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Eastern University – Nicanor Reyes Medical Foundation

BASIC PEDIATRICS: IMCI STRATEGY
Dra. Galia, MD

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)
- An integrated approach to child health that focuses on the well-
being of the whole child.
- It aims to reduce death, illness and disability, and to promote
improved growth and development among children under five
years of age.
- It includes both preventive and curative elements that are
implemented by families and communities as well as by health
facilities.

WHO ARE THE CHILDREN COVERED BY THE IMCI PROTOCOL?
- Sick children from birth up to 2 months (Sick young infant)
- Sick children 2 months up to 5 years (Sick child)

WHAT DOES IMCI OFFERS? RATIONALE FOR THE INTEGRATED APPROACH IN THE
- It offers simple and effective methods to prevent and manage MANAGEMENT OF SICK CHILDREN
the leading causes of serious illness and mortality in young - Majority of deaths are caused by 5 preventable and treatable
children. conditions namely:
- The guidelines promote evidence-based assessment and o pneumonia, diarrhea, measles, malaria, and malnutrition
treatment, using a syndromic approach that supports the - 3 out of 4 episodes of childhood illness are caused by this
rational, effective, and affordable use of drugs. condition
- most children have more than one illness at one time.
WHERE IS IT INTENDED TO BE USED? - single diagnosis may not be possible or appropriate
- The approach is designed for use in outpatient clinical settings
with limited diagnostic tools, limited medications, and limited WESTERN PACIFIC REGION
opportunities to practice complicated procedures. - In the Western Pacific region where Philippines belong, almost
- Take note that the IMCI protocol is designed for use only in half a million children die of the 5 major diseases earlier
outpatient clinical settings with limited diagnostic tools, limited mentioned
medications, and limited opportunities to practice complicated - 527,000 children die before their 5th birthday
procedures. - 97% occurred in six countries, namely, Cambodia, China, the
- The management, therefore, may differ in hospital-setting and Lao People's Democratic Republic, Papua New Guinea, the
in areas with immediate access to diagnostic and treatment Philippines, and Vietnam
modalities.

COMPONENTS OF IMCI STRATEGY
- Improvements in the case management skills of health worker;
- Improvements in the health system required to deliver child
health interventions effectively;
- Improvements in family and community practices.

WHY IMCI?
- 10M children die each year in developing countries before they
reach their 5th birthday (1998)
- 7 in 10 deaths are due to acute respiratory infections (mostly
pneumonia), diarrhea, measles, malaria, or malnutrition --often
in combine
- Many are not properly assessed and treated and that their
parents are poorly advised

IMCI IN THE PHILIPPINES
- In the Philippines, IMCI started as a pilot basis in 1996

VISION: 20|20 1

 intended initially for Health workers and hospital staff at the practices, and counsel to solve any feeding problems.
frontline level - Then counsel the mother about her own health.

ACCELERATING IMPLEMENTATION OF IMCI IN THE PHILIPPINES FOLLOW-UP
2015-2025 - Give follow-up care and if necessary, reassess the child for new
- General objective: problem.
o To accelerate IMCI implementation all over the country.
- Specific objectives: By 2025, SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS
o To establish IMCI-ICATT training units and core trainers FOR ALL SICK CHILDREN up to 5 years of age who are brought to the
in all regions of the country clinic
o To implement IMCI in at least 80% of primary health - Ask the Child’s Age
care facilities (barangay health centers and BHSs) - If young infant age up to 2 months
o To integrate IMCI in all medical, nursing and midwifery o Use the Chart:
schools § ASSESS
o To establish IMCI referral hospitals in all provinces and § CLASSIFY, AND
cities § TREAT THE SICK YOUNG INFANT
o To establish core IMCI activities in the barangays. (to be - If the child is from 2 months up to 5 years
identified) o Use the charts:
§ Assess and classify the sick child
INTEGRATED CASE MANAGEMENT PROCESS § Treat the child
- Assess and Classify the sick child § Counsel the mother
- Treat the child
- Counsel FOR ALL SICK CHILDREN UP TO 5 YEARS OF AGE WHO ARE
- Follow-up BROUGHT TO THE CLINIC
- ASSESS the Child: Check for danger signs (or possible bacterial
ASSESS infection)
- by checking first the danger signs (or possible bacterial infection o Ask about main symptoms
in a young infant) o If a main symptom is reported, Assess further.
- ask questions about common conditions o Check nutrition and immunization status
- examining the child o Check for other problems
- check nutrition and immunization status - CLASSIFY the child’s illnesses: use a color coded triage system
- check other health problems to classify the child’s main symptoms and his or her nutrition or
feeding status
CLASSIFY o If URGENT REFERRAL: is needed and possible
- using a color-coded triage system § IDENTIFY URGENT PRE-REFERRAL TREATMENT
o urgent pre-referral treatment and referral (red) needed for the child’s classification
o specific medical treatment and advice (yellow) § TREAT THE CHILD: give urgent pre-referral
o simple management (green) treatment needed
§ REFER THE CHILD: explain to the child’s caretaker
TREAT THE CHILD the need for referral.
- Identify specific treatments for the child • Calm the caretaker’s fears and help resolve
o if requires urgent referral, give essential treatment any problems. Write a referral note
before transfer • Give instructions and supplies needed to
o if needs treatment at home, develop an integrated care for the child on the way to the hospital
treatment plan and give the first dose of drugs in the o If NO URGENT REFERRAL is needed or possible
clinic § IDENTIFY TREATMENT needed for the child’s
o if should be immunized, give immunizations classifications: identify specific medical
- Provide practical treatment options treatments and or advice
o teach caretaker how to give oral drugs § TREAT THE CHILD: give the first dose of oral drugs
o how to feed and give fluids in the clinic and or advise the child’s caretaker
o how to treat local infections • Teach the caretaker how to give oral drugs
and how to treat local infections at home
COUNSEL • If needed give immunizations
- Assess feeding, including assessment of breastfeeding § COUNSEL THE MOTHER: Assess the child’s

