The sick child: IMCI in practice

Most children who die before their fifth birthday die of a few common illnesses, often more than one at a time: pneumonia, diarrhoea, malaria, measles and malnutrition. IMCI was designed so that a health worker with a chart can find all of a child's problems at one visit, rather than treating only the one the carer mentions.

The routine

1. Ask what the child's problems are. Is this a first visit or a follow-up for this problem?
2. Check for general danger signs.
3. Ask about the main symptoms: cough or difficult breathing, diarrhoea, fever, ear problem.
4. Check for acute malnutrition and anaemia, HIV status, immunisation and feeding.
5. Classify each problem, identify treatment, treat, counsel the carer and plan follow-up.

General danger signs

• Not able to drink or breastfeed.
• Vomits everything.
• Has had convulsions in this illness.
• Lethargic or unconscious.
• Convulsing now.

Preventing low blood sugar

If the child can breastfeed, ask the mother to breastfeed. If not, but the child can swallow, give expressed breast milk or a breast-milk substitute, or sugar water (4 level teaspoons of sugar in a 200 mL cup of clean water): 30 to 50 mL before departure. If the child cannot swallow and you are trained, give 50 mL by nasogastric tube.

This lesson summarises the IMCI chart. The full one-page guide is the protocol Cough or difficult breathing in a child aged 2 months to 5 years.

Assess

• Ask for how long the child has had cough or difficult breathing.
• The child must be calm. Count the breaths in one full minute.
• Look for chest indrawing; look and listen for stridor and wheeze.
• If you have a pulse oximeter, refer if oxygen saturation is below 90%.

• Amoxicillin: at least 40 mg/kg per dose twice daily. Dispersible 250 mg tablets: 1 tablet twice daily (2 to 12 months), 2 tablets (12 months to 3 years), 3 tablets (3 to 5 years).
• Chest indrawing in a child who is HIV-exposed or infected: first dose of amoxicillin and refer.
• Wheeze with fast breathing or chest indrawing: try a rapid-acting inhaled bronchodilator up to three times, 15 to 20 minutes apart, then reassess and classify.
• Cough for more than 14 days or recurrent wheeze: refer for possible TB or asthma.

Assess

Ask for how long and whether there is blood in the stool. Look at the general condition (lethargic or unconscious? restless and irritable?), look for sunken eyes, offer the child a drink (not able to drink or drinking poorly? drinking eagerly?), and pinch the skin of the abdomen (goes back very slowly, more than 2 seconds? slowly?).

• Diarrhoea for 14 days or more: severe persistent diarrhoea if dehydrated (treat dehydration and refer), persistent diarrhoea if not (feeding advice, multivitamins and minerals including zinc for 14 days, follow up in 5 days).
• Blood in the stool: dysentery. Give ciprofloxacin for 3 days (dose from your chart) and follow up in 3 days.
• Child 2 years or older with severe dehydration where there is cholera: antibiotic for cholera.

Plan A: home treatment, four rules

1. Give extra fluid: 50 to 100 mL of ORS after each loose stool under 2 years; 100 to 200 mL from 2 years. Breastfeed more often and for longer. Give 2 ORS packets to take home.
2. Give zinc (20 mg tablet) for 14 days: half a tablet daily from 2 to 6 months; one tablet daily from 6 months.
3. Continue feeding (exclusive breastfeeding under 6 months).
4. Know when to return.

Plan B: some dehydration

Give about 75 mL/kg of ORS over 4 hours in the clinic, in small frequent sips from a cup. If the child vomits, wait 10 minutes and continue more slowly. After 4 hours, reassess, reclassify and choose the plan to continue.

Plan C: severe dehydration

If you can start IV fluid now, give Ringer's lactate (or normal saline) 100 mL/kg: 30 mL/kg in 1 hour then 70 mL/kg in 5 hours for infants under 12 months; 30 mL/kg in 30 minutes then 70 mL/kg in 2.5 hours from 12 months. If not, refer urgently if IV is available within 30 minutes; otherwise give ORS by nasogastric tube (or mouth) at 20 mL/kg per hour for 6 hours if you are trained.

Fever means a history of fever, the child feels hot, or an axillary temperature of 37.5 °C or above. First decide the malaria risk: high, low, or none (and no travel to a malaria area).

Assess

• Ask for how long; if more than 7 days, has the fever been present every day? Measles in the last 3 months?
• Look or feel for a stiff neck; look for a runny nose; look for a bacterial cause (tender swelling, sores, painful limb, red tender skin, pain on passing urine in older children); look for signs of measles.
• Do a malaria test: in every fever case in high-risk areas; in low-risk areas when there is no obvious cause.

Malaria in practice

• Test before you treat. Treat malaria only when the test is positive. If no test is available: in a high-risk area classify fever as malaria; in a low-risk area classify as malaria only if there is no obvious other cause.
• No malaria risk and no travel to a malaria area: classify as fever, treat the cause found, and follow up in 2 days if fever persists.
• First dose in the clinic. Give the first dose of the oral antimalarial (for example artemether-lumefantrine where it is first line) and watch the child for one hour; if the child vomits within an hour, repeat the dose. Give it with food.
• Fever every day for more than 7 days: refer for assessment.
• Severe malaria or very severe febrile disease: give the first dose of rectal or IM artesunate (or IM quinine) as your chart shows, the first dose of an antibiotic, prevent low blood sugar, and refer urgently. If referral is truly impossible, continue the pre-referral treatment as the chart and national policy describe.

