Ghai Essential Pediatrics8th

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Clinical Assessment and Classification

All infants with diarrhea should be assessed for presence of dehydration. A number of clinical signs are used to determine the level of dehydration: infant's general condition (lethargic or unconscious or restless/irritable); sunken eyes and elasticity of skin (skin pinch goes back very slowly, slowly or immediately). In addition the infant is assessed for persistent diarrhea and dysentery.

Persistent diarrhea is an episode of diarrhea, with or without blood, which begins acutely and lasts at least 14 days.Persistentdiarrheais usually associated with weight loss and often with serious nonintestinal infections. Persistent diarrhea in a young infant is considered as severe illness and requires urgent referral. Similarly, visible blood in stool in a young infant is classified as severe dysentery and the infant should be referred to hospital.

Allyounginfantswithdiarrheaareclassifiedfordegree of dehydration and in addition may be classified if they havepersistentdiarrheaand/ordysentery. Younginfants with severe dehydration will need IV fluids while those with some dehydration are treated as plan B with oral rehydration. Young infants with no dehydration will require more fluid to prevent dehydration (see Chapter on diarrhea).

Checking for Feeding Problems or Malnutrition

All sick young infants seen in outpatient health facilities should be routinely evaluated for adequate feeding and have their weight checked. Weight-for-age compares the young infant's weight with the infants of the same age in the reference population (WHO-NCHS reference). The very low weight-for-age or severely underweight identifies children whose weight is -3 standard deviations below the mean weight of infants in the reference population (Z score <-3). The low weight for age or moderately under­ weight identifies children whose weight is -2 standard deviations below the mean weight of infants in the refer­ ence population (Z score <-2). Infants who are very low weight for age are given pink classification and should be referred to a hospital. Infants who are low weight for age need special attention to how they are fed and on keeping them warm.

To assess the young infant for feeding problems the mother is asked specific questions about infant feeding to determine if the feeding practices are optimal. The weight of the child and feeding history is taken into consideration to determine if breast feeding technique needs to be checked. Thus an exclusively breastfed infant who is not low weight for age does not require any intervention and is therefore not observed for breastfeeding. If the mother giveshistoryoffeedingproblemor theinfant islowweight for age and has no indication for referral the mother is observed for breastfeeding. Breastfeeding is observed to see the signs of attachment and whether the infant is suckling effectively. Mothers of infants with problem in

feeding are counseled appropriately. Infants who are not low weight for age and have no feeding problem are classified as 'no feeding problem' and counseled about home care of young infant.

Checking Immunization Status

Immunization status should be checked in all sick young infants. A young infant who is not sick enough to be referred to a hospital should be given the necessary immunizations before he is sent home.

Assessing Other Problems

All sick young infants need to be assessed for other potential problems mentioned by the mother or observed during the examination. If a potentially serious problem is found or there are no means in the clinic to help the infant, he should be referred to hospital.

Identify Treatment and Treat

The next step is to identify treatmentrequiredfor the young infant according to the classification. All the treatments required are listed in the 'Identify Treatment' column of the ASSESS and CLASSIFY THE SICK YOUNG INFANT,

Chart 30.1. If a sick young infant has more than one classification, treatment required forall theclassifications must be identified. The first step is to determine if there is need to refer the child to hospital.

All infants and children with a severe classification (pink) are referred to a hospital as soon as assessment is completed and necessary pre-referral treatment is administered. Successful referral of severely ill infants to the hospital depends on effective counseling of the caretaker. The first step is to give urgent prereferraltreatment (written in bold font in identify treatment section of chart). This may be:

•Administering first dose of antibiotic

•Treatment of severe dehydration

•Warming the young infant using skin-to-skin contact (kangaroo mother care) and keeping the infant warm on the way to the hospital

•Prevention of hypoglycemia with breastmilk; if young

infant is not able toswallowgiveexpressedbreast milk/ appropriate animal milk with added sugar by I nasogastric tube

•In young infants with diarrhea, giving frequent sips of ORS solution on the way to the hospital.Young infants who have local infection, feeding problemor low weight, ordiarrheawith some dehydrationshouldTreatment in Outpatient Clinic and at Home

have treatment initiated in clinic which is to be continued at home (Table 30.1). Counseling a mother/caretaker is critical for home care. The health professional should use goodcommunicationskills while counseling the mother/ caretaker for treatment (Box 30.1).

Table 30.1: Treatment guidelines for managing sickyoung infant in outpatients and at home

Treatn1.ent of local infections

-Local bacterial infection: Give oral amoxicillin N cotrimoxa­ zole or x 5 days (avoid cotrimoxazole in infants 1 month of age who are premature or jaundiced)

-Skin pustules or umbilical infection: Teach to apply gentian violet paint twice daily at home.

-Discharge from ear: Teach to dry the ear by wicking

Some and no dehydration

- Treat dehydration as per WHO guidelines for treatment of dehydration.

