young infant according to the steps on the YOUNG INFANT chart. (You will learn more about managing sick young infants later in the course). Look to see if the child s weight and temperature have been measured and recorded. If not, weigh the child and measure his temperature later when you assess and classify the child s main symptoms. Do not undress or disturb the child now. It is helpful when assessing children to leave the child with the mother throughout the examination if possible. Ask the mother to undress the child if this is necessary. Young children are alarmed if they are approached by a stranger and will usually cry. This will make the examination difficult. Start with those parts of the assessment where the child must be calm, like counting the breathing. Leave any part of the assessment that may distress the child to the end. Ask the mother what the child s problems are. Record what the mother tells you about the child s problems. 5

6 An important reason for asking this question is to open good communication with the mother. Using good communication helps to reassure the mother that her child will receive good care. When you treat the child for the illness later in the visit, you will need to teach and advise the mother about caring for her sick child at home. So it is important to communicate well with the mother from the beginning of the visit. To use good communication skills: Listen carefully to what the mother tells you. This will show her that you are taking her concerns seriously. Use words the mother understands. If she does not understand the questions you ask her, she cannot give the information you need to assess and classify the child correctly. Give the mother time to answer the questions. For example, she may need time to decide if the symptom or sign you asked about is present. Ask additional questions when the mother is not sure about her answer. When you ask about a main symptom or related sign, the mother may not be sure if it is present. Ask her additional questions to help her give clearer answers. Determine if this is an initial or follow-up visit for this problem If this is the child s first visit for this episode of an illness or problem, then this is an initial visit. If the child was seen before by an IMCI trained practitioner for the same illness, this is a follow-up visit. A follow-up visit has a different purpose to an initial visit. During a follow-up visit, the health worker finds out if the treatment given during the initial visit has helped the child. If the child is not improving or is getting worse after a few days, the health worker refers the child to a hospital or changes the child s treatment. Find out what type of visit this is by asking the mother and looking at the RTHC or patient held record. You will learn how to carry out a follow-up visit later in the course when you come to study the FOLLOW-UP module. The examples and exercises in this module describe children who have come for an initial visit. Initial visits and follow-up visit records must be entered on the RTHC. 6

7 2. GENERAL DANGER SIGNS Check all 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 during this illness the child is lethargic or unconscious A child with a general danger sign has a serious illness. Children with a general danger sign need URGENT referral to hospital. They may need lifesaving treatment with injectable antibiotics, oxygen or other treatments that may not be available in your clinic. For any child with a general danger sign complete the rest of the assessment immediately. How to provide urgent treatment is described in the next module TREAT THE CHILD. Here is the first box on the chart. It tells you how to 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. Also look to see if he is unable to drink because he is breathing very fast. This is a very important sign as you will learn in the next section. 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 7

8 her answer clear. For example, ask the mother how often the child vomits. Also ask: does the child vomit every time the child swallows food or fluids? 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 during this illness? During a convulsion, the child s arms and legs stiffen because the muscles are contracting. Saliva may run out of the mouth and/or nose. The child loses consciousness and is not able to respond when spoken to or to any other stimulus. There may be jerking movements of the arms and legs, and the breathing may be irregular. In small infants there is a stiffness of all the muscles that makes breathing impossible. Because convulsing infants and children do not breathe well, they are usually cyanosed with blue lips and tongue. Ask the mother if the child has had convulsions during this current illness. Use words the mother understands. For example, the mother may know convulsions as fits or spasms. If the mother is unsure describe to her what a convulsion looks like. 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 illness. There must be no delay in starting his treatment and arranging for referral. You will learn to record information about the sick child on a form called a Recording Form. The front of the Recording Form is similar to the ASSESS & CLASSIFY chart. It lists the questions to ask the mother and the signs for which you should look, listen and feel. In most of the exercises in this module, you will only use part of the Recording Form. As you learn each step in the chart, you will use more of the Recording Form. Your facilitator will show you a Recording Form and tell you how to use it. 8

9 EXERCISE A All exercises can be found in the Exercises book 9

10 3. ASSESS AND CLASSIFY COUGH OR DIFFICULT BREATHING Respiratory infections can affect any part of the respiratory tract such as the nose, throat, larynx, trachea, bronchi, bronchioles or the lung tissue itself. A child with cough or difficult breathing may have pneumonia or another severe respiratory infection. Pneumonia is an infection of the lungs and may be caused by either bacteria, a virus or other organisms. In South Africa, pneumonia is often caused by bacteria. The most common bacteria are Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae. Pnuemocystis jiroveci is also a common cause of pneumonia in young infants who have HIV infection. Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection). There are many children who come to the clinic with less serious respiratory infections. Most children with cough or difficult breathing have a mild infection. For example, a child who has a cold may cough because the back of the throat feels dry and inflamed. 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. Another common cause of cough is a respiratory allergy. This may be accompanied by a wheeze (see below). Health workers need to identify the few, very sick children with cough or difficult breathing who need treatment with antibiotics. Fortunately, health workers can identify almost all cases of pneumonia by checking for these two clinical signs: fast breathing and chest indrawing. When children develop pneumonia their lungs become stiff, because the inflammation causes some swelling of the lung tissue and squeezes some of the air out. Fast breathing is one of the body s responses to stiff lungs and hypoxia (too little oxygen). When the pneumonia becomes more severe, the lungs become even stiffer. Chest indrawing may develop. Chest indrawing is a sign of severe pneumonia as well as 10

11 some other serious diseases, such as metabolic acidosis as seen in severe dehydration. Stridor is a harsh sound when the child breathes in and is a sign of obstruction of the upper airway in the region of the larynx (see illustration). This obstruction is usually caused by an infection and must always be regarded as serious. A child with cough or difficult breathing may also have a wheeze. The child will need specific treatment for this. Children with a recurrent wheeze or a cough for a long time (more than 14 days) will need further assessment as these symptoms may be caused by asthma, TB, Lymphoid Interstitial Pneumonitis (LIP) or whooping cough. All children with a cough for more than 14 days should be assessed and classified for TB, as this is a common condition in South Africa you will learn to do this later in this module. Many children with a cough for more than 14 days will need to be referred for further assessment. 3.1 ASSESS COUGH OR DIFFICULT BREATHING A child with cough or difficult breathing is assessed for: How long the child has had the cough or difficult breathing Fast breathing Chest indrawing Stridor when the child is calm Wheeze Here is the box in the Assess column that lists the steps for assessing a child for cough or difficult breathing: Does the child have 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. At times the mother may say that the child has a tight chest. A tight chest is usually associated with a wheeze. If the mother answers NO, look to see if you think the child has cough or difficult breathing. You may notice during the further assessment of the child that in fact he is coughing. You will then have to return to this cough box. If the child does not have 11

12 cough or difficult breathing, ask about the next main symptom, diarrhoea. 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 14 days has a chronic cough. This may be a sign of tuberculosis, asthma, LIP, whooping cough or another problem. COUNT the breaths in one minute You must count the breaths the child takes in one minute to decide if the child has fast breathing. The child must be quiet and calm when you look and listen to his breathing. If the child is frightened, crying or angry, you will not be able to obtain an accurate count of the child s breaths. Tell the mother you are going to count her child s breathing. Remind her to keep her child calm. If the child is sleeping, do not wake the child. Count the breathing at the beginning of the assessment before you touch the child or undress him and before he has started to cry. To count the number of breaths in one minute: 1. Use a watch with a second hand or a digital watch. a. Ask another health worker to watch the second hand and tell you when 60 seconds have passed. You look at the child s chest and count the number of breaths. b. Usually there is no other health worker to help you. Then hold the watch near the child where you can see the second hand. Glance at the second hand as you count the breaths the child takes in one minute. 2. Look for breathing movements anywhere on the child s chest or abdomen. Usually you can see breathing movements even on a child who is dressed. If you cannot see this movement easily, ask the mother to gently lift the child s shirt. If the child starts to cry, ask the mother to calm the child before you start counting. If you are not sure about the number of breaths you counted (for example, if the child was restless and it was difficult to watch the chest, or if the child was upset or crying), repeat the count. The cut-off for fast breathing depends on the child s age. Normal breathing is faster 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. 12

13 Note: The child who is exactly 12 months old has fast breathing if you count 40 or more breaths per minute. Before you look and listen for the next three signs chest indrawing, wheeze and stridor watch the child to determine when the child is breathing IN and when the child is breathing OUT. LOOK for chest indrawing If you did not lift the child s shirt when you counted the child s breaths, ask the mother to lift it now. Look for chest indrawing when the child breathes IN. Look at the lower chest wall (lower ribs). The child has chest indrawing if the lower chest wall goes IN when the child breathes IN. Chest indrawing occurs when the effort the child needs to breathe in is much greater than normal. In normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the child breathes IN. When chest indrawing is present, the lower chest wall goes IN when the child breathes IN. If you are not sure that chest indrawing is present, look again. If the child s body is flexed at the waist, it is hard to see the lower chest wall move. Ask the mother to change the child s position so that he is lying flat on her lap. If you still do not see the lower chest wall go IN when the child breathes IN, the child does not have 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. If only the soft tissue between the ribs goes in when the child breathes in (also called intercostal indrawing or intercostal recession), the child does not have chest indrawing. In the IMCI assessment, chest indrawing is lower chest wall indrawing. It does not include intercostal indrawing. 13

14 LOOK and LISTEN for stridor or wheeze Stridor is a harsh noise made when the child breathes IN. Stridor happens when there is a swelling of the larynx, trachea or epiglottis. 1 This swelling interferes with air entering the lungs. It can be life-threatening if the swelling blocks the child s airway. 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. This is unlike the harsh noise of stridor. 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. Wheeze is a soft whistling sound best heard when the patient is breathing OUT. Wheezing is the sound produced by narrowing of the smaller airways in the lungs. This narrowing makes it difficult to breathe out and empty all the air out of the lungs. The whistling noise is caused by the air being pushed through the small narrowed airways. Children with a wheeze often take a longer time than usual to breathe out. If you hear a wheeze when you are assessing the child with a cough or difficult breathing you will then assess for wheeze as follows: 3.2 ASSESS WHEEZE Children may develop a wheeze when they have a viral upper respiratory tract infection like a cold or flu. The child with a wheeze needs treatment at the clinic and for some days after that. If the wheeze is caused by an infection it may clear up within a few days and may not recur. If a child with a wheeze has had a wheeze before, this is a recurrent wheeze and could be due to asthma. This child needs 1 These conditions are often called croup. 14

