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.

IMCI Case Management

Danger signsMain Symptoms

Nutritional statusImmunization status

Other problems

Need to Refer

Specific treatment

Homemanagement

ClassificationFocused

Assessment

Identify treatmentTreat

Counsel caretakersFollow-up

Treatment

Counsel & Follow-up

Check for general danger signs

Ask:• Not able to drink or

breastfeed,• Vomits everything, • Convulsions, orLook:• Abnormally sleepy or difficult

to awakenNeed to Refer

(except in severe dehydration)

Ask about the main symptoms

• Cough or difficulty in breathing

• Diarrhea• Fever• Ear problem

Cough or difficulty in breathing

Ask:• For how long?Look:• Count RR• Chest indrawing• Stridor

The child must be

calm.

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

1st dose of antibiotic Vitamin A Breastfeeding/sugar water URGENT REFERRAL

Any general danger sign or Chest indrawing or Stridor

PNEUMONIA

Antibiotic for 5 days Relieve cough with safe remedy Advise mother on danger signs Follow up in 2 days

Fast breathing2 – 12 months old: ≥ 50/minute1 year or older: ≥ 40/minute

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

No signs of pneumoniaor a very severe disease

Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

SEVERE 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

Classify for dehydration

Plan C

IV treatment within 30 minutes

IV fluid: LRS 100 ml/kg body weight(in 6 hrs for infants; 3 hrs for children)

Plan C: To treat dehydration quickly

NO

NO

Oresol/NGT

Oresol p.o.

Plan C: To treat dehydration quickly

NO

NO

Oresol/NGT

URGENT REFERRAL

SOME DEHYDRATION

2 of the following: Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly

Classify for dehydration

Plan B

Age < 4 mos 4-12 mosAmount 200-400 400-700

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.

Plan B: Treat some dehydration with ORS

Age 12 mos-2 yrs

2-5 yrs

Amount 700-900 900-1400

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.

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.

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.

Plan B: Treat some dehydration with ORS

NO DEHYDRATION

Not enough signs to classify as SEVERE DEHYDRATION orSOME DEHYDRATION

Classify for dehydration

Plan A

Give extra fluid.

Plan A: Treat diarrhea at home

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.

Persistent diarrhea: 14 days or more

• Treat dehydration• Give Vitamin A• Refer to hospital

+ Dehydration=severe persistent diarrhea

Persistent diarrhea: 14 days or more

• Advise regarding feeding

• Give Vitamin A• Follow up in 5 days

No dehydration=persistent diarrhea

Blood in the stool = dysentery

• Oral antibiotic for shigella for 5 days

• Follow up in 2 days

Fever: (history/temperature 37.5°C or above)

Malaria risk?

Measles now or w/in last 3 mos

Dengue risk?

Fever: Ask about malaria risk

• Residing in endemic area?OR:• Travel & overnight

stay in endemic area, or• Blood transfusion

w/in past 6 mos

Malaria risk +

• Blood smear• Ask: Duration of fever?

Present everyday?• Look: Stiff neck

Runny noseOther signs of

measles

Malaria risk + any general danger sign or stiff

neck

• Quinine (under med. supervision)

• 1st dose of antibiotic, Paracetamol

• Urgent referral

Very severe febrile disease/malaria

Malaria risk +, blood smear +No runny nose, no measles

• Oral antimalarial• Paracetamol• Follow up in 2 days• > 7 days fever hospital for

assessment

Malaria

No malaria riskAny general danger sign or stiff

neck

• 1st dose of antibiotic, Paracetamol

• Urgent referral

Very severe febrile disease

Measles now or w/in last 3 mosClouding of cornea or

Deep or extensive mouth ulcers

• 1st dose of antibiotic, Vitamin A• Urgent referral

Severe complicated measles

Measles now or w/in last 3 mosPus draining from the eye or

Mouth ulcers

• Vitamin A• Tetracycline eye

ointment• Gentian violet• Follow up in 2 days

Measles with eye orMouth complications

Measles now or w/in last 3 mosNo other signs

Vitamin A

Measles

If there is Dengue risk

Bleeding gums, nose, in vomitus or stools

Black vomitus or stoolsPersistent abdominal painPersistent vomitingSkin petechiaeSlow capillary refillNo signs, but fever > 3 days

Tourniquet test

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.

Any of the danger signsor + tourniquet test

• 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

Severe Dengue hemorrhagic fever

Ear problem:tender swelling behind ear

• 1st dose of antibiotic• Paracetamol for pain• Urgent referral

Mastoiditis

Ear discharge < 14 days orEar pain

• Antibiotic for 5 days• Paracetamol for pain• Wicking• Follow up in 5 days

Acute ear infection

Ear discharge for 14 days or more

• Wicking• Follow up in 5 days

Chronic ear infection

Visible severe wasting or Edema on both feet orSevere palmar pallor

• Vitamin A• Urgent referral

Severe malnutrition or severe anemia

Some palmar pallor orVery low weight for age

• Assess for feeding problem• Pallor: iron & Mebendazole in

children > 2 yrs• Wt for age very low: Vitamin

A

Anemia or very low weight for age