Republic of the Philippines

City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

College of Allied Health Studies

Detailed Learning Module(Case-Based Learning Module)

Program: Graduate in Midwifery

Course Code: MDW 204(Seminar in Midwifery)

Title: Classification of the Sick Child aged 2 months up to 5 years old

Check for general danger signs
Check for the presence of cough or difficulty in breathing

Module No. 2

I. Introduction: The component of the training or this module shows on how to care for a sick child aged 2
months to 5 years.The material in this component is presented in five parts corresponding to the steps of
integrated case management. First is the assess and classify the sick child in which it shows you how to assess
a child by checking for danger signs, asking questions about common conditions, examining the child, and
checking nutrition and immunization status. It also shows you how to classify a child's illness using a colour-
coded triage system.

Next is to identify treatment that shows on how to identify treatment for a sick child. If the child requires
urgent referral, the health worker needs to give essential treatment before the patient is transferred. If the
child needs treatment at home, as a health worker we should to develop a comprehensive treatment plan.
Next is the Treat. In this part it shows on how to treat a sick child and provides practical treatment
instructions, including guidance on teaching the mother or other caregiver how to give oral drugs, how to feed
the child and give fluids during illness, and how to treat local infections at home.

During the steps of counsel the mother, using good communication skills about child feeding based on feeding
recommendations and feeding assessment including assessment of breastfeeding practices is important.It is
also includes the increased fluids during illness, when to return to a health worker and about her own health.

Lastly the follow-up steps. In this part it shows on how to provide follow-up care. When there is a new
problem as a health worker should do full assessment as in initial visit.

II. Learning Objectives: After studying the module, the student should be able to:
1. Know on how to assess and classify a sick child from the presence of danger signs to the child with
cough or difficulty in breathing using the IMCI recording form.
2. Know how to record information collected about the child’s signs and symptoms while using the case
scenario and see children during clinical practice sessions.
3. Differentiate the different clinical symptoms of general danger signs and the actions to be taken when
general danger signs are present
4. Know how to assess the signs and symptoms of cough or difficulty breathing, taking into account the
presence or absence of general danger signs and classify it according to the IMCI chart.

III. Topics and Key Concepts

Topic 1: Assess and classify child

 The assess and classify part of this module/training is divided into following:
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

1. Ask the mother about the child's problems

2. Check for general danger signs
3. Assess main symptoms:
 Cough or difficulty breathing
 Diarrhea
 Fever
 Ear problem
4. Check for acute malnutrition and anemia
5. Check immunization status, Vitamin A, oral health and deworming status
6. Assess other problems

1. Ask the mother about the child's problems

 When a mother brings her child to see you, it is important to establish good communication with her.

 You may have to treat the child's illness later in the visit. You will need to give the mother advice and
teach her how to care for her sick child at home. So it is important to have good communication with
the mother from the beginning of the visit.

 Some simple techniques will help you to be more effective when you see the mother and her sick
child.

o Greet the mother appropriately without hurrying and ask her to sit with her child.
o Try to:
 avoid using words that suggest judgment of the mother and baby such as "wrong" or
"bad"
 sit so that your head is level with the mother's head
 look at the mother and pay attention as she speaks
 remove barriers (table or notes) between you and the mother
 make the mother feel that you have time to listen to her.

o Look to see if the child's weight and temperature have been recorded. If not, wait until later
when you assess and classify the child's main symptoms. Then weigh the child and measure
the child's temperature.

o Do not undress or disturb the child at this stage.

o Ask the mother what the child's problems are. An important reason for asking this question
is to start communicating well with the mother. Good communication helps to reassure the
mother that her child will receive good care. Later in the visit, you will need to teach and
advise the mother about caring for her child at home. It will be easier for you to do so if you
have good communication with the mother from the beginning of the visit.

o Find out if this is an initial or follow-up visit for the problem.

 If this is the child's initial visit for a particular episode of an illness or problem, then you
will need to use the IMCI case-management procedure to assess and classify the child.
 If the child was seen a few days ago for the same illness, this is a follow-up visit.
The purpose of a follow-up visit, is to find 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, you will need to refer the child to a hospital or change the child's treatment. You
will learn how to carry out a follow-up visit later in the training.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

TOPIC 2: Check for general danger signs

 All sick children should be routinely checked for general danger signs
 Always check ALL sick children for general danger signs.
 General danger signs are:
1. the child is not able to drink or breastfeed
2. the child vomits everything
3. the child has had convulsions during the present illness or has convulsions now
4. the child is lethargic or unconscious
 A child with a general danger sign has a serious problem. All children with a general danger sign need
urgent referral to hospital.