15 different treatment and referral for an assessment by the doctor to decide whether continuing treatment and follow-up for asthma is needed. Asthma is a condition where the airways in the lung are very sensitive and can easily become inflamed. The airways also become narrower, this is known as bronchoconstriction (you may also be familiar with the term bronchspasm ). Bronchoconstriction may occur in response to particles in the air that the child is allergic to, like dust and pollen, or when the child has a cold. The child with asthma may have a wheeze, difficult breathing and usually also a cough. The cough is usually chronic and worse at night. Children with asthma may also have other allergic conditions like eczema and hayfever. Other family members often have a history of eczema, hay-fever or asthma. In a child where you heard a wheeze today, you will need to assess and decide if this is the first time the child has had wheezing or whether the child has a recurrent wheeze. A child with a wheeze is assessed for: Previous episodes of wheeze Frequent coughing at night Prolonged wheezing for more than one week Whether the child is a known to have asthma This is the assessment box for wheeze on the cough page that lists the steps for assessing a child with a wheeze: ASK: Has the child had a wheeze before this illness? If the child has had a wheeze before, this is a recurrent problem and needs further assessment. ASK: Does the child frequently cough at night? Coughing, usually worse at night, may be the only symptom of recurrent wheeze or asthma. ASK: Has the child had a wheeze for more than 7 days? A wheeze caused by a viral infection will usually get better quickly. If the child has had a wheeze for longer than a week, this is a more severe episode and needs further assessment. 15

16 ASK: Is the child on treatment for asthma? This child has recurrent wheeze and should get treatment today according to IMCI. Long-term treatment and regular follow-up also needs to be provided according to local guidelines for management of asthma. 3.3 CLASSIFY COUGH OR DIFFICULT BREATHING CLASSIFICATION TABLES Signs of illness and their classifications are listed on the ASSESS & CLASSIFY chart in classification tables (also known as algorithms). Most classification tables have three rows. Each row is coloured either red, yellow, or green. The colour of the rows tells you quickly if the child has a serious illness. You can also quickly choose the appropriate treatment. A classification in a red row means that the child needs urgent attention and referral or admission for inpatient care. This is a severe classification. A classification in a yellow row means that the child needs an appropriate antibiotic, an oral antipyretic, bronchodilator or other treatment. The treatment includes teaching the mother how to give the oral drugs or to treat local infections at home. The health worker advises her about caring for the child at home and when she should return. A classification in a green row means the child does not need specific medical treatment such as antibiotics. The health worker advises the mother how to care for her child at home. For example, you might advise her on feeding her sick child or giving warm water with lemon juice to soothe the throat or stop the cough. Depending on the combination of the child s signs and symptoms, the child is classified in either the red, yellow, or green row. That is, the child with a cough is classified only once in each classification table. * * * There are three possible classifications for a child with cough or difficult breathing. They are: SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA COUGH OR COLD 16

17 Here is the classification table for cough or difficult breathing: How to use the classification table: After you assess for the main symptom and related signs, classify the child s illness. Always look at the top (red) row first. Move down to the yellow row only if the child does not fit into the red classification. Finally look at the green row only if the child has not been classified into either of the two previous categories. For example, to classify cough or difficult breathing: 1. Look at the red (or top) row. Does the child have a general danger sign? Does the child have chest indrawing or stridor when calm? If the child has a general danger sign or any of the other signs listed in the red row, select the severe classification, SEVERE PNEUMONIA OR VERY SEVERE DISEASE. 2. If the child does not have the severe classification, look at the yellow (or second) row. Does the child have fast breathing? If the child has fast breathing, the sign in the yellow row, and the child does not have a severe classification, select the classification in the yellow row, PNEUMONIA (see below). 17

18 3. If the child does not have the severe classification or the classification in the yellow row, look at the green (or bottom) row. 4. If the child does not have any of the signs in the red or yellow row, select the classification in the green row, COUGH OR COLD. 5. Whenever you use a classification table, start with the top row. In each classification table, a child receives only one classification. If the child has signs from more than one row, always select the more serious classification. EXAMPLE: This child has a general danger sign and fast breathing. Classify the child with the more serious classification SEVERE PNEUMONIA OR VERY SEVERE DISEASE. Your facilitator will answer any questions you have about classifying illness according to the ASSESS & CLASSIFY chart. Here is a description of each classification for cough or difficult breathing. 18

19 SEVERE PNEUMONIA OR VERY SEVERE DISEASE A child with cough or difficult breathing and any of the following signs: any general danger sign, or 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 pertussis (whooping cough), bronchiolitis, asthma or other wheezing problem. Chest indrawing develops when the lungs become stiff. The effort needed to breathe in is much greater than normal. A child with chest indrawing has a higher risk of death from pneumonia or other respiratory problem than the child who has fast breathing and no chest indrawing. If the child is tired, and if the effort needed to expand the stiff lungs is too great, the child s breathing slows down. Therefore, a child with chest indrawing may not always 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 children 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. So whenever a child shows signs of pneumonia, give the child an appropriate antibiotic. As mentioned above in South Africa a common cause of severe pneumonia in HIVinfected infants is Pneumocystis (jiroveci) pneumonia (PCP). A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is seriously ill. He needs urgent referral to a hospital for treatment, such as oxygen, an injectable antibiotics and/or a bronchodilator. Before the child leaves your clinic, give the first dose of an appropriate antibiotic (ceftriaxone). The antibiotic helps prevent severe pneumonia from becoming worse. It also helps to treat the child for possible other serious bacterial infections such as sepsis or meningitis. If the child is under 6 months of age and has chest indrawing, also give a first dose of oral co-trimoxazole to treat for possible Pneumocystsis jiroveci pneumonia (PCP). If there is wheezing in a child with SEVERE PNEUMONIA OR VERY SEVERE DISEASE you will assess for wheeze and treat accordingly before referral (see below). Treat for and to prevent low blood sugar and keep the child warm on the way to hospital if he has not got a fever. PNEUMONIA A child with cough or difficult breathing who has fast breathing but no general danger sign, no chest indrawing and no stridor when calm, is classified as having PNEUMONIA. If the child is breathing fast and is wheezing he may have asthma or 19

20 bronchiolitis. If the child has a wheeze, also assess and classify for wheeze (see below). Treatment Treat the child for PNEUMONIA with an appropriate antibiotic (amoxycillin). If the child has a wheeze, assess and classify according to the classification table for wheeze. Show the mother how to give the antibiotic. A child who has a chronic cough (a cough lasting more than 14 days) may have tuberculosis, asthma, LIP, whooping cough or another problem. You need to consider tuberculosis as this is a common and potentially serious problem you will later need to consider TB and classify the child for TB using the TB chart on page 8 of the Chart Booklet. Also advise the mother to give a warm home remedy to soothe the cough. The mother will give this treatment at home. The mother must be warned about the use of harmful remedies, such as inhaling smoke or oral drops of patent medicines intended for external use only. Advise her when to return for follow-up and when to return immediately, such as if there is difficulty in breathing or the child becomes more ill for any reason. COUGH OR COLD A child with cough who has no general danger signs, no chest indrawing, no stridor when calm and no fast breathing is classified as having COUGH OR COLD. Treatment A child with COUGH OR COLD does not need an antibiotic. The antibiotic will not relieve the child s symptoms. It will not prevent the cold from developing into pneumonia. The mother brought her child to the clinic because she is concerned about her child s illness, so give the mother advice about good home care. Advise her how to soothe the throat and relieve the cough with a safe remedy such as breastmilk, or warm water or tea with sugar, lemon or honey (if available). 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. As with PNEUMONIA, remember that a child with a cough for more than 14 days needs to be assessed for TB and other causes of a chronic cough. If a child with COUGH OR COLD has a wheeze, assess and classify for wheeze (see below). How to give each of these treatments will be explained in detail in the TREAT THE CHILD module. 3.4 CLASSIFY WHEEZE There are two possible classifications for the child with wheeze: 20

21 RECURRENT WHEEZE WHEEZE Here is the classification table for wheeze: How to use the classification table: This table is used in the same way as the classification table for cough and difficult breathing. The difference is that both of the rows in this classification table are yellow because all children with wheeze will need treatment. Children with a wheeze will also have a classification for cough and difficult breathing, so treatment for wheeze will be given as well as the treatment for the cough or difficult breathing. 1. Start at the top row. If the child has ever had a wheeze before, or often has a cough at night, or has had the wheeze for more than a week, or is known to have asthma, the child is classified as RECURRENT WHEEZE. 2. If the mother has not said YES to any of the questions in the assessment of wheeze, the child is classified as WHEEZE (FIRST EPISODE). Here is a description of each classification for wheeze: RECURRENT WHEEZE Child with wheeze and any of the following in the history: previous wheeze frequent cough at night wheeze for more than a week known asthma is classified as RECURRENT WHEEZE Treatment A child with RECURRENT WHEEZE needs treatment with a bronchodilator (salbutamol) used with a spacer to relieve the wheeze, and with a course of prednisone. Make sure that the mother knows how to give the bronchodilator at home using a MDI (metered-dose inhaler) and spacer. The child also has cough and difficult breathing, and will receive treatment according to that classification as well as the treatment for wheeze. A child with SEVERE PNEUMONIA OR VERY SEVERE DISEASE and RECURRENT WHEEZE will be 21

