Transcript Slide 1

ASSESS AND
CLASSIFY
GENERAL DANGER
SIGNS
Assess and classify chart used for a sick
child –not for immunization or non
medical
 ALL children must be weighed and plotted
on Road to Health Card at every visit
 ALL children must have their temperature
measured before consultation

DANGER SIGNS
First step in clinical assessment of
patient
 Triage
 Very ill child recognized early
 Treatment initiated at primary health
care site before referral
 All staff should be well trained in
picking up these signs

These signs are colour coded
REDsuggest a serious illness and
child needs URGENT referral
 Has
the child had convulsions in this
illness?
 Is the child lethargic or unconscious?
 Does the child vomit everything?
 Is the child able to drink or
breastfeed?
VIDEO
COUGH
OR
DIFFICULTY
BREATHING
241 NEW
CASES OF
LRTI/1000
CHILDREN
Steps in assessment

Check for general danger signs

How long has child had cough?

Count respiratory rate

Is there stridor?

Is there wheeze?
Classification of a child with cough
and difficulty breathing
Any general danger sign
OR
Chest indrawing
OR
Stridor in a calm child
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
Fast breathing
PNEUMONIA
No signs of pneumonia or COUGH OR COLD
very severe disease
Classification of a child with
wheeze
Wheeze
before this illness
OR
Frequent cough at night
OR
Wheeze for a week or more
OR
Known asthma
All other children with
wheeze
RECURRENT
WHEEZE
WHEEZE
(FIRST EPISODE)
ASSESS AND CLASSIFY THE SICK CHILD
AGE 2 MONTHS UP TO 5 YEARS
Do a rapid appraisal of all waiting children.
ASK THE MOTHER WHAT THE CHILDS PROBLEMS ARE. Determine if this is an initial
follow-up
or visit for this problem.
 If follow-up visit, use the follow
-up instructions on pages 23
-27.
 If initial visit, as
sess the child as follows:
CHECK FOR GENERAL DANGER SIGNS
ASK: Is the child able to drink or breastfeed?
A child with any general danger sign requires urgent attention: comp
assessment, start pre
-referral treatment and refer
urgently. If the child is
lethargic or unconscious, test for low blood sugar then treat / preven
LOOK: Is the child:
Does the child vomit everything?
Has the child had convulsions during this
llness?
i
(if convulsing now see p.12)
a) lethargic or
b) unconscious
Red
ASSESS
CLASSIFY
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult
breathing?
IF YES, ASK: LOOK, LISTEN,
FEEL:
 For how long?
 Count the breaths in
one minute.
 Look for chest
indrawing.
 Look and listen for
}
Classify
COUGH or
DIFFICULT
BREATHING
 Any general
danger sign
or
 Chest indrawing
or
 Stridor in calm
child
TREATMENT(Urgent pre-referral treatments are i
 Give first dose of ampicillin IM OR ceftriaxone IM. (p. 12)
SEVERE
 Give 1st dose cotrimoxazole (5ml) if less than 6 months old (
PNEUMONIA
 Give oxygen (p. 13 )
OR VERY
 If stridor: give nebulised adrenaline (p. 12)
SEVERE DISEASE
 Test for low blood sugar, then treat or prevent (p. 13)
 Keep child warm, and refer URGENTLY
Red
 Fast breathing
PNEUMONIA
stridor or wheeze.
Give amoxycillin for 5 days (p. 8)
Soothe the throat and relieve the cough (p. 11)
If coughing for more than 21 days, refer
r possible
fo
TB or asthma
Advise mother when to return immediately (p. 21)
Follow-up in 2 days
Yellow
CHILD
 No signs of
AND IF WHEEZE, ASK:
Has the child had a wheeze before this illness?
Does the child frequently cough at night?
Has the child hada wheeze for more than 7 days?
Is the child on treatment for asthma at present?





pneumonia
or very severe
disease
AND if
WHEEZE
Classify
 Soothe the throat and relieve cough (p. 11)
COUGH OR COLD  If coughing for more than 21 days, refer for possible TB or asthm
en to return immediately (p. 21)
 Advise mother wh
Green
 Follow up in 5 days if not improving
 Yes to any question
RECURRENT
WHEEZE
Yellow
 All other children
with wheeze




Give salbutamol & prednisone if referring for a severe classif
Give salbutamol via spacer for 5 days (p. 9)
Give oral pre
dnisone for three days (p. 9)
Refer non urgently
for assessment
 Give salbutamol if referring for a severe classification
WHEEZE
 Givesalbutamolvia spacer for 5 days (p. 9)
(FIRST EPISODE)  Follow-up in 5 days if sti
ll wheezing
Yellow
VIDEO
DIARRHOEA
Steps in assessment

Check for general danger signs

For how long ?

