Fever in a 3-year-old
Fever is the commonest reason a young child is brought to a health centre in a malaria area. The IMCI chart asks the same questions in the same order for every child, so that the one child in ten who is dangerously ill is not missed among the others.
- Setting: Rural health centre in a high malaria transmission area
- For nurses, clinical officers, doctors and community health workers trained in IMCI
- Reviewed October 2026
The presentation
Baraka, 3 years old, is carried in by his mother. He has had a hot body for 2 days and has been less playful. He is still breastfeeding at night and drinking water. He has not vomited. He weighs 13 kg.
| Sign | Value |
|---|---|
| Axillary temperature | 38.8 °C |
| Breathing rate | 34 per minute (counted for a full minute) |
| Pulse | 128 per minute |
| Conscious level (AVPU) | Alert, cries when examined |
| Weight | 13 kg |
Tests at hand: Malaria rapid diagnostic test (RDT) · Haemoglobin (Hb) · Blood glucose (finger-prick) · Mid-upper arm circumference (MUAC)
- MalariaStill possible
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missStill possible
- Pneumonia Must not missStill possible
- MeaslesStill possible
- Ear infectionStill possible
- Urinary or other bacterial infectionStill possible
- Viral illness (cold, sore throat)Still possible
- Anaemia (with the fever)Still possible
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
Before anything else: does Baraka have an emergency sign or a general danger sign? Name the signs you check.
Model answer
First the emergency signs (WHO triage for children): obstructed or absent breathing, severe respiratory distress, central cyanosis, shock (cold hands, capillary refill longer than 3 seconds, fast weak pulse), coma or convulsions, and severe dehydration in a child with diarrhoea. Any one needs treatment now.
Then the four IMCI general danger signs, in every sick child: not able to drink or breastfeed; vomits everything; has had convulsions in this illness, or is convulsing now; lethargic or unconscious.
Baraka has none. He drank from a cup in front of you, has not vomited, has had no fits and is alert and crying. He can be assessed in the normal IMCI order.
RememberAny general danger sign with fever is very severe febrile disease: pre-referral treatment and urgent referral, whatever the malaria test shows.Differential now- MalariaStill possible
- Pneumonia Must not missStill possible
- MeaslesStill possible
- Ear infectionStill possible
- Urinary or other bacterial infectionStill possible
- Viral illness (cold, sore throat)Still possible
- Anaemia (with the fever)Still possible
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missLess likely (moved down)
- Step 2 of 7 · Ask
Which main symptoms does the IMCI chart ask about, and what else do you ask because he has fever?
Model answer
- Cough or difficult breathing? Diarrhoea? Fever? Ear problem? (the four main symptoms, asked in every child).
- For fever: for how long? If more than 7 days, has it been there every day?
- Has he had measles within the last 3 months?
- Has he travelled, and does he sleep under an insecticide-treated net?
- Immunisations: check the card, including measles vaccine.
No cough, no diarrhoea, no ear pain or discharge. Fever for 2 days. No measles. The family's net tore last season. His card shows he is up to date, including measles vaccine.
Differential now- MalariaLeading (moved up)
- Urinary or other bacterial infectionStill possible
- Viral illness (cold, sore throat)Still possible
- Anaemia (with the fever)Still possible
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missLess likely
- Pneumonia Must not missLess likely (moved down)
- MeaslesLess likely (moved down)
- Ear infectionLess likely (moved down)
- Step 3 of 7 · Look
What do you look and feel for, and why each one?
Model answer
- Stiff neck: with fever, it means very severe febrile disease (possible meningitis).
- Runny nose: a cold is a common cause of fever and makes malaria less likely in a low-risk area.
- Signs of measles: a generalised rash with cough, runny nose or red eyes.
- Any bacterial cause of fever: local tenderness, mouth sores, refusing to use a limb, hot tender swelling, red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
- Palmar pallor: compare his palm with his mother's (anaemia).
- Nutrition: MUAC, and oedema of both feet.
No stiff neck, no runny nose, no rash, ears normal. No local source of infection. His palms are paler than his mother's but not white: some palmar pallor. MUAC 148 mm, no oedema.
Differential now- MalariaLeading
- Anaemia (with the fever)Leading (moved up)
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missLess likely
- Pneumonia Must not missLess likely
- Urinary or other bacterial infectionLess likely (moved down)
- Viral illness (cold, sore throat)Less likely (moved down)
- MeaslesSet aside for now (moved down)
- Ear infectionSet aside for now (moved down)
- Step 4 of 7 · Test
Which tests do you do, and what results would change your plan?
Model answer
- Malaria RDT: in a high malaria risk area, IMCI tests every child with fever who has no severe classification. Treat on a positive test.
- Haemoglobin, because he is pale. In children aged 24 to 59 months, below 70 g/L (7 g/dL) is severe anaemia; 70 to 99 g/L is moderate.
- Glucose is not needed: he is alert, drinking and has not had a fit. Check it in any child who is lethargic, unconscious or convulsing.
- MUAC is already done: 148 mm is normal.
Results: RDT positive for P. falciparum. Hb 96 g/L (9.6 g/dL): moderate anaemia.
Differential now- MalariaLeading
- Anaemia (with the fever)Leading
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missLess likely
- Pneumonia Must not missLess likely
- MeaslesSet aside for now
- Ear infectionSet aside for now
- Urinary or other bacterial infectionSet aside for now (moved down)
- Viral illness (cold, sore throat)Set aside for now (moved down)
- Step 5 of 7 · Do
How do you classify Baraka on the IMCI chart?