VISION: 20|20 2

 feeding, including breastfeeding practices and CHECK FOR GENERAL DANGER SIGNS
solve feeding problems, if present. ASK
• Advise about feeding and fluids during - Not able to drink, or breastfeed or
illness and about when to return to a health - Vomits everything or
facility - Convulsions or
• Counsel the mother about her own health. - Abnormally sleepy or difficult to awaken
- FOLLOW-UP CARE: give follow-up care when the child returns
to the clinic and, if necessary, reassess the child for new
problems. LOOK
- See if the child is lethargic or unconscious
THE SICK CHILD (2 MONTHS TO 5 YEARS) - Is the child convulsing now?
- Cough or difficult breathing
- Diarrhea **IF YES: URGENT REFERRAL IS NEEDED**
- Fever A child with any general danger sign needs URGENT attention;
- Ear problem complete the assessment and any pre-referral treatment
- Malnutrition and feeding immediately so referral is not delayed.
- Immunization status
ASSESS/LOOK/FEEL IF ANY GENERAL DANGER SIGN PRESENT:
FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE CLASSIFICATION: à VERY SEVERE DISEASE
BROUGHT TO THE CLINIC TREATMENT:
- GREET the mother appropriately and ask about her child - Give diazepam if convulsing now
o LOOK to see if the child’s Weight and temperature have - 
Quickly complete the assessment

been recorded - Give any pre-referral treatment immediately
- ASK the mother what child’s problems are - Treat to prevent low blood sugar
- DETERMINE if this is an initial visit or a follow-up visit for this - 
Keep the child warm
problem - 
Refer URGENTLY.
o IF INITIAL VISIT
§ ASSESS and CLASSIFY the child following the - Convulsion is a danger sign only when:
guidelines o Occurs in less than 6 months
o IF FOLLOW-UP VISIT o More than one episode
§ GIVE FOLLOW-UP CARE according to the o Occurring for more than 15 minutes
guidelines. o This definition EXCLUDES SIMPLE FEBRILE CONVULSIONS

USE GOOD COMMUNICATION SKILLS COUGH OR DIFFICULTY IN BREATHING, IF YES:
- Listen carefully to what the mother tells you ASK:
- Use words the mother understands - For how long
- Give the mother time to answer the questions
- Ask additional questions when the mother is not sure about LOOK FOR:
her answer - Count RR
- RECORD IMPORTANT INFORMATION - Chest indrawing
- Listen for Stridor
ASSESS - Listen for Wheezing
- ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS à THE CHILD MUST BE CALM AND NOT EATING
ARE
o Determine if this is an initial or follow-up visit for this If wheezing with either fast breathing or chest indrawing:
problem. - Give a trial of rapid acting inhaled bronchodilator for up to
o If follow-up visit, use the follow-up instructions on three times 15-20 minutes apart.
TREAT THE CHILD PART; - Count the breaths and look for chest indrawing again, and
o If initial visit, assess the young infant as follows; then classify
- Ask how long is the cough
CLASSIFY - Look for fast breathing and chest indrawing - fast breathing
- USE ALL BOXES THAT MATCH THE INFANT’S SYMPTOMS AND is defined as:
PROBLEMS TO CLASSIFY THE ILLNESS o >/=50/min in a 2-12 months
o >/= 40/min in 1-5 years

VISION: 20|20 3

 - Look and listen for stridor and wheezing: RATIONALE FOR MANAGEMENT OF CHILDREN WITH WHEEZE
o if wheezing, a trial of rapid acting inhaled - Wheeze can cause fast breathing and or chest indrawing
bronchodilators should be given - Good response to inhaled bronchodilator may cause fast
- Cough or difficult breathing is classified into severe breathing or chest indrawing to disappear
Pneumonia or Very Severe Disease which requires urgent - Only children with wheeze and signs of pneumonia (fast
referral; breathing and/or chest indrawing) need antimicrobials
- Pneumonia when there are no danger signs but with chest - Wheezing without signs of pneumonia only need
indrawing and fast breathing; and bronchodilator treatment
- Cough or Cold when there are no signs of Pneumonia or ANTIOBIOTIC TREATMENT FOR PNEUMONIA
very severe disease - Children aged 2-59 months pneumonia (chest indrawing
and or high RR) should be treated with oral amoxicillin of
ASSESS/LOOK/FEEL IF WITH: at least 40mg/kg/dose twice a day for five days
- ANY general danger sign or
- Stridor in calm child IF WITH DIARRHEA, IF YES
CLASSIFICATION: à SEVERE PNEUMONIA OR VERY SEVERE DISEASE ASK:
TREATMENT: - How long
st
- 1 dose of antibiotic - Is there blood in the stool
- URGENT REFERRAL
- Prevent Low Blood Sugar LOOK:
- Look at the child's general condition. Is the child:
ASSESS/LOOK/FEEL IF CHEST INDRAWING AND FAST BREATHING o Lethargic or unconscious?
ONLY: o Restless and irritable?
- 2-12 months old: > or = 50/minute - Look for sunken eyes.
- 12 months to 5 years: > or = 40/minute - Offer the child fluid. Is the child:
CLASSIFICATION: à PNEUMONIA o Not able to drink or drinking poorly?
TREATMENT: o Drinking eagerly, thirsty?
- Antibiotic for 5 Days (Amoxicillin) - Pinch the skin of the abdomen. Does it go back:
- If wheezing (or disappeared after rapidly
acting o Very slowly (longer than 2 seconds)?
bronchodilator) give an inhaled bronchodilator for 5 days*** o Slowly?
- 
If chest indrawing in HIV exposed/infected child, give first
dose of amoxicillin and refer. ASSESS/LOOK/FEEL FOR DEHYDRATION
- Soothe the throat and relieve the cough with a safe remedy
If 2 of the following signs:
coughing for more than 14 days or recurrent wheeze, refer for - Lethargic or unconscious
possible TB or asthma assessment - Sunken eyes
- Safe throat Remedy - Not able to feed/drinking poorly
o Calamansi - Skin pinch goes back very slowly (> 2secs)
o Ginger CLASSIFICATION: à SEVERE DEHYDRATION
o Tamarind TREATMENT:
o Breast milk - If child has no other severe classification:
- Follow-up in 3 Days o Give fluid for severe dehydration (Plan C) OR
- If child also has another severe classification:
ASSESS/LOOK/FEEL: IF NO SIGNS OF PNEUMONIA OR A VERY o Refer URGENTLY to hospital with mother giving
SEVERE DISEASE frequent sips of ORS on the way
CLASSIFICATION: à COUGH OR COLD o Advise the mother to continue breastfeeding
TREATMENT: - If child is 2 years or older and there is cholera in your area,
- If wheezing (or disappeared after rapidly acting give antibiotic for cholera
bronchodilator) give an inhaled bronchodilator for 5 days***

