Integrated Management of Childhood Illness I MC I Students Handbook

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Integrated Management of Childhood Illness (IMCI) Student's Handbook
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Government of the People’s Republic of Bangladesh
IMCI
STUDENT’S HANDBOOK - 2019
IMCI STUDENT’S HANDBOOK

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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
(IMCI)
Government of the People’s Republic of Bangladesh

2019

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Advisory Board
Prof Mohammod Shahidullah, Chair-NTWC, President BPA & BMDC
Professor. Md. Abdul Mannan, Professor of Neonatology, BSMMU
Prof. Dr. Nazmun Nahar, Professor of Paediatrics, BIRDEM
Prof. Dr. Abid Hossain Mollah, Professor of Pediatrics, BIRDEM
Dr.Md. Shamsul Haque, Line Director, MNCAH, DGHS
Dr. Shams El Arifeen, Senior Director & Senior Scientist, Maternal and Child Health Division,
icddr,b
Technical Contribution
WHO
UNICEF
Save the Children
icddr,b
Dr Md. Emdadul Haque, Deputy Director, ME&HMD, DGHS
Dr. Md Abdul Wadud, DPM, Monitoring and Data Quality, NNHP & IMCI, DGHS
Dr. Sabina Ashrafee Lipi, DPM, Training and Child Injury, NNHP & IMCI, DGHS
Dr. Md. Jahurul Islam, DPM, Newborn Health, NNHP & IMCI, DGHS
Dr ANM Ehtesham Kabir, Focal Point, NNHP Cell, NNHP & IMCI, MNCAH, DGHS
Dr. Mahbuba Khan, NPO-Making Pregnancy Safer and Healthy Aging, WHO
Dr. Samina Sharmin, Health Specialist, UNICEF
Dr. Sabbir Ahmed, Advisor, Pneumonia Centinel Commitment (PCC) Project, Save the Children
Dr. Ziaul Ahsan, Project Manager, EHD Project, Ipas, Bangladesh
Dr. Jobayer Chisti, Senior Scientist, icddr,b
Dr. Ahmed Ehsanur Rahman, Associate scientist, icddr,b
Dr. Sabrina Jabeen, Research Investigator, icddr,b
Dr. Goutom Banik, Research Investigator, icddr,b
Dr. Md. Rezaul Hasan, Deputy Project Coordinator, icddr,b
Reviewed by
Dr. Md. Shariful Islam, Assistant Director and Program Manager, NNHP & IMCI, DGHS
Dr. Sabina Ashrafee Lipi, DPM, Training and Child Injury, NNHP & IMCI, DGHS
Dr. Md. Jahurul Islam, DPM, Newborn Health, NNHP & IMCI, DGHS
Dr ANM Ehtesham Kabir, Focal Point, NNHP Cell, NNHP & IMCI, MNCAH, DGHS
Dr. Ahmed Ehsanur Rahman, Associate scientist, MCHD, icddr,b

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Dr. Sabrina Jabeen, Research Investigator, MCHD, icddr,b
Dr. Anika Tasneem Chowdhury, Project Research Physician, MCHD, icddr,b
Supported by
Nazir Ahmed Talukder, Field Research Manager, MCHD, icddr,b
A.F.M.Azim Uddin, Field Research Officer, MCHD, icddr,b
Sultan Md. Ershadur Rahman, Field Research Officer, MCHD, icddr,b
Md. Hafizur Rahman, Field Research Assistant, MCHD, icddr,b
Financial Support by
USAID
NIHR Global Health Research Unit on Respiratory Health (RESPIRE) based at the University of
Edinburgh
Printed by
Director General of Health Service, Ministry of Health & Family Planning

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Integrated Management of Childhood Illness was prepared by the World Health
Organization (WHO) and UNICEF.
The Bangladesh adapted version is prepared by National Newborn Technical Working
Committee and IMCI, Directorate General of Health Services, Ministry of Health and
Family Welfare, Bangladesh with support from WHO-Bangladesh, UNICEF-Bangladesh,
Save the Children-Bangladesh, Bangladesh Paediatric Association and icddr,b.

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Contents
CHAPTER I .......................................................................................................................................11
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ....................................................11
INTRODUCTION .........................................................................................................................11
RATIONALE FOR AN EVIDENCE-BADED SYNDROMIC APPROACH TO CASE
MANAGEMENT ..........................................................................................................................15
COMPONENTS OF THE INTEGRATED APPROACH .............................................................17
THE PRINCIPLES OF INTEGRATED CARE ............................................................................17
THE IMCI CASE MANAGEMENT PROCESS ..........................................................................19
MATERIALS REQUIRED FOR IMCI TEACHING ...................................................................20
CHAPTER II .....................................................................................................................................23
OUTPATIENT MANAGEMENT OF CHILDREN .........................................................................23
AGE 2 MONTHS UP TO 5 YEARS .................................................................................................23
LEARNING OBJECTIVES ..........................................................................................................23
ASSESS & CLASSIFY SICK CHILDREN ..................................................................................24
CHEKING FOR GENERAL DANGER SIGNS .......................................................................26
COUGH OR DIFFICULT BREATHING .................................................................................30
DIARRHOEA ............................................................................................................................39
FEVER .......................................................................................................................................49
EAR PROBLEMS .....................................................................................................................61
CHECKING MALNUTRITION ...............................................................................................64
CHECKING ANAEMIA ...........................................................................................................77
CHECKING IMMUNIZATION STATUS ...................................................................................81
CHECKING THE CHILD’S VITAMIN-A AND DEWORMING STATUS AND
SUPPLEMENTTATION ...............................................................................................................83
ASSESSING THE CHILD’S FEEDING ......................................................................................87
ASSESSING OTHER PROBLEMS..............................................................................................88
IDENTIFY TREATMENT AND TREAT THE CHILD ..............................................................88
REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS ........................................88
IDENTIFY TREATMENT ........................................................................................................91
TREATMENT AT OUTPATIENT DEPARTMENT .............................................................104
TREATMENT OR LOCAL INFECTIONS (Annex-VII) .......................................................106
COUNSELLING A MOTHER OR CAREGIVER .....................................................................106

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CHAPTER III ..................................................................................................................................111
OUTPATIENT MANAGEMENT OF SICK YOUNG INFANTS 0 DAY UP TO 2 MONTHS ...111
ASSESS AND CLASSIFY THE SICK YOUNG INFANTS .....................................................111
ASSESSMENT OF SICK YOUNG INFANT 0 DAY UP TO 2 MONTHS ..........................114
CLASSIFICATION OF SICK YOUNG INFANT 0 DAY UP TO 2 MONTHS....................118
CHECKING IMMUNIZATION STATUS .............................................................................127
ASSESSING OTHER PROBLEMS........................................................................................128
IDENTIFY TREATMENT AND TREAT THE SICK YOUNG INFANT 0 DAY UP TO 2
MONTHS ....................................................................................................................................131
URGENT PRE-REFERAL TREATMENTS FOR SICK YOUNG INFANTS 0 DAY UP TO 2
MONTHS FOR VERY SEVERE DISEASES ........................................................................131
TREATMENT AT THE OUTPATIENT DEPARTMENT FOR SICK YOUNG INFANTS 0
DAY UP TO 2 MONTHS .......................................................................................................132
COUNSELLING A MOTHER OR CAREGIVER .................................................................132
IMCI REGISTERS ..........................................................................................................................134
IMCI register for child aged 2- 59 months ..................................................................................134
IMCI register for infants of 0-2 months ......................................................................................135
ANNEXURES .................................................................................................................................136
ANNEX-I.....................................................................................................................................137
ANNEX-II ...................................................................................................................................145
ANNEX-III ..................................................................................................................................151
ANNEX – IV ...............................................................................................................................153
ANNEX- V ..................................................................................................................................162
ANNEX -VI .................................................................................................................................167
ANNEX – VII ..............................................................................................................................170
ANNEX –VIII .............................................................................................................................176
ANNEX – IX ...............................................................................................................................177
ANNEX – X ................................................................................................................................182
ANNEX – XI ...............................................................................................................................183
ANNEX – XII ..............................................................................................................................186
ANNEX – XIII ............................................................................................................................188
ANNEX – XIV ............................................................................................................................192

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CHAPTER I
INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESS
INTRODUCTION
Although globally under-five (U5) mortality has decreased by almost a third since 1970s, this
reduction has not been evenly distributed throughout the world. However, Bangladesh has made
significant progress in decreasing childhood mortality – between 1993 and 2017. Under 5 mortality
decreased from 133 to 45 death per 1000 live births, infant mortality from 87 to 38 death per 1000
live births, neonatal mortality from 52 to 30 deaths per 1000 live births. It is also notable that deaths
in the neonatal period account for 67% of all under-five deaths. Under 5 children are dying due to
Acute respiratory infections (mostly pneumonia), Diarrhoea, Measles, Malaria or Malnutrition
– and often due to combination of these conditions.
Mortality reductions are associated with improved coverage of effective interventions to prevent or
treat the above-mentioned causes of child mortality. Increased coverage of vaccines, Vitamin A
supplementation, oral rehydration therapy (ORT) for diarrhea and antibiotics for pneumonia, have
been central to mortality reduction. As a consequence of successful implementation of these
interventions – Bangladesh has achieved the MDG4 target for under-5 mortality (48 per 1000 live-
births) well ahead of stipulated time i.e. the year 2015; however, the country is yet to achieve the
target of Newborn and Infant mortality.

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Note: The mortality rates are defined as follows:
Neonatal mortality : the probability of dying within the twenty-eight days of life; expressed
per 1000 live births.
Infant mortality : the probability of dying before the first birthday; expressed per 1000 live
births.
Under-five : the probability of dying between birth and the fifth birthday; expressed
mortality per 1000 live births.
Infant and childhood mortality are sensitive indicators of inequity and poverty. Millions of children
in the low-income countries are often caught in the vicious cycle of poverty and ill health – poverty
leads to ill health and ill health leads to poverty. Quality of care is another important indicator of
inequities in child health.
*Source: Bangladesh Demographic and Health Survey (BDHS) – 2017-18

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Major causes of death in
neonates and children under five
Global -2012
Acute resp infection

2%
Acute resp infection
14%
Prematurity
Neonatal death
16% 44%
Other
6%
Other NCDs
4%
Birth asphyxia / trauma

11%
Injuries
5%
Other neonatal conditions

(Group 10
3% Other conditions (Group 1)
6%
Congenital abnormalities
4%
Tetanus
1% Other
Malaria
1% 8%
Diarrhoeal Diseases Meningitis/ Encephalitis

10% Measles HIV/ AIDS
3%
2% Pertusis 2%
1%
45% of global under five deaths are associated

with nutrition related factors*
Sources:
(1) WHO. Global Health Observatory
(https://www.who.int/gho/child_health/index.html)
(2) *For undernutrition: Black et al. Lancet, 2013

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Causes of under five deaths:
Bangladesh
Column1
Unspecific or
undertermined
10%
Pneumonia
18%
Other causes
19%
Birth asphyxia
16%
Congenital
malformation
6%
Serious infection
Prematurity
9%
13%
Drowning
9%
Note: Other causes include neonatal tetanus, neonatal jaundice, birth injury, diarrhea, malnutrition,
and other.
Source:
Bangladesh Demographic and Health Survey – 2017-18

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Every day, millions of parents seek health care for their sick children, taking them to hospitals, health
centers, community clinics, pharmacists, doctors, and traditional healers. Surveys reveal that many
sick children are not properly assessed and treated by these health care providers, and that their
parents are poorly advised. At first-level health facilities in low-income countries, diagnostic
supports such as X-ray and laboratory services are minimal or non-existent, drugs and equipment are
often scarce. Limited supplies and equipment and lack of awareness of parents make it difficult for
the health care provider to practices complicated clinical procedure. Instead, they often rely on history
and signs and symptoms to determine the management
Providing quality care to sick children in these situations is a Improvements in child health
serious challenge. Experience and scientific evidence show are not necessarily dependent
that improvements in child health are not necessarily on the use of sophisticated and
depending on the use of sophisticated and expensive expensive technologies.
technologies, on the other hand effective strategies based on
holistic approach is sufficient to address the common illness of under five children.
RATIONALE FOR AN EVIDENCE-BADED SYNDROMIC

APPROACH TO CASE MANAGEMENT
Many well-known prevention and treatment A more integrated approach in

strategies undertaken separately have already managing sick children is needed to
proven effective for saving young lives. Childhood achieve better outcomes. Child health
programmes need to move beyond
vaccinations have successfully reduced deaths from addressing single disease to addressing
vaccine preventable diseases. Oral rehydration the overall health and well-being of the
therapy has contributed to a major reduction in child.
diarrhoeal deaths. Effective antibiotics have saved

millions of children with pneumonia. Prompt treatment of malaria has saved a lot of lives. Even
breastfeeding practices have reduced childhood deaths. These interventions were not integrated
initially. While each of these interventions has shown great success, accumulating evidence suggests
that a more integrated approach in management of sick children is needed to achieve better outcomes.
Child health programmes need to move beyond single disease to address the overall health and well-
being of the child. Because any children present with overlapping sign and symptoms of disease, a

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single diagnosis may not be feasible or appropriate. This is especially true for first-level health
facilities where examinations involve few instruments, little or no laboratory tests, and no X-ray.
To address the illness of under five children as a whole, the World Health Organization (WHO), in
collaboration with UNICEF and many other agencies, institutions and professional bodies developed
and introduced a strategy known as the Integrated Management of Childhood Illness (IMCI).
Although the major reason for developing the IMCI strategy stemmed from the needs of curative
care, the strategy also addresses aspects of nutrition, immunization and other important elements of
disease prevention and health promotion. Government of People’s Republic of Bangladesh adopted
IMCI in 1998 and implementation started in year 2000.
IMCI as a key strategy for Improving child health

Management of sick Nutrition Immunization Other disease Prevention
children Promotion of growth and
development
The objectives of the strategy are:

• To reduce under five mortality
• To reduce the frequency and severity of illness and disability
• To improve growth and development
The IMCI clinical guidelines target children are less than 5 years old, the age group that bears the
highest burden of deaths from common childhood diseases. This approach has been considered as
important way of achieving Millennium Development Goal (MDG-4).
It is an evidence-based, syndrome approach to case management that supports the rational, effective
and affordable use of drugs and diagnostic tools. The approach can be used to determine the:
• Health problem (s) the child may have
• Severity of the child’s condition
• Actions that can be taken to care for the child (e.g. refer the child immediately)
It may be mentioned that along with treatment the health status of the children can be improved by
proper counselling of the parents on:
- Appropriate feeding practices
- Bringing the sick child to the health centers as soon as symptoms arise, without any delay

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COMPONENTS OF THE INTEGRATED APPROACH
The IMCI strategy includes both preventive and curative interventions. The aim of the strategy is
to improve health care practices in health facilities, the health system (infrastructure and
health care delivery) and at home.
The strategy includes three main components:

• Improvements in the case-management skills of health care providers
• Improvements in the overall health system required for effective management of
childhood illness
• Improvements in family and community health care practices
THE PRINCIPLES OF INTEGRATED CARE
The IMCI guidelines are based on the following principles:

• All sick children must be examined for “General danger signs/signs for VERY SEVERE
DISEASE” which indicate the need for immediate referral or admission to a hospital
• All sick children must be routinely assessed for major symptoms
For children 2 months up to 5 yrs: Cough or difficult breathing, diarrhoea, fever and ear
problems; for young infants age 0 up to 2 months: very severe diseases, jaundice and
diarrhoea
• They must also be routinely assessed for nutritional and immunization status, feeding
problems and other problems
• Status of Vitamin A supplementation 6 months up to 5 years
• Deworming status for children age 6 months up to 5 years
• A combination of individual signs leads to a child’s classification(s) rather than a diagnosis.
Classification(s) indicate the severity of condition(s). They call for specific actions based on
whether the child
o Should be urgently referred to higher level of care
o Requires specific treatments (such as antibiotics or anti-malarial treatment), or
o May be safely managed at home

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The classifications are colour coded: “Pink” suggests hospital referral or admission, “Yellow”
indicates need for initiation of treatment, and “Green” calls for home treatment
• The IMCI guidelines address most, but not all of the major reasons for which a sick child is
brought to a clinic. A child coming with chronic problems or less common illnesses may
require special care. The guidelines do not describe the management of trauma or other acute
emergencies due to accidents or injuries
• IMCI management procedures use a limited number of essential drugs and encourage active
participation of caregivers in the treatment of children
• An essential component of the IMCI guidelines is the counselling of caregivers about home
care, including counselling about feeding, fluids and when to return to the health facility

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THE IMCI CASE MANAGEMENT PROCESS
As the disease burden, clinical signs and symptoms vary at different age groups. IMCI guidelines
recommend case management procedure based on 2 age categories:
• Age up to 2 months (0 day to 59 days)
• Age 2 months up to 5 years (2 months to 59 months)
The case management of a sick child brought to a first-level health facility includes a number of
important elements (See Chart 1 & 2)
On arrival, health care provider will do the following task:

At Outpatient Health Facility
• Assessment
• Classification and identification of treatment
• Referral, treatment of the child or counseling of the child’s caregiver (depending on the
classification(s) identified)
• Follow-up care
At Referral Health Facility
• As soon as they arrive in hospital, rapid screening of sick children for emergency signs should
be done according to Emergency Triage Assessment and Treatment (ETAT) See Annex-VIII
• After admission diagnosis should be done by clinical evaluation and proper investigations.
Then appropriate treatment and monitoring of patient’s progress
• Follow up care
At Home
• Teaching mothers or other caregiver how to give oral drugs and treat local infections
• Counseling mothers or other caregivers about
- Food
- Fluids
- When to return
- Her own health

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MATERIALS REQUIRED FOR IMCI TEACHING
• IMCI Students’ Handbook: This book will help students to improve their case management
skill. Part of the chart booklet that summarizes the steps in case management is being
incorporated into this book
• Wall charts: There are 5 wall charts. The first three charts are for management of the sick
child age 2 months up to 5 years and the two other charts for management of the sick young
infant age 0 day up to 2 months
• Video
• IMCI Register for children of 0 to 2 months and 2 to 59 months
• Patient

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Chart 1. IMCI Case Management in the Outpatient Health Facility, First-level Referral
Facility and at Home for the Sick child from Age 2 Months up to 5 Years
THE INTEGRATED MANAGEMENT PROCESS (2 MONTHS UP TO 5 YEARS)
OUTPATIENT HEALTH FACILITY
CHECK FOR GENERAL DANGER SIGNS

• Convulsion (S)
• Lethargy/Unconsciousness
• Inability to drink/Breastfeed
• Vomits everything
ASSESS MAIN SYMPTOMS

