1. At the start of a sick child (2 months to 5 years) consultation
Ask the mother what the child’s problems are.
Determine if this is an initial or follow-up visit for this problem.

2. IMCI Case Management Classification Focused Assessment Need to Refer
Danger signs
Main Symptoms
Nutritional status
Immunization status
Other problems
Specific treatment
Home
management
Counsel & Follow-up
Treatment
Counsel caretakers
Follow-up
Identify treatment
Treat

3. Check for general danger signs
Ask:
Not able to drink or breastfeed,
Vomits everything,
Convulsions, or
Look:
Abnormally sleepy or difficult
to awaken
Need to Refer
(except in severe dehydration)

4. Ask about the main symptoms
Cough or difficulty in breathing
Diarrhea
Fever
Ear problem

5. Cough or difficulty in breathing
Ask:
For how long?
Look:
Count RR
Chest indrawing
Stridor
The child must be calm.

6. Any general danger sign or
Chest indrawing or
Stridor
SEVERE PNEUMONIA OR
VERY SEVERE DISEASE
1st dose of antibiotic
Vitamin A
Breastfeeding/sugar water
URGENT REFERRAL

8. Fast breathing
2 – 12 months old: ≥ 50/minute
1 year or older: ≥ 40/minute
PNEUMONIA
Antibiotic for 5 days
Relieve cough with safe remedy
Advise mother on danger signs
Follow up in 2 days

9. or a very severe disease NO PNEUMONIA: COUGH OR COLD
No signs of pneumonia
or a very severe disease
NO PNEUMONIA: COUGH OR COLD
If cough ≥ 30 days
 refer to hospital for assessment
Relieve cough with safe remedy
Advise mother on danger signs
Follow up in 5 days if no improvement

10. Diarrhea: Classify
For dehydration
Persistent diarrhea
Blood in the stool

11. Classify for dehydration
2 or more of the following:
Abnormally sleepy/difficult to wake
Sunken eyes
Not able to feed/drinking poorly
Skin pinch goes back very slowly
SEVERE DEHYDRATION
Plan C

13. Plan C: To treat dehydration quickly
IV fluid: LRS 100 ml/kg body weight
(in 6 hrs for infants; 3 hrs for children) NO
IV treatment within 30 minutes NO
Oresol/NGT

14. Plan C: To treat dehydration quickly
Oresol/NGT NO
Oresol p.o. NO
URGENT REFERRAL

15. Classify for dehydration
2 of the following:
Restless, irritable
Sunken eyes
Drinks eagerly, very thirsty
Skin pinch goes back slowly
SOME DEHYDRATION
Plan B

16. Plan B: Treat some dehydration with ORS
Determine the amount (in ml) of Oresol
to be given in 4 hours
= weight of the child (in kg) X 75, or
if weight is unknown, use this chart.
Age
< 4 mos
4-12 mos
Amount

17. Plan B: Treat some dehydration with ORS
Determine the amount (in ml) of Oresol
to be given in 4 hours
= weight of the child (in kg) X 75, or
if weight is unknown, use this chart.
Age
12 mos-2 yrs
2-5 yrs
Amount

18. Plan B: Treat some dehydration with ORS
Show the mother how to give Oresol to
the child: frequent sips from a cup
If the child vomits, wait for 10 minutes.
Then continue, but more slowly.
Continue breastfeeding if the child
wants to breastfeed.
If the child develops puffy eyelids, stop
ORS.

19. Plan B: Treat some dehydration with ORS
After 4 hours:
Reassess the child & classify for
dehydration.
Select appropriate plan.
Begin feeding the child in the health
center.

20. Classify for dehydration
Not enough signs to classify as
SEVERE DEHYDRATION or
SOME DEHYDRATION
NO DEHYDRATION
Plan A

21. Plan A: Treat diarrhea at home
Give extra fluid.
Up to 2 yrs
50 – 100 ml after each LBM
2 -4 yrs
100 – 200 ml after each LBM
Continue feeding.
Know when to return.

22. Persistent diarrhea: 14 days or more
+ Dehydration=severe persistent diarrhea
Treat dehydration
Give Vitamin A
Refer to hospital

23. Persistent diarrhea: 14 days or more
No dehydration=persistent diarrhea
Advise regarding feeding
Give Vitamin A
Follow up in 5 days

24. Blood in the stool = dysentery
Oral antibiotic for shigella for 5 days
Follow up in 2 days

25. Fever: (history/temperature 37.5°C or above)
Malaria risk?
Measles now or w/in last 3 mos
Dengue risk?

26. Fever: Ask about malaria risk
Residing in endemic area?
OR:
Travel & overnight
stay in endemic area, or
Blood transfusion
w/in past 6 mos

27. Malaria risk +
Blood smear
Ask: Duration of fever?
Present everyday?
Look: Stiff neck
Runny nose
Other signs of measles

28. Malaria risk + any general danger sign or stiff neck
Very severe febrile disease/malaria
Quinine (under med. supervision)
1st dose of antibiotic, Paracetamol
Urgent referral

29. Malaria risk +, blood smear + No runny nose, no measles
Oral antimalarial
Paracetamol
Follow up in 2 days
> 7 days fever  hospital for assessment

30. No malaria risk Any general danger sign or stiff neck
Very severe febrile disease
1st dose of antibiotic, Paracetamol
Urgent referral

31. Severe complicated measles
Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers
Severe complicated measles
1st dose of antibiotic, Vitamin A
Urgent referral

32. Measles now or w/in last 3 mos Pus draining from the eye or Mouth ulcers
Measles with eye or
Mouth complications
Vitamin A
Tetracycline eye ointment
Gentian violet
Follow up in 2 days

33. Measles now or w/in last 3 mos No other signs
Vitamin A

34. If there is Dengue risk Bleeding gums, nose, in vomitus or stools
Black vomitus or stools
Persistent abdominal pain
Persistent vomiting
Skin petechiae
Slow capillary refill
No signs, but fever > 3 days  Tourniquet test

35. Slow capillary refill Indicates poor skin perfusion
Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.

36. Any of the danger signs or + tourniquet test
Severe Dengue hemorrhagic fever
If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS
Any other signs of bleeding  Plan C
Urgent referral
Do not give aspirin

37. Ear problem: tender swelling behind ear
Mastoiditis
1st dose of antibiotic
Paracetamol for pain
Urgent referral

39. Ear discharge < 14 days or Ear pain
Acute ear infection
Antibiotic for 5 days
Paracetamol for pain
Wicking
Follow up in 5 days

40. Ear discharge for 14 days or more
Chronic ear infection
Wicking
Follow up in 5 days

42. Visible severe wasting or Edema on both feet or Severe palmar pallor
Severe malnutrition or severe anemia
Vitamin A
Urgent referral

43. Some palmar pallor or Very low weight for age
Anemia or very low weight for age
Assess for feeding problem
Pallor: iron & Mebendazole in children > 2 yrs
Wt for age very low: Vitamin A