IMNCI Students Handbook PDF

HAND BOOK ON IMNCI
Foreword
"IMNCI" is an integrated strategy which deals with a number of priority health problems
resulting in major cause of mortality and morbidity in under five children. Children
brought to health facilities are often found suffering from more than one morbid condition,
making a single diagnosis impossible. These children require a combined therapy for
successful treatment. In IMNCI efforts have been made to focus on the child as a whole,
rather than on a single disease or condition fostering holistic approach to child health and
development.
Majority of the patients attending the outpatient departments (OPD) in our hospitals are
children. Problems seen in the OPD clinics are typical of what most health professional
graduates will come across later in their careers. Developing core knowledge and skill in
outpatient paediatrics is essential for undergraduate students as part of their basic
education.
IMNCI pre service training has already been introduced in undergraduate curriculum,
referring to the process of developing the practice of standardized protocol-based
management of the most common medical conditions that afflict children. Introducing this
in medical and paramedical education, before graduates enter service, will lend a hand to
their real life situation
This Handbook on IMNCI is a training module for pre service training for medical
students to develop knowledge, master skills before graduation & to empower future
health care providers in relevant decision making. It focuses on approach to the sick child
in an integrated manner, considering the child as a whole and not just for the illness he/she
has been brought. The "STUDENT'S HANDBOOK IMNCI" adopts a uniform
presentation while dealing with different subjects consisting of an overview of the
integrated case management; assessment and classification of the sick child; identifying
treatment priorities; appropriate treatment; knowledge on communications and counseling
skills and follow up of sick child. It emphasizes assessment of growth, nutrition,
immunization status and primary and underlying illnesses. The coverage umbrella is
expanded to provide guidelines to include the most vulnerable period in the child's life by
being adapted to local needs. IMCI offers a strategy for improving the state of children in
Bhutan. This approach could help the country in achieving the Millennium Development
Goals of reducing the under-five mortality.
HAND BOOK ON IMNCI
Acknowledgement
Reviewing committee
1. Dr. K. P. Tshering, Pediatrician, Head of Paediatric Department , JDWNRH
2. Dr. Drupthob Sonam, Medical Superintendent, JDWNRH
3. Dr. H. P. Chhetri, Pediatrician, Military Hospital, Lungtenphu
4. Dr. P. Bhandari, Pediatrician, ERRH, Mongar
5. Dr. Shukhrat Rakhimdjanov, Health Specialist, UNICEF Country Office, Bhutan
6. Dr. Ripa Chakma, Lecturer, RIHS
7. Ms. Deki Pem, Lecturer, RIHS
8. Mr. Thukten Tshering, Chief Pharmacist, JDWNRH
9. Mr. Tandin Dorji, CPO, CDD, DoPH, MoH
10. Mr. Kaka, PO, EMTDD, DMS, MoH
11. Mr. Sonam Zangpo, Sr. PO, IMNCI-ARI/CDD, DoPH
12. Mrs. Yeshi Chhoden, Program Assistant, UNICEF Country Office, Bhutan
13. Dr. Pelden Wangchuk, MO, Damphu Hospital, Tsirang
14. Dr. Kinley Wangdi, Medical Superintendent, Phunstholing General Hospital,
Chuka
Proof reading and edited by:
Dr. Ripa Chakma, Lecturer, RIHS
Ms. Deki Pem, Lecturer, RIHS
Formatting:
Ms Karma Sonam, Assistant Information Technology officer
Produced by: IMNCI-ARI/CCD Program
Department of Public Health
Ministry of Health, Thimphu
Financial and Technical Support:
UNICEF Country Office
2011
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HAND BOOK ON IMNCI
Contents
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ................................ 1

1.1
Introduction ........................................................................................................... 1
1.2 RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TO

CASE MANAGEMENT ........................................................................................... 2
1.3
COMPONENTS OF THE INTEGRATED APPROACH .................................... 3
1.4
THE PRINCIPLES OF INTEGRATED CARE ................................................... 3
1.5
THE IMNCI CASE MANAGEMENT PROCESS ............................................... 4
2 OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO YEARS 7

2.1
LEARNING OBJECTIVES .................................................................................. 7
2.2
ASSESSMENT OF SICK CHILDREN ................................................................ 7
2.2.1 History taking- COMMUNICATING WITH THE PARENTS OR

CAREGIVER ................................................................................................................ 8
2.2.2
CHECKING FOR GENERAL DANGER SIGNS ........................................... 9
2.2.3
CHECKING MAIN SYMPTOMS ................................................................. 11
2.2.3.1 COUGH OR DIFFICULT BREATHING .................................................. 11

2.2.3.2 Diarrhoea ...................................................................................................... 14
2.2.3.3 FEVER ........................................................................................................ 21

2.2.3.4 EAR PROBLEMS....................................................................................... 28
2.2.4
CHECKING NUTRITIONAL STATUS - MALNUTRITION AND

ANAEMIA ...................................................................................................... 32
2.2.5
CHECKING IMMUNIZATION, VITAMIN A and DEWORMING STATUS

39
2.2.6
ASSESSING THE CHILD'S FEEDING ........................................................ 41
2.2.7
ASSESSING OTHER PROBLEMS ............................................................... 44
2.3
identify treatments FOR SICK CHILDREN....................................................... 45
2.3.1
REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS ............. 45
2.3.2
TREATMENT IN OUTPATIENT CLINICS ................................................. 48
2.3.2.1 ORAL DRUGS ........................................................................................... 48

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HAND BOOK ON IMNCI
2.3.2.2 TREATMENT OF LOCAL INFECTIONS ........................................... 53

2.3.2.3 COUNSElLING A MOTHER OR CAREGIVER ...................................... 58
CHAPTER 3 ....................................................................................................................... 62
3
OUTPATIENT Management of SICK Young Infants Up to 2 Months ..................... 62

3.1
Learning Objectives ............................................................................................ 62
3.2
ASSESSMENT OF sick YOUNG INFANTS .................................................... 62
3.2.1
Classification of very severe disease............................................................... 65
3.2.2
Check for jaundice. ......................................................................................... 66
3.2.3
DIARRHOEA ................................................................................................. 68
3.2.4
FEEDING PROBLEMS OR LOW WEIGHT ................................................ 70
3.2.5
CHECKING IMMUNIZATION STATUS .................................................... 72
3.2.6
ASSESSING OTHER PROBLEMS ............................................................... 73
3.3
Treatment Procedures for SICK Infants .............................................................. 75

3.3.1
REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS ........................... 75
3.3.2
TREATMENT IN OUTPATIENT CLINICS ................................................. 77
3.3.2.1 ORAL DRUGS ........................................................................................... 77

3.3.2.2 COUNSELLING A Mother or Caregiver ................................................... 78
3.3.2.3 FOLLOW-UP CARE .................................................................................. 84
3.4 Recording forms ..........................................................................................................85
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HAND BOOK ON IMNCI
CHAPTER 1
1
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
1.1
INTRODUCTION
Although, globally under-five (U5) mortality has decreased by almost a third since the
1970s, this reduction has not been evenly distributed throughout the world. According to the
2005 World Health Report, globally mortality rates in children under 5 years of age fell
throughout the later part of the 20th century: from 146 per 1000 live births in 1970 to 88 in
2003. Towards the turn of the millennium, however, the overall downward trend started to
falter in some parts of the world. Mortality in U5 children in low- to middle-income
countries is still very high.1Every year more than 10 million children in these countries die
before they reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory
infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition and often to a
combination of these conditions.
In Bhutan, Infant Mortality Rate continues to be high at 40/1000 live births and Under Five
Mortality Rate at 60/1000 live births per year. One out of nearly 16 children die before
reaching the age of five years. Most of this mortality is in the first four weeks of life.
Major health problems in Bhutan
Acute respiratory infection
Diarrhoeal diseases
Under-nutrition is common among children
Tuberculosis and malaria are the other major health problems.
Every day, millions of parents seek health care for their sick children, taking them to
hospitals, health centres, pharmacists, doctors, and traditional healers. Surveys reveal that
many sick children are not properly assessed and treated by these health care providers, and
that their parents are poorly advised.2 At first-level health facilities in low-income countries,
diagnostic supports such as X-ray and laboratory services are minimal or non-existent, and
drugs and equipment are often scarce. Limited supplies and equipment and lack of awareness
of parents make it difficult for the health care provider to practice complicated clinical
procedure. Instead, they often rely on history and signs and symptoms to determine the
management.
Providing quality care to sick children in these situations is a
serious challenge. Experience and scientific evidence show
that improvements in child health are not necessarily
dependent on the use of sophisticated and expensive
technologies, on the other hand effective strategies based on
holistic approach is sufficient to address the common illness
Improvements in child health

are not necessarily dependent
on the use of sophisticated and
expensive technologies.
1. World Health Organization. World health report 2005 Make every mother and child count. Geneva, WHO, 2005.
2
World Health Organization. Report of the Division of Child Health and Development 1996-1997. Geneva, WHO, 1998.
HAND BOOK ON IMNCI
of under five children.