The one-page guides are Fever in a child under 5, Uncomplicated malaria and Severe malaria: pre-referral treatment. Use the antimalarial and doses in your national policy.

Measles

Measles is a generalised rash with one of cough, runny nose or red eyes. In a child with measles now or in the last 3 months, look for mouth ulcers (deep and extensive?), pus draining from the eye and clouding of the cornea.

Pneumonia, stridor, diarrhoea, ear infection and malnutrition after measles are classified in their own charts.

Second case: fever in a low-risk area

Child N, 4 years, lives in a low malaria risk area. He has had fever for 3 days and has a hot, tender swelling on his left thigh that he will not let you touch. No danger signs, no stiff neck, no rash, no cough. He has not travelled.

Acute malnutrition

Look for oedema of both feet, find the weight-for-height or length z-score, and measure MUAC in children 6 months or older.

Anaemia

• Severe palmar pallor: severe anaemia, refer urgently.
• Some palmar pallor: anaemia. Give iron (not if the child is on RUTF, which already contains iron); mebendazole if 1 year or older and none in the last 6 months; follow up in 14 days. Keep giving iron daily, with a review and a new supply every 14 days, for 2 months, and refer if still pale after 2 months.
• Assess for sickle cell disease where it is common.

Assess feeding

Assess feeding in every child under 2 years, and in any child with moderate acute malnutrition, anaemia, or confirmed or exposed HIV. Ask how the child is fed and compare the answers with the recommendations for the child's age.

• Breastfeeding: how many times a day? At night too?
• Other foods or fluids: what, how many times a day, and with what (cup, bottle, spoon)?
• For a child with moderate acute malnutrition or poor growth: how large are servings? Does the child have their own plate? Who feeds the child, and how? What food is available at home?
• During this illness, has feeding changed?

IMCI feeding recommendations

Name one or two specific changes, not a list of everything. Praise what the carer is doing well. If you find a feeding problem, arrange follow-up in 5 to 7 days, as the chart row for that child says. Children with severe acute malnutrition need the Acute malnutrition in children protocol; in emergencies see Malnutrition in emergencies.

Counsel the carer

• Fluids: breastfeed more often and for longer; increase other fluids such as soup, rice water or clean water.
• Feeding: keep feeding during and after illness, following the feeding recommendations for the child's age.
• Show how to give oral medicines at home and check the carer can do it before leaving.
• Look after the mother's own health too: tetanus vaccine, family planning, her own illness.

Second case: a feeding problem at 10 months

Baby P, 10 months, comes for a cough. She has no danger signs and is classified as cough or cold. MUAC is 128 mm, no oedema, no pallor. Her mother breastfeeds 4 times a day and gives thin porridge twice a day from a bottle. She has never given egg, fish or meat because she thought the baby was too young.

About 3 million young infants die every year in the first 59 days of life, 98% of them in low- and middle-income countries, and sepsis, meningitis and pneumonia cause more than half a million of these deaths. Signs are often subtle and change fast: a baby who feeds poorly or moves less may be very ill. Young infants up to 2 months (0 to 59 days) are assessed with their own chart.

Possible serious bacterial infection: the 7 signs

• Not feeding well, or not able to feed at all.
• Convulsions.
• Fast breathing, 60 breaths per minute or more, in an infant aged 0 to 6 days (count for a full minute in a calm infant; repeat if high).
• Severe chest indrawing.
• Temperature 38 °C or above.
• Temperature below 35.5 °C.
• Movement only when stimulated, or no movement at all.

Source: WHO recommendations for management of serious bacterial infections in infants aged 0 to 59 days, 2024

Before referral: give the first IM dose of ampicillin and gentamicin, prevent low blood sugar (breastfeed, or give expressed breast milk or sugar water by cup or tube) and keep the infant warm on the way, ideally skin to skin with the mother. When the family cannot reach or accept referral, the outpatient regimens above need daily visits and a careful check on day 4. The one-page guide with doses is The sick young infant up to 2 months.

Also check every young infant for

The HIV-exposed infant

Ask about the mother's HIV status at every young infant visit. If she has never been tested, test her; if she is positive, the infant needs a virological test. Antibody tests cannot diagnose HIV in a child under 18 months, because the mother's antibodies can persist until then.

An infant with a positive virological test needs ART and HIV care started without delay, with co-trimoxazole: see HIV testing and starting ART. In the IMCI sick child chart, an HIV-exposed or HIV-infected child with chest indrawing is referred, and every HIV-exposed child has feeding assessed (lesson 5).

Second case: an HIV-exposed infant at 6 weeks

Baby R, 6 weeks, comes for immunisation. His mother has been on ART since early pregnancy and her last viral load was suppressed. He is exclusively breastfed and has taken nevirapine since birth. He is well, feeding well, and his weight is normal for age. He has not had an HIV test.

Answer all 15 questions, then press Mark. You need 12 or more to pass. You can look back at the lessons: the aim is learning. A pass gives a printable certificate of completion for 4 hours of self-directed learning; you need a free account, signed in, to issue it.