• Cough/Difficulty Breathing
• Diarrhoea
• Fever
• Ear Problems
• Malnutrition
• Anaemia
ASSESS IMMUNIZATION STATUS

and FEEDING PROBLEMS
VIT - A STATUS
DEWORMING
Check for OTHER PROBLEMS
CLASSIFY ILLNESS and

IDENTIFY TREATMENT
According to Colour-Coded
Management Charts
Urgent Referral Treatment at Outpatient Health Home Management

Facility

Pre-referral Treatments
• Treat Local Infection
Advise Parents Caregiver is counseled on how to:
• Give Oral Drugs
Refer Child/ young infants • Give oral drugs at home
• Advise and Teach
• Treat local infections at home
Parents/ Care taker
• Continue feeding
• Follow-up
• When to return immediately
• Follow-up
REFERRAL FACILITY
• Emergency Triage assessment and
Treatment (ETAT)
• Diagnosis
• Treatment
• Monitoring
• Follow-up

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Chart 2. IMCI Case Management in the Outpatient Health Facility, First-level Referral
Facility and at Home for the Sick Young Infant aged (0 DAY up to 2 Months)
THE INTEGRATED MANAGEMENT PROCESS (0 DAY UP TO 2 MONTHS)
CHECK FOR VERY SEVERE DISEASES

· Unconsciousness/drowsy
· Convulsion or H/O Convulsion
· Unable to feed
· Persistent Vomiting
· Bulging fontanels
· Apnoea
· Central Cyanosis
· Major Bleeding
· Weight < 1500 gm
· Major congenital malformation
· Surgical condition requiring hospitalization
· Severe chest indrawing
· Fever (37.5°C* or above) or low body temperature (less than 35.5°C*)
· Not feeding well
· Movement only when stimulated/ no movement at all
· Fast breathing (60 breaths per minute or more) for age 0-6 days
CHECK FOR JAUNDICE

ASSESS AND CLASSIFY
DIARRHOEA
CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS
CLASSIFY ILLNESS and IDENTIFY TREATMENT

According to colour coded management charts
Urgent Referral Treatment at Outpatient Health Home Management

Facility

Pre-referral Treatments Caregiver is counseled on how to:
• Treat Local Infection
Advise Parents • Give oral drugs at home
• Give Oral Drugs
Refer Child/ young infants • Treat local infections at
• Advise and Teach
Parents/ Care taker home
• Follow-up • Continue feeding

• When to return immediately
• Follow-up
REFERRAL FACILITY
• Emergency Triage
assessment and Treatment
(ETAT)
• Diagnosis
• Treatment
• Monitoring
• Follow-up

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CHAPTER II
OUTPATIENT MANAGEMENT OF CHILDREN
AGE 2 MONTHS UP TO 5 YEARS
LEARNING OBJECTIVES
This section of the hand book will describe and help the students to practice the following skills:
• Greeting of mother/caregiver
• Asking the mother/caregiver about the child’s problem
• Checking general danger signs
• Asking the mother/caregiver about the main symptoms:
- Cough or difficult breathing
- Diarrhoea
- Fever
- Ear problem
- Malnutrition
- Anaemia
• When a main symptom is present:
- Assessing the child further for sings related to the main symptom
- Classifying the illness according to the sings which are present or absent
• Checking the child’s immunization status, vitamin A, de-worming status and deciding if
the child needs any immunization today
• Assessing other problems
• Identify the treatment
• Treating the child
• Counseling mother and follow up

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ASSESS & CLASSIFY SICK CHILDREN
The assessment procedure for this age group includes the following steps:
• Greeting the mother/care giver
• Asking the mother/care giver about the child’s problem
• Checking for general danger signs
• Checking four main symptoms
• Checking nutritional status
• Checking immunization status; Vitamin-A, de-worming status
• Assessing the child’s feeding
• Assessing other problem

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Note: Immunization schedule may be changed according to latest national Expended program of
immunization (EPI) schedule of Bangladesh.
GREETING
Greet the mother/care giver appropriately and ask her to sit with her child.
ASKING
As the mother/care giver what the child’s problems are: Record what the mother tells you about the
child’s problems. An Important reason for asking this question is to open good communication with
the mother. Using good communication helps to assure the mother that her child will receive good
care.
CHEKING FOR GENERAL DANGER SIGNS

General danger signs indicate signs that may or may not be specific for particular illness however
they are serious conditions, For example, a child with general danger signs may have meningitis,
encephalitis, septicemia, Dengue shock syndrome, severe pneumonia, cerebral malaria or
another severe disease, Great care should be taken to ensure that these general danger signs are not
overlooked because they suggest that a child is severely ill and needs urgent attention.
The following danger signs should be routinely checked for all children.
LETHARGIC/ UNCONCISOUSNESS
GENERAL CONVULSING NOW /

VOMITS DANGER HISTORY OF
EVERYTHING CONVULSION
SIGNS
NOT ABLE TO DRINK

OF BREASTFEED

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The child is not able to drink or breastfeed. A child may be unable to drink either because s/he is
too weak or s/he cannot swallow. Do not rely completely on the mother’s statement for this, but
observe while she tries to breastfeed or to offer the child something to drink.
The child vomits everything. This means that the child vomits everything (food, drink, medicine)
whatever is offered. It is important to note because such a child will not be able to take medication
or fluids for re-hydration.
The child has had convulsion(s) during the present illness or convulsing now. Convulsions may
be associated with meningitis, cerebral malaria or other life-threatening conditions or even with
minor illness like fever. All children who have had convulsion(s) should be considered seriously ill
and needs urgent treatment with rapid acting anticonvulsant such as per rectal diazepam and referred
to hospital.
The child is lethargic or unconscious. An unconscious child does not respond to any stimuli (Sound
or gentle shaking of limbs). A lethargic child responds a little to stimuli, but does not take any notice
of his or her surroundings. These signs may be associated with many serious conditions.
If a child has one or more of these signs, s/he must be considered seriously ill and always need
referral.
In order to start treatment for severe illnesses without delay, the child should be quickly assessed for
the most important causes of serious illness—pneumonia, diarrhoea, and fever (especially associated
with malaria and measles). A rapid assessment of nutritional status is also essential, as malnutrition
could also contribute to death.
• Any general danger sign Pink:
VERY SEVERE DISEASE

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An example of assessment for general danger signs:
Example: Use the IMCI Register for 2 to 59 months for General Danger Signs
Case
Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 99.50 F. The physician asked. “What
are the child’s problems?” The mother said “Fatima has been coughing for 6 days, and she is having
difficult breathing.” This is the initial visit for this illness.
The physician checked Fatima for general danger signs. The mother said that “Fatima is able to drink.
She has not been vomiting. She did not have convulsions during this illness. The physician asked/
“Does Fatima seem unusually sleepy?” The mother said, “Yes”. The physician clapped his hands.
He asked the mother to shake the child. Fatima opened her eyes, but did not look around. The
physician talked to Fatima, but she did not watch his face. She stared blankly and appeared not to
notice what was going on around her.

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CHECKING THE MAIN SYMPTOMS
After checking for general danger signs, the health care provider must check for the main symptoms:
• Cough or difficult breathing

• Diarrhoea
• Fever
• Ear problems
• Malnutrition
• Anaemia
The first three symptoms are included because they often result in death. Ear problems are included
because they are considered one of the main causes of hearing loss and sometimes it may give rise
to CNS infections like meningitis and brain abscess. Malnutrition and anaemia may complicate the
other conditions.
COUGH OR DIFFICULT BREATHING

A child presenting with cough or difficult breathing for less than 14 days may suffer from pneumonia
or other serious respiratory infection.
CLINICAL ASSESSMENT
Four key clinical signs are used to assess a sick child with cough or difficult breathing:
• Respiratory rate, distinguishes children who have pneumonia from those who do not
• Chest indrawing indicates pneumonia
• Stridor indicates upper air-way obstruction
• Wheeze indicates lower air way obstruction
• Oxygen saturation (SpO2) <90% measured with a pulse oximeter
Fast breathing is the single most sensitive and specific among clinical signs of pneumonia in under-
five children. Even detection of crepitation on auscultation by an expert is less sensitive as a single
sign than fast breathing. Cut off value decrease with increasing age.
Child’s Age Cut-off Rate for Fast Breathing

2 months up to 11 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more

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Chest indrawing is defined as the inward movement of the lower chest wall with inspiration. It is
more specific than inter-costal indrawing, which involves the soft tissue between the ribs without
involvement of the bony structure of the chest wall. Chest indrawing should only be considered if it
is consistently present in a calm child. Severe chest indrawing is deep and easily visible.
Note: Crying, blocked nose or breastfeeding can cause temporary chest indrawing.
Stridor is a harsh sound heard during inspiration due to obstruction of upper air way. Stridor in a
clam child is an acute emergency.
Wheeze is a musical sound heard during expiration. Wheezing sound is most often associated with
asthma and bronchiolitis. Sometimes it is difficult of differentiate between children with bronchiolitis
and those with pneumonia.
Note: If wheezing is present with fast breathing or chest indrawing give a trial of rapid acting
nebulized bronchodilator for up to three times 20 minutes apart. Count the breaths and look for chest
indrawing again after the patient become calm and quit, and then classify. If child improves it is most
likely bronchiolitis or asthma. If does not improve, consider as pneumonia. The child who has
recurrent wheeze need further evaluation and follow up.
Oxygen saturation (SpO2) <90% indicates that the patient is hypoxic and the patient needs oxygen
administration and/or needs urgent referral to hospital which has the facility. Oxygen saturation is
measured with a pulse oximeter.
CLASSIFICATION OF COUGH OR DIFFICULT BREATHING

Based on a combination of the above clinical signs, children presenting with cough or difficult
breathing can be classified into three categories:
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Children who have either a general danger sign or stridor in calm condition or oxygen saturation
<90% should be classified as SEVERE PNEUMONIA OR VERY SEVERE DISEASE. Children in
this classification are most likely to have infections with invasive bacteria and life-threatening
disease.

31
• Any general danger signs Pink:
or
• Stridor in calm child SEVERE PNEUMONIA OR VERY
or SEVERE DISEASE
• Oxygen saturation (SpO2)
<90%
PNEUMONIA
Children who have fast breathing and chest indrawing, but do not have any danger sign should be
classified as PNEUMONIA.
• Chest indrawing Yellow:
or PNEUMONIA
• Fast breathing
COUGH OR COLD
Children who have cough or difficult breathing but no signs of SEVERE PNEUMONIA OR VERY
SEVERE DISEASE, or pneumonia, should be classified as COUGH OR COLD.
Green:
• No signs of pneumonia or very severe disease
COUGH OR COLD
Note: However, a child with chronic cough (more than 14 days) or recurrent wheezing needs to be
further assessed and referred to exclude tuberculosis, asthma, whooping cough or other problems.
Note: If pulse oximeter is available, determine the oxygen saturation and refer if <90 %

32
VIDEO EXERCISE
“Check for general danger signs” and “Does the child have cough or difficult breathing?”
Exercise A
1. For each of the children shown, answer the question
Is the child lethargic or unconscious?
YES NO
Child 1
Child 2
Child 3
Child 4
2. For each of the children shown in the video, answer the question
Does the child have fast
breathing?
Age Breaths per YES NO
minute
Mano 4 years 65
Wumbi 6 months 66
For each of the children Does the child have chest indrawing?
shown in the video, answer
the question
YES NO
Mary
Jenna
Ho
Anna
Lo

33
Does the child have stridor?
YES NO
Petty
Helen
Simbu
Hassan

34
VIDEO CASE STUDY

35
36
Example: Use the part of IMCI register with the main symptom cough or difficult breathing?
Case
Fatima is 18 months old. She weighs 11.5kg. Her temperature is 99.50F. After greeting, the physician
asked, “What are child’s problems?” The mother said “Fatima has been coughing for 6days, she is
having difficult breathing.” This is the initial visit for this illness.
The physician checked Fatima for general danger signs. The mother said that Fatima is able to drink,
she has not been vomiting. She did not have convulsions during this illness. The physician asked,
physician talked to Fatima, but she did not watch his face. She stared blankly and appeared not to
The physician asked the mother to lift Fatima’s shirt. He then counted the number of breaths the child
took in a minute. He counted 41 breaths per minute. The physician did not see any chest in drawing.
He did not hear strider or wheeze. He then measured Fatima’s oxygen saturation (SpO2) with a pulse
oximeter which indicated that her oxygen saturation was 95%.

37
38
DIARRHOEA
A child presenting with diarrhea should first be assessed for general danger signs and the child’s
caregiver should be asked if the child has cough or difficult breathing.
A child with diarrhea may have three conditions:
• Acute watery diarrhea (including)
• Dysentery (blood in stool)
• Persistent diarrhea (diarrhea that lasts 14 days or more)
All child with diarrhea should be assessed for:

- Signs of dehydration
- How long the child has had diarrhea
- Blood in the stool to determine if the child has dysentery
CLINICAL ASSESSMENT
A number of clinical signs are used to assess the degree of dehydration.
Child’s general condition

Depending on the degree of dehydration, a child with diarrhea may be lethargic or unconscious (this
is also a general danger signs) or look restless/irritable. Children who cannot be consoled and calmed
should be considered restless or irritable.
Sunken eyes. The eyes of a dehydrated child may look sunken. In a severely malnourished child who
is visibly wasted (that is, who has marasmus), the eyes may always look sunken, even if the child is
not dehydrated. The sign “sunken eyes” is less reliable in a visibly wasted child, it can still be used
to classify the child’s dehydration. If confused ask mother about recent development of sunken eyes.
Child’s reaction when offered to drink. A child is considered not able to drink if s/he is not able to
take fluid in his/her mouth and swallow it. For example, a child may not be able to drink because
s/he is lethargic or unconscious or is too weak to drink. On the other hand, a child is considered
thirsty/drinking eagerly, if the child wants to drink more. e.g. Observe if the child reaches out for the
cup or spoon when you offer him/her water. When the water is taken away, see if the child is crying.
If the child takes a drink only with encouragement and does not want to drink more perhaps, s/he is
not thirsty.

39
Elasticity of skin. Check Standard Procedures for Skin Pinch
elasticity of skin by skin pinch. • Locate the area on the child’s abdomen half way between
When released, the skin pinch the umbilicus and the side of the abdomen; then pinch the
goes back (a) very slowly skin using the thumb and the radial side of the index finger
(longer than 2 seconds), • The hand should be placed so that when the skin is pinched,
indicates one of the signs of the fold of skin will be in a line up and down the child’s
severe dehydration (b) slowly body and not across the child’s body
(less than 2 seconds) indicates
• It is important to firmly pick up all of the layers of skin and
one of the signs some
the tissue under them for one second and then release it
dehydration or (c) immediately
indicates that the child has no
dehydration.
In an overweight child, or a child

with oedema, the skin may go back immediately even if the child is dehydrated.
CLASSIFICATION OF DEHYDRATION
BASED ON A COMBINATION OF THE ABOVE CLINICAL SIGNS, CHILDREN
PRESENTING WITH DIARRHOEA ARE CLASSIFIED IN TO THREE CATEGORIES:
SEVERE DEHYDRATION
Children with SEVERE DEHYDRATION present with two or more of the following signs: lethargic
or unconscious, sunken eyes, not able to drink or drinking poorly and skin pinch goes back very
slowly. These children may have a fluid deficit equaling or greater than 10 percent of their body
weight.
Pink:
Two of the following signs:
• Lethargic or unconscious
• Sunken eyes
SEVERE DEHYDRATION
• Not able to drink or drinking poorly
• Skin pinch goes back very slowly
*Drinking poorly means able to suck but not able to swallow

40
SOME DEHYDRATION
Children with SOME DEHYDRATION present with two or more of the following signs: restless/
irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly. these Children may have
a fluid deficit equaling 5 to 10 percent of their body weight.
Two or more of the following signs: Yellow:
• Restless/ irritable,
• Sunken eyes, SOME DEHYDRATION
• Drinks eagerly/thirsty,
• Skin pinch goes back slowly
NO DEHYDRATION
Children not having enough signs to be classified as some or severe dehydration, will be classified
as NO DEHYDRATION. These children may have fluid deficit of <5 % of their body weight.
• Not enough signs to classify as more or severe Green:
dehydration
NO DEHYDRATION
Note: If one sign of severe dehydration and one sign of some dehydration are present, it will be
considered as some dehydration.
CLASSIFICATION OF PERSISTENT DIARRHOEA
Persistent diarrhoea is an episode of diarrhoea with or without blood, which begins acutely and lasts
at least 14 days or more.
Persistent diarrhoea almost never occurs in infants who are exclusively breast-fed
Many children with persistent diarrhoea are malnourished and they are at increased risk of death.
Children with persistent diarrhea should be classified based on the presence or absence of any
dehydration:

41
SEVERE PERSISTENT DIARRHOEA
Children with persistent diarrhea who have any degree of dehydration should be classified as
SEVERE PERSISTENT DIARRHOEA and should be managed in the hospital as they require special
treatment.
Pink:
• Dehydration present (Some or Severe)
PERSISTENT DIARRHEA
Children with persistent diarrhea who have no signs of dehydration should be classified as
PERSISTENT DIARRHEA.
Yellow:
• No dehydration
PRESISTENT DIARRHOEA
CLASSIFICATION OF DYSENTERY
DYSENTERY
About 10% of all diarrheal episodes in under-five children are due to dysentery and this causes up to
15% of all diarrheal deaths.
The mother or caregiver of a child with diarrhea should be asked if there is blood in the stool. A child
is classified as having DYSENTERY if the mother or caregiver reports blood in the child’s stool.
Green:
• Blood in the stool
DYSENTERY
Dysentery is especially severe in infants and in children who:

- Are malnourished
- Develop clinically evident dehydration during their illness and
- Are not breast-fed

42
It also has a more harmful effect on nutritional status than acute watery diarrhea. Dysentery occurs
with increased frequency and severity in children who have measles or have had measles in the
preceding 3 months.

43
VIDEO EXERCISE AND CASE STUDY
Does the child have diarrhoea?
Exercise B
1. For each of the children shown, answer the question:
Does the child have sunken eyes?
YES NO
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
2. For each of the children shown, answer the question:

Does the skin pinch go back:
Very slowly? Slowly? Immediately?
Child 1
Child 2
Child 3
Child 4
Child 5

44
VIDEO CASE STUDY

45
46
Example: Part of the IMCI register with the main symptom diarrhea.
Case
Fatima is 18 months old. She weighs 11.5kg. Her temperature is 99.50F. The physician asked, “What
are the Childs problems?” The mother said, “Fatima has been coughing for 6 days, and she is having
trouble breathing.” This is the initial visit for this illness.
The physician checked Fatima for general danger sings. The mother said that Fatima is able to drink.
She has not been vomiting. She did not have convulsions during this illness. The physician asked,
physician talked to Fatima, but she did not watch his face. She stared blanked and appeared not to
took in a minute. He counted 41 breaths per minute. The physician did not see any chest in-drawing.
The physician asked, “Does the child have diarrhea?” The mother said, “Yes for 3 days.” There was
no blood in the stool. Fatima’s eyes looked sunken. The physician asked, “Do you notice anything
deferent about Fatima’s eyes” The mother said, “Yes.” He gave the mother some clean water in the
cup and asked her to offer it to Fatima. When offered, Fatima would not drink. When pinched, the
skin of Fatima’s abdomen went back very slowly.

