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Referral and warning signs
When to refer
URGENT REFERRAL TO HOSPITAL if ANY general danger sign is present.
Red flags
- Any of the 5 general danger signs is a red flag requiring immediate action and referral.
Signs and symptoms
- Check for General Danger Signs (Ask/Look):
- - Unable to drink or breastfeed?
- - Vomits everything?
- - Has had convulsions during this illness?
- - Is the child lethargic or unconscious?
- - Is the child convulsing now?
Risk factors
- Underlying severe illness (e.g., severe pneumonia, meningitis, severe malaria, severe dehydration, sepsis, severe malnutrition).
Diagnosis
Clinical assessment
Systematic assessment by asking the caregiver about the first three signs and observing the child for the last two signs.
Investigations
- Assessment is primarily clinical.
- Blood glucose check (if available and child lethargic/unconscious/convulsing).
Diagnostic criteria
Presence of ANY ONE of the five general danger signs.
Management
Non-pharmacological management
- Immediate Actions if ANY danger sign is present:
- - Quickly complete the rest of the IMCI assessment (check main symptoms like cough, diarrhoea, fever).
- - Give pre-referral treatments immediately.
- - Treat to prevent low blood sugar: Encourage breastfeed if able OR give expressed breast milk / sugar water (1 tsp sugar in 50ml water) by cup or NGT.
- - Keep the child warm.
- - Refer URGENTLY to Hospital.
Pharmacological treatment
- Pre-referral Treatments (based on other assessments):
- - If convulsing now: Give Rectal Diazepam 0.5 mg/kg.
- - If signs of severe febrile disease/malaria: Give pre-referral Rectal Artesunate (10mg/kg) or IM/IV Artesunate (if available).
- - If signs of severe pneumonia/very severe disease: Give first dose IM antibiotic (e.g., Ampicillin 50mg/kg + Gentamicin 7.5mg/kg OR Benzylpenicillin 50,000 IU/kg).
Monitoring
Monitor vital signs and level of consciousness pending referral.
Complications
- Death if underlying condition not treated promptly.
- Complications of underlying severe illness (e.g., brain damage from meningitis/hypoglycaemia, respiratory failure).
Prevention
- Immunization.
- Malaria prevention (bed nets).
- Good nutrition.
- Prompt care seeking for childhood illnesses.
Patient education
- Teach caregivers to recognize ALL general danger signs.
- Emphasize the need to seek care IMMEDIATELY if any danger sign occurs.
- Explain any pre-referral treatments given.
Uganda-specific notes
IMCI strategy is standard practice. Recognition of danger signs at community (VHT) and primary facility level is critical for timely referral. Pre-referral treatments (Rectal Artesunate, Rectal Diazepam, IM antibiotics) are vital.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.3.21 (Check for General Danger Signs)
- IMCI Chart Booklet, MOH Uganda
(Standard IMCI algorithm)