1.2
RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TO

CASE MANAGEMENT
Many well-known prevention and treatment strategies undertaken separately have already
proven effective for saving young lives. Childhood vaccinations have successfully reduced
deaths from vaccine preventable diseases. Oral rehydration therapy has contributed to a
major reduction in diarrhoea deaths. Effective antibiotics have saved millions of children
with pneumonia. Prompt treatment
of malaria has saved a lot of lives.
A more integrated approach to managing sick
Even modest improvements in
children is needed to achieve better outcomes.
breastfeeding practices have reduced
Child health programmes need to move beyond
childhood
deaths.
These
addressing single diseases to addressing the
interventions were not integrated.
overall health and well being of the child.
While each of these interventions
has shown great success, accumulating evidence suggests that a more integrated approach in
management of sick children is needed to achieve better outcomes. Child health programmes
need to move beyond single diseases to address the overall health and well being of the child.
Because many children present with overlapping signs and symptoms of diseases, a single
diagnosis may not be feasible or appropriate. This is especially true for first-level health
facilities where examinations involve few instruments, little or no laboratory tests, and no Xray.
To address the illness of under five children as a whole, the World Health Organization
(WHO), in collaboration with UNICEF and many other agencies, institutions and
individuals, developed and introduced a strategy known as the Integrated Management of
Neonatal and Childhood Illness (IMNCI). Although the major reason for developing the
IMNCI strategy stemmed from the needs of curative care, the strategy also addresses aspects
of nutrition, immunization, and other important elements of disease prevention and health
promotion.
IMNCI as a key strategy for Improving child health
Management of Nutrition
sick children
immunization
Other disease prevention

Promotion of
development
growth and
The objectives of the strategy are to reduce death, the frequency and severity of illness and
disability, and to contribute to improved growth and development.
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HAND BOOK ON IMNCI
The IMNCI clinical guidelines target children less than 5 years old, the age group that bears
the highest burden of deaths from common childhood diseases. It is an evidence-based,
syndromic approach to case management that supports the rational, effective and affordable
use of drugs and diagnostic tools. The approach can be used to determine the:
Health problem(s) the child may have;
Severity of the childs condition
Actions that can be taken to care for the child (e.g. refer the child immediately).
It may be mentioned that along with treatment the health status of the children can be
improved by proper counselling of the parents on:
Appropriate feeding practices
Bringing the sick child to the health centres as soon as symptoms arise, without any
delay
A critical example of the need for timely care is Africa, where approximately 80 percent of
childhood deaths occur at home, before the child has any contact with a health facility.3
1.3
COMPONENTS OF THE INTEGRATED APPROACH
The IMNCI strategy includes both preventive and curative interventions. The aim of the
strategy is to improve health care practices in health facilities, the health system
(infrastructure and health care delivery) and at home. The core of the strategy is integrated
case management of the most common childhood problems with a focus on the most
common causes of death. It does not include management of trauma and other acute
emergencies due to accidents.
The strategy includes three main components
Improvements in the case-management skills of health care providers.
Improvements in the overall health system required for effective management of

childhood illness.
Improvements in family and community health care practices.
1.4
THE PRINCIPLES OF INTEGRATED CARE
The IMNCI guidelines are based on the following principles:
All sick children must be examined for general danger signs which indicate the
need for immediate referral or admission to a BHU/hospital.
All sick children must be routinely assessed for major symptoms (for children age
2 months up to 5 years: cough or difficult breathing, diarrhoea, fever, ear problems;
Oluwole D et al. Management of childhood illness in Africa. British medical journal, 1999, 320:594-595.
HAND BOOK ON IMNCI
for young infants up to 2 months: very severe disease, diarrhoea, jaundice and
feeding.
They must also be routinely assessed for nutritional and immunization status,
feeding problems and other problems
Assess Vitamin A supplementation and de-worming status for children age 2 months
up to 5 years.
Only a limited number of carefully selected clinical signs are used, based on
evidence of their sensitivity and specificity to detect disease.4 These signs were
selected considering the conditions and realities of first-level health facilities.
A combination of individual signs leads to a childs classification(s) rather than a

diagnosis. Classification(s) indicate the severity of condition(s). They call for
specific actions based on whether the child:
a. Should be urgently referred to higher level of care.
b. Requires specific treatments (such as antibiotics or anti-malarial treatment), OR
c. May be safely managed at home.
The classifications are colour coded: pink suggests hospital referral or admission,
yellow indicates need for initiation of treatment, and green calls for home treatment.
The IMNCI guidelines address most, but not all of the major reasons for which a
sick child is brought to a clinic. A child coming with chronic problems or less
common illnesses may require special care. The guidelines do not describe the
management of trauma or other acute emergencies due to accidents or injuries.
IMNCI management procedures use a limited number of essential drugs and

encourage active participation of caregivers in the treatment of children.
An essential component of the IMNCI guidelines is the counselling of caregivers
about home care, including counselling about feeding, fluids and when to return to
the health facility.
1.5
THE IMNCI CASE MANAGEMENT PROCESS
As the disease burden, clinical signs and symptoms vary at different age groups, imnci
guidelines recommend case management procedure based on 2 age categories
Young infants aged up to 2 months
Children aged 2 months up to 5 years
Sensitivity and specificity measure the diagnostic performance of a clinical sign compared with that of the gold standard, which by
definition has a sensitivity of 100% and a specificity of 100%. Sensitivity measures the proportion or percentage of those with the
disease who are correctly identified by the sign. In other words, it measures how sensitive the sign is in detecting the disease.
(Sensitivity = true positives / [true positives + false negatives]) Specificity measures the proportion of those without the disease who
are correctly called free of the disease by using the sign. (Specificity = true negatives / [true negatives + false positives])
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HAND BOOK ON IMNCI
The case management of a sick child brought to a first-level health facility includes a number
of important elements.
At Outpatient Health Facility
Assessment
Classification and identification of treatment
Referral, treatment of the child or counselling of the childs caregiver (depending on

the classification(s) identified).
Follow-up care
At Referral Health Facility
Rapid screening of sick children for emergency sign as soon as they arrive in health
facility , following Emergency Triage Assessment and Treatment (ETAT)
Follow up care
At Home
Teaching mothers or other caregiver how to give oral drugs and treat local infections.
Counselling mothers or other caregivers about:
a. Food and fluids
b. Give oral drugs at home
c. Treat local infections at home
d. When to return
e. Her own health
Course method and materials
In addition to this handbook Students Handbook on IMNCI, a chart booklet that
summarizes the steps in case management. The same information is shown on 5 wall charts.
The first three charts are for management of the sick child age 2 months up to 5 years and the
two other charts- for management of the sick young infant age up to 2 months.
HAND BOOK ON IMNCI
HAND BOOK ON IMNCI
CHAPTER 2
2
OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5

YEARS
2.1
LEARNING OBJECTIVES
This section of the handbook will describe and allow the students to practice the following
skills:
Asking the mother/caregiver about the childs problem.
Checking general danger signs.
Asking the mother/caregiver about the four main symptoms:
2.2
cough or difficult breathing
diarrhoea
fever
ear problem
When a main symptom is present:
assessing the child further for signs related to the main symptom.
classifying the illness according to the signs which are present or absent.
Checking for signs of malnutrition and anaemia and classifying the childs nutritional
status.
Checking the childs immunization status and deciding if the child needs any
immunization today.
Assessing other problems.

ASSESSMENT OF SICK CHILDREN
The assessment procedure for this age group includes a number of important steps that must
be taken by the health care provider, including: (1) Asking the mother/caregiver about the
childs problem; (2) checking for general danger signs; (3) checking four main symptoms;
(4) checking nutritional status; (5) assessing the childs feeding; (6) checking immunization
status; Vit-A, de-worming status, and (7) assessing other problems.
HAND BOOK ON IMNCI
2.2.1 HISTORY TAKING- COMMUNICATING WITH THE PARENTS OR

CAREGIVER
Asking mother about the childs problem
General Danger Signs
Main Symptoms
Cough or Difficult Breathing
Diarrhoea
Fever
Ear Problems
Nutritional Status
Immunization Status
Vitamin A-Status
De-worming
Feeding Assessment
Other Problems
It is critical to communicate effectively with the child's mother or caregiver. Good

communication techniques and an integrated assessment are required to ensure that common
problems or signs of disease or malnutrition are not overlooked. Using good communication
helps to reassure the mother or caregiver that the child will receive appropriate care. In
addition, the success of home treatment depends on how well the mother or caregiver knows
how to give the treatment and understands its importance.
The steps of good communication:
Listen carefully to what the parents or caregiver says:

This will show them that you take their concerns seriously.
Use words the caregiver understands:
Try to use local words and avoid medical terminology
Give the caregiver time to answer questions:

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HAND BOOK ON IMNCI
S/he may need time to reflect and decide if a clinical sign is present.
Ask additional questions when the caregiver is not sure about the answer:
A caregiver may not be sure if a symptom or clinical sign is present. Ask additional
questions to help her/him to give clear answers.
2.2.2 CHECKING FOR GENERAL DANGER SIGNS

