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Integrated Management of newborn and Childhood Illness Module: 4. Assess and Classify Coughs or Difficult Breathing

Study Session 4  Assess and Classify Coughs or Difficult Breathing

Introduction

Pneumonia and other causes of acute respiratory infection are also described in Study Session 34 of the Communicable Diseases Module.

Coughs or difficult breathing are common problems in children under five years of age in Ethiopia. In some children the cause of cough could be pneumonia. Pneumonia is a serious disease that may cause death. However, these deaths can be prevented by early identification and treatment, so it is important that you know the signs to look for and what action you should take when you think a child brought to your health post has pneumonia.

In this study session you will learn how to assess and classify a sick child with a cough or difficult breathing. You will also learn how to treat and give follow-up care.

Learning Outcomes for Study Session 4

When you have studied this session, you should be able to:

4.1  Define and use correctly all of the key words printed in bold. (SAQs 4.1, 4.2 and 4.3)

4.2  Record information accurately about a child. (SAQ 4.1)

4.3  Identify when a child has fast breathing. (SAQs 4.2 and 4.3)

4.4  Identify a child with chest in-drawing. (SAQs 4.2 and 4.3)

4.5  Identify stridor in a calm child. (SAQs 4.1, 4.2 and 4.3)

4.6  Assess and classify coughs or difficult breathing. (SAQs 4.2 and 4.3)

4.7  Treat and give follow-up care for a child with cough or difficult breathing. (SAQs 4.2 and 4.3)

4.1  Assessing coughs or difficult breathing

In order to assess coughs or difficult breathing, you need to know about the structure of the airways. Figure 4.1 shows the terms for the main structures that you need to know. You may already be familiar with some or even all of the terms.

The respiratory tract.
Figure 4.1  The respiratory tract.

You can see in Figure 4.1 that the airway (or respiratory tract) structures include the nose, throat, larynx, trachea and bronchi (the main air tubes inside the lungs). Coughs or difficult breathing may occur when there is an infection of the respiratory tract. These infections may be severe respiratory tract infections such as pneumonia (acute) which require antibiotics for treatment, or they can be mild infections such as a cold, which can be treated by the family at home.

Health Extension Practitioners must be able to identify the few very sick children who have cough or difficult breathing, which need treatment with antibiotics. Fortunately, it is possible to identify almost all cases of pneumonia by checking for these two clinical signs: fast breathing and chest in-drawing. Stridor in a child (see the definition below) can also be a sign of pneumonia or another very severe disease.

For all sick children who come to your practice, ask the mother if the child has cough or difficult breathing.

You are now going to look at the steps involved in assessing and classifying children with cough or difficult breathing.

For all sick children whom you encounter in your practice, you should ask the mother or caregiver whether the child has cough or difficult breathing. You should then ask how long the child has had cough or difficult breathing.

Then you need to assess for the following:

Fast breathing:  breathing rate per minute higher than normal for the age group.

Chest in-drawing:  the lower chest wall (lower ribs) goes in when the child breathes in.

Stridor:  a harsh noise which is made when the child breathes in.

Stridor is pronounced ‘stry-dore’.

Box 4.1 below is taken from the IMNCI Assess and Classify chart booklet and summarises the steps you should take when assessing a child for a cough or difficult breathing.

Box 4.1  Assessing cough or difficult breathing

How to assess for cough or difficult breathing table.

You are now going to look at each of these steps in more detail.

ASSESS whether the child has cough or any difficult breathing

Difficult breathing is 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.’

If the mother says the child does not have cough or difficult breathing, you should still look at the child yourself to see whether you think the child has either of these symptoms. If the child does not have cough or difficult breathing, you do not need to assess the child further for signs related to either of these symptoms. You should go on to ask about the next main symptom, which is diarrhoea (you will read about how to assess and classify diarrhoea in Study Session 5).

If the mother answers ‘Yes’ to your question about whether the child has cough or difficult breathing, you should ask her the next question.

ASK: how long has the child had cough or difficult breathing?

A child who has had cough or difficult breathing for more than 21 days has a chronic cough. This may be a sign of tuberculosis, asthma, whooping cough or another respiratory problem.

COUNT the number of breaths the child takes in one minute

Count the breathing rate as you would in a young infant. The cut-off for fast breathing depends on the child's age. Young infants usually breathe faster than older infants and young children.

If the child is:The child has fast breathing if you count:
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years:40 breaths per minute or more

You should note that the child who is exactly 12 months old has fast breathing if you count 40 breaths per minute or more.

LOOK for chest in-drawing

You learned about chest in-drawing (also called subcostal redrawing or subcostal retraction) and how to examine a young infant for this sign, in Study Session 3 of this Module. In a child age two months up to five years, if chest in-drawing is clearly visible and present all the time during an examination, it is a sign of severe pneumonia or very severe disease (see Figure 4.2 which illustrates in-drawing). Unlike in the young infant, mild chest in-drawing is not normal in older infants and children.