Is there blood in the stool?

How much and what type of fluid is the
mother giving?
Diarrhoea
Assessment
Persistent
of dehydration diarrhoea
for ALL
conditional
Dysentery
conditional
Classification of Diarrhoea
2 of the following signs
Lethargic or unconscious
Not able to drink or drinking poorly
Sunken eyes
Skin pinch goes back very slowly
2 of the following signs
Restless/irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
SEVERE
DEHYDRATION
Not enough signs to classify as severe or
some dehydration
NO VISIBLE
DEHYDRATION
SOME
DEHYDRATION
Mistakes in taking a skin pinch:
Pinching either too close to the midline or too
far laterally
Pinching the skin in an horizontal direction
Not pinching the skin long enough
Releasing the skin so that the finger and
thumb remain in a closed position
Classification of skin pinches:
Normal — it goes back immediately
Slowly — the fold is visible for less than 2
second
Very slowly — the fold is visible for more than
2 seconds.
Types of diarrhoea

Acute -Diarrhoea that at most needs
hydration support for 7 days/< and resolves
completely in 14 days

Prolonged acute -diarrhoea of such severity
that hydration support is required for longer
than 7 days but less than 14 days

Persistent -diarrhoea of such severity that
hydration support is required for longer than
14 days

Chronic - diarrhoea continuing for longer
than 14 days but not severe enough to require
extra fluids to maintain hydration
Classification of persistent
diarrhoea
Dehydration persistent
SEVERE
PERSISTENT
DIARRHOEA
No dehydration
PERSISTENT
DIARRHOEA
Persistent diarrhoea accounts for
10% of all diarrhoea BUT
contributes to 30-50% of diarrhoea
mortality
Classification of Dysentery
Dehydration present
OR
Child is below 12
months
Age 12 months and more
and
No dehydration
SEVERE DYSENTERY
DYSENTERY
Does the child have
diarrhoea?
for
DEHYDRATION
in all children
with diarrhoea
IF YES, ASK: LOOK OR FEEL:
 For how long?
 Look at the child’s general condition.
Is the child:
 Is there blood in the Lethargic or unconscious?
Restless and irritab
le?
stool?
 Look for sunken eyes
 How much and what
fluid is mother giving?
Classify
 Offer the child fluid.
DIARRHOEA
Is the child:
Not able to drink, or drinking
poorly?
Drinking eage
rly, thirsty?
Two of the following signs:
 Lethargic or unconscious

SEVERE 
 Sunken eyes
DEHYDRATION
 Not able to drink or drinking

poorly

 Skin pinch goes back very
Red
slowly
Start treatment for severe dehydration (
Refer URGENTLY
Give frequent sips of ORS on the way
Advise the mother
to continue breastfeedin
possible
Two of the following signs:

 Restless, irritable

SOME
 Sunken eyes

 Drinks eagerly, thirsty DEHYDRATION

 Skin pinch goes back slowly
Yellow
Give fluids to treat for some dehydration (
Advise mother to continue breastfeeding a
Advise the mothe
r when to return immediately (
Follow
-up in 2 days if not improving
 Not enough signs to classify
as severe or some
dehydration
 Give fluid and food for diarrhoea at home (
NO VISIBLE
 Advise mother when to return immediately
DEHYDRATION
 Follow
-up in 5
days if not improving
Green
 Pinch the skin of the abdomen.
Does it go back:
slowly?
or very slowly? (more than 2
seconds)
and if diarrhoea
14 days or more
 Dehydration present
SEVERE  Start treatment for dehydration
PERSISTENT  Refer URGENTLY
DIARRHOEA  Give frequent sips of ORS on the way