Feeding problem or low weight

-Skin pustules or umbilical infection: Teach to apply gentian Teach correct positioning and attachment for breastfeeding Teach the mother to manage breast and nipple problems Treatthrush: Tell the mother to paint the mouth of the young infant with gentian violet 0.25% twice daily

Feeding with a cup and spoon: Wherever indicated teach the mother correct technique of feeding

Counsel themother/caretakerabout other feedingproblems.

Keep the young infant warm

-Teach the mother how to keep the young infant with low weight or low body temperature warm (do not bathe the young infant but sponge with lukewarm water to clean, provide skin to skin contact; keep the room warm: clothe

the baby in 3-4 layers properly covering the head with a cap and hands and feet with gloves and socks respectively, cover the baby and the mother with additional quilt or shawl, especially in cold weather).

Checking for General Danger Signs

Asickchildbroughttoanoutpatientfacilitymayhavesigns thatclearlyindicateaspecificproblem. Forexample,achild may present with cough and chest indrawing which indicate severe pneumonia. However, some children may present with serious, nonspecific signs called General Danger Signsthatdonotpointtoaparticular diagnosis.For example, achildwhoislethargic orunconsciousmayhave meningitis, severe pneumonia, cerebral malaria or any othersevere disease. Great care should be taken to ensure thatthesegeneraldangersignsarenotoverlookedbecause they suggest that a child is severely ill and needs urgent attention. The following general danger signs should be routinely checkedin all children: (i) history ofconvulsions duringthepresentillness, (ii)unconsciousnessorlethargy, (iii) inability to drink or breastfeed when mother tries to breastfeed or to give the child something to drink, and (iv) child vomits everything.

If achildhas one or more of these signs, he must be consi­ dered seriously ill and will almost always need referral. In ordertostart treatment for severeillnesses without delay, the child should be quickly assessed for the main symptoms and malnutrition and referred urgently to a hospital.

Assessing for Main Symptoms

After checking for general danger signs, the health care provider must enquire about the following main symp­ toms: (i) cough or difficult breathing; (ii) diarrhea; (iii) fever; and (iv) ear problems. If the symptom is present the child is evaluated for that symptom (Chart 30.2).

Box 30.1: Effective communication and counseling-APAC

•Ask and listen: Ask the mother/caretaker and listen carefully to find out the young infant/child's problems and what the mother/caretaker is already doing for the young infant/ child

•Praise: Praise the mother/caretaker for what she has done well

•Advise and teach: Advise the mother/caretaker how to take care of young infant/child at home (for tasks which require mother/caretaker to carry out treatment at home: give information, show an example, and let her practice)

•Check: Before the mother/caretaker leaves, always check her understanding by asking questions to find out what she understands and what needs further explanation

OUTPATIENT MANAGEMENT OF SICK

CHILD AGE 2 MONTHS UP TO 5 YEARS

Assess and Classify Sick Child

Theassessmentprocedureissimilartothatofyoung infant including: (i) history taking and communicating with the caretaker about the child's problem; (ii) checking for general danger signs; (iii) checking main symptoms; (iv) checking for malnutrition; (v) checking for anemia; (vi) assessing thechild's feeding; (vii) checking immunization status; and (viii) assessing other problems (Chart 30.2).

Cough or difficult breathing A child with cough or diffi­ cult breathing may have pneumonia or severe respiratory infection. Indevelopingcountries, pneumonia is often due to bacteria. The most common are Streptococcus pneumo­ niae and Haemophilusinfiuenzae. Many children are brought to the clinic with less serious respiratory infections. Most children with cough or difficult breathing have only a mild infection. They do not need treatment with antibiotics. Their families can manage them at home. Very sick children with cough or difficult breathing need to be identified as they require antibiotic therapy. Fortunately, one canidentifyalmostall cases ofpneumoniaby checking for these two clinical signs: fast breathing and chest indrawing. Chest indrawing is a sign ofsevere pneumonia.

Clinical assessment andclassification. Achild presentingwith cough or difficult breathing should first be assessed for general danger signs. This child may have pneumonia or another severe respiratory infection. Three key clinical signs are used to assess a sick child with cough or difficult breathing: fast breathing (cut-off respiratory rate for fast breathing is 50 breaths per minute or more for a child 2 monthsupto 12months,and40breathsper minuteormore for 12 months up to 5 yr); lower chest wall indrawing and stridor in a calm child. Based on a combination of the above clinical signs, children presenting with cough or difficult

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Chart 30.2 (Contd.)

Does the child have diarrhea?

'Ifreferral is not possible. see the section When, Referral Is Not Possible in the module Treat the Child

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breathing can be classified into one of the three categories. Achild withgeneraldanger signorchestindrawingorstri­ derisclassifiedasseverepneumoniaorveryseveredisease and merits urgent referralto the hospital. A sick child with cough who has fast breathing is classified as pneumonia andhistreatmentinitiatedinclinicwithoralantimicrobials. A child withcough with none of these signsis classified as cough and cold and given home remedies to soothe throat and counseled for home care.