A sick child with signs of chest-in drawing represented by two pictures. One of expiration and the other of inspiration.
Figure 4.2  Signs of chest in-drawing in a sick child

LISTEN for stridor

Stridor happens when there is a swelling of the larynx, trachea or epiglottis (see Figure 4.1 to remind yourself where these structures are). 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.

Listen for stridor when the child breathes in. Put your ear near the child's mouth because stridor can be difficult to hear. A child who is not very ill may have stridor only when crying or upset. Be sure to listen for stridor when the child is calm.

  • What three signs in a sick child indicate the possibility of pneumonia or another very severe disease?

  • If you identify any general danger sign, fast breathing, or chest in-drawing, and if you hear a harsh noise from the child when calm and breathing in (stridor), the child is likely to have severe pneumonia or another very severe disease.

4.2  Classifying coughs or difficulty in breathing

After assessing the child, your next step is to classify the cough or difficult breathing to determine the severity of the child’s illness. To classify a child you need the classification table, a section of which is reproduced below (Table 4.1). The treatment column is included – you will be looking at treatment in more detail in Section 4.3 of this study session.

Table 4.1  Classification table for coughs and difficult breathing.

4.2.1  How to use the classification table:

There are three possible classifications for a child with a cough or difficult breathing:

  • Severe pneumonia or very severe disease, or
  • Pneumonia, or
  • No pneumonia: cough or cold.
To classify a cough or difficult breathing:
  1. Look at the top row in the classification table which sets out the signs you need to assess. If the child has a general danger sign (you learned about general danger signs in Study Session 1 of this Module), chest in-drawing or stridor, you should select the severe classification given in the top (pink) row of the table: severe pneumonia or very severe disease.
  2. If the child does not have the severe classification, look at the middle (yellow) row. If the child has fast breathing, but does not have signs in the top row of the classification table, you should select the classification in the middle (yellow) row: pneumonia (see Box 4.2 below)

Whenever you use a classification table, you should start with the top (pink) row.

Box 4.2  Classification of pneumonia

3  If the child does not have any of the signs in the top (pink) or middle (yellow) row, select the classification in the bottom (green) row: no pneumonia: cough or cold. If the child has signs from more than one row, always select the more serious classification.

  • If a child has cough, a general danger sign and fast breathing, how would you classify the child?

  • You should classify the child with the more serious classification – severe pneumonia or very severe disease (see Box 4.3).

Box 4.3  Classification of severe pneumonia

Now you have looked at the different classifications of cough or difficult breathing you are going to learn about the treatment that should be provided to the sick child.

4.3  Treatment of cough or difficult breathing

The treatment of a child’s cough or difficult breathing will depend on your assessment and classification of their illness. This section looks at the different treatments depending on the level of classification.

4.3.1  Treatment for severe pneumonia or very severe disease

A child classified as having severe pneumonia or very severe disease is seriously ill. The child needs urgent referral to a hospital for treatments such as oxygen or injectable antibiotics.

Important!A child classified as having severe pneumonia or very severe disease needs urgent referral to a hospital.

If a child has been classified with severe pneumonia or a very severe disease you should give the child the first dose of Cotrimoxazole (see Table 4.2 in Section 4.3.2 below) before the child leaves your health post. The antibiotic helps prevent severe pneumonia from becoming worse.

Then refer the child urgently to the hospital.

Referring a child to the hospital

There are four steps you should follow when referring a child to the hospital:

A hospital.
  1. Explain to the mother the need for referral, and get her agreement to take the child. If you suspect that she does not want to take the child, find out why. Possible reasons are:
    • She thinks that hospitals are places where people often die, and she fears that her child will die there too.
    • She does not think that the hospital will help her child.
    • She cannot leave home and tend to her child during a hospital stay because:

    −  there is no one to take care of her other children, or

    −  she is needed for farming, or

    −  she may lose a job.

    • She does not have money to pay for transportation, hospital bills, medicines or food for herself during the hospital stay.
  2. Calm the mother’s fears and help her resolve any problem. For example:
    • If the mother fears that her child will die at the hospital, reassure her that the hospital has physicians, supplies and equipment that can help her child.
    • Explain what will happen at the hospital and how that will help her child.
    • If the mother needs help at home while she is at the hospital, ask questions and make suggestions about who could help. For example, ask whether her husband, sister or mother could help with the other children or with meals while she is away.
    • Discuss with the mother how she can travel to the hospital. Help arrange transportation if necessary.

    You may not be able to help the mother solve all her problems and/or be certain that she goes to the hospital. However, it is important to do everything you can to help. If referral is not possible, there are some things you can do for the child at your health post.