Give additional dose Vitamin A (p.16)
Red
 No visible dehydration
– 19)(p. 18
 Counsel the mother about feeding
PERSISTENT  Give additional dose Vitamin A (p. 16)
DIARRHOEA  Consider symptomatic HIV infection (p. 7)
 Advise the mother when to return immedia
Yellow
-up in 5 days
 Follow
 Dehydration present
and if blood
in stool
SEVERE
 Refer URGENTLY
or
DYSENTERY
 Age less than 12 months
Red
 Age 12 months or more
and
 No dehydration
 Treat for 5 days with nalidixic acid (p. 8)
DYSENTERY  Advise when to return immediately (p.21)
-up in 2 days
 Follow
Yellow
VIDEO
FEVER
Meningitis
Malaria
Measles

Fever is a common manifestation of many
diseases –Malaria, measles and meningitis
are among the more serious

URTI’s are more frequent causes of fever
in a well nourished child
Fever more than 7 days:

Differentiates between simple viral fevers and
other diseases where the only presenting
symptom is fever

Detects conditions needing diagnostic and
therapeutic intervention
– Tuberculosis, HIV/AIDS, urinary tract
infection, relapsing fever, typhoid,
osteomyelitis
Steps in assessment of fever

Does the child have any danger signs?

How long has child had a fever?

What is the malaria risk in the area?

What is the malaria risk for the child?

What is the measles risk for the child?
Malaria

Caused by parasite Plasmodium falciparum

Transmitted by bite of female Anopheles
mosquito
•
WHO estimates 1999: 1 in 4 childhood
deaths, indirectly or directly
Diagnosis of malaria
Have high index of suspicion as signs of
malaria may overlap with other illness
 Children have more severe disease!
 Main symptoms
fever – coincides with release of parasite
into blood stream
anaemia – acute or chronic
 Diagnosis made on thick blood smear –
identify ring forms of parasite within RBC

Slide of ring forms
Steps in assessment of malaria

Know risk category – area of residence,
- travel history
- seasonal variation

Additional history of pattern of fever may aid
in diagnosis

Know resistance pattern of Malaria

Malaria is a notifiable disease!
Does the child have fever?
By history, by feel, or axillary temp 37.5° C or above
IF YES, DECIDE THE CHILD’S MALARIA
 Any general danger sign
For suspected
meningitis
RISK:
Malaria Risk means: Lives in malaria zone or visited a malaria
zone in the previous mo
nth. If in doubt, classify for malaria
risk.
ASK ABOUT THE LOOK AND FEEL:
FEVER:
 Look and feel for:
- stiff neck
- bulging fontanelle
 For how long?
 None of the above signs
Classify
FEVER:
 Any general danger sign
 Do a rapid malaria test
IF MALARIA TEST NOT AVAILABLE:
 Look for a cold with runny nose
 Look for another adequate
cause of fever

or
 Stiff neck or bulging
AND if
Malaria Risk
fontanelle
and
 Malaria test any result
or
not done
Give paracetamol for high fever (p. 10)
Treat for other causes
FEVERAdvise mother when to return immediately (p. 21
OTHER CAUSE If feverhas been daily for more thandays
7 , refer
Follow-up in 2 days if fever persists
Treat for Malaria (p. 9)
SUSPECTED Treat for SUSPECTED MENINGITIS
SEVERE
Test for low blood sugar, then treat or preven
MALARIA
Give onedose of paracetamol for high fever (p
Refer URGENTLY
Red
 Malaria test positive
MALARIA
Generalised rash with either:
 Runny nose, or
 Red eyes, or
 Cough
Use the Measles chart (p.40)
Give first dose of ampicillin IM or ceftriaxone
SUSPECTED Test for low blood sugar, then treat or preven
MENINGITIS Give one dose of paracetamol for fever 38°C
(p.11)
Refer URGENTLY
Red
Yellow
AND IF MALARIA RISK:
Consider measles if:
or
 Stiff neck or bulging
fontanelle
Yellow
 Malaria test not done,
and
 No other adequate cause
of fever found
 Malaria test negative
If ageless than 12 months, Refer URGENTLY
Treat for malaria (p. 9)
Give paracetamol for high fever (p. 10)
Advise moth
er when to return immediately (p. 21)
Notify confirmed malaria cases
Follow-up in 2 days if fever persists
If ageless than 12 months, Refer URGENTLY
Follow local guideline for suspected malaria (
SUSPECTED Give paracetamol for highver
fe (p. 10)
MALARIA
Advise mother when to return immediately (p. 21
If fever has been for more than 7 days,
refer
Yellow
Follow-up in2 days if fever persists
Give paracetamol for high fever (p. 10)
or
Treat for other causes
FEVER Malaria test not done and
Advise mother when to return immediately (p. 21
 A cold with runny nose, OTHER CAUSE Follow-up in 2 days if fever persists
or
If fever is present daily for more than 7 days,
refer
 Other adequate cause
Yellow
of fever found
Measles
Had become uncommon due to regular measles
campaign in South Africa
 Current epidemic with measles associated
deaths
 Also needs high index of suspicion (only more
experienced staff likely to recognize)
 Mortality due to secondary immunocompromise
 ALL Measles must have serological
confirmation