22 referred for hospital treatment because of the severe classification. Before referral give a bronchodilator using a nebulizer (or an MDI and spacer if a nebulizer is not available) and the first dose of prednisone. Children, who are not referred urgently, also need further assessment by the doctor to provide ongoing treatment and further follow-up if required. This is not an urgent referral and the child can be seen at the next asthma clinic at the hospital or when a doctor next visits the clinic. Advise the mother when to return for follow-up, and when to return immediately. WHEEZE (FIRST EPISODE) A child who is wheezing but has no features of recurrent wheeze is classified as WHEEZE (FIRST EPISODE). This is the first time this child has had a wheeze. Treatment The treatment is a bronchodilator (salbutamol). If the child has any other severe classification, give the bronchodilator (by nebulizer or MDI and spacer) before the child is referred to hospital. If the child is not referred, she will be treated at home with an inhaler (MDI) and spacer. It is important that the mother knows how to use the inhaler and spacer at home. Advise her about when to return. EXAMPLE: Read this case study. Also study how the health worker classified this child s illness. * * * Bongi is 18 months old. He weighs 11.5 kg. His temperature is C. His mother brought him to the clinic because he has a cough. She says he is having trouble breathing. This is his initial visit for this illness. The health worker checked Bongi for general danger signs. Bongi is able to drink. He has not been vomiting. He has not had convulsions. He is not lethargic or unconscious. How long has Bongi had this cough? asked the health worker. His mother said he had been coughing for 5 or 6 days. Bongi sat quietly on his mother s lap. The health worker counted the number of breaths the child took in a minute. She counted 41 breaths per minute. She thought, Since Bongi is over 12 months of age, the cut-off for determining fast breathing is 40. He has fast breathing. The health worker did not see any chest indrawing. She did not hear stridor, but she does hear a whistling noise as Bongi is breathing out. Bongi does have a wheeze. The health worker assesses Bongi for wheeze. She asks the mother if she has ever heard this wheezing noise before, the mother says no. The health worker then asks if Bongi often coughs at night, the mother says that he has been coughing at night on and off over the past few months. He has had the wheeze for 5 or 6 days since he started coughing, and is not known to have asthma. 22

23 Here is how the health worker recorded Bongi s case information and signs of illness: 1. To classify Bongi s illness, the health worker looked at the classification table for cough or difficult breathing. a. First, she checked to see if Bongi had any of the signs in the red row. She thought, Does Bongi have any general danger signs? No, he does not. Does Bongi have any of the other signs in this row? No, he does not. Bongi does not have any of the signs for a severe classification. b. Next, the health worker looked at the yellow row. He thought, Does Bongi have signs in the yellow row? He has fast breathing. c. The health worker classified Bongi as having PNEUMONIA. 23

24 2. She wrote PNEUMONIA on the Recording Form. 3. To classify Bongi for wheeze she looked at the classification table for wheeze. a. First she checked if Bongi had any of the signs in the top row (remember in the wheeze classification table the top row is a yellow row, but you still start at the top row to classify). She thought Has Bongi had a wheeze before? No the mother says not. Has he got a frequent cough at night? Yes, he does. He has not had a wheeze for a week or more and he is not known to have asthma. b. Since Bongi has one sign in the top (yellow) row the health worker classified Bongi as RECURRENT WHEEZE. 4. The health worker wrote the wheeze classification, RECURRENT WHEEZE, on the recording form: 24

25 EXERCISE B EXERCISE C Video modules

26 4. ASSESS AND CLASSIFY DIARRHOEA Diarrhoea occurs when stools contain more water than normal. Diarrhoea is also called loose or watery stools. Diarrhoea is common in children, especially those between 6 months and 2 years of age. It is also common in babies under 6 months who are drinking infant feeding formulas. Frequent passing of normal stools is not diarrhoea. The number of stools normally passed in a day varies with the diet and age of the child. Mothers usually know when their children have diarrhoea. They may say that the child s stools are loose or watery. Mothers may use a local word for diarrhoea. Babies who are exclusively breastfed often have stools that are soft; this is not diarrhoea. The mother of a breastfed baby can recognise diarrhoea because the consistency or frequency of the stools is not normal for this child. What are the Types of Diarrhoea? Most types of diarrhoea, which cause dehydration, are loose or watery. Cholera is one example of loose or very watery diarrhoea. Only a small proportion of all loose or watery diarrhoeal illnesses are due to cholera. If an episode of diarrhoea lasts less than 14 days, it is acute diarrhoea. Acute watery diarrhoea often causes dehydration and contributes to malnutrition. The death of a child with acute diarrhoea is usually due to dehydration. If the diarrhoea lasts 14 days or more, it is persistent diarrhoea. It is a common problem in HIV-infected children. Up to 20% of episodes of diarrhoea become persistent. Persistent diarrhoea often causes nutritional problems, dehydration and/or loss of weight and contributes to deaths of children. Diarrhoea 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. A child may have both watery diarrhoea and dysentery. 4.1 ASSESS DIARRHOEA Ask about diarrhoea in ALL children A child with diarrhoea is assessed for how long the child has had diarrhoea blood in the stool to determine if the child has dysentery how much and what type of fluid has been given at home signs of dehydration Look at the following steps for assessing a child with diarrhoea: 26

27 Does the child have diarrhoea? ASK: Does the child have diarrhoea? Use words for diarrhoea the mother understands. 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 diarrhoea. If the mother answers YES, or if the mother said earlier that diarrhoea was the reason for coming to the clinic, record her answer. Then assess the child for signs of dehydration, persistent diarrhoea, and dysentery. ASK: For how long? If diarrhoea for 14 days or more, has the child lost weight? Diarrhoea, which lasts 14 days or more is persistent diarrhoea. 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 diarrhoea. If there is blood in the stool the child has dysentery. ASK: How much and what type of fluid has been given at him? Some home remedies, such as enemas and purgatives, are the cause of diarrhoea or may make the diarrhoea worse. It is also important to find out if the mother has attempted oral rehydration at home, and if so, with what. You can then give health education about how to prevent dehydration in the future with sugar salt solution. If she has already given sugar salt solution at home, check that she is using the right quantities of sugar and salt, and praise her for giving her child the right treatment. 27

28 Next, check for signs of dehydration. * * * When a child becomes dehydrated, he is at first restless and irritable. If dehydration continues, the child becomes lethargic or unconscious. As the child s body loses fluids, the eyes may look sunken. When pinched, the skin will go back slowly or very slowly. 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 diarrhoea. A child has the sign restless and irritable if the child is restless and irritable all the time or every time he is touched and handled. If an infant or child is calm when breastfeeding, but again restless and irritable when he stops breastfeeding, he has the sign restless and irritable. Many children are upset just because they are in the clinic. Usually these children can be consoled and calmed. They do not have the sign restless and irritable. LOOK for sunken eyes. The eyes of a child who is dehydrated may look sunken. Decide if you think the eyes are sunken. Then ask the mother if she thinks her child s eyes look unusual. Her opinion helps you confirm whether the child s eyes are sunken. Note: In a severely malnourished child who is visibly wasted (who has marasmus), the eyes may always look sunken, even if the child is not dehydrated. In this case the mother may tell you that the child s eyes look the same as before the diarrhoea started. Even though sunken eyes are less reliable as a sign of dehydration in a visibly wasted child, you should 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. 28

29 PINCH the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Ask the mother to place the child on her lap or on the examining table so that the child is flat on his back with his arms at his sides (not over his head) and his legs straight. Locate the area on the child s abdomen halfway between the umbilicus and the side of the abdomen. To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain. Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down the child s body and not across the child s body. Firmly pick up all of the layers of skin and the tissue under them. Pinch the skin for one second and then release it. When you release the skin, look to see if the skin pinch goes back: very slowly (longer than 2 seconds) slowly immediately If the skin stays up for even a shot time (sometimes called tenting ) after you release it, decide that the skin pinch goes back 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 oedema, 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. 29

30 4.2 CLASSIFY DIARRHOEA EXERCISE D There are three classification tables for classifying diarrhoea: All children with diarrhoea are classified for dehydration. If the child has had diarrhoea for 14 days or more, also classify the child for persistent diarrhoea. If the child has blood in the stool, also classify the child for dysentery. So every child with diarrhoea will have at least one classification, this is for dehydration. However, a child with diarrhoea may be classified for persistent diarrhoea or dysentery as well, if these are present. So a child with diarrhoea could have as many as three classifications CLASSIFY DEHYDRATION Every child with diarrhoea is classified for dehydration. There are three possible classifications of dehydration in a child with diarrhoea: DIARRHOEA WITH SEVERE DEHYDRATION DIARRHOEA WITH SOME DEHYDRATION NO VISIBLE DEHYDRATION This is the classification table for dehydration: To classify the child s dehydration, begin with the red (or top) row. 30

31 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 from the red row are not present, look at the yellow (or middle) row. If two or more of the signs in this row are present, classify the child as having SOME DEHYDRATION. If a child has one sign in the SEVERE DEHYDRATION box and one sign in the SOME DEHYDRATION box you classify as SOME DEHYDRATION. If two or more of the signs from the yellow row are not present, classify the child has having NO VISIBLE DEHYDRATION. This child does not have enough signs to be classified as having SOME DEHYDRATION. Some of these children may have one sign of dehydration or have lost fluids without showing signs. * * * EXAMPLE: A 4 month old child named Clara was brought to the clinic, because she had diarrhoea for 5 days. She did not have danger signs and she was not coughing. She had not been given any treatment or extra fluids. The health worker assessed the child s diarrhoea. He recorded the following signs: The child does not have two signs in the red row. The child does not have SEVERE DEHYDRATION. The child had two signs from the yellow row. The health worker classified the child s dehydration as SOME DEHYDRATION. The health worker recorded Clara s classification on the Recording Form. Here is a description of each classification for dehydration: SEVERE DEHYDRATION If the child has two or more 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 as SEVERE DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids. The box Plan C: Treat for Severe Dehydration Quickly on the TREAT chart describes how to give fluids to severely dehydrated children. Refer the child after IV treatment has been started. You will learn more about Plan C in the TREAT THE CHILD module. 31

