WHAT IS IMCI?

A strategy for reducing mortality and

morbidity associated with major causes of
childhood illness
A joint WHO/UNICEF initiative since 1992
Currently focused on first level health
facilities
Comes as a generic guidelines for
management which have been adapted to
each country
 INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS
INTRODUCTION

Pneumonia, diarrhea, dengue hemorrhagic fever, malaria,

measles and malnutrition cause more than 70% of the deaths in
children under 5 years of age. All these are preventable diseases
in which when managed and treated early could have prevented
these deaths.

There are feasible and effective ways that health worker

in health centers can care for children with these illnesses and
prevent most of these deaths. WHO and UNICEF used updated
technical findings to describe management of these illnesses in a
set of integrated guidelines for each illness. They then
developed this protocol to teach the integrated case
management process to health worker who see sick children and
know which problems are most important to treat. Therefore,
effective case management needs to consider all of a child’s
symptoms.
For those children who can be treated at home,
caregivers are taught how to provide treatment
and when to seek care for their children. The
guidelines also identify actions to prevent illness
through the immunization of sick children,
supplementation of micronutrients, promotion of
breastfeeding, and counseling of mothers to solve
feeding problems. It is also an important factor to
teach families when to seek care for a sick child
as part of the case management process. This
approach, which combines steps to manage and
prevent several different conditions, is
comprehensive and systematic.
DISTRIBUTION OF 11.6 MILLION DEATHS AMONG
CHILDREN LESS THAN 5 YRS OLD IN ALL
DEVELOPING COUNTRIES, 1995

MALNUTRITION 54%
Others 32%
ACUTE RESPIRATORY INFECTIONS
(ARI) 19 %
DIARRHEA 19%
Perinatal 18%
MEASLES 7%
MALARIA 5%
 OBJECTIVES OF IMCI

To reduce significantly global

morbidity and mortality associated
with the major causes of illnesses in
children

To contribute to healthy growth and

development of children
The CASE MANAGEMENT PROCESS is used to
assess and classify two age groups:

age 1 week up to 2 months

age 2 months up to 5 years

And how to use the process shown on the

chart will help us to identify signs of serious
disease such pneumonia, diarrhea, malaria,
measles, DHF, meningitis, malnutrition and
anemia.
 THE CASE MANAGEMENT
PROCESS
The charts describes the following steps;

1. assess the child or young infant

2. classify the illness
3. identify the treatment
4. treat the child
5. counsel the mother
6. give follow up care
 THE CLASSIFICATION TABLE
The classification tables on the assess
and classify have 3 ROWS .

COLOR of the row helps to IDENTIFY

RAPIDLY whether the child has a
SERIOUS DISEASE requiring
URGENT ATTENTION.
Each row is colored either –

PINK – means the child has a severe classification and

needs urgent attention and referral or admission
for inpatient care.

YELLOW – means the child needs a specific medical

treatment such as an appropriate antibiotic, an oral
anti-malarial or other treatment; also teaches the
mother how to give oral drugs or to treat local
infections at home. The health worker teaches the
mother how to care for her child at home and when
she should return.

GREEN – not given a specific medical treatment such as

antibiotics or other treatments. The health worker
teaches the mother how to care for her child at
home.

Always start at the top of the classification table. If the child has signs from
more than 1 row always select the more serious classification.
WHY NOT USE THE PROCESS FOR CHILDREN
AGE 5 YEARS OR MORE?
The case management process is designed for children < 5yrs of
age, although. Much of the advise on treatment of pneumonia, diarrhea,
malaria, measles and malnutrition, is also applicable to older children, the
ASSESSMENT AND CLASSIFICATION of older children would differ. For
example, the cut off rate for determining fast breathing would be different
because normal breathing rates are slower in older children. Chest
indrawing is not a reliable sign of severe pneumonia as children get older
and the bones of the chest become more firm.

In addition, certain treatment recommendations or advice to

mothers on feeding would differ for >5yrs old. The drug dosing tables only
apply to children up to 5yrs old. The feeding advice for older children may
differ and they may have different feeding problems.

Because of differences in the clinical signs of older and younger

children who have these illnesses, the assessment and classification
process using these clinical signs is not recommended for older children.
 WHY NOT USE THIS PROCESS FOR
YOUNG INFANTS AGE < 1 WEEK OLD?