OPTIONAL CHART: MEASLES
 Any general danger sign
Give additional dose Vitamin A (p. 16)
SEVERE
If clouding of the cornea or pus draining from the eye
or
COMPLICATED apply chloramphenicol eye ointment
 Clouding of cornea
MEASLES
Give first dose of amoxycillin syrup (p. 8)
or
REFER URGENTLY to hospital
 Deep or extensive mouth
ulcers
If the child has measles
if MEASLES
now, or within the last 3  Look for mouth ulcers.
now or within
Are they deep and extensive?
months:
last
3 months,
 Look for pus draining from the
Classify
eye.

Is there someone else with
 Look for clouding of the ea.
corn
measles at home?
 Pus draining from the eye
Give additional dose Vitamin A (p. 16)
MEASLES WITH If pus draining from the eye, treat eye infection with
or
 Mouth ulcers, but able to EYE OR MOUTH chloramphenicol eye ointmen
t
COMPLICATIONSIf mouth ulcers, treat with polyvidone or gentian violet (p.
eat
Take a specimen of blood and urine, and send these to th
National Institute of Virology (NIV)
Notify EPI coordinator
Follow-up in 2 days
 Measles now or within the
last 3 months.
MEASLES
Give additional dose Vitamin A (p. 16)
Treat and notify. Look for other measles cases.
Take a specimen of blood and urine,dan
send these to the
National Institute of Virology (NIV)
Notify EPI coordinator
Follow-up in 2 days
VIDEO
EAR PROBLEM
Hearing loss accounts for 35% of
South Africa’s disabled population
In Africa and South Africa otitis
media is the largest contributing
factor to hearing loss.

Ear infection is not a cause of mortality
BUT is major cause of morbidity i.e. days
of illness , hearing loss and spread to CNS

Small children often rub their ears –not a
sign of infection!

In the younger child, fever and irritability
may be the only symptoms of ear infection
Steps in assessment

Is there ear pain?

Is there ear discharge?

If yes, for how long?

Examine for ear discharge

Feel for tender swelling behind the ear
VIDEO
MALNUTRITION
AND
ANAEMIA

Malnutrition co-morbid disease in 60% of
all deaths

South African prevalence :
Stunting 21.6%
Under weight for age (UWFA) 10.1
Wasting 3.7%

Anaemia is proxy marker of malnutrition
and disease such as malaria and worm
infestation
Steps in assessment

Has child lost weight?