32 SOME DEHYDRATION If the child does not have signs of SEVERE DEHYDRATION, look at the next row. 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 and thirsty, skin pinch goes back slowly classify the child s dehydration as SOME DEHYDRATION. Treatment The child who has SOME DEHYDRATION needs fluid and food. Treat the child in the clinic with Oral Rehydration Salts (ORS) solution. In addition to fluid, the child who has 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. This treatment is described in the box entitled Plan B: Treat for Some Dehydration With ORS on the TREAT chart and will be described further in the TREAT THE CHILD module. NO VISIBLE DEHYDRATION A child who does not have two or more signs in either the red or yellow row is classified as having NO VISIBLE DEHYDRATION. Treatment This child needs extra fluid to prevent dehydration. A child who has NO VISIBLE DEHYDRATION needs home treatment. The 3 rules of home treatment are: 1. Give extra fluid 2. Continue feeding 3. When to return. Plan A: Treat for Diarrhoea At Home describes what fluids to advise the mother to use and how much she should give. A child with NO VISIBLE DEHYDRATION also needs 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. Your facilitator will lead a drill to help you review the steps for checking a child for general danger signs. You will also review the steps for assessing a child with cough or difficult breathing. EXAMPLE: Mano has had diarrhoea for five days. He has no blood in the stool and he has not lost weight. His mother has been giving sugar salt solution at home. He is not lethargic or unconscious, but irritable and his eyes look sunken. His father and mother also think that Mano s eyes are sunken. When the health worker offers Mano 32

33 some water, the child drinks eagerly. When the health worker pinches the skin on the child s abdomen, it goes back slowly. Record the child s signs and classification for dehydration on the Recording Form. Circle the child s signs on the classification table to show how you selected the child s classification. EXERCISE E 33

34 4.2.2 CLASSIFY PERSISTENT DIARRHOEA After you have classified the child s dehydration, classify the child for persistent diarrhoea if the child has had diarrhoea for 14 days or more. Persistent diarrhoea is a dangerous condition with a high mortality. Persistent diarrhoea is commonly seen in children infected with HIV. There are two classifications for persistent diarrhoea. SEVERE PERSISTENT DIARRHOEA PERSISTENT DIARRHOEA Here is the classification table for persistent diarrhoea: SEVERE PERSISTENT DIARRHOEA If a child has had diarrhoea for 14 days or more and also has SOME or SEVERE DEHYDRATION, classify the child s illness as SEVERE PERSISTENT DIARRHOEA. A child who is loosing weight, should also be classified as having SEVERE PERSISTENT DIARRHOEA. Treatment Children with diarrhoea lasting 14 days or more who are also dehydrated need referral to hospital. These children need special attention to help prevent further 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 diarrhoea. PERSISTENT DIARRHOEA A child who has had diarrhoea 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 diarrhoea. Feeding recommendations for persistent diarrhoea are explained in the COUNSEL THE MOTHER module and in the Chart Booklet. 34

35 4.2.3 CLASSIFY DYSENTERY If a child with diarrhoea has blood in the stool after you have completed the classification for dehydration you will also classify for dysentery. There are two classifications for dysentery: SEVERE DYSENTERY DYSENTERY Here is the classification table for dysentery: SEVERE DYSENTERY Classify a child with blood in the stool as SEVERE DYSENTERY if the child is younger than 12 months old or if the child is dehydrated. These children may have blood in the stool due to a serious abdominal condition like intussusception. They need further investigation and should be referred URGENTLY. Children with dysentery at times have convulsions, which also calls for immediate referral. Treatment If the child has SOME DEHYDRATION or SEVERE DEHYDRATION and has dysentery, rehydration should be started. Then this child should also be managed in hospital. It is unusual for dysentery to cause dehydration, and this should be investigated. Refer this child URGENTLY. DYSENTERY Classify children with diarrhoea and blood in the stool as having DYSENTERY if they are older than one year and are not dehydrated. Treatment Give an antibiotic recommended for Shigella in your area. You can assume that Shigella caused the dysentery 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. Therefore in a primary care setting it is usually not done. 35

36 Note: A child with diarrhoea may have one or more classifications for diarrhoea. (This is similar to the child with a cough who is also wheezing.) Every child with diarrhoea must have a classification for dehydration. Record the classification for dehydration in the Classify column on the Recording Form. If the child has persistent diarrhoea or dysentery write the classification for this below the classification for dehydration. See the example below where the child has blood in the stool. As well as the classification for dysentery the health worker first also assessed and classified for dehydration. EXERCISE F EXERCISE G You will now watch Module 5 in the video, and do the corresponding exercises. At the end of this videotape exercise, there will be a group discussion. 36

37 5. ASSESS AND CLASSIFY FEVER A child with fever may have meningitis, malaria, measles or another severe disease. Or, a child with fever may have a simple cough or cold, flu or other viral infection. MENINGITIS is an infection of the meninges and the cerebro-spinal fluid surrounding the brain and spinal cord. This serious condition can result in severe brain damage or death. The common clinical features are fever and vomiting with irritability, headache, drowsiness or loss of consciousness, and convulsions. A bulging fontanelle with or without a stiff neck strongly suggests meningitis. In young infants the stiff neck often appears later than it does in older children. Any child with fever could have meningitis. Treatment As this is a life threatening condition rapid and effective action is called for. Urgent referral is essential. Pre-referral treatment includes ceftriaxone IM, ensuring that the blood sugar level is normal and correcting it where necessary. If the child has had a convulsion or is unconscious he needs to be given oxygen. MALARIA is caused by parasites (plasmodium falciparum) in the blood. These are transmitted through the bite of anopheles mosquitoes. Fever is the main symptom of malaria. It can be present all the time or come and go at regular intervals. Other signs of malaria are shivering, sweating, headaches and vomiting. A child with malaria may have chronic anaemia (with no fever) as the only sign of illness. (You will read more about anaemia in Section 7.0.). In severe cases of malaria the child may be lethargic or unconscious and may have convulsions. A common cause of lethargy in a child with malaria is low blood sugar. 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 malaria and pneumonia. Children with malaria may also have diarrhoea. They need anti-malarial treatment and treatment for the diarrhoea. Most of South Africa is free of malaria. The areas at highest risk of malaria in South Africa are Mpumalanga (mainly lowveld), Limpopo (mainly north-eastern part and areas bordering Zimbabwe and Botswana) and the north-eastern parts of KwaZulu- Natal. Malaria transmission in South Africa is seasonal. Malaria cases start to rise in October, peaking during the summer months (November to May). The least transmission occurs during June to September. Malaria is present all year in most of our neighbouring countries, except Lesotho. Health workers in these areas are aware of the risk of malaria where they are working. However even in places where there is no malaria, a child is at risk of malaria if he has travelled to a malaria area within the previous month. Any child with fever, who has travelled to or from a malaria area within the past month, should be classified as a malaria risk. Health workers in a non-malaria area may not suspect malaria as a possible cause of the child s fever. This may be a dangerous situation since malaria can easily be missed. 37

38 Decide whether there is a risk of malaria in every child with fever, since malaria is a major cause of death in young children and can develop into a very severe condition very quickly. Deciding Malaria Risk: To classify and treat children with fever, you must know the malaria risk in your area. A child has malaria risk if: Malaria occurs in the place where the child is living. This includes parts of Northern KwaZulu-Natal, the Lowveld areas of Mpumalanga and Limpopo (which includes the Kruger National Park), and neighbouring countries; or: The child has been to a place where malaria occurs in the past month. A child has no malaria risk if: Malaria does not occur where the child lives, and he has not visited a malaria area in the past month. You must know the malaria status for your area, and you will be informed if it changes. In areas where malaria is seasonal, find out what time of year it occurs. When assessing a child with a fever you must first classify all children for possible meningitis. Then decide if the child could have a malaria risk. If he has a malaria risk, also classify the child for malaria. MEASLES is a viral infection that has caused very severe illness and many deaths in infants and young children. Measles epidemics have become uncommon in South Africa, and very few cases are now seen. This is due to regular campaigns and the inclusion of two doses of measles vaccine in the immunization schedule. However, outbreaks do occasionally occur these tend to affect very young infants, adults and older children, and young children who are HIV-infected. Therefore when assessing a child with fever, always look for signs of measles. Only a few of the more experienced health workers can easily recognise a child with measles. Young infants should be protected against measles by the mother s antibodies circulating in the infant s blood. All 9 months old infants need to get the first measles vaccination, which should be repeated at the age of 18 months to ensure that the child is fully protected. Where there are measles outbreaks, infants between the ages of 6 and 9 months are given an extra dose of measles vaccination in addition to the standard doses. Measles always starts with fever and a runny nose together with a dry cough, just like flu. The rash comes on only on the 4 th or 5 th day of the illness. It is deep red and irregular and first appears behind the ears and then affects the face, trunk and limbs. Before the rash appears there are fine spots, like salt grains on the inside of the cheek (Koplik spots). As the rash comes on larger white spots appear in the mouth and pharynx and the eyes become very red, painful and sensitive to light. (It is also known as the 3 C s illness: Cough, Coryza, Conjunctivitis). The measles virus depresses the immune system for many weeks after the illness. This leaves the child at risk of developing other infections. 38

39 Measles also makes great demands on the body s vitamin A reserves. Some children may show signs of vitamin A deficiency after measles. Complications of measles are less severe if vitamin A is given during the illness. Complications of measles occur in about 30% of patients and include: Diarrhoea Pneumonia Stridor Mouth ulcers Corneal ulcers, possibly leading to blindness Ear infection Measles contributes to malnutrition because it causes diarrhoea, high fever, loss of appetite and sores in the mouth. This is especially true for those children deficient in vitamin A. It is very important to encourage the mother to give the child small feeds throughout the day. 5.1 ASSESS FEVER Does the child have fever? By history, by touch or by axillary temperature 37.5ºC or above? ASK: A child has the main symptom fever if the child: has a history of fever or feels hot or has an axillary temperature of C or above If the child has a fever, first decide if there is a malaria risk. Then assess for suspected meningitis. how long the child has had fever stiff neck bulging fontanelle generalised rash other causes of fever If there is a malaria risk then do a rapid malaria test if available. Consider other causes of fever. If the child has a generalised rash and fever consider measles. * * * 39

