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Steps in the IMCI Case Management Process:

1. Assess and Classify
2. Identify Treatment
3. Treat
4. Counsel the Mother
5. Follow-Up

A. Assess and Classify Sick Children 2 months up to 5 Years

1. Determine which age group the child belongs:

1 week up to 2 months
2 months up to 5 years
2. Record the child’s data : Name, Age in months, Weight in kg., temperature, etc.

3. Ask the mother what the child’s problems are.

4. Determine if this is an initial or follow – up visit:
Initial visit – 1st visit for this episode of an illness or problem
Follow-up visit- the child has been seen a few days ago for the same illness
- if the child’s condition improved, still the same or is getting better

4. Check for general danger signs:

a. not able to drink or breastfeed
• too weak to drink and is not able to suck or swallow when offered a drink or
• if not sure: ask mother to offer child a drink of clean water or breast milk
• A child may have difficulty sucking when his nose is blocked. If the nose is
blocked, clean it.
b. vomits everything
• a child is not able to hold anything down at all
• if in doubt, offer the child water
c. convulsions (during this illness)
• arms and legs stiffen because muscles are contracting
• the child may lose consciousness or not be able to respond to spoken directions or
handling, even if eyes are open
• “fits” or “spasms” or “jerky movements”
Note: Shiver is not convulsion. There is no loss of consciousness.
d. abnormally sleepy or difficult to awaken
• drowsy and does not show interest in what is happening around him
• stare blankly and appear no to notice what is going on around him
• does not respond when touched, shaken or spoken to
Note: 1. If the child is asleep and has cough or difficult breathing, count the number
of breaths first before you try to wake the child.
2. If there is any general danger sign, complete the assessment and any
pre-referral treatment immediately so referral is not delayed.

5. Assess and classify cough or difficult breathing

• 2 Common Causes of Pneumonia
1. Stretococcus pnemoniae
2. Hemophilus influenzae
• 2 Causes of Death
1. hypoxia – too little oxygen
2. sepsis – generalized infection

• Health workers can identify almost all causes of pneumonia by checking for 2
clinical signs: 1. fast breathing – body’s response to stiff lungs and hypoxia
2. chest indrawing

Assess cough or difficult breathing:

Does the child have cough or difficult breathing? “fast” or “noisy” or “interrupted”?
* If the answer is NO, look back to see if you think the child has cough or difficult breathing.
• how long?
chronic cough – more than 30 days
- may be sign of tuberculosis, asthma, whooping cough or another
• fast breathing
a. count the breaths in one minute
1. child must be quiet and calm
2. no feeding, crying or angry
∗ Ask the mother to lift the child’s shirt. If you are not sure about the number of
breaths you counted, repeat the count.

b. cut-off for fast breathing:

if the child is: fast breathing is:
2 months up to 12 months 50 breaths/ minute or more
12 months up to 5 years 40 breaths/ minute or more

∗Determine if the child is breathing IN or breathing OUT

• chest indrawing – the lower chest wall goes IN when the child breaths IN
NORMAL: the whole chest wall and abdomen move OUT when the child breaths
Best position : lying down
Conditions : clearly visible
Note: intercostals indrawing or intercostals retractions and subcostal indrawing are
not chest indrawing.

• Look or listen for stridor.

Stridor – harsh noise made when the child breaths IN
- happens when there is swelling of the larynx, trachea, or epiglottis
∗Put your ear near the child’s mouth and look at the movement of the abdomen to
determine if child is breathing IN or OUT
wet noise - blocked nose
wheezing - harsh noise while breathing OUT; not stridor


6. Assess and classify diarrhea

diarrhea – loose or watery stool
- defined as 3 or more loose or watery stools in a 24 – hour period

• how long?
• blood in stool
• signs of dehydration

If YES, asses for:

• dehydration
• persistent diarrhea – 14 days or more
• Dysentery
Asses for dehydration:
• Abnormally sleepy or difficult to awaken
• Restless and irritable: (all the time)
• Sunken eyes: If not sure, ask the mother if the child’s eyes look unusual.
• Offer the child fluid :
Not able to drink - if he is not able to take fluid in his mouth and swallow it
Drinking poorly – if the child is weak and cannot drink without help.
Drinking eagerly, thirsty – reaches out for the cup or spoon when you offer water.
• Pinch the skin of the abdomen:
Goes back very slowly – longer than 2 seconds
Goes back slowly – the skin stays up for even a brief time after release.



7. Assess Fever:

A child has the main symptom fever if:

- the child has history of fever – no fever now but had fever within 72 hours or
- the child feels hot or
- the child has an axillary temperature of 37.5 C or above

Decide malaria risk:

- child lives in malarious area or

- has been in a malaria risk area in the past 4 weeks.