47
48
FEVER
All sick children should be checked for fever. Fever is a very common condition and is often the
main reason for bringing children to the health center. It may be caused by minor infection, but may
also be the most obvious sign of a life-threatening illness, particularly malaria, especially severe
malaria (P. falciparum), or other severe infections, including meningitis, typhoid fever or measles.
When diagnostic facility is limited, it is important first to identify those children who need urgent
referral with appropriate pre-referral treatment (antimalaria or antibacterial). To determine malaria
Rapid Diagnostic Test (RDT) can be done.
CLINICAL ASSESSMENT
Body temperature should be checked in all sick children brought to an outpatient clinic. Children are
considered to have fever if their body temperature is above 99.50 F (axillary). In the absence of a
thermometer, children are considered to have fever if they feel hot. Feel the child’s abdomen or axilla
to determine fever. Fever may also be considered if the mother gives a history of fever.
A child presenting with fever should be assessed for:

• Stiff neck
• Runny nose
• Duration of fever
• Malaria
• Measles
Stiff neck. Failure on the part of the child to move his/her neck easily. It is a sign of meningitis. How
to assess? If the child is conscious and alert, check neck stiffness by asking the child to bend his/her
neck to look down but if the child is unconscious then by very gently bending the child’s head forward
(trying to touch the upper part of the anterior chest wall with chin).
Runny nose means watery secretion from nose which occurs usually due to common cold.
Duration of fever Most fevers due to viral illnesses go away within seven days. A fever that has
been present every day for more than seven days indicates that the child has a more severe disease
such as typhoid fever.

49
Malaria is one of the major public health problems in Bangladesh. Out of 64 districts, 13 bordering
districts in the east and northeast part of Bangladesh belong to the high and low risk malaria zone -
Rangamati, Khagrachari, Bandarban, Chattogram, Cox’s Bazar, Kurigram, Sherpur, Mymensingh,
Netrokona, Sunamganj, Sylhet, Habiganj and Moulvi Bazar. A total of 13.25 million populations are
at risk of malaria inhabited in those districts. Over 90% of the total cases are reported from three
Chittagong Hill Tract Districts. (Rangamati, Khagrachari and Bandarban), including Chittagong and
the coastal district Cox’s Bazar*. There is sporadic incidence of malaria in other parts of the country.
The World Health Organization (WHO) has proposed definitions of malaria risk settings for countries
and areas with risk of malaria caused by P. falciparum.
A high malaria risk setting is defined as a situation in which more than 5 percent of cases of febrile
disease in children age 2 months up to 5 years are malaria disease. A low malarial risk setting is a
situation where fewer than 5 percent of cases of febrile disease in children age 2 months up to 5 years
are malarial disease. If malaria does not occur normally, the setting is considered to have no malaria
risk. From no malaria risk area, travelling to a high/low risk zone within last 1 month – should
be considered as high/low risk for malaria.
*Malaria Situation in Bangladesh. Malaria National Strategic Plan-2015-2020.

50
Other endemic infections with a public health importance in the area, (e.g. dengue fever), should also
be considered. In such situations, national guide line for management of dengue should be followed.
Measles. Considering the high risk of complications and death due to measles, children with fever
should be assessed for signs of current or previous measles (within the last three months). Measles
infections causes serious immunodeficiency and deaths usually occur due to pneumonia, diarrhoea,
laryngotracheitis and encephalitis. Other complications (usually non-fatal include conjunctivitis,
otitis, mouth ulcers. Significant disability can result from measles e.g. Exophthalmia including
blindness, severe malnutrition, chronic lung disease (bronchiectasis and recurrent infection), and
flare up of tuberculosis and neurological dysfunction.
Detection of measles is based on fever with a generalized rash plus at least one of the following signs:
red eyes, runny nose or cough. The mother should be asked about the occurrence of measles within
the last three months. Measles can be prevented by vaccine at 9 completed months of age.
CLASSIFICATION OF FEVER
Before going for the classification, the first consideration needs to be done is, whether the child is
coming from the high or low or no malaria risk area.
Child from high or low malaria risk area
VERY SEVERE FEBRILE DISEASE

Child who come from high or low malaria risk area with fever and any general danger sign or stiff
neck are classified as VERY SEVERE FEBRILE DISEASE and should be referred urgently to a
hospital after pre-referral treatment.
or
• Stiff neck VERY SEVERE FEBRILE DISEASE
MALARIA
Children with fever but no general danger sign or Stiff neck should be classified as having
MALARIA, if blood for RDT POSITIVE/ Other Malaria test is POSITIVE.

51
• RDT POSITIVE/ Other Malaria test POSITIVE Yellow:
MALARIA
FEVER – NO MALARIA
Children with fever but no general danger sign or Stiff neck, RDT NEGATIVE/ Other Malaria test
NEGATIVE or with runny nose, rash of measles or any other cause of fever should be classified as
having FEVER – NO MALARIA.
• RDT NEGATIVE/ Other Malaria test Green:
NEGATIVE
• Other causes of fever PRESENT FEVER – NO MALARIA

52
Child from No Malaria risk area or no tavel to Malaria risk area

Children who come from No malaria risk area with fever and any general danger sign of stiff neck
are classified as VERY SEVERE FEBRILE DISEASE and should be referred urgently to a hospital
with pre-referral treatment.
or
• Stiff neck VERY SEVERE FEBRILE DISEASE
FEVER
Children with fever (or history of fever) having neither general danger sign nor stiff neck are
classified as FEVER.
• No general danger sign Green:
or
• No Stiff neck FEVER
These children need follow-up. If their fever lasts for more than seven days, they should be referred
for further assessment to determine the cause of the fever.
CLASSIFICATION OF MEASLES
All children with fever should be checked for signs of measles. If signs of measles present or there
is history of measles within the last 3 months, then the children should also be checked for general
danger sign and complications of measles particularly clouding of cornea, mouth ulcer and pus
draining from eyes.
SEVERE COMPLICATED MEASLES

When a child with measles displays any general danger sign, or deep and extensive mouth ulcers or
clouding of the cornea, they should be classified as SEVERE COMPLICATED MEASLES. These
children should be urgently referred to a hospital with a pre-referral treatment.

53
• Any general danger signs or Pink:
• Clouding of cornea or
• Deep or extensive mouth ulcers SEVERE COMPLICATED MEASLES *
*Other important complications of measles are pneumonia, stridor, diarrhoea and malnutrition are
classified in other labels.
MEASLES WITH EYE OR MOUTH COMPLICATIONS

Children with less severe measles complications, such as pus draining from the eye (a sign of
conjunctivitis) or non-deep and non-extensive mouth ulcers, are classified as MEASLES WITH EYE
OR MOUTH COMPLICATIONS.
• Pus draining from the eye Yellow:
or
• Mouth ulcers MEASLES WITH EYE OR MOUTH
COMPLICATIONS
If the child with measles has pus draining from eyes but having no mouth ulcer, then classification is
only measles with eye complication. Similarly, a child with mouth ulcer without pus draining from
eyes, the classification is measles with mouth complication.
MEASLES
If child comes with measles or history of measles within the last three months but having no
complications of measles are classified as measles.
• Measles now or withi8n the last 3 months Green:
MEASLES
Note: Complication of measles may occur within 3 months due to immunodeficiency.

54
VIDEO EXERCISE ON FEVER
1. Answer to the question for each of the children shown:
Dose the child have stiff neck?
YES NO
Child 1
Child 2
Child 3
Child 4

55
56
VIDEO CASE STUDY

57
Look for local tenderness. oral sores, refusal to use a limb, hot tender swelling, red tender skin or
boil, lower abdominal pain or pain on passing urine in older children.

58
Example: Use the IMCI register up to the main symptom-fever
Case
Fatima is 18 months old. She weighs 11.5kg. Her temperature is 99.50F. The physician asked, “What
are the Childs problems?” The mother said, “Fatima has been coughing for 6 days, and she is having
trouble breathing.” This is the initial visit for this illness.
The physician checked Fatima for general danger sings. The mother said that Fatima is able to drink.
She has not been vomiting. She did not have convulsions during this illness. The physician asked,
physician talked to Fatima, but she did not watch his face. She stared blanked and appeared not to
took in a minute. He counted 41 breaths per minute. The physician did not see any chest in-drawing.
The physician asked, “Does the child have diarrhea?” The mother said, “Yes for 3 days.” There was
no blood in the stool. Fatima’s eyes looked sunken. The physician asked, “Do you notice anything
deferent about Fatima’s eyes” The mother said, “Yes.” He gave the mother some clean water in the
cup and asked her to offer it to Fatima. When offered, Fatima would not drink. When pinched, the
skin of Fatima’s abdomen went back very slowly.
Because Fatima’s temperature is 99.50F and she feels hot, the physician assessed Fatima further for
signs related to fever. The mother said Fatima’s fever began 2 days ago. The risk of malaria is low.
Fatima has not had measles within the last 3 months and there are no signs suggesting measles. She
does not have stiff neck. The physician noticed that Fatima has runny nose. The physician performed
RDT and the test result came POSITIVE.

59
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EAR PROBLEMS
Ear problems are the next condition that should be checked in all children brought to the outpatient
health facility. A child presenting with an ear problem should first be assessed for general danger
signs, cough or difficult breathing, diarrhoea and fever. A child with an ear problem may have an ear
infection. Although ear infections rarely cause death, they are the main cause of deafness in low-
income areas, which in turn leads to learning problems. Ear infection also may cause meningitis as a
complication.
CLINICAL ASSESSMENT
If there is an ear problem look for the following clinical signs:
Tender swelling behind the ear. The most serious complication of an ear infection is an infection
in the mastoid bone. It usually manifests with tender swelling behind the child’s ears.
Ear pain. In the early stages of acute ear infection, a child may have ear pain, which usually causes
the child to become irritable and rub the ear frequently.
Ear discharge of pus. This is another important sign of an ear infection. When a mother reports an
ear discharge, the health care provider should check for pus draining from the ears and find out how
long the discharge has been present.
CLASSIFICATION OF EAR PROBLEMS

Based on the simple clinical signs above, the child’s condition can be classified in the following
ways:
MASTOIDITIS
Children who have ear problem and presenting with tenderness and swelling of the mastoid bone are
classified as having MASTOIDITIS and should immediately be referred to the hospital for treatment,
after giving a pre-referral treatment.
• Tender swelling behind the ear Pink:
MASTOIDITIS

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ACUTE EAR INFECTION
Children with ear pain or ear discharge (or pus) for less than 14 days (reported by the mother) are
classified as ACUTE EAR INFECTION.
• Ear pain Yellow:
or
• Pus is seen draining from the ear and or discharge is ACUTE EAR INFECTION
reported for less than 14 days
CHRONIC EAR INFECTION

Children with ear discharge (or pus) for 14 days or more, are classified as CHRONIC EAR
INFECTION.
• Pus is seen draining from the ear and discharge is Yellow:
reported for 14 days or more
NO EAR INFECTION
Children having neither pain nor discharge from the ear are classified as NO EAR INFECTION.
• No ear pain Green:

and
• No pus seen draining from the ear NO EAR INFECTION
Example: Use the IMCI register up to the main symptom ear problem
Case
Meena is 3 years old. She weighs 13kg. Her temperature is 99.50F. Her mother came to the hospital
because Meena has felt hot for 2days. She was crying last night and complained that her ear was
hurting. The physician checked and found no general danger signs. Meena does not have cough or
difficult breathing. She has 36 breaths/ min. Her oxygen saturation (SpO2) is 99%. She does not have

62
diarrhea. Her malaria risk is high. The physician performed the RDT and the result was POSITIVE
for malaria. Her fever was classified as MALARIA.
Next the physician asked about Meena’s ear problem. The mother said she is sure that Meena has ear
pain. The child cried most of the night because her ear hurt. There has not been any ear discharge.
The physician did not see any pus draining from the child’s ear, she felt behind the child’s ears and
found no tender swelling.

63
CHECKING MALNUTRITION
After assessing for general danger signs and the main symptoms, all children should be assessed for
malnutrition.
There are two main reasons for routine assessment of nutritional status in sick children:
• To identify children with severe malnutrition who are at increased risk of death and need
argent referral to provide active treatment; and
• To identify children with sub-optimal growth, who may be benefited from nutritional
counseling
CLINICAL ASSESSMENT
As reliable height boards are difficult to find in most outpatient health facilities, nutritional status
should be assessed by looking and feeling for the following clinical signs.

64
Oedema of both feet. The presence of oedema in both feet may be a sign of COMPLICATED
SEVERE ACUTE MALNUTRITION. Children with oedema of both feet may have other diseases
like nephritic syndrome. There is no need, however, to differentiate these conditions in the outpatient
settings or at the first level health facility because referral is necessary in both cases.
Weight for height or length

WHO growth charts are being used by pediatricians and health care providers for assessing the
growth of infant and young children around the world since 2006. Growth charts have been
constructed by observing the growth of large number of children over time. The WHO standard
reflects a more accurate description of physiological growth of children. Although there are many
types of growth charts but in this student’s handbook there are six charts. They are:
• Weight for age – Birth to 5 years (Girls)
• Weight for age – Birth to 5 years (Boys)
• Weight for length – Birth to 2 years (Girls)
• Weight for length – Birth to 2 years (Boys)
• Weight for height – 2 to 5 years (Girls)
• Weight for height – 2 to 5 years (Boys)
Weight for age chart has 5 lines where weight for length and weight for height growth charts have 7
lines - Middle line is the median. It is expressed as 0. The line above and below the median are the
deviations from the mean and expressed as z score. Three lines above are expressed as +1, +2 and +3
score and two lines below the mean are expresses as -1, -2 and 3 respectively.
To determine weight- for- length/ height (2 months up to5yrs)
• Weight of the child will be taken in kg. The child should wear light clothing when he is
weighed.
• Length (up to 2yrs)/height (2yrs and above) of the child will be taken. Supine length is
measured by infantometer and height is measured by stadiometer

65
Figure: Infantometer
Figure: Stadiometer
• Use the weight – for – length/ height (Girls/Boys) chart to determine weight for length/height
- Look at the left-hand axis to locate the line that shows the child’s weight in kg
- Look at the bottom axis of the chart to locate the line that shows the child’s length
/height in cm
- Look at the point on the chart where the line for the child’s weight meets the line for
the child’s length/height
• Decide if the point is above, on, or below the middle curve. If the child’s (age 2 months up to
5years) weight-for-height/length Z score is less than – 3, he/she will be classified as
SEVERE ACUTE MALNUTRITION (SAM). These children are at increased risk of
infection and death. If the child’s weight –for-height/length Z score between -3 and – 2
he/she will be classified as MODERATE ACUTE MALNUTRITION (MAM). When
WFH/L z score is -2 or more, there is NO ACUTE MALNUTRITION.

66
To determine weight – for –age (birth up to 5years)
• Weight of the child will be taken. Use a scale which you know gives accurate weights. The
child should wear light clothing when he is weighed. Ask the mother to help remove any coat,
sweater, or shoes
• Use the weight for age chart to determine weight- for- age
- Look at the left-hand axis to locate the line that shows the child’s weight in kg
- Look at the bottom axis of the chart to locate the line that shows the child’s age in
years
- Look at the point on the chart where the line for the child’s weight meets the line for
the child’s age
• Decide if the point is above, on or below the middle curve
If the child’s (age up to 2 months) weight-for-age falls below the line expressed as -2, he/she will be
classified as VERY LOW WEIGHT FOR AGE.
Mid upper arm circumference (MUAC). It is also used as a tool to assess the nutritional status of
children. It is the measurement of the left arm midway between tip of the olecranon and acromion
process. Children are considered to have SEVERE ACUTE MALNUTRITION (SAM) if the MUAC
is < 115 mm. If MUAC is 115 up to 125 mm he/she will be classified as MODERATE ACUTE
MALNUTRITION (MAM). If MUAC IS 125 mm or more he/she will be classified as NO ACUTE
MALNUTRITION.
Figure: MUAC

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68
69
70
71
72
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CLASSIFICATION OF MALNUTRITION
Using a combination of the clinical signs above, children can be classified in one of the following
categories:
• COMPLICATED SEVERE ACUTE MALNUTRITION
• UNCOMPLICATED SEVERE ACUTE MALNUTRITION
• MODERATE ACUTE MALNUTRITION
• NO ACUTE MALNUTRITION

74
COMPLICATED SEVERE ACUTE MALNUTRITION
Children with COMPLICATED SEVERE ACUTE MALNUTRITION are at high risk of death. They
need urgent referral to a hospital.
• Oedema of both feet Pink:

or
• WFH/L less than –3 zscores
or
• MUAC less than 115mm and any one of the
COMPLICATED SEVERE ACUTE
following:
MALNUTRITION
• Medical complication present
or
• Not able to finish Nutritional therapy
or
• Breastfeeding problem

75
UNCOMPLICATED SEVERE ACUTE MALNUTRITION
Children with UNCOMPLICATED SEVERE ACUTE MALNUTRITION also have a higher risk of
severe disease.
• WFH/L less than –3 z-scores Yellow:
or
UNCOMPLICATED SEVERE ACUTE
• MUAC less than 115 mm
MALNUTRITION
and
• Able to finish nutrition therapy
MODERATE ACUTE MALNUTRITION

Children with MODERATE ACUTE MALNUTRITION should be assessed for feeding problems.
• WFH/L between –3 and –2 z-scores Yellow:
or
MODERATE ACUTE
• MUAC 115 up to 125 mm
MALNUTITION
NO ACUTE MALNUTRITION
Children who are not severe or moderate acute malnutrition are classified as having NO ACUTE
MALNUTRITION.
• WFH/L between 2 z scores or more Green:
or
• MUAC 125 mm or more NO ACUTE MALNUTITION
Because children less than 2 years of age have a higher risk of feeding problems and malnutrition
than older children do, their feeding should be assessed. If problems are identified, the mother needs
to be counseled about feeding her child according to the IMCI feeding recommendations during
sickness and health (Page-164)

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CHECKING ANAEMIA
CLINICAL ASSESSMENT
Palmar pallor. It is used to identify the sick children with anaemia. Where feasible, hemoglobin
estimation may be done.
To see if the child has palmar pallor, look at the skin of the child’s palm. Hold the child’s palm gently.
Do not over stretch the fingers backward. Put it on your palm. Compare the colour of the child’s palm
with your own palm
If the skin of the child’s palm is pale, the child has some palmar pallor.
If the skin of the palm is very pale that it looks white, the child has severe palmar pallor.
CLASSIFICATION OF ANAEMIA
Children can be classified in one of the following categories:
SEVERE ANAEMIA
Children with SEVERE ANAEMIA who have severe palmar pallor need urgent referral to a hospital
for blood transfusion.
• Severe palmar pallor Pink:
SEVERE ANAEMIA
ANAEMIA
Children with some palmar pallor have ANAEMIA and should be assessed for feeding problems.
This assessment should identify common and important problems with feeding that can be corrected
by proper and effective counseling.
• Some palmar pallor Yellow:
ANAEMIA

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NO ANAEMIA
Children who have no palmar pallor are classified as having NO ANAEMIA.
• No palmar pallor Green:
NO ANAEMIA
Example: Use the part of the IMCI register up to Malnutrition and Anaemia
Case
Amin is 9 months old. He weighs 7 kg, length is 72 cm and MUAC is 118mm. His temperature is
98.20 F. He is at the hospital today because his mother and father are concerned about his diarrhoea.
He does not have any general danger signs. He has cough for 2 days. His oxygens saturation (SpO2)
is 99% and he takes 44 breaths/min. He has chest indrawing. He has had diarrhoea for 5 days, and is
classified as diarrhoea with SOME DEHYDRATION. He does not have fever. He does not have an
ear problem.
Next, the physician checked for nutritional status. His palm appears pale. He does not have oedema
of both feet. The physician uses the weight for length chart (Boys) to determine Amin’s weight-for-
length.

