Counting breaths and classifying cough: an IMCI skills session

Key messages to land

1. Check the general danger signs in every sick child first.
2. The child must be calm; count for a full minute.
3. Fast breathing: 50 or more at 2 to 12 months; 40 or more at 12 months to 5 years.
4. Chest indrawing or fast breathing without a danger sign is pneumonia: oral amoxicillin at home and review in 3 days.
5. A danger sign or stridor in a calm child: first dose of antibiotic and urgent referral.
6. No antibiotic for cough or cold.

Running the breath-counting station

• Counts vary most when the child is crying or feeding, or when people count for 30 seconds and double. Insist on a full minute.
• If two counts on the same child fall either side of the cut-off, count again.
• Without videos, one participant breathes at a set rate from a card while lying down and the others count; then switch to a doll and point out where indrawing would be seen.

Common misunderstandings

"Crackles mean pneumonia"

IMCI classifies on breathing rate, chest indrawing and danger signs, not on the stethoscope.

"Chest indrawing always needs referral"

Under the 2014 IMCI chart, chest indrawing without danger signs is treated with oral amoxicillin at home, except in HIV-exposed or infected children, who are referred.

"Give antibiotics for every cough"

Cough or cold without fast breathing or chest indrawing needs a safe remedy for the throat and follow-up in 5 days if not improving.

"Count for 15 seconds and multiply"

Short counts are inaccurate. Count for one full minute.

Adapting the session

For community health workers, follow your national community case management policy: they treat fast breathing with amoxicillin and usually refer chest indrawing. If you have pulse oximeters, add 10 minutes to practise using them (refer if saturation is below 90%).

Case 1: Case 1: Baby N, 5 months

Baby N has had cough for 2 days. He is breastfeeding well and has no danger signs. Calm, his breathing rate is 56 per minute. There is no chest indrawing, stridor or wheeze. Weight 6.5 kg. His mother tested HIV-negative this year.

1. Classify and treat.
   Answer: Pneumonia: fast breathing (56 is 50 or more for 2 to 12 months). Oral amoxicillin dispersible 250 mg, 1 tablet twice daily for 5 days (or 3 days for fast breathing alone if your national chart allows it in a low-HIV setting). First dose in clinic.
2. What advice and follow-up?
   Answer: Keep breastfeeding; give every dose; return immediately if he cannot breastfeed, becomes sicker or develops a fever; follow up in 3 days.

Case 2: Case 2: Girl O, 3 years

O has had cough and difficult breathing for 3 days. She is drinking. Calm, her breathing rate is 36 per minute, but the lower chest wall goes in each time she breathes in. No stridor, no wheeze. Her HIV status is unknown; her mother has never been tested.

1. How do you classify her?
   Answer: Pneumonia, on chest indrawing (her breathing rate is not fast for her age).
2. Does her HIV status matter?
   Answer: Yes. Chest indrawing in a child who is HIV-exposed or infected needs a first dose of amoxicillin and referral. Offer HIV testing to the mother and child; if the child is not exposed, treat with oral amoxicillin (3 years: 3 dispersible 250 mg tablets twice daily for 5 days) and review in 3 days.

Case 3: Case 3: Boy P, 14 months

P has had cough for a day and is very sleepy; his mother cannot wake him properly to feed. Breathing rate 52 per minute with chest indrawing.

1. Classify and act.
   Answer: Lethargic is a general danger sign: severe pneumonia or very severe disease. Give the first dose of the antibiotic your chart specifies, prevent low blood sugar, keep him warm and refer urgently. Do not delay for a full assessment.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. What must you check first in every sick child?
   1. Temperature
   2. General danger signs
   3. Weight
   4. Immunisation card
2. For how long should you count breaths?
   1. 15 seconds
   2. 30 seconds
   3. One full minute
   4. Two minutes
3. Fast breathing in a child aged 2 months up to 12 months is:
   1. 40 or more per minute
   2. 50 or more per minute
   3. 60 or more per minute
   4. 30 or more per minute
4. Fast breathing in a child aged 12 months up to 5 years is:
   1. 30 or more
   2. 40 or more
   3. 50 or more
   4. 60 or more
5. What is chest indrawing?
   1. Soft tissue between the ribs going in
   2. The lower chest wall going in when the child breathes in
   3. The belly moving out
   4. Flaring of the nose
6. Stridor in a calm child is classified as:
   1. Cough or cold
   2. Pneumonia
   3. Severe pneumonia or very severe disease
   4. Wheeze
7. Dispersible amoxicillin 250 mg for a child aged 12 months up to 3 years with pneumonia:
   1. 1 tablet twice daily
   2. 2 tablets twice daily
   3. 3 tablets twice daily
   4. 1 tablet once daily
8. When is a child with pneumonia seen again?
   1. After 3 days
   2. After 5 days
   3. After 7 days
   4. Only if worse
9. A child has wheeze with fast breathing. What do you do before classifying?
   1. Give amoxicillin
   2. Refer at once
   3. Try a rapid-acting inhaled bronchodilator up to three times, then reassess
   4. Nothing different
10. A child has had cough for 3 weeks. What does IMCI advise?
    1. Another course of amoxicillin
    2. Refer for possible TB or asthma assessment
    3. Cough syrup
    4. No action

Answer key

1. B. General danger signs come first; any one needs urgent action.
2. C. Count for a full minute in a calm child.
3. B. 50 or more at 2 to 12 months; 40 or more at 12 months to 5 years.
4. B. 40 breaths per minute or more.
5. B. Lower chest wall indrawing: the lower chest goes in on breathing in.
6. C. Stridor in a calm child, or any danger sign, is the severe (pink) classification: first dose of antibiotic and urgent referral.
7. B. 2 tablets twice daily (10 to under 14 kg), usually for 5 days.
8. A. Follow up pneumonia in 3 days.
9. C. Up to three trials 15 to 20 minutes apart, then count again, look for chest indrawing and classify.
10. B. Cough for more than 14 days or recurrent wheeze: refer for TB or asthma assessment.