40 The box below lists the steps for assessing a child for fever. The box describes how to assess the child for signs of meningitis, malaria, and other causes of fever ASSESS FOR MENINGITIS Ask about, measure and feel for fever in ALL sick children. ASK: Does the child have fever? Check to see if the child has a history of fever, feels hot or has a temperature of 37.5 C 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 37.5 C or above, the child has fever. If the child s temperature has not been measured, do so before you go any further. If the child does not have fever (by history or temperature 37.5 C or above), tick NO on the Recording Form. Ask about the next main symptom, ear problem. Do not assess the child for signs related to fever. 40

41 If the child has fever (by history, by feel or temperature 37.5 C or above), assess the child for additional signs related to fever. History of fever is enough to assess the child for fever even if the measured temperature is not 37.5 C or above. 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 a viral illness get better 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 tuberculosis or typhoid fever. All children who have had fever for seven days or more, must be assessed and classified for TB. You will be taught how to do this later in the module. LOOK or FEEL for bulging fontanelle and stiff neck. A child with fever and bulging fontanelle with or without stiff neck should be regarded as having meningitis. In the absence of a stiff neck or bulging fontanelle any general danger sign can also indicate meningitis. A child with meningitis needs urgent treatment with injectable antibiotics and referral to a hospital. A bulging fontanelle is best found with the infant in the sitting position: the hand is curved over the back of the head and gradually brought forward. The bulging fontanelle can be felt above the surrounding bones of the head. In the early stages before it bulges the fontanelle is full and it is more tense than usual. The child should be calm and not crying when you feel for a bulging fontanelle. The fontanelle is closed by 18 months of age, so there is no need to feel for a bulging fontanelle in a child older than this. Look for a stiff neck as 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. 41

42 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 torch on the toes or umbilicus or tickle the 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 let the child lie on his back. Hold the child s head with a hand on each side with the 4th and 5th fingers behind the head. Gently bring the head forward bending the neck. If there is any neck stiffness the child will resist this and experience pain. In infants and young children it may take a day or two after meningitis has started before they get neck stiffness. Do not wait for neck stiffness to appear before you consider meningitis. A danger sign or bulging fontanelle could appear first. ASSESS FOR OTHER CAUSES OF FEVER If the child has already been classified as PNEUMONIA or has diarrhoea this is probably the cause of the fever. Common Cold Fever is very common in young children and is often caused by a cold (viral upper respiratory tract infection). Check if there is a runny nose. A child with a runny nose probably has a cold. This child may also be coughing (without fast breathing) and have a sore throat. This type of viral infection gets better by itself within a few days and no treatment with antibiotics is required. Measles Measles case definition The following signs and symptoms make up the case definition for Suspected measles: 42

43 Fever AND Maculopapular ( blotchy ) rash AND One of the following 3Cs: Cough, OR Coryza ( runny nose ) OR Conjunctivitis This case definition provides an early alert in an environment where measles has not been eliminated. Measles cases are now unusual in South Africa due to the success of immunization campaigns. However they do still occur. A single case of measles could quickly lead to an outbreak, so it is important to ensure that the appropriate action is taken to confirm any possible measles cases and prevent an outbreak. Notifying cases which meet the case definition criteria contributes to measles control and surveillance efforts, even when the illness turns out not to be measles. If the child fits the measles case definition, take action as follows: What to do in suspected measles cases? Contact your local EPI co-ordinator who will advise you what to do. Complete measles case investigation form and fax to the provincial and/or national Department of Health. Collect blood for serological tests. Collect midstream urine (MSU) for virus isolation. Refrigerate blood and urine specimens. Send the urine and blood specimens, in a cold chain, and a copy of the case investigation form to the National Institute for Communicable Diseases in Johannesburg. Other viral infections A measles rash does not have vesicles (blisters), as in chicken pox. Do not confuse measles with other common childhood rashes such as chicken pox, scabies or heat rash. Scabies occurs on the hands, feet, ankles, elbows, buttocks and axilla. It also itches. Heat rash can be a generalised rash with small bumps and vesicles, which itch. A child with heat rash is not unwell. Ask the mother about rashes or other skin conditions like an abscess. Undress the child and look carefully for any rash. Also look for any skin infections like abscesses, infected insect bites or cellulitis, which may be a cause of fever. Ear problem Also ask about ear problems (the next main symptom), an ear infection is a common cause of fever in a young child. Tonsillitis If you are still unable to find a cause for the fever ask about sore throat. Sore throats are more common in young children. The child with tonsillitis will have great difficulty in eating due to the pain when swallowing. They usually also have excess saliva for the same reason. The child may be able to tell you that the throat is sore. Look at the throat to see if the child has tonsillitis. Many children have very large tonsils this 43

44 does not mean that there is tonsillitis. Look for redness and inflammation of the tonsils as well as spots of pus on the surface of the tonsils. If there is tonsillitis treat the child with amoxycillin or penicillin. Slight redness of the throat alone is usually due to a viral infection and does not require treatment with antibiotics. OPTIONAL EXERCISES H, I and J ASSESS FOR MALARIA if there is a risk If the child is living in an area where malaria cases occur, the child is at risk of malaria. Clinics situated in malaria areas should consider all children with a fever as being at risk of malaria. In many areas where malaria cases occur, the risk of malaria may be present only for some months of the year. Local guidelines should be used to determine when the risk is present. In non-malaria areas ask whether the child has travelled to a malaria area. A child who is not living in a malaria area is also at risk if he has visited a malaria area within the past month. Any child with a fever who is at risk of malaria needs to be assessed and classified for malaria and for meningitis. If there is no malaria risk, go onto the next main symptom of ear problem, there is no need to assess further for malaria. CHECK: Rapid Malaria test if available If malaria risk is present, the most reliable way to diagnose malaria is with a rapid malaria test. This is a blood test, which measures malaria parasites in the blood. Clinics in areas where malaria risk is present should have this test available and you can use the result of the rapid malaria test to classify for malaria. Clinics may not always have rapid malaria tests available, especially if the child has travelled from a malaria area into an area where malaria cases do not usually occur. Where co-artemether is the recommended treatment the child should always have a positive malaria test before getting treatment for malaria. So if a rapid malaria test is not available at your clinic, refer to the nearest facility where the test is available. In the areas/provinces that are free of malaria any child suspected of having malaria must be referred immediately. The referral note must state very clearly that there is a risk of malaria for this child. 44

45 5.2 CLASSIFY FEVER There are two fever classification tables on the ASSESS & CLASSIFY chart. One is for classifying meningitis. All children with fever are classified for meningitis. There is a second fever classification table; this classification table is for malaria. If the child is at risk of malaria, you will also classify for malaria. So a child with fever without malaria risk will only have one fever classification, the classification for meningitis. If malaria risk is present the child will also have a classification for malaria CLASSIFY MENINGITIS It is important to consider and check for meningitis in every child with a fever because it is easy to overlook meningitis in the early stages of the disease. A child with meningitis will quickly become very sick and can die within a few hours. So every child with fever must be assessed and classified for meningitis. There are two possible classifications when you classify meningitis in a child with fever: SUSPECTED MENINGITIS FEVER OTHER CAUSE To classify a child for meningitis use the classification table for meningitis above. SUSPECTED MENINGITIS EXAMPLE: A 9 month old boy is brought to the clinic because he has had fever for 2 days. He has not eaten for 2 days. He vomited twice during the night. This was recorded as a Danger Sign present. Because the child has a bulging fontanelle, he was classified as SUSPECTED MENINGITIS. He was given ceftriaxone IM. He also had a temperature of 39 C so he was given paracetamol by mouth. The blood sugar level was tested with glucose strips and found to be normal. The child was referred urgently. The mother was asked to give him sips of sugar salt solution (SSS) frequently during the trip. Even if 45

46 the child did not have a bulging fontanelle, he would still be classified as SUSPECTED MENINGITIS because he has a general danger sign: he has not eaten for 2 days. FEVER OTHER CAUSE Once you are satisfied that the child does not have any danger signs or signs of meningitis, other common causes of fever must be considered. All other children can be classified as FEVER OTHER CAUSE but it is still very important to look for an underlying cause of the fever as described above. Colds and influenza ( flu ) or other simple viral illnesses are the most common cause of fever in infants and young children. Tonsillitis and other forms of sore throat are more common in those over 2 years of age. Other causes of fever include pneumonia, ear infections, TB, typhoid, urinary tract infections, abscesses and other forms of cellulitis. Treatment of patients with a fever depends on the cause of the illness. If you see a child with a fever you should always look for the cause. If you find a cause you should treat appropriately. Viral infections like colds and flu do not improve with antibiotics. It is important not to give antibiotics unless you have identified an infection, which will respond to antibiotics. Do not give children antibiotics for a fever: look for a cause and give antibiotics only if a response is likely. Most children do not need them and will recover by themselves. They are being exposed unnecessarily to side effects of the antibiotics. If no definite cause has been found, the mother is asked to bring him back immediately if he shows features of more serious illness. (You will learn more about this in the COUNSEL THE MOTHER module.) He must be seen again and assessed carefully after 2 days if the fever persists. A child with a prolonged fever (every day for more than 7 days) must have TB excluded. Children with fever for more than 7 days, who do not TB, should be referred for further investigations CLASSIFY MALARIA This section applies to children at risk of malaria. This may be either because you are working in a malaria risk area OR because you are seeing a child that has recently visited a malaria area. There are four possible classifications for MALARIA in a child with a malaria risk. SUSPECTED SEVERE MALARIA MALARIA SUSPECTED MALARIA FEVER OTHER CAUSE To classify fever when there is a malaria risk, use the classification table for MALARIA above. SUSPECTED SEVERE MALARIA If there is a risk of malaria and the child has any general danger sign, bulging fontanelle or a stiff neck, classify the child as having SUSPECTED SEVERE MALARIA. Check the rapid malaria test. 46

