Diagnostic reasoning case · WHO IMCI and Pocket book of hospital care for children
A child who had a fit
A child who has had a fit and is now awake is easy to send home by mistake. At first-level care you cannot tell a harmless febrile seizure from the first fit of cerebral malaria or meningitis, so IMCI counts any convulsion in this illness as a danger sign.
- Setting: Health centre in a high malaria transmission area, 90 minutes by road from the district hospital
- For nurses, clinical officers, doctors and community health workers trained in IMCI
- Reviewed October 2026
The presentation
Amani, 2 years old, is brought in by her father. She has had fever since yesterday. One hour ago at home her whole body went stiff and then jerked for 'about three minutes'. She was sleepy afterwards. She is now awake and crying. She weighs 12 kg.
| Sign | Value |
|---|---|
| Axillary temperature | 39.4 °C |
| Breathing rate | 36 per minute |
| Pulse | 150 per minute |
| Conscious level (AVPU) | Alert, irritable |
| Weight | 12 kg |
Tests at hand: Blood glucose (finger-prick) · Malaria rapid diagnostic test (RDT) · Haemoglobin (Hb) · Mid-upper arm circumference (MUAC)
Starting differential
- Febrile seizureStill possible
- Severe (cerebral) malaria Must not missStill possible
- Bacterial meningitis Must not missStill possible
- Low blood sugar Must not missStill possible
- Head injury or poisoning Must not missStill possible
- Other infection causing the fever (pneumonia, ear, urine)Still possible
- Epilepsy (first unprovoked seizure)Less likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Amani is in front of you. What do you check in the first minute, and what would you do if she started fitting again?
Model answer
Check for emergency signs: airway and breathing, shock, coma, convulsing now. Then the general danger signs. She is breathing normally, warm hands, alert and crying; she is not convulsing now.
If she fits again
- Turn her on her side and clear the airway. Put nothing in her mouth.
- Give diazepam 0.5 mg/kg rectally (10 mg/2 mL solution: 1.5 mL for 12 months up to 3 years, 10 to under 14 kg), with a small syringe without a needle.
- Check for low blood sugar, then treat or prevent it. Give oxygen if available.
- If the fit has not stopped after 10 minutes, repeat the diazepam once.
Danger signShe has had a convulsion during this illness. That is already one of the four IMCI general danger signs, even though she is awake now.Differential now- Severe (cerebral) malaria Must not missLeading (moved up)
- Febrile seizureStill possible
- Bacterial meningitis Must not missStill possible
- Low blood sugar Must not missStill possible
- Head injury or poisoning Must not missStill possible
- Other infection causing the fever (pneumonia, ear, urine)Still possible
- Epilepsy (first unprovoked seizure)Less likely
- Step 2 of 7 · Ask
What do you ask about the fit and the illness?
Model answer
- What did it look like: whole body or one side? How long? Did she wake fully in between? How many fits?
- Any fits before, with or without fever? Is her development normal?
- Vomiting, unable to drink, headache or neck pain, irritability, a rash?
- A fall or knock to the head? Could she have swallowed any medicine, chemical or plant at home?
- Malaria risk: where they live, a bed net; any antimalarial given.
- Cough, diarrhoea, ear problem; immunisations.
One fit, the whole body, about 3 minutes, sleepy for half an hour then awake. Never had a fit before; walking and saying words like her brothers. No vomiting, drinking well. No fall, nothing swallowed. They have no net. No cough, no diarrhoea, no ear discharge. Immunisations up to date.
Differential now- Severe (cerebral) malaria Must not missLeading
- Febrile seizureStill possible
- Bacterial meningitis Must not missStill possible
- Low blood sugar Must not missStill possible
- Other infection causing the fever (pneumonia, ear, urine)Still possible
- Epilepsy (first unprovoked seizure)Set aside for now (moved down)
- Head injury or poisoning Must not missSet aside for now (moved down)
- Step 3 of 7 · Look
What do you look for on examination, and why?
Model answer
- Level of consciousness again, and whether she can sit and stand (prostration is a sign of severe malaria).
- Stiff neck; repeated fits, very irritable, a non-blanching petechial or purpuric rash (meningitis).