Achild withcoughor coldnormallyimprovesinone or two weeks. However, a child with chronic cough (more than 30 days)needs to be further assessed (and,if needed, referred)toexcludetuberculosis,asthma,whoopingcough

or any other problem).

Diarrhea A child with diarrhea passes stools with more waterthannormal.Achildwithdiarrheamayhave (i)acute waterydiarrhea (including cholera); (ii)dysentery (bloody diarrhea); or (iii)persistent diarrhea (diarrhea that lasts 14 days or more).

Most diarrhealepisodesarecaused byagents forwhich antimicrobials are not effective and therefore antibiotics should not be used routinely for treatment of diarrhea. Antidiarrheal drugs do not providepractical benefits for children with acute diarrhea, and some may have dan­ geroussideeffects. Thereforethesedrugs shouldneverbe given to children.

Clinical assessment and classification. All children with diarrhea should be assessed for dehydration based on the following clinical signs: child's general condition (lethargic or unconscious or restless/irritable); sunken eyes; child's reaction when offered to drink (not able to drink or drinking poorly or drinking eagerly/thirsty or drinking normally) and elasticity of skin (skin pinch goes back very slowly, slowly or immediately). In addition a child with diarrhea should be asked how long the child has had diarrhea and if there is blood in the stool. This will allow identification of children with persistent diarrhea and dysentery.

ChildrenwithseveredehydrationrequireimmediateIV infusionaccordingtoWHOtreatmentguidelinesdescribed in plan C. Children with some dehydration require active oral treatment with ORS as per plan B. Patients with diarrhea and nodehydrationareadvisedtogivemorefluid than usual to prevent dehydration according to WHO treatment plan A.

Allchildrenwithpersistentdiarrheaareclassified based on presence or absenceof dehydration. Children with per­ sistent diarrhea and dehydration are classified as severe persistentdiarrheaandneedtobe referredtohospitalafter treatment of dehydration. Children with persistent diar­ rhea and no dehydration can be safely managed on out­ patient basis with appropriate feeding. Children with dysentery are given effective antibiotics for shigellosis.

Fever Fever is a very common condition and is often the main reason for bringing children to the health center. It

may be caused by minor infections,but may also be the most obvious sign of a life-threatening illness, e.g. P. falciparum malaria or meningitis. When diagnostic capacity is limited,it is important first to identify those children who need urgent referral with appropriate prereferraltreatment (antimalarialorantibacterial).All sick children should be assessed for fever if it is reported by mother or fever is present on examination.

Clinicalassessmentand classification. Inendemicareastherisk of malariatransmissionis defined by areas of high and low malariariskinthecountry.National AntiMalaria Program (NAMP) has defined areas depending on malaria risk. A child presenting with fever is assessed and classified dependingonriskofmalaria. Historyofdurationoffeveris importantinevaluatingfever.Iffeverhaspersisteddailyfor more than seven days the child needs to be referred to hospitalforassessmentanddiagnostictests.Theothersigns lookedforinachildwithfeverincludegeneraldanger signs (assessedearlier)andsignsofmeningitis,e.g.bulgingfontanel and stiffneck. Besidesthese,signsofmeaslesand runnynose are also looked for.

Ifthechildhasmeasles currentlyor within thelastthree months,he should be assessed for possible complications. Some complications of measles are assessed as main symptoms,e.g. cough/difficultbreathing,diarrheaandear infections. Clouding of cornea and mouth ulcers areasses­ sed along withmeasles.Cloudingof corneais adangerous eye complication. If not treated,cornea can ulcerate and cause blindness. An infant with corneal clouding needs urgent treatment with vitamin A.

Before classifying fever, one should check for other obvious causes of fever.

Childrenwithfever areclassifiedbasedonthepresence ofanyofthegeneraldangersigns,stiffneck,levelofmalaria risk in the area and presence/absence of symptoms like runny nose, measles or clinical signs of other possible infection. In high malaria riskarea all children with fever needtogetantimalarialtreatmentasperNAMPguidelines. In areas with low malaria risk children with fever with no otherobviouscauseareclassifiedas malaria andshouldbe evaluated with blood smear and treated with oral anti­ malarial drugs (chloroquine). In low malaria risk area childrenwith fever with anothercauseoffever (e.g. cough and coldor earinfectionordiarrhea)areclassifiedasfever, malaria unlikely and given symptomatic treatment for fever.Sincethemalariariskmaychangewithtime malaria is treated as per national guidelines.

Earproblems Achildwithanearproblemmayhaveotitis. It may be acute or chronic infection. If the infection is not treated,the ear drum mayperforate. Ear infections are the maincauseofdeafnessinlow-incomeareas,which in-turn leads to learning problems. The middle ear infection can also spread from the ear and cause mastoiditis and/or meningitis. Thesickchildisassessedforearinfectionif any ear problem is reported.