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CHECKING IMMUNIZATION STATUS
The immunization status of every sick child brought to a health facility should be checked. Following
situations are contraindicated to immunize the sick children:
• Children who are being referred urgently to the hospital should not be immunized
• There is no medical contraindication
Minor illness (runny nose, mild cough cold etc.) is not a contraindication to immunization
Live vaccines (BCG, measles and oral polio) should not be given to children with immunodeficiency
diseases, or to children who are immune-suppressed due to malignant disease, therapy with
immunosuppressive agents or irradiation. However. all the vaccines, including BCG can be given to
children who have or are suspected of having HIV infection but are not yet symptomatic.
Penta - Pentavalent vaccine contains DPT, HepB and Hib

• Should not be given to children with recurrent convulsions
• Should not be given to children who have had convulsion(s) or shock within three days of a
previous dose of Penta. In these cases DT/TT, HepB+Hib can be given separately
Routine Immunization Schedule

Immunization Schedule for 0-11 months and 15 months old children
No. Interval Ideal time

Disease Vaccine Dose of Between of Site of Route of
Dose Dose Vaccination Vaccination Administration
Tuberculosis BCG 0.05 ml 1 - Just After Left upper arm Intra-muscular
Birth
Diphtheria, 6 weeks Intra-muscular
Whooping Pentavalent 10 weeks Anterolateral
Cough, Vaccine 14 weeks Aspect (outer)
Tetanus, (DPT+Hep- 0.5 ml 3 4 weeks of left mid-thigh
Hepatitis-B, B+Hib)
Haemophilus
Influenza-B
Pneumococcal 6 weeks Anterolateral Intra-muscular
Pneumonia PCV 0.5 ml 3 4 weeks 10 weeks Aspect (outer)
18 weeks of right mid-thigh
6 weeks By mouth
Poliomyelitis OPV 2 drops 3 4 weeks 10 weeks Oral
14 weeks

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IPV Anterolateral
0.5 ml 2 8 weeks 6 weeks Aspect (outer) Intra-muscular
14 weeks of right mid-thigh
Measles and After Anterolateral
Rubella MR 0.5 ml 1 Completion Aspect (outer) Subcutaneous
- of 9 of right mid-thigh
months
Measles and After Anterolateral
Rubella MR 0.5 ml 1 Completion Aspect (outer) Subcutaneous
- of 15 Of left mid-thigh
months
Other points to be remembered during vaccination:

Complete all vaccines by 15 months of age and according to schedule
Vaccine that needs repeated doses will not be effective if given before minimum interval of 28 days
There is no maximum time interval between the doses of OPV, Penta & TT
If there is no scar or ulcer within three months of BCG vaccination, repeat the vaccine
Three doses of OPV (OPV1, OPV2 and OPV3) at 6,10 and 14 weeks have to be given along with
Penta 1, Penta 2 and Penta 3. One dose of IPV should be given at 14 weeks. PCV 1, PCV 2 and PCV
3 should be given along with Penta 1, Penta 2 and Penta 3 at 6 weeks, 10 weeks and 14 weeks. MR
vaccine should be given after completion of 9 months and 15 months.
OPV can be given in diarrhoeal illness also. But it should be considered as an extra dose and should
be repeated after 28 days
Even if there is history of rash/measles, vaccine against measles should not be withheld
Note: Immunization schedule may be changed according to latest national Expanded Programme of
Immunization (EPI) schedule of Bangladesh.

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CHECKING THE CHILD’S VITAMIN-A AND DEWORMING
STATUS AND SUPPLEMENTTATION
VITAMIN A • Vitamin A can be supplemented to children
SUPPLEMENTATION aging
STATUS - 6 months up to 12 months: 100,000 IU
- One year and older: 200,000 IU
• Give every child a dose of Vitamin ‘A’ every
6 months from the age of 6 months. Record
the dose on the child’s card
• If the child has had a dose of Vitamin ‘A’
within the past month, do not give Vitamin ‘A
• Give an extra dose* of Vitamin ‘A’ (same
dose as for supplementation) as part of

treatment if the child has MEASLES or
PERSISTENT DIARRHOEA
MULTIVITAMINS/ • For acute diarrhea, 20mg Zn once daily for 10
MINERAL days (6 months up to 5 years)
SUPPLEMENTATION • For persistent diarrhoea, ½ tablet of 20mg Zn
once daily for 10 days and multivitamin daily
for 14 days (2 months up to 6 months)
DEWORMING STATUS • If child is 1 year or older
• Has not received a dose of albendazole in the
last 6 months give the dose for de-worming
Example: Use Immunization status section of the IMCI register
Case
Salim is 4 months old. He has no general danger signs. He is classified as diarrhea with NO
DEHYDRATION. His immunization record shows that he received BCG, OPV 1, OPV 2, Penta-1
Penta 2, PCV 1, PCV 2 and IPV.

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ASSESSING THE CHILD’S FEEDING
All children less than 2 years old and all children classified, as anemia or very low weight needs to
be assessed for feeding.
Feeding assessment includes questioning the mother or caregiver about:
• Breast feeding frequency and night feeds All children under age 2
• Types of complementary foods or fluids, frequency of years should have a
feeding assessment, except
feeding and whether feeding is active; and
those who needs urgent
• Feeding patterns during the current illness referral.
The mother or caregiver should be given appropriate advice
to overcome any feeding problems found.
Note: It is important to take time to counsel the mother carefully and completely.
Example: Use the IMCI register
Case
Salim is 4 months old. He has no general danger sign. He is classified as NO ANAEMIA and NO
ACUTE MALNUTRITION. He was assessed for identification of feeding problems. Mother noticed
that she breastfed her child but it was not enough. She breastfed 5 times in 24 hours. She used to feed
at night. She thinks that the child remains hungry so she used to give cow’s milk 3 times daily with
feeding bottle which is approximately 100 ml. Mother feed the child herself. The child’s feeding
remains unchanged during this illness.

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ASSESSING OTHER PROBLEMS
Apart from assessing general danger signs and main symptoms, IMCI also addresses assessment of
other problems like tuberculosis, conjunctivitis, skin problems and different causes of fever etc.
Through this process children with other conditions will receive necessary treatment or referral.
In addition, this guideline also addresses the health problems of the mother or caregiver. (see page -
166)
IDENTIFY TREATMENT AND TREAT THE CHILD

IMCI classification are not necessarily specific diagnoses, but they indicate what action needs to be
taken. In the IMCI guidelines, all classifications are colour coded: pink calls for hospital referral or
admission, yellow for initiation of treatment at health center and green means that the child can be
sent home with home-care management and advice on when to return. After completion of the
assessment and classification procedure, the next step is to identify treatment & treat the child. In
this section treatment urgent & non-urgent referral is discussed.
REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS

All infants and children with a severe classification (pink) are referred to a hospital as soon as
assessment is completed and necessary pre-referral treatment is administered. Conditions requiring
urgent referral include:
• VERY SEVERE DISEASE (any one of the 4 general danger signs)
• SEVERE PNEUMONIA OR VERY SEVERE DISEASE
• VERY SEVERE FEBRILE DISEASE
• SEVERE COMPLICATED MEASLES
• SEVERE DEHYDRATION WITH OTHER SEVERE CLASSIFICATION
• SEVERE PERSISTENT DIARRHOEA
• MASTOIDITIS
• SEVERE MALNUTRITION
• SEVERE ANAEMIA
Note: If a child only has severe dehydration and no other severe classification and IV infusion is
available in the outpatient clinic, an attempt should be made to re-hydrate the sick child before
referral.

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Successful referral of severely ill children to the hospital depends on effective counselling of the
caregiver. If s/he does not accept referral, available options (to treat the child by repeated clinic or
home visits) should be considered. If the caregiver accepts referral, s/he should be given a short, clear
referral note, and should get information on what to do during transportation, particularly if the
hospital is at a distant place.
The Referral Note should include:
• Name and age of the child

• Reason for referral
• Treatment that has been given
• Any other information that the referral health facility needs to know e.g. about treatment
given
• Date time, and place of referral

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URGENT PRE-REFERRAL TREATMENTS FOR CHILDREN AGE 2 MONTHS UP TO 5
YEARS
• Appropriate antibiotic (Annex –III)

• Artesunate/ Artemether (for SEVERE MALARIA) (Annex-VI)
• P/R Diazepam for convulsion (Annex-XI)
• Vitamin A
• Nebulized or oral salbutamol
• Prevention of hypoglycemia with breast milk or sugar water (Annex-XI)
• Paracetamol for high fever (101.50 F or above) or pain
• Tetracycline eye ointment (if clouding of the cornea or pus draining from eye)
• ORS solution so that the mother can give frequent sips on the way to the hospital
NON-URGENT REFERRAL
Child with some illness does not need urgent referral but require referral for evaluation. Condition
requiring non-urgent referral includes:
• Cough that has lasted more than 2 weeks
• Fever that has lasted 7 days or more
• SEVERE PERSISTENT DIARRHOEA
IDENTIFY TREATMENT
IDENTIFY TREATMENT OF COUGH OR DIFFICULTM BREATHING
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Children who have either any general danger sign or stridor or whose oxygen saturation (SpO2) is
<90% - Children in this group are most likely have infection with invasive bacterial organisms and
disease which may be life threatening. This warrants the use of injectable antibiotics and early
referral.

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PNEUMONIA
Children who have only fast breathing and/or chest indrawing should be classified as PNEUMONIA.
They can be treated with oral antibiotics at home. Treatment on this classification has been shown
effective to reduce mortality.
COUGH OR COLD
Children who have cough or difficult breathing but no signs of SEVERE PNEUMONIA OR VERY
SEVERE DISEASE or PNEUMONIA, should be classified as COUGH OR COLD.
Such children may require a safe cough remedy to soothe the throat relieve cough. A child with cough
and cold normally improves in one or two weeks. However, a child with chronic cough (more than
14 days) needs to be further assessed (and referred) to exclude tuberculosis, asthma. whooping cough,
of or other problem.

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*In setting where inhaled bronchodilator is not available, syrup Salbutamol may be tried but not
recommended for treatment of severe acute wheeze.
Note: Antibiotic should not be used routinely for cough or cold, as it neither shortens the duration of
illness nor prevents complications.

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IDENTIFY TREATMENT OF DIARRHOEA
SEVERE DEHYDRATION
SOME DEHYDRATION
NO DEHYDRATION
Note: Antibiotics should not be used routine for treatment of diarrhoea. Most diarrhoeal episodes are
self-limiting and caused by agents for which antibiotics are not required, except Cholera and
Shigellosis.
Cholera – Tetracycline or Erythromycin for 3 days
Dysentery- Ciprofloxacin for 5 days

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IDENTIFY TREATMENT OF PERSISTENT DIARRHOEA

Children with persistent diarrhoea who have any degree of dehydration (severe or some) is classified
as SEVERE PERSISTENT DIARRHOEA and should be managed in the hospital as they require
further evaluation. But before referral, treatment of dehydration should be initiated first, unless there
is another severe classification.
PERSISTENT DIARRHOEA
Children with persistent diarrhoea who have no sign of dehydration should be classified as
PERSISTENT DIARRHOEA and can be managed in the outpatient clinic at least initially
Proper feeding is the most important aspect of treatment for most children with PERSISTENT
DIARRHOEA. The goals of nutritional therapy are to:
• Provide a sufficient intake of energy, protein, vitamins and minerals to facilitate the repair
process in the damaged mucosa and to improve nutritional status
• Avoid giving foods or drinks that may aggravate diarrhoea (Annex-IV)
• Reduce the amount of animal milk [or lactose] in the diet, for those who are not breast-
fed
Note: Routine treatment of PERSISTENT DIARRHOEA with antimicrobials is not essential. Some
children, however, have non-intestinal infections that require specific antimicrobial therapy, The
PERSISTENT DIARRHOEA of such children will not improve until these infections are diagnosed
and treated correctly.

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IDENTIFY TREATMENT OF DYSENTERY
DYSENTERY
A child who is classified as dysentery should be treated with antibiotics.
Note: For diagnosis of dysentery, it is not always necessary to do routine stool examination & culture
sensitivity.
All Children with dysentery should be treated promptly with an antibiotic effective against Shigella
because:
• Bloody diarrhoea in children under 5 is caused more frequently by Shigella
• Shigellosis is more likely to result in complications and death if effective antimicrobial
therapy is not begun promptly
IDENTIFY THEATMENT OF FEVER
CHILD FROM HIGH OR LOW MALARIA RISK AREA

Children with fever and with any general danger sign of stiff neck are classified as VERY SEVERE
FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral treatment with
antibiotics. But as the risk of Falciparum malaria is high or low such children should also receive a
pre-referral dose of an anti-malarial drug after an RDT (Rapid Diagnostic test) or other Malaria test.
FOR CHILDREN BEING REFFERED WITH VERY SEVERE FEBRILE DISEASE:

Give first dose of Artesunate and refer the child urgently to hospital.
Note: Patient should be observed for hypotension and hypoglycemia

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IF REFFERAL IS NOT POSSIBLE
• Give the first dose of Artesunate in the clinic
• Give Artemisinin-based combination Therapy (ACT) in the clinic and observe for one hour.
If child vomits within an hour repeat the dose
• The second dose of Co-artem should be taken 8 hours after first dose for better action. It
should be taken with fatty food as this increase the absorption of Co-artem
• Chloroquine is given for 3days. If the child is less than 10kgs and you have given him 150mg
tablet of Chloroquine, then, give the same dose (that means 1/2 tablets) for 2days and ¼ tablet
on the 3rd day
MALARIA
FEVER-NO MALARIA
Note: Look for local tenderness, oral sores, refusal to use a limb, hot tender swelling, red tender skin
or boils, lower abdominal pain or pain on passing urine in older children. Evidence of another
infection lower the possibility of malaria, therefore children who have another infection and malaria
test is negative, should not be given an anti-malarial.

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NO MALARIA RISK AREA

Children with fever and any general danger sign or stiff neck are classified as VERY SEVERE
FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral treatment with
antibiotics.
FEVER
Children with fever having neither general danger signs nor stiff neck are classified as having
FEVER. These Children need follow-up. If their fever lasts for more than seven days, they should be
referred for further assessment to determine causes of prolonged fever.
Note: Children with high fever, defined as an axillary temperature greater than 101.5 0 F should be
given a single dose of paracetamol to prevent hyperthermia.
IDENTIFY TREATMENT OF MEASLES

All Children with fever should be checked for signs of measles and measles complications.
SEVERE COMPLICATED MEASLES

When a child with measles displays any general danger sign or deep and extensive mouth ulcers or
clouding of the cornea, they should be classified as SEVER COMPLICATED MEASLES. These
Children should be urgently referred to a hospital with a per-referral treatment with VIT A, and
tetracycline eye ointment.

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MEASLES WITH EYE OR MOUTH COMPLICATIONS
Children with less severe complications, such as pus draining from the eye (a sign of conjunctivitis)
or non-deep and non-extensive mouth ulcers, are classified as MEASLES WITH EYE OR MOUTH
COMPLICATIONS. These children can be safely treated at the outpatient facility. The treatment
includes oral vitamin A, tetracycline eye ointment for pus draining from the eye and Nystatin
ointment and tablet Riboflavin for mouth ulcers.
MEASLES
If children come with measles or history of measles within last 3 months, having no complications
of measles are classified as MEASLES and they should be treated with Vitamin A only.
Note: Dose of Vit A for children 6 months to 12 months old is 1 lac IU and for children one year and
older is 2 lac IU.

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IDENTIFY TREATMENT OF EAR PROBLEMS
MASTOIDITIS
Children presenting with tenderness and swelling (behind the ear) of the mastoid hone are classified
as having MASTOIDITIS and should immediately be referred to the hospital after giving a pre-
referral treatment with 1st dose of antibiotic and one dose of paracetamol for pain.
ACUTE EAR INFECTION

Children with ear pain or ear discharge for less than 14 days are classified as having ACUTE EAR
INFECTION and should be treated for five days with the same first-line antibiotic as for pneumonia.

Children with ear discharge for 14 days or more, are classified as CHRONIC EAR INFECTION.
Generally, antibiotics are not recommended because their efficacy is not proven in chronic ear
infection. However, dry the ear by wicking and follow-up in 5 days is recommended.
NO EAR INFECTION
Children having neither pain nor discharge from the ear, are classified as NO EAR INFECTION and
do not require any specific treatment.

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IDENTIFY THEATMENT OF MALNUTRITION
COMPLICATED SEVERE ACUTE MALNUTRITION

Children with COMPLICATED SEVERE ACUTE MALNUTRITION and are at high risk of death
from various severe diseases. They need urgent referral to a hospital where their treatment (special
feeding, antibiotics or blood transfusions. etc.) can be carefully monitored.
UNCOMPLICATED SEVERE ACUTE MALNUTRITION

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MODERATE ACUTE MALNUTRITION
Children with MODERATE ACUTE MALNUTRITION also have a higher risk of severe disease
and should be assessed for feeding problems. This assessment should identify common, important
feeding problems that can be corrected if the caregiver is provided with appropriate counselling.
NO ACUTE MALNUTRITION

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IDENTIFY TREATMENT ANAEMIA
SEVERE ANAEMIA
Children with SEVERE ANAEMIA who have severe palmar pallor need urgent referral to a hospital
for blood transfusion.
ANAEMIA
When children are classified as having ANAEMIA they should be treated with oral iron. During
treatment, then child should be seen every two weeks (follow-up), at which time an additional 14
days of iron treatment is given. It there is no improvement in pallor after two weeks, the child should
be referred to the hospital for further assessment. Iron is not given to children with severe
malnutrition who will be referred.
NO ANAEMIA
Children who have no palmar pallor are classified as having NO ANAEMIA.