General danger signs indicate signs that may or may not be specific for a particular illness,
however they are serious conditions. For example, a child with general danger signs may
have meningitis, encephalitis, septicaemia, Dengue shock syndrome, severe pneumonia,
cerebral malaria or another severe disease. Great care should be taken to ensure that these
general danger signs are not overlooked because they suggest that a child is severely ill and
needs urgent attention.
The following danger signs should be routinely checked in all children.
LETHARGY
LETHARGY UNCONSCIOUSNESS
DANGER
VOMITS EVERYTHING
EVERYTHING
CONVULSIONS
SIGNS
INABILITY TO DRINK
OR BREASTFEED
1. The child is unable to drink or breastfeed. A child may be unable to drink either
because s/he is too weak or because s/he cannot swallow. Do not rely completely on the
mother's statement for this, but observe while she tries to breastfeed or to give the child
something to drink.
2. The child vomits everything. This means that the child vomits everything (like food,
drink, medicine) whatever offered. It is important to note because such a child will not be
able to take medication or fluids for re-hydration.
3. The child has had convulsions during the present illness. Convulsions may be
associated with meningitis, cerebral malaria or other life-threatening conditions or with
minor illness like fever. All children who have had convulsions should be considered
seriously ill because the more serious causes of convulsions cannot be ruled out without
investigations done in a hospital.
4. The child is unconscious or lethargic. An unconscious child does not respond to any
stimuli (sound or movement of limbs). A lethargic child responds a little to stimuli, but
9
HAND BOOK ON IMNCI
does not take any notice of his or her surroundings. These signs may be associated with
many serious conditions.
If a child has one or more of these signs, s/he must be considered seriously ill and will
almost always need referral. In order to start treatment for severe illnesses without delay, the
child should be quickly assessed for the most important causes of serious illness acute
respiratory infection (ARI), diarrhoea, and fever (especially associated with malaria and
measles). A rapid assessment of nutritional status is also essential, as malnutrition could also
contribute to death.
Example: Top part of a recording form with General Danger Signs
CASE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5 F. The health
worker asked, What are the childs problems? The mother said Phuntsho has been
coughing for 6 days, and she is having trouble breathing. This is the initial visit for this
illness.
The health worker checked Phuntsho for general danger signs. The mother said that
Phuntsho is able to drink. She has not been vomiting. She did not have convulsions during
this illness. The health worker asked, does Phuntsho seem unusually sleepy? The mother
said, Yes. The health worker clapped his hands. He asked the mother to shake the child.
Phuntsho opened her eyes, but did not look around. The health worker talked to Phuntsho,
but she did not watch his face. She stared blankly and appeared not to notice what was going
on around her.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Name of the health facility: Thinleygang BHU
Childs Name: Phuntsho Age/sex: 18 months/F
Date: 1/1/2011
Weight: 11.5 kg
Temperature 99.50 C/F
ASK: What are the childs problems? Cough, trouble breathing Initial visit? Follow-up visit? __
ASSESS (Circle all signs present)
CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
General danger sign present?
NOT ABLE TO DRINK OR BREASTFEED
Yes No __
LETHARGIC or UNCONSCIOUS
VOMITS EVERYTHING
Remember to use danger sign when

selecting classifications
CONVULSIONS
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HAND BOOK ON IMNCI
2.2.3 CHECKING MAIN SYMPTOMS

After checking for general danger signs, the health care provider must check four main
symptoms: (1) cough or difficult breathing; (2) diarrhoea; (3) fever; and (4) ear problems.
The first three symptoms are included because they often result in death. Ear problems are
included because they are considered one of the main causes of hearing loss and sometimes it
may give rise to CNS infections like Meningitis and brain abscess.
COUGH OR DIFFICULT BREATHING
A child presenting with cough or difficult breathing may suffer from pneumonia or other
serious respiratory infection.
CLINICAL ASSESSMENT
Three key clinical signs are used to assess a sick child with cough or difficult breathing:
Respiratory rate, which distinguishes children who have pneumonia from those who
do not;
Chest indrawing, which indicates severe pneumonia; and
Stridor, which indicates upper air-way obstruction and require hospital admission.
High respiratory rate or fast breathing is the single most sensitive and specific among
clinical signs of Pneumonia in under-five children. Even crepitation on auscultation by an
expert is less sensitive as a single sign than fast breathing.
Cut-off rates for fast breathing depend on the childs age. Normal breathing rates are higher
in children age 2 months up to 12 months than in children age 12 months up to 5 years.
Childs Age
Cut-off Rate for Fast Breathing
2 months up to 12 months
50 breaths per minute or more
12 months up to 5 years
40 breaths per minute or more
Chest in-drawing, defined as the inward movement of the lower chest wall with inspiration,
is a useful indicator of severe pneumonia. It is more specific than inter-costal in drawing,
which involves the soft tissue between the ribs without involvement of the bony structure of
the chest wall.5 Chest in-drawing should only be considered present if it is consistently
present in a calm child. Agitation, a blocked nose or breastfeeding can cause temporary chest
in-drawing.
Mulholland EK et al. Standardized diagnosis of pneumonia in developing countries. Pediatric infectious disease journal, 1992,
11:77-81.
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HAND BOOK ON IMNCI
Stridor is a harsh sound heard during inspiration {breathes in} due to obstruction of upper
airway.
Calm children, who have stridor should be referred. Wheeze is a musical sound heard during
expirations. Wheezing sound is most often associated with asthma and bronchiolitis. At this
level, no distinction can be made between children with bronchiolitis and those with
pneumonia.
Note: If wheezing and either fast breathing or chest indrawing: Give a trial of rapid
acting inhaled bronchodilator for up to three times 20 minutes apart. Count the breaths
and look for chest indrawing again, and then classify.
CLASSIFICATION OF COUGH OR DIFFICULT BREATHING
Based on a combination of the above clinical signs, children presenting with cough or
difficult breathing can be classified into three categories:
1. Children who have either a general danger sign or chest indrawing or stridor.
Children in this group are most likely to have infection with invasive bacterial organisms and
diseases which may be life threatening. This warrants the use of injectable antibiotics and
early referral.
Any general danger
SEVERE
sign or
Give
first
dose
of
an
appropriate
antibiotic.
PNEUMONIA
Chest indrawing or
OR VERY
Treat the child to prevent low blood

sugar.
Stridor in calm child

SEVERE DISEASE
Refer URGENTLY to hospital.*
Children who have fast breathing, as defined by WHO, in about 80 percent cases, can be
detected as children with pneumonia. They can be treated with oral antibiotics at home.
Treatment on this classification has been shown effective to reduce mortality.
Give an appropriate antibiotic for 5 days.
Soothe the throat and relieve the cough with a

safe remedy.
If coughing more than 3 weeks or if having

recurrent wheezing refer for assessment for
TB or asthma.
Advise mother when to return immediately.
Follow-up in 2 days.
Fast breathing.
PNEUMONIA
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HAND BOOK ON IMNCI
2. Children who have cough or cold but no signs of Pneumonia or very severe disease, do
not require antibiotics. Such children may require a safe remedy to relieve cough. A child
with cough and cold normally improves in one or two weeks. However, a child with
chronic cough (more than 30 days) needs to be further assessed (and, if needed, referred)
to exclude tuberculosis, asthma, whooping cough or other problem.
No signs of pneumonia
or very severe disease.
NO
PNEUMONIA:
COUGH OR
COLD
If coughing more than 30 days refer

for assessment.
Soothe the throat and relieve the cough with

a safe remedy.
Follow-up in 5 days if not improving.
Note: Antibiotic should not be used routinely for cough or cold, as it neither shorten
EXAMPLE: Top part of recording form with the main symptom cough or difficult
breathing.
CASE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5 F. The health
illness.
on around her.
The health worker asked the mother to lift Phuntshos shirt. He then counted the number of
breaths the child took in a minute. He counted 41 breaths per minute. The health worker did
not see any chest in drawing. He did not hear stridor or wheeze.
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HAND BOOK ON IMNCI

Date: 1/1/2011
Weight: 11.5 kg
ASK: What are the childs problems? Cough, trouble breathing
Initial visit? Follow-up visit? __
CLASSIFY
General danger sign

present?

Yes _ No _____
VOMITS EVERYTHING
CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Severe
or
Yes No_
pneumonia
very
severe
Disease
For how long? 6 Days * Count the breaths in one minute.

* 41 breaths per minute.
fast breathing
* Look for chest indrawing.

* Look and listen for stridor.
DIARRHOEA
A child presenting with diarrhoea should first be assessed for general danger signs and the
child's caregiver should be asked if the child has cough or difficult breathing.
Diarrhoea is the next symptom that should be routinely checked in every child brought to the
clinic. A child with diarrhoea may have three potentially lethal conditions: (1) acute watery
diarrhoea (including cholera); (2) dysentery (bloody diarrhoea); and (3) persistent diarrhoea
(diarrhoea that lasts 14 days or more). All children with diarrhoea should be assessed for: (a)
signs of dehydration; (b) how long the child has had diarrhoea; and (c) blood in the stool to
determine if the child has dysentery.
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HAND BOOK ON IMNCI
CLINICAL ASSESSMENT
A number of clinical signs are used to assess the degree of dehydration.
1. Childs general condition. Depending on the degree of dehydration, a child with
diarrhoea may be lethargic or unconscious (this is also a general danger sign) or look
restless/irritable. Only children who cannot be consoled and calmed should be considered
restless or irritable.
2. Sunken eyes. The eyes of a dehydrated child may look sunken. In a severely
malnourished child who is visibly wasted (that is, who has marasmus), the eyes may
always look sunken, even if the child is not dehydrated. Even though the sign sunken
eyes is less reliable in a visibly wasted child, it can still be used to classify the childs
dehydration.
3. Childs reaction when offered to drink. A child is considered not able to drink if s/he is
not able to take fluid in his/her mouth and swallow it. For example, a child may not be
able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the
child is weak and cannot drink without help. S/he may be able to swallow only if fluid is
put in his/her mouth.
A child has the sign of drinking eagerly, thirsty if it is clear that the child wants to drink
more. Notice if the child reaches out for the cup or spoon when you offer him/her water.
When the water is taken away, see if the child is unhappy because s/he wants to drink more.
If the child takes a drink only with encouragement and does not want to drink more, s/he
does not have the sign drinking eagerly,
thirsty.
Standard Procedures for Skin Pinch
4. Elasticity of skin.
Check elasticity of skin by skin pinch.
When released, the skin pinch goes
back (a) very slowly (longer than 2
seconds), (b) slowly (skin stays up even
for a brief instant), or (c) immediately.
In a child with marasmus (severe
malnutrition), the skin may go back
slowly even if the child is not
dehydrated.
Locate the area on the child's abdomen halfway

between the umbilicus and the side of the abdomen;
then pinch the skin using the thumb and the radial
side of the index finger.
The hand should be placed so that when the skin is

pinched, the fold of skin will be in a line up and down
the child's body and not across the child's body.
It is important to firmly pick up all of the layers of

skin and the tissue under them for one second and
then release it.
In an overweight child, or a child with oedema, the skin may go back immediately even if the
child is dehydrated.
After the child is assessed for dehydration, the caregiver of a child with diarrhoea should be
asked how long the child has had diarrhoea and whether there is blood in the stool. This
will allow identification of children with persistent diarrhoea and dysentery respectively.
CLASSIFICATION OF DEHYDRATION
Based on a combination of the above clinical signs, children presenting with diarrhoea
are classified into three categories:
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HAND BOOK ON IMNCI
1. Children with severe dehydration will be presenting with two or more of the following
signs: lethargic or unconscious, sunken eyes, not able to drink or drinking poorly and
skin pinch goes back very slowly. These children may have a fluid deficit equalling or
greater than 10 percent of their body weight.
Two of the following signs:
SEVERE
classification:
Lethargic or unconscious
Sunken eyes
Not able to drink or
DEHYDRATION
Give fluid for severe dehydration

(Plan C). OR
drinking poorly
If child has no other severe
If child also has another severe

classification:
Skin pinch goes back very
slowly.
Refer URGENTLY to hospital

with mother giving frequent sips
of ORS on the way.
Advise the mother to continue

breastfeeding
If child is 2 years or older and there

is cholera in patients area, give
antibiotic for cholera.
2. Children with some dehydration will be presenting with two of the following signs:
restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly. These
children may have a fluid deficit equalling 5 to 10 percent of their body weight.
Two of the following
signs:
Restless, irritable
Sunken eyes
Drinks
thirsty
eagerly,
SOME
DEHYDRATION
Give fluid, zinc and food for some dehydration

(Plan B).
If child also has a severe classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding.