- Soothe the throat and relieve the cough with a safe remedy ASSESS/LOOK/FEEL FOR DEHYDRATION
- If coughing for more than 14 days or recurrent wheezing, refer 2 of the following signs:
for possible TB or asthma assessment
 - Restless, irritable
- Follow-up in 5 days if not improving - Sunken eyes
- If wheezing, give inhaled bronchodilator for 5 days - Drinks eagerly, thirsty
- Skin pinch goes back slowly (< 2secs)
CLASSIFICATION: à SOME DEHYDRATION

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 TREATMENT: COMPOSITION OF THE OLD AND REFORMULATED ORS
- Give fluid, zinc supplements, and food for some dehydration
(Plan B)

- If child also has a severe classification:
o Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way
o Advise the mother to continue breastfeeding
- Advise mother when to return immediately
- Follow-up in 5 days if not improving



ASSESS/LOOK/FEEL FOR DEHYDRATION
IF WITH FEVER
- IF Not enough signs to classify as SEVERE DEHYDRATION OR
FEVER:
SOME DEHYDRATION 0
- Fever is defined by history or feels hot or temperature 37.5 C
CLASSIFICATION: à NO DEHYDRATION 0 0 0
or above (based on axillary T ; rectal T is 0.5 C)
TREATMENT
- Decide if the area is Malaria Risk
- Give fluid, zinc supplements, and food to treat diarrhea at
- Look for any bacterial cause of fever
home (Plan A)
o local tenderness
- 
Advise mother when to return immediately
o oral sores
- Follow-up in 5 days if not improving
o refusal to use limb

o hot tender swelling
ASSESS/LOOK/FEEL IF DIARRHEA: 14 DAYS OR MORE
o red tender skin or boils
- Dehydration present
o lower abdominal pain or pain in passing urine in older
CLASSIFICATION: à SEVERE PERSISTENT DIARRHEA
children
TREATMENT:

- Treat Dehydration before referral unless the child has another
IF YES:
severe classification
- Decide Malaria Risk:
- Refer to hospital


ASK:
ASSESS/LOOK/FEEL IF DIARRHEA: 14 DAYS OR MORE
- Does the child live in a malaria area?

- No dehydration
- Has the child travelled during the past 3 weeks and, if so,
CLASSIFICATION: à NO DEHYDRATION BUT WITH PERSISTENT
where?
DIARRHEA

TREATMENT:
THEN ASK:
- Advise regarding feeding a child who has persistent diarrhea
- For how long?
- Give multivitamins and minerals with Zinc for 14 days
- 
If more than 7 days, has fever been present every day?
- Give Vitamin A
- 
Has the child had measles within the last 3 months?
- Follow-up in 5 days


LOOK AND FEEL:
ASSESS/LOOK/FEEL IF WITH BLOOD IN THE STOOL
- Look or feel for stiff neck.
- Blood in the Stool
- Look for runny nose.

CLASSIFICATION: à DYSENTERY
- Look for any bacterial cause of fever**.
TREATMENT:
- Look for signs of MEASLES.
- Oral antibiotic: CIPROFLOXACIN for 3 days
o Generalized rash and

- Follow-up in 3 days
o One of these: cough, runny nose, or red eyes.
- Advise mother when to return immediately


DO A MALARIA TEST: IF NO SEVERE CLASSIFICATION
TREATMENT FOR DIARRHEA
- In all fever cases with malaria risk.

- Use of low/reduced osmolarity Oral Rehydration Salts
- If no obvious cause of fever present.
(ORS)

- Providing children with zinc for 14 days:
FEVER: ASK ABOUT MALARIA RISK
o Children > 6 months 20 mg zinc
- Residing in endemic area?
o Children < 6 months 10 mg of zinc
- OR Travel and overnight stay in endemic area (within the past
- Ciprofloxacin as first line drug for bloody diarrhea
4 weeks)
(dysentery)
à IF YES, DO A BLOOD SMEAR

VISION: 20|20 5

 ASSESS/LOOK/FEEL IF FEVER WITH MALARIA RISK ASSESS/LOOK/FEEL IF FEVER NO MALARIA RISK
- With Any General Danger Sign Present - No general danger signs
- Stiff Neck - No Stiff Neck
CLASSIFICATION: à VERY SEVERE FEBRILE DISEASE CLASSIFICATION: à FEVER
TREATMENT: TREATMENT:
- Give first dose of ARTESUNATE OR ORAL QUININE for severe - Give one dose of paracetamol in clinic for high fever (38.5°C or
malaria (under medical supervision)
 above)

- Give first dose of an appropriate antibiotic - Give appropriate antibiotic treatment for any identified
- 
Treat the child to prevent low blood sugar bacterial cause of fever

- Give one dose of paracetamol in clinic for high fever (38.5°C - Advise mother when to return immediately
or above)
 - 
Follow-up in 3 days if fever persists

- Refer URGENTLY to hospital - If fever is present every day for more than 7 days, refer for
assessment
ASSESS/LOOK/FEEL IF FEVER WITH MALARIA RISK:
- (+) Blood Smear MALARIA DIAGNOSIS
CLASSIFICATION: à MALARIA - Prompt parasitological confirmation by microscopy or
TREATMENT: alternatively by Rapid Diagnostic Tests (RDTs) is
- Give recommended first line oral antimalarial recommended in ALL patients suspected of malaria before
- Give one dose of PARACETAMOL in clinic for high fever treatment is started.
(38.5°C or above) TREATMENT OF VERY SEVERE DISEASE IN MALARIA RISK ARE
- Give appropriate antibiotic treatment for an identified - Pre-referral treatment includes RECTAL ARTESUNATE
bacterial cause of fever
 suppository or oral Quinine and IM AMPICILLIN AND
- Advise mother when to return immediately GENTAMICIN
- 
Follow-up in 3 days if fever persists TREATMENT OF UNCOMPLICATED FALCIFARUM MALARIA
- If fever is present every day for more than 7 days, refer for - Artemisinin-based combination therapies (ACTs) should be
assessment used in the treatment of uncomplicated P. falciparum
malaria
ASSESS/LOOK/FEEL IF FEVER WITH MALARIA RISK: - ACTs should include at least 3 days of treatment with an
- (-) Blood Smear artemisinin derivative
- Other cause of Fever Present
CLASSIFICATION: à FEVER, NO MALARIA FEVER: MEASLES
TREATMENT: ASSESS/LOOK/FEEL IF THE CHILD HAS MEASLES NOW OR WITHIN
- Give one dose of PARACETAMOL in clinic for high fever THE LAST 3 MONTHS:
(38.5°C or above)
 - Look for mouth ulcers.