The process on young infant chart

is designed for infants age 1 week up
to 2 months. It greatly differs from
older infants and young children. In
the first week of life, newborn infants
are often sick from conditions related
to labor and delivery. Their
conditions require special treatment.
 IDENTIFICATION AND
PROVISION OF TREATMENT

Curative component adapted to address the

most common life-threatening conditions
in each country
Rehydration (diarrhea, DHF)
Antibiotics (pneumonia, “severe disease”)
Antimalarial treatment
Vitamin A (measles, severe malnutrition)
PROMOTIVE AND PREVENTIVE
ELEMENTS

Reducing missed opportunities for

immunization (vaccination given if
needed)
Breastfeeding and other nutritional
counseling
Vitamin A and iron supplementation
Treatment of helminth infections
The Integrated Case
Management Process
 Learning Objectives
At the end of the session, the students
will be able to:

(1) describe the overall case

management process;

(2) state in order the steps in the

management process
 Overall Case Management
Process
Outpatient
1 - assessment
2 - classification and identification of treatment
3 - referral, treatment or counseling of the child’s
caretaker (depending on the classification
identified)
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of
patient’s progress
 SUMMARY OF THE INTEGRATED CASE MANAGEMENT PROCESS
For all sick children age 1 week up to 5 years who are brought to a first-level health facility

ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If a
main symptom is reported, assess further. Check nutrition and immunization status. Check for other
problems.

CLASSIFY the child’s illnesses: Use a colour-coded triage system to classify the child’s main symptoms
and his or her nutrition or feeding status.

IF URGENT REFERRAL is needed and possible IF NO URGENT REFERRAL isneeded or possible

IDENTIFY URGENT IDENTIFY TREATMENT needed for the child’s classifications:

PRE-REFERRAL TREATMENT(S) Identify specific medical treatments and/or advice.
needed for the child’s classifications.
. TREAT THE CHILD: Give the first dose of oral drugs in the clinic
and/or advise the child’s caretaker. Teach the caretaker how to
TREAT THE CHILD: Give urgent pre- give oral drugs and how to treat local infections at home. If needed,
referral treatment (s) needed. give immunizations.

REFER THE CHILD: Explain to the
child’s caretaker the need for referral.
Calm the caretaker’s fears and help
resolve any problems. Write a
referral note. Give instructions and
supplies needed to care for the child
on the way to the hospital.
COUNSEL THE MOTHER: Assess the child’s feeding, including
breastfeeding practices, and solve feeding problems, if present.
Advise about feeding and fluids during illness and about when to
return to a health facility. Counsel the mother about her own
health.
FOLLOW-UP care: Give follow-up care when the child returns to the
clinic and,if necessary, reassess the child for new problems.
 Summary of the Integrated case
Management Process

For all sick

children age 1
week up to 5
years who are
brought to a first-
level health
facility
Summary of the Integrated case
Management Process

ASSESS the Child:

 Check for danger signs
(or possible bacterial
infection).
 Ask about main symptoms.
 If a main symptom is
reported, assess further.
Check nutrition and
immunization status.
 Check for other problems
 Summary of the Integrated Case
Management Process
Classify the child’s illness:

Use a color-coded
triage system to classify
the child’s main
symptoms and his or
her nutrition or feeding
status.
 Summary of the Integrated
Case Management Process

IF URGENT

REFERRAL
is needed and
possible
 Summary of the Integrated Case
Management Process
IDENTIFY URGENT
PRE-REFERRAL
TREATMENT(S)
Needed prior to
referral of the child
according to
classification
Summary of the Integrated Case
Management Process

TREAT THE
CHILD:
Give urgent pre-
referral
treatment(s)
needed.
Summary of the Integrated Case
Management Process
REFER THE CHILD:
Explain to the child’s
caretaker the need for
referral.
Calm the caretaker’s
fears and help resolve
any problems. Write a
referral note.
Give instructions and
supplies needed to care
for the child on the way
to the hospital
 Summary of the Integrated
Case Management Process

IF NO URGENT
REFERRAL
is needed or
Possible
 Summary of the Integrated
Case Management Process
IDENTIFY
TREATMENT
needed for the
child’s
classifications:
identify specific
medical
treatments
and/or advice
 Summary of the Integrated Case
Management Process
TREAT THE CHILD:
Give the first dose of
oral drugs in the clinic
and/or advice the
child’s caretaker.
Teach the caretaker
how to give oral
drugs and how to
treat local infections
at home.
If needed, give
immunizations.
 Summary of the Integrated
Case Management Process
COUNSEL THE MOTHER:
 Assess the child’s feeding,
including breastfeeding
practices, and solve feeding
problems, if present.
 Advise about feeding and
fluids during illness and about
when to return to a health
facility.
 Counsel the mother about her
own health.
Summary of the Integrated Case
Management Process
FOLLOW-UP
CARE:
Give follow-up
care when the
child returns to
the clinic and, if
necessary, re-
asses the child for
new problems.
 SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS

FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic

ASK THE CHILD’S AGE

IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years

USE THE CHART: USE THE CHART:

œ ASSESS, CLASSIFY AND TREAT
 œ ASSESS AND CLASSIFY THE SICK CHILD

THE SICK YOUNG INFANT TREAT THE CHILD
COUNSEL THE MOTHER
 THE SICK
CHILD AGE 2
MONTHS TO 5
YEARS:

ASSESS AND
CLASSIFY
 SUMMARY OF ASSESS AND CLASSIFY

Ask the mother or caretaker about the child’s problem.