  3. Write a referral note for the mother to take with her to the hospital. Tell her to give it to the nurse or doctor. In your referral note you should include the following information:
    • the name and age of the child
    • the date and time of referral
    • a description of the child’s problems
    • the reason for referral (the symptoms and signs leading to the severe classification)
    • treatments that you have given
    • any other information that the nurse or doctor at the hospital needs to know in order to care for the child, such as earlier treatment of the illness or immunizations needed
    • your name and the name of your health post.
  4. Give the mother any supplies and instructions needed to care for her child on the way to the hospital.
    • If the hospital is far, give the mother additional doses of antibiotics and tell her when to give them to the child during the trip. If you think the mother will not actually go to the hospital, give her the full course of antibiotics, and teach her how to give them at home.
    • Show the mother how to keep the young child warm during the trip.
    • Advise the mother to continue breastfeeding.
    • If the child has some or severe dehydration and can drink, give the mother some oral rehydration solution (ORS) for the child to sip frequently on the way.
  • What reasons might a mother give you for not wanting to take her child to a hospital?

  • The mother may be anxious about whether her child will receive the right care or may believe that hospitals are places where children often die. Even if she wants to take her child, she may be worried about leaving her other children without care, or may be afraid of losing her job if she is away for too long or not having the money to pay for hospital bills.

  • What could you do as a Health Extension Practitioner to reassure a mother who is anxious about taking her child to hospital?

  • You could explain to the mother what treatment her child is going to receive at the hospital and that this is the best chance the child has of getting well again. You might be able to suggest people who can help with her other children while she is away, and you might also be able to arrange transportation for her and the child.

4.3.2  Treatment for pneumonia

If you have classified the child as having pneumonia you can treat the child without referring him or her to hospital. The child will need treating with antibiotics.

Table 4.2 below sets out the oral antibiotics from which you can select the appropriate antibiotic and the dose. The first-line antibiotic is the drug that you give first. If the child does not respond to the first antibiotic (cotrimoxazole) you gave, then you should replace the first antibiotic with another one; the latter one is called second-line antibiotic (for example, amoxicillin). Among the three types of cotrimoxazole formulation, choose the one that is available in your health post.

Table 4.2  Antibiotic dosage for pneumonia.

COTRIMOXAZOLE

(Trimethoprim + Sulphamethoxazole)

Give two times daily for five days

AMOXICILLIN

Give three times daily for five days

AGE or WEIGHTADULT TABLET

80 mg Trimethoprim

+ 400 mg Sulphamethoxazole

PAEDIATRIC TABLET

20mg Trimethoprim

+ 100 mg Sulphamethoxazole

SYRUP

40 mg Trimethoprim

+ 200 mg

Sulphamethoxazole per 5 ml

TABLET

250 mg

SYRUP

125 mg per 5 ml

2 months up to 12 months (4‒10 kg)½25 ml½5 ml
12 months up to 5 years (10‒19 kg)137.5 ml110 ml

4.3.3  Treatment for no pneumonia: cough or cold

A child with ‘no pneumonia: cough or cold’ does not need an antibiotic. You should give the mother advice about good home care. Teach her how to soothe the child’s throat and relieve the cough with a safe remedy such as breastmilk for exclusively breastfed infants, or home fluids such as tea with honey or fruit juice. Cough syrups are usually harmful so advise the mother that she should avoid using these. Advise her to watch for fast or difficult breathing and to return to the health post if either one of these develops in the child.

A child with a cold normally improves in one to two weeks. However, a child who has chronic cough (a cough lasting more than 21 days) may have tuberculosis, asthma, whooping cough or another problem. You should refer the child with a chronic cough to the hospital for further assessment.

4.4  Follow-up care for pneumonia

If a child has been classified with pneumonia, it is important that the mother is told to return to the health post in two days’ time for a follow-up visit. You should assess the child for cough or difficult breathing in the way outlined in Box 4.4.

Important!You should always refer a child to hospital if there are general danger signs or chest in-drawing.

Box 4.4  Follow-up care for pneumonia

The following case study will help you check your understanding of what you have read so far in this study session.

Case Study 4.1  Aziz’s case

Aziz is 18 months old. He weighs 11.5 kg. His temperature is 37.5°C. His mother brought him to the health post because he had cough. She says he was having trouble breathing. This is his initial visit for this illness.

The Health Extension Practitioner checked Aziz for general danger signs. Aziz was able to drink. He had not been vomiting. He had not had convulsions. He was not convulsing, lethargic or unconscious.

The Health Extension Practitioner asked the mother, ‘How long has Aziz had this cough?’ His mother said that Aziz had been coughing for six or seven days. Aziz sat quietly on his mother’s lap. The Health Extension Practitioner counted the number of breaths the child took in a minute and counted 41 breaths. She thought, ‘Since Aziz is over 12 months of age, the cut-off for determining fast breathing is 40. He has fast breathing’.