- Give appropriate antibiotic treatment for an identified - Are they deep and extensive?
bacterial cause of fever - Look for pus draining from the eye. Look for clouding of the
- 
Advise mother when to return immediately cornea.
- 
Follow-up in 3 days if fever persists

- If fever is present every day for more than 7 days, refer for ASSESS/LOOK/FEEL IF MEASLES NOW OR WITHIN LAST 3 MONTHS
assessment - Any General Danger Sign
- With Clouding Of Cornea Or
FEVER: NO MALARIA RISK - With Deep Or Extensive Mouth Ulcers
ASSESS/LOOK/FEEL IF FEVER: NO MALARIA RISK AND NO TRAVEL CLASSIFICATION: à SEVERE COMPLICATED MEASLES
TO MALARIA RISK TREATMENT:
- With Any General Danger Sign Or - Give Vitamin A
st
- Stiff Neck - 1 dose of Antibiotic
CLASSIFICATION: à VERY SEVERY FEBRILE DISEASE - If clouding of the cornea or pus draining from the eye, apply
TREATMENT: TETRACYCLINE eye ointment
- Give first dose of an appropriate antibiotic.
 - URGENT REFERRAL
- Treat the child to prevent low blood sugar.

- Give one dose of paracetamol in clinic for high fever (38.5°C ASSESS/LOOK/FEEL IF MEASLES NOW OR WITHIN LAST 3 MONTHS
or above).
 - Pus Draining From The Eye Or
- Refer URGENTLY to hospital. - Mouth Ulcers

VISION: 20|20 6

 CLASSIFICATION: à MEASLES WITH EYE OR MOUTH - DO NOT GIVE ASPIRIN.
COMPLICATIONS
TREATMENT: ASSESS/LOOK/FEEL DENGUE
- Give Vitamin A - If No Sign Of Severe Dengue Hemorrhagic Fever
- If pus draining from the EYE, TETRACYCLINE eye ointment CLASSIFICATION: à FEVER, DHF UNLIKELY
- If MOUTH ULCERS, teach the mother to treat with GENTIAN - Give ORS
VIOLET - Advise mother when to return immediately
- Follow-up in 3 days - Follow-up in 3 days if fever persists or child shows signs of
- Advise mother when to return immediately bleeding.
- DO NOT GIVE ASPIRIN
ASSESS/LOOK/FEEL IF MEASLES NOW OR WITHIN LAST 3 MONTHS
- Measles Now Or Within Last 3 Months CHILD HAS EAR PROBLEM
CLASSIFICATION: à MEASLES IF YES, ASK:
TREATMENT: - Is there ear pain?

- Give Vitamin A - Is there ear discharge? If yes, for how long?
LOOK AND FEEL:

ASSESS DENGUE - Look for pus draining from the ear.
ASK: - 
Feel for tender swelling behind the ear.
- Has the child had any bleeding from the nose or gums or in
the vomitus or stools?
 ASSESS/LOOK/FEEL EAR PROBLEM
- Has the child had black vomitus? - Tender Swelling behind the ear
- Has the child had black stools? CLASSIFICATION: à MASTOIDITIS
- Has the child had persistent abdominal pain? TREATMENT:
st
- 
Has the child had persistent vomiting - 1 dose of Appropriate Antibiotic
st
LOOK AND FEEL: - Give 1 dose Paracetamol for Pain
- URGENT REFERRAL
- 
Look for bleeding from nose or gums.

- Look for skin petechiae.
ASSESS/LOOK/FEEL EAR PROBLEM
- 
Feel for cold and clammy extremities.
- Pus is seen draining from the ear and discharge is reported for
- Check for slow capillary refill.
less than 14 days, or

- Ear pain.
if none of above ASK or LOOK and FEEL signs are present and the
CLASSIFICATION: à ACUTE EAR INFECTION
child is 6 months or older and fever is present for more than 3 days.
TREATMENT:
- Perform the tourniquet test.
- Antibiotic for 5 days

- PARACETAMOL for pain
ASSESS/LOOK/FEEL DENGUE
- Dry the ear Wicking
- Bleeding from nose or gums or
- Follow-up in 5 days
- Bleeding in stools or vomitus or

- Black stools or
ASSESS/LOOK/FEEL EAR PROBLEM
- vomitus or

- Pus seen draining from the ear and discharge is reported For
- Skin petechiae or
14 Days Or More
- Cold and clammy extremities or
CLASSIFICATION: à CHRONIC EAR INFECTION
- Capillary refill more than 3 seconds or
TREATMENT:
- persistent abdominal pain
- Dry the ear by Wicking
- 
Persistent vomiting or
- QUINOLONE ear drops for 2 weeks (14 days)
- 
Tourniquet test positive
- Follow-up in 5 days
CLASSIFICATION: à SEVERE DENGUE HEMORRHAGIC FEVER

TREATMENT:
ASSESS/LOOK/FEEL EAR PROBLEM
- If persistent vomiting or persistent abdominal pain or skin
- No ear pain and
petechiae or positive tourniquet test are the only positive
- No pus seen draining from the ear
signs, give ORS(Plan B
CLASSIFICATION: à NO EAR INFECTION
- )
If any other signs of bleeding are present, give fluids
TREATMENT:
rapidly(Plan C).
- No Treatment
- Treat the child to prevent low blood sugar.

- Refer all children URGENTLY to hospital.