If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the
problem, give follow-up care according to PART VII)

Check for general danger signs.

Ask the mother or caretaker about the four When a main symptom is present:
main symptoms: œ assess the child further for signs related to

œ cough or difficult breathing,
 the main symptom, and
œ diarrhoea,
 œ classify the illness according to the signs

œ fever, and 
 œ ear problem which are present or absent.

Check for signs of malnutrition and anaemia and classify the child’s nutritional status

Check the child’s immunization status and decide if the child needs any immunizations today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Child

(PART V), and Counsel the Mother (PART VI)
 SUMMARY OF ASSESS AND
CLASSIFY

Ask the mother or caretaker

about the 4 main symptoms:
cough or difficult breathing
diarrhoea
fever, and
ear problem

When a main symptom is present:

Assess the child further for signs related
to the main symptom, and
Classify the illness according to the signs
which are present or absent
 When a child is brought to the clinic

FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC

GREET the mother appropriately and Use Good Communication skills:

ask about her child.
LOOK to see if the child’s weight and
temperature have been recorded
ASK the mother what the child’s problems are
(see also Chapter 25)
— Listen carefully to what the mother tells you.
— Use words the mother understands
— Give the mother time to answer the questions.
---Ask additional questions when the mother is
not sure about her answer.
Record Important Information

DETERMINE if this is an initial visit or a follow-up visit for this problem

IF this is an INITIAL VISIT for the IF this is a FOLLOW-UP VISIT for the problem
problem

ASSESS and CLASSIFY the child following GIVE FOLLOW-UP CARE according to the
the guidelines in this part of the handbook (PART II) guidelines in PART VII of this handbook
 When the child is brought to the
clinic
Use Good Communication
Skills:

Listen carefully to what the

mother tells you
Use words the mother
understands
Give mother time to
answer questions
Ask additional questions
when mother not sure of
answer
Record important information
 GENERAL DANGER SIGNS

For ALL sick children ask the mother about the child’s problem, then
CHECK FOR GENERAL DANGER SIGNS

CHECK FOR GENERAL DANGER SIGNS

Make sure
ASK: LOOK: that a
•Is the child able to drink or breastfeed? See if the child is lethargic or unconscious
• child with
any
•Does the child vomit everything?
danger
•Is the child had convulsions? sign is
referred
after
receiving
urgent
A child with any general danger sign needs URGENT attention; complete the pre-
assessment and any pre-referral treatment immediately so referral is not delayed referral
treatment.

Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear
problems.CHECK for malnutrition and anaemia, immunization status and for other problems.
 GENERAL DANGER SIGNS
ASK:
Is the child able to
drink or breastfeed?
Does the child vomit
everything?
Has the child had
convulsions?
LOOK:
See if the child is
lethargic or
unconscious
 Cough or Difficult Breathing

For ALL sick children ask the mother about the child’s problem, check for
general danger signs,
Ask about cough or difficult breathing and then
ASK : DOES THE CHILD HAVE COUGH?

If NO If YES

IF YES, ASK: LOOK, LISTEN, FEEL:

Classify
œ For how long?
  Count the breaths in one minute.
œ
œ Look for chest indrawing

} CHILD
MUST
COUGH or
DIFFICULT
BREATHING
œ Look and listen for stridor

BE
CALM

If the child is: Fast breathing is:

2 months up 50 breaths per
to 12 months minute or more

12 months up 40 breaths per

to 5 years minute or more

CLASSIFY the child’s illness using the colour-coded classification table for cough or difficult breathing.

Then ASK about the main symptoms : fever, ear problem, and CHECK for malnutrition
and anaemia, immunization status and for other problems
 Cough or Difficult Breathing?

IF YES, ASK:
For how long?

LOOK, LISTEN, FEEL:

Count the breaths in one minute.

2-12 mos = fast breathing >/= 50/min
12 mos-5yrs = fast breathing >/=
40/min

Look for chest indrawing

Look and listen for stridor

Classify COUGH or DIFFICULT BREATHING

CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
•Any general danger •Give first dose of an appropriate
sign or SEVERE antibiotic.
•Chest indrawing or PNEUMONIA •Refer URGENTLY to hospital.
•Stridor in calm
OR VERY
child.
SEVERE DISEASE

•Fast breathing •Give an appropriate oral

PNEUMONIA antibiotic for 5 days.
•Soothe the throat and relieve the
cough with a safe remedy.
•Advise mother when to return
immediately.
•Follow-up in 2 days.

No signs of NO PNEUMONIA: •If coughing more than 30 days,

pneumonia COUCH OR COLD refer for assessment.
or very severe •Soothe the throat and relieve the
disease. cough with a safe remedy.
•Advise mother when to return
immediately.
•Follow-up in 5 days if not
 Diarrhea
For ALL sick children ask the mother about the child’s problem, check for general danger signs,
ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHEA?

If NO If YES

Does the child have diarrhea?

