At the start of a sick child (2 months to 5 years) consultation
Ask the mother what the childs problems are. Determine if this is an initial or followup visit for this problem.
IMCI Case Management
Focused Assessment Danger signs Main Symptoms Nutritional status Immunization status Other problems Classification
Need to Refer
Specific treatment
Home management
Treatment Identify treatment Treat
Counsel & Follow-up Counsel caretakers Follow-up
Check for general danger signs
Ask: Not able to drink or breastfeed, Vomits everything, Convulsions, or Look: Abnormally sleepy or difficult to awaken
Need to Refer (except in severe dehydration)
Ask about the main symptoms
Cough or difficulty in breathing Diarrhea Fever Ear problem
Cough or difficulty in breathing
Ask: For how long? Look: Count RR Chest indrawing Stridor
The child must be calm.
Any general danger sign or Chest indrawing or Stridor
SEVERE PNEUMONIA OR VERY SEVERE DISEASE
1st dose of antibiotic Vitamin A Breastfeeding/sugar water URGENT REFERRAL
Fast breathing 2 12 months old: 50/minute 1 year or older: 40/minute
PNEUMONIA
Antibiotic for 5 days Relieve cough with safe remedy Advise mother on danger signs Follow up in 2 days
No signs of pneumonia or a very severe disease
NO PNEUMONIA: COUGH OR COLD
If cough 30 days refer to hospital for assessment Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement
Diarrhea: Classify For dehydration
Persistent diarrhea Blood in the stool
Classify for dehydration
2 or more of the following:
Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly
SEVERE DEHYDRATION
Plan C
Plan C: To treat dehydration quickly
IV fluid: LRS 100 ml/kg body weight (in 6 hrs for infants; 3 hrs for children)
NO
IV treatment within 30 minutes
NO
Oresol/NGT
Plan C: To treat dehydration quickly
Oresol/NGT
NO
Oresol p.o.
NO
URGENT REFERRAL
Classify for dehydration
2 of the following:
Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly
SOME DEHYDRATION
Plan B
Plan B: Treat some dehydration with ORS
Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Age < 4 mos 4-12 mos
Amount
200-400
400-700
Plan B: Treat some dehydration with ORS
Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Age 12 mos-2 yrs 2-5 yrs
Amount
700-900
900-1400
Plan B: Treat some dehydration with ORS
Show the mother how to give Oresol to the child: frequent sips from a cup If the child vomits, wait for 10 minutes. Then continue, but more slowly. Continue breastfeeding if the child wants to breastfeed. If the child develops puffy eyelids, stop ORS.
Plan B: Treat some dehydration with ORS
After 4 hours: Reassess the child & classify for dehydration. Select appropriate plan. Begin feeding the child in the health center.
Classify for dehydration
Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION
NO DEHYDRATION
Plan A
Plan A: Treat diarrhea at home
Give extra fluid.
Up to 2 yrs 50 100 ml after each LBM
2 -4 yrs
100 200 ml after each LBM
Continue feeding. Know when to return.
Persistent diarrhea: 14 days or more
+ Dehydration=severe persistent diarrhea
Treat dehydration Give Vitamin A Refer to hospital
Persistent diarrhea: 14 days or more
No dehydration=persistent diarrhea
Advise regarding feeding Give Vitamin A Follow up in 5 days
Blood in the stool = dysentery
Oral antibiotic for shigella for 5 days Follow up in 2 days
Fever: (history/temperature 37.5C or above)
Malaria risk?
Measles now or w/in last 3 mos Dengue risk?
Fever: Ask about malaria risk
Residing in endemic area? OR: Travel & overnight w/in past stay in endemic area, or 6 mos Blood transfusion
Malaria risk +
Blood smear Ask: Duration of fever? Present everyday? Look: Stiff neck Runny nose Other signs of measles
Malaria risk + any general danger sign or stiff neck
Very severe febrile disease/malaria
Quinine (under med. supervision) 1st dose of antibiotic, Paracetamol Urgent referral
Malaria risk +, blood smear + No runny nose, no measles
Malaria
Oral antimalarial Paracetamol Follow up in 2 days > 7 days fever hospital for assessment
No malaria risk Any general danger sign or stiff neck
Very severe febrile disease
1st dose of antibiotic, Paracetamol Urgent referral
Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers
Severe complicated measles
1st dose of antibiotic, Vitamin A Urgent referral
Measles now or w/in last 3 mos Pus draining from the eye or Mouth ulcers
Measles with eye or Mouth complications
Vitamin A Tetracycline eye ointment Gentian violet Follow up in 2 days
Measles now or w/in last 3 mos No other signs
Measles
Vitamin A
If there is Dengue risk
Bleeding gums, nose, in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs, but fever > 3 days Tourniquet test
Slow capillary refill
Indicates poor skin perfusion Press down firmly with your finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.
Any of the danger signs or + tourniquet test
Severe Dengue hemorrhagic fever
If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS Any other signs of bleeding Plan C Urgent referral Do not give aspirin
Ear problem: tender swelling behind ear
Mastoiditis
1st dose of antibiotic Paracetamol for pain Urgent referral
Ear discharge < 14 days or Ear pain
Acute ear infection
Antibiotic for 5 days Paracetamol for pain Wicking Follow up in 5 days
Ear discharge for 14 days or more
Chronic ear infection
Wicking Follow up in 5 days
Visible severe wasting or Edema on both feet or Severe palmar pallor
Severe malnutrition or severe anemia
Vitamin A Urgent referral
Some palmar pallor or Very low weight for age
Anemia or very low weight for age
Assess for feeding problem Pallor: iron & Mebendazole in children > 2 yrs Wt for age very low: Vitamin A