VISION: 20|20 7

 THEN CHECK FOR MALNUTRITION - Give ready-to-use therapeutic food if available for a child aged
LOOK AND FEEL: (Signs of Acute Malnutrtion) 6 months or more

- Look for edema of both feet - Counsel the mother on how to feed the child.
- Determine WFH/L z-score using the WHO growth standard - Assess for possible TB infection

charts - Advise mother when to return immediately
- Measure the Mid-Upper Arm Circumference using MUAC tape - Follow up in 5 days
in all children 6 months or older
- Offer Ready-to-Use Therapeutic Food (RUTF) for appetite test ASSESS/LOOK/FEEL NUTRITIONAL STATUS
- WFH/L between -3 and - 2 z-scores OR
APPETITE TEST - MUAC 115 up to 125 mm.
- Offer appropriate amount of RUTF to the child to eat: CLASSIFICATION: à MODERATE ACUTE MALNUTRITION
- After 30 minutes check if the child was able to finish or not TREATMENT
able to finish the amount of RUTF given and decide: - Assess the child's feeding and counsel the mother on the
- Child ABLE to finish at least one-third of a packet of RUTF feeding recommendations
portion (92 g) or 3 teaspoons from a pot within 30 minutes. - 
If feeding problem, follow up in 5 days
- Child NOT ABLE to eat one-third of a packet of RUTF portion - Assess for possible TB infection.
(92 g) or 3 teaspoons from a pot within 30 minutes. - Advise mother when to return immediately
- If WFH/L less than -3 z-scores or MUAC less than 115 mm, - Follow-up in 30 days
then:
- Check for any medical complication present: ASSESS/LOOK/FEEL NUTRITIONAL STATUS
o Any general danger sign

- WFH/L - 2 z-scores or more OR
o Any severe classification
- MUAC 125 mm or more.
o Pneumonia with chest indrawing
- If no medical complications present: CLASSIFICATION: à NO ACUTE MALNUTRITION
o Child is 6 months or older, offer RUTF*** to eat. Is TREATMENT
the child: - If child is less than 2 years old, assess the child's feeding and
§ Not able to finish RUTF portion? counsel the mother on feeding according to the feeding
§ Able to finish RUTF portion? recommendations
o Child is less than 6 months, assess breastfeeding:
- Give micronutrient powder supplement.
(see page 45 of 77)
§ Does the child have a breastfeeding - If feeding problem, follow-up in 5 days
problem?
MICRONUTRIENT POWDER
ASSESS/LOOK/FEEL NUTRITIONAL STATUS - Give Micronutrient Powder Supplement or (MNP) daily to
- Edema of both feet OR children 6 - 23 months old
- WFH/L less than -3 z- scores OR MUAC less than 115 mm AND - 
Use this at 6 months of age during the introduction of
any one of the following: complementary feeding
o Medical
complication present or - 
Mix MNP into complementary food preferably soft or semi-
o 
Not able to finish RUTF or solid before feeding it to the child
o 
Breastfeeding problem. - Do not add MNP to food before or during cooking
CLASSIFICATION: à COMPLICATED SEVERE ACUTE MALNUTRITION o for 6 - 11 months infant, give a total of 60 sachets
TREATMENT: over a period of 6 months

- Give first dose appropriate antibiotic o for 12 - 23 months children, give 60 sachets every 6
- Treat the child to prevent low blood sugar months for a total of 120 sachets in a year
- 
Keep the child warm
- Refer URGENTLY to hospital CHECK FOR ANEMIA
- If the child has severe acute malnutrition and is receiving
ASSESS/LOOK/FEEL NUTRITIONAL STATUS RUTF, DO NOT GIVE iron because there is already adequate
- WFH/L less than -3 z- scores OR amount of iron in RUTF
- MUAC less than 115 mm AND LOOK FOR:
- Able to finish RUTF. - Severe Palmar Pallor
CLASSIFICATION: à UNCOMPLICATED SEVERE ACUTE - Some Palmar Pallor
MALNUTRITION
TREATMENT ASSESS/LOOK/FEEL ANEMIA
- Give oral antibiotics for 5 days
 - Severe Palmar Pallor
- Continue breastfeeding
 CLASSIFICATION: à SEVERE ANEMIA

VISION: 20|20 8

 TREATMENT: TREATMENT:
- Urgent Referral - Initiate ART treatment and HIV care

- Give COTRIMOXAZOLE prophylaxis*

ASSESS/LOOK/FEEL ANEMIA - Assess the child’s feeding and provide appropriate
- Some Palmar Pallor counselling to the mother

CLASSIFICATION: à ANEMIA - Advise the mother on home care
Assess or refer for TB
TREATMENT: assessment and INH preventive therapy

- Give Iron*
 - Follow-up regularly as per national guidelines
- Give MEBENDAZOLE If Child Is 1 Year Or Older And Has Not
Had A Dose In The Previous 6 Months ASSESS/LOOK/FEEL HIV STATUS
- Advise Mother When To Return Immediately - Mother HIV-positive AND negative virological test in
a
- Follow-Up In 14 Days breastfeeding child or only stopped less than 6 weeks ago OR
- Mother HIV-positive, child not yet tested OR
ASSESS/LOOK/FEEL ANEMIA - Positive serological test in a child less than 18 months’ old
- No Palmar Pallor CLASSIFICATION: à HIV EXPOSED
CLASSIFICATION: àNO ANEMIA TREATMENT:
TREATMENT: - Give COTRIMOXAZOLE prophylaxis

- If child is less than 2 years old, assess the child's feeding and - Start or continue ARV prophylaxis as recommended

counsel the mother according to the feeding - Do virological test to confirm HIV status**

recommendations - Assess the child’s feeding and provide appropriate
o If feeding problem, follow-up in 5 days counselling to the mother

o Give micronutrient powder (MNP) - Advise the mother on home care

- Follow-up regularly as per national guidelines
HIV INFECTION
- What we need to know about HIV: ASSESS/LOOK/FEEL HIV STATUS
o We need to ask if the mother had an HIV test - Negative HIV test in mother or child
o Learn how to decide the HIV status of the mother CLASSIFICATION: à HIV INFECTION UNLIKELY
o Ask about the breastfeeding status of the child TREATMENT:
o If no test has been done, to request for the test - Treat, counsel and follow-up existing infections

ASK * Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed
- Has the mother or child had an HIV test? children until confirmed negative after cessation of breastfeeding.

