Check for general danger signs. Do you find any? Health worker: No, I do not find any general danger signs in this case. Case 2: Hassan Hassan is 3 years old. He weighs 12 kg. His temperature is 39oC. The health worker asked, 'What are the child's problems?' The mother said, 'Hassan has been vomiting everything for 2 days.' This is Hassan's initial visit for this problem.

1. INTERGRATED MANAGEMENT
OF CHILDHOOD ILLNESS (IMCI)
INTRODUCTION TO IMCI

2. INTRODUCTION TO IMCI AND
IMCI CHART BOOKLET
 Backgroud
 In kenya, 74 out of every 1000 children born
do not live to be five years of age (KDHS
2008/09)
 70% of all deaths are attributed to easily
preventable and treatable diseases namely;-
Acute respiratory infections (mostly
Pneumonia),Diarrhoea ,Measles, Malaria
,Malnutrition &Anaemia and HIV

3. Cont……………
 Often children succumb to a
combination of these conditions-with
children presenting in H/Fs with the
combined s & s of more than one of
these Diseases
 Evidence has shown that many of
these children are not
comprehensively assessed ,treated

4. Cont…….
 WHO and UNICEF saw the need to improve
the care given to children and they developed
the IMCI strategy.
 Kenya adopted this strategy in 2000 and it
forms a critical part of the KEPH

5. What is IMCI?
 IMCI case Mnx approach offers simple
and effective methods to
comprehensively prevent and manage
the leading causes of serious illness and
Mortality in children below 5 years
 With IMCI ,sick children are not only
treated for the s & s they present with in
the H/F , but are also assessed for other
conditions they maybe suffering from

6. IMCI is based on these principles
 All children aged upto 5 years are examined
for general danger signs and all young infants
are assessed for signs of very severe disease-
 These signs indicate the need for immediate
referral or admission to hospital
 Children and infants are assessed for main
symptoms.
 For older children, the symptoms include:
Cough ,or difficult in breathing ,diarrhoea
,fever ,HIV ,ear infection ,Anaemia,Measles
and Malnutrition

7. Cont……
 A combination of individual signs then lead to
the Child’s Classification within one or more
symptom groups.
 Essential drugs are then used to treat the
children
 Lastly , counseling of care givers regarding
home care, appropriate feeding and fluids and
when to return to facility-immediate or follow up
is done

8. IMCI has 6 Major steps
1. Assessment
2. Classification
3. Identify treatment
4. Treat the child
5. Counsel the mother
6. Follow up care

9. IMCI Chart Booklet
 Kenya’s IMCI guidelines are packaged in
this booklet.
 The chart booklet provides a simplified
step-by –step guide to HCPs on case
management of under fives visiting the
H/Fs
 The chart summarizes and describes the
IMCI process (Steps)

10. Objectives
 By the end of this session, the learner will be
able to:
 • Determine if admission or urgent referral is
needed
 • Identify and give urgent pre referral treatments
 • Determine and give the appropriate treatments.
 • Administer first treatment at the clinic
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10

11. Cont……………………
 Teach the caregiver how and when to give
treatment at home and check his/her
understanding
 • Treat various classifications of dehydration
 • Immunize children according to the national
schedule
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11

12. REALITIES IN CHILD
HEALTH…..
A call to action to save children
meeting, 14th – 16th june 2012 in
Washington DC

13. Trends in child mortality in Kenya – KDHS
2008/9
77
115
52
74
Infantmortality Under-five mortality
2003 KDHS 2008-09 KDHS

14. North
Eastern
80
Eastern
52
Rift
Valley
59
Nyanza
149
Western
121
Central
51
Nairobi
64
Coast
87
Under-five Mortality by Province – KDHS 2008/9
Deaths per 1,000 live
births for the 10-year
period before the
survey

15. Child Mortality: Causes of Child Mortality in Kenya
10 April 2024
15
Source: World Health Statistics 2011, WHO
16%
20%
9%
11%
1%
10%
10%
8%
3%
19%
3%
Pneumonia Diarrhoeal Causes HIV/AIDS
Malaria Measles Prematurity
Birth Asphyxia Neonatal Sepsis Congential Anomalies
Other diseases Injuries

16. 10 April 2024
16
Source: World Health Statistics 2011, WHO
0%
5%
10%
15%
20%
25%
Diarrhoeal diseases Pneumonia Malaria
21%
16%
11%
17%
14%
18%
15%
18%
8%
Kenya, Regional & Global picture on Diarrhoea,
Pneumonia & Malaria Mortality
Kenya Africa Global

17. How do we address this high mortality rates?
 We Need simple, standard guidelines for these conditions:
 In diagnosis
 In management
• The guidelines must be also scientifically and professionally
sound
• WHO and UNICEF developed a package for countries with
infant mortality rate >40/1000 live births. Kenya has since
adopted this
• This package is called Integrated Management of
Childhood Illness (IMCI)