Look or feel for stiff neck:

- look to see if the child moves and bends his neck easily as he looks around or
- draw the child’s attention to his toes or
- gently support his back and bend the head forward toward hid chest.

Look for runny nose ( not history of runny nose)

Look for signs of Measles: generalized rash and any one of the following: cough,
runny nose, or red eyes. Measles rash: begins behind the ears and on the neck,
spreads to the face, and to the rest of the body; does not have vesicles or pustules;
does not itch.

If the child has measles now or within the last 3 months, assess for:
- mouth ulcers – painful open sore on the inside of the mouth and lips or tongue
- pus draining from the eye
- clouding of the cornea – hazy area in the cornea

Assess for Dengue Hemorrhagic Fever all children two months of age or older.-
Look and feel for signs of bleeding and shock:
- bleeding from the nose and gums
- skin petechiae – small hemorrhages in the skin; look like small dark red spots
or patches in the skin; not raised, not tender; if you stretch the skin they do not
lose their color.
- Cold and clammy extremities
- If with cold and clammy extremities, check for slow capillary refill ( longer
than 3 seconds
- Perform the tourniquet test if: there are no signs in the ASK or LOOK and
FEEL, the child is 6 months or older, and the fever is present for more than 3


8. Assess Ear Problem

Assess the child for :
- Ear pain
- Ear discharge ; Present less than 2 weeks – Acute ear infection
Present 2 weeks or more – Chronic Ear Infection
- Tender swelling behind the ear


9. Check for malnutrition and anemia:

Look for visible severe wasting – a child with visible severe wasting has marasmus, a form of
severe malnutrition.. A child has this sign if he is thin, has no fat, and looks like skin and bones.

Look for palmar pallor – a sign of anemia

Some palmar pallor – the skin on the child’s palm is pale
Severe palmar pallor – the palm is very pale or so pale that it looks white
Look and feel for edema of both feet – the child may have kwashiorkor, a form of severe

Determine weight for age:

Very low weight for age – child’s weight is below the bottom curve of a weight for age chart.


10. Check the child’s immunization status.

11. Check the child’s Vitamin A status.

12. Assess other Problems.

B. Management of the Sick Young Infant Age 1 Week Up to 2 Months

1. Assess the sick young infant

Check the young infant for possible bacterial infection.

1. Ask if the child had convulsion at any time after birth.

2. Count the number of breaths in one minute. Fast breathing is 60 breaths per
minute or more.
3. Look for severe chest indrawing. Mild chest indrawing is normal in a young
infant or young child. Severe chest indrawing is very deep and easy to see.
4. Look for nasal flaring – widening of the nostrils when the young infant breaths in.
5. Look and listen for grunting – soft, short sounds when breathing out.
6. ‘Look and feel for bulging fontanelle. Fontanelle is the soft spot on the top of the
young infant’s head, where the bones of the head have not formed completely.
7. Look at the umbilicus – is it red or draining pus?
8. Measure temperature or feel for fever or low body temperature. Fever (axillary
temperature 37.5 C or more; rectal temperature 38 C or more). Hypothermia
( axillary temperature below 35.5 C; rectal temperature below 36 C).
9. Look for skin pustules – red spots or blisters which contain pus. A severe pustule
is large of has redness extending beyond the pustule.
10. LOOK: See if the child is abnormally sleepy or difficult to awaken.
11. LOOK at the young infant’s movement. Are they less that normal?


Assess Diarrhea

- For how long?

- Is there blood in the stool?
- Look at the young infant’s general condition. Is it “Abnormally sleepy or
difficult to awaken” or “Restless and irritable”?
- Look for sunken eyes.
- Pinch the skin of the abdomen. Does it go back very slowly? Or slowly?


Check for feeding problem or low weight.

Assess Breastfeeding.

4 Signs of Good Positioning;

- with infant’s head and body straight
- facing her breast, with infant’s nose opposite her nipples
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and shoulders
4 Sign of Good Attachment:
- Chin touching breast
- Mouth wide open
- Lower lip turned outward
- More areola visible above than below the mouth.

Suckling effectively – the infant suckles with slow, deep sucks and sometimes pauses.
You may see or hear the infant swallowing.

Not suckling effectively – he is taking only rapid, shallow sucks. You may see
indrawing of the cheeks. You do not see or hear swallowing.

Not suckling at all – not able to suck breastmilk into his mouth and swallow.

Look for ulcers or white patches in the mouth (thrush). Thrush looks like milk cuds
on the inside of the cheek, or thick white coating of the tongue. Try to wipe it off.
Milk curds will be removed but thrush will remain.

Check the Young Infant’s Immunization Status

Assess Other Problems