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TREATMENT AT OUTPATIENT DEPARTMENT
ORAL DRUGS
Always start with a first-line drug. These are usually less expensive, more readily available in a given
country and easier to administer. Give a second-line drug (which are usually more expensive and
more difficult to obtain) only if a first-line drug is not available or if the child illness does not respond
to the first-line drug. The health care provider also needs to teach the mother or caregiver how to give
oral drugs & how to measure the drugs at home.
ASK THE MOTHER TO GIVE THE FIRSST DOSE TO HER CHILD

Explain that if a child is vomiting, give the drug even though the infant may vomit it up. Tell the
mother to watch the infant for 30 minutes. If the infant vomits within the 30 minutes give another
dose. If the child is dehydrated and vomiting, wait until the child is rehydrated before giving the dose
again.
EXPLAIN CAREFULLY HOW TO GIVE THE DRUG, THEN LABEL AND PACKAGE
THE DRUG
Tell the mother how much of the drug to give her child. Tell her how many times per day to give the
dose. Tell her when to give it (such as early morning, lunch, dinner, before going to bed) and for how
many days.
EXPLAIN THAT ALL THE ORAL DRUG (TABLETS OR SYRUPS) MUST BE USED TO
FINISH THE COURSE OF TREATMENT, EVEN IF THE INFANT GETS BETTER
Explain to the mother that if the child seems better, she should continue to treat the infant. This is
important because the bacteria may still be present even though the signs of disease are gone.
THE DRUGS COMMONLY USED AT OUTPATIENT DEPARTMENT OPD
Oral antibiotics. The IMCI chart shows how many days and how many times each day to give the
antibiotic. Determine the correct dose of antibiotics based on the child’s weight. If the child’s weight
is not available, use the child’s age. Always check if the same antibiotic can be used for treatment of
different classifications a child may have. For example, the same antibiotic could be used to treat
both PNEUMONIA and ACUTE EAR INFECTION (i.e Amoxycillin for 5 days) (Annex-IV)

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Oral antimalarials. Oral antimalarials vary from country to country. In a case of uncomplicated
falciparum malaria first-line of treatment would be Artemether + Lumefantrine combination (ACT).
In vivax malaria treatment should be started with Chloroquine + Primaquine. (Annex-VI)
Paracetamol. If child has high fever and ear pain give one dose of paracetamol in the OPD. Give the
mother enough paracetamol for further use. Tell her to give one dose every six hours until the
fever/ear pain sub sides. (Annex-IV)
Iron. A child with ANAEMIA needs iron. Give syrup to the child under 12 months of age. If the
child is 12 months or older give iron tablets. Give the mother enough iron for 14 days. Ask her to
return for more iron in 14 days. Also tell her that the iron may make the child’s stools black. (Annex-
IV)
Vitamin A. Vitamin A is given to a child with MEASLES or PERSISTENT DIARRHOEA. Vitamin

A helps to prevent Xeropthalmia and help to regenerate cells that line the lung, gut, mouth and throat.
It may also help the immune system to prevent other infections. Vitamin A is available in capsule.
Use the child’s age to determine the dose. Give Vit-A to the child in the OPD. Each dose of Vitamin
A should be recorded because of danger of an overdose.
Zinc. Zinc is being recommended along with ORS to treat diarrhoea for children 2 months up to 5
years of age. Zinc is as an essential mineral and is an essential component of over 180 enzymes. Food
rich in zinc are milk, spinach, nuts, oats and beans.
In diarrhoea Zinc works in the following ways:
• It boosts the immune system
• It helps in healing of intestinal lining so, help in epithelial regeneration
• It improves absorption of fluids
• It reduces the rate of further attack of diarrhoea
Safe remedy for cough and cold. Breast milk is a good soothing remedy. Simple home remedies
(honey, lemon tea, tulsi pata juice, ginger) are enough in relieving cough or soothing the throat.
Suppression of cough is not desirable because couth is a physiological reflex to eliminate lower
respiratory tract secretion. There is no evidence that commercial cough and cold remedies are
effective, rather these are harmful.

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TREATMENT OR LOCAL INFECTIONS (Annex-VIII)
If the child, age 2 months up to 5 years, has a local infection, the mother or caregiver should be taught
how to treat the infection at home.
Instructions may be given about how to: Eye Treatment for Children Being
• Treat eye infection with tetracycline eye Referred
ointment If the child will be referred and the child
• Dry the ear by wicking needs treatment with tetracycline eye
ointment, clean the eye gently. Pull down
• Give ear drop
the lower lid. Squirt the first dose of
• Treat mouth ulcers with Nystatin ointment tetracycline eye ointment onto the lower
• Soothe the throat and relieve the cough with a eyelid.
safe remedy
COUNSELLING A MOTHER OR CAREGIVER

It is Essential to communicate effectively with child’s mother or care giver. The success of
management of a sick child depends on how well the mother/caregiver understands the situation and
extent of support they provide in caring their child i.e. when and how to provide treatment, their
feeding, understands their importance and knows when to return to a health care provider.
THE STEPS OF GOOD COMMUNICATION

• Listen carefully to what the parents or caregiver says. This will show them that you take
their concerns seriously
• Use words the caregiver understands. Try to use local words and avoid medical
terminology
• Give the caregiver time to answer questions. S/he may need time to reflect and decide if
a clinical sign is present
• Ask additional questions when the caregiver is not sure about the answer. A caregiver
may not be sure if a symptom or clinical sign is present. Ask additional questions to help
her/him to give clear answers

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COUNSELING THE MOTHER OR CAREGIVER OF A SICK CHILD INCLUDES THE
FOLLOWING ESSENTIAL ELEMENTS
• Ask and listen to find out what the infant’s problems are and what the mother is already
doing for the infant
• Praise the mother for what she has done well
• Advise her how to care for her infant at home
• Check the mother’s understanding with good checking questions
WHEN CHECKING THE MOTHER’S UNDERSTANDING

• Ask question that require the mother to explain what, how, how much, how many, when
or why. Do not ask questions that can be answered with just a “Yes” or “No”. Example
of a good checking question: “What foods will you give to your child?” or “How often
should you breast feed your child?”
• Give the mother time to think and then answer
• Praise the mother for correct answer
• If she needs it, give more information, examples or practice
FOLLOWING POINTS SHOULD BE REMEMBERED WHILE TALKING WITH THE

MOTHER
• Use simple and easy words that she understands
• Use teaching aids that are familiar
• Give feed-back when she practices. Praise what was done well and make corrections
• Allow more practices if needed
• Encourage the mother to ask questions
The content of the actual advice will depend on the child’s condition and classifications. Below are
essential elements that should be considered when counselling a mother or care giver:
• Advise to continue feeding and increase fluids during illness
• Teach how to give oral drugs or to treat local infection
• Counsel to solve feeding problems (if any)
• Advise when to return

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ADVICE TO CONTINUE FEEDING AND INCREASE FLUIDS
The IMCI handbook contains (Annex-VII) feeding recommendations for different age groups. These
feeding recommendations are appropriate both when the child is sick and when the child is healthy.
During illness, children’s appetite and thirst may be decreased. However, mother and caregiver
should be counselled to increase fluids and to offer the types of food recommended for the child’s
age, as often as recommended, even though a child may take small amount at each feeding. After
each episode of illness, correct feeding practice helps make up for weight loss and helps prevent
malnutrition. When the child is well, it helps to prevent future illness.
TEACH HOW TO GIVE ORAL DRUGS OR TO TREAT LOCAL INFECTION AT HOME

Simple steps should be followed when teaching a mother or caregiver how to give oral drugs or treat
local infections. These steps include:
• Determine the appropriate drugs and dosage for the child’s age or weight
• Tell the mother or caregiver what the treatment is and why it should be given
• Demonstrate how to measure a dose
• Describe the treatment steps
• Watch the mother or caregiver practice measuring a dose
• Ask the mother or caregiver to give the dose to the child
• Explain carefully how and how often to do the treatment at home
• Explain that all oral drug (tablets or syrups) must be used to finish the course of treatment,
even if the child gets better
• Check the mother’s or caregiver’s understanding
COUNSEL TO SOLVE FEEDING PROBLEMS (IF ANY)

Based on the type of problems identified, it is important to give correct advice about the nutrition of
the young child both during and after illness. Give proper advice that promotes breastfeeding,
improves weaning practices with locally appropriate energy-and nutrient-rich foods. Specific and
appropriate complementary foods should be recommended and the frequency of feeding by age
should be explained clearly. Encourage exclusive breastfeeding for the first six months. Discourage
use of feeding bottles for children of any age and provide guidance on how to solve problems with
breastfeeding. The latter includes assessing the adequacy of attachment and suckling. Specific
feeding recommendations should be provided for children with PERSISTENT DIARRHOEA.

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Feeding counselling relevant to identify feeding problems is described in the feeding
recommendation chapter.
ADVICE WHEN TO RETURN

During counseling every mother or caregiver needs to be advised about when to return to a health
facility.
The health care provider should:
• Teach signs that mean to return immediately for further care
• Advise when to return for a follow-up visit; and
• Determine the schedule of the next well-child or immunization visit
The table below lists the specific times to advise a mother or caregiver to return to a health facility.
IMMEDIATELY
FOLLOW-UP
Note: Advice mother when to return for the next immunization according to the schedule.

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FOLLOW-UP CARE
Some sick children will need to return for follow-up care. At a follow-up visit, see if the child is
improving on the drug or other treatment that was prescribed. Some children may not respond to a
particular antibiotic or antimalarial, and may need to try a second-line drug. Children with
PERSISTENT DIARRHOEA also need follow-up to be sure that the diarrhoea has stopped. Children
with FEVER or eye infection need to be seen if they are not improving. Follow-up is especially
important for Children with a feeding problem to ensure they are being fed adequately and are gaining
weight.
When a child comes for follow-up of an illness, ask the mother or caregiver if the child has developed
any new problems. If she answers yes, the child requires a full assessment: check for general danger
signs and assess all the main symptoms and the child’s nutritional status.
If the child does not have a new problem, use the IMCI follow-up instructions for each specific
problem:
• Assess the child according to the instructions
• Use the information about the child’s signs to select the appropriate treatment
• Give the treatment

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CHAPTER III
OUTPATIENT MANAGEMENT OF SICK YOUNG
INFANTS 0 DAY UP TO 2 MONTHS
LEARNING OBJECTIVES
This section of the handbook will describe the following tasks and so that the students can practice
them:
• Greeting the mother/caregiver
• Assessing and classifying a young infant for very severe diseases
• Assessing and classifying a young infant for jaundice
• Assessing and classifying a young infant with diarrhoea
• Checking for feeding problem or low weight, assessing breastfeeding and classifying
feeding, immunization status
ASSESS AND CLASSIFY THE SICK YOUNG INFANTS

There are some clinical signs observed in young infants which differ from those in older children (2
months – 5 years). Young infant’s clinical signs have special characteristics that must be considered
when classifying their illnesses:
• They can become sick and die very quickly from severe diseases
• They frequently have only general danger signs like, less movements, fever or low body
temperature, poor feeding etc.
• Mild chest indrawing is normal in young infants because their chest wall is soft
For these reasons, assessment, classification and treatment of the sick young infants are different
from older child.
The assessment procedure for this age group includes:

• Greeting the mother/caregiver, history taking and communicating with the caregiver
about the young infant’s problem
• Checking for very severe diseases

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• Checking for jaundice
• Assessing if the young infant has diarrhoea
• Checking for feeding problems or low weight
• Checking for young infant’s immunization status
• Assessing other problems
As the signs of pneumonia and other serious bacterial infections cannot be easily distinguished
in this age group, it is recommended that all sick young infants should be assessed first for signs
of very severe disease.
The sick young infants should be assessed using the IMCI register for the young infants of 0 to
2 months
IMCI register for sick young infant is given here:

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ASSESSMENT OF SICK YOUNG INFANT 0 DAY UP TO 2 MONTHS
At the beginning of assessment and classification of sick young infants; some of the clinical
signs that indicate very severe disease are to be look for. These clinical signs are briefly
discussed below:
Unconscious/drowsy. Is the child in coma? Check the level of consciousness on the ‘AVPU’
scale:
A= Alert
V= responds to Voice
P= responds to Pain
U= Unconscious
If the child is not awake and alert, try to arouse the child by talking or shaking the arm. If the
child is not alert but responds to voice, he or she is lethargic. If there is no response, ask the
mother whether the child has been abnormally sleepy or difficult to wake. Determine whether
the child responds to pain or unresponsive to a painful stimulus. If this is the case, the child is
in coma/ unconscious.
Stopped feeding well. Ask the mother this question. Any difficulty mentioned by the mother
is important. A young infant who was feeding well earlier but is not feeding well now may
have a serious infection. These infants who are either not able to feed or are stopped feeding
well should be referred urgently to hospital.
This is the most important and earliest sign of infection in young infants.
Note: When an infant takes less than 50% of the previous feeding is called stopped feeding well
Convulsion. All children who have had convulsions during the present illness or is convulsing
now should be considered seriously ill.
Persistent vomiting is known as a symptom of a large variety of systemic disorders. It can be

defined as vomiting for 3 or more times in 1 hour. It is widely used as a warning sign of severe
illness.
Apnoea is defined by the cessation of breathing for 20 seconds or longer. Ask mother, if the
infant had such episode of breathing cessation for 20 seconds or more. Use the commonly used
word “suffocation”.

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Major bleeding. Ask the mother if the infant has had major bleeding (bleeding from mouth,
nose, throat and rectum, etc.) during this current illness. Use words the mother understands.
Bulging fontanelles. A bulging fontanelle is an outward curving of an infant’s soft spot

(fontanelle). A tense or bulging fontanelle occurs when fluid builds up in the brain or the brain
swells, causing increased pressure inside the skull. Bulging fontanelle is sign of meningitis in
young infants with an open fontanelle.
Central cyanosis. Determine whether there is bluish or purplish discoloration of the tongue in
the inside of the mouth and tip of the nose. Central cyanosis is a sign of hypoxia (Diminished
O2 saturation in blood < 90%).
Major congenital malformation. Look, if the child has any following physical
malformations:
• Cleft lip and palate
• Bowel obstruction
• Abdominal wall defects
• Myelomeningocoele
• Congenital dislocation of the hip
• Talipes equinovarus (club foot)
Major bleeding/ surgical condition required hospitalization. If major bleeding occurs, it is

usually in the gastrointestinal tract, respiratory tract and intracranial hemorrhage, particularly

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in infants with very severe or prolonged shock. Internal bleeding may not become apparent for
many hours, until the first black stool is passed. Look for major bleeding (bleeding from mouth,
nose, throat and rectum etc.) or such condition which require hospitalization.
Fast breathing. Young infants usually breathe faster than older children do. The breathing rate
of a healthy young infant is usually less than 60 breaths per minute. Therefore, 60 breaths per
minute is the cut –off rate to identify fast breathing is this age group. If the count is 60 breaths
or more, the count should be repeated, because the breathing rate of a young infant is often
irregular.
The young infant will occasionally stop breathing for a few seconds, followed by a period of
faster breathing. If the second count is also 60 breaths or more, the young infant has fast
breathing.
Severe chest indrawing. Mild chest indrawing is normal in a young infant because of softness
of the chest wall. Severe chest indrawing is very deep and easy to see. It is a sign of pneumonia
or other serious bacterial infection in a young infant.
Fever/hypothermia may equally indicate bacterial infection. Fever in a young infant may
indicate a serious bacterial infection, and may be the only sign. Young infants can also respond
to infection by dropping their body temperature / Hypothermia to below 950 F.
Movement only when stimulated or No movement at all. Young infant’s often sleep most
of the time and this is not a sign of illness. If a young infant does not wake up during the
assessment, ask the mother to wake him. An awake young infant will normally move his arms
or legs or turn his head several times in a minute if you watch him closely. Observe the infant’s
movements while you do the assessment. If the infant is awake but has no spontaneous
movements, gently stimulate the young infant. If the infant moves only when stimulated and
then stops moving, or does not move even when stimulated, it is a sign of severe disease.
Redness of the umbilicus or draining pus is a sign of umbilical infection. Early recognition
and treatment of an infected umbilicus are essential.

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Skin pustules Examine the skin of entire body. Skin pustules are red spots or blisters which
contain pus.
Clinical features Probable Diseases/Conditions

Convulsion(s) Meningitis, Encephalitis, Hypoglycemia and
Hypocalcaemia
Stopped feeding well Septicemias, Meningitis, Pneumonia and other
serious illness
Fast breathing & severe chest indrawing Pneumonia, Heart failure
Less movement Septicemia, Severe dehydration
Lethargy/Unconscious Septicemia, Meningitis, Severe dehydration

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CLASSIFICATION OF SICK YOUNG INFANT 0 DAY UP TO 2 MONTHS
VERY SEVERE DISEASES
POSSIBLE SERIOUS BACTERIAL INFECTION or VERY SEVERE DISEASE –

CRITICAL ILLNESS (VSD-CI)
A sick young infant classified as POSSIBLE SERIOUS BACTERIAL INFECTION or VERY
SEVERE DISEASE – CRITICAL ILLNESS (VSD-CI) who has any of the following signs
Any one or more of the Pink:
following signs:
• Unconsciousness/drowsy POSSIBLE
• Convulsion or H/O Convulsion SERIOUS
• Unable to feed BACTERIAL
• Persistent Vomiting INFECTION
• Bulging fontanels or
• Apnoea VERY SEVERE
• Central Cyanosis DISEASE - CRITICAL
• Major Bleeding ILLNESS
• Weight < 1500 gm (VSD-CI)
• Major congenital malformation
• Surgical condition requiring hospitalization

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CLINICAL SEVERE INFECTION (VSD-CSI)
Any one or more of the Pink:
following signs
• Severe chest indrawing POSSIBLE
• Fever (37.5°C* or above) or SERIOUS

BACTERIAL
low body temperature (less than
INFECTION
35.5°C*) or
• Not feeding well VERY SEVERE
• Movement only when DISEASE–
stimulated/ no movement at all CLINICAL
SEVERE
INFECTION
(VSD-CSI)

FAST BREATHING PNEUMONIA (0-6 DAYS)
• Fast breathing (60 breaths per minute or more) for age Pink:
0-6 days
POSSIBLE
SERIOUS
BACTERIAL
INFECTION
or
VERY SEVERE
DISEASE- FAST
BREATHING
PNEUMONIA
(0-6 DAYS)

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FAST BREATHING PNEUMONIA (7-59 DAYS)
• Fast breathing (60 breaths per minute or more) for age Yellow:
7-59 days
FAST
BREATHING
PNEUMONIA
(7-59 DAYS)
LOCAL BACTERIAL INFECTION
• Umbilicus red or draining pus Yellow:

• Skin pustules
LOCAL
BACTERIAL
INFECTION
INFECTION UNLIKELY
• None of the signs of very severe disease Green:
INFECTION
UNLIKELY
JAUNDICE Check for jaundice- Yellow colouration of skin, sclera and mucus membrane.
There are three classifications for jaundice.