18. Separate disease
Specific clinical
Guidelines and
Training materials
National
programs
conduct disease
specific training
courses
Integration of
clinical guidelines
by the health
Worker
Integrated clinical
cases management
National
programs
collaborate in
integrated
training courses
Integrated clinical
guidelines and
training materials
Improving Health Workers Skills
Vertical programs Approach
IMCI case management Approach

19. Objective of IMCI Case Management
Training:
 To improve the quality of care provided to
children under five years
 To contribute to the reduction in childhood
mortality

20. IMCI Clinical Guidelines
2 months 5 years
IMCI Guidelines
Sick Child
Birth
Sick Young infant

21. Important to note:
 IMCI does not cover all symptoms
 IMCI strategy is not reviewing all pediatric
medicine
 Emphasis is how to deal more effectively with
the most common problems in sick children
brought to the clinic
 IMCI strategy takes into consideration the
overlapping of these symptoms and conditions

22. Important to note…..
 The core interventions is integrated management
of five most important causes of death, namely:
1. Acute Respiratory Infections
2. Diarrhoea
3. Measles
4. Malaria
5. Malnutrition and Anemia, HIV
6. Young infant infection
 IMCI also addresses the common
signs/symptoms that make the mother to bring
the child to hospital

23. The IMCI Case Management Process
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23
 This must be performed on all sick children
 The IMCI Case Management Process includes;
– Assessing and classifying the sick child 2 months
up to 5 years
– Identifying treatment and treating the child
– Counseling the caregiver
– Assessing and classifying the sick young infant
– Follow up care
This process is detailed in the IMCI chart booklet

24. The Chart Booklet and the Recording form
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24 Chart Booklet
 The chart booklet is a IMCI case management job aid
which gives a step by step guide on the case
management process
 Health care providers need to continuously refer to this
document throughout the case management process
 Many mistakes service providers make in assessment,
classification and management of sick children and
young infants is due to failing to use this job aid
Recording Form ( Chart booklet pages 43 -46)
 There is sick child recording form and a sick young infant
recording form
 Each is used for the corresponding age group
 The assessment findings, Classifications and
management options for the child should be recorded on

25. ASSESSING AND
CLASSIFYING A SICK CHILD
AGED 2 MONTHS UPTO 5
YEARS
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25

26. ASSESSING AND CLASSIFYING THE
SICK CHILD
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26
• A sick child is often brought to clinic due to a
particular problem/ symptom
• However, the illness may be due to more than one
disease condition
• The assessment process therefore should not be
limited to the presenting problem alone

27. PROCESS OF ASSESSING AND
CLASSIFYING THE SICK CHILD
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27
This must be performed when assessing all sick
children
1. Ask what the child’s problem is
2. Check for the 5 General Danger signs
3. Assess for the 4 main symptoms
4. Check for malnutrition and anaemia
5. Check for HIV Exposure and infection
6. Check for immunization, Vitamin A & Deworming
status
7. Assess if the child has any other problems

28. 1. Ask about the child’s problem
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28
 Greet the caregiver, make her/ him feel
comfortable
 Ask the caregiver what the child’s problems are
and record them as the caregiver tells you
 Take the child’s bio data and basic vital signs
 Remember to use good communication skills i.e.
 Use words the mother understands
 Give mother time to answer questions
 Listen carefully to what the mother says
 Ask additional questions / probe if answers not clear

29. 2. Check for the 5 General Danger signs
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29
 Not able to drink or breastfeed
 Vomits everything
 History of convulsions in the current illness
 Lethargic or unconscious
 Convulsing now
Child with any General Danger sign needs
URGENT
attention: complete assessment , give any pre
referral treatment immediately and refer.

30. Not able to drink or breastfeed:
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30
“Not able to drink or breast-feed” means
that
the child is not able to suck or swallow when
offered a drink or breast milk.
NB: if not sure of the mother’s answer, offer
the child clean water/ breastmilk

31. Vomiting everything:
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31
 Vomiting everything” means;
 child is not able to hold anything down at all.
 What goes down comes back up.
 NB: if not sure of the mother’s answer, offer
the child clean water/ breastmilk. Observe if
the child vomits

32. convulsions:
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32
A convulsion is any involuntary movement in any
part of the body
• A child can have this danger sign if there is
history of convulsions or convulsing during the
visit.
• A history of convulsions only counts as a
danger sign if the convulsions happened during
the present illness.
• Use words for convulsions that caregivers
understand. eg fits or spasms

33. Lethargic or unconscious:
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33
“Lethargic or unconscious" means that:
 the child is not awake and alert when he
should be
 He is drowsy and does not show interest in
what is happening around him.
 the child may stare blankly and appears not to
notice what is going on around him.; or
 Unconscious child cannot be awakened. He
does not respond when touched, shaken or
spoken to