IF YES, ASK: LOOK, LISTEN, FEEL:
œ For how long?
 œ Look at the child’s general condition.

Is the child:
œ Is there blood in the

stool Lethargic or unconscious?
Restless or irritable?

œ Look for sunken eyes.


Classify
œ Offer the child fluid. Is the child:

DIARRHEA
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?

œ Pinch the skin of the abdomen.


Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and
anaemia, immunization status and for other problems.
Child with dehydration
 Diarrhea
Does the child have
diarrhea?
IF YES, ASK:
For how long?
Is there blood in the
stool?
LOOK, LISTEN, FEEL:
Look at the child’s general
condition, is the child:
Lethargic or unconscious?
Restless or irritable?

Look for sunken eyes

Offer the child fluid. Is the child: Pinch the skin of the
Not able to drink or drinking poorly? abdomen.
Drinking eagerly, thirsty? Does it go back:
Very slowly (> than 2 secs)?
Slowly?
 CLASSIFICATION TABLE FOR DEHYDRATION
SIGNS
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking
poorly
Skin pinch goes back very
slowly
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
Not enough signs to
classify as some or
severe dehydration.
IDENTIFY TREATMENT
CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
If child has no other severe classification:
— Give fluid for severe dehydration (Plan C).
SEVERE OR
DEHYDRATION If child also has another severe
classification:
— Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
If child is 2 years or older and there is
cholera in your area, give antibiotic for
cholera.
Give fluid and food for some dehydration (Plan B).
If child also has a severe classification:
SOME — Refer URGENTLY to hospital with mother
DEHYDRATION giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
Give fluid and food to treat diarrhoea
at home (Plan A).
NO Advise mother when to return
DEHYDRAT immediately.
ION Follow-up in 5 days if not improving.
 CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

Treat dehydration before

Dehydration SEVERE referral unless the child has
present PERSISTENT another severe classification.
DIARRHEA Refer to hospital.

Advise the mother on feeding a child

No dehydration PERSISTENT who has PERSISTENT DIARRHOEA.
DIARRHEA Follow-up in 5 days.
 CLASSIFICATION TABLE FOR DYSENTERY

IDENTIFY TREATMENT
(Urgent pre-referral treatments are
SIGNS CLASSIFY AS in bold print.)

Treat for 5 days with an

oral antibiotic
Blood in the DYSENTERY recommended for
stool Shigella in your area.
Follow-up in 2 days.
 Fever
For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask
about cough or difficult breathing, diarrhoea and then
ASK: DOES THE CHILD HAVE FEVER?

If NO If YES

Does the child have fever?

( by history or feels hot or temperature 37.5 C** or above)

IF YES:
Decide the Malaria Risk: high or low

THEN ASK: LOOK AND FEEL:

 For how long?
œ  Look or feel for stiff neck.
œ
œ If more than 7 days, has
 œ Look for runny nose.

fever been present every day?
Look for signs of MEASLES
œ Has the child had measles within

the last 3 months?  Generalized rash and
œ
œ One of these: cough, runny nose,

or red eyes.

If the child has measles now or œ Look for mouth ulcers.


within the last 3 months: Are they deep and extensive?
 Look for pus draining from the eye.
œ
œ Look for clouding of the cornea.


CLASSIFY the child’s illness using the colour-coded classification tables for fever.

Then ASK about the next main symptom: ear problem, and CHECK for malnutrition and anaemia,
immunization status and for other problems.
 Does the child have FEVER? Fever
IF YES, decide the malaria risk:
high or low
THEN ASK:
For how long?
If more than 7 days, has fever
been
present every day?
Has the child had measles within
the
last 3 months?
If the child LOOK AND FEEL:
Look for runny nose
Look or feel for stiff neck
LOOK FOR SIGNS OF MEASLES
LOOK FOR SIGNS OF
has measles now or within the last 3
months DENGUE/DHF
-Rash -Mouth ulcers -bleeding tendencies
-Cough -Pus from eyes -flushing
-Runny nose -Clouding of cornea -(+) tourniquet test
-Red eyes -rash
CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A
MALARIA RISK AREA

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

•Any general danger •Give first dose of an appropriate

sign antibiotic.
•Stiff neck •Treat the child to prevent low blood
VERY SEVERE sugar.
FEBRILE •Give one dose of paracetamol in
DISEASE clinic for high fever (38.5° C or above).
•Refer URGENTLY to hospital.

•NO general danger •Give one dose of paracetamol in

sign clinic for high fever (38.5° C or above).
AND FEVER— •Advise mother when to return
•NO Stiff neck. MALARIA immediately.
UNLIKELY •Follow-up in 2 days if fever persists.
•If fever is present every day for more
than 7 days, REFER for assessment.
 CLASSIFICATION TABLE FOR MEASLES
(IF MEASLES NOW OR WITHIN THE LAST 3 MONTHS)

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

•Any general danger •Give vitamin A.

sign or SEVERE •Give first dose of an appropriate
•Clouding of cornea or COMPLICATED antibiotic.
•Deep or extensive MEASLES*** •If clouding of the cornea or pus
mouth ulcers. draining from the eye, apply
tetracycline eye ointment.
•Refer URGENTLY to hospital.
•Pus draining from the •Give vitamin A.
eye or MEASLES WITH •If pus draining from the eye, treat
•Mouth ulcers EYE OR MOUTH eye infection with tetracycline eye
COMPLICATIONS* ointment.
** •If mouth ulcers, treat with gentian
violet.
•Follow-up in 2 days.