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SEVERE JAUNDICE
A sick young infant classified as SEVERE JAUNDICE is one who has yellow palms and soles
or has jaundice within 24 hours of age.
• Any jaundice if age less than 24 hours Pink:
or
• Yellow palms and soles at any age SEVERE
JAUNDICE
JAUNDICE
A sick young infant classified as JAUNDICE is one who has jaundice which appeared after 24
hours of age and the palms and soles are not yellow.
• Jaundice appearing after 24 hours of age Yellow:
and
• Palms and soles not yellow JAUNDICE
NO JAUNDICE
A Young infant classified as NO JAUNDICE who has none of the signs of SEVERE
JAUNDICE and JAUNDICE.
• No jaundice Green:
NO JAUNDICE

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Example: Use part of the IMCI Register with very severe diseases
Case
Jalil is 6 weeks old. He weighs 4.5 kg. His temperature is 98.60 F. The physician asked “What
are the infant’s problems?” The mother said, “Jalil has diarrhoea and a skin rash for the last 3
days”. This is the initial visit for this illness.
The physician Checks the young infant for signs of very severe disease and jaundice. His
mother says that Jalil did not have convulsion. The physician counts 55 breaths per minute. He
finds no chest indrawing. The umbilicus is normal. There are skin pustules. Jalil is not lethargic
or unconscious, and his movements are normal. He does not have jaundice.

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DIARRHOEA
All sick young infants should be checked for diarrhoea. Assessment, classification and
management of diarrhoea in sick young infants are similar to those in older children. However,
assessing thirst by offering a drink is not reliable, so “drinking poorly” is not used as a sign for
the classification of dehydration.
SEVERE DEHYDRATION
Two of the following signs: Pink:
• Movement only when stimulated or no movement at all
• Sunken eyes SEVERE
• Skin pinch goes back very slowly DEHYDRATION
SOME DEHYDRATION
Two of the following signs: Yellow:
• Restless, irritable
• Sunken eyes SOME
• Skin pinch goes back slowly DEHYDRATION
NO DEHYDRATION
• Not enough signs to classify as some or severe Yellow:
dehydration
NO
DEHYDRATION
Example: Use part of the IMCI register for young infant of 0-2 months with diarrhoea

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Case
finds no chest indrawing. The umbilicus is normal. The body temperature is normal. There are
skin pustules. Jalil is not lethargic or unconscious, and his movements are normal. He does not
have jaundice.
When the physician asks the mother about Jalils diarrhoea, the mother replies that it began 3
days ago. Jalil is crying. He stopped once when his mother put him the breast. He began crying
again when she stopped breastfeeding. His eyes look normal, not sunken. When the skin of his
abdomen is pinched, it goes back slowly.

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FEEDING PROBLEMS OR LOW WEIGHT
All sick young infants seen in outpatient health facilities should be assessed for weight and
feeding status. Special attention is given to breast-feeding technique.
ASSESSMENT OF FEEDING
• Breast feeding frequency including night feeds
• Type of other foods or fluid
• Frequency of other feeding and how feeding is given and
• Feeding patterns during this illness
Breastfeeding
Signs of good Positioning Signs of good Attachment
• The whole body fully supported • Chin touching breast
• Body close to the mother • Mouth wide open
• Straight head and body • Lower lip turned outward
• Facing breast, nose opposite to nipple • More areola visible above than below the
mouth

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CLASSIFICATION OF FEEDING PROBLEMS OR LOW WEIGHT
VERY LOW WEIGHT FOR AGE

• Weight < 2 kg in infants less than 7 days Pink:
VERY LOW
WEIGHT
FOR AGE
FEEDING PROBLEM OR LOW WEIGHT

• Not well attached to breast Yellow:
• Not suckling effectively
• Less than 8 breastfeeds in 24 hours FEEDING PROBLEM
• Receives other foods or drinks OR
• Low weight for age LOW WEIGHT
• Thrush (ulcers or white patches in mouth)
NO FEEDING PROBLEM
• Not low weight for age and no other signs of Green:
inadequate feeding
NO FEEDING PROBLEM
Note: To find out the low weight for age use the weight-for age growth chart- Birth to 5 years.
If weight-for age falls below the line expressed as -2, he/she will be classified as low weight
for age.
CHECKING IMMUNIZATION STATUS

As for older children, immunization status should be checked in all sick young infants. Illness
is not a contraindication to immunization.
• At birth, BCG should be given.
• Check the mothers immunization status and Vit-A status and give her T.T and Vit-
A if needed
• At 6 Weeks, Penta 1, OPV 1, PCV 1 and IPV should be given

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ASSESSING OTHER PROBLEMS
As for older children, all sick young infants need to be assessed for other problems mentioned
by the mother or observed during the examination. If a serious problem is found s/he should be
referred to hospital.
Example: Use the IMCI register for young infant of 0-2 months
Case
finds no chest indrawing. The umbilicus is normal. The body temperature is normal. There are
skin pustules. Jalil is not lethargic or unconscious, and his movements are normal. He does not
have jaundice.
When the physician asks the mother about Jalils diarrhoea, the mother replies that it began 3
days ago. Jalil is crying. He stopped once when his mother put him the breast. He began crying
again when she stopped breastfeeding. His eyes look normal, not sunken. When the skin of his
abdomen is pinched, it goes back slowly.
Jalil’s mother says that she has no difficulty in feeding him. He breastfeeds about 5 times in 24
hours. She gives him other foods and drinks 2-3 times a day. The physician uses weight for age
chart and determines that Jalil’s weight (4.5 kg) is not low for his age (6 weeks). Since Jalil is
breastfeeding less than 8 times in 24 hours and is taking other foods or drinks, the physician
decides to assess breastfeeding. Jalil’s mother agrees to breastfeed now. The physician
observes that Jalil’s chin is touching the breast. His mouth is wide open and his lower lip is
turned outward. More areola is visible above than below the mouth. His sucks are deep and
slow. Jalil has straight head and body, body close to the mother, the whole body full supported,
facing breast and nose opposite to nipple. When Jalil stops breastfeeding, the physician looks
in his mouth. He sees no ulcers or white patches in his mouth.

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129
130
IDENTIFY TREATMENT AND TREAT THE SICK YOUNG
INFANT 0 DAY UP TO 2 MONTHS
URGENT PRE-REFERAL TREATMENTS FOR SICK YOUNG INFANTS 0 DAY UP

TO 2 MONTHS FOR VERY SEVERE DISEASES
The first step is to give urgent pre-referral treatment(s). Possible pre-referral treatment include:
• First dose of intramuscular antibiotics
• Keeping the infant warm on the way to the hospital
• Prevention of hypoglycaemia with breast milk*
• Frequent sips of ORS solution on the way to the hospital
Note: * Sugar water can be given if breast milk is not available during transport
CLASSIFICATION TREATMENT
POSSIBLE For all infants before referral:
SERIOUS Prevent low blood sugar by giving breast milk or sugar water.
BACTERIAL Advise mother how to keep the infant warm on the way to the
INFECTION OR hospital.
VERY SEVERE Give first dose of antibiotics. The recommended choices are
DISEASES intramuscular Gentamycin and oral Amoxycillin
SEVERE JAUNDICE Encourage breastfeeding
If suckling poorly, give expressed breast milk by cup and spoon
SEVERE If infant do not have other severe classification treat according to
DEHYDRATION plan C
VERY LOW Prevent low blood sugar by giving breast milk or sugar water.
WEIGHT
FOR AGE

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TREATMENT AT THE OUTPATIENT DEPARTMENT FOR SICK YOUNG
INFANTS 0 DAY UP TO 2 MONTHS
FAST BREATHING Give an appropriate oral antibiotic. The recommended choices are
PNEUMONIA oral Amoxycillin.
(7-59 DAYS) Prevent low blood sugar by giving breast milk or sugar water.
LOCAL UMBILICAL/ Give an appropriate oral antibiotic. The recommended choices are
SKIN INFECTION oral Amoxycillin.
Treat local infections and teach the mother to do it at home. (see
chart booklet)
SOME Treat according to plan B
DEHYDRATION
NO DEHYDRATION Treat according to plan A
FEEDING PROBLEM Give appropriate feeding advice.
OR LOW WEIGHT (Including correct position and attachment)
If thrush, teach the mother how to treat thrush at home (see chart
booklet).
ORAL DRUGS
The first dose of oral drugs for a young infant should always be given in the clinic. In addition,
the mother or caregiver should be taught how to give an oral antibiotic at home. That is,
teaching how to measure a single dose, showing how to crush a tablet (if syrup is not available)
and mix it with breast milk.
COUNSELLING A MOTHER OR CAREGIVER

As with older children, the success of home treatment depends on how well the mother or
caregiver knows how to give the treatment, understands its importance, and knows when to
return to a health care provider.
• Counselling the mother or caregiver of a sick young infant:
- Teach how to give oral drugs
- Teach how to treat local infection.

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- Teach how to manage breast or nipple problem
- Teach correct positioning and attachment for breastfeeding
• Counsel on feeding problems.
• Counsel the mother about her own health
• Advise about food and fluids: Advise to breastfeed frequently, at least 8 times/24
hours and/ or as often as possible and for as long as the infant wants, day and night,
during sickness and health
• Advise when to return immediately
• Advice when to return for follow-up visit
• Advise when to return for the next immunization according to immunization

schedule

133
IMCI REGISTERS
IMCI register for child aged 2- 59 months

134
IMCI register for infants of 0-2 months

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ANNEXURES
(For further reading)
Annex - I Assess, Classify and Treat the sick child age 2 months up to 137
5 years
Annex - II Assess, Classify and Treat the sick young infant aged up to 145
2 months
Annex – III Urgent pre-referral treatments 151
Annex - IV Treatment of the sick child in outpatient settings 153
Annex - V Use of Pulse Oximeter 162
Annex - VI Malaria treatment regimen 167
Annex – VII Counsel the mother 170
Annex – VIII Teach the mother to treat local infection at home 176
Annex - IX ETAT 177
Annex - X Management of shock, hypoglycemia and convulsion 182
Annex – XI How to give Oxygen 183
Annex - XII Possible diagnosis or children with general danger signs and 186
4 main symptoms
Annex – XIII IYCF 188
Annex – XIV ECD 192

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ANNEX-I

137
138
139
140
141
142
143
144
ANNEX-II

145
146
147
148
149
150
ANNEX-III
SUMMERY URGENT PRE-REFERAL TREATMENTS FOR THE SICK CHILD FROM AGE 2 MONTHS UP TO 5 YEARS
For all children before referral:
Prevent low blood sugar by giving breast milk or sugar water.
DANGER SIGN- If the child is convulsing, give Diazepam rectally. If convulsions continue after 10minutes, give a
CONVULSIONS second dose of diazepam rectally.
SEVERE PNEUMONIA Give first dose of an appropriate antibiotic. Recommended choices are oral Amoxycillin and
OR VERY intramuscular Gentamicin
SEVERE DISEASE
VERY SEVERE Give one dose of Paracetamol for high fever (101.30F or above). Give first dose of rectal Artisunate (If
FEBRILE available)) or oral Co-artemether for SEVERE MALARIA (high or low malaria risk). Give first dose
DISEASE of an appropriate antibiotic.
SEVERE Give the first dose of appropriate antibiotic.
COMPLICATED Give vitamin A (for children from 6-12 months 100,000 IU & one year and older 200,000 IU
MEASLES
SEVERE WHO TREATMENT PLAN C
DEHYDRATION If there is no other severe classification, IV fluid should be given in the outpatient clinic according to
WHO Treatment Plan C (Annex-IV). Give 100ml/kg IV fluid, Cholera saline /Ringers lactate solution

151
is preferred. Normal saline does not correct acid or replace potassium loses, but can be used. Plain
glucose or dextrose solutions are not acceptable for the treatment of severe dehydration.
If IV infusion is not possible, urgent referral to the hospital for IV treatment is recommended. When
referral takes more than 30 minutes, fluid should be given by nasogastric tube. If none of these are
possible and the child can drink ORS solution must be given by mouth. Note: In areas where Cholera
cannot be excluded for patients more than 2years old with severe dehydration, antibiotics are
recommended. Two recommended choices are Tetracycline and Erythromycin.
SEVERE PERSISTENT If there is no other severe classification, treat dehydration before referral using WHO treatment Plan B
DIARRHOEA for some dehydration and plan C for severe dehydration, then refer to hospital.
MASTOIDITIS Give first dose of an appropriate antibiotic. Two recommended choices are oral Amoxycillin and
intramuscular Gentamicin. Give first dose of paracetamol for pain.
COMPLICATED Give first dose of an appropriate antibiotic. Recommended choices are oral Amoxycillin and
SEVERE ACUTE intramuscular Gentamicin
MALUTRITION

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ANNEX – IV
TREATMENT IN THE OUTPATIENT HEALTH FACILITY OF THE SICK CHILD FROM AGE 2 MONTH UP TO 5 YEARS
PNEUMONIA • Give antibiotic for 5days.
The choice of antibiotic is based on the fact that most childhood pneumonia of bacterial origin is due to
Streptococcus pneumonia or Hemophilus influenzae. PNEUMONIA can be treated with oral
Amoxycillin for 5 days. This antibiotic is usually effective against these two bacteria, relatively
inexpensive, widely available and is on the essential drug list of most countries.
• Soothe the throat and relieve the cough with a safe remedy
• Advise mother when to return immediately
• Follow-up in 3 days
COUGH OR COLD • Soothe the throat relieve the cough with a safe remedy
• Advise mother when to return immediately
• Follow-up in 5 days

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SEVERE Start IV fluid immediately. If the child can drink, give ORS by mouth till the drip is ready. Give
DEHYDRATION 100ml/kg of cholera saline or Ringer’s Lactate Solution (or, if not available, normal saline), divided as
follows:
Age First give 30ml/kg in Then give 70ml/kg in:
Infants (under 12 months) 1 hour 5 hours
Children (12 months up to 5years) 30 minutes 21/2 hours
Repeat once if radial pulse is still very weak or not detectable.
• Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more
rapidly. Also, give ORS (about 5ml/kg/hour) as soon as the child can drink. Usually after 3-4 hours
(infant) or 1-2 hours (children).
• Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then CHOOSE
THE APPROPRIATE Plan (A, B, or C) to continue treatment.
Note: If possible, observe the child at least 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
SOME DEHYDRATION WHO TREATMENT PLAN B
• Give initial treatment with ORS over a period of four hours. The approximate amount of ORS
required is 75ml/kg. During these four hours, the mother slowly gives the recommended amount of
ORS by spoonful or sips.

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Note: If the child is breast-fed, breast-feeding should continue. Children under 6 months who, are not
breastfed-should be given 100-200 ml plain water during this period to prevent hypernatremia
• If the child vomits, wait for 10 minutes and then give more slowly
• If the child wants more give more ORS solution
• After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin.
When there are no signs of dehydration, the child is put on Plan A. If there is still some dehydration,
Plan B should be repeated. If the child now has severe dehydration, the child should be put on Plan
C
NO DEHYDRATION WHO Treatment Plan A
Plan A focuses on the four rules of home treatment:
• Give extra fluids
• Give Zinc supplementation
• Continue feeding
• Advice the caregiver when to return
- If there is blood in the stool
- The child drinks poorly
- Becomes sicker or is not getting better in 5 days
Fluid should be given as soon as diarrhoea starts. The child should take as much as s/he wants.
Correct home therapy can prevent dehydration in many cases. ORS may be used at home to prevent
dehydration. However, other fluids that are commonly available in the home which may be less costly,

155
more convenient and effective especially when given with food e.g. Chira-pani. Cooked rice water
(Bhater Mar) yogurt.
Note: Fluids which should be avoided - Very sweet tea, soft drinks, and sweetened fruit drinks should
be avoided. They can cause osmotic diarrhoea an hypernatremia. Fluids with purgative action and
stimulants (e.g. coffee and some medicinal teas or infusions) also to be avoided.
Continue feeding. Encourage mother to continue breast-feeding and family food according to age.
Recommended home fluid should be:
• Easy to prepare. The recipe should be familiar and its preparation should not require much effort or
time. The required ingredients and measuring utensils should be readily available and inexpensive.
• Acceptable. The fluid should be one that are culturally acceptable and the mother is willing to give
freely to a child with diarrhoea and that the child will readily accept.
• Effective. Fluids that are safe are also effective. Most effective fluids are those containing
carbohydrates, protein and some salt. However, nearly the same result is obtained when fluids are
given freely along with weaning foods that contain salt.
Encourage the mother to continue breastfeeding. If the child is artificially fed with animal milk, limit it
to ½ of the previous amount, what the child was taking. Greater amount may aggravate the diarrhoea.