34. Exercise A ( General Danger signs)
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34
Case 1: Salina
Salina is 15 months old. She weighs 8.5 kg. Her temperature is 38.5o
C.
The health worker asked, "What are the child's problems?" The mother said, "Salina
has been coughing for 4 days, and she is not eating well." This is Salina's initial visit
for this problem.
The health worker checked Salina for general danger signs. He asked, "Is Salina able
to drink or breastfeed?" The mother said, "No. Salina does not want to breastfeed."
The health worker gave Salina some water. She was too weak to lift her head. She
was not able to drink from a cup.
Next he asked the mother, "Is she vomiting?" The mother said, "No." Then he asked,
"Has she had convulsions?" The mother said, "No."
The health worker looked to see if Salina was lethargic or unconscious. When the
health worker and the mother were talking, Salina watched them and looked around
the room. She was not lethargic or unconscious.
Now answer the questions

35. Exercise A ( General Danger signs)….
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35
Write Salina's name, age, weight and temperature in the spaces provided on the top
line of the form.
b. Write Salina's problem on the line after the question "Ask -- What are the
child's problems?"
c. Tick () whether this is the initial or follow-up visit for this problem.
d. Does Salina have a general danger sign? If yes, circle her general danger sign
in the box with the question, "Check for general danger signs."
In the top row of the "Classify" column, tick () either "Yes" or "No" after the
words, "General danger sign present?"

36. Exercise A ( General Danger signs)
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36
Case 2: Justin
Justin is 4 years old. He weighs 10 kg. His temperature is 380
C.
The health worker asked about the child's problems. Justin's parents said, "He is
coughing and has ear pain." This is his initial visit for this problem.
The health worker asked, "Is your child able to drink or breastfeed?" The parents
answered, "Yes." "Does Justin vomit everything?" he asked. The parents said, "No."
The health worker asked, "Has he had convulsions?" They said, "No." The health
worker looked at Justin. The child was not lethargic or unconscious. He was not
convulsing then.

37. Exercise A ( General Danger signs)
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37
Write Justin's name, age, weight and temperature in the spaces provided on the top
line of the form.
b. Write Justin's problem on the line after the question, "Ask -- What are the
child's problems?"
c. Tick () whether this is the initial or follow-up visit.
d. Does Justin have a general danger sign? If yes, circle the sign on the
Recording Form. Then tick () "Yes" or "No" after the words, "General
danger sign present?"
Tell the facilitator when you have completed this exercise.

38. 3. Four main symptoms
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38
The health worker attending to a sick child
MUST ask about all the four main symptoms
below.
 Cough or difficult breathing
 Diarrhoea
 Fever
 Ear problem
When a symptom is present, assess further on
that symptom.

39. Cough or Difficult breathing
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39
 Pneumonia is among the leading causes of
death in children under five years
 In Kenya, it is currently responsible for 16% of
under five deaths
 Most children with cough or difficult breathing
have only a cough or a cold
 A few children with cough or difficult breathing
may also have pneumonia

40. A
musical
sound
heard
during
expirati
on
ASSESSING FOR COUGH OR DIFFICULT
BREATHING - THE CHILD MUST BE CALM
 For how
long?
 Count the
breaths in one
minute
 Look for chest
in drawing
 Look and listen
for stridor
 Look and listen
for wheeze
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40
IF YES, ASK
LOOK, LISTEN, FEEL
2 months up to 12
months
12 months up to 5
years
50 breaths per minute
or more
40 breaths per minute
or more
If the child is: Fast breathing is:
Present
if
the
lower
chest
wall
moves
IN
during
inspiration
A
harsh
sound
heard
during
inspiration
Does the child have cough or difficult breathing?

41. Introduction to the classification tables
- Chart booklet page2
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41
 Classification tables contain signs of illness and their
classifications on the ASSESS & CLASSIFY chart.
 Most classification tables have three rows with distinct
colours.
 The colour of the rows tells you quickly if the child has a
serious illness.
 You can also quickly choose the appropriate treatment.
Colour coding
 Pink = Severe Classification needing admission or urgent
referral
 Yellow = A classification needing treatment/ intervention
with drugs
 Green = Not serious and in most cases no drugs are

42. CLASSIFICATION TABLES FOR COUGH
OR DIFFICULT BREATHING
SIGNS CLASSIFY AS
• Any general danger signs
OR
•Chest indrawing in calm child
OR
•Stridor in calm child
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
Fast breathing PNEUMONIA
No signs of very severe
disease or pneumonia
NO PNEUMONIA:
COUGH OR COLD
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42

43. Exercise B – General Danger Signs and
Cough
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43
Case 1: Gyatsu
Gyatsu is 6 months old. He weighs 5.5 kg. His temperature is 38
C. His mother said
he has had cough for 2 days. The health worker checked for general danger signs.
The mother said that Gyatsu is able to breastfeed. He has not vomited during this
illness. He has not had convulsions and is not convulsing now. Gyatsu is not
lethargic or unconscious.
The health worker said to the mother, "I want to check Gyatsu's cough. You said he
has had cough for 2 days now. I am going to count his breaths. He will need to
remain calm while I do this."
The health worker counted 58 breaths per minute. He did not see chest indrawing.
He did not hear stridor nor wheeze.

