Protocol · WHO IMCI
The sick young infant up to 2 months
Young infants show serious infection with few and subtle signs, and they deteriorate fast. A short checklist of seven signs finds most of them. Refer every infant with a sign of serious infection; where the family cannot reach hospital, WHO-recommended simplified antibiotic regimens can be given close to home with careful follow-up.
- Based on WHO IMCI
- For health workers at first-level facilities and community health workers
- Reviewed October 2026
1Who / when
- Any infant from birth up to 2 months (0 to 59 days) brought sick, and at postnatal home visits.
- Community health workers: check for danger signs at every postnatal visit and help the family seek care.
- Infants 2 months and older: use the IMCI sick child charts.
2Red flags: refer now
Possible serious bacterial infection (PSBI): the 7 signs
- Not feeding well, or not able to feed at all.
- Convulsions.
- Fast breathing: 60 or more per minute (count a full minute; repeat if high).
- Severe chest indrawing.
- Temperature 38 °C or above, or below 35.5 °C.
- Movement only when stimulated, or no movement at all.
Critical illnessNot able to feed at all, no movement at all, or convulsions = critical illness. Give first-dose antibiotics, prevent low blood sugar, keep warm, refer urgently.
3Assess
- The infant must be calm. Count breaths for one minute; look for severe chest indrawing; measure axillary temperature.
- Watch movement; if asleep, wake gently. Does the infant move on its own, only when stimulated, or not at all?
- Look at the umbilicus (red or pus?) and skin (pustules).
- Jaundice: when did it start? Are palms and soles yellow?
- Diarrhoea and dehydration; feeding (observe a breastfeed), weight for age, thrush.
- Mother's and infant's HIV status; immunisations.
4Classify
| Signs | Classify as | Action |
|---|---|---|
| Not able to feed at all, no movement at all, or convulsions | Critical illness | Pre-referral treatment; refer urgently |
| Not feeding well, moves only when stimulated, temperature 38 °C or more or below 35.5 °C, severe chest indrawing, or fast breathing at 0 to 6 days | Clinical severe infection | First-dose antibiotics; refer. If referral not possible: outpatient regimen |
| Fast breathing as the only sign, age 7 to 59 days | Fast breathing (pneumonia) | Oral amoxicillin for 7 days at home; no referral needed |
| Red or pus-draining umbilicus, or skin pustules | Local bacterial infection | Oral amoxicillin 5 days, gentian violet; review in 2 days |
| Jaundice under 24 hours of age, or yellow palms and soles | Severe jaundice | Prevent low blood sugar; refer urgently |
| None of these | Severe disease or local infection unlikely | Home care |
5Treat
Before referral
- First dose of IM ampicillin 50 mg/kg and gentamicin (5 mg/kg in the first week of life; 7.5 mg/kg after). Use 10 mg/mL gentamicin; avoid undiluted 40 mg/mL.
- Prevent low blood sugar: breastfeed; or 10 mL/kg (20 to 50 mL) expressed breast milk or sugar water by cup or nasogastric tube.
- Keep warm: skin-to-skin contact on the way, or well covered with a hat.
When the family cannot accept or reach referral
- Clinical severe infection: oral amoxicillin 50 mg/kg per dose twice daily for at least 7 days plus IM gentamicin once daily for 7 days (5 to 7.5 mg/kg; low birthweight 3 to 4 mg/kg). If 7 days of injections are not possible: gentamicin for 2 days with the 7 days of amoxicillin; a check on day 4 is essential.
- Fast breathing alone, 0 to 6 days: refer; if not possible, oral amoxicillin 50 mg/kg twice daily for at least 7 days.
- Critical illness: keep trying to refer. If impossible, ampicillin plus gentamicin for at least 10 days by a trained worker.
6Follow-up
- Outpatient severe infection: the infant is seen daily for the injections; close follow-up is essential, with a careful check on day 4. Refer at once if any critical illness sign appears or the infant is not improving.
- Fast breathing alone: arrange close follow-up; refer if worse or any other PSBI sign appears.
- Local infection: review after 2 days; pus or redness the same or worse: refer.
- Jaundice: review in 1 day; feeding problem: 2 days; low weight for age: 14 days.
7Counsel
- Breastfeed only, often, day and night. Keep the infant warm; skin-to-skin contact helps.
- Give every dose of amoxicillin until finished.
- Return at once if the baby is breastfeeding poorly, less active, sicker, has a fever or feels cold, breathes fast or with difficulty, or the palms and soles turn yellow.
Your baby has a serious infection and needs hospital care today. If you truly cannot go, we will give injections here every day and you must come back each day, or straight away if she stops feeding or moving well.
8When to refer
- Urgently: critical illness; clinical severe infection; fast breathing in the first week of life; severe jaundice; severe dehydration.
- Outpatient-treated infant who develops a critical sign, or is not better by day 4.
- Jaundice still present after 2 weeks of age, or appearing after 14 days.
- Not able to attach or feed, or losing weight despite counselling.
9Sources
- World Health Organization. WHO recommendations for management of serious bacterial infections in infants aged 0–59 days. 2024. 7-sign IMCI algorithm, critical illness, clinical severe infection, fast breathing, outpatient regimens when referral is not possible, antibiotic doses.
- World Health Organization. Guideline: managing possible serious bacterial infection in young infants when referral is not feasible. 2015. Gentamicin and amoxicillin outpatient doses; day-4 assessment.
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Local bacterial infection, jaundice, pre-referral care, keeping warm, low blood sugar, follow-up intervals, when to return.
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.