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Other foods according to age should be given in frequent, small meals, at least six times a day. All
children with PERSISTENT DIARRHOEA should receive supplementary multivitamins and minerals
(iron, magnesium, zinc) each day for two weeks.
DIARRHEOEA IN Diarrhoea is a serious and often fatal event in children with severe malnutrition. For management of
CHILDREN WITH dehydration in severely malnourished children, full – strength ORS solution should not be used for oral
SEVERE or NG rehydration. It provides too much sodium and too little potassium. A suitable oral solution can
MALNUTRITION be prepared by:
• Dissolving a new ORS (containing 75 m Eq/1 of sodium) packet in to 2 liters of clean water
• Adding 45 ml of potassium chloride solution (from stock solution containing 100 g KCL/1); and
• Adding 50g sucrose
This modified solution provides less sodium (37.5mmol/) more potassium (40 mmol/l) and added sugar
(25 g/l), which is appropriate for severely malnourished children with diarrhoea.
DYSENTERY The four key elements of dysentery treatment are:

• Antibiotics
• Fluids
• Feeding
• Zinc

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CIPROFLOXACIN
AGE or WEIGHT (15 mg/kg)
Give two times daily for 3 days
Tablet
250 mg
2 months up to 4 months (4 - <6 kg) 1/4
4 months up to 3 years (6 - <14kg) 1/2
3 years up to 5 years (14 - <19 kg) 1
Follow-up After 3 days. If there is no improvement in 3 days, refer the child.
CHOLERA First line Antibiotic: TETRACYCLINE

Second line Antibiotic: ERYTHROMYCINE
Age or Weight TETRACYCLINE ERYTHROMYCINE
Give four times daily for 3 Give four times daily for 3 days
days
250 mg Tablet 500 mg Tablet
2yrs – 5 yrs (10 – 19 kg) 1 1
MALARIA • Give an oral antimalarial drug (Annex-V)

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• Give one dose of paracetamol for high fever (101.50 F/38.50 C or above) and advice mother to give
paracetamol at home for fever
FEVER – NO MALARIA/ Give one dose of paracetamol for high fever (101.50 F/38.50 C or above). Treat other obvious causes of
FEVER fever.
MEASLES WITH EYE Give first dose of Vitamin A. If clouding of cornea or pus draining from the eye is present, apply
OR MOUTH tetracycline eye ointment. If mouth ulcers, treat with Nystatin ointment and tablet Riboflavin.
COMPLICATIONS
MEASLES Give first dose of Vitamin A
(CURRENTLY OR AGE VITAMIN ‘A’ Dose
WITHIN THE LAST 3 6 months up to 12 months 100,000 IU
MONTHS) One year and older 200,000 IU
ACUTE EAR • Give appropriate antibiotic for 5 days. Recommended antibiotics are oral Amoxycillin or
INFECTION Cotrimoxazole
• Give one dose of paracetamol for pain and advice mother to give paracetamol at home for pain
• Dry the ear by wicking
CHRONIC EAR • Dry the ear by wicking
INFECTION • Treat with topical quinolone ear drops for 14 days
UN COMPLICATED Assess the child’s feeding and counsel the mother on the feeding recommendations.
SEVERE ACUTE

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MALNUTRITION OR
MODERATE ACUTE
MALNUTITION
ANAEMIA If pallor is present give iron or Multiple Micro-nutrient
Give Albendazole/Mebendazole if the child is 1 year or older and has not had a dose in the previous six
months.
AGE Mebendazole Albendazole
Dose Dose
1- 2 year 500 mg 200 mg
2- 5 year 500 mg 400 mg
NO ACUTE If the child is less than 2 years old, assess the child’s feeding and counsel the mother accordingly on
MALNUTITION feeding.
AND
NO ANAEMIA

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PNEUMONIA
AND AGE or WEIGHT AMOXYCILLIN
Give two times daily for 5 days
ACUTE EAR
Tablet/ Dispersible Tablet Syrup
INFECTION
250 mg 125 mg per 5 ml
2 months up to 12 months (4 - 1 6 - 15 ml
<10 kg)
12 months up to 3 years (10 - 2 15 - 20 ml

<14 kg)
3 years up to 5 years (14 - <19 3 20 - 30 ml

kg)

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ANNEX- V
USE OF PULSE OXIMETRY
HYPOXIA
Red blood cells contain a substance called hemoglobin. The hemoglobin is the one that binds
with oxygen and carries the oxygen. When hemoglobin is carrying oxygen it is described as
“saturated with oxygen” Oxygen saturation is a term referring to the concentration of oxygen
in the blood. It measures the percentage of hemoglobin binding sites in the bloodstream
occupied by oxygen. The amount of oxygen carried by the hemoglobin is measured in
percentage of oxygen saturation or referred as SpO2 (Peripheral hemoglobin oxygen
saturation). It is an estimation of the oxygen saturation level.
Normal blood oxygen levels are considered as SpO2 of 95-100 percent. Between 90 and 95
percent, your blood oxygen level is considered low but it is not necessarily indicative of a
health issue. If the level is below 90 percent, it is considered low resulting in hypoxia.
Hypoxia- If the oxygen saturation level in blood is <90%.
WHAT LEVEL OF SPO2 IS IMPORTANT DURING CLINICAL CARE?

• SpO2 should always be above 90% during patient care
• When the SpO2 falls 90% or below the patient is hypoxic and needs oxygen to be
administered or the patient should be referred to hospital for oxygen
A pulse oximeter is an early-warning device for Hypoxia. Its use is simple and non- invasive.
A pulse oximeter consists of the monitor containing the batteries and display, and the probe
that senses the pulse.
THE PULSE OXIMETER MONITOR

The monitor contains the microprocessor and display. The display shows the oxygen saturation,
the pulse rate and the waveform detected by the sensor. The monitor is connected to the patient
via the probe. During use, the monitor updates its calculations regularly to give an immediate
reading of oxygen saturation and pulse rate. The pulse indicator is continuously displayed to
give information about the circulation. The audible beep changes pitch with the value of oxygen

162
saturation and is an important safety feature. The pitch drops as the saturation falls and rises as
it recovers. This allows you to hear changes in the oxygen saturation immediately, without
having to look at the monitor all the time.
THE PULSE OXIMETER PROBE

The oximeter probe consists of two parts, the light emitting diodes (LEDs) and a light detector
(called a photo-detector). Probes are designed for use on the finger, toe or ear lobe. They are
of different types. Ear probes are lightweight and are useful in children or if the patient is very
vasoconstricted. Small probes have been designed for children but an adult hinged probe may
be used on the thumb or big toe of a child. For finger or toe probes, the manufacturer marks
the correct orientation of the nail bed on the probe. The probe connects to the oximeter using a
connector with a series of very fine pins.
PRACTICAL USE OF THE PULSE OXIMETER
Step 1: Ensure the pulse oximeter is well charged. Connect the probe to the pulse oximeter.
Step 2: Select the appropriate probe with particular attention to correct sizing and where it
will go (usually finger, toe or ear). Turn the pulse oximeter on. Always make sure the alarms
are on.
Step 3: The probe emits a red light when the machine is switched on; check that you can see
this light to make sure the probe is working properly.

163
Step 4: Ask the mother to calm the baby. If used on a finger or toe, make sure the area is
clean and well exposed.
Step 5: Put the probe in the toe and position the probe carefully; make sure it fits easily
without being too loose or too tight.
Step 6: Allow several seconds for the pulse oximeter to detect the pulse and calculate the
oxygen saturation. Once the unit has detected a good pulse, the oxygen saturation and pulse

164
rate will be displayed. Look for the displayed pulse indicator that shows that the machine has
detected a pulse. Without a pulse signal, any readings are meaningless.
Step 7: If reading is taken from the thumb, avoid the arm being used for blood pressure
monitoring as cuff inflation will interrupt the pulse oximeter signal.
If no signal is obtained on the oximeter after the probe has been placed on a finger, check the
following:
• Is the probe working and correctly positioned? Try another location.
• Does the patient have poor perfusion?
• Check the temperature of the patient. If the patient or the limb is cold, gentle rubbing
of the digit or ear lobe may restore a signal.
Tip: If you are uncertain that the probe is working properly, check it by
testing it on your own finger.
WHAT DO THE ALARMS ON A PULSE OXIMETER TELL YOU?
The alarms are as follows:

• Low saturation emergency (hypoxia) SpO2 <90%
• No pulse detected
• Low pulse rate
• High pulse rate

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CARE OF PULSE OXIMETER
• Keep the battery fully charged

• When the probe gets dirty, clean it gently with a damp cloth or alcohol swab
• Position safely to avoid dropping or damage from spillages
• Insert the plug or the lead correctly to avoid damage. Always look at the shape of the lead
before inserting
• Disconnect the probe carefully holding it firmly
• When disconnecting the probe, grip the cable firmly and not the cable
• When not in use, always coil the lead and position the probe where it cannot be damaged
SEVERAL FACTORS CAN INTERFERE WITH THE CORRECT FUNCTION OF A

PULSE OXIMETER INCLUDING:
• Light – Bright light (such as the operating theatre light or sunlight) directly on the
probe may affect the reading. Shield the probe from direct light.
• Shivering – Movement may make it difficult for the probe to pick up a signal.
• Pulse volume – The oximeter only detects pulsatile flow. When the blood pressure is
low due to hypovolaemic shock or the cardiac output is low or the patient has an
arrhythmia, the pulse may be very weak and the oximeter may not be able to detect a
signal
• Vasoconstriction reduces blood flow to the peripheries. The oximeter may fail to
detect a signal if the patient is very cold and peripherally vasoconstricted.
• Carbon monoxide poisoning may give a falsely high saturation reading. Carbon
monoxide binds very well to haemoglobin and displaces oxygen to form a bright red
compound called carboxy haemoglobin. This is only an issue in patients following
smoke inhalation from a fire.

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ANNEX -VI
MALARIA TREATMENT REGIMEN

Pre-referral treatment:
• Artesunate suppository should be used. Dose is 10 mg/kg body weight
• Immediate referral should be made to the nearest health facility
Hospital treatment:
• Oral antimalaria drug should be started and full dose should be given
FALCIPARUM MALARIA
First line treatment:

Artemether + Lumefantrine combination (ACT – Artemether Combination Therapy)- 6 doses
over 3 days
Drug Day No of Dose Time 5-<15kg 15-<20kg
(5 months up to (3 years up to 5
3 years) years)
Tab. Day - 1 1st 0 hour 1 2
Artemether + 2nd 8 hour 1 2
Lumefantrine Day - 2 3rd 24 hour 1 2
combination 4th 36 hour 1 2
Day - 3 5th 48 hour 1 2
6th 60 hour 1 2
• Artemether + Lumefantrine combination (ACT) is to be given after confirming the

diagnosis and treatment should be started immediately (0 hours). The second dose
should be given 8 hours after the first dose. The subsequent dose will be given 24
hours after first dose (or 16 hours after giving second dose). Then the doses are to
be given 12 hourly until the total 6 doses have been achieved.
• Artemether + Lumefantrine combination (ACT) is well absorbed with fatty meal so
encourage the patients to have it with milk or other fatty meals

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VIVAX MALARIA
If BSE &/or RDT is positive for P. vivax then it will be labeled as VM

In this case –
Chloroquine 3 days + Primaquine 14 days (cq3+pq14)
Chloroquine Primaquine
Day 1 Day 2 Day 3 Give daily
for 14 days
AGE or Tablet Syrup Tablet Syrup Tablet Syrup Tablet
WEIGHT 15 50 mg 15 50 mg 15 50 mg 2.5 mg
mg Base mg Base mg Base
per per per
5 ml 5 ml 5 ml
2 months up
to 12 months 1/2 7.5 ml 1/2 7.5 ml 1/4 4 ml 0
(4 - <10 kg)
12 months up
to 5 years 1 15 ml 1 15 ml 1/2 7.5 ml 1
(10 – 19 kg)

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IF RDT AND BLOOD SMEAR NOT AVAILABLE
Chloroquine
Day 1 Day 2 Day 3
Tablet Syrup Tablet Syrup Tablet Syrup
AGE or WEIGHT 15 50 mg 15 50 mg 15 50 mg
mg Base mg Base per mg Base per
per 5 ml 5 ml
5 ml
2 months up to 12
1/2 7.5 ml 1/2 7.5 ml 1/4 4 ml
months (4 - <10 kg)
12 months up to 5
1 15 ml 1 15 ml 1/2 7.5 ml
years (10 – 19 kg)
*For further treatment please see Revised malaria treatment regimen – 2017 (Recommended
by national malaria control programme of DGHS)

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ANNEX – VII
COUNSEL THE MOTHER

170
171
172
173
174
COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS
If the child is not being fed as described in the above recommendations, counsel the mother
accordingly. In addition:
• If the mother reports difficulty with breastfeeding, assess breastfeeding:
See YOUNG INFANT chart. As needed, show the mother correct positioning and
attachment for breastfeeding
• If the child is less than 6 months old and is taking other milk or foods:
- Build mother’s confidence that she can produce all the breast milk that the child needs
- Suggest giving more frequent, longer breastfeeds day or night and gradually reducing
other milk or foods
• If other milk needs to be continued, counsel the mother to:
- Breastfeed as much as possible, including at night. Make sure that other milk is a locally
appropriate breast milk substitute. Make sure other milk is correctly and hygienically
prepared and given in adequate amounts
- Finish prepared milk within an hour
• If the child is not being fed actively, counsel the mother to:
- Sit with the child and encourage eating
- Give the child an adequate serving in a separate plate or bowl
• If the child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and for longer if possible
- Use soft, varied, appetizing, favorite foods to encourage the child to eat as much as
possible and offer frequent small feeds
- Clear a blocked nose if it interferes with feeding
- Expect that appetite will improve as child gets better
• If the child has poor appetite:
- Plan small, frequent meals
- Clear a blocked nose
- Check regularly
• If the child has sore mouth or ulcers:
Give soft foods that will not burn the mouth, such as, eggs, mashed potatoes, banana,
papaya, mango etc.
• Follow-up any feeding problem in 2 days

175
ANNEX –VIII

176
ANNEX – IX
EMERGENCY TRIAGE ASSESSMENT AND TREATMENT (ETAT)

Deaths in hospital often occur within 24 hours of admission. Many of these deaths could be
prevented if very sick children are identified soon after their arrival and treatment is started
immediately. This chapter outlines a process of rapid screening to determine whether any
emergency or priority signs are present.
TRIAGE is the process of rapidly screening of sick children when they first arrive in hospital
and placing them in one of the following groups:
• Those with emergency signs, require emergency treatment to prevent death
• Those with priority signs, should be given priority while waiting in the queue so
that they can be assessed and treated without delay
• Those with neither emergency nor priority signs to get routine treatment
EMERGENCY SIGNS
• Stridor
• Severe respiratory distress
• Central cyanosis
• Grunting
• Signs of shock (capillary refill time> 3 seconds; and weak, rapid pulse)
• Coma
• Convulsions
• Signs suggesting severe dehydration on child with diarrhoea
If any of these signs are found immediately give the appropriate emergency treatment
PRIORITY SIGNS
If no emergency signs are present: Check for priority signs. These are –
• Oedema of both feet
• Visible severe wasting
• Severe palmer pallor

177
• Any sick young infant (<2 months old)
• Lethargy, drowsiness, unconsciousness
• Continually irritable and restless
• Major burns
• Any respiratory distress
• Child with urgent referral note from another facility
These children need prompt assessment to determine what further treatment is needed, they
should not be asked to wait in the queue. If a child has trauma or other surgical problems, get
surgical help.
If children have neither emergency nor priority signs, then assess and treat the child but will
follow regular queue like non-urgent patients.
Note: Give emergency treatment to the child with severe malnutrition. During the triage
process, all children with severe malnutrition will be assessed for priority signs for prompt
treatment as the case-fatality rate in these children is very high. They should be specifically
assessed for serious problems such as hypoglycemia, hypothermia, severe infection, severe
anemia and xerophthalmia and should be treated accordingly.

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TRIAGE OF ALL SKCK CHILDREN
EMRGENCY SIGNS
If any sign is positive:
• Give treatment (s) (recommended)
• Call for help
• Draw blood for emergency laboratory investigation (glucose, Hb% and blood film for MP)
ASSES TREATMENT
AIRWAY and • Difficult breathing or If foreign body aspiration
BREATHING • Central Cyanosis or • Send the child to appropriate place
Any sign
• Severe respiratory distress positive
If there is no foreign body
• Give oxygen
• Keep the child warm
• Offer appropriate treatment
ASSES • Cold extremities • Give oxygen
CIRCULATION • Capillary refill longer than 3 Any sign • Keep the child warm
seconds positive • Stop any bleeding
• Weak and rapid pulse

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Check for • If no severe malnutrition:
severe • Insert IV and begin giving fluids rapidly
malnutrition
If severe malnutrition:
If lethargy or unconscious:
• Give IV glucose orally or by NG tube
• Insert IV line and give fluids
If not lethargic or unconscious:
• Give IV glucose orally or by NG tube
• Proceed immediately to full assessment and treatment
3.COMA/ • Coma or • Manage airway
CONVULSION • Convulsion (now) Any sign • If convulsing, give P/R diazepam or paraldehyde rectally
positive • Ensure proper position for unconscious child (if head or
neck trauma is suspected stabilize the neck first)
• Give IV glucose

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4.SEVERE Diarrhoea plus any two of these: • Keep the child warm
DEHYDRATION • Lethargy/unconsciousness
Any 2
• Sunken eyes signs
If No severe malnutrition:
• Very slow skin pinch positive • Insert Iv line and begin fluids rapidly and Diarrhoea
• Drinking poorly/unable to Treatment Plan C in hospital
drink
Check for
If Severe malnutrition:
severe
DO NOT GIVE I/V FLULD EXCEPT THE PATIENT IS IN
Malnutrition
SHOCK
• Give ORS through NG tube
• Proceed immediately to full assessment and treatment
PRIORITY SIGNS
Children with the following sign/signs need prompt assessment and treatment:
• Visible severe wasting
• Odema of both feet
• Severe palmer pallor
• Lethargy
• Continually irritable and restless
• Respiratory distress
Note: Any sick young infant and any child referred urgently from another facility also need prompt assessment and treatment

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ANNEX – X
HOW TO GIVE OXYGEN
Oxygen can be delivered by-

• Nasal prongs
• Nasal Catheter
• Face mask
• Head box
NASAL PRONGS
• Place the prongs just inside nostrils and secure with adhesive tape
Indications of Oxygen
• Unable to drink
• Cyanosis
• Head nodding
• Restlessness
• Convulsion
• Respiratory rate > 70br/min
NASAL CATHETER
• Use 8 F size tube
• Measure the distance from the side of the nostril to the
inner eyebrow margin with the catheter
• Insert the catheter to this depth
• Secure with adhesive tape
Start oxygen flow at 1-2 liters/minute

182
ANNEX – XI
HOW TO MANAGE SHOCK, HYPOGLYCEMIA AND CONVULSION
Shock. It is a clinical state characterized by diminished tissue perfusion and manifested by

weak, rapid pulse, hypotension, cold extremities and capillary refill time > 3 sec. It may be due
to:
• Hypovolemia (Hypovolemic shock)
• Cardiac failure (Cardiogenic shock)
• Septicemia (Septic shock)
There are two other types of shocks - one is neurogenic and another is anaphylactic. In this
section, we will discuss the management of hypovolemic shock for children with or without
malnutrition.
MANAGEMENT OF SHOCK WITH/ WITHOUT SEVERE MALNUTRITION

183
*Note: If the child deteriorates further during the IV rehydration (breathing increases by 5
breaths/min or pulse by 25 beats/min), stop the infusion because IV fluid can precipitate heart
failure.
SHOCK WITHOUT SEVERE MALNUTRITION (HYPOVOLEMIA):

Initial treatment:
Fluid – Bouts of 20 ml/kg of normal saline/Ringers lactate solution should be given rapidly
until pulse is perceptible and BP recordable.
Child with severe hypovolemic shock, may require maximum of 60 – 80ml/kg fluid within 1st
1-2 hrs. After initial treatment, reassess and identify the cause and treat accordingly.
MANAGEMENT OF HYPOGLYCEMIA
• Insert IV canula and draw blood rapidly for emergency laboratory investigations
• Check blood glucose immediately with dextrostix. If low (< 2.5mmol/liter i.e.
45mg/dl in a well-nourished or <3 mmol/liter i.e. 54 mg/dl in a severely
malnourished child) is considered as hypoglycemia.
Or if dextrostix is not available but clinically suspected to have hypoglycemia
- Give 5 ml/kg or 10% dextrose solution by IV route (1ml 25% glucose +1.5ml
distilled water)
- Re-check the blood glucose in 30 minutes of glucose injection. If it is still low,
repeat
- Re-check the blood glucose in 30 minutes of glucose injection. If it is still low,
repeat
- Feed, as soon as the child regains consciousness
- If not able to take food, give:
Milk or sugar solution via nasogastric tube

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HOW TO GIVE P/R DIAZEPAM FOR CONVULSION
Diazepam:
Dose :0.5mg/kg
Take the calculated amount of diazepam in a 3cc syringe and put a butterfly needle at the nozzle
of the syringe. Cut the butterfly needle along the half way of the tube and then introduce about
4-5 cm into the anus. Then push the medicine & press the buttock around the anus for 2 minutes.