The Health Extension Practitioner did not see any chest in-drawing. She did not hear stridor.

The chart below shows you how the Health Extension Practitioner recorded Aziz's case information and signs of illness:

To classify Aziz’s illness, the Health Extension Practitioner looked at the classification table for coughs or difficulties in breathing.

First she checked to see if Aziz had any of the signs in the pink row. She considered, ‘Does Aziz have any general danger signs? No, he does not. Does Aziz have any of the other signs (chest in-drawing and stridor in a calm child) in this row? No, he does not. Therefore Aziz does not have any of the signs for severe pneumonia or very severe disease.’

Next, the Health Extension Practitioner looked at the yellow (middle) row. She thought, ‘Does Aziz have signs in the yellow (middle) row? He has fast breathing.’

The Health Extension Practitioner classified Aziz as having pneumonia and she wrote this down on the Recording Form (see below).

In this study session you have learned how to assess and classify cough or difficult breathing in children under five years. You looked at how to treat the sick child, when you need to refer a child urgently to hospital, what follow-up care is required, and what advice on home treatment you should give to the mother or child’s caregiver.

Summary of Study Session 4

In Study Session 4, you have learned that:

  1. In Ethiopia it is common for children under five years of age to develop cough.
  2. To assess cough or difficult breathing, the steps you should take are:
    • look for general danger signs
    • ask about duration of the cough or difficult breathing
    • count the breathing rate
    • look for chest in-drawing
    • listen for stridor.
  3. Your assessment will enable you to classify the child’s cough or difficult breathing and determine what treatment you should give, including referring the child urgently to hospital if they have severe pneumonia or very severe disease.
  4. When using a classification table you should always begin with the top (pink) row and if a child has signs in more than one row you should always select the more serious classification.
  5. There are four steps you should take when referring a child to the hospital: explain the need for referral, reassuring and supporting the mother, writing a referral note, and giving the mother supplies and instructions for the journey.

Self-Assessment Questions (SAQs) for Study Session 4

Now you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Read this case study and then answer the questions below.

Case Study 4.2 for SAQ 4.1

Getu is six months old. He weighs 5.5 kg. His temperature is 38°C. His mother says he has had a cough for two days. The Health Extension Practitioner checked for general danger signs. The mother says that Getu is able to breastfeed and that he has not vomited during this illness. He has not had convulsions. Getu is not convulsing, lethargic or unconscious during his visit to the health post.

The Health Extension Practitioner said to the mother, ‘I want to check Getu's cough. You said he has had a cough for two days now. I am going to count his breathing. He will need to remain calm while I do this’.

The Health Extension Practitioner counted 58 breaths per minute. She did not see chest in-drawing and did not hear stridor.

SAQ 4.1 (tests Learning Outcomes 4.1, 4.2 and 4.5)

Record this information on the recording form which is reproduced below.

Answer

The table below shows you the information you should have included on Getu’s record form. Check this against the one you completed for SAQ 4.1 to see if you have written down the same information and in the right boxes.

Read Case Study 4.3 and then answer the questions that follow.

Case Study 4.3 for SAQ 4.2

Askale is eight months old, and weighs 6 kg. Her temperature is 39°C. Her parents say she has had a cough for three days and is having trouble breathing. Her mother says she will not breastfeed or take other fluids. Askale has not had convulsions or vomiting, but she is lethargic, is taking 55 breaths per minute and there is a harsh noise when she breathes in.

SAQ 4.2 (tests Learning Outcomes 4.1, 4.3, 4.4, 4.5, 4.6 and 4.7)

  • a.How would you classify Askale’s illness? Give reasons for your answer and explain what treatment you would provide.
  • b.What might Askale’s parents be concerned about and how would you reassure them?
Answer
  • a.You should have classified Askale as having severe pneumonia or very severe disease. This is because she has had a cough for three days and her breathing can be assessed as ‘fast breathing’. She also has stridor and trouble breathing. You would need to refer Askale urgently to hospital, giving her a first dose of antibiotic (cotrimoxazole) before she leaves the health post.
  • b.You will recall that there are four steps for referral, including calming the mother’s anxieties, as she may fear that her child will die in hospital or be worried about who can help her at home while she is away. It would be important for you to give the mother advice about keeping the child warm on the way to hospital, and tell her that she should continue breastfeeding.

SAQ 4.3 (tests Learning Outcomes 4.1, 4.3, 4.4, 4.5, 4.6 and 4.7)

How should you treat a child whom you classify as having just a cough or a cold?

Answer

If you classify a child as just having cough or a cold, then all you need to do is to encourage the carer to give fluids to soothe the throat. The child should also return to the heath post for a follow-up in two days time.