IF YES:
 ** If virological test is negative, repeat test 6 weeks after the
- Decide HIV status: breastfeeding has stopped; if serological test is positive, do a
o Mother: POSITIVE or NEGATIVE Child: virological test as soon as possible.
§ Virological test POSITIVE or NEGATIVE

§ Serological test POSITIVE or NEGATIVE
CHECK IMMUNIZATION STATUS

- Birth
If mother is HIV positive and child is negative or unknown, ASK:
o BCG
- Was the child breastfeeding at the time or 6 weeks before the
o HepB0
test?
- 6 Weeks
- 
Is the child breastfeeding now?
o DPT+Hib1
- 
If breastfeeding, ASK: Is the mother and child on ARV
o HepB1
prophylaxis?
o OPV1

o RTV1
IF NO, THEN TEST:
o PCV1
- Mother and child status unknown: TEST mother.

- 10 Weeks
- Mother HIV positive and child status unknown: TEST child. o DPT+Hib2

o HepB2
ASSESS/LOOK/FEEL HIV STATUS
o OPV2
- Positive virological test in child OR o RTV2
- Positive serological test in a child 18 months or older
o PCV2
CLASSIFICATION: à CONFIRMED HIV INFECTION
- 14 Weeks
o DPT+Hib3

VISION: 20|20 9

 o HepB3 COUNSEL AND FOLLOW-UP CARE
o OPV3 WHEN TO RETURN TO HEALTH WORKER
o RTV3 - FOLLOW-UP VISIT: Advise the mother to come for follow-up at
o PCV3 the earliest time listed for the child's problems.
- 9 months
RETURN FOR FOLLOW-UP
o Measles IF THE CHILD HAS:
IN:
- 12-15 months
- PNEUMONIA

o MMR
- DYSENTERY
- RTV AND PCV: in selected areas only due to limited supplies
- 
MALARIA, if fever persists
- Pentavalent vaccine includes DPT, HIB, HepB
- FEVER: NO MALARIA, if fever

persists
- *Children who are HIV positive or unknown HIV status with
- MEASLES WITH EYE OR
symptoms consistent with HIV should not be vaccinated with 3 days
MOUTH COMPLICATIONS
BCG.
- 
MOUTH OR GUM ULCERS OR
o Infant born to mother with TB disease, do not give BCG
THRUSH
first, instead give Isoniazid Preventive therapy {IPT} for
- FEVER: DENGUE
3 months. If TST negative after 3 months, give BCG.
HEMORRHAGIC FEVER
- `**DPT+HIB+HepB is available as pentavalent vaccine

UNLIKELY
- ***Second dose of measles vaccine may be given at any
opportunistic moment during periodic supplementary - PERSISTENT DIARRHEA

immunization activities as early as one month following the first - ACUTE EAR INFECTION

dose. - CHRONIC EAR INFECTION 5 days
- ***HIV-positive infants and pre-term neonates who have - COUGH OR COLD, if not
received 3 primary vaccine doses before 12 months of age may improving
benefit from a booster dose in the second year of life. - UNCOMPLICATED SEVERE
14 days
- ****Rotavirus Vaccine is given to children in selected areas due ACUTE MALNUTRITION
to limited supplies; Rotavirus Vaccine is available as 2 dose or 3 - FEEDING PROBLEM 5 days
dose schedule

- *****Pneumococcal Conjugate Vaccine (PCV ) is given to - ANEMIA 14 days
children in selected areas only due to limited supplies.
- MODERATE ACUTE
30 days
MALNUTRITION
THEN CHECK VITAMIN A SUPPLEMENTATION STATUS (for children
6 months or older)
- Given if child was not given in the past 6 months - CONFIRMED HIV INFECTION According to national
- Give every child a dose of Vitamin A every six months from the HIV EXPOSED recommendations
age of 6 months.
- Record the dose on the child's chart.
WHEN TO RETURN IMMEDIATELY
THEN CHECK THE CHILD’S DEWORMING STATUS: Advise mother to return immediately if the child has any of
- Routine Worm Treatment these signs:
o Give every child ALBENDAZOLE/MEBENDAZOLE every 6 Any sick child Not able to drink or
months form the age of one year. breastfeed Becomes
o Record the dose on the child’s card sicker
Develops a fever
If child has COUGH OR COLD, Fast breathing Difficult
THEN CHECK FOR ORAL HEALTH also return if: breathing
- Advise mother to bring the child to a dentist every 6 months If child has diarrhea, also return
for dental check-up from the age 6 months. if: Blood in stool Drinking
poorly

VISION: 20|20 10

 SICK YOUNG INFANT AGE UP TO 2 MONTHS - 
Fast breathing (60 breaths per minute or more) or
Check for the following: - Severe chest indrawing or
- Very severe disease and local bacterial infection - Fever (37.5°C* or above) or
- Jaundice - Low body temperature (less than 35.5°C*) or
- Diarrhea - 
Movement only when stimulated or no movement at all.
- HIV infection CLASSIFICATION à VERY SEVERE DISEASE
- Feeding problem or low weight for age TREATMENT
- Give first dose of intramuscular antibiotics
SUMMARY MANAGEMENT OF SICK YOUNG INFANT - Treat to prevent low blood sugar

- Ask the mother or caretaker about the young infant’s problem - Refer URGENTLY to hospital **
- If this is an initial visit for the problem, follow the steps below - 
Advise mother how to keep the infant warm on the way to the
(if this is a follow-up visit for the problem, give follow-up care_ hospital
- Check for VERY SEVERE DISEASE AND LOCAL BACTERIAL
INFECTION and classify the illness ASSESS/LOOK/FEEL ALL YOUNG INFANTS
- Check for JAUNDICE and classify the illness - Umbilicus red or draining pus or