Model answer
Symptom Classification Fever, high malaria risk, RDT positive, no danger sign, no stiff neck Malaria Some palmar pallor Anaemia MUAC 125 mm or more, no oedema No acute malnutrition He has none of the bedside signs of severe malaria: he is not prostrate, has had no convulsions, his breathing is not deep or laboured, he is not jaundiced or bleeding, and he drinks and does not vomit everything. This is uncomplicated malaria, with anaemia.
Differential now- MalariaLeading
- Anaemia (with the fever)Leading
- Very severe febrile disease (severe malaria, meningitis, sepsis) Must not missSet aside for now (moved down)
- Pneumonia Must not missSet aside for now (moved down)
- MeaslesSet aside for now
- Ear infectionSet aside for now
- Urinary or other bacterial infectionSet aside for now
- Viral illness (cold, sore throat)Set aside for now
- Step 6 of 7 · Do
What treatment does he get today?
Model answer
- Artemether-lumefantrine (20 mg/120 mg), or your national first-line ACT. At 5 to under 15 kg: 1 tablet per dose, twice a day for 3 days (six doses), the first two doses about 8 hours apart, with food or breast milk.
- Give the first dose in the clinic and watch him. If he vomits within an hour, repeat the dose.
- Paracetamol for fever of 38.5 °C or above: one 100 mg tablet (2 months to 3 years, 4 to under 14 kg) every 6 hours until the high fever is gone.
- Iron for anaemia: one dose a day for 14 days (12 months to 3 years: 2 mL of iron syrup, 20 mg iron per mL, or half a 60 mg iron/folate tablet), then more iron at each 14-day visit for 2 months. In a malaria area, iron goes together with malaria diagnosis, treatment and a bed net.
- Mebendazole 500 mg once, because he is over 1 year and has had no dose in the last 6 months.
He keeps the first dose down.
- Step 7 of 7 · Ask
What does his mother need to know, and when do you see him again?
Model answer
- Give all six doses of the antimalarial, even when he feels better.
- Come back at once if he cannot drink or breastfeed, becomes sicker, or has a fit, becomes very sleepy or vomits everything.
- Come back in 3 days if the fever is still there. At that visit, look again for danger signs and other causes of fever; if the fever has been present every day for more than 7 days, refer for assessment.
- Come back in 14 days for more iron and to check his pallor; if he is still pale after 2 months, refer for assessment.
- Sleep under an insecticide-treated net every night.
The test shows malaria. One tablet twice a day for three days will cure it, with food. Bring him back straight away if he cannot drink, gets sicker, has a fit or is very sleepy. Come back in three days if the fever is still there.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Very severe febrile disease (severe malaria, meningitis, sepsis) | Any general danger sign (not able to drink, vomits everything, convulsions, lethargic or unconscious) or a stiff neck; prostration, deep breathing, jaundice, bleeding, dark urine. | Pre-referral artesunate (in a malaria area), first dose of an appropriate antibiotic, prevent low blood sugar, paracetamol for high fever; refer urgently. |
| Severe anaemia | Severe palmar pallor (palms white), or Hb below 70 g/L at 6 to 59 months; breathlessness with pallor. | Refer urgently: the child may need a transfusion. |
| Pneumonia hidden behind the fever | Cough or difficult breathing with fast breathing (40 or more per minute at 12 months to 5 years) or chest indrawing. | Classify and treat as pneumonia as well as malaria; refer if a danger sign or stridor. |
| Severe complicated measles | Generalised rash with cough, runny nose or red eyes, plus clouding of the cornea, deep or extensive mouth ulcers or a danger sign. | Vitamin A, first dose of antibiotic, eye ointment if eye signs; refer urgently. |
Decision at first-level care
Baraka has uncomplicated falciparum malaria with moderate anaemia. He has no general danger sign, no stiff neck and no sign of severe malaria, and he keeps the first dose down. He is treated at home with a 3-day ACT, paracetamol, iron and mebendazole, with clear return advice, review in 3 days if the fever persists and in 14 days for the anaemia.
Source: WHO IMCI chart booklet (2014); WHO guidelines for malaria (2026); WHO guideline on haemoglobin cutoffs (2024).
- Positive malaria test, no general danger sign, no stiff neck, no sign of severe malaria.
- Can drink and keeps the first dose down.
- Some palmar pallor, not severe: iron and mebendazole, review in 14 days.
- Vomited the first dose: repeat it and watch for an hour before sending home.
- Negative test and no cause found, no danger sign: paracetamol and review in 3 days if the fever persists.
- Any general danger sign or stiff neck, after pre-referral treatment.
- Severe palmar pallor or Hb below 70 g/L.
- Vomits every dose of the ACT.
- Fever every day for more than 7 days, or still pale after 2 months of iron.
Key learning points
- Check the four general danger signs in every sick child before anything else.
- In a high malaria risk area, test every child with fever who has no severe classification; treat a positive test with a full 3-day ACT by weight.
- Ask about all four main symptoms even when the mother only mentions fever: pneumonia and diarrhoea are often there too.
- Look at the palms of every child: some pallor means iron and deworming; severe pallor means urgent referral.
- Give the first dose in the clinic, and tell the mother exactly when to come back at once and when to come back for review.
Sources
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. General danger signs; main symptoms; fever and measles classification; malaria testing by risk; anaemia classification, iron and mebendazole; paracetamol; when to return; follow-up.
- World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. 2013. Emergency signs in triage; fever without localising signs.
- World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. Parasitological diagnosis; artemether-lumefantrine weight bands and dose timing; signs of severe malaria.
- World Health Organization. Guideline: daily iron supplementation in infants and children. 2016. In malaria areas, iron is given alongside malaria prevention, diagnosis and treatment.
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024. Anaemia severity at 24 to 59 months.