Growth –Plot weight on RTHC
- Interpret shape of curve

Look for visible wasting

Look and Feel for oedema of both feet

Look for pallor
THEN CHECK FOR MALNUTRITION
AND ANAEMIA

ASK:
LOOK and FEEL:
Has the child lost
GROWTH
weight?
Plot the weight on the RTHC:
 Is the child today:
- Normal weight
- Low weight or
- Very low weight
Classify all for
NUTRITIONAL
STATUS
Look at the shape of the weight curve:
 Does it show:
- Weight gain unsatisfactory
(That is, flattening curve or
weight loss) or
- Gaining weight
 Look for visible severe wasting
Very low weight
Give additional dose Vitamin A (p. 16)
or
SEVERE Test for low blood sugar, then treat or pr
 Visible severe wasting MALNUTRITION
Refer URGENTLY
or
childwarm
Keep the
 Oedema of both feet
Red
 Low weight
Assess feeding & counsel (p.17) If feeding
or
If no feeding problem follow up after 14 days
 WeightgainunsatisfactoryNOT GROWING
f worms if due (p.16)
Treator
WELL
(p.21)
Advisewhento return immediately
Follow Vitamin A schedule (p. 16)
refer non
-urgently
If PERSISTENT DIARRHOEA,
If close TB contact, manage according to loc
Yellow Follow up in 14 days
 Not low weight
and /or
 Gaining weight
 Feel for oedema of both feet
AND classify all  Severe palmar pallor or
ANAEMIA
 Look for palmar pallor. Is there:
children
 Hb < 6,0 g/dl
- Severe palmar pallor?
For ANAEMIA
- Some palmar pallor?
 Some palmar pallor or
 Hb 6 up to 10,0 g/dl
 If any pallor, check haemoglobin
(Hb) level

No pallor
 If child is less than 2 years, assess and cou
GROWING  If feeding problem, follow
-up in five days
WELL
if due (p. 16)
 Treat for worms
Green
 Follow Vitamin A schedule (p. 16)
SEVERE  Refer URGENTLY
ANAEMIA
Red
Give Iron (p. 10)
ANAEMIA Assess feeding & counsel (p. 18)
Treat for worms if due (p. 16)
-up in 14 days
Yellow Follow
NOANAEMIA If child is less than 2 years, assess feeding a
VIDEO
HIV
Consider HIV status and symptoms
ASK, LOOK AND FEEL FOR FEATURES OF
SYMPTOMATIC HIV INFECTION:








CLASSIFY for
symptomatic HIV
infection
Is there PNEUMONIA now?
Has the child ever had ear discharge?
Is there low weight for age?
Has weight gain been unsatisfactory?
Is there PERSISTENT DIARRHOEA now or in the past three months
?
Enlarged lymph glands in 2 or more of these sites: neck, axilla or groin?
Look for oral thrush
Look for parotid enlargement
ASK:
features present
 Two or less features
present
if status unknown
 Offer testing for mother or child,
SUSPECTED  Start co-trimoxazole prophylaxis (p. 8)
SYMPTOMATIC  Treat for oral thrush (p. )
HIV
 Counselthe mother (p. 22)
Yellow  Follow-up in 14 days
SYMPTOMATIC  Counsel mother about her health and precautions
HIV UNLIKELY
against HIV infection (p. 22)
Green
If yes,
CLASSIFY
HIV test results
 Has the mother OR the child had a positive HIV test?
 Three ormore
 Positive test in child
age 15 months or
more
Yellow
 Mother+ve,
Children under 15 months may test positive because of antibodies from an
HIV positive mother, and not because the child is HIV
trulyinfected. If a child
has been tested at 12 months, a positive test should be confirmed at 15
months.
 Check if mother knows her status
 Follow-up in one month
HIV
INFECTION
 ArrangeHIV testing for the child from 15 months
and Child not tested
or
 child positive under
POSSIBLE HIV  Start cotrimoxazole prophylaxis from age 6 weeks
INFECTION
(p. 8)
15 months
 Follow-up
Yellow
Yellow
Use the most recentefinite
d
HIV test results. Routine antenatal blood tests
of mothers do not include HIV. HIV is a separate test with specific
sent.
con
 Mother +ve,and
Note: If the child is breastfeeding the HIV test must be repeated at least 6
months after breastfeeding stops
 Negative test in child
age 15 months or
more*
in one mont
h
 Continue with assessment
HIV NEGATIVE  Counselto keep the child HIV negative (p. 19)
Green
Green
THEN CHECK THE CHILD’S IMMUNISATION STATUS
IMMUNIZATION
SCHEDULE:
AGE
VACCINE
Birth
6 weeks
10 weeks
14 weeks
9 months
18 months
5 years
BCG
DPT-Hib 1
DPT-Hib 2
DPT-Hib 3
OPV-0
OPV 1
OPV 2
OPV 3
DPT 4
DT
OPV 4
OPV 5
ASSESS ANY OTHER PROBLEM
HepB 1
HepB 2
HepB 3
Measles 1
Measles2
Give all missed immunisations on this visit (observing contraindications). Include sick childre
and those without their car
ds.
If the child has no RTHC, give a new one today.
Advise mother when to return for the next immunization.
Give routine Vi
tamin A (page 16) and record it on RTHC
the .
MAKE SURE ACHILDWITH ANY GENERAL DANGER SIGN IS REFERRED
treat
e.g. skin infection, scabies, mouth ulcers, eye infection, tonsillitis after first dose of an appropriate antibiotic and other urgentments.
CHECK MOTHER’S HEALTH
CLINICAL PRESENTATION OF HIV
Any of the following signs is suggestive of underlying HIV infection in children.
The presence of one or more of these signs indicates the need for an HIV test:
Weight loss or abnormally slow growth
Chronic/ Recurrent diarrhoea
Prolonged fever (>1 month)
Generalised lymph node enlargement
Severe oral or pharyngeal thrush (candidiasis)
Bilateral parotid gland enlargement
Enlarged spleen
Enlarged liver
Severe eczema/ seborrhoea dermatitis
Recurrent herpes simplex
Severe chicken pox/ zoster infection
Recurrent common infections, e.g. ear infections, pharyngitis
Suppurative otitis media (discharging ear infection) if chronic (>3 weeks)
Persistent cough (> 21 days)
Severe pneumonia in a child less than 1 year of age
Recurrent pneumonia or other recurring respiratory tract infection
Pneumocystis Carinii Pneumonia (PCP)
Progressive encephalopathy – loss of previously achieved milestones, convulsions or abnormal
behaviour
Infections with unusual organisms/opportunistic infections (OI)
MODIFIED WHO CLINICAL STAGING
Stage I -MILD