- Ask the mother or caretaker about DIARRHEA - Skin pustules
o If the diarrhea is present CLASSIFICATION à LOCAL BACTERIAL INFECTION
§ Assess the infant further signs related to diarrhea TREATMENT
and - Give an appropriate oral antibiotic
§ Classify the illness according to the signs which - Teach the mother to treat local infections at home
are present or absent - Advise mother to give home care for the young infant
Follow
- Check for HIV Infection and classify the illness up in 2 days
- Check for FEEDING PROBLEM OR LOW WEIGHT and classify
- Check the immunization status and Vitamin A status and ASSESS/LOOK/FEEL ALL YOUNG INFANTS
decide if the infant needs any immunization today or mother - None of the signs of very severe disease or local bacterial
needs Vitamin A infection
- Assess any other problems, and Assess Mother’s health needs CLASSIFICATION à SEVERE DISEASE OR LOCAL INFECTION
- Then: Identify Treatment, Treat the infant, and Counsel the UNLIKELY
Mother (Part IV) TREATMENT:
- Advise the mother to give home care
CHECK FOR VERY SEVERE FEBRILE DISEASE AND LOCAL BACTERIAL
INFECTION CHECK FOR JAUNDICE
ASK: If jaundice present, ASK:
- Is the infant having difficulty in feeding? - When did the jaundice appear first?
- Has the infant had convulsions (fits)? LOOK AND FEEL:
- Look for jaundice (yellow eyes or skin)
Look at the young
LOOK, LISTEN, FEEL: infant's palms and soles. Are they yellow?
- Count the
breaths in one
minute.
o Repeat
 the count if more than 60 breaths per minute. ASSESS/LOOK/FEEL JAUNDICE

- Look for severe
chest indrawing. - Any jaundice if age less than 24 hours or
Yellow palms and
**YOUNG INFANT MUST BE CALM** soles at any age
- Measure axillary temperature. CLASSIFICATION à SEVERE JAUNDICE
- 
Look at the umbilicus. Is it red or draining pus? TREATMENT:
- 
Look for skin pustules. - Treat to prevent low blood sugar

- Look at the young infant's movements.
If infant is sleeping, ask - Refer URGENTLY to hospital

the mother to wake him/her. - Advise mother how to keep the infant warm on the way to
o Does the infant move on his/her own? the hospital
- If the young infant is not moving, gently stimulate him/her. -
o Does the infant not move at all? ASSESS/LOOK/FEEL JAUNDICE
- Jaundice appearing after 24 hours of age and

ASSESS/LOOK/FEEL ALL YOUNG INFANTS - Palms and soles not yellow
Any one of the following signs CLASSIFICATION à JAUNDICE
- Not feeding well or TREATMENT:
- Convulsions or - Advise the mother to give home care for the young infant


VISION: 20|20 11

 - Advise mother to return immediately if palms and soles TREATMENT
appear yellow. - Give fluid and breast milk for some dehydration (Plan B)

- If the young infant is older than 14 days, refer to a hospital for - If infant has any severe classification:
assessment
 o Refer URGENTLY to hospital with mother giving
- Follow-up in 1 day frequent sips of ORS on the way
o Advise the mother to continue breastfeeding
ASSESS/LOOK/FEEL JAUNDICE - Advise mother when to return immediately
- No Jaundice - Follow-up in 2 days if not improving
CLASSIFICATION à NO JAUNDICE
TREATMENT: ASSESS/LOOK/FEEL DIARRHEA FOR DEHYDRATION
- Advise the mother to give home care for the young infant - Not enough signs to classify as some or severe dehydration.
CLASSIFICATION à NO DEHYDRATION
CHECK FOR DIARRHEA TREATMENT
What is diarrhea in a young infant? - Give fluids to treat diarrhea at home and continue
- A young infant has diarrhea if the stools have change from breastfeeding (Plan A)

usual pattern and are many and watery ( more water than - Advise mother when to return immediately
fecal matter). - Follow-up in 2 days if not improving
- The normally frequent or semi-solid stools of a breastfed baby
are not diarrhea. CHECK FOR HIV INFECTION
ASK
IF YES, LOOK AND FEEL: - Has the mother and/or young infant had an HIV test?
- Look at the young infant's general condition: Infant's IF YES:
movements - What is the mother's HIV status?:
o Does the infant move on his/her own?
 o Serological test POSITIVE or NEGATIVE
o Does the infant not move even when stimulated but - What is the young infant's HIV status?:
then stops? o Virological test POSITIVE or NEGATIVE
o 
Does the infant not move at all? o Serological test POSITIVE or NEGATIVE
o 
Is the infant restless and irritable? If mother is HIV positive and NO positive virological test in child
- Look for sunken eyes.
 ASK:
- Pinch the skin of the abdomen. Does it go back: - Is the young infant breastfeeding now?

o Very slowly (longer than 2 seconds)? - Was the young infant breastfeeding at the time of test or
o or slowly? before it?
- 
Is the mother and young infant on PMTCT ARV prophylaxis?*
ASSESS/LOOK/FEEL DIARRHEA FOR DEHYDRATION
Two of the following signs: IF NO test: Mother and young infant status unknown
- Movement only when stimulated or no movement at all
 - Perform HIV test for the mother; if positive, perform
- Sunken eyes virological test for the young infant
- 
Skin pinch goes back very slowly.
CLASSIFICATION à SEVERE DEHYDRATION ASSESS/LOOK/FEEL HIV STATUS
TREATMENT: - Positive Virological Test in young infants
- If infant has no other severe classification: CLASSIFICATION à CONFIRMED HIV INFECTION
- Give fluid for severe dehydration (Plan C) OR TREATMENT:
- If infant also has another severe classification: - Give COTRIMOXAZOLE prophylaxis from age 4-6 weeks
Give
o Refer URGENTLY to hospital with mother giving HIV ART and care
Advise the mother on home care
frequent sips of ORS on the way - Follow-up regularly as per national guidelines
o Advise the mother to continue breastfeeding
ASSESS/LOOK/FEEL HIV STATUS
ASSESS/LOOK/FEEL DIARRHEA FOR DEHYDRATION - Mother HIV positive AND negative virological test in
Two of the following signs: young
infant breastfeeding or if only stopped less than 6 weeks
- Restless and irritable ago. OR
- Sunken eyes
 - Mother HIV positive, young infant not yet tested OR
- Skin pinch goes back slowly. - Positive serological test in young infant
CLASSIFICATION à SOME DEHYDRATION CLASSIFICATION à HIV EXPOSED

VISION: 20|20 12

 TREATMENT: - Follow-up any feeding problem or thrush in 2 days Follow-up
- Give cotrimoxazole prophylaxis from age 4-6 weeks
 low weight for age in 14 days.
- Start or continue PMTCT ARV prophylaxis as per national
recommendations** ASSESS/LOOK/FEEL FEEDING
- Do virological test at age 4-6 weeks or repeat 6 weeks after - Not low weight for age and no other signs of inadequate
the child stops breastfeeding feeding.
- Advise the mother on home care
 CLASSIFICATION à NO FEEDING PROBLEM
- Follow-up regularly as per national guidelines TREATMENT:
- Advise mother to give home care for the young infant