47 A child with fever and any general danger sign, bulging fontanelle and/or stiff neck is likely to have meningitis, and/or severe malaria (including cerebral malaria) or sepsis. A child with these signs has also been classified as SUSPECTED MENINGITIS. This is because it is not possible to distinguish between these severe diseases without laboratory tests. Treatment The choice of anti-malarial treatment will depend on what is recommended for your local area. Most parts of South Africa now use Co-artemether (Artemether and Lumefantrine in combination). This should only be given if the malaria test is positive and the child is older than 12 months. Other children should be referred urgently so that a test can be done or treatment given this includes children less than 12 months of age and children who have not had a malaria test. All children with this classification will also be given treatment for SUSPECTED MENINGITIS and referred urgently to hospital. MALARIA (rapid malaria test available) NOTE: There are three yellow rows in the classification table for malaria, the first yellow row is used to classify for malaria if the rapid malaria test is available in your clinic. If the child does not have signs of SUSPECTED SEVERE MALARIA look at the next (yellow) row. When there is a risk of malaria, a child should have had a rapid malaria test. If this is positive the child is classified as having MALARIA. If the test is negative, move down to the last yellow row. If the rapid malaria test is not available in your clinic you cannot classify as MALARIA since the diagnosis cannot be confirmed. Do not use this row to classify, move down to the second yellow row to classify if the rapid malaria test is not available/ not done. Treatment Treat a child classified as having MALARIA with the appropriate anti-malarial. Children younger than 12 months should be referred for treatment. Details of how to give this treatment will be described in the TREAT THE CHILD module. If there is also cough and fast breathing, the child may have malaria or pneumonia, or both. It is not possible without laboratory tests to find out if the child has malaria or pneumonia. You will have managed the child for cough and fast breathing already. Give paracetamol if the child has high fever (axillary temperature of 38 C or above). SUSPECTED MALARIA (RAPID MALARIA TEST NOT DONE) If the rapid malaria test is not available or was not done in your clinic and the child is at risk of malaria, you must refer the child to a facility where testing and treatment is available. Co-artemether is currently recommended as treatment for malaria in all parts of South Africa (remember that national and local guidelines may change from time to time). Co-artemether should not be given to treat a child with malaria unless the 47

48 diagnosis is confirmed. You will need to refer the child with malaria risk to a facility where testing is available. FEVER OTHER CAUSE (rapid malaria test available and is negative or it is not available, but there is another adequate cause for fever) For this you use the third yellow row. It is yellow because you may have to give treatment for the other cause. If you are working in a clinic where the rapid malaria test is available and the test was negative, classify the fever as FEVER OTHER CAUSE. If there is an obvious other cause for the fever, such as an upper respiratory infection, the classification should also be FEVER OTHER CAUSE. This child does not have malaria. Treatment Treat the child for any other cause that may have been identified. If the child's fever is high (more than 38ºC), give paracetamol. Advise the mother to return for follow-up in 2 days if the fever persists. She must also know when to bring the child back immediately. If there is still no obvious cause for the fever at the followup visit you will refer the child then. You will learn more about follow-up visits in the FOLLOW-UP module. If the fever has been present every day for more than 7 days, remember to assess and classify for TB. EXAMPLE: Busi is two years old and has had a fever on and off for three days. Her temperature today is 37.5ºC. There is malaria risk in the area where she lives and there have been a few malaria cases this year in her village. The health worker did not find any general danger signs. Busi does not have cough or diarrhoea. The health worker checked for stiff neck, but Busi was able to move her neck easily. The health worker then looked for another cause of the fever. She looked at the classification box for meningitis: The health worker looked at the red row. Busi did not have any signs of SUSPECTED MENINGITIS, so she recorded the classification as follows: 48

49 She then assessed Busi for malaria. Unfortunately rapid malaria tests are out of stock at her clinic today. She checks the classification box for MALARIA to see what she should do. In order to classify Busi for MALARIA, the health worker looked first at the red row. Busi did not have any signs in the red row so the health worker did not select the classification SUSPECTED SEVERE MALARIA. She looked at the first yellow row, but could not use this row because she was unable to do the rapid malaria test. So she moved down to the next yellow row, which is the row to classify if the malaria test is unavailable. The health worker selects the classification SUSPECTED MALARIA. She recorded the findings on the recording form as follows: CLASSIFY MEASLES In a child who fits the measles case definition, classify for measles. Look at the optional measles chart in your Chart Booklet (page 42). Children with measles may be classified as: SEVERE COMPLICATED MEASLES or MEASLES WITH MOUTH OR EYE COMPLICATIONS or MEASLES EXERCISE K EXERCISE L 49

50 6. ASSESS AND CLASSIFY EAR PROBLEM A child with an ear problem may have an ear infection. When a child has an ear infection, pus collects behind the eardrum and causes pain and fever and there may be hearing loss. If the child is not treated for the infection, the eardrum may burst. The pus discharges, and the child feels less pain. The fever may stop, but the child suffers from poor hearing because the eardrum has a hole in it. Usually the eardrum heals by itself. At other times the discharge continues, the eardrum does not heal, and the child may become deaf in that ear unless treated. Sometimes where the infection has been present for many months or years it can spread from the ear to the bone behind the ear (the mastoid bone) 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 under-resourced communities. Deafness causes serious learning problems in school. It also isolates the child and interferes with social development. The ASSESS & CLASSIFY chart helps you identify ear problems due to ear infection. Infants and small children usually cannot localise the pain they experience to the ear. Irritability and some fever may be the only signs of an infection in the ear. 6.1 ASSESS EAR PROBLEM A child with ear problem is assessed for: ear pain. Does the ear pain wake the child at night? ear discharge if discharge is present, how long the child has had discharge tender swelling behind the ear, a sign of mastoiditis Here is the box from the "Assess" column that tells you how to assess a child for ear problem. Ask about ear problem in ALL sick children. 50

51 ASK: Does the child have an ear problem? If the mother answers NO, record her answer. Do not assess the child for ear problem. Go to the next question and 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. An older child can tell you if there is pain in the ear, but in a younger child it may be difficult to decide whether there is ear pain. ASK: Does the ear pain wake the child at night? Ear pain in a child is usually severe and makes the child distressed and irritable. A child with ear pain will not usually sleep well and may wake in the night crying with the pain. If the mother tells you that she thinks the child may have ear pain because the child has been scratching or pulling the ear but the child is otherwise well and not distressed, it is unlikely that this is the pain of a middle ear infection. 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. At times mothers report ear discharge, which had been seen some days before but that this is no longer there. This should not be recorded as ear discharge. 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 for the ear problem depending on how long the ear discharge has been present. Ear discharge that has been present for 2 weeks or more is treated as a chronic ear infection. 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. 51

52 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. Always check the scalp for sores that could be the cause of swollen lymph glands. 6.2 CLASSIFY EAR PROBLEM There are four classifications for ear problems: MASTOIDITIS ACUTE EAR INFECTION CHRONIC EAR INFECTION NO EAR INFECTION Here is the classification table for ear problem from the ASSESS & CLASSIFY chart. MASTOIDITIS If a child has tender swelling behind the ear, classify the child as having MASTOIDITIS. Treatment Refer to hospital urgently. This child needs treatment with injectable antibiotics (ceftriaxone). He may also need surgery. Before the child leaves for hospital, give the first dose of the antibiotic and give one dose of paracetamol if the child is in pain. 52

53 ACUTE EAR INFECTION If you see pus draining from the ear and discharge has been present for less than two weeks, classify the child's illness as ACUTE EAR INFECTION. If the mother says that the child has ear pain, ask whether the pain wakes the child at night. If the child is able to tell you that the ear is hurting or if the child is distressed with pain or the mother tells you the child has been distressed with pain earlier, classify as ACUTE EAR INFECTION. However if the only history is that the child seems to have been scratching or pulling the ear but otherwise does not appear to be in pain, do not classify. Explain to the mother that children often rub their ears and it is not always a sign of ear pain. Treatment Give a child with an ACUTE EAR INFECTION amoxycillin for 5 days. Antibiotics for treating pneumonia are also 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. The child should be seen again after 5 days if there is still pain or if the ear is still discharging. A follow-up visit after 14 days must be scheduled for all children with ACUTE EAR INFECTION. 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 causing acute ear infections. Do not give antibiotics to a child with a chronic ear infection. Appropriate drops (usually acetic acid) if available, are instilled into the ear after drying the ear by wicking whenever pus can be seen. 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. (This will be described in the COUNSEL THE MOTHER module). NO EAR INFECTION If there is no ear pain (or pain that does not wake the child at night) 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. The infant or small child, who is irritable and slightly feverish but does not have ear pain, may have an ear infection, but is unable to locate the pain. This child will have a fever for which no cause is obvious, so you will ask the mother to bring the child back after two days if there is no improvement. One reason for doing this is because by then there may be pus draining from the ear. 53

54 EXERCISE M 7. CHECK FOR MALNUTRITION AND ANAEMIA Check all sick children for signs of malnutrition and anaemia Malnutrition is the main or contributing cause of death of more than 70% of children dying in our hospitals. Therefore we need to be very conscientious about identifying and managing any form of malnutrition and anaemia. A mother may bring her child to the clinic because the child has an acute illness. The child may not have specific complaints that point to malnutrition or anaemia. A sick child can be malnourished, but the health worker or the child s family may not notice the problem. A child with malnutrition has a higher risk of many types of disease and of death. Even children with mild and moderate malnutrition have an increased risk of death from other illnesses like diarrhoea and pneumonia. Identifying children with malnutrition and treating them can help prevent many severe diseases and death. Many malnourished children can be treated at home. Severe cases need referral to hospital for special feeding, blood transfusion, 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. The most common type of malnutrition is protein-energy malnutrition. Proteinenergy malnutrition develops when the child is not getting enough energy and/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 have both marasmus and kwashiorkor The child may not grow well and become stunted (too short) Malnutrition affects approximately 25% of the children in South Africa. That means that one out of every four children has some form of malnutrition. More than 50% of children dying of whatever cause in South African hospitals are found to be malnourished. Therefore it is very important for health workers to identify these malnourished children and manage them carefully. 54

