29.1 OUTPATIENT MANAGEMENT OF CHILDREN FROM 2 MONTHS UP TO 5 YEARS
Important steps in the management of these cases according to IMNCI guidelines 2021 are as follows:
Step I. Assessment for danger signs: All sick children should be assessed for four important danger signs(a) convulsions or history of convulsions, (b) lethargy/uncon- sciousness, (c) inability to drink/breastfeed, and (d) vomiting.
Presence of any one or more of these signals classify these cases as Very severe disease Who need immediate referral to hospital after quick evaluation for main symptoms (step II) to decide pre-referral treatment, if required. Baby should be kept warm, treated for low blood sugar if required and must be give rectal diazepam (0.5 mg/kg), if convulsing. Diazepam may be repeated after 10 minutes if convulsions continue.
Step II. Assessment for major symptoms: All sick children, should then be assessed for followingfour major symptoms(a) cough/difficult feeding, (b) diarrhea,
(c) fever, and (d) ear problems.
a. Children with cough or difficult breathing must be assessed for(a) respiratory rate, (b) chest indrawing, (c) stridor, (d) wheezing, and (e) SpO 2.
If wheezing with fast breathing/chest indrawing, Give three doses of rapid-acting bronchodilator, i.e Nebulized salbutamol or 2-4 puffs of salbutamol inhaler at 20 minutes interval and reassess again.
Accordingly, they are classified in three categories for severity and treatment purpose as follows(a) severe pneumonia or very severe disease, (b) pneumonia, and (c) no pneumonia: (cough or cold) (Table 29.1).
b. Children with diarrhea must be assessed for: (a) duration of diarrhea (lt;/gt;14 day), (b) presence of dehydration, and (c) presence of blood in stools. Dehydration is assessed on the basis of four signs (a) general condition, e.g. lethargic/unconscious or restless/irritable, (b) sunken eyes, (c) ability to drink water, and (d) skin turgor or elasticity, on pinching.
Accordingly, they are classified in six categories for severity and treatment purpose, as follows: (a) severe dehydration, (b) some dehydration, (c) no dehydration, (d) severe persistent diarrhea, (e) persistent diarrhea, and (f) dysentery (Table 29.2).
c. Children with fever are first assessed for the risk of falciparum malaria (endemicity) and dengue (season), followed by evaluation for: (a) duration of fever, (b) stiff neck, (c) septic focus, (d) signs of active measles, e.g. rash, cough, runny nose or red eyes, (e) H/o measles in past 3 months with presence of mouth ulcers or pus discharge from eyes.
Dengue must be suspected in children with fever 2-7 days during dengue season, who should also be assessed for warning signs: (a) cold extremities with
TABLE 29.1: IMNCI classification for cough/difficult breathing (2 months - 5 years)
Severe pneumonia or very severe disease
Signs:
(a) Any general danger sign, (b) Stridor, (c) SpO2 lt;90%.
Treatment:
Give first dose of IM antibiotics
Refer urgently, ensure warmth during transfer
Provide oxygen on the way to hospital
Pneumonia
Signs:
(a) Fast breathing, (b) Chest indrawing
Treatment:
Give oral amoxicillin for 5 days
Inhaled/oral salbutamol for 5 days, if wheezing
Safe home remedies[XXVII] [XXVIII] in children gt; 6 months Follow-up after 2 days or SOS No Pneumonia TABLE 29.2: IMNCI classification for diarrhea (2 months - 5 years) Severe Dehydration Signs: (any two) (a) Lethargic/unconscious, (b) Sunken eyes, (c) Inability to drink (d) Very low skin turgor Treatment: Give IV fluids as WHO-Plan C Refer urgently (if has another severe classification) Advise ORS and breastfeeding during transfer PO antibiotics, if there is cholera outbreak (in children gt; 2 year) Some Dehydration Signs: (any two) (a) Restless/Irritable, (b) Sunken eyes, (c) Thirsty, drinks eagerly, (d) Low skin turgo Treatment: Give ORS/oral fluid as WHO-Plan B Give Zinc and continue foods Refer urgently (if has another severe classification) Advise ORS and breastfeeding during transfer Follow-up after 5 days or SOS No Dehydration Signs: Not enough signs for some/severe dehydration Treatment: Give ORS/oral fluids as WHO-Plan A Give Zinc and continue foods Follow-up after 5 days or SOS Severe persistent diarrhea TABLE 29.3: IMNCI classification for fever (2 months - 5 years) Very Severe Febrile Illness Signs: (a) Any general danger sign or (b) Stiff neck Treatment: Give first dose of IM antibiotics Give fist dose of artesunate/quinine (if RDT+/Malaria endemic) Treat/prevent hypoglycaemia Give one dose of paracetamol, if fever gt;38.5ฐC Refer urgently (or treat if referral not possible) MalariaZsuspected malaria Signs: RDT + ve /not possible and no other alternative cause Treatment: Give oral antimalarials as per national guidelines Give one dose of Paracetamol, if Fever gt;38.5ฐC Follow-up after 2 days or SOS Fever, Malaria Unlikely Signs: Negative RDT, other cause present Treatment: Give one dose of paracetamol, if fever gt;38.5ฐC Treat possible cause Follow-up after 2 days or SOS Reassess if fever continues for gt; 7 days Severe Dengue Syndrome With Warning Signs Signs: (any one) (a) Any general danger Signs, (b) Cold extremities with weak/ rapid pulse (c) Severe abdominal pain (d) Bleeding from any site (e) Positive tourniquet test Treatment: Give first dose of IM antibiotics Refer urgently Plenty of oral fluids/ORS on the way to hospital Give one dose of paracetamol, if Fever gt;38.5ฐC Dengue Fever Signs: No warning signs Treatment: Give one dose of paracetamol, if Fever gt;38.5ฐC Advice home care Follow-up after 2 days or SOS