 If during assessment you found presence of a general danger sign you should complete the rest of
assessment immediately. If the child is to be referred, you should give urgent pre-referral treatment.

Check for general danger signs

1. ASK: Is the child able to drink or breastfeed?
o A child who is not able to suck or swallow when offered a drink or breast
milk because he or she is too weak or cannot swallow has the danger sign
not able to drink or breastfeed.
o Ask the mother if the child is able to drink or breastfeed. Make sure that the
mother 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 ask: "Is the child able to take fluid
into his or her mouth and swallow it?"
o If you are not sure about the mother's answer, ask her to offer the child a
drink of clean water or breast milk. Look to see if the child is swallowing the
water or breast milk.
o Remember: A child who is breastfed may have difficulty sucking when his or
her nose is blocked. If the child's nose is blocked, clean it. If the child can
breastfeed after his or her nose is cleared, the child does not have the
danger sign "not able to drink or breastfeed".
2. ASK: Does the child vomit everything?
o A child who is not able to hold anything down at all has the danger 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.
o Ask the mother if the child vomits everything. When you ask the question,
use words the mother understands.
o When you or the mother are not sure if the child is vomiting everything,
help her to make her answer clear.
o For example, ask the mother: "How often the child vomits? Also ask: "Each
time the child swallows food or fluids, does the child vomit?"
o If you are still not sure of the mother's answers, ask her to offer the child a
drink. See if the child vomits
3. LOOK: Is the child having convulsions now?
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

o ASK: Has the child had convulsions during the present illness?
o During a convulsion, the child's arms and legs stiffen because the muscles
are contracting. The child may lose consciousness or not be able to respond
to spoken directions.

o Convulsions may be the result of fever.

In this instance, they do little harm beyond frightening the mother. But
convulsions may be associated with meningitis, cerebral malaria or other life
threatening conditions.
o Convulsions is considered a life threatening danger sign are:
1. Any convulsions in children aged less than 6 months.
2. More than one episode of convulsions during the present illness or convulsions lasting for more than 15
minutes in children aged 6 months or more.
o One episode of generalized convulsions during the current febrile illness in a child aged 6 months or more
lasting for less than 15 minutes are considered simple febrile convulsions, NOT a general danger sign.

o LOOK: Is the child is unconscious or lethargic?

o An unconscious or lethargic child is likely to be seriously ill.
These signs may be associated with many conditions.
o A lethargic child is not awake and alert when he or she
should be. The child is drowsy and does not take any notice
of his or her surroundings or does not respond normally to
sounds or movement. Often the lethargic child does not
look at his or her mother or watch your face when you talk.
The child may stare blankly and appear not to notice what is
going on around him or her.
Ask the mother if the child seems unusually sleepy or if she
cannot wake the child.
An unconscious child cannot be
Look to see if the child wakens when the mother talks or shakes
wakened. The child does not
the child or when you clap your hands.
respond when he or she is touched,
shaken or spoken to
CLASSIFICATION
 A child who is not able to drink or breastfeed, or vomits everything, or has had convulsions during the
present illness or has convulsions now, or is lethargic or unconscious or is not able to drink or
breastfeed has a danger sign and is classified as VERY SEVERE DISEASE

Any general danger sign VERY SEVERE DISEASE

 A child classified as VERY SEVERE DISEASE has a severe problem and needs URGENT attention. There
must be no delay in treatment.

Fill in a case recording form

After completing an assessment for general danger signs, write down your findings on a case recording form.
An example is given below. You will use your findings to decide how to classify the child's condition.

Example of how to fill in a case recording form

Fatima is 18 months old. She weighs 11.5 kg, her length is 84 cm. Her temperature is 37.5°C. The health worker
asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6 days, and she is
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

having trouble breathing." This is the initial visit for this illness.

The health worker checked Fatima for general danger signs. The mother said that Fatima is able to drink. She
has not been vomiting. She has not had convulsions during this illness and she does not have convulsions now.
The health worker asked, "Does Fatima seem unusually sleepy?" The mother said, "Yes." The health worker
clapped his hands. He asked the mother to shake the child. Fatima opened her eyes, but did not look
around.The health worker talked to Fatima, but the child did not watch the health worker's face. Fatima stared
blankly and appeared not to notice what was going on around her.

TOPIC 3: Assess cough or difficulty breathing

For ALL sick children, ASK the mother: "Does the child have a cough or difficulty breathing?"
 If the mother answers "NO", DO NOT ASSESS the child for cough or difficulty breathing. Go to the next
question.
 If the mother answers "YES", ASSESS and classify cough or difficulty breathing as described in Key
steps and in the IMCI chart.
 A child with a cough or difficulty breathing may have pneumonia or another severe respiratory
infection, which would require referral or treatment with antibiotics.