185
ANNEX – XII
POSSIBLE DIAGNOSES OF CHILDREN WITH GENERAL DANGER SIGNS AND FOUR MAIN SYMPTOMS
MAIN SYMPTOMS AND POSSILBLE DIAGNOSES

Unconsciousness, Lethargy or Cough of difficult breathing Diarrhoea Fever
convulsions
• Meningitis • Pneumonia • Acute watery diarrhoea • Malaria
• Encephalitis/Encephalopathy • Severe anaemia • Cholera • Septicemia
• Cerebral Malaria • Cardiac failure • Dysentery • Typhoid
• Febrile convulsion • Congenital Heart disease • Persistent diarrhoea • Urinary tract infection
• Hypoglycemia • Pulmonary tuberculosis • Diarrhoea with severe • Meningitis
• Head injury • Pertussis malnutrition • Otitis media
• Poisoning • Foreign body in larynx • Osteomyelitis
• Shock (can cause lethargy or • Empyema • Septic arthritis
unconsciousness, but is unlikely to • Pneumothorax • Skin and soft tissue
cause convulsions) infection
• Diabetic ketoacidosis • Pneumonia
• Viral infections
• Tonsillitis

186
The following are possible diagnoses • Retropharyngeal abscess
of young infants referred to the • Sinusitis
hospital with lethargy: • Measles
• Birth asphyxia, hypoxic ischemic • Meningococcal infection
encephalopathy, birth trauma such • Typhus
as trauma to the brain • Dengue hemorrhagic fever
• Intercranial hemorrhage
• Kernicterus due to Hemolytic
disease of the new born
• Neonatal tetanus
• Meningitis
• Sepsis

187
ANNEX – XIII
INFANT AND YOUNG CHILD FEEDING
Appropriate feeding practices are essential for proper nutrition, development and survival of
infant and young children. These feeding practices which include both breast feeding and
complementary feeding are collectively known as infant and young child feeding (IYCF)
practice.
BREAST FEEDING
Breast feeding promotion is a key child survival strategy. It is the best gift that a mother can
give to her baby. It is a complete food and contains all the nutrients those a baby needs for
normal growth, development and protection against infections.
It is estimated that about 1 million newborn deaths could be prevented globally, if breast
feeding would have been initiated within ½ hour of birth. There is also published evidence that
U5 mortality rate could be reduced by 13% through exclusive breast-feeding up to 6 months.
Further 6% deaths can be prevented by timely starting of proper complementary feeding with
continuation of breast feeding up to 2 years of age.
Therefore, promotion of early initiation of breast feeding (within half an hour of birth),
ensuring exclusive breast feeding for 6 months, adding proper complementary feeding after
completion of 6 months of age with continued breast feeding up to 2 years of age are the
essential steps of child survival.
There are documented scientific evidence that exclusively breastfed babies have less diarrhoea,
less respiratory and other infections and more survival rate than formula fed babies.
PRE-LACTEAL FEEDING
It is the feeding of anything other than breast milk given prior to the establishment of breast
feeding e.g. Honey, water, mustard oil, sugar water (misri-pani) etc.
Hazards of pre-lacteal feeding
This hazardous practice may lead to higher risk of colostrum rejection, lactational failure,
infection, malnutrition & deaths.

188
FACTORS FOR SUCCESSFUL BREAST FEEDING
Proper positioning and good attachment
Proper positioning and good attachment of the baby with mother and her breast is needed for
successful breast feeding. During breastfeeding-baby suck, pauses and suck again in slow deep
sucking, and mother may hear baby’s swallowing.
Proper positioning Good attachment
• The baby is fully supported • The baby’s chin is touching the breast
• Body close to the mother • The baby’s mouth is open widely
• Straight head and body • The baby’s lower lip is turned outwards
• Facing breast, nose opposite to the • More areola is seen above than below
nipple
Exclusive breast feeding

Giving baby only breast milk, not even a drop of water or other foods till 6 months of age, is
exclusive breast feeding. Baby does not require any other food during the initial 6months of
age for optimum growth and development.
For successful breast feeding, 3 most important elements are:
• Mother’s commitment
• Mother’s nutrition
• Mother’s mental well-being.
HOW TO ENSURE BREAST FEEDING?

• Building confidence to the mother about her ability to breastfeed her child
• Explaining the benefits of breast feeding and hazard of artificial feeding
• Allowing extra and nutritious food to the mother

189
• Special care to the mother’s health
• Showing and helping mother good positioning and attachment during feeding her
child
• Motivation and support form other family members as well as peer groups
Breast feeding is an unique way of providing nutrition for optimum growth and development
of infants. Breast feeding should be initiated within half an hour of delivery and no pre-lacteal
foods should be given. Infants should be exclusively breastfed for the first six months of life
and after that infant should be fed nutritionally adequate and safe complementary foods to meet
their increasing nutritional requirements. Breast feeding should be continued for two years of
age and beyond.
To ensure exclusive breastfeeding accurate information should be provided to the mother.
Mothers should get support from their husbands, families and communities and from the health
care provider. However, every effort should be given to improve the diet of the mother. In
addition, the danger of the bottle feeding and of breast milk substitutes should be clearly
communicated to mothers, their husbands and families at every opportunity.
COMPLEMENTARY FEEDING
Complementary feeding (CF) means giving other foods, in addition to breast milk, after
completion of 6 months of age. Appropriate CF means provision of right foods at right time in
right amount prepared and delivered hygienically along with breast milk to sustain growth of
the baby. During the period of complementary feeding a baby is made gradually accustomed
to eating family foods.
Good complementary foods should be-

• A combination of energy rich (rice, ruti, oil, noodles, potato), body building (fish,
meat, egg, pulses) and protective (fruits, micronutrients and vegetables) foods
• Clean and safe
• Easy to prepare from family foods, should be home-cooked & nutritionally
adequate
• Locally available and affordable
• Easy for child to eat and liked by the child

190
Frequency of giving of complementary foods
• 6-12 months: 3 times daily
• By 12-24 months: Continue complementary foods, increasing to at least 5 times (3
meals and 2 snacks) daily along with breast feeding
• By 3rd year: Accustom to family foods gradually
OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES BY AGE OF

CHILD
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 24
Age in
month
Initiate breast feeding

Continue breast feeding
within half hour of birth
No pre-lacteal feeds No bottle feeding
Give colostrum
Feed CF 2-3 Feed CF 3-4 times a day plus snacks
Exclusive breastfeeding
times a day
(no liquids or food other
plus snacks
than breastmilk)
Increase frequency, amount and variety of

No bottle feeding
complementary foods, including animal foods,
fruits and vegetables, legumes, oils/fat. Gradually
Do not start CF complete transition to family food
(complementary feeding)
*Source: National Strategy for IYCF 2007

Infants are particularly vulnerable during the transition period when complementary feeding
begins. To ensure their nutritional needs, complementary feeding has to be started at the end
of 6 months of the age along with breast feeding. To ensure exclusive breast feeding, accurate
information should be provided to the mother. Mothers should get support from their husbands,
families and communities and from the health care provider. However, every effort should be
given to improve the diet of the mother. In addition, the danger of the bottle feeding and of
breast milk substitutes should be clearly communicated to mothers, their husbands and families
at every opportunity.

191
ANNEX – XIV
EARLY CHILDHOOD DEVELOPMENT
Period from conception to 5 years of age is early childhood. This period is the key to subsequent
growth. development & ultimate productivity. The developmental process that a child goes
through during this period is termed as ‘Early Childhood Development’.
A CHILD
• According to the UN convention, all human beings aged 0 to 18 years are children
• According to the National children policy – all human beings aged 0 to 18 years are
children
THE LIFE OF A CHILD CAN BE DIVIDED INTO SEVERAL STAGES

• Intra-uterine: Embryo and foetus
• Neonate (birth to 28 days of age)
• Early infancy (the first six months)
• Late infancy (6 to 12 months)
• Toddler (1 to 3 years)
• Pre-school child (3-6 years)
• Late childhood (6 to 9 years)
• Adolescence (10 to 18 years)
IMPORTANCE OF EARLY CHILDHOOD DEVELOPMENT

Early Childhood Development (ECD) is one of the most important periods in life of a human
being when the foundations for future learning and quality of life takes place.
Between the sixth week and fifth months of pregnancy, 100 billion cells grow in baby’s brain.
Some of these brain cells are connected at birth, but most are not. During the first 5 years of
life maximum connections occur. After 5 years of age connection occurs at a slower rate in the
baby’s brain.
At birth, 100 billion neurons form more than 50 trillion connections in the brain. Each neuron
is capable of forming up to 15,000 connections or synapses. By 3 years of age, about 1,000
trillion synapses will have been formed. These synapses constitute wiring that allows

192
learning/development to take place. About 80 – 90% of neuronal connections are completed
within 5 years.
GROWTH AND DEVELOPMENT

Growth and development is one of the most common concern of the parents.
Growth refers to physical maturation and signifies an increase in size of the body parts and
various organs. It occurs as a result of tissue hyperplasia, hypertrophy and differentiation.
Development means attainment of functional maturity, which implies acquisition of skills,

emotional development & social adaptation.
A complete child is one who has both the optimum physical growth and mental development.
FACTORS INFLUENCING GROWTH AND DEVELOPMENT

• Genetic: Heredity influences growth & development
• Nutrition: Nutritional deficiency considerably retards growth
• Health status of pregnant mothers has a positive impact on growth & development
• Influence of hormones like thyroxin, GH, insulin etc. also have an immense
influence on growth & development
• Associated childhood diseases (genetic, chromosomal abnormalities, chronic
illnesses like TB, heart diseases, kidney diseases etc.) have an adverse effect.
• Emotional and cultural: Emotional trauma from unstable family, loss of parents,
inadequate schooling all have negative effect on growth & development
• Intrauterine: Intrauterine growth retardation (IUGR) and maternal infections and
diseases adversely affect the fetus and thereby the newborn infants
• Socio-economic: Poor socioeconomic condition affects growth & development
• Environmental: Physical surroundings (e.g. sunshine, living standard,
psychological, social interactions have a positive effect over growth &
development)
• Growth potentials: The smaller the child at birth the smaller he is likely to be in
subsequent years. The reverse is also usually true

193
HOLISTIC DEVELOPMENT OF A CHILD
A child is not merely a body of flesh and bones. A child also has a mind. Hence for the complete
well-being of a child we have to ensure care of both body and mind. Only then we can say that
we have addressed the whole child. The complete development of the child encompassing both
growth & development is termed ‘Holistic development’.
KEY NEEDS OF A CHILD

For optimum growth we have to ensure adequate nutrition & health care. For optimum
development we have to ensure the presence of an environment which facilitates positive
interaction of the child with his caregivers and surrounding animate & inanimate objects,
besides nutrition & health care.
BRAIN GROWTH & INTERACTION
GROWTH
• At Birth
30% of adult brain weight achieved
• At 3 years
85% of adult brain weight achieved
Most of the brain weight is attained by 3-5 years.
• After birth
Brain development depends on increase in connections
INTERACTION
It is a continuous process of give and take between:

194
People
Child
Things in the
environment
Repeated interactions stimulation from the environment increase the connections.
Increased
connections
DEVELOPMENT
BRAIN
• Key points on brain development

a. Brain is not mature at birth
KEY POINTS ON BRAIN DEVELOPMENT

• Brain is not mature at birth
• Brain is changed by experience
• Human development depends on the interaction between nature and nurture
• The human brain has a remarkable capacity to change, but timing is crucial within
5 years Of life.
• Any insult adversely impairs brain development
Malnourished children have better outcome when nutrition, as well as, stimulation
is given
• Principles of brain development
- Development is a continuous process from conception to maturity
- Development depends on maturation & myelination of nervous system

195
- Sequence of development (cranio-caudal) is same for all, but rate of
development varies from child to child
DOMAINS OF DEVELOPMENT
Gross motor concerns with the posture and gross movements e.g. Head control, sitting,
throwing, catching, standing, walking and balance.
Fine motor and vision deals with hand manipulation, reaching and grasping. Vision deals with
sight. Both together deals with hand–eye coordination, finger control, placing and replacing of
objects.
Hearing and speech. Normal hearing is necessary for speech and language development.
Speech and language development is greatly influenced by the environment.
Social behavior and play. It is concerned with social and personal relationship and affection
such as interaction with other children and with adults. In addition, play is important for
selfcare (such as dressing, feeding, toilet training and table manners and with the development
of individual personality).
MILESTONES OF DEVELOPMENT AT DIFFERENT AGES

Age Group Gross Motor Fine motor & vision Hearing & speech Social behavior and play
6 weeks • Pulled to sit: • Stares at mother’s • Startle response • Social smile: Child
Partial head face during feeding smiles in response to
lag (visual fixation) mother’s smile without
any stimuli
3 months • Neck control • Holds rattle placed • Turns head to • Recognizes his mother
achieved in hand sound
6 months • Sits with • Transfers objects • Monosyllable: • Plays with paper
support from one hand to Ba, Da, Ka
other
9 months • Crawls • Finger thumb • Bisyllable: mama, • Plays pat-a-cake (hand
apposition: picks dada, baba clapping)
pellet between tip of

196
thumb and tip of
fore finger
12 months • Walks holding • Points with index • Responds to own • Drinks from cup
furniture finger name by turning
when calling
15 months • Climbs • Takes off shoes • R Will say around • Kisses pictures of
upstairs 15 words animal
18 months • Climbs up & • Takes off socks • Points to 3 body • Toilet control: indicate
down • Scribble on papers parts on requests - toilet needs-potty.
eye, nose and
mouth
When to suspect Developmental Delay?*

If a child has (no/not)-
• Social Smile : by 3 months of age
• Neck control : by 5 months of age
• Sits without support : by 12 months of age
• Stands without support : by 18 months of age
• Walks well : by 20 months of age
• 2-3 words sentence : by 36months of age

: by 48 months of age
• Tells self-name
: by 60 months of age
• Toilet Control
*Kalra V. Practical Paediatric Neurology. 2nd Edn. Arya Publication, New Delhi, 2008
EARLY STIMULATION
Infants who show early signs of developmental delay need early stimulation which include
measures, such as, making additional efforts to make the child sit or walk, giving toys, playing
with the child, speaking & encouraging him to speak, prompting the child to interact with
others.

197
AUTISM
Autism is a neuro-developmental disorder of children characterized by –
• Impaired social interaction and communication (Impairment in eye contact and poor
response to name being called)
• Failure to develop pretend play (social imitative play) and not following the
instruction
• Restricted, repetitive and stereotyped patterns of behavior, interest and activities
One of the most important things you can do as a parent or caregiver is to learn the early signs
of autism and become familiar with the typical development milestones that your child should
be reaching.
The following “red flags” may indicate the child is at risk for an autism spectrum disorder. If
the child exhibits any of the following, please don’t delay to refer the child to a child
development center of tertiary level hospital (Shishu Bikash Kendro) for an evaluation.
RED FLAGS*
• No gig smiles or other warm, joyful expressions by six months or thereafter
• No back-and-forth sharing of sounds, smiles or other facial expressions by nine
months
• No babbling by 12 months
• No back-and-forth gestures such as pointing, showing, reaching or waving by 12
months
• No words by 16 months
• No meaningful, tow-word phrases (not including imitating or repeating) by 24
months
• Any loss of speech, babbling or social skills at any age
THE END

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IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

Government of the People’s Republic of Bangladesh

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

INTEGRATED MANAGEMENT OF CHILDHOOD

IMCI STUDENT’S HANDBOOK

*Source: Bangladesh Demographic and Health Survey (BDHS) – 2017-18

IMCI STUDENT’S HANDBOOK

Acute resp infection

Birth asphyxia / trauma

Other neonatal conditions

Diarrhoeal Diseases Meningitis/ Encephalitis

45% of global under five deaths are associated

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

RATIONALE FOR AN EVIDENCE-BADED SYNDROMIC

Many well-known prevention and treatment A more integrated approach in

diarrhoeal deaths. Effective antibiotics have saved

IMCI STUDENT’S HANDBOOK

IMCI as a key strategy for Improving child health

The objectives of the strategy are:

IMCI STUDENT’S HANDBOOK

The strategy includes three main components:

THE PRINCIPLES OF INTEGRATED CARE

The IMCI guidelines are based on the following principles:

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

On arrival, health care provider will do the following task:

IMCI STUDENT’S HANDBOOK

IMCI STUDENT’S HANDBOOK

THE INTEGRATED MANAGEMENT PROCESS (2 MONTHS UP TO 5 YEARS)

OUTPATIENT HEALTH FACILITY

CHECK FOR GENERAL DANGER SIGNS

ASSESS MAIN SYMPTOMS

ASSESS IMMUNIZATION STATUS

Check for OTHER PROBLEMS

CLASSIFY ILLNESS and

Urgent Referral Treatment at Outpatient Health Home Management

OUTPATIENT HEALTH FACILITY

IMCI STUDENT’S HANDBOOK

THE INTEGRATED MANAGEMENT PROCESS (0 DAY UP TO 2 MONTHS)

OUTPATIENT HEALTH FACILITY

CHECK FOR VERY SEVERE DISEASES

CHECK FOR JAUNDICE

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

CLASSIFY ILLNESS and IDENTIFY TREATMENT

Urgent Referral Treatment at Outpatient Health Home Management

OUTPATIENT HEALTH FACILITY

• Follow-up • Continue feeding

IMCI STUDENT’S HANDBOOK

OUTPATIENT MANAGEMENT OF CHILDREN

AGE 2 MONTHS UP TO 5 YEARS

IMCI STUDENT’S HANDBOOK