4Stages in the management of a sick child (Ref. Chart 1, p. xxii) TriageEmergency treatmentHistory and examinationLaboratory investigations, if requiredMain diagnosis and other diagnosesTreatmentSupportive careMonitoringDischarge planningFollow-up
5Have you noticed any emergency or priority signs? Temperature: 36,80C, pulse: 130/min, RR: 40/min, capillary refill time: below 2 seconds, weight: 8 kg, sunken eyes, normal skin turgor
6Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distressCentral cyanosisSigns of shockComaConvulsionsSevere dehydrationPriority signs (Ref. p. 6)Tiny babyTemperatureTraumaPallorPoisoningPain (severe)Respiratory distressRestless, irritableReferralMalnutritionOedema of both feetBurns
7HistorySarah had been well 5 days ago, but then she began to have loose watery stools 8-10 times a day. There was no blood or pus in the stool.Past medical history: previously well, no significant past historyImmunization: completed according to Expanded Programme on Immunization schedule, measles dueSocial history: lives with her mother and sister, 4 years oldMedications: noneAllergies: not known
8ExaminationSarah was crying continuously, she only stopped briefly when her mother put her to her breast. When she was offered ORS she drank eagerly.Vital signs: temperature: 36.8 °C, pulse: 130/min, RR: 40/minWeight: 8 kgEyes: sunkenSkin: normal skin turgor (skin pinch goes back immediately)Chest: air entry was good bilaterally and there were no added soundsCardiovascular: both heart sounds were audible and there was no murmurAbdomen: bowel sounds were active and there was no organomegalyNeurology: restless and irritable; no neck stiffness and no other focal signs
9Differential diagnoses List possible causes of the illnessMain diagnosisSecondary diagnosesUse references to confirm (Ref. p. 127)
10Differential diagnoses (continued) Acute (watery) diarrhoeaCholeraDysenteryPersistent diarrhoeaDiarrhoea with severe malnutritionDiarrhoea associated with recent antibiotic useIntussusception
11Additional questions on history Diarrhoeafrequency of stoolsnumber of daysblood in stoolsLocal reports of cholera outbreakRecent antibiotic or other drug treatmentAttacks of crying with pallor in an infant
12Further examination based on differential diagnoses Look for:Signs of dehydration such as: restlessness, irritability, lethargy, sunken eyes, skin pinch returns slowlyBlood in stoolSevere malnutritionAbdominal massAbdominal distension
13Further examination based on differential diagnoses Sunken eyes(Ref. p. 127)
14Classification of the severity of dehydration in children with diarrhoea Rapid assessment of hydration status and classification of severity of dehydration in children with diarrhoea:ClassificationSigns or symptomsSeveredehydrationTwo or more of the following signs:lethargy/unconsciousnesssunken eyesunable to drink or drinking poorlyskin pinch goes back very slowly (>2 seconds)Somerestlessness, irritabilitydrinks eagerly, thirstyskin pinch goes back slowlyNoNot enough signs to classify as some or severe dehydration(Ref. Table 12, p. 128)
15Please summarize the signs of dehydration you noticed in Sarah
16Classification of the severity of dehydration in children with diarrhoea Signs or symptomsSeveredehydrationTwo or more of the following signs:lethargy/unconsciousnesssunken eyesunable to drink or drinking poorlyskin pinch goes back very slowly (>2seconds)Somerestlessness, irritabilitydrinks eagerly, thirstyskin pinch goes back slowlyNoNot enough signs to classify as some or severe dehydration(Ref. Table 12, p. 128)
17What investigations would you like to do to make your diagnosis ?
18At this stage no additional investigations are necessary
19Diagnosis Summary of findings: Examination: restlessness, irritability, sunken eyes, drinks eagerly, thirstyAcute diarrhoea with some dehydration
21Treatment Plan B (Ref. Chart 14, p. 135) In the first 4 hours give 75 ml per kg of ORS as shown in table belowShow the mother how to give the child ORS solution, a teaspoonful every 1-2 minutes if the child is under 2 years; frequent sips from a cup for an older child
22Treatment (continued) After 4 hours:- Reassess the child and check the signs of dehydration- Select the appropriate plan to continue (discharge if necessary to Treatment Plan A or C)- Begin feeding the child in clinicIf the mother must leave before completing treatment:- Show her how to prepare ORS at home- Give her enough ORS packets to complete rehydration- Explain the 4 Rules of Home Treatment:Give extra fluidGive zinc supplementsContinue feedingWhen to return
23Treatment (drugs)Antibiotic treatment is rarely necessary (Ref. p. 126)Only for:Dysentery (mostly Shigella)CholeraNeonates with diarrhoea and feverAnti-diarrhoeal agentsNever necessary and often harmful!
24What supportive care and monitoring are required?
25Supportive CareCheck regularly to see if there are problems (Ref. p )If the child vomits, wait 10 minutes, then, resume giving ORS solution more slowlyIf the child's eyelids become puff, stop ORS solution and give plain water or breast milkAdvise breastfeeding mothers to continue to breastfeed whenever the child wantsInfection control: hand washing in clinic and hospital
26Monitoring The child should be checked by nurses frequently Use a Monitoring chart (Ref. p. 320, 413)Pay special attention to signs of dehydration such as:lethargy/unconsciousnesssunken eyesunable to drink or drinking poorlyskin pinch goes back slowly or very slowly (>2seconds)restlessness, irritabilitydrinks eagerly, thirsty
27Summary Sarah was rehydrated with oral rehydration solution. She was discharged on the same day when she was alert, able to drink and eat.Before discharge home Sarah was given zinc supplements.At the time of discharge her mother was given advice on how to give extra fluid, to continue feeding and when to return.She was also given a Mother’s card containing this information and two packets of oral rehydration solution.