•Measles now or within •Give vitamin A.

the last 3 months. MEASLES

*** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in
other tables.
Fever With Rashes
 Ear Problem
For ALL sick children ask the mother about the ask about cough or difficult breathing,
diarrhoea, fever and then
ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

If NO If YES

Does the child have an ear problem?

IF YES ASK: LOOK AND FEEL:

•Is there ear pain? •Look for pus draining from the
•Is ther ear discharge? ear.
If yes, for how long? •Feel for tender swelling behind
the ear.

CLASSIFY the child’s illness using the colour-coded-classification table for ear
problem.

Then CHECK for malnutrition and anaemia, immunization status and for other problems.
 Ear Problem
Does the child have an EAR
PROBLEM?
IF YES, ASK
Is there ear pain?
Is there ear discharge?
If yes, for how long?

LOOK AND FEEL:

Look and pus draining
from the ear
Feel for tender swelling
behind the ear.
 CLASSIFICATION TABLE FOR EAR PROBLEM

IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)

•Give first dose of an appropriate

•Tender swelling antibiotic.
behind the ear. MASTOIDITIS •Give first dose of paracetamol for
pain.
•Refer URGENTLY to hospital.
•Pus is seen draining •Give an oral antibiotic for 5 days.
from the ear and •Give paracetamol for pain.
discharge is reported ACUTE EAR •Dry the ear by wicking.
for less than 14 days, INFECTION •Follow-up in 5 days.
or
•Ear pain.
•Pus is seen draining •Dry the ear by wicking.
from the ear and CHRONIC EAR •Follow-up in 5 days.
discharge is reported INFECTION
for 14 days or more.

•No ear pain and No No additional treatment

pus seen draining NO EAR
from the ear. INFECTION
 Malnutrition and Anemia
For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea,
fever, ear problem and then
CHECK FOR MALNUTRITION AND ANAEMIA.

THEN CHECK FOR MALNUTRITION AND ANAEMIA

LOOK AND FEEL:
Classify
•Look for visible severe wasting. NUTRITIONAL
•Look for palmar pallor. Is it: Severe palmar STATUS
pallor?
Some palmar pallor?
•Look for oedema of both feet.
•Determine weight for age.

CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition
and anemia

Then CHECK immunization status and for other problems.

 Malnutrition and Anemia
CHECK FOR MALNUTRITION
AND ANEMIA
LOOK AND FEEL:
Look for visible severe wasting
Look for palmar pallor. Is it:
Severe palmar pallor?
Some palmar pallor?
Look for edema of both feet
Determine weight for age

CLASSIFY NUTRITIONAL
STATUS
Child with Anemia and
Malnutrition
CLASSIFICATION TABLE FOR MALNUTRITION AND ANAEMIA
SIGNS
•Visible severe wasting or
•Severe palmar pallor or
•Oedema of both feet.
•Some palmar pallor or
•Very low weight for age.
•Not very low weight for age
and no other signs or
malnutrition.
IDENTIFY TREATMENT
CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
•Give Vitamin A.
SEVERE •Refer URGENTLY to hospital.
MALNUTRITION OR
SEVERE ANAEMIA
•Assess the
feeding according to the FOOD box on the COUNSEL
THE MOTHER chart.
ANAEMIA OR VERY — If feeding problem, follow-up in 5 days.
LOW WEIGHT •If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk.
— Give mebendazole if child is 2 years or older and
has not had a dose in the previous 6 months.
•Advise mother when to return immediately.
•If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
•If child is less than 2 years old, assess the
NO ANAEMIA AND NOT feeding and counsel the mother on feeding
VERY LOW WEIGHT according to the FOOD box on the COUNSEL THE
MOTHER chart.
— If feeding problem, follow-up in 5 days.
•Advise mother when to return immediately.
 Immunization Status
For ALL sick children ask the mother about the child’s about cough or difficult
breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia
and
CHECK IMMUNIZATION STATUS.
THEN CHECK THE CHILD’S IMMUNIZATION STATUS

AGE VACCINE
Birth BCG OPV-0
6 weeks DPT-1 OPV-1
IMMUNIZATION 10 weeks DPT-2 OPV-2
SCHEDULE: 14 weeks DPT-3 OPV-3
9 months Measles

DECIDE if the child needs an immunization today, or if the mother should be

told to come back with the child at a later date for an immunization.
Note: Remember there are no contraindications to immunization of a sick child
if the child is well enough to go home.

