CARE OF THE CHILD

APPLYING
INTEGRATED
MANAGEMENT OF
CHILDHOOD
ILLNESSES (IMCI)
Overview of Integrated Management of
Childhood Illnesses (IMCI) Process
The Integrated Management of Childhood Illness
strategy has been introduced in an increasing
number of countries in the region since
1995. IMCI is a major strategy for child survival,
healthy growth and development and is based on
the combined delivery of essential interventions
at community, health facility and health systems
levels. IMCI includes elements of prevention as
well as curative and addresses the most common
conditions that affect young children. The
strategy was developed by the World Health
Organization (WHO) and United Nations
Children’s Fund (UNICEF).
OBJECTIVES OF IMCI
Reduce death and frequency and severity of illness and disability, and
Contribute to improved growth and development
COMPONENTS OF IMCI
✓Improving case management skills of health workers
✓Improving over-all health systems
✓Improving family and community health practices
Rationale for an integrated approach in the management of sick children
Majority of these deaths are caused by 5 preventable and treatable conditions
namely: pneumonia, diarrhea, malaria, measles and malnutrition. Three (3) out of
four (4) episodes of childhood illness are caused by these five conditions
Most children have more than one illness at one time. This overlap means that
a single diagnosis may not be possible or appropriate.
BASIS FOR CLASSIFYING THE CHILD’S ILLNESS
(please see enclosed portion of the IMCI Chartbooklet) The child’s illness is
classified based on a color-coded triage system:
PINK- indicates urgent hospital referral or admission
YELLOW- indicates initiation of specific Outpatient Treatment
GREEN – indicates supportive home care
Steps of the IMCI Case management Process
The following is the flow of the IMCI process. At the out-patient health
facility, the health worker should routinely do basic demographic data
collection, vital signs taking, and asking the mother about the child's problems.
Determine whether this is an initial or a follow-up visit. The health worker then
proceeds with the IMCI process by checking for general danger signs, assessing
the main symptoms and other processes indicated in the chart below.
Take note that for the pink box, referral facility includes district,
provincial and tertiary hospitals. Once admitted, the hospital protocol is used in
the management of the sick child.
The children and infants are then assessed for main symptoms:

In older children the main symptoms

include:
• Cough or difficulty breathing
• Diarrhoea
• Fever and Ear Infection
In young infants the main symptoms
include:
• Local bacterial infection
• Diarrhoea
• Jaundice
IMCI Computerized Adaptation and Training Tool
(ICATT)
• Computerized, adaptable tool for training in
the Integrated Management of Childhood
Illness (IMCI). A joint project of WHO and the
Novartis Foundation for Sustainable
Development, ICATT is now available for use
globally.
• Chart booklet builder: The IMCI guidelines
developed by WHO have been summarized in
a set of charts presented in a chart booklet.
The library includes reference and educational
materials on IMCI and related child health
issues, developed by WHO and other
international agencies. It also includes a wide
variety of videos, pictures and sounds that are
used for audiovisual practice
Management of Sick Child Aged 2 Months to 5 Years

COUGH OR DIFFICULTY BREATHING

ASSESS CLASSIFY IDENTIFY TREATMENT
Any general danger Pink:
•Give first dose of an appropriate antibiotic
signs or stridor in calm SEVERE PNEUMONIA OR •Refer URGENTLY to hospital
child. VERY SEVERE DISEASE

•Give oral Amoxicillin for 5 days

•If wheezing (or disappeared after rapidly acting bronchodilator)
give an inhaled bronchodilator for 5 days
•If chest indrawing in HIV exposed/infected child, give first dose of
Yellow: amoxicillin and refer.
Fast breathing •Soothe the throat and relieve the cough with a safe remedy
PNEUMONIA
•If coughing for more than 14 days or recurrent wheeze, refer for
possible TB or asthma assessment
•Advise mother when to return immediately
•Follow-up in 3 days

•Treat wheeze with inhaled salbutamol for 5 days

Yellow: •Soothe the throat and relieve the cough with a safe remedy
Wheezing
WHEEZE •Sooth throat and relieve cough with safe remedy
• Advise mother when to return immediately
•Follow-up in 5 days if not improving
 DIARRHEA
ASSESS CLASSIFY IDENTIFY TREATMENT