Respiratory infections can occur in any part of the respiratory tract: the nose,
throat, larynx, trachea, air passages or lungs.

You can see the main elements of a child respiratory system. If you have
speakers you can hear different cough sounds when you make a click with your
computer mouse over mouth, larynx and trachea.

A child with a cough or difficulty breathing may have pneumonia or another

severe respiratory infection.

Pneumonia is an infection of the lungs. Children with bacterial pneumonia may

die from hypoxia (too little oxygen) or sepsis (generalized infection).
o Both bacteria and viruses can cause pneumonia. In low- and middle-income countries,
pneumonia is often caused by bacteria. The most common are:
1. Streptococcus pneumoniae
2. Haemophilus influenzae
Nevertheless many children are often brought to the clinic with less serious respiratory infections. Most
children with a cough or difficulty breathing have only a mild infection. These children are not seriously ill.
They do not need treatment with antibiotics. Their families can manage them at home.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

CLINICAL ASSESSMENT
 Difficulty breathing means 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." When you
ask the mother if the child has a cough or difficulty breathing and the mother answers
"NO", see if you think the child has a cough or difficulty breathing.
 A child with a cough or difficulty breathing is assessed for:
1. How long the child has had a cough or difficulty breathing
2. Fast breathing
3. Chest indrawing
4. Stridor
5. Wheezing
ASK: For how long has the child had a cough or difficulty breathing?
 A child who has had a cough or difficulty breathing for more than 2 weeks has a chronic
cough. This may be a sign of tuberculosis, asthma, whooping cough or another problem.

COUNT the breaths in one minute

 You must count the breaths the child takes in one minute to decide whether the child has fast
breathing.
 The child must be quiet and calm when you watch and listen to his or her breathing.
 Cut-off rates for fast breathing (the point at which breathing is considered to be fast) depend on the
child's age. Normal breathing rates are higher in younger children.

Child's age: Fast breathing:

2 months up to 12 months 50 or more breaths per minute
12 months up to 5 years 40 or more breaths per minute

Note: A child who is exactly 12 months old has fast breathing if you count 40 or more breaths per minute.

LOOK for chest indrawing

 Lower chest wall indrawing (the inward movement of the bony structure of the chest wall when the
child breathes in) is an indicator of pneumonia. It is more specific than intercostal indrawing, which
concerns the soft tissue between the ribs without involvement of the bony structure of the chest wall.

 If you did not lift the child's shirt when you counted the child's breaths, ask the mother to lift it now.
o Before you look for chest indrawing watch the child to determine when the child is breathing in
and when the child is breathing out.
 Look for chest indrawing when the child breathes in.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

o 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.
o 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.

Note: 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 (intercostal indrawing or intercostal retraction),
the child does not have chest indrawing. In this assessment, chest indrawing means lower chest wall
indrawing. It does not include intercostal indrawing.

To learn more about the management of a child with a cough or difficulty breathing, look at the following
pictures.
Look for chest indrawing.
 Chest indrawing is defined as a definite inward movement
of the lower chest wall while breathing in (inspiration). For
observing chest indrawing, the child should be preferably
made to lie flat in the bed or in the mother's lap. A child is
said to have a definite chest in-drawing only if it is
persistent. This child has a chest indrawing. The lower chest
wall goes IN when the child breathes IN.

You can see another example of chest indrawing.

 This child also has a chest indrawing. The lower chest wall
goes IN when the child breathes IN.

LOOK and LISTEN for stridor

 Stridor is a harsh noise made when the child breathes in. Stridor happens when there is a swelling of the
larynx, trachea or epiglottis. These conditions are often called croup. This swelling interferes with air
entering the lungs. It can be life-threatening when the swelling causes the child's airway to be blocked. A
child who has stridor when calm has a dangerous condition.

 To look and listen for stridor, look to see when the child breathes in.
o Listen for stridor when the child breathes in. Put your ear near the child's mouth because stridor can
be difficult to hear.
o Sometimes you will hear a wet noise if the child's nose is blocked. Clear the nose, and listen again. A
child who is not very ill may have stridor only when crying or upset. Be sure to look and listen for
stridor when the child is calm.

LOOK and LISTEN for wheezing

 Wheezing is a soft musical noise made when the child is breathing out. Wheezing is caused by a
narrowing of the air passages in the lungs. Breathing out takes longer than normal and requires effort.

