2.1. Relationship to the IMCI approach and stages of hospital care

The Pocket book is symptom-based in its approach, the symptoms following the sequence in the IMCI guidelines: cough, diarrhoea, fever. The diagnoses also closely match the IMCI classifications, except that the expertise and investigative capacity in a hospital setting allow classifications such as ‘very severe disease’ or ‘very severe febrile disease’ to be defined more precisely, making possible such diagnoses as severe pneumonia, severe malaria, septicaemia and meningitis.

Classifications for conditions such as pneumonia and dehydration follow the same principles as in the IMCI. Young infants (≤ 2 months) are considered separately (see Chapter 3), as in the IMCI approach. Severely malnourished children are also considered separately (see Chapter 7), because they require special attention and treatment if their high mortality risk is to be reduced.

In hospital, the stages of management for any child are:

• emergency triage
• emergency treatment (if required)
• taking a history
• examination
• laboratory investigations (if required)
• making a diagnosis or a differential diagnosis
• treatment
• supportive care
• monitoring
• planning discharge
• follow-up

This chapter summarizes taking a history, examining the child, laboratory investigations and making a differential diagnosis.

2.2. Taking history

Taking a history generally starts with understanding the presenting complaint: “Why did you bring the child?” It progresses to the history of the present illness. The symptom-specific chapters give some guidance on questions that should be asked about symptoms, which help in a differential diagnosis of the illness. These include personal, vaccination, family, social and environmental histories. They might lead to important counselling messages, such as sleeping under a bednet for a child with malaria, breastfeeding or sanitary practices for a child with diarrhoea, or reducing exposure to indoor air pollution for a child with pneumonia.

In younger infants, the history of pregnancy and birth is important. The feeding history of infants and younger children is essential, as this is often when malnutrition begins. For older children, information on development milestones is important. Whereas the history is obtained from a parent or caretaker for younger children, older children can contribute important information. You must establish a rapport with the child and the parent before starting the examination. In general, children between the ages of 8 months and 5 years require the most flexible approach.

2.3. Approach to the sick child and clinical examination

All children must be examined fully, so that no important sign is missed. In contrast to the systematic approach for adults, however, examination of a child should be organized in a way that does not upset the child. The approach to examining children should be flexible. Ideally, you will perform the most ‘invasive’ part of the examination (e.g. the head and neck examination) last.

• Do not upset the child unnecessarily.
• Leave the child in the arms of the mother or carer.
• Observe as many signs as possible before touching the child:

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  Does the child speak, cry or make any sound?

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  Is the child alert, interested and looking about?

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  Does the child appear drowsy?

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  Is the child irritable?

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  Is the child vomiting?

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  Is the child able to suck or breastfeed?

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  Is the child cyanosed or pale?

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  Does the child show signs of respiratory distress?

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  Does the child use auxiliary muscles of breathing?

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  Is there lower chest wall indrawing?

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  Does the child appear to breathe fast?

• Count the respiratory rate.

These and other signs should be recorded before the child is disturbed. You might ask the mother or caretaker to cautiously reveal part of the chest to look for lower chest wall indrawing or to count the respiratory rate. If the child is distressed or crying, he or she might have to be left for a brief time with its mother in order to settle, or the mother could be ask to breastfeed, before key signs such as respiratory rate can be measured.

Then proceed to signs that require touching the child but are minimally disturbing, such as feeling the pulse or listening to the chest. You obtain little useful information if you listen to the chest of a crying child. Signs that involve interfering with the child, such as recording the temperature, testing for skin turgor, capillary refill time, blood pressure or looking at the child's throat or ears should be done last. Measure the oxygen saturation with a pulse oximeter in all children who have fast breathing or chest indrawing.

• Perform bedside tests if available and appropriate
  Some test may easily be performed at the point of care, sometimes called point of care tests:

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  glucostix for an urgent blood sugar

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  rapid diagnostic test for malaria or

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  any other simple bedside tests.

2.4. Laboratory investigations

Laboratory investigations are targeted on the basis of the history and examination and help narrow the differential diagnosis. The following basic laboratory investigations should be available in all small hospitals that provide paediatric care in developing countries:

• Hb or packed cell volume
• full blood count
• blood smear for malaria parasites
• blood glucose
• microscopy of CSF
• urinalysis (including microscopy)
• blood grouping and cross-matching
• HIV testing

In the care of sick newborns (< 1 week), blood bilirubin is also an essential investigation.

Other common investigations are valuable:

• pulse oximetry,
• chest X-ray,
• stool microscopy
• blood cultures.

Indications for these tests are outlined in the appropriate sections of this Pocket book. Other investigations, such as pulse oximetry, chest X-ray, blood cultures and stool microscopy, are valuable in making a diagnosis.

2.5. Differential diagnoses

After the assessment has been completed, consider the various conditions that could cause the child's illness and make a list of possible differential diagnoses. This helps to ensure that wrong assumptions are not made, a wrong diagnosis is not chosen, and rare problems are not missed. Remember that a sick child might have more than one clinical problem requiring treatment.

Section 1.5, Tables 1–4) present the differential diagnoses for emergency conditions encountered during triage. Further tables of symptom-specific differential diagnoses for common problems are given at the beginning of each chapter, with details of the symptoms, examination findings and results of laboratory investigations that can be used to determine the main diagnosis and any secondary diagnoses.

After the main diagnosis and any secondary diagnoses or problems have been determined, treatment should be planned and started. Once again, if there is more than one diagnosis or problem, treatment might have to be given together. The list of differential diagnoses should be reviewed after observing the response to treatment or in the light of new clinical findings. The diagnosis might be revised at this stage or additional diagnoses included in the considerations.