Skin pinch goes
3. back
Children
slowlynot having enough signs to be classified as some or severe dehydration , will be
classified as No Dehydration .These children
Follow-up
mayin have
5 daysfluid
if notdeficit
improving.
of <5% of their
body weight.
16
HAND BOOK ON IMNCI
Not enough signs to

classify as some or
severe dehydration
Give fluid, zinc and food to treat diarrhoea

at home (Plan A).
NO
DEHYDRATION
Advise
mother
immediately.
when
to
return
Follow-up in 5 days if not improving.
Note:
1. Antibiotics should not be used routinely for treatment of diarrhoea. Most diarrhoeal
episodes are self-limiting and caused by agents for which antibiotics are not required,
except Cholera.
2. Anti-diarrhoeal agents - including anti-motility agents (e.g., loperamide, codeine,
diphenoxylate with atropine, and tincture of opium), adsorbents (e.g., kaolin), Bismuth
subsalicylate and charcoal - do not provide practical benefits for children with diarrhoea,
and some may have dangerous side effects. These drugs should never be given to
children with diarrhoea.
Persistent diarrhoea almost never occurs in
Classification of Persistent Diarrhoea
infants who are exclusively breast-fed.
Persistent diarrhoea is an episode of
diarrhoea, with or without blood, which
begins acutely and lasts at least 14 days or more.
Persistent diarrhoea is usually associated with weight loss and often with serious nonintestinal infections. Many children with persistent diarrhoea are malnourished and they are
at increased risk of death.
Note: Persistent diarrhoea almost never occurs in infants who are exclusively breast-fed.
Many children with diarrhoea for 14 days or more should be classified based on the presence
or absence of any dehydration:
1. Children with persistent diarrhoea who have any degree of dehydration should be
classified as Severe Persistent diarrhoea and should be managed in the hospital as they
require special treatment
Dehydration present
SEVERE PERSISTENT
DIARRHOEA
Treat dehydration before

referral unless the child has
another severe
classification.
Refer to hospital.
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HAND BOOK ON IMNCI
2. Children with persistent diarrhoea who have no signs of dehydration should be classified
as Persistent diarrhoea and can be managed in the outpatient clinic initially, however if
required, they also needs to be managed at hospital.
No dehydration
PERSISTENT
Advise the mother on feeding a child

who has:
PERSISTENT DIARRHOEA.
Give multivitamins/minerals and zinc

for 10 days
DIARRHOEA
Proper feeding is the most important aspect of treatment

for most children with persistent
diarrhoea. The goals of nutritional therapy are to:
a. Provide a sufficient intake of energy, protein, vitamins and minerals to facilitate the
repair process in the damaged gut mucosa and to improve nutritional status;
b. Avoid giving foods or drinks that may aggravate diarrhoea;
c. Reduce the amount of animal milk [or lactose] in the diet, for those who are not
breast-fed.
d. Ensure adequate food intake during convalescence to correct any malnutrition.
Routine treatment of persistent diarrhoea with antimicrobials is not effective. Some children,
however, have non-intestinal or intestinal infections that require specific antimicrobial
therapy. The persistent diarrhoea of such children will not improve until these infections are
diagnosed and treated correctly.
CLASSIFICATION OF DYSENTERY
The mother or caregiver of a child with diarrhoea should be asked if there is blood in the
stool.
A child is classified as having
childs stool.
Blood in the stool
DYSENTERY
if the mother or caregiver reports blood in the
DYSENTERY
Treat for 5 days with an oral

antibiotic recommended for
Shigella in your area.
It is not necessary to examine the stool or perform laboratory tests to diagnose dysentery.
Stool culture, to detect pathogenic bacteria, is rarely possible. Moreover, at least two days
are required to obtain the results of a culture.
About 10 percent of all diarrhoeal episodes in children under five years are due to dysentery, but
these cause up to 15 percent of all diarrhoeal deaths.
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Bloody diarrhoea in young children is usually a sign of invasive enteric infection that carries
a substantial risk of serious morbidity and death. About 10 percent of all diarrhoea episodes
in under-5 children are due to dysentery, but these cause up to 15 percent of all diarrhoeal
deaths.6
Dysentery is especially severe in infants and in children who (a) are malnourished (b)
Develop clinically evident dehydration during their illness and (c) are not breast-fed. It also
has a more harmful effect on nutritional status than acute watery diarrhoea. Dysentery occurs
with increased frequency and severity in children who have measles or have had measles in
the preceding month, and diarrhoeal episodes that begin with dysentery are more likely to
become persistent than those that start without blood in the stool.
All children with dysentery (bloody diarrhoea) should be treated promptly with an antibiotic
effective against Shigella because: (a) bloody diarrhoea in children under 5 is caused more
frequently by Shigella than by any other pathogen; (b) shigellosis is more likely to result in
complications and death if effective antimicrobial therapy is not begun promptly; and (c)
early treatment of shigellosis with an effective antibiotic substantially reduces the risk of
severe morbidity or death.
Example: Top part of the recording form with the main symptom diarrhoea.
CASE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 99.5F. The health
illness.
on around her.
not see any chest in-drawing. He did not hear stridor or wheeze.
The health worker asked, Does the child have diarrhoea? The mother said, Yes for 3
days. There was no blood in the stool. Phuntshos eyes looked sunken. The health worker
asked, Do you notice anything different about Phuntshos eyes? The mother said, Yes.
He gave the mother some clean water in a cup and asked her to offer it to Phuntsho. When
offered, Phuntsho would not drink. When pinched, the skin of Phuntshos abdomen went
back slowly.
Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1 ISBN 92 4 1592330
Geneva, World Health Organization, 2005
6
19
HAND BOOK ON IMNCI

Date: 1/1/2011
Weight: 11.5 kg

CLASSIFY
General
present?
Yes No _
danger
sign
VOMITS EVERYTHING
CONVULSION
S
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Severe
Yes No_
pneumonia
very severe Disease
For how long? 6
Days * Count the breaths in one minute.

*_41_ breaths per minute.
Fast breathing

DOES THE CHILD HAVE DIARRHOEA?

For
how
long?
Days
Is there blood in the stool?
Look
at
Yes
the
No _____
general
condition
Is the child:
Lethargic or unconscious?
Severe dehydration
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking
poorly?
Pinch the skin of the abdomen. Does it go back: Very slowly (<2 seconds )
or
Slowly ?
20
or
HAND BOOK ON IMNCI

FEVER
All sick children should be checked for fever. Fever is a very common condition and is often
the main reason for bringing children to the health centre. It may be caused by minor
infections, but may also be the most obvious sign of a life-threatening illness, particularly
malaria, especially lethal malaria (P. falciparum), or other severe infections, including
meningitis, typhoid fever, or measles. When diagnostic facility is limited, it is important first
to identify those children who need urgent referral with appropriate pre-referral treatment
(antimalarial or antibacterial).
Clinical Assessment
Body temperature should be checked in all sick children brought to an outpatient clinic.
Children are considered to have fever if their body temperature is above 99.5F (axillary). In
the absence of a thermometer, children are considered to have fever if they feel hot. Fever
may also be considered if the mother gives a history of fever.
A child presenting with fever should be assessed for:
I.
Stiff neck: A stiff neck is a sign of meningitis. If the child is conscious and alert,
check stiffness by asking the child to bend his/her neck to look down or by very
gently bending the childs head forward. It should move normally.
II.
Runny nose: means watery secretion from nose which occurs usually due to common
cold.
Duration of fever. Most fevers due to viral illnesses go away within few days. A fever that
has been present every day for more than seven days indicates that the child has a more
severe disease such as typhoid fever.
Malaria: Malaria is one of the major public health problems in Bhutan. Out of 20 districts,
10 of them have seasonal transmission (population 234,630) and malaria outbreaks are an
annual feature causing high morbidity and mortality in the affected population. Five districts
are endemic (population 234,633) adjoining the international borders with the state of West
Bengal and Assam on the Indian side.
Note: Risk of malaria and other endemic infections in situations where routine microscopy is
not available or the results may be delayed, the risk of malaria transmission must be defined.
The World Health Organization (WHO) has proposed definitions of malaria risk settings for
countries and areas with risk of malaria caused by P. falciparum. A high malaria risk setting
is defined as a situation in which more than 5 percent of cases of febrile disease in children
age 2 to 59 months are malarial disease. A low malarial risk setting is a situation where
fewer than 5 percent of cases of febrile disease in children age 2 to 59 months are malarial
disease, but in which the risk is not negligible. If malaria does not normally occur in the area,
the setting is considered to have no malaria risk. In low/no malaria risk area, travelling to a
high risk zone within 1 month should be considered as high risk for malaria.
Other endemic infections with a public health importance in the area, (e.g. dengue
haemorrhagic fever or relapsing fever), should also be considered. In such situations, the
national health authorities normally adapt the IMNCI clinical guidelines locally.
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HAND BOOK ON IMNCI
Measles. Considering the high risk of complications and death due to measles, children with
fever should be assessed for signs of current or previous measles (within the last three
months). Measles infections cause serious immunodeficiency and deaths usually occur from
pneumonia (67 percent), diarrhoea (25 percent), larynigotracheitis and encephalitis. Other
complications (usually non-fatal) include conjunctivitis, otitis media, and mouth ulcers.
Significant disability can result from measles e.g. xeropthalmia including blindness, severe
malnutrition, chronic lung disease (bronchiectasis and recurrent infection), and flare up of
TB and neurological dysfunction.7
Detection of measles is based on fever with a generalised rash, plus at least one of the
following signs: red eyes, runny nose, or cough.
The mother should be asked about the occurrence of measles within the last three months.
Despite great success in improving immunization coverage in many countries, substantial
numbers of measles cases and deaths continue to occur. Although the vaccine should be
given at 9 months of age, immunization often does not take place or delayed because of false
contraindications, lack of vaccine, failure of a cold chain or lack of awareness.
CLASSIFICATION
OF FEVER: BEFORE GOING FOR THE CLASSIFICATION, THE FIRST