55 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 quantities 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. Several other diseases tend to be more severe in children, who are deficient in vitamin A. The child is also at risk of blindness. A child with vitamin A deficiency may also be too short for his age (stunted). Malnutrition and anaemia often occur together but you will assess and classify separately for malnutrition and anaemia. 7.1 ASSESS FOR MALNUTRITION Here is the box from the "Assess" column on the ASSESS & CLASSIFY chart. It describes how to assess a child for malnutrition and anaemia. Assess ALL sick children for malnutrition and anaemia: ASK: Has the child lost weight? 55

56 If a mother says that her child has lost weight this is a sign that the child may have malnutrition, or be in danger of developing malnutrition, or there could be a serious underlying illness. This history is particularly important if the child does not have a RTHC, which should show you the trend in weight gain. Children may lose some weight during an illness because of poor appetite or diarrhoea. Healthy children will quickly recover if they are given an extra meal a day on recovery from the illness. One of the features of HIV infection is failure to thrive, even when the diet is adequate. Recurrent illnesses are likely to result in malnutrition. Children who live in the poorest homes where food is scarce are most vulnerable to recurrent infections. The resulting malnutrition makes the child more likely to develop another infection leading to further deterioration in the nutritional state. This leads to a vicious cycle of poverty, disease and malnutrition. There may also be a loss of weight in a child who has a serious underlying infection like TB or HIV disease. A child where there is a history of weight loss needs careful attention to nutrition and monitoring of weight gain. Determine weight-for-age. Weight-for-age compares the child's weight with the weight of other children of the same age. The weight you measure in the clinic is plotted on a graph. This graph represents the expected weights of normal children of that age. A normal child may be smaller or larger than most children of the same age but will usually grow at a speed in proportion to his size. This is why well nourished children usually follow the curves of the graph on the RTHC. The growth chart below shows weight gain for two babies of the same age but with different weights; both of these children are growing well. kg kg BIRTH MONTH YEA

57 GOOD WEIGHT GAIN Two different sets of lines are used on RTHCs. In the past, centile lines were used more recently lines based on Z-scores have been introduced. It is important that you are able to use both sets of lines, as it is likely that you will see children with RTHCs with both kinds of lines. Although there are some differences between the two sets of line, the way in which weights are plotted and interpreted does not change. The table below shows the two sets of line and how they correspond to each other. For example, for practical purposes the 97th centile and the -2 z-score line can be regarded as the same. Likewise the 60% expected line and the -3 z-score line are the same. Centiles z-score 97 th centile + 2 line 50 th centile 0 line 3 rd centile - 2 line 60% expected - 3 line Normal children will have a weight between the 97 th and 3 rd centile lines (or between the +2 and -2 lines). The difference between these curves shows the wide range of weights for normal children. In other words since normal children are not all the same size, these lines can be used to decide whether a child s weight is normal. The 50 th centile (or 0 line) represents the average weight of children at any particular age. Children who are below the bottom curve (3 rd centile or -2 line) are low weight-forage and need special attention: you would need to find out about the type of food the child eats, as well as the quantity and frequency of meals. In IMCI low weight is used to describe a child whose weight is below the 3 rd centile or -2 line. The marasmus line represents 60% of the average weight for a child of that age. This is much the same as the -3 line. A child whose weight falls below this line has marasmus or is very low weight. In IMCI the term very low weight is used to describe children whose weight falls below the marasmus line. Look at the curves on your RTHC and identify the lines which are the 97 th centile, the 50 th centile, the 3 rd centile and the marasmus line. If you are looking at a RTHC with z-score lines, identify the +2, the 0, the -2 and the -3 lines. To determine weight-for-age using the RTHC: Weigh the child if he has not already been weighed today. Use an accurate scale. The child should wear light clothing when he is weighed. Ask the mother to help remove any coat, jersey, shoes and nappy. Calculate the child's age in months. The birth month and all subsequent months should already be written in the first box and those following it along the bottom of the RTHC. You need to check that this has been done correctly. 57

58 Plot the birth weight on the graph on the dotted line above the birth month (if not already plotted). Then plot the weight-for-age today as follows: Look at the left-hand axis to locate the line going across that shows the child's weight. Look at the bottom axis of the chart to locate the dotted line going upwards from the current month. This line shows the child's age in months. Find the point on the chart where the line for the child's weight meets the line for the child's age. The weight must always be plotted on the dotted line in the middle of the month column. Decide if the point is above, on, or below the 3rd centile or -2 line. In order to complete the assessment of weight-for-age, decide whether or not the child has low weight or very low weight: If the point is above or on the 3 rd centile (or - 2) line, the child is NOT low weight-for-age. If the point is below the 3 rd centile (or - 2) line, the child is low weight-for-age. If the child s weight falls below the 60% of expected weight (or - 3) line (marasmus line), the child is very low weight. (Remember that the expected weight curve is the 50th centile or 0 line). Always compare the appearance of the child with the recorded weight. If the recorded weight is well below the 3 rd centile (or - 2) line you must expect to see a small, malnourished child. If the recorded weight does not match the appearance of the child, check that the scales are accurate. The problem may also be that the weight was recorded incorrectly. LOOK: at the shape of the curve A single weight measurement on the growth chart does not give enough information to assess growth. The shape of the curve is more important than the actual centile (or z-score) that the weight of the child falls on. For example a child could have lost weight and still not be low weight at this visit. Poor or unsatisfactory weight gain is a serious sign and is just as important as low weight-for-age. Any child where there is poor weight gain needs careful monitoring. This poor weight gain may be due to feeding problems or an underlying disease like TB or HIV infection. Look at the shape of the weight curve that has been plotted on the growth chart from previous visits: If the weight of the child follows the curves on the growth chart there is good weight gain. If the curve is flattening the child has had poor weight gain. If the curve is dropping (going downwards) the child has lost weight. 58

59 POOR WEIGHT GAIN kg kg BIRTH MONTH YEA These curves show the same weight for two children. One of the children is growing well (child B) but the other child (child A) has poor weight gain. The child with poor weight gain is not below the third centile and has gained some weight since the last visit. The shape of the curve shows that the weight gain is less than would be expected over this time period. This may be because this child has had a recent illness or a feeding problem. It is important for child A that feeding is assessed and that the mother is given appropriate feeding advice. The child should be seen at least every 2 weeks. If the weight gain does not improve with nutritional advice, this child should be referred for investigation. You should not wait until the weight falls below the 3rd centile (or - 2) line to refer this child. Poor weight gain may indicate HIV infection. Loss of weight and poor weight gain are two of the eight features which IMCI uses to assess and classify HIV infection. Careful assessment and charting of the weight-for-age are also very important for HIV-infected children on antiretroviral treatment. Steady weight gain after treatment has been started suggests a good response. 59

60 EXERCISE N Tell your facilitator when you are ready to discuss your answers 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. This assessment step helps you identify children with visible severe wasting. They will need urgent treatment and referral to a hospital. To look for visible severe wasting, remove the child's clothes. Look for wasting of subcutaneous fat and 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. 60

61 LOOK and FEEL for oedema of both feet A child with oedema of both feet may have kwashiorkor, another form of severe malnutrition. Oedema occurs 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. Other common signs of kwashiorkor include thin, sparse and pale hair; dry, scaly and discoloured skin, especially of the arms and legs; a puffy moon face. In very severe cases there may be open sores, especially in the nappy area. 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 (dorsum) of each foot. The child has oedema if a dent remains in the child's foot when you lift your thumb. EXERCISE O 61

62 7.2 ASSESS FOR ANAEMIA Anaemia and iron deficiency are also common among South African children. They interfere with the body s resistance to infection and the child s normal development. Not eating foods rich in iron can lead to iron deficiency and anaemia. Anaemia is a reduced number of red cells or a reduced quantity 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. The anaemia may develop slowly. Often, anaemia in these children is due to both malnutrition and malaria Other rare causes 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. Compare the colour of the child's palm with your own palm and with the palms of other children or the mother. If the skin of the child's palm is pale, the child has some palmar pallor. If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor. If there is pallor, do a haemoglobin estimation in the clinic. This will help you to classify anaemia. Note: Anaemia is one of the side effects of antiretroviral treatment. EXERCISE P Tell your facilitator when you are ready to discuss your answers to this exercise 62

63 7.3 CLASSIFY MALNUTRITION AND ANAEMIA Classify all children for malnutrition and anaemia CLASSIFY MALNUTRITION There are three classifications for malnutrition. They are: SEVERE MALNUTRITION NOT GROWING WELL GROWING WELL This is the classification table for malnutrition: SEVERE MALNUTRITION If the child is very low weight, or 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 will need special feeding, antibiotics, micronutrients, such as vitamin A, and certain electrolytes. Before the child leaves for hospital, give the child treatment for or to prevent low blood sugar and give a dose of vitamin A and antibiotics. The child must be kept warm on the way to hospital. Even on a warm day these very ill children need to be kept warm. NOT GROWING WELL Classify the child as NOT GROWING WELL: if the child is low weight-for-age or 63