ASSESS/LOOK/FEEL HIV STATUS - Praise the mother for feeding the infant well
- Negative HIV test in mother or young infant
CLASSIFICATION à HIV INFECTION UNLIKELY ASSESS BREASTFEEDING
TREATMENT - Has the infant breastfed in the previous hour?
- Treat, counsel, and follow-up existing infections o If the infant has not fed in the previous hour, ask the
**HIV is assessed same with sick child** mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE o (If the infant was fed during the last hour, ask the
Ask: mother if she can wait and tell you when the infant is
- Is the infant breastfed? If yes, how many times in 24 hours?
 willing to feed again.)
- Does the infant usually receive any other foods or drinks? If
§ Is the infant well attached?
yes, how often?
§ not well attached good attachment
- If yes, what do you use to feed the infant?
LOOK, LISTEN, FEEL: - TO CHECK ATTACHMENT, LOOK FOR:
- Determine weight for age. o Chin touching breast

- Look for ulcers or white patches in the mouth (thrush). o Mouth wide open
o 
Lower lip turned outwards

ASSESS/LOOK/FEEL FEEDING o More areola visible above than below the mouth
- Not well attached to breast or
 o (All of these signs should be present if the attachment
- Not suckling effectively or is good.)

- Less than 8 breastfeeds in 24 hours or - Is the infant suckling effectively (that is, slow deep sucks,
- Receives other foods or drinks or
Low weight for age or sometimes pausing)?
- Thrush (ulcers or white patches in mouth). o not suckling effectively suckling effectively
CLASSIFICATION à FEEDING PROBLEM OR LOW WEIGHT - Clear a blocked nose if it interferes with breastfeeding.
TREATMENT
- If not well attached or not suckling effectively, teach correct CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-
positioning and attachment BREASTFED INFANTS

o If not able to attach well immediately, teach the - for HIV exposed infants and not breastfeeding
mother to express breast milk and feed by a cup
- If breastfeeding less than 8 times in 24 hours, advise to ASK
increase frequency of feeding. Advise the mother to - What milk are you giving?
breastfeed as often and as long as the infant wants, day and - How many times during the day and night?

night - How much is given at each feed?
- If receiving other foods or drinks, counsel the mother about - How are you preparing the milk?
breastfeeding more, reducing other foods or drinks, and using - 
Let mother demonstrate or explain how a feed is prepared,
a cup
 and how it is given to the infant.
- If not breastfeeding at all*: - Are you giving any breast milk at all?

o Refer for breastfeeding counselling and possible - What foods and fluids in addition to replacement feeds is
relactation* given?
o 
Advise about correctly preparing breast-milk - How is the milk being given?

substitutes and using a cup - Cup or bottle?
- Advise the mother how to feed and keep the low weight infant - 
How are you cleaning the feeding utensils?
warm at home
 LOOK, LISTEN, FEEL:
- If thrush, teach the mother to treat thrush at home Advise - Determine weight for age.
mother to give home care for the young infant - Look for ulcers or white patches in the mouth (thrush).

VISION: 20|20 13

 ASSESS/LOOK/FEEL FEEDING o Give only breastfeeds to the young infant.
- Milk incorrectly or unhygienically prepared or o Breastfeed frequently, as often and for as long as the
- Giving inappropriate replacement feeds or infant wants.
- Giving insufficient replacement feeds or - MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL
- An HIV positive mother mixing breast and other feeds before 6 TIMES.
months or o 
In cool weather cover the infant's head and feet and
- Using a feeding bottle or Low weight for age or dress the infant with extra clothing.
- Thrush (ulcers or white patches in mouth). - WHEN TO RETURN:
CLASSIFICATION à FEEDING PROBLEM OR LOW WEIGHT FOLLOW-UP VISIT
TREATMENT IF THE INFANT HAS RETURN FOR FIRST FOLLOW-
- Counsel about feeding UP IN:
- 
Explain the guidelines for safe replacement feeding JAUNDICE 1 DAY
- Identify concerns of mother and family about feeding.
 LOCAL BACTERIAL INFECTION 2 DAYS
- If mother is using a bottle, teach cup feeding FEEDING PROLEM
- Advise the mother how to feed and keep the low weight infant THRUSH
warm at home DIARRHEA
- 
If thrush, teach the mother to treat thrush at home LOW WEIGHT FOR AGE 14 DAYS
- Advise mother to give home care for the young infant
 COFIRMED HIV INFECTION According to National
- Follow-up any feeding problem or thrush in 2 days HIV EXPOSED Recommendations
- Follow-up low weight for age in 14 days
- When to Return Immediately (Advise the mother to return
ASSESS/LOOK/FEEL FEEDING immediately if the young infant has any of these signs):
- Not low weight for age and no other signs of inadequate o Breastfeeding poorly
feeding. o 
Reduced activity
CLASSIFICATION à NO FEEDING PROBLEM o 
Becomes sicker

TREATMENT o Develops a fever

- Advise mother to give home care for the young infant
 o Feels unusually cold
- Praise the mother for feeding the infant well o 
Fast breathing
o 
Difficult breathing
THEN CHECK IMMUNIZATION AND VITAMIN A STATUS o 
Palms and soles appear yellow
- Birth
o BCG
o HepB0
- 6 Weeks
o Pentavalent1
o OPV1
o RTV1
o PCV1

- Give all missed doses on this visit.
- Include sick infants unless being referred.
- Advise the caretaker when to return for the next dose.
- *Note: DPT-HIB-HEP B is available as Pentavalent vaccine
VITAMIN A
- Give 200,000 IU to the MOTHER within 6 weeks of delivery

ASSESS OTHER PROBLEMS
ASSESS THE MOTHER’S HEALTH NEEDS
- Nutritional status and anemia, contraception.
- Check hygienic practices. Smoking cessation in the family.

COUNSEL THE MOTHER
ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG
INFANT
- EXCLUSIVELY BREASTFEED THE YOUNG INFANT
 Notes from Lecture PPT, IMCI booklet.

VISION: 20|20 14