CONSIDERATION NEEDS TO BE DONE, WHETHER THE CHILD IS COMING FROM THE HIGH, LOW OR
NO MALARIA RISK AREA.
If the malaria risk in the local area is low or no ask:
Have you traveled with the child outside this area?
If yes, have you been to a malarious area in the last 30 days?
Reclassify the malaria risk as high if there has been travel to a malarious area in the
last 30 days.
The child may have acquired malaria during travel. Many mothers will know whether the
area where they traveled has malaria transmission. If a mother does not know or is not sure,
ask about the area and use your own knowledge of whether the area has malaria. If you are
still not sure, assume the malaria risk is high.
1. Child from high malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY SEVERE
FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral treatment
with antibiotics (the same choice as for severe pneumonia or very severe disease). But as the
risk of Falciparum malaria is high, such children should also receive a pre-referral dose of an
anti-malarial.
7 World Health Organization. Technical basis for the case management of measles. Document WHO/EPI/95. Geneva, WHO, 1995.
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Any danger sign or
stiff neck
VERY SEVERE
FEBRILE
DISEASE
Give quinine for severe malaria

(first dose)
Give first dose of an appropriate

antibiotic.

sugar.
Give one dose of paracetamol in

clinic for high fever (38.5C or
above).
Children with fever but no general danger sign
or stiff neck should be classified as
having MALARIA.
Fever (by history

or feels hot or
temperature
37.5C*cor
above)
Refer URGENTLY to hospital.

Make MP slide
If PFR +ve admit and treat accordingly
o If PV+ treat accordingly
MALARIA
Give one dose of paracetamol in clinic

for high fever (38.5C or above).
Advise mother
immediately.
Follow-up in 2 days if fever persists.
If fever is present every day for more
when
to
return
Treat the child classified as having MALARIA withthan

an 7antimalarial
after
the MP slide is
days, refer for
assessment.
positive for PFR or PV.
2. Child from Low Malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY
SEVERE FEBRILE DISEASE and should be referred urgently to a hospital after pre-referral
treatment with antibiotics (the same choice as for severe pneumonia or very severe disease).
But as the risk of Falciparum malaria is high, such children should also receive a pre-referral
dose of an anti-malarial.
Any danger sign or
stiff neck
VERY SEVERE
FEBRILE
DISEASE
Give quinine for severe malaria (first dose)
Give first dose of an appropriate antibiotic.
Treat the child to prevent low blood sugar.
Give one dose of paracetamol in clinic for high

fever (38.5C or above).
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HAND BOOK ON IMNCI
Children with fever (or history of fever) having neither general danger sign nor stiff neck or
no runny nose (a sign of ARI), no measles, and no other obvious cause of fever (pneumonia,
sore throat, etc.) are classified as malaria. They should be treated at outpatient clinic with an
oral anti-malarial and paracetamol.
NO runny nose
and
MALARIA
NO measles
and
NO other
causes of fever
Make MP slide
o
If PFR +ve admit and treat accordingly
If PV+ treat accordingly.

If fever is present every day for more than 7 days,

refer for assessment.
Children with runny nose, measles or clinical signs of other possible infection are classified
as having Fever Malaria Unlikely. These children need follow-up. If their fever lasts for
more than seven days, they should be referred for further assessment to determine causes of
prolonged fever.
Runny nose present

or
Measles present
Other causes of
fever present
FEVERMALARIA
UNLIKELY
Give one dose of paracetamol in clinic for

high fever (38.5C or above).
If fever is present every day for more than 7

days, refer for assessment.
Evidence of another infection lowers the probability that the child's illness is due to malaria.
Therefore, children in low malaria risk area, which have evidence of another infection,
should not be given an anti-malarial.
Note: Children with high fever, defined as an axillary temperature greater than 100F should
be given a single dose of paracetamol to combat hyperthermia.
3. Child from No Malaria risk area
Children with fever and any general danger sign or stiff neck are classified as VERY
SEVERE FEBRILE DISEASE and should be referred urgently to a hospital after prereferral treatment with antibiotics (the same choice as for severe pneumonia or very severe
disease).
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HAND BOOK ON IMNCI
Any danger sign or
stiff neck
VERY SEVERE
FEBRILE

antibiotic.
DISEASE

sugar.
Give one dose of paracetamol in

clinic for high fever (38.5C or
above).
All other cases of fever are classified as Fever No Malaria and treated for the respective
cause.
Any fever
FEVER-NO
MALARIA

Treat Other Causes of fever
If fever is present every day for more than 7

days, refer for assessment.
CLASSIFICATION OF MEASLES
All children with fever should be checked for signs of measles and measles complications.
1. Severe complicated measles: when a child with measles displays any general danger sign
or deep and extensive mouth ulcers or clouding of the cornea, they should be classified as
severe measles. These children should be urgently referred to a hospital with a prereferral treatment.
Any danger sign or
Clouding of cornea or
Deep or extensive
mouth ulcers
Severe complicated
measles
Give Vitamin A.

antibiotic.
If clouding of the cornea or pus

draining from the eye, apply
chloromycetine eye ointment.
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HAND BOOK ON IMNCI
2. Measles with eye or mouth complications: Children with less severe measles
complications, such as pus draining from the eye (a sign of conjunctivitis) or non-deep
and non-extensive mouth ulcers, are classified as measles with eye or mouth
complications. These children can be safely treated at the outpatient facility. The
treatment includes oral vitamin A, tetracycline ointment for children with pus draining
from the eye, and gentian violet for children with mouth ulcers.
Pus
draining
from the eye or
Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
Give Vitamin A.
If pus draining from the eye, treat

eye infection with chloromycetine
eye ointment.
If mouth ulcers, treat with gentian

violet.
3. Measles: If no signs of measles complications have been found after a complete

assessment, a child is classified as having Measles.These children can be effectively and
safely managed at home with vitamin A treatment.
Measles now or within

the last 3 months
Measles
Give Vitamin A
EXAMPLE: Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.60F. The
health workerasked, What are the childs problems? The mother said Phuntsho has been
illness.
Phuntsho is able to drink. She has not been vomiting. She has not had convulsions during
this illness. The health worker asked. Does Phuntsho seem unusually sleepy? The mother
said, Yes. The health worker clapped his hands, He asked the mother to shake the child.
but she did not look into his face. She stared blankly and appeared not to notice what was
going on around her.
not see any chest in drawing. He did not hear strido or wheeze.
The health worker asked, Does the child have diarrhoea? The mother said, Yes, for 3
asked Do you notice anything different about Phuntshos eyes? The mother said, Yes.
26
HAND BOOK ON IMNCI
offered the cup, Phuntsho would not drink. When pinched, the skin of Phuntshos abdomen
went back slowly.
Because Phuntshos temperature is 98.60F and she feels hot, the health worker assessed
Phuntsho further for signs related to fever. The mother said Phuntshos fever began 2 days
ago. The risk of malaria is low. Phuntsho has not had measles within the last 3 months, and
there are no signs suggesting measles. She does not have stiff neck. The health worker
noticed that Phuntsho has a runny nose.
Childs Name: Phuntsho
Date: 1/1/2011
Age/sex: 18 months/F
Weight: 11.5 kg
CLASSIFY
General danger sign

NOT
ABLE
TO
DRINK
BREASTFEED present?
OR
Yes No _
VOMITS EVERYTHING
CONVULSIONS
Severe pneumonia
Yes No_
or
For how long? __6_ Days * Count the breaths in one minute.
Disease
very
Fast breathing

Yes
No _____
For how long? 3 Days
Look at the general condition
Is the child:
Severe
Dehydration

poorly
27
severe
HAND BOOK ON IMNCI
Drinking eagerly, thirsty

Pinch the skin of the abdomen. Does
it go back:
Very slowly (longer than 2 seconds or
Slowly ?
DOES THE CHILD HAVE FEVER? Yes _ No ____ (by history/feels hot or temp.
Very severe Febrile
more than 99.5 F)

Decide Malaria Risk: High
Low No
Disease
If Low or No than ask: Have you travelled outside this area?

If yes, have you been in a malarious area during last 30 days?
* For how long? 2 Days
* Look or feel for stiff neck
* If more than 7 days, has fever
* Look for Runny nose
been present every day?