Then CHECK for other problems.

 Immunization Status
CHECK IMMUNIZATION
STATUS:
IMMUNIZATION
SCHEDULE
Birth - BCG, HepB1
6 weeks - DPT1, OPV1,
HepB2
10 weeks - DPT2,
OPV2,
HepB3
14 weeks - DPT3, OPV3,
HepBbooster
9 mos - measles
 How to check the Immunization
Status

If an infant has not

received any
immunization, then give
–BCG
–DPT 1 , OPV 1
–Hepatitis B 1
 THE SICK YOUNG
INFANT AGE 1 WEEK
UP TO 2 MONTHS:
ASSESS AND
CLASSIFY
 SUMMARY OF ASSESS AND CLASSIFY
Ask the mother or caretaker about the young

If this is an INITIAL VISIT for the problem, follow the steps below.
(If this is a follow-up visit for the problem, give follow-up care according to
PART VII)

Check for POSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker about If diarrhoea is present:

DIARRHOEA: •assess the infant further for signs related to
diarrhoea, and
•classify the illness according to the signs
which are present or absent.

Check for FEEDING PROBLEM OR LOW WEIGHT and classify the

Check the infant’s immunization status and decide if the infant needs any
immunization today.
Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Infant (PART V),
and Counsel the Mother (PART VI)
How to check a young infant for possible bacterial infection
For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION

CHECK FOR POSSIBLE BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL:
•Has the infant had •Count the breaths in one minute.
Repeat the count if elevated. YOUNG
convulsions? •Look for severe chest indrawing. INFANT
•Look for nasal flaring MUST BE
•Look and listen for grunting. CALM
•Look and feel for bulging fontanelle.
•Look for pus draining from the ear.
•Look at the umbilicus. Is it red or draining pus?
Does the redness extend to the skin?

•Measure temperature (or feel for fever or low body temperature)

•Look for skin pustules. Are there many or severe pustules?
•See if the young infant is lethargic or unconscious.
•Look at the young infants’s movements. Are they less than normal?

CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL
INFECTION.

Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other
problems.
 CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
•Convulsions or •Give first dose of intramuscular
•Fast breathing (60 breaths
per minute or more) or antibiotics.
•Severe chest indrawing or •Treat to prevent low blood sugar.
•Nasal flaring or •Advise mother how to keep the infant
•Grunting or
•Bulging fontanelle or warm on the way to hospital.
•Pus draining from ear or POSSIBLE •Refer URGENTLY to hospital
•Umbilical redness SERIOUS
extending to the skin or
•Fever (37.5 C* or above or BACTERIAL
feels hot) or low body INFECTION
temperature (less than 35.5
C* or feels cold) or
•Many or severe skin
pustules or
•Lethargic or unconscious or
•Less than normal
movement.

•Red umbilicus or •Give an appropriate oral antibiotic.

draining pus or LOCAL •Teach the mother to treat local infections
•Skin pustules. BACTERIAL at home.
INFECTION •Advise mother to give home care for the
young infant.
•Follow-up in 2 days

*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.
How to assess and classify a young infant for diarrhea?

For ALL sick young infants check for signs of possible bacterial infection and
then
ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSESS AND CLASSIFY the young infant’s diarrhoea using the
DIARRHOEA box in the YOUNG INFANT chart. The
process is very similar to the one used for the sick child (see Chapter 8).

Then CHECK for feeding problem or low weight, immunization status and other
problems.
 For ALL sick young infants check for signs of possible bacterial infection, ask about
diarrhoea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

ASK: LOOK, LISTEN, FEEL:
œ Is there any difficulty feeding?
 œ Determine weight for age.

œ Is the infant breastfed? If yes,how many times in 24 hours?

œ Does the infant usually receive any other foods or drinks?

If yes, how often?
œ What do you use to feed the infant?


IF AN INFANT: Has any difficulty feeding,

Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age,
AND
Has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
œ Has the infant
 If the infant has not fed in the previous hour, ask the mother to put her
breastfed in the infant to the breast. Observe the breastfeed for 4 minutes.
previous hour?
(If the infant was fed during the last hour, ask the mother if she can wait
and tell you when the infant is willing to feed again.)

 Is the infant able to attach?

œ
no attachment at all not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
— Chin touching breast
— Mouth wide open
— Lower lip turned outward
— More areola visible above then below the mouth
(All these signs should be present if the attachment is good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
no suckling at all not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
œ Look for ulcers or white patches in the mouth (thrush).


CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight.

Then CHECK immunization status and for other problems.

CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT
SIGNS
•Not able to feed or
• No attachment at all or
•Not suckling at all.
•Not well attached to breast or
•Not suckling effectively or
•Less than 8 breastfeeds in 24 hours
or
•Receives other foods or drinks or
•Low weight for age or
•Thrush (ulcers or white patches in
mouth).
•Not low weight for age and no other
signs of inadequate feeding.
IDENTIFY TREATMENT
CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
NOT ABLE TO FEED •Give first dose of intramuscular antibiotics.
POSSIBLE •Treat to prevent low blood sugar.
SERIOUS BACTERIAL •Advise the mother how to keep the young infant warm on the way
INFECTION to hospital.
•Refer URGENTLY to hospital.
• Advise the mother to breastfeed as often and for as long as the infant
wants, day and night.
-If not well attached or not suckling effectively, teach correct
positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise to
FEEDING PROBLEM OR LOW increase frequency of feeding.
WEIGHT • If receiving other foods or drinks, counsel mother about breastfeeding
more, reducing other foods or drinks, and using a cup.
•If not breastfeeding at all:
— Refer for breastfeeding counselling and possible
relactation.
— Advise about correctly prepared breastmilk
substitutes and using a cup.
• If thrush, teach the mother to treat thrush at home.
• Advise mother to give home care for the young infant.
•Follow-up any feeding problem or thrush in 2 days. Follow-up low
weight for age in 14 days.
•Advise mother to give home care for the young infant.
NO FEEDING •Praise the mother for feeding the infant well.
PROBLEM
Communicate and Counsel
GOOD CHECKING QUESTIONS POOR QUESTIONS

How will you prepare the ORS solution? Do you remember how to mix the
ORS?

How often should you breastfeed your child? Should you breastfeed your child?

On what part of the eye do you apply Have you used ointment on your child
the ointment? before?

How much extra fluid will you give after each Do you know how to give extra
loose stool? fluids?

Why is it important for you to wash your hands? Will you remember to wash your
hands?
GIVE FOLLOW-UP
CARE
Follow-up care for the sick young
infant

When to return immediately

– Signs of any of the following:
–Breastfeeding or drinking
poorly
–Becomes sicker
–Develops a fever
–Fast breathing
–Difficult breathing
–Blood in the stool
Follow-up care for the sick young
infant
Follow-up in 2 days – on
antibiotics for local bacterial
infection or dysentery
Follow-up in 2 days - with a
feeding problem or oral thrush
Follow-up in 14 days – with low
weight for age
FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

If the child has: Return for follow-up in:

PNEUMONIA 2 days
DYSENTERY
MALARIA, if fever persists
FEVER—MALARIA UNLIKELY, if fever
persists
MEASLES WITH EYE OR MOUTH
COMPLICATIONS

PERSISTENT DIARRHOEA ACUTE EAR 5 days

INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving

PALOR VERY 14 days

LOW WEIGHT FOR AGE 30 days

 MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Name:___________ Age:___________
ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________
ASSESS (Circle all signs present)
CHECK FOR POSSIBLE BACTERIAL INFECTION
•Has the infant had convulsions?
DOES THE YOUNG INFANT HAVE DIARRHOEA?
•For how long? _______ Days
•Is there blood in the stools?
Weight:____________________kg________________________ Temperature:_______________ C
CLASSIFY
•Count the breaths in one minute. _______ breaths per minute
Repeat if elevated ________ Fast breathing?
•Look for severe chest indrawing.
•Look for nasal flaring.
•Look and listen for grunting.
•Look and feel for bulging fontanelle.
•Look for pus draining from the ear.
•Look at umbilicus. Is it red or draining pus?
Does the redness extend to the skin?
•Fever (temperature 37.5 C or feels hot) or low body temperature
(below 35.5° C or feels cool).
•Look for skin pustules. Are there many or severe pustules?
•See if young infant is lethargic or unconscious.
•Look at young infant's movements. Less than normal?
Yes _____ No ______
•Look at the young infant's general condition. Is the infant: Lethargic
or unconscious?
Restless or irritable?
•Look for sunken eyes.
•Pinch the skin of the abdomen. Does it go back: Very slowly (longer
than 2 seconds)?
Slowly?
 MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Name:___________ Age:___________ Weight:____________________kg________________________ Temperature:_______________ C
ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________
ASSESS (Circle all signs present) CLASSIFY

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT •Determine weight for age. Low _____ Not Low _____
•Is there any difficulty feeding? Yes_____ No______
•Is the infant breastfed? Yes_____ No_____
•IfYes, how many times in 24 hours?_____ times
•Does the infant usually receive any
other foods or drinks? Yes_____ No_____
If Yes, how often?

•What do you use to feed the child? If infant has not fed in the previous hour, ask the mother to put her
ASSESS BREASTFEEDING: infant to the breast. Observe the breastfeed for 4 minutes.
•Has the infant breastfed in the previous hour? •Is the infant able to attach? To check attachment, look for:
— Chin touching breast Yes _____ No
_____
— Mouth wide open Yes _____ No _____
— Lower lip turned outward Yes _____ No _____
— More areola above than below the mouth
Yes _____ No _____
no attachment at all not well attached good attachment
•Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling at all not suckling effectively suckling effectively
•Look for ulcers or white patches in the mouth (thrush).

CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS Circle immunizations needed today. Return for next
BCG DPT1 DPT2 immunization on:
OPV 0 OPV 1 OPV 2
(Date)

If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to
hospital:
 TREAT

Return for follow-up on _________________

Give any immunization/s needed today.
 MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Name: ____________________________________________________________________Age:____________________Weight:_______kg Temperature:________ C

ASK: What are the child's problems?_______________________________________________________________________Initial visit?________________Follow-up Visit?__________

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS General danger signs

present?
NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING LETHARGIC OR UNCONSCIOUS Yes ___ No ___
CONVULSION Remember to use
danger sign when
selecting classifications

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes ___ No ___
•For how long? ____ Days •Count the breaths in one minute.
________ breaths per minute. Fast breathing?
•Look for chest indrawing.
•Look and listen for stridor.

DOES THE CHILD HAVE DIARRHOEA? Yes ___ No ___

•For how long? _____ Days •Look at the child's general condition. Is the child:
•Is there blood in the stools? Lethargic or unconscious?
Restless or irritable?
•Look for sunken eyes.
•Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
•Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___

Decide Malaria Risk: High Low

•For how long? _____ Days •Look or feel for stiff neck.
•If more than 7 days, has fever been present every day? •Look for runny nose.
•Has child had measles within the last three months? Look for signs of MEASLES:
Generalized rash and
One of these: cough, runny nose, or red eyes.

If the child has measles now •Look for mouth ulcers.

or within the last 3 months: If Yes, are they deep and extensive?
•Look for pus draining from the eye.
•Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No___
•Is there ear pain? •Look for pus draining from the ear.
•Is there ear discharge? •Feel for tender swelling behind the ear.
IfYes, for how long? ___ Days

THEN CHECK FOR MALNUTRITION AND ANAEMIA •Look for visible severe wasting.
•Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
•Look for oedema of both feet.
•Determine weight for age.
Very Low ___ Not Very Low ___

CHECK THE CHILD'S IMMUNIZATION STATUS Circle immunizations needed today. Return for next immunization
_____ ______ ______ ______ on:
BCG DPT1 DPT2 DPT3

_______ _______ ______ ______

________ (Date)
OPV 0 OPV 1 OPV 2 OPV
3 Measles
ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old

•Do you breastfeed your child? Yes____ No ____ FEEDING PROBLEMS

IfYes, how many times in 24 hours? ___ times.
Do you breastfeed during the night? Yes___ No___
•Does the child take any other food or fluids? Yes___ No ___
IfYes, what food or fluids?
____________________________________________________
____________________________________________________
How many times per day? ___ times.
What do you use to feed the child? _____________________
If very low weght for age: How large are servings?
_________________________________________________
Does the child receive how own serving? ________________
Who feeds the child and how? ________________________

•During the illness, has the child's feeding changed?

Yes ____ No ____
If Yes, how?
 TREAT

Return for follow-up on ______________

Advise mother when to return immediately.
Give any immunization/s needed today.

Feeding Advice
CATEGORIES OF PROVINCES CONSIDERED
WITH MALARIA

Category A – Provincews with no significant improvement in

malaria situation in the last 10 years or situation worsened in the
last 5 yrs; average no. of cases >1000 in the last 10 yrs

- Kalinga - Mindoro Occ - Compostela valley

- Apayao - Palawan - Saranggani
- Mt. Province - Quezon - Zamboanga del Sur
- Ifugao - Misamis Or - Agusan del Sur
- Isabela - Davao del Norte - Agusan del Norte
- Cagayan - Davao del Sur - Surigao del Sur
- Quirino - Davao oriental - Tawi-tawi
- Zambales - Bukidnon - Sulu - Basilan
Category B – Provinces where situation has improved in the
last 5yrs or average no. of cases 100 to <1000 cases/yr

- Abra - Laguna
- Pangasinan - Camarines Norte
- Ilocos norte - Camarines Sur
- Nueva Vizcaya - Sultan Kudarat
- Nueva Ecija - So. Cotabato
- Bulacan - North Cotabato
- Bataan - Lanao del Sur
- Mindoro Or - Lanao del Norte
- Rizal - Maguindanao
- Aurora - Zamboanga del Norte
- Tarlac - Romblon
Category C – Provinces with significant reduction
in cases in the last 5 yrs

- Benguet - Antique
- Ilocos Sur - Sorsogon
- La Union - Negros Occ
- Pampanga - Negros Or
- Batangas - Eastern Samar
- Cavite - Western Samar
- Marinduque - Misamis Occ
- Masbate - Surigao del Norte
- Batanes - Albay
 Category D – Provinces that are malaria-free
although some are still potentially malarious sue to
toe presence of the vector.

Cebu Iloilo Biliran

Bohol Capiz Leyte Norte and
and Sur
Catanduanes Guimaras
Aklan Siquijor
Northern Samar Camiguin
IMCI

Thank you!