Severe Complicated Measles Signs: (Measles now or in last 3 months) and Any general danger signs, or clouding of cornea, or Deep/ extensive mouth ulcers Treatment: Give first dose of IM antibiotics Give single oral dose of vitamin A Give antibiotic eye ointment if eye signs Refer urgently (or treat if referral not possible) Measles with EyeZMouth Complications Signs: (Measles now or in last 3 mo) and Pus draining from eyes or oral ulcers Treatment: Give single oral dose of Vitamin A Give antibiotic eye ointment if eye signs Give gentian violet for oral ulcers Follow-up after 2 days Measles Signs: Measles now or in last 3 months Treatment: Give single oral dose of vitamin A TABLE 29.4: IMNCI classification for child with ear problems (2 months - 5 years) Mastoiditis Signs: Tender swelling behind the ear Treatment: Give first dose of IM antibiotics Refer urgently Give one dose of paracetamol for pain Acute Ear Infection Signs: (a) Pus discharge lt;14 days or (b) Ear pain Treatment: Give Oral amoxicillin for 5 days Dry the ear with wicking Follow-up after 5 days or SOS Chronic Ear infection Signs: Pus discharge from ear for gt;14 days Treatment: Dry the ear by wicking Topical Quinolone ear drops for 2 weeks Follow-up after 5 days No Ear Infection Signs: No ear pain or discharge Treatment: No additional treatment TABLE 29.5: IMNCI classification for malnutrition (2 months - 5 years) Severe Acute Malnutrition with Medical Complications Signs: (a) WFL lt;-3 SDS, or (b) MUAC lt;11.5 cm, or (c) B/L pedal edema and medical complication Treatment: Give first dose of IM antibiotics Refer urgently, ensure warmth during transfer Treat/preventive hypoglycemia Severe Acute Malnutrition without Medical Complications Signs: (a) WFL lt;-3 SDS, or (b) MUAC lt;11.5 cm, and No medical complication Treatment: Give oral amoxicillin for 5 days Give Single oral dose of vitamin A Give multivitamins and zinc for 14 days Dietary assessment and counseling Follow-up after 7 days or SOS Moderate Acute Malnutrition Signs: (a) WFL lt;-3 to lt;-2 SDS, or (b) MUAC 11.5 -12.4 cm Treatment: Dietary assessment and counseling Follow-up after 7 days or SOS No Acute Malnutrition TABLE 29.6: IMNCI classification for anemia (6 months - 2 year) Severe Anemia Signs: Severe palmer pallor (Hb lt;7 gm/dl) Treatment: Refer urgently Some Anemia Signs: Some palmar pallor (Hb 7-10.9 gm/dl) Treatment: PO Iron-Folic acid for 14 days Dietary assessment and counseling Follow-up in 14 days or SOS No Anemia Signs: No palmar pallor Treatment: Prophylactic iron-folic acid (if gt;6 month old) Accordingly, classify the child to three categories for severity and treatment purpose: (a) severe anemia, (b) anemia, (c) no anemia (Table 29.6). c. d. Feeding problems must be assessed in all babies lt;2 years with uncomplicated SAM, MAM and anemia, with special reference to: (a) breastfeeding - frequency, night-feeds, etc., (b) complimentary feeds, and (c) feeding during current illness. Mother should be advised appropriately in cases with feeding problems. She must also be praised for correct practices. Step IV. Assessment for other problems: Although IMNCI guidelines focus of main symptoms, many other problems, e.g. conjunctivitis, may co-exist in sick children that need to be recorded and managed accordingly. Step V. Referral to the hospital: Following categories of cases (Pink-color code) needs urgent referral: (a) severe pneumonia or very severe disease, (b) severe persistent diarrhea, (c) very severe febrile illness, (d) severe dengue/dengue with warning signs, (e) severe complicated measles, (f) mastoiditis, (g) severe acute malnutrition with complications, and (h) severe anemia (in addition to those with General Danger Signals - Step I). Cases of diarrhea with severe or some dehydration need urgent referral only, if some other severe classification is present. Some other categories of cases may also need Non-urgent referral after follow-up. Referral note to the hospital should include: (a) name and age of patient, (b) date and time of referral, (c) description of child's problem, (d) reasons for referral, (e) treatment given, and (f) any other information. Pre-referral treatment: All these cases should also receive essential pre-referral treatment, e.g. (a) first dose of antibiotics (Ampicillin and Gentamycin), (b) antimalarial as per national guidelines including artesunate or quinine, if from falciparum prevalent area or having positive RDT, (c) prevention of hypoglycemia by giving breast milk or sugar water, (d) prevention of hypothermia by skin to skin contact, (e) others, e.g. Step VI. Treatment at the outpatient clinic: IMNCI guidelines provide specific treatment recommendations for cases with less severe classifications (yellow or green code) or those with severe classification but referral not possible, which must be administered at the clinic undersupervision or at home after proper counseling to the mother or caretaker (see relevant tables). These interventions also include feeding advice, necessary immunizations and teaching the mother to given oral drugs at home. Mother should also be trained to recognize signs that need urgent follow-up. Step VII. Follow-up: All cases with less severe classifications (Yellow/Green) must be asked to followญup immediately if(a) unable to accept breast-feeds or drink liquids, (b) become sicker, or (c) develop fever, fast breathing, difficult breathing or blood in stools. IMNCI guidelines recommends specific follow-up periods in other cases, as specified in tables. 29.2