General danger signs in the sick child: assess, classify by colour and refer

What it is

In AIEPI, the first step with every sick child aged 2 months to 5 years is to look for the general danger signs, before anything else. They act like the red triage of any service: whatever the cause, a child with one of them has a very severe illness and needs urgent referral. The young infant under 2 months has its own, longer list of signs of very severe disease. The nurse checks these signs in the first minutes of the contact, records them on the AIEPI form and starts the pre-referral care the chart sets out.

Reference values

• Child 2 months to 5 years, any one of: not able to drink or breastfeed; vomits everything; convulsions; lethargic or unconscious. Classification: very severe disease.
• Young infant under 2 months, any one of: moves only when stimulated or is lethargic, cannot breastfeed, vomits everything, convulsions, central cyanosis, pallor or early or marked jaundice.
• Also in the young infant: severe chest indrawing, respiratory rate 60 or more or below 30 per minute, heart rate above 180 or below 100 per minute, capillary refill over 2 seconds.
• Also in the young infant: axillary temperature below 35.5 °C or above 38 °C, bulging fontanelle, apnoea, nasal flaring, grunting, stridor or wheeze, and fewer than 4 urinations in 24 hours.

What you need

• The AIEPI recording form and the chart of procedures.
• A watch or timer to count breathing for a full minute, and a thermometer.
• A cup of clean water or the breast, to watch the child drink.

How to measure it (and why)

1. Greet the carer and ask what problem brings the child; mark if it is a first or follow-up visit — the danger-sign check comes before the main symptoms.
2. Ask: can the child drink or breastfeed? — a child too weak to drink or suck has a very severe illness.
3. If in doubt, offer water or the breast and watch — what you see is more reliable than the answer.
4. Ask: does the child vomit everything? — if nothing stays down, oral fluids and medicines cannot work.
5. Ask about convulsions during this illness — a recent convulsion signals a severe illness of the nervous system or a severe infection.
6. Look: is the child lethargic or unconscious? Speak, clap or ask the mother to move the child — a sleepy child who does not respond normally is lethargic.
7. Circle every sign found on the form and classify — one sign is enough for the red row.
8. If a sign is present, finish the assessment quickly and start the pre-referral care the chart sets out — referral must not wait for a full work-up.

How to read it

• No danger sign: continue with the main symptoms (cough, diarrhoea, fever, ear, throat) and the rest of the assessment.
• Any danger sign: the child's classification is very severe disease, whatever the other classifications are.
• In the young infant, 'looks unwell' or 'moves only when stimulated' is itself a danger sign: trust the clinical impression.
• A child who improves in the clinic still needs the referral the chart indicates; danger signs can come back.

Next step: when to call for help

• Any general danger sign: tell the nurse in charge and the doctor at once and arrange urgent referral, per institutional protocol.
• Keep the child warm, continue breastfeeding if the child can suck, and give the pre-referral care the chart sets out, as ordered.
• Convulsing now, cyanosis or apnoea: call for immediate help and support the airway and breathing.
• Explain to the family why the child must go now and write the referral note with the signs found and the care given.

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Elsewhere in DurgiPedia

• Vital signs in children: how they change with age

Connections

← All of nursing

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Cuadro de procedimientos AIEPI (Atención Integrada a las Enfermedades Prevalentes de la Infancia) (Ministerio de Salud y Protección Social de Colombia, 2016); AIEPI: Guía del facilitador clínico (Ministerio de Salud y Protección Social de Colombia / Organización Panamericana de la Salud, 2012); Manual clínico para el aprendizaje de AIEPI en enfermería: cuaderno de trabajo (Organización Panamericana de la Salud, 2009).

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