44. Exercise B – General Danger Signs and
Cough…
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44
a. Record Gyatsu's signs on the Recording Form given
b. To classify Gyatsu's illness, look at the classification table for cough or
difficult breathing in your chart booklet. Look at the pink (or top) row.
Decide: Does Gyatsu have a general danger sign? Yes___ No ___
- Does he have chest indrawing or stridor when calm? Yes __ No __
- Does he have the severe classification SEVERE PNEUMONIA OR VERY
SEVERE DISEASE? Yes___ No___
c. If he does not have the severe classification, look at the yellow (or middle) row.
- Does Gyatsu have fast breathing? Yes___ No___
d. How would you classify Gyatsu's illness? Write the classification on the Recording
Form.

45. Exercise B – General Danger Signs and
Cough…
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45
Case 2: Wambui
Wambui is 8 months old. She weighs 6 kg. Her temperature is 390C. Her
father told the health worker, "Wambui has had cough for 3 days. She is
having trouble breathing. She is very weak." The health worker said, "You
have done the right thing to bring your child today. I will examine her now."
The health worker checked for general danger signs. The mother said,
"Wambui will not breastfeed. She will not take any other drinks I offer her."
Wambui does not vomit everything and has not had convulsions. She is not
convulsing now. Wambui is lethargic. She did not look at the health worker
or her parents when they talked.
The health worker counted 55 breaths per minute. He saw chest indrawing.
He decided Wambui had stridor because he heard a harsh noise when she
breathed in. He did not hear wheeze.
• Record Wambui's signs and classification on the Recording Form given
Be prepared to explain to your facilitator how you selected the child's
classification.

46. Exercise B – General Danger Signs and
Cough…
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46
Case 3: Pemba
Pemba is 18 months old. He weighs 9 kg, and his temperature is 37
C. His mother
says he has had a cough for 3 days.
The health worker checked for general danger signs. Pemba's mother said that he is
able to drink and has not vomited anything. He has not had convulsions and is not
convulsing now. Pemba was not lethargic or unconscious.
The health worker counted the child's breaths. He counted 38 breaths per minute.
The mother lifted the child's shirt. The health worker did not see chest indrawing. He
did not hear stridor when he listened to the child's breathing. He heard wheeze
Record Pemba's signs on the Recording Form given. Then look at the classification
table for cough or difficult breathing on the chart booklet. Classify this child's illness
and write your answer in the Classify column.

47. Exercise C – General Danger Signs and
Cough
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47

48. DIARRHOEA
Def..
Diarrhoea is passage of three or more watery
stools in 24 hours
 It is common in children, especially those between
6 months and 2 years of age
 It is the 2nd leading cause of mortality in under-
fives. Most of these deaths are usually due to
dehydration.
 If an episode of diarrhoea lasts less than 14 days,
it is an acute diarrhoea and if 14 days or more, it is
persistent diarrhoea. Diarrhoea with blood in the
stool, with or without mucus, is called dysentery
 Frequent passage of normal stool is not diarrhoea
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48

49. Diarrhoea : Transmission
49
Poor personal hygiene Human Waste Disposal
Contaminated/Unsafe Water
62% of Kenyan households use
water from dams, lakes,
streams, boreholes!!
30% have access to piped water
14% of Kenyan households
(1.2m) use bushes and
buckets
74% use pit latrines
Poor personal hygiene
Poor food preparation
practices
The prevention arm of diarrhoea focuses on these three – WASH + BF, Vitamin A

50. Diarrhoea prevalence by province- KDHS 2008
50
Province Diarrhoea Prevalence
All diarrhoea Bloody diarrhoea
Coast 27.2 6.2
Western 17.2 2.0
Nyanza 16.2 4.2
North eastern 16.0 3.6
Rift valley 15.9 2.2
Eastern 14.9 1.1
Central 14.4 1.5
Nairobi 11.9 0.4
National average 16.6 5.1

51. Diarrhoea Policy Objective
51  To reduce diarrhea associated morbidity and mortality in children
below five years

52. Child
reaches
out
for
the
container
when
withdrawn
Child
too
weak
to
swallow
ASSESSING FOR DIARRHOEA
 For
how
long?
 Is
there
blood
in the
stool?
• Look at the child’s general
condition
-Lethargic or unconscious?
-Restless or irritable?
• Look for sunken eyes
• Offer the child fluid. Is the child:
-Not able to drink or drinking
poorly?
-Drinking eagerly, thirsty?
• Pinch the skin of the abdomen.
Does it go back;
-Very slowly (longer than 2
seconds?
-Slowly
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52 IF YES, ASK LOOK AND FEEL
Child
cannot
be
calmed
Does the child have diarrhea?

