Table 2.
Clinical scenarios illustrating alignment and differences between IMCI24 and PACK Child guides arranged according to six key features of child healthcare
| 1 | IDENTIFICATION AND MANAGEMENT OF THE SICK CHILD | ||
| Example: 2-year-old child presents with signs and symptoms of severe pneumonia—worsening cough and difficulty breathing for 4 days. Now with lower chest indrawing. | |||
| Management steps | IMCI | PACK Child | Comments |
| Check for danger signs | Yes | Yes | This clinical scenario aims to demonstrate that PACK Child management steps align well with IMCI management steps. |
| Assess cough | Yes | Yes | |
| Oxygen therapy | Yes | Yes | |
| Management of wheeze offered | Yes | Yes | |
| Management of stridor offered | Yes | Yes | |
| Pre-referral ceftriaxone | Yes | Yes | |
| Co-trimoxazole therapy | Yes | Yes | |
| Hypoglycaemia management | Yes | Yes | |
| Urgent referral | Yes | Yes | |
| 2 | INTEGRATION OF CURATIVE AND PREVENTIVE CARE | ||
| Example: 18-month-old child presents with 2-day history of diarrhoea. No danger signs. No blood or mucus. No dehydration. No feeding problem. | |||
| Management steps | IMCI | PACK Child | Comments |
| Check for danger signs | Yes | Yes | This clinical scenario aims to demonstrate that PACK Child aims to streamline the use of the guide in response to presenting symptom: Number of pages consulted in IMCI guide to manage this case=23 pages. Number of pages consulted in PACK Child to manage this case=8 pages |
| Assess level of dehydration | Yes | Yes | |
| Give fluid according to level of dehydration | Yes | Yes | |
| Advise when to return immediately | Yes | Yes | |
| Zinc therapy | Yes | Yes | |
| Follow-up of diarrhoea | Yes | Yes | |
| Assess and interpret growth (then check all children for malnutrition) | Yes | Yes | |
| Assess feeding | Yes | Yes | |
| Developmental screen | Yes | Yes | |
| Basic examination | Yes | Yes | |
| Check HIV risk | Yes | Yes | |
| Check TB risk | Yes | Yes | |
| Check immunisation status | Yes | Yes | |
| Symptom screen | Yes | Yes | |
| Assess caregiver health | Yes | Yes | |
| Advice for caregiver at home | Yes | Yes | |
| Vitamin A and deworming, if needed | Yes | Yes | |
| Follow-up for routine child visit | Yes | Yes | |
| Psychosocial risk (like parenting, neglect/abuse and grants) | No | Yes | |
| Mental health (behaviour) | No | Yes | |
| 3 | GUIDANCE FOR THE WELL-CHILD VISIT | ||
| Example: 12-month-old well child is brought for immunisations. | |||
| Management steps | IMCI | PACK Child | Comments |
| Symptom screen | IMCI is designed for use during a sick-child consultation and, while it may integrate preventive care during a curative consultation, it has no formal entry point for the well child between the ages of 2 months and 5 years. IMCI does provide an entry point for the infant <2 months old for a well-baby visit; however, this is limited to a symptom screen, advice for home care and feeding counselling. |
Yes | |
| Feeding screen | Yes | ||
| Assess and interpret growth | Yes | ||
| Developmental screen | Yes | ||
| Assess HIV risk | Yes | ||
| Assess TB risk | Yes | ||
| Assess caregiver health | Yes | ||
| Psychosocial risk | Yes | ||
| Mental health (behaviour) | Yes | ||
| Basic examination | Yes | ||
| Health promotion messages | Yes | ||
| Immunisation, if needed | Yes | ||
| Vitamin A and deworming, if needed | Yes | ||
| Follow-up for routine care | Yes | ||
| 4 | STREAMLINED MANAGEMENT OF MULTIPLE PRESENTING SYMPTOMS | ||
| Example: 3-year-old boy presents with 3-week history of loss of weight and a cough. No danger signs. No respiratory distress. No wheeze. Not growing well. HIV negative. TST positive. | |||
| Management steps | IMCI | PACK Child | Comments |
| Check for danger signs | Yes | Yes | Regardless of multiple possible entry points, in this case, loss of weight, not growing well or cough, PACK guides the clinician to the same management steps. |
| Assess cough | Yes | Yes | |
| Assess for TB | Yes | Yes | |
| Identify TB contact | Yes | Yes | |
| TB investigations (tuberculin skin test, gastric washing, sputum test, chest X-ray, if available) | Yes | Yes | |
| Relieve cough (warm water/weak tea) | Yes | Not included | |
| Advise when to return immediately | Yes | Yes | |
| Ask about diarrhoea | Yes | Symptom screen included on routine care | |
| Ask about fever | Yes | ||
| Ask about ear problem | Yes | ||
| Ask about sore throat | Yes | ||