Two of the following signs: •If child has no other severe classification: Give fluid
Lethargic or for severe dehydration (Plan C) OR
unconscious Sunken eyes •If child also has another severe
Pink: classification: Refer URGENTLY to hospital with mother giving
Not able to drink or frequent sips of ORS on the way
SEVERE DEHYDRATION
drinking poorly •Advise the mother to continue breastfeeding.
Skin pinch goes back • If child is 2 years or older and there is cholera in your
very slowly. area, give antibiotic for cholera

•Give fluid, zinc supplements, and food for some

Two of the following dehydration (Plan B)
signs: Restless, irritable • If child also has a severe classification: Refer
Yellow: URGENTLY to hospital with mother giving frequent sips of ORS
Sunken eyes on the way
SOME DEHYDRATION
Drinks eagerly, thirsty •Advise the mother to continue breastfeeding
Skin pinch goes back slowly. •Advise mother when to return immediately
• Follow-up in 5 days if not improving

Not enough signs to classify •Give fluid, zinc supplements, and food to
Green: treat diarrhoea at home (Plan A)
as some or severe •Advise mother when to return immediately
NO DEHYDRATION
dehydration. • Follow-up in 5 days if not improving
CLASSIFY: DIARRHOEA 14 days or more
•Treat dehydration before referral unless the child has another severe
Pink:
Dehydration present. classification
SEVERE PERSISTENT DIARRHOEA •Refer to hospital

Yellow: •Advise the mother on feeding a child who has PERSISTENT DIARRHOEA
•No dehydration. PERSISTENT DIARRHOEA • Give multivitamins and minerals (including zinc) for 14 days
•Follow-up in 5 days

•Blood in the Stool Yellow: DYSENTERY •Give Ciprofloxacin for 3 days

GIVE EXTRA FLUID TO DIARRHOEA AND CONTINUE FEEDING

PLAN A: Treat Diarrhoea at PLAN B: Treat Some Dehydration with ORS

Home ORS in 4 hours period
•Counsel the mother on the 4 Rules of 200ml-450ml(<6kg;up to 4 months old)
Home Treatment: 450ml-800ml(6-10kg;4-12months old)
1. Give Extra Fluid​ 800ml-960ml(10-12kg;12months-2 years old)
INTAKE: Up to 2 years 50-100ml after 960ml-1600ml(12-19kg;2-5 years old)
each loose stools
2 yrs or more 100-200ml
after loose stool
2. Give Zinc Supplements: 2months up PLAN C: Treat Severe Dehydration Quickly
to 6 months-1/2 tablet daily for 14 days ❑ Start IV Fluid immediately
AND 6 months or more-1 tablet daily ❑ Reassess the child every 1-2 hours
for 14 days ❑ Start Rehydration by NG tube
3. Continue Feeding​(exclusive
❑ Refer Urgently to the Hospital
breastfeeding less than 6 months)
4. When to Return ​
 FEVER
ASSESS CLASSIFY IDENTIFY TREATMENT
•Give first dose of artesunate or quinine for severe malaria
•Give first dose of an appropriate antibiotic
Pink:
Any general danger sign or stiff neck. •Treat the child to prevent low blood sugar
VERY SEVERE FEBRILE DISEASE
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Refer URGENTLY to hospital.
•Give recommended first line oral antimalarial
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Give appropriate antibiotic treatment for an identified bacterial cause of
Yellow:
Malaria test POSITIVE. fever
MALARIA
•Advise mother when to return immediately
•Follow-up in 3 days if fever persists
•If fever is present every day for more than 7 days, refer for assessment
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Give appropriate antibiotic treatment for an identified bacterial cause of
Green: fever
•Malaria test NEGATIVE.
FEVER •Advise mother when to return immediately
•Other cause of fever PRESENT.
NO MALARIA •Follow-up in 3 days
•if fever persists If fever is present every day for more than 7 days, refer for
assessment
 •Give first dose of an appropriate antibiotic.
•Treat the child to prevent low blood sugar.
Any general danger sign or Pink:
•Give one dose of paracetamol in clinic for high fever
stiff neck. VERY SEVERE FEBRILE DISEASE
(>38.5 degree Celsius)
•Refer URGENTLY to hospital