Asymptomatic
Generalized lymphadenopathy
Hepatomegaly
Splenomegaly
Parotomegaly
Chronic suppurative OM
Eczema/ Seborrhoeic Dermatitis
Stage III- SEVERE






Stage II-MODERATE
• Unexplained chronic diarrhoea ( 2 weeks)
• Failure to thrive, 60 - 80% expected body
weight, Not responding to nutritional
rehabilitation or anti-TB therapy (if clinically
indicated). Other correctable causes excluded
• Recurrent or severe bacterial infection
• Oral candidiasis beyond neonatal period –
Severe persistent or recurrent, not responding
to topical therapy
• Neutropaenia (neutrophil count < 500 X
109/l)
•Severe lymphoid interstitial pneumonitis
• ≥ 2 episodes Zoster or severe herpetic disease






Progressive encephalopathy
Recurrent septicaemia ( 2 episodes)
Bronchiectasis
Disseminated fungal infection
Disseminated mycobacterial infection,
HSV causing mucocutaneous ulcer
persisting > 1 month, or bronchitis,
oesophagitis,
pneumonitis, oesophagitis in a child
older > 1 month.
Pneumocystis carinii Pneumonia (PCP)
Progressive multifocal
leukoencephalopathy.
Cerebral toxoplasmosis with onset > 1
month of age
Recurrent/persistent Salmonella ESBL
Malignancies
Does the child have an ear problem?
IF YES, ASK:
LOOK AND FEEL:
Classify
EAR PROBLEM
 Is there ear pain? Look for pus draining from the
Give ampicillin
IMOR ceftriaxone IM (p. 12)
 Tender swelling behind MASTOIDITIS  Give first dose of paracetamol (p. 10)
the ear
 Refer URGENTLY
Red
ear.
 Is there ear
 Feel for tender swelling behind
discharge?
If yes, for how long?the ear.
 Give amoxycillin for 5 days (p. 8)
 If ear discharge:
 Pus seen draining from
the ear and discharge isACUTE EAR
- Teach mother to clean ear by dry wick
INFECTION
reported for less than 14
n (p.
pai10)
 Give paracetamol for
 Follow
days
-up in 5 days if pain
ordischarge persists
or
-up in 14 days
 Follow
 Ear pain
Yellow
 Pus is seen draining
CHRONIC EAR 
from the ear
INFECTION 
and

 discharge is reported for

14 days or
more
Teach mother to clean ear by dry wicking (p
Then instil recommended ear drops, if availa
Tell the mother to
mecoback if she suspects hea
Follow up in 14 days
Yellow
 No ear pain
and
 no pus seen draining
from the ear
NO EAR
INFECTION
Green
 No additional treatment