| Assess and interpret growth (check for malnutrition) | Yes | Yes | |
| Feeding assessment and counselling | Yes | Not included, unless feeding problem | |
| Assess HIV risk | Yes | Yes | |
| Deworming and vitamin A, if needed | Yes | Yes | |
| Arrange follow-up | Yes | Yes | |
| Notify and register in TB register | Yes | Yes | |
| Give TB treatment (dosing tables) | Yes | Yes | |
| Routine follow-up TB | Yes | Yes | |
| Check immunisation status | Yes | Yes | |
| Assess any other problems | Yes | Yes | |
| Check caregiver’s health | Yes | Yes | |
| Step-by-step guidance on how to perform a tuberculin skin test (TST) | No | Yes | |
| Screen for other contacts | No | Yes | |
| Advise about importance of treatment adherence | No | Yes | |
| Advise about TB treatment side effects | No | Yes | |
| Guidance on TB and HIV co-infection (like ART dosage adjustments) | No | Yes | |
| 5 | LONG-TERM HEALTH CONDITIONS—IDENTIFICATION AND MANAGEMENT | ||
| Example: 4-year-old boy known with epilepsy has had 3 fits in the last month, lasting 5 minutes each. Not fitting now. No associated illness or fever reported. | |||
| Management steps | IMCI | PACK Child | Comments |
| Prompted to integrate routine care into every visit | No | Routine care itemised in scenario 3 | |
| Check adherence | No | Yes | |
| Check side effects | No | Yes | |
| Check other medication interactions | No | Yes | |
| Review fit diary: assess triggers | No | Yes | |
| Ask about mental health (behaviour) | No | Yes | |
| Ask about school problems | No | Yes | |
| Check development | No | Yes | |
| Advise the caregiver | No | Includes health education and support | |
| Doctor review of medication: | No | Yes | |
| Medication table provided | |||
| When to refer to a specialist | No | Yes | |
| When to follow up routinely | No | Yes | |
| When to consider reducing treatment | No | Yes | |
| 6 | TASK SHIFTING | ||
| Example: 3-year-old girl has a 3-day history of wheeze. This is the 4th presentation for wheeze in 3 months. No danger signs. No respiratory distress. Nocturnal cough. Not on asthma treatment. Growing well. | |||
| Management steps | IMCI | PACK Child | Comments |
| Check for danger signs | Yes | Yes | This clinical scenario demonstrates how PACK Child might empower a nurse to perform additional tasks where she previously referred to a doctor. In this case, task-shifting may include instituting a trial of asthma treatment, screening for triggers and other allergy symptoms, providing advice and education, and demonstrating inhaler techniques. |
| Assess cough | Yes | Yes | |
| Salbutamol via spacer for 5 days | Yes | Yes | |
| Refer non-urgently for assessment | Yes | Prompted later for confirmation of diagnosis | |
| Ask about diarrhoea | Yes | Symptom screen included in routine care | |
| Ask about fever | Yes | ||
| Ask about ear problem | Yes | ||
| Assess and interpret growth (then check all children for malnutrition) | Yes | Yes | |
| Check for anaemia | Yes | Yes | |
| Assess HIV risk | Yes | Yes | |
| Assess TB risk | Yes | Yes | |
| Then check immunisation status | Yes | Yes | |
| Assess any other problem | Yes | Yes | |
| Check the caregiver’s health | Yes | Yes | |
| Vitamin A and deworming, if needed | Yes | Yes | |
| Addresses smoking in house | No | Yes | |
| Excludes TB | No | Yes | |
| Assesses recurrent respiratory symptoms (asthma diagnosis algorithm) | No | Yes | |
| Trial of treatment given: | No | Yes | |
| Corticosteroid inhaler for 2 months | |||
| Step-by-step guidance on inhaler (with spacer) technique | No | Yes | |
| Refer non-urgently for assessment if trial of treatment not effective | No | Yes | |
| Prompts a likely asthma diagnosis if trial effective (non-urgent doctor confirmation within 1 month) | No | Yes | |
| Asthma routine care started | No | Yes | |
| Assesses symptom control | No | Yes | |
| Allergy screen | No | Yes | |
| Adherence screen (inhaler technique assessment) | No | Yes | |
| Advice covers passive smoking, treatment education, recognition of acute exacerbations, trigger avoidance | No | Yes | |
| Annual influenza vaccination | No | Yes | |
| Step-up and step-down corticosteroid inhalers according to symptom control | No | Yes | |
| Prednisone course for acute exacerbations | No | Yes | |
| When to return immediately | No | Yes | |
| When to follow up for routine asthma visit | No | Yes | |
ART, antiretroviral therapy; IMCI, Integrated Management of Childhood Illness; PACK, Practical Approach to Care Kit; TB, tuberculosis.