Almost six million children under the age of five died in 2015, the majority in low-income countries due to treatable infectious diseases including pneumonia, diarrhoea and malaria. National and global health initiatives have mainly focused on improving access to basic care, including UNICEF’s/WHO’s Integrated Management of Childhood Illness (IMCI) and, later, the integrated Community Case Management (iCCM) programmes aimed at community healthcare worker programmes in rural areas. These programmes prioritise sensitivity in identifying suspected infections to initiate early provision of antimalarial drugs, antibiotics, oral rehydration solution and zinc. However, identification of severe illness for referral to supportive treatments (e.g. oxygen, fluids and glucose) and the provision of emergency care at lower level facilities has been identified as a weakness in health systems in low-income settings.

Under iCCM and IMCI, children with signs of severe illness are referred. Data on the proportion of children who are eligible for referral in Malawi is limited, however estimates for pneumonia suggest 29% of children presenting to health centres should be referred. Attending referrals is commonly difficult and caregivers can delay due to transportation and/or financial barriers. As a consequence, children may arrive at hospital at a very late stage of illness, with half of all paediatric hospitals deaths occurring within 24 hours of admission. Understanding the decision making process around referrals, from both the caregiver and healthcare provider perspective is important to improve guidelines around emergency treatment at frontline settings.

Emergency Triage Assessment and Treatment (ETAT) is a WHO recommended approach to rapidly assess and direct children to the most appropriate care in a hospital setting. It is based on assessing airways and breathing, circulation, consciousness or convulsions and dehydration (ABC3D). ETAT and IMCI have several similarities between these emergency signs and general paediatric danger signs.

A key area of overlap is around hypoglycaemia, with IMCI guidelines stating that suspected hypoglycaemia should be treated with sublingual sugar at frontline facilities. Sublingual dextrose gel in the treatment of neonatal hypoglycaemia has been shown to be beneficial, but this too costly for most LMIC settings. Instead, the currently recommended treatment of potential hypoglycaemia is sublingual sugar, i.e. sugar mixed with water that is administered under the tongue of the child. This has shown to rapidly increase the blood sugar levels though the evidence is limited and restricted to small studies.  Hypoglycaemia is not uncommon in paediatric infections, and the risk is increased by duration of fasting anorexia, a common presentation in young children with infections. Studies from sub-Saharan Africa have reported that 1.8 – 7.3% of children admitted to hospitals are hypoglycaemic , and a study from Tanzania found that these children had a case fatality rate of 41.9% . Therefore, earlier recognition and treatment of dysglycaemia could improve paediatric hospital presentation; however, there is limited data on hypoglycaemia prevalence at frontline settings, and how current IMCI recommendations for treatment are being implemented.

Routine screening for hypoxemia also provides an opportunity for improved case management, as hypoxemia is strongly associated with paediatric pneumonia mortality. IMCI currently includes hypoxemia (oxygen saturation of <90%) as a referral criterion, although availability of oximeters outside of hospital settings is not common in low-income settings.  Additionally, an oxygen saturation of <93% may be a more appropriate referral threshold, with associations with mortality and treatment failure. However, more evidence on how hypoxemia could develop during the referral pathway is important to inform these guidelines. Including ETAT’s more comprehensive assessment criteria of ABC3D to triage emergency cases poses a potential opportunity to enhance the recognition of acute medical emergencies at frontline facilities, including the immediate treatment of emergency signs prior to referral.  Evidence is needed around current practice and the feasibility of screening and treating ETAT emergency signs, including presumptive glucose treatment. A key question is whether with limited resources, these should be invested in optimising quick referrals to hospital for treatment or supporting frontline facilities to provide immediate treatment with the aim of stabilising children prior to referrals.


The overarching aim of this study is to determine whether implementing ETAT at frontline facilities in a rural sub-Saharan African setting, with a focus on the assessment and presumptive treatment of hypoglycaemia would not only be a feasible, but a desirable intervention to improve paediatric mortality outcomes.


This aim will be met through four objectives:

  1. To establish the capacity of frontline healthcare facilities in Malawi to deliver ETAT
  2. To determine current knowledge and implementation of IMCI and ETAT by healthcare workers at frontline facilities in Malawi
  3. To investigate the associations between emergency and danger signs, referral decision making at frontline facilities, referral attendance and outcomes across the different levels of the health system in Malawi
  4. To estimate the prevalence of dysglycemia, hypoxemia and emergency signs amongst children presenting with an acute medical condition to health centres in Malawi