•Give one dose of paracetamol in clinic for high fever

(>38.5 degree Celsius)
•Give appropriate antibiotic treatment for any
Green:
•No danger signs. identified bacterial cause of fever
FEVER
•No stiff neck. •Advise mother when to return immediately
•Follow-up in 2 days if fever persists
• If fever is present every day for more than 7 days, refer
for assessment
ASSESS CLASSIFY IDENTIFY TREATMENT
•Any general danger sign or •Give Vitamin A treatment
•Clouding of cornea or •Give first dose of an appropriate antibiotic
Pink:
•Deep and extensive mouth ulcers. •If clouding of the cornea or pus draining from the eye,
SEVERE COMPLICATED MEASLES
apply tetracycline eye ointment
•Refer URGENTLY to hospital

•Give Vitamin A treatment

•If pus draining from the eye, treat eye infection with tetracycline
•Pus draining from the eye or
eye ointment
•Mouth Ulcers
Yellow: MEASLES WITH EYE OR •If mouth ulcers, treat with gentian violet
MOUTH COMPLICATIONS •Follow-up in 3 days

•Measles now or within the last 3 Green:MEASLES

•Give Vitamin A treatment
months
EAR PROBLEM
ASSESS CLASSIFY IDENTIFY TREATMENT
Look for pus draining from the
•Give first dose of an appropriate antibiotic
ear Pink:
•Give first dose of paracetamol for pain
Tender swelling behind the ear MASTOIDITIS
•Refer URGENTLY to hospital

•Give an antibiotic for 5 days

•Pus draining less than 14 days Yellow:​ACUTE EAR INFECTION • Give paracetamol for pain
•Dry the ear by wicking
• Follow-up in 5 days

•Dry the ear by wicking

•Pus draining more than 14 days Yellow: CHRONIC EAR
•Treat with topical quinolone eardrops for 14 days
INFECTION • Follow-up in 5 days

•No Ear pain and pus draining Green:NO EAR INFECTION

•No Treatment
from the ear
ACUTE MALNUTRITION
ASSESS CLASSIFY IDENTIFY TREATMENT
Edema of both feet OR WFH/L less than -
•Give first dose appropriate antibiotic
3 z scores OR MUAC less than 115 mm Pink:​ COMPLICATED SEVERE ACUTE
• Treat the child to prevent low blood sugar
AND any one of the following: Medical MALNUTRITION
• Keep the child warm
complication present or Not able to finish
•Refer URGENTLY to hospital
RUTF or Breastfeeding problem.

•Give oral antibiotics for 5 days

• Give ready-to-use therapeutic food for a child aged 6 months or more
Yellow:​ UNCOMPLICATED SEVERE ACUTE
FH/L less than -3 zscores OR MUAC less • Counsel the mother on how to feed the child
MALNUTRITION
than 115 mm AND Able to finish RUTF. •Assess for possible TB infection
•Advise mother when to return immediately
•Follow up in 7 days
•Assess the child's feeding and counsel the mother on the feeding
Yellow: MODERATE ACUTE recommendations
WFH/L between -3 and - 2 z-scores OR •If feeding problem, follow up in 7 days
MUAC 115 up to 125 mm.
MALNUTRITION •Assess for possible TB infection.
•Advise mother when to return immediately
•Follow-up in 30 days

Green: ​NO ACUTE MALNUTRITION If child is less than 2 years old, assess the child's feeding and counsel the
WFH/L - 2 z-scores or more OR MUAC 125
mother on feeding according to the feeding recommendations If feeding
mm or more
problem, follow-up in 7 days
ANAEMIA
ASSESS CLASSIFY IDENTIFY TREATMENT

Pink: SEVERE ANAEMIA

Severe palmar pallor •Refer URGENTLY to hopsital

•Give iron
•* Give mebendazole if child is 1 year or older and has
•Some pallor Yellow: ANAEMIA not had a dose in the previous 6 months
•Advise mother when to return immediately
•Follow-up in 14 days

