Chapter 7. 2 Initial assessment

Assess for general danger signs or emergency signs and take a history concerning:

  • recent intake of food and fluids
  • usual diet before the current illness
  • breastfeeding
  • duration and frequency of diarrhoea and vomiting
  • type of diarrhoea (watery/ bloody)
  • loss of appetite
  • family circumstances
  • cough > 2 weeks
  • contact with TB
  • recent contact with measles
  • known or suspected HIV infection/exposure.

On examination, look for:

  • shock: lethargic or unconscious; with cold hands, slow capillary refill (> 3 s), or weak (low volume),
  • rapid pulse and low blood pressure
  • signs of dehydration
  • severe palmar pallor
  • bilateral pitting oedema
  • eye signs of vitamin A deficiency:
    • dry conjunctiva or cornea, Bitot spots
    • corneal ulceration
    • keratomalacia
Children with vitamin A deficiency are likely to be photophobic and will keep their eyes closed. It is important to examine the eyes very gently to prevent corneal rupture. 
  • localizing signs of infection, including ear and throat infections, skin infection or pneumonia.
  • signs of HIV infection
  • fever (temperature >37.5 °C or >99.5°F) or hypothermia (rectal temperature <35.5 °C or <95.9°F)
  • mouth ulcers
  • skin changes of kwashiorkor:
    • hypo- or hyperpigmentation
    • desquamation
    • ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)
    •  exudative lesions (resembling severe burns) often with secondary infection (including Candida).
  • Conduct an appetite test:
  • Check if the child has appetite by providing ready-to-use therapeutic food.


Laboratory investigations should be conducted for Hb or EVF, especially if there is severe palmar pallor.