64 has poor weight gain, with a flattened weight curve Treatment A child classified as NOT GROWING WELL 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 FEEDING box on the COUNSEL THE MOTHER chart. Give vitamin A in the clinic unless a dose has been given in the past 6 months. All children should have a regular dose of vitamin A every 6 months from the age of 6 months. This is particularly important in a child who is low weight-for-age. Every child should also be given a dose of mebendazole every 6 months from the age of one year. This treatment is for worm infestation. Worms are a cause of malnutrition and anaemia, and are very common in many areas of South Africa. Giving all children this treatment regularly reduces the spread of worms in the community. A child that has a feeding problem should return after 5 days. A child who is low weight or shows poor weight gain should return for follow-up after 14 days. Mothers of these children should also be encouraged to come to the clinic regularly for growth monitoring for the next few years. If a child also has PERSISTENT DIARRHOEA, refer NON-URGENTLY. All remaining children should be classified as: GROWING WELL If the child is not low weight-for-age, is gaining weight satisfactorily and there are no other signs of malnutrition, classify the child as GROWING WELL. 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 FEEDING 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. Mothers of these children should be encouraged to bring the children for regular growth monitoring. Tell the mother about the importance of watching the growth of the child so that any problems can be identified early. You should use the RTHC when you are counselling the mother, so that she can realise the importance of her child s road to health All children classified as GROWING WELL should receive mebendazole every 6 months from the age of one year, because worm infestation is a common problem contributing to ill health of children. All children should also receive regular Vitamin A supplementation from the age of 6 months. Regular treatment for worm infestation and Vitamin to give A supplementation should become part of the routine care of all children in the well-child clinic together with 64

65 immunization and growth monitoring, as well as part of the care for the sick child. In the same way as for immunization, all clinic visits should be used as an opportunity to ensure that doses of vitamin A and mebendazole are up to date. Always write all these doses given on the RTHC. Feeding assessment A feeding assessment should be done on all children who are classified as NOT GROWING WELL and for all children under the age of two years. Remember, 60% of children who die under 5 years have malnutrition as part of the cause. For example in the child classified as NOT GROWING WELL this may not be immediately obvious. Infants over the age of 6 months and young children are more vulnerable to malnutrition. Children are also more likely to become malnourished at times when feeding practices are changing, like when the mother leaves home to go to work or stops breastfeeding or when complementary feeds are added. You will learn about feeding recommendations and how to do a feeding assessment in the COUNSEL THE MOTHER module later in the course. However it should be emphasised that this is an important part of assessing and classifying for malnutrition and should not be forgotten. It has been shown that IMCI practitioners in South Africa often forget to assess feeding and giving feeding advice. This means that these children are not getting good quality care and are more vulnerable to diseases and death. Children that are not receiving the food that is recommended, in quality and quantity, are likely not to be as active as they should. This activity is essential for their intellectual development that determines the ability to learn. The feeding recommendations allow practitioners to give appropriate and relevant advice to mothers about giving the best nutrition to the child and so giving the child the best start in life. Feeding advice should be relevant both to the age of the child and to the family s social and economic situation CLASSIFY ANAEMIA Classify all children for anaemia as well as for malnutrition. There are three possible classifications for anaemia: SEVERE ANAEMIA ANAEMIA NO ANAEMIA This is the classification table for anaemia: 65

66 SEVERE ANAEMIA A child with severe palmar pallor or where the haemoglobin is found to be below 7.0g/dl should be classified as SEVERE ANAEMIA. Treatment A child with severe anaemia may have malaria, severe worm infestation or be losing blood. This child needs to be referred to hospital to investigate the cause of the anaemia. The appropriate treatment will depend on the cause and may include blood transfusion and treatment with iron. ANAEMIA A child with some palmar pallor or haemoglobin measurement 6.0 g/dl up to 10g/dl should be classified as ANAEMIA. Treatment Treat the child with iron. When there is a high risk of malaria in a child with signs of anaemia, give an antimalarial if the rapid malaria test is positive. The anaemia may be due to malaria. This child will also be given treatment for worm infestation with mebendazole as part of the treatment (see above). It is important to advise the mother that the child will need to be given iron for 2 months to fill the iron stores, which are empty. The child should also be given a diet rich in iron. NO ANAEMIA All remaining children will be classified as NO ANAEMIA. EXERCISE Q 66

67 8. CONSIDER HIV INFECTION HIV infection is an important cause of childhood morbidity and mortality in South Africa. In some parts of the country more than 30% of women attending antenatal clinics are HIV infected. In the absence of any intervention approximately one third of the babies born to these HIV infected mothers will get the infection from their mother. Some HIV transmission from the mother to the baby (MTCT) occurs before birth and at the time of delivery. Others can be infected by transmission of HIV through breastfeeding. Much of this transmission can and must be prevented by PMTCT. Infant feeding is a key part of PMTCT, which will be discussed in the SICK YOUNG INFANT module. HIV exposed infants also benefit from receiving cotrimoxazole prophylaxis it is important that these infants are identified and provided with the treatment. Early diagnosis of HIV infection is also extremely important. Early initiation of antiretroviral treatment in young infants, even when they have very few or even no signs and symptoms, has been shown to reduce the number of children who die. It is therefore crucial that all children whose mothers have been part of the PMTCT programme are tested for HIV infection at six weeks of age. PCR testing is now available at all Primary Health Care clinics. Likewise health workers should consider possible HIV infection every time that they see a child. This will allow children to be identified early and managed appropriately. All health care providers need to be able to advise HIV positive patients. The mother of an HIV infected child also needs information about her own HIV positive status, so that she can make informed decisions regarding treatment and lifestyle. She should be encouraged to disclose her status to her partner and other family members, and with regard to future pregnancies. HIV and AIDS are the biggest health threat to the people of South Africa. Unfortunately there is still a lack of awareness, and many health workers are afraid to talk about this with patients. This fear needs to be overcome, as we owe it to the patient and her family that the correct information is given to them. Unless we as health care providers are prepared to speak openly about this disease, we will add to the common stigmatisation of people living with HIV and AIDS. 8.1 ASSESS THE CHILD S HIV TEST Just as all children were assessed for malnutrition and anaemia, HIV infection needs to be considered in all children. The first step in the assessment is to assess and classify the child based on the child s HIV test. If the child has not had an HIV test (or if a test has been done, but no result is available) then the child should be classified based on the mother s HIV test result, or on features of HIV infection. ASK: Has the child had an HIV test? If the child has not had an HIV test, then move to the next section, where you will ask about the mother s HIV status and look for features of HIV infection. 67

68 Below 18 months of age, use an HIV PCR test to determine the child s HIV status. Do not use an antibody test to determine HIV status in this age group remember that the mother s antibodies can pass to the baby through the placenta. Therefore HIV antibodies in the infant may come from the mother and may indicate that the infant has been exposed to HIV infection, rather than that the infant is HIV-infected. A positive PCR test indicates that the virus is in the blood, and that the infant is actually infected with the virus. In children 18 months and older, use a rapid (antibody) test to determine the child s HIV status. If the rapid test is positive then it should be repeated. If the second test is positive, this confirms HIV infection (in a child older than 18 months). If the second test is negative, send blood to the laboratory for a lab HIV ELISA test. Remember that all children who have had a PCR test should have an HIV antibody (rapid) test at 18 months of age. If the child has had a test, then you will need to find out some more information. ASK: What was the result? Remember that this is sensitive information, and that it is important to ensure confidentiality. Record whether the test was positive, negative, or if no result is available. If the test has been sent, but no result is available, you should try to obtain the test result or send another specimen, if necessary. Again you will need to ask further questions, based on the answer to this question. If the test was positive, ASK: Is the child on ART? This is important information to know as it will affect your management of the child. If the test was negative: ASK: Is the child breastfeeding? ASK: Was the child breastfeeding at the time that the test was done? ASK: Had the child stopped breastfeeding for six weeks before the test was done? Because HIV can be transmitted through breastmilk, a child who has initially tested negative may still develop HIV infection. It is therefore important to know if the child was breastfeeding when the test was done, or had been breastfed in the six weeks before the test was done. 8.2 CLASSIFY THE CHILD S HIV TEST There are three possible classifications CONFIRMED HIV INFECTION POSSIBLE HIV INFECTION HIV NEGATIVE The classification box is shown below: 68

69 CONFIRMED HIV INFECTION A child with a positive HIV test should be classified as having CONFIRMED HIV INFECTION. Remember that a PCR test must be used when testing children younger than 18 months of age. Children who are on ART can also be assumed to have confirmed HIV infection. POSSIBLE HIV INFECTION As described above, it is not possible to be completely sure that a mother has not passed the virus to her child until the child has stopped breastfeeding for six weeks. Infants who have tested negative for HIV, but who were still breastfeeding when the test was done (or who had breastfed in the six weeks before the test was done), should be classified as having POSSIBLE HIV INFECTION. HIV NEGATIVE If the child has a negative test and was not breastfed in the six weeks before the test was done, then the child should be classified as being HIV NEGATIVE. If the child has symptoms then it is important to consider other causes of these signs and symptoms. 8.3 ASSESS THE MOTHER S HIV STATUS AND FEATURES OF HIV INFECTION In cases where the child has not had an HIV test, it is important to consider the mother s HIV status and whether or not the child has any features that suggest HIV infection. The box from the Chart Booklet is shown below. 69

70 ASK: Has the mother had an HIV test? If no, move on the next part of the assessment. If yes, ASK: What was the result of the test? Ask the mother if she has had an HIV test. All mothers should have been offered testing during their pregnancy. If the mother has not had a test, move on to the next part of the assessment. Remember to offer the mother testing when you come to management of the child. If the mother had had a test, ask her what the result was. Remember that a mother may have tested negative in the past, and then later developed HIV infection. Therefore a negative test does not always mean that the mother is not HIV positive now. The more recent the test, the more likely it is to be accurate. ASK, LOOK and FEEL for features of HIV infection A child who is being assessed for features of HIV infection is assessed according to the features below: Is there PNEUMONIA now? Is there PERSISTENT DIARRHOEA now or in the past three months? Has the child ever had ear discharge? Is there low weight-for-age? Has weight gain been unsatisfactory? Enlarged lymph glands in 2 or more of these sites: neck, axilla or groin? Look for oral thrush Look for parotid enlargement There are several other features commonly found in HIV positive children. (For details see the WHO provisional HIV Clinical Staging: Appendix 1 in the Guidelines for the Management of HIV-infected Children). However, for classification purposes the above eight features are sufficient. 70