If child is less than 2 years old, assess the child's

Green: NO ANAEMIA feeding and counsel the mother according to the
•No palmar pallor
feeding recommendations If feeding problem, follow-
up in 5 days
 HIV INFECTION
ASSESS CLASSIFY IDENTIFY TREATMENT
•Initiate ART treatment and HIV care Give cotrimoxazole
prophylaxis*
•Positive virological test in child •Assess the child’s feeding and provide appropriate counselling
OR Positive serological test in a Yellow: CONFIRMED HIV INFECTION to the mother
child 18 months or older •Advise the mother on home care
•Assess or refer for TB assessment and INH preventive therapy
•Follow-up regularly as per national guidelines
Mother HIV-positive AND
•Give cotrimoxazole prophylaxis
negative virological test in a
•Start or continue ARV prophylaxis as recommended
breastfeeding child or only
•Do virological test to confirm HIV status
stopped less than 6 weeks ago
Yellow: HIV EXPOSED •Assess the child’s feeding and provide appropriate counselling
OR Mother HIV-positive, child
to the mother
not yet tested OR Positive
• Advise the mother on home care
serological test in a child less
•Follow-up regularly as per national guidelines
than 18 months old

•Negative HIV test in mother or Green: HIV INFECTION UNLIKELY

Treat, counsel and follow-up existing infections
child
 Management of Sick Young Infant Aged 1 Week up to 2 Months
LOCAL BACTERIAL INFECTION
ASSESS CLASSIFY IDENTIFY TREATMENT
Any one or more of the
following signs:
• Not able to feed at all or
not feeding well or
• Convulsions or • Severe •➜ Give fi rst dose of intramuscular antibiotics.
chest indrawing or •➜ Treat to prevent low blood sugar.
Pink:POSSIBLE SERIOUS
• High body temperature • ➜ Advise the mother how to keep the infant warm on
BACTERIAL INFECTION or VERY
(38°C* or above) or the way to the hospital.
SEVERE DISEASE
• Low body temperature • ➜ Refer URGENTLY to hospital. OR
(less than 35.5°C*) or • ➜ If referral is REFUSED or NOT FEASIBLE, treat in the
• Movement only when clinic until referral is feasible.
stimulated or no movement
at all or • Fast breathing (60
breaths per minute or more)
in infants less than 7 days old
ASSESS CLASSIFY IDENTIFY TREATMENT
•• Fast breathing (60 breaths •➜ Give oral amoxicillin for 7 days.
per minute or more) in Yellow: PNEUMONIA • ➜ Advise the mother to give home care.
infants 7–59 days old •➜ Follow up in 3 days.
•➜ Give amoxicillin for 5 days.
•➜ Teach the mother how to treat local infections at
• Umbilicus red or draining Yellow: LOCAL BACTERIAL
home.
pus • Skin pustules INFECTION • ➜ Advise the mother to give home care.
• ➜ Follow up in 2 days

•• No signs of bacterial
➜ Advise the mother on giving home care to the
infection or very severe Green: INFECTION UNLIKELY
young infant.
disease
 JAUNDICE
ASSESS CLASSIFY IDENTIFY TREATMENT
• Any jaundice in an infant aged •➜ Treat to prevent low blood sugar.
less than 24 hours or • ➜ Refer URGENTLY to hospital.
Pink: SEVERE JAUNDICE
• Yellow palms or soles at any • ➜ Advise the mother how to keep the infant warm on the
age way to the hospital.

•➜ Advise the mother to give home care.

•➜ Advise the mother to return immediately if the infant’s
• Jaundice appearing after 24
palms or soles appear yellow.
hours of age and Yellow: JAUNDICE
• ➜ If the young infant is older than 3 weeks, refer to a
• Palms or soles not yellow
hospital for assessment.
•➜ Follow-up in 1 day.

• No jaundice Green: NO JAUNDICE ➜ Advise the mother on giving home care to the young infant.
Vitamin A
Supplementation
Give every child a dose of
Vitamin A every six
months from the age of 6
months. Record the dose
on the child's chart
ROUTINE WORM
TREATMENT
Give every child
mebendazole every 6
months from the age of
one year. Record the dose
on the child's card.