53. Classifying a child with
diarrhoea
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53
 Children with diarrhoea die as a result of
dehydration.
 ALL children with diarrhoea MUST first be
classified for dehydration

54. CLASSIFICATION OF DEHYDRATION
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54
SIGNS CLASSIFY AS
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 (> 2 seconds)
SEVERE DEHYDRATION

55. CLASSIFICATION OF DEHYDRATION
cont’d
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55
SIGNS CLASSIFY AS
Two or more of the following
signs
 Restless or irritable
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back
slowly (within 2 seconds)
SOME
DEHYDRATION
• Not enough signs to classify
as some or severe
dehydration
NO DEHYDRATION

56. IF DIARRHOEA LASTS 14 DAYS OR
MORE OR THERE IS BLOOD IN STOOL
 Dehydration present SEVERE
PERSISTENT
DIARRHOEA
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56
SIGNS CLASSIFY AS
• No Dehydration PERSISTENT DIARRHOEA
• Blood in the stool DYSENTERY

57. EXERCISE E
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57
In this exercise, you will practice assessing and classifying dehydration
in children with diarrhea. Read the following case studies of children
with diarrhea. Use the dehydration classification table in the chart.
1. Pano has had diarrhea for five days. He has no blood in the stool.
He is irritable. His eyes are sunken. His father and mother also
think that Pano's eyes are sunken. The health worker offers Pano
some water, and 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.
2. Jane has had diarrhea for 3 days. There was no blood in the stool.
The child was not lethargic or unconscious. She was not irritable or
restless. Her eyes were sunken. She was able to drink, but she
was not thirsty. The skin pinch went back immediately.
Record the signs of dehydration and classify them on the Recording
Form

58. EXERCISE E…..
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58
3. Gretel has had diarrhea for 2 days. She does not have
blood in the stool. She is restless and irritable. Her eyes
are sunken. She is not able to drink. A skin pinch goes
back very slowly.
• Record the signs of dehydration and classify them on the
Recording Form:
4. Jose has had diarrhea for five days. There is blood in
the stool. The health worker assesses the child for
dehydration. The child is not lethargic or unconscious. He
is not restless and irritable. His eyes look normal and are
not sunken. When offered water, the child drinks eagerly.
A skin pinch goes back immediately.
• Record the child’s signs and classify them on the
Recording Form

59. EXERCISE F
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59
Rana is 14 months old. She weighs 12 kg. Her
temperature is 37.50C. Rana's mother said the child has
had diarrhoea for 3 weeks.
Rana does not have any general danger signs. She does
not have cough or difficult breathing.
The health worker assessed her diarrhoea. He noted she
has had diarrhoea for 21 days. He asked if there has been
blood in the child's stool. The mother said, "No." The
health worker checked Rana for signs of dehydration. The
child is irritable throughout the visit. Her eyes are not
sunken. She drinks eagerly. The skin pinch goes back
immediately.
 Record the child’s signs and classify them on the
Recording Form

60. Fever
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61
 Fever is present if :-
 There is history from parent/caregiver or
 Child feels hot or
 Child has temperature 37.50
c or above
 A child with fever may have malaria, measles or another
severe disease. Malaria currently causes 11% of under five
deaths
 Fever may also be due to a simple cough, cold or other
viral infection.
 To classify and treat fever, you must know malaria risk in
your area
 High Malaria risk; > 5% of fever cases in children are
due to malaria
 Low Malaria risk; 5% or less of fever cases in children
are due to malaria

61. DOES THE CHILD HAVE FEVER?
THEN ASK:
 For how long?
 If more than 7 days, has fever
been present everyday?
 Has the child had signs of measles
within the last 3 months?
• Look or feel for stiff neck
• Look for running nose
Look for signs of MEASLES
• Generalized rash and One of
these: cough, runny nose, or
red eyes
Look for any other cause of fever
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62
LOOK AND FEEL
IF YES
Decide malaria risk: high, low or no
risk
NOTE: If you can’t test, don’t withhold treatment
TEST NEGATIVE
•P. falciparum or P. vivax
absent
TEST POSITIVE
•P. falciparum
PRESENT
•P. vivax PRESENT
DO A MALARIA TEST:
If NO general danger sign or stiff neck
• High Malaria risk: Do a malaria test in
all fever cases
• Low malaria risk: Do a malaria test if
no obvious cause of fever
• No malaria risk: Do a malaria test if
no obvious cause of fever

62. DOES THE CHILD HAVE FEVER?.....
If the child has signs of measles now or within
the last 3 months
• Look for mouth ulcers, are they deep or
extensive?
• Look for pus draining from the eye
• Look for clouding of the corner
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63
Check for Complications of MEASLES

63. CLASSIFY FOR FEVER – High Malaria
Risk
 Any general danger
sign OR
 Stiff neck
VERY SEVERE
FEBRILE DISEASE
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64
SIGNS CLASSIFY AS
Malaria test positive* MALARIA
• Malaria test NEGATIVE
or
• Runny nose PRESENT or
• Measles PRESENT or
• Other cause of fever
PRESENT**
FEVER-NO MALARIA
*If malaria test is not available, classify as malaria
** Other possible causes of bacterial infection may
include urinary tract infection, typhoid, cellulitis and
osteomyelitis.

