Every year children get sick from common and treatable infections, including: pneumonia, diarrhoea and malaria. Malawi has introduced guidelines at village clinics, health centres and hospitals to try and improve the diagnosis and treatment of these common illnesses (IMCI – health centres and iCCM – village clinics). These guidelines focus on identifying all children that might be sick and providing them with essential treatments like antimalarial drugs, antibiotics, oral rehydration solution and zinc. However, they are not as good at distinguishing between children who are very sick from those that are not as sick.

Children who are very sick should be referred to hospital for admission, where they will be given different treatments, like IV antibiotics and oxygen. In Malawi, almost one in three children who come to the health centre with a common infection might need to be referred to the hospital – however, information on this is poor. Attending referrals is also difficult for many families because of challenges with transport and costs. This means that by the time children get to the hospital they can be too sick to help. To try and improve the way children are diagnosed and referred, we need to understand how decisions are made for referrals by caregivers and healthcare providers, and how a child’s symptoms change during this time.

Two symptoms that are easy to measure and are useful for classifying if a child is very sick are: low blood sugar (hypoglycemia) and low blood oxygen (hypoxemia). Both of these can be common in children with infections, and children with these have a higher risk of dying. Earlier testing and treatment of these symptoms could reduce deaths in children in Malawi – but there is not enough data on how many children at health centres have low blood oxygen or glucose.


This study has two aims:

  1. To investigate the association between having emergency and danger signs in children at health centers, and referral decision making by healthcare providers and caregivers and outcomes
  2. To estimate the prevalence of low blood glucose and oxygen and danger signs among children presenting with an acute medical condition to health centres in Malawi


These aims 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