- Breathing: deep or laboured (acidosis in severe malaria); fast breathing or chest indrawing (pneumonia).
- Pallor of palms, jaundice, bleeding.
- Ears, throat, skin; MUAC and oedema of both feet.
She is irritable but alert and sits on her father's lap. No stiff neck, no rash. Breathing not deep, no indrawing. Some palmar pallor, no jaundice. Ears normal. MUAC 140 mm.
Differential now- Severe (cerebral) malaria Must not missLeading
- Febrile seizureStill possible
- Low blood sugar Must not missStill possible
- Bacterial meningitis Must not missLess likely (moved down)
- Other infection causing the fever (pneumonia, ear, urine)Less likely (moved down)
- Epilepsy (first unprovoked seizure)Set aside for now
- Head injury or poisoning Must not missSet aside for now
- Step 4 of 7 · Test
Which tests do you do, in what order?
Model answer
- Glucose first. Low blood sugar is common after a fit and in severe malaria, and is easy to treat. Low is below 2.5 mmol/L (45 mg/dL), or below 3 mmol/L (54 mg/dL) in a severely malnourished child. If you cannot measure it in a child who is not fully awake, treat as low sugar.
- Malaria RDT: she has fever in a high-risk area.
- Haemoglobin, because she is pale; anaemia is common in severe malaria.
Results: glucose 4.6 mmol/L. RDT positive for P. falciparum. Hb 89 g/L (8.9 g/dL).
Differential now- Severe (cerebral) malaria Must not missLeading
- Febrile seizureLess likely (moved down)
- Bacterial meningitis Must not missLess likely
- Other infection causing the fever (pneumonia, ear, urine)Less likely
- Low blood sugar Must not missSet aside for now (moved down)
- Epilepsy (first unprovoked seizure)Set aside for now
- Head injury or poisoning Must not missSet aside for now
- Step 5 of 7 · Do
Could this simply be a febrile seizure? How does IMCI classify her, and why?
Model answer
A febrile seizure is common between 6 months and 5 years, is usually short and generalised, and the child recovers fully. Her story fits. But in a child with falciparum malaria, a fit can be the first sign of cerebral malaria, and meningitis cannot be ruled out at the health centre (no lumbar puncture). A positive RDT does not exclude a second cause.
Finding IMCI classification Fever, malaria area, and a general danger sign (convulsions in this illness) Very severe febrile disease So she is treated as severe and referred, even though she looks better now. Febrile seizure stays possible, but it is a diagnosis for the hospital to make after observation.
Differential now- Severe (cerebral) malaria Must not missLeading
- Bacterial meningitis Must not missStill possible (moved up)
- Febrile seizureLess likely
- Other infection causing the fever (pneumonia, ear, urine)Less likely
- Low blood sugar Must not missSet aside for now
- Epilepsy (first unprovoked seizure)Set aside for now
- Head injury or poisoning Must not missSet aside for now
- Step 6 of 7 · Do
What pre-referral treatment does she get before she leaves?
Model answer
- Artesunate for severe malaria: IM 3 mg/kg (under 20 kg) = 36 mg, into the front of the thigh. If no injection can be given, rectal artesunate 10 mg/kg (12 to 19 kg: three 50 mg suppositories or one 200 mg).
- First dose of an appropriate antibiotic because meningitis cannot be excluded: IMCI gives IM ampicillin 50 mg/kg and gentamicin 7.5 mg/kg, or use your national chart.
- Prevent low blood sugar: breastfeed, or 30 to 50 mL of milk or sugar water by mouth (4 level teaspoons of sugar in 200 mL of clean water).
- Paracetamol for the high fever (one 100 mg tablet).
- Keep diazepam ready for the journey and show the accompanying adult what to do if she fits.
Differential now- Severe (cerebral) malaria Must not missLeading
- Bacterial meningitis Must not missStill possible
- Febrile seizureLess likely
- Low blood sugar Must not missSet aside for now
- Epilepsy (first unprovoked seizure)Set aside for now
- Head injury or poisoning Must not missSet aside for now
- Other infection causing the fever (pneumonia, ear, urine)Set aside for now (moved down)
- Step 7 of 7 · Do
How do you send her safely, and what do you tell her father?