 Look and listen for wheezing when the child breathes out.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

o Hold your ear near the child's mouth because the wheezing noise can be difficult to hear. Sometimes
so little air moves that there is no noise. Look to see if the breathing out phase requires great effort
and is longer than normal.
o If wheezing and either fast breathing or chest indrawing:
 Give a trial of rapid acting inhaled bronchodilator for up to three times 15-20 minutes
apart. Count the breaths and look for chest indrawing again, and then classify.

CLASSIFY THE CHILD'S COUGH OR DIFFICULTY BREATHING

 Based on the clinical signs found during the clinical assessment, the child's condition can be classified
into one of three categories for: pre-referral treatment; specific treatment; or home care.

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

 A child with any general danger sign or stridor when calm is classified as having SEVERE PNEUMONIA
OR VERY SEVERE DISEASE
 Any general danger sign SEVERE PNEUMONIA OR VERY SEVERE
 Stridor in calm child DISEASE

PNEUMONIA
 A child with a cough or difficulty breathing who has chest indrawing or fast breathing and NO general
danger signs and NO stridor when calm is classified as having PNEUMONIA.
 Chest indrawing or PNEUMONIA
 Fast breathing

 If the child is wheezing and does NOT have a general danger sign or stridor, test the child for
response to a rapid acting bronchodilator. Wait for 15 minutes and reassess the child. If there is still
chest indrawing or fast breathing, repeat the test twice before classifying the child's illness as
pneumonia.

 A child with wheezing should receive inhaled bronchodilator for 5 days. A child who has a chronic
cough (a cough lasting more than 2 weeks) may have tuberculosis, asthma, whooping cough or
another problem. A child with a chronic cough needs to be referred to hospital for further
assessment.

 A child with chest indrawing usually has a more severe pneumonia than a child with fast breathing
and no chest indrawing. Or the child may have another serious acute lower respiratory infection, such
as bronchiolitis, pertussis, or a wheezing problem.

 Chest indrawing develops when the lungs become stiff. The effort the child needs to breathe is much
greater than normal. If the child is tired, and if the effort the child needs to expand the stiff lungs is
too great, the child's breathing slows down. Therefore, a child with chest indrawing may not have fast
breathing. Chest indrawing may be the child's only sign of pneumonia.

COUGH OR COLD
 A child with cough or difficult breathing who has no general danger signs, no stridor when calm, no
chest indrawing, and no fast breathing is classified as having COUGH OR COLD.

 No signs of pneumonia or COUGH OR COLD

very severe disease

 If the child is wheezing, give an inhaled bronchodilator or, if not available, oral salbutamol for 5 days.
If the wheezing is recurrent, refer the child for assessment.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

 A child with a cold normally improves in one to two weeks. But a child who has a chronic cough (a
cough lasting more than two weeks) may have tuberculosis, asthma, whooping cough or another
problem. A child with a chronic cough needs to be referred to hospital for further assessment

Fill in a case recording form

 After completing an assessment for cough or difficulty breathing, write your findings on the record
form as shown in the example below.
 Example of how to fill in a case recording form
Fatima is 18 months old. She weighs 11.5 kg, her length is 84 cm. Her temperature is 37.5 °C. The health worker asked,
"What are the child's problems?" The mother said "Fatima has been coughing for 6 days, and she is having trouble
breathing." This is the initial visit for this illness.

The health worker checked Fatima for general danger signs. The mother said that Fatima is able to drink. She has not
been vomiting. She has not had convulsions during this illness. The health worker asked, "Does Fatima seem unusually
sleepy?" The mother said, "Yes." The health worker clapped his hands. He asked the mother to shake the child. Fatima
opened her eyes, but did not look around. The health worker talked to Fatima but she did not watch his face. She
stared blankly and appeared not to notice what was going on around her.

The health worker asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a
minute. He counted 41 breaths per minute. The health worker did not see any chest indrawing. He did not hear stridor
and he did not hear wheezing.

IV. Teaching and Learning Materials and Resources

o Reference book
o Have your copy of the chart booklet IMCI manual and chart(soft and hard copy)IMCI forms(2 to 5
years old and sick child up to 2 months)
o -Midwifery Skills Procedure Checklist
o -white paper and pen/computer
o -Download to your cellphone the IMCI chart

References:
WHO Global Health Observatory(http://www.who.int/who/child health/en/index.html)

Prepared by:
Maria Sandra C. Rivera, RM MCHS

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 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
Olongapo City Sports Complex, East Tapinac, Olongapo City
Tel. No. (047) 224-2089 loc. 314

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