64. CLASSIFY FOR FEVER – Low and No
Malaria Risk
 Any general danger
sign OR
 Stiff neck
VERY SEVERE
FEBRILE DISEASE
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65
SIGNS CLASSIFY AS
Malaria test positive* MALARIA
• No general danger signs
• No stiff Neck
• Malaria test Negative
FEVER-NO MALARIA

65. Classify Measles- If signs of MEASLES now or
within the last 3 months
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66
***Other important complications of measles-pneumonia, stridor, diarrhoea,
ear infection and malnutrition are classified in other tables
SIGNS CLASSIFY AS
• Generalized rash of measles and
one of: Cough, runny nose or red
eyes
SUSPECTED MEASLES
• Any general danger sign or
• Clouding of the cornea or
• Deep or extensive mouth ulcers
SEVERE
COMPLICATIONS OF
MEASLES***
• Pus draining from the eye or
• Mouth ulcers
EYE OR MOUTH
COMPLICATIONS OF
MEASLES***
• No pus draining from the eye and
no mouth ulcers
NO EYE OR MOUTH
COMPLICATIONS OF
MEASLES

66. Exercise H…
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68
Part 2
Study photographs 12 through 21 showing
children with rashes. For each photograph, tick
whether the child has the generalized rash of
measles. Use the answer sheet provided

67. Exercise K – Classify illness in children with signs of
fever
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69
Case : Atika
Atika is 5 months old. She weighs 5 kg. Her temperature is 36.50C.The risk of
Malaria is high. Her family brought her to the clinic because she feels hot and has
had cough for 2 days.
She is able to drink. She has not vomited or had convulsions, and is not lethargic or
unconscious.
The health worker said, "I am going to check her cough now." The health worker
counted 43 breaths per minute. There was no chest indrawing and no stridor when
Atika was calm. Atika did not have diarrhea.
"Now, I will check her fever," said the health worker. Atika lives in an area where
many cases of malaria occur all year long (high malaria risk). Her mother said,
"Atika has felt hot off and on for 2 days." She has not had measles within the last 3
months. She does not have stiff neck or runny nose.
Atika has a generalized rash. Her eyes are red. She has mouth ulcers. They are
not deep and extensive. She does not have pus draining from the eye. She does
not have clouding of the cornea.
Record the child's signs and classify them on the Recording Form on this page.

68. Video exercise L
10/04/2024
70 In this exercise, you will;
 Watch a demonstration of how to assess and
classify a child with fever.
 See examples of signs related to fever and
measles.
 Practice identifying stiff neck.
 Watch a case study.
Write down your answers in the forms provided

69. EAR PROBLEM
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71
• A child with an ear problem may have an ear infection.
• Ear infection may cause pus to collect behind the ear drum
causing pain and often fever.
• If not treated, the ear drum may burst ,discharge pus and
the child feels less pain.
• However, the child may suffer poor hearing or worse
deafness
• Ear infection may lead to Mastoiditis or Meningitis

70. ASSESS for EAR PROBLEM
 Is there ear pain?
 Is there ear
discharge? if yes, for
how long?
 Pus draining from the
ear
 Feel for tender
swelling behind the
ear
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72
If the child has ear
problem-ASK
LOOK AND FEEL
Does the child have an ear problem?

71. CLASSIFY CHILD EAR PROBLEM
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73
SIGNS CLASSIFY AS
• Tender swelling behind the ear MASTOIDITIS
• Pus seen draining from the ear or
• discharge is reported for less than
14 days or
• Ear pain
ACUTE EAR INFECTION
• Pus is seen draining from the ear
or
• discharge is reported for more than
14 days
CHRONIC EAR
INFECTION
• No ear pain and
• No pus seen or reported draining
from the ear
NO EAR INFECTION

72. Good Nutrition and Malnutrition
Components of Nutrition
 Good nutrition results from the adequate intake of
macronutrients, micronutrients and water to supply the
metabolic (anabolic and catabolic) processes in the body.
 There are two components of nutrition;
1. Macronutrients
2. Micronutrients

73. What is Malnutrition?
 Malnutrition is defined as a state when the body does not
have enough of the required nutrients (under-nutrition) or
has excess of required nutrients (over-nutrition).
 Inadequacies of macro or micro nutrients may result in
failure to thrive, poor growth or wasting.
 These processes are often measured by their
anthropometrical consequences (weight for age, height for
age or weight for height).
 Under nutrition is the most common form of malnutrition in
developing countries.

74. Global situation
 Globally Over 2 million children are severely
malnourished at any given time.
 Out of the 10 million children who die yearly, 5 million
succumb to malnutrition related causes
 Moderate and Severely Malnourished children have 3 –
9 times higher chances of death than well nourished
children.
 Widespread hunger and malnutrition continue to exist
amid natural calamities, wars, drought and disease

75. Common types of Malnutrition in children
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77
 protein-energy malnutrition :- this may result from either
inadequate intake or frequent illnesses and may lead to
 The child may become severely wasted, a sign of
marasmus.
 The child may develop oedema, a sign of kwashiorkor.
 The child may not grow well and become stunted (too
short).
 Malnutrition due to inadequate Vitamins such as vitamin
A deficiency, or minerals such as iron deficiency
anaemia.
 Anaemia may also result from infections, worm
infestations malaria , sickle cell disease amongst others

76. KEY NUTRITIONAL PROBLEMS IN
KENYA
 Growth Faltering
 Micronutrient deficiencies
(Iodine, Iron, Vitamin A)
 Sub-optimal Breastfeeding

77. CHECK FOR MALNUTRITION AND
ANAEMIA
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79
Check all sick children for signs suggesting malnutrition and
anemia.
 A child with malnutrition has a higher risk of many types of
disease and death.
 Malnutrition is an underlying cause in 60% of under five mortality
 Sick children brought to clinic may not have specific complaints
that point to malnutrition or anemia.
 Health workers or the child's family often fail to detect
malnutrition.
 Identifying and treating malnutrition can help prevent many
severe diseases and death.
 Severe cases need referral to hospital whereas less severe
cases may be managed at home.
 In malnourished children, checking for TB and HIV infection is
important.

78. ASSESS FOR MALNUTRITION
Ask: Is there history of TB contact?
10/04/2024
80 LOOK AND FEEL:
• Take the child’s weight for age and plot on mother/ child health booklet to determine
the z-score
• Take the child’s length/height for age and plot on mother/child health booklet to
determine the z-score
• Determine the growth pattern; Is the growth faltering? (Weight curve is flattening or
dropping for at least 2 consecutive months?)
• Look for oedema of both feet
• Look for visible severe wasting
For children aged 6 months up to 59 months, determine MUAC:
• < 11.5cm
• 11.5 -12.5cm
• 12.5 - 13.5cm
For children aged 6 monthsup to 59 months,
determine Z Score􀀝
• < -3
• -3 to < -2
• -2 to < -1

79. Anemia
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81  The condition of having a lower-than-normal number of
red blood cells or quantity of hemoglobin. Anemia
diminishes the capacity of the blood to carry oxygen.
Common Causes
 Iron deficiency; may result from a diet deficient in iron
 Intestinal parasites
 Repeated nose bleeds
 Haemolysis, due to: Malaria and other Inherited blood
disorders like sickle cell disease)
 Chronic illness, such as tuberculosis and AIDS
 Severe malnutrition (due to lack of protein to produce
haemoglobin)

80. ASSESS for ANAEMIA
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82
Look for palmar pallor. Is it:
• Severe palmar pallor?
• Some palmar pallor?
• No palmar pallor?

81. CLASSIFY NUTRITIONAL STATUS
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83
SIGNS CLASSIFY AS
For all children:
• With visible severe wasting
• Oedema of both feet,
• <-3 Z Score ( weight for age or weight for height/Length)
For children 6 months upto 59 months: MUAC <11.5 cm
SEVERE
ACUTE
MALNUTRITION
For all age groups:
• Static weight or losing weight
• 3 to <-2 Z- Score
If age 6 months upto 59 months MUAC 11.5 to 12.5 cms
MODERATE
ACUTE
MALNUTRITION
For all age groups:
• Static weight or losing weight
• -2 to <-1 Z- Score
If age 6 months upto 59 months MUAC 12.5 to 13.5cms
AT RISK OF
ACUTE
MALNUTRITION
Weight between
• -1 to +2
NO
MALNUTRITION

82. CLASSIFY ANAEMIA
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84
SIGNS CLASSIFY AS
• Severe palmar pallor SEVERE
ANAEMIA
• Some palmar pallor ANAEMIA
• No palmar pallor NO
ANAEMIAON

83. CHECK FOR HIV EXPOSURE AND
INFECTION
10/04/2024
85
 Children may acquire HIV infection from an infected mother
through vertical transmission in utero, during delivery or
while breastfeeding.
 Without any intervention, 30 – 40% babies born to infected
mothers will themselves be infected.
 Most children born with HIV die before they reach their fifth
birthday, with most not surviving beyond two years
 Good treatment can make a big difference to children with
HIV and their families.
 The child’s status may also be the first indicator that their
parents are infected too

84. ASSESS FOR HIV EXPOSURE AND INFECTION
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86
ASK
• Ask for mother’s
HIV status to
establish child’s
HIV exposure*.Is it:
- Reactive
- Non reactive
- Unknown
• Ask if child has
had any TB
Contact.
LOOK, FEEL AND DIAGNOSE:
Child ≤18 months
• If Mother’s HIV status is unknown,
conduct an antibody test (rapid test)
on mother or child to determine HIV
exposure
• If mother’s or child’s antibody test is
POSITIVE the child is HIV exposed.
Take DBS for DNA PCR testing at 6
weeks or earliest contact thereafter
Child ≥18 months
If mother’s antibody test is POSITIVE,
the child is exposed. Conduct an
antibody test on the child.

85. ASSESS FOR HIV EXPOSURE AND INFECTION…
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87
PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV
INFECTION IN CHILDREN <18 MONTHS
LOOK and FEEL:
• Pneumonia ***
• Oral Candidiasis /thrush
• Severe sepsis
• Other AIDS defining
conditions**
Presumptive HIV diagnosis should be confirmed at the earliest opportunity.

86. CLASSIFY HIV STATUS
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88
SIGNS CLASSIFY AS
• Child<18 months and DNA PCR test POSITIVE
• Child>18 months and Antibody test POSITIVE
CONFIRMED
HIV
INFECTION
Children <18months
• If mother’s HIV status is POSITIVE and no test result for child
OR
• If Child with antibody test POSITIVE
OR
• If DNA PCR test is NEGATIVE
HIV EXPOSED
• No test results for child or mother
• 2 or more of the following conditions:
• Severe pneumonia
• Oral candidiasis/thrush
• Severe Sepsis
OR
• An AIDS defining condition
SUSPECTED
SYMPTOMATIC
HIV
INFECTION
• If child is <18 months with UNKNOWN mother’s HIV status
and tests antibody NEGATIVE
• If child is >18 months and tests antibody NEGATIVE
HIV
INFECTION
UNLIKELY

87. CHECK THE CHILD’SIMMUNIZATION,
VITAMIN A & DEWORMING STATUS
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89
 Immunization is one of the most cost effective
health intervention for disease control.
 It targets children under the age of 5 years.
 It needs tremendous inputs and effort to make it
happen.
 Immunization coverage can be enhanced
through;
 Routine Immunization
 Supplemental Immunizations
 Surveillance of the target diseases
 Mopping up in high risk areas

88. CHECK THE CHILD’SIMMUNIZATION, VITAMIN A &
DEWORMING STATUS ….
A child's body require Vitamin A for; Growth and development,
Protection against infections & reinforces the body’s immunity
Vit A deficiency may result from; Inadequate intake of vitamin A
rich foods, Poor absorption of the vitamin A & rapid utilization
of vitamin A stores due to illnesses
Vit A deficiency may lead to
 Increased incidence of illness
 Delays recovery from infections
 Leads to eye damage and may even lead to blindness
 Increases the risk of death in sick children

89. CHECK THE CHILD’SIMMUNIZATION,
VITAMIN A & DEWORMING STATUS ….
10/04/2024
91
 Remember, Vit A supplementation can;
 Reduces measles mortality by 50%
 Reduces diarrhea mortality by 33%
 Reduces all causes of mortality by 23%

90. CHECK CHILD’SIMMUNIZATION
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92
Vaccines
Age BCG Oral Polio Diphtheria/
Pertussis/
Tetanus/HepB/
Haemophilus
influenzae type B
(pentavalent)
PCV 10 Rota
Virus****
Measles
Birth BCG* OPV 0
(Birth-2wks
6 Weeks OPV 1 Pentavalent 1 PCV10 1 ROTA 1
10 Weeks OPV 2 Pentavalent 2 PCV10 2 ROTA 2
14 Weeks OPV 3 Pentavalent 3 PCV 10 3
6 Months Measles**
9 Months Measles Yellow
Fever***

91. CHILD’SIMMUNIZATION – PLEASE NOTE
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93
 *If BCG not given at birth, it should not be given to children with
symptomatic HIV /AIDS
 **Measles vaccine at 6 months is for HIV exposed/ infected children
 ***Yellow fever vaccine should not be given to children with symptomatic
HIV /AIDS
 ***Yellow fever vaccine is only offered in ( Koibatek, Baringo, Keiyo,
Marakwet ) in Rift valley province
 ****Rota Virus vaccine should not be given to children over 15 months
 Pentavalent not given if child had convulsion following previous dose or a
child with recurrent convulsions or another active neurological disease
 PCV10 & Pentavalent not given to Infants with a moderate or severe
illness (temperature ≥39°C) until their condition improves.
 PCV10 &Pentavalent contraindicated if severe allergic reactions or shock
to a prior dose or any component of the vaccine.
 Do not delay referrals of children with severe classifications to administer
immunizations

92. CHECK CHILD’S VITAMIN A &
DEWORMING
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94
Age Vitamin A Deworming
6 months Vitamin A Deworming
12 months Vitamin A Deworming
18months Vitamin A Deworming
24months Vitamin A Deworming
30months Vitamin A Deworming
36months Vitamin A Deworming
42months Vitamin A Deworming
48months Vitamin A Deworming
54months Vitamin A Deworming
60months Vitamin A Deworming

93. ASSESS OTHER PROBLEMS THE CHILD
MIGHT HAVE
10/04/2024
95 It is important to remember that the already discussed IMCI
case management process ;
• Does not cover all symptoms
• Is not reviewing all pediatric medicine
• Remember to address some complaints the caregiver
may have raised, eg
• she may have said the child has an itchy skin
• You may have observed another problem the mother
didn’t say eg jiggers.
• Treat any other problems according to your training,
experience and clinic policy.
• Refer the child for any other problem you cannot manage
in clinic.