Model answer
- Arrange transport now; call ahead if you can.
- Write a referral note: the fit (time, length, type), the RDT and glucose results, and the time and dose of each medicine given.
- On the way: lie her on her side if she becomes drowsy or fits; keep her cool but not cold; keep offering breast milk or sugar water.
- Afterwards: at home, a child who has had a febrile fit may have another with a later fever. A bed net prevents the next malaria.
The fit and the malaria test mean she may have the dangerous kind of malaria. I have given her the first treatment, but she needs the hospital today. If she has another fit on the way, lay her on her side and do not put anything in her mouth.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Severe (cerebral) malaria | Fever in a malaria area with convulsions, impaired consciousness, prostration, deep breathing, jaundice, severe pallor or dark urine; positive test. | Pre-referral artesunate, antibiotic if meningitis possible, prevent low sugar; refer urgently. |
| Bacterial meningitis | Fever with stiff neck, bulging fontanelle, repeated fits, very irritable, lethargy, non-blanching rash. | First dose of antibiotic now (and antimalarial in a malaria area); refer urgently. |
| Low blood sugar | Glucose below 2.5 mmol/L (below 3 mmol/L if severely malnourished); drowsy, fitting; severe malaria. | Treat at once (sugar by mouth or nasogastric tube; IV glucose where trained) and find the cause. |
| Status epilepticus | A fit lasting more than 5 minutes, or not waking between fits. | Rectal diazepam, repeat once after 10 minutes if still fitting; oxygen; refer urgently. |
| Head injury or poisoning | History or signs of trauma; medicines or chemicals at home. | Stabilise and refer; bring the container. |
Decision at first-level care
Amani had a convulsion during a febrile illness, a general danger sign, and has falciparum malaria. Cerebral malaria and meningitis cannot be excluded at the health centre. She is classified as very severe febrile disease: IM artesunate, a first dose of antibiotic, sugar to prevent hypoglycaemia and paracetamol, then urgent referral.
Source: WHO IMCI chart booklet (2014); WHO Pocket book of hospital care for children (2013); WHO guidelines for malaria (2026).
Treat here
- No danger sign of any kind in this illness (no convulsion, can drink, no vomiting everything, alert), positive malaria test: oral ACT at home.
- Known epilepsy, fit stopped, usual pattern, no fever or new cause: continue the usual medicine and review.
Observe and review
- Brief fit that stopped, glucose normal, waiting for transport: keep on her side, diazepam ready, recheck consciousness and glucose.
- In hospital, a simple febrile seizure with a cause found and full recovery is observed for about 24 hours.
Refer (urgently, now)This patient
- Any convulsion during a febrile illness in a child under 5, at first-level care.
- A fit lasting more than 5 minutes, repeated fits, or not waking between fits.
- Stiff neck, non-blanching rash, lethargy or a focal fit.
- Head injury or possible poisoning.
Key learning points
- A convulsion during this illness is an IMCI general danger sign, even if the child is awake when you see her.
- Check glucose in every child who has fitted; if you cannot, treat as low sugar.
- In a malaria area, a child with fever and a fit gets pre-referral artesunate and, if meningitis is possible, a first dose of antibiotic.
- Rectal diazepam 0.5 mg/kg for a fit; repeat once after 10 minutes; never put anything in the mouth.
- A febrile seizure is a diagnosis made after serious causes are excluded, not before.
Sources
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. General danger signs; very severe febrile disease; rectal diazepam 0.5 mg/kg and dose table, repeat after 10 minutes; IM ampicillin and gentamicin before referral; artesunate before referral; preventing low blood sugar; paracetamol.
- World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. 2013. Emergency signs; differential diagnosis of convulsions (meningitis, cerebral malaria, febrile convulsions at 6 months to 5 years, hypoglycaemia, head injury, poisoning); glucose thresholds 2.5 and 3 mmol/L; treat as hypoglycaemia if glucose cannot be measured.
- World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. Signs of severe malaria; pre-referral IM and rectal artesunate doses.
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. Convulsion lasting more than 5 minutes as status epilepticus; complex febrile seizure (focal, longer than 15 minutes, or repeated in the same illness).
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.