* Has the child had measles
within the last 3 months?
Look for signs of MEASLES:

* Generalized rash and
* One of these: cough, runny nose, or red eyes
If the child has measles now
* Look for mouth ulcers
Or within the last 3 months:
* If yes, are they deep and extensive?

* Look for pus draining from the eye.
* Look for clouding of the cornea.
EAR PROBLEMS
Ear problems are the next condition that should be checked in all children brought to the
outpatient health facility. A child presenting with an ear problem should first be assessed for
general danger signs, cough or difficult breathing, diarrhoea and fever. A child with an ear
problem may have an ear infection. Although ear infections rarely cause death, they are the
main cause of deafness in low-income areas, which in turn leads to learning problems. Ear
infection also may cause meningitis as a complication.
CLINICAL ASSESSMENT
If there is an ear problem, look for the following simple clinical signs:
Tender swelling behind the ear. The most serious complication of an ear infection is an
infection in the mastoid bone. It usually manifests with tender swelling behind the childs
ears.
Ear pain. In the early stages of acute ear infection, a child may have ear pain, which usually
causes the child to become irritable and rub the ear frequently.
Ear discharge of pus. This is another important sign of an ear infection. When a mother
reports an ear discharge, the health care provider should check for pus draining from the ears
28
HAND BOOK ON IMNCI
and find out how long the discharge has been present.
Classification of Ear Problems
Based on the simple clinical signs above, the childs condition can be classified in the
following ways:
Children presenting with tenderness and swelling (behind the ear) of the mastoid
bone are classified as having MASTOIDITIS and should immediately be referred to the
hospital for treatment, after giving a pre-referral treatment with a dose of antibiotic
and a single dose of Paracetamol for pain.
Give
Tender swelling behind the ear
first
dose
of
an
appropriate
antibiotic.
MASTOIDITIS
Give first dose of paracetamol for pain.

Children with ear pain or ear discharge (or pus) for fewer than 14 days are classified as
having ACUTE EAR INFECTION and should be treated for five days with the same first-line
antibiotic as for pneumonia.
Ear pain or
Pus is seen draining from
the ear and discharge is
reported for less than 14
days
Acute ear infection
Give an antibiotic for 5 days.
Give paracetamol for pain.
Dry the ear by wicking.
Children with ear discharge (or pus) for 14 days or more, are classified as CHRONIC
EAR INFECTION. Generally, antibiotics are not recommended because they are
expensive and their efficacy is not proven, however dry the ear by wicking and
follow-up in 5 days is recommended.
Pus is seen draining from the ear
and discharge is reported for 14
days or more.

CHRONIC EAR
INFECTION
Treat
with
topical
ciprofloxacin ear drops for
14 days
Follow up in 5 days.
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Children having neither pain nor discharge (pus) draining from the ear, are classified as
NO EAR INFECTION
and do not require any specific treatment.
No ear pain and

no pus seen draining from the
ear.
NO EAR INFECTION
No additional treatment.
Example: Ear problem section of the case recording form:

Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.60F. The health
illness.
went back slowly.
Next the health worker asked about Phuntshos ear problem. The mother said she is sure that
Phuntsho has ear pain. She cries most of the night because her ear hurt. There has not been
ear discharge. The health worker did not see any pus draining from her ear, health worker
felt behind the childs ears and found no tender swelling.
30
HAND BOOK ON IMNCI

Date: 1/1/2011
Weight: 11.5 kg

Assess (circle all signs present)
CLASSIFY
General danger sign

NOT
ABLE
TO
DRINK
BREASTFEED present?
OR
Yes No _
VOMITS EVERYTHING
CONVULSIONS
Severe pneumonia
Yes No_
or
Disease
very
Fast breathing

Yes

For
how
long?
Days
Look
at
the
No _____
general
condition Severe
Is the child:
Dehydration

poorly

it go back: Very slowly (longer than
2 seconds) or slowly?
31
severe
HAND BOOK ON IMNCI
Very severe Febrile
more than 99.5 F)

Disease
Low No


Look for signs of MEASLES:

*One of these: cough, runny nose, or red eyes

DOES THE CHILD HAVE AN EAR PROBLEM?

* Is there ear pain?
* Is there ear discharge?
Yes___ No ___
* Look for pus draining from the ear.
Acute Ear
Infection
* Feel for tender swelling behind the ear.
If yes, for how long ? 1 Day
2.2.4 CHECKING NUTRITIONAL STATUS - MALNUTRITION AND ANAEMIA

After assessing for general danger signs and the four main symptoms, all children should be
assessed for malnutrition and anaemia.
There are two main reasons for routine assessment of nutritional status in sick
children:
To identify children with severe malnutrition and/or severe anaemia who are at
increased risk of death and need urgent referral to provide active treatment; and
To identify children with sub-optimal growth.
CLINICAL ASSESSMENT
Because reliable length (infantometer)/height boards (stadiometer) are difficult to find in
most outpatient health facilities, nutritional status should be assessed by looking and feeling
for the following clinical signs:
Visible severe wasting. This means severe wasting of the shoulders, arms, buttocks, and legs
with easily seen ribs. It is usually assessed by looking at the buttock.
Palmar pallor. Although this clinical sign is less specific than many other clinical signs
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HAND BOOK ON IMNCI
included in the IMNCI guidelines, it can allow health care providers to identify sick children
with severe anaemia. Where feasible, the specificity of anaemia diagnosis may be greatly
increased by using a simple laboratory test for Hb estimation.
To see if the child has palmar pallor, look at the skin of the child's palm. Hold the child's
palm open by grasping it gently from the side. Do not stretch the fingers backwards. This
may cause pallor by blocking the blood supply. Compare the colour of the child's palm with
your own palm and with the palms of other children.
If the skin of the child's palm is pale, the child has some palmar pallor.
If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar
pallor.
Oedema of both feet. The presence of oedema in both feet may signal kwashiorkor. Children
with oedema of both feet may have other diseases like nephrotic syndrome. There is no need,
however, to differentiate these conditions in the outpatient settings or at the first level health
facility because referral is necessary in both cases.
Weight for age. When length/height boards are not available in outpatient settings, a weight
for age (a standard WHO or national growth chart) helps to identify children with very low
(Z score less than 3) weight for age that is at increased risk of infection and poor growth
and development.
To determine weight for age:
1. Calculate the childs age in months.
2. Weigh the child if he has not already been weighed today. Use a scale which you know
gives accurate weights. The child should wear light clothing when he is weighed.
Ask the mother to help remove any sweater or shoes.
3. Use the weight for age chart to determine weight for age.
Look at the left-hand axis to locate the line that shows the child's weight.
Look at the bottom axis of the chart to locate the line that shows the age in months.
Find the point on the chart where the line for the weight meets the line for the age.
4. Decide if the point is below the Very Low Weight for Age line, between the Very Low
and Low Weight for Age lines or above the Low Weight for Age line.
If the point is below the Very Low Weight for Age line, the child is very low weight
for age.
If the point is above or on the Very Low Weight for Age line and below the Low
Weight for Age line, the child is low weight for age.
If the point is above or on the Low Weight for Age line, the child is not low weight
for age.
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WEIGHT FOR AGE CHART
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Classification of Nutritional Status and Anaemia

Using a combination of the simple clinical signs above, children can be classified in one of
the following categories:
Children with visible severe wasting, or Severe Palmar Pallor or oedema of both feet
should be classified as Severe malnutrition or Severe Anaemia and are at high risk of
death from various severe diseases. They need urgent referral to a hospital where
their treatment (special feeding, antibiotics or blood transfusions, etc.) can be
carefully monitored.
Visible severe wasting

or
Severe palmar pallor or
Oedema of both feet
SEVERE
Give Vitamin A if Visible Sever

Wasting and /or Oedema of both feet
present.
MALNUTRITION OR
SEVERE ANAEMIA
sugar
Children with very low weight for age should be classified as very low weight for age. They
also have a higher risk of severe disease and should be assessed for feeding problems. This
assessment should identify common, important feeding problems that can be corrected if
the caregiver is provided with appropriate counselling. When children are classified as
having ANAEMIA they should be treated with oral iron. During treatment, the child should
be seen every two weeks (follow-up), at which time an additional 14 days of iron treatment is
given. If there is no improvement in pallor after two weeks, the child should be referred to
the hospital for further assessment. Iron is not given to children with severe malnutrition who
will be referred.
Some Palmar Pallor Or
Very low weight for

age
Anaemia Or
Very low
weight
Assess the childs feeding and counsel the mother on

feeding according to the FOOD box on the COUNSEL
THE MOTHER chart.
If pallor:
Give iron.
If malaria high risk make smear and give

antimalarial if positive
Advice mother when to return immediately.
If pallor, follow up in 14 days.
If very low weight for age, follow up in 30 days.
Give ALBENDAZOLE if child is 15 months or older

and was not given a dose during 6 months.
Advice mother when to return immediately.

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Children who are not very low weight for age and do not show other signs of malnutrition
including pallor are classified as having No anaemia and not very low weight. Because
children less than 2 years of age have a higher risk of feeding problems and malnutrition than
older children do, their feeding should be assessed. If problems are identified, the mother
needs to be counselled about feeding her child according to the recommendations of IMCI
clinical guidelines.
Not very low weight for age
and no sign
malnutrition.
of
severe
NO ANAEMIA AND
NOT VERY
LOW WEIGHT
If child is less than 2 years old,

assess the childs feeding and
counsel the mother on feeding
according
to
the
feeding
recommendations.
If feeding problem, follow-up in
5 days.
Advice mother when to return
immediately.
Example: Malnutrition and Anaemia section of the case recording from.

Phuntsho is 18 months old. She weighs 11.5 kg. Her temperature is 98.60F. The health
illness.
went back slowly.
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Next the health worker asked about Phuntshos ear problem. The mother said she is sure that
Phuntsho has ear pain. She cries most of the night because her ear hurt. There has not been
ear discharge. The health worker did not see any pus draining from her ear, health worker
felt behind the childs ears and found no tender swelling.
Next, the health worker checked for signs of malnutrition. The child does not have visible
severe wasting but her palm appears pale. She does not have oedema of both feet. The health
worker uses the weight for age chart to determine Phuntshos weight for her age.

Date: 1/1/2011

ASSESS
CLASSIFY
(CIRCLE
Weight: 11.5 kg
ALL
SIGNS

NOT
ABLE
TO
DRINK
OR
BREASTFEED
PRESENT)
General danger sign
present?
Yes No _
VOMITS EVERYTHING
CONVULSIONS
Severe pneumonia
or
very severe
Disease
Yes No_
Fast breathing

Yes

For how long? 3 Days
Look at
Is the child:
the
No _____
general
condition Severe
Not able to drink or drinking poorly
Dehydration
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it go back: Very slowly (longer than
2 seconds) or Slowly?
more than 99.5 F)
Very severe Febrile
Disease
Low No

* Look for signs of MEASLES:
* One of these: cough, runny nose, or red eyes

DOES THE CHILD HAVE AN EAR PROBLEM?

* Is there ear pain?
Yes___ No ___
* Look for pus draining from the ear.
* Is there ear discharge?
Acute
Infection
Ear
* Feel for tender swelling behind the ear.
If yes, for how long? 1 Day

THEN CHECK FOR MALNUTRITION and ANAEMIA
Anaemia and
Look for visible severe wasting
Not very
weight
Look for palmer pallor

Severe palmer pallor? Some palmer pallor
Look for oedema of both feet.
Determine weight for age.
Very Low _____ Not Very Low
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2.2.5 CHECKING IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

The immunization status of every sick child brought to a
health facility should be checked. Illness is not a
contraindication to immunization. In practice, sick
children may be even more in need of protection provided
by immunization than well children. A vaccines ability to
protect is not diminished in sick children.
Illness is not a contraindication to

immunization. A vaccines ability to
protect is not diminished in sick
children.
As a rule, there are only four common situations that are contraindications to immunization
of sick children:
IMMUNIZATION SCHEDULE
Children who are being referred urgently to the hospital should not be immunized. There is
no medical contraindication, but if the child dies, the vaccine may be incorrectly blamed for
the death.
Live vaccines (BCG, measles, polio,) should not be given to children with immunodeficiency
diseases, or to children who are immuno-suppressed due to malignant disease, therapy with
immunosuppressive agents or irradiation. However, all the vaccines, including BCG can be
given to children who have, or are suspected of having, HIV infection but are not yet
symptomatic.
DPT2/ DPT3 should not be given to children who have had convulsions or shock within
three days of a previous dose of DPT. In these cases, DT can be administered instead of
DPT.
DPT should not be given to children with recurrent convulsions or another active
neurological disease of the central nervous system. DT can be administered instead.
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CHECKING THE CHILDS
VITAMIN
A If child is 6 months or older and has not received a
dose of Vitamin A in the last 6 months, give a dose of
SUPPLEMENTATION STATUS
vitamin A in the clinic.
Up to 1 yr =100,000 IU
> 1 yr = 200,000 IU
If child is 15 months or older and has not received a
DEWORMING STATUS
dose of albendazole in the past 6 months give a dose

for de-worming
Example: Immunization status section of the case recording form.

Kinley is 4 months old. He has no general danger signs. He is classified as diarrhoea with
NO DEHYDRATION. His immunization record shows that he received BCG PLUS Hep B
0, OPVO, OPV1, OPV2, DPT1, and DPT2 and HEP-B 1 and HEP B 2.
CHECK THE CHILDS IMMUNIZATION STATUS Circle Immunization needed today
______
AGE
VACCINE
Birth
BCG + HepB-0
OPV 0
DPT-1+ Hep.B-1+ Hib-1

6 Weeks
DPT-2 + Hep.B-2+ Hib-2
OPV-1
10 Weeks
DPT-3 + Hep.B-3+ Hib-3
OPV-2
MR-1
OPV-3
14 Weeks
DT+MR-2
9 Months
24 Months
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BCG DPT1HepB1 DPT 2HepB2
_____ _____ ______

OPV 0 OPV 1
OPV 2
Return for next

immunization on
(Date)________________
DPT 3 HepB3
_____ _____
OPV 3 MR-1
_____
MR-2
_____
VitA
__________
Albendazole
2.2.6 ASSESSING THE CHILD'S FEEDING

All children less than 2 years old and all children classified,
as ANAEMIA OR VERY LOW WEIGHT needs to be
assessed for feeding.
All children under age 2 years

should have a feeding
assessment, even if they have
a normal Z-score.
Feeding assessment includes questioning the mother or

caregiver about:
1. Breast feeding frequency and night feeds;
2. Types of complimentary foods or fluids, frequency of feeding and whether feeding is
active; and
3. Feeding patterns during the current illness. The mother or caregiver should be given
appropriate advice to overcome any feeding problems found.
However, if the mother has already received many treatment instructions and is
overwhelmed, you may delay assessing feeding and counselling the mother about feeding
until a later visit. Even though you may feel hurried, it is important to take time to counsel
the mother carefully and completely. When counselling a mother about feeding, you will use
some of the same communication skills described earlier.
For example, you will ask the mother questions to determine how she is feeding the child.
You will listen carefully to the mothers answers so that you can make your advice relevant
to her. You will praise the mother for appropriate practices and advise her about any
practices that need to be changed. You will use simple language that the mother can
understand. Finally, you will ask checking questions to ensure that the mother knows how to
care for her child at home.
To assess feeding, ask the mother the following questions. These questions are at the bottom
of the sick child case recording form. These questions will help you find out about the childs
usual feeding and feeding during this illness:
Do you breastfeed your child? If yes: how many times during the day?
Do you also breastfeed during the night?
Does the child take any other food or fluids? If yes: What food or fluids?
How many times per day?
What do you use to feed the child?
How large are servings? Does the child receive his own serving?
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HAND BOOK ON IMNCI
Who feeds the child and how?
During this illness, has the childs feeding changed? If yes, how?
Listen for correct feeding practices as well as those that need to be changed. As you listen to
the mother, you may look at the Feeding Recommendations during Sickness and Health that
are appropriate for the childs age (see page 18 of the chart book). If an answer is unclear,
ask another question. For example, if the mother of a very-low-weight child says that
servings are large enough, you could ask, When the child has eaten, does he still want
more?
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Identify feeding problems

It is important to complete the assessment of feeding and identify all the feeding problems
before giving advice. Based on the mothers answers to the feeding questions, identify any
differences between the childs actual feeding and the feeding recommendations. These
differences are problems. Some examples of feeding problems are listed below.
EXAMPLES OF FEEDING PROBLEMS
CHILDS ACTUAL FEEDING
RECOMMENDED FEEDING
A 3-month-old is given sugar water as A 3-month-old should be given only breast

well as breast milk.
milk and no another food or fluid.
A 2-year-old fed only 3 times each day.
A 2-year-old should receive 2 extra feedings

between meals, as well as 3 meals a day.
An 8-month-old is still breastfed.
A breastfed 8-month-old should also be given

adequate
servings
of
a
complementary food 3 times a day.
nutritious
In addition to differences from the feeding recommendations, some other problems may
become apparent from the mothers answers. Other common feeding problems are:
Difficulty breastfeeding
The mother may mention that breastfeeding is uncomfortable for her, or that her child seems
to have difficulty breastfeeding. If so, you will need to assess breastfeeding as described on
the YOUNG INFANT chart. You may find that infants positioning and attachment could be
improved.
Use of feeding bottle
Feeding bottles should not be used. They are often dirty, and germs easily grow in them.
Fluids tend to be left in them and soon become spoiled or sour. The child may drink the
spoiled fluid and become ill. Also, sucking on a bottle may interfere with the childs desire to
breastfeed.
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Lack of active feeding

Young children often need to be encouraged and assisted to eat. This is especially true if a
child has very low weight. If a young child is left to feed himself, or if he has to compete
with siblings for food, he may not get enough to eat. By asking, Who feeds the child and
how? you should be able to find out if the child is actively being encouraged to eat.
Not feeding well during illness
The child may be eating much less, or eating different foods during illness. Children often
lose their appetite during illness. However, they should still be encouraged to eat the types of
food recommended for their age, as often as recommended, even if they do not eat much.
They should be offered their favorite nutritious foods, if possible, to encourage eating.
EXAMPLE:
Kinley is 4-months old. He has no general danger sign. He is classified as no anaemia and
not very low weight. He was assessed for identification of feeding problems.
CLASSIFY
ASSESS CHILD FEEDING if child has ANAEMIA OR VERY LOW WEIGHT Feeding
or is less than 2 years old.
problem:
* Do you breastfeed your child?
Yes
No ___ If yes, how many times in 24
hours? ___5__ times. Do you breastfeed during the night? Yes No __

Not breastfed
Does the child take any other food or fluids? Yes No ____
If yes, what food or fluids?
enough
Cows milk
How many times per day? 3 times. What do you to feed the child? Feeding bottle
Often giving
Cows milk
How large are servings? 100ml

Does the child receive his own serving? No
using feeding
bottle
Who feeds the child and how? Mother through feeding bottle
During this illness, has the childs feeding changed? yes ___ No
If yes, how?
2.2.7 ASSESSING OTHER PROBLEMS

The IMNCI clinical guidelines focus on four main symptoms. In addition, the assessment
steps within each main symptom take into account several other common problems. For
example, conditions such as tuberculosis, conjunctivitis and different causes of fever such as
sore throat, skin infection etc is routinely assessed within the IMNCI case management
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HAND BOOK ON IMNCI
process. If the guidelines are correctly applied, children with these conditions will receive
presumptive treatment or urgent referral.
Nevertheless, health care providers still need to consider other causes of severe or acute
illness. It is important to address the childs other complaints and to ask questions about the
caregivers health (usually, the mothers).
2.3
IDENTIFY TREATMENTS FOR SICK CHILDREN
IMNCI classifications are not necessarily specific diagnoses, but they indicate what action
needs to be taken. In the IMNCI guidelines, all classifications are colour coded: pink calls for
hospital referral or admission, yellow for initiation of treatment, and green means that the
child can be sent home with home-care management and advice on when to return. After
completion of the assessment and classification procedure, the next step is to identify
treatment.
2.3.1 REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS
All infants and children with a severe classification (pink) are referred to a hospital as
soon as assessment is completed and necessary pre-referral treatment is administered.
Conditions requiring urgent referral are
listed in Chart 2.
The Referral Note Should Include:
Note: If a child only has severe
dehydration and no other severe
classification, and IV infusion is
available in the outpatient clinic, an
attempt should be made to re-hydrate the
sick child.
Name and age of the child;
Date and time of referral;
Description of the child's problems;
Reason for referral (symptoms and signs leading to

severe classification);
Successful referral of severely ill
Treatment that has been given;

children to the hospital depends on
Any other information that the referral health facility

effective counselling of the caregiver. If
needs to know in order to care for the child, such as
s/he does not accept referral, available
earlier treatment of the illness or any immunizations
needed.
options (to treat the child by repeated
clinic or home visits) should be
considered. If the caregiver accepts
referral, s/he should be given a short, clear referral note, and should get information on what
to do during transportation, particularly if the hospital is distant.
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URGENT PRE-REFERRAL TREATMENTS FOR CHILDREN AGE 2 MONTHS UP TO 5 YEARS

(See Chart 2)
Appropriate antibiotic
Quinine (for severe malaria)
Vitamin A
Prevention of hypoglycaemia with breast milk or sugar water
Paracetamol for high fever (100.3F or above) or pain
Chloramphinicol eye ointment (if clouding of the cornea or pus draining from eye)
ORS solution so that the mother can give frequent sips on the way to the hospital
Non-urgent treatments, e.g., wicking a draining ear or providing oral iron treatment, should
be deferred to avoid delaying referral or confusing the caregiver.
If a child does not need urgent referral, check to see if the child needs non-urgent referral
for further assessment; for example, for a cough that has lasted more than 30 days, or for
fever that has lasted seven days or more. These referrals are not urgent and other necessary
treatments may be done before referral.
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Chart2. URGENT PRE-REFERRAL TREATMENTS FOR THE SICK CHILD FROM

AGE 2 MONTHS UP TO 5 YEARS
TREATMENT
Classification
For all children before referral:

Prevent low blood sugar by giving breast milk or sugar water (.0.5gm /kg)
SIGN-
If the child is convulsing, give diazepam (10 mg/2 ml solution) in dose 0.1
ml/kg rectally; if convulsions continue after 10 minutes, give a second dose
of diazepam rectally.
SEVERE PNEUMONIA
OR VERY SEVERE
DISEASE
Give first dose of an appropriate antibiotic. /kg) or amoxicillin (50 mg/kg).

If the child cannot take an oral antibiotic (children in shock or those who
vomits everything or are unconscious), give the first dose of intramuscular
ampicilin (100 mg/kg). Other options for an intramuscular antibiotic for prereferral use include .
DANGER
CONVULSIONS
Give one dose of paracetamol (15 mg/kg) for high fever (101.3F or above).
Give first dose of intramuscular quinine (20 mg/kg) for severe malaria (high
malaria risk).
Give first dose of an appropriate antibiotic.
Give first dose of appropriate antibiotic.
SEVERE
Give vitamin A (for children from 9-12 months 1 lac unit & > 1 yr 2 lac
COMPLICATED
Unit
MEASLES
If there is clouding of the cornea or pus draining from the eye, apply
chloramphinicol eye ointment.
SEVERE
WHO TREATMENT PLAN C
If there is no other severe classification, IV fluids should be given in the
DEHYDRATION
outpatient clinic according to WHO Treatment Plan C
Give 100ml/kg IV fluids; Normal saline/Ringers lactate solution is
preferred. Normal saline does not correct acidosis or replace potassium
loses, but can be used. Plain glucose or dextrose solutions are not acceptable
for the treatment of severe dehydration.
If IV infusion is not possible, urgent referral to the hospital for IV treatment
is recommended.
When referral takes more than 30 minutes, fluids should be given by
nasogastric tube. If none of these are possible and the child can drink ORS
solution must be given by mouth.
Note: In areas where Cholera cannot be excluded for patients more than 2
years old with severe dehydration, doxycilline is re recommended.
doxycillin
SEVERE PERSISTENT If there is no other severe classification, treat dehydration before referral
using WHO Treatment Plan B for some dehydration and Plan C for severe
DIARRHOEA
dehydration. Then refer to hospital.
VERY
SEVERE
FEBRILE DISEASE
mastoiditis
Give first dose of an appropriate intramuscular antibiotic and then refer.

Give first dose of paracetamol for pain.
SEVERE
MALNUTRITION
OR
SEVERE ANAEMIA
Give first dose of vitamin A, as mentioned above. Prevent low blood sugar
by giving breast milk or sugar water.
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2.3.2 TREATMENT IN OUTPATIENT CLINICS

The treatment associated with each non-referral classification (yellow and green) is clearly
spelled out in the IMCI guidelines. Treatment uses a minimum of affordable essential drugs
(see chart 2).
ORAL DRUGS
Always start with a first-line drug. These are usually less expensive, more readily available
in a given country, and easier to administer. Give a second-line drug (which are usually more
expensive and more difficult to obtain) only if a first-line drug is not available, or if the
child's illness does not respond to the first-line drug. The health care provider also needs to
teach the mother or caregiver how to give oral drugs at home.
DETERMINE THE APPROPRIATE DRUGS AND DOSAGE FOR THE CHILDS
AGE OR WEIGHT
Use the TREAT THE YOUNG INFANT pages of the chart book to determine the appropriate
drug and dosage to give the young infant.
TELL THE MOTHER THE REASON FOR GIVING THE DRUG TO THE CHILD,
INCLUDING:
Why you are giving the oral drug to her child, and
What problem it is treating?
DEMONSTRATE HOW TO MEASURE A DOSE.

Collect a container of the drug and check its expiry date. Do not use expired drugs. Count out
the amount needed for the child. Close the container.
If you are giving the mother tablets:
Show the mother the amount to give per dose. If needed, show her how to divide a tablet. If a
tablet has to be crushed before it is given to an infant, add a few drops of clean water and
wait a minute or so. The water will soften the tablet and make it easier to crush.
If you are giving the mother syrup:
Show the mother how to measure the correct number of millilitre (ml) for one dose at home.
Use the bottle cap or a common spoon, such as a spoon used to stir sugar into tea or coffee.
Show her how to measure the correct dose with the spoon.
One teaspoon (tsp.) equals approximately 5.0 ml (see below).
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MILLILITRES (ml)
TEASPOONS (tsp.)
1.25 ml
1/4 tsp.
2.5 ml
tsp.
5.0 ml
1 tsp.
7.5 ml
1 tsp.
10.0 ml
2 tsp.
15 ml
3 tsp.
Adjust the above amounts based on the common spoons in your area.
WATCH THE MOTHER PRACTICE MEASURING A DOSE BY HERSELF
Ask the mother to measure a dose by herself. If the dose is in tablet form and the infant
cannot swallow a tablet, tell the mother to crush the tablet. Watch her as she practices. Tell
her what she has done correctly. If she measured the dose incorrectly, show her again how to
measure it.
ASK THE MOTHER TO GIVE THE FIRST DOSE TO HER INFANT
Explain that if an infant is vomiting, give the drug even though the infant may vomit it up.
Tell the mother to watch the infant for 30 minutes. If the infant vomits within the 30 minutes
(the tablet or syrup may be seen in the vomit), give another dose. If the infant is dehydrated
and vomiting, wait until the child is rehydrated before giving the dose again.
EXPLAIN CAREFULLY HOW TO GIVE THE DRUG, THEN LABEL AND
PACKAGE THE DRUG
Tell the mother how much of the drug to give her infant . Tell her how many times per day to
give the dose. Tell her when to give it (such as early morning, lunch, dinner, before going to
bed) and for how many days.
Follow the steps below:
a. Write the full name of the drug and the total amount of tablets, capsules or syrup to
complete the course of treatment.
b. Write the correct dose for the patient to take (number of tablets, capsules, squirts or
spoonfuls, that is, , 1, 1 ). Write when to give the dose (early morning, lunch,
dinner, before going to bed).
c. Write the daily dose and schedule, such as tablet twice daily for 5 days
Write the instructions clearly so that a literate person is able to read and understand them. Put
the total amount of each drug into its own labelled drug container (an envelope, paper, tube
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HAND BOOK ON IMNCI
or bottle). Keep drugs clean. Use clean containers. After you have labelled and packaged the
drug, give it to the mother. Ask checking questions to make sure she understands how to
treat her infant.
IF MORE THAN ONE DRUG WILL BE GIVEN, COLLECT, COUNT AND
PACKAGE EACH DRUG
Collect one drug at a time. Write the instructions on the label. Count out the amount needed.
Put enough of the drug into its own, labelled, package. Finish packaging the drug before you
open another drug container.
Explain to the mother that her child is getting more than one drug because he had more than
one illness. Show the mother the different drugs. Explain how to give each drug. If
necessary, draw a summary of the drugs and times to give each drug during the day.
EXPLAIN THAT ALL THE ORAL DRUG TABLETS OR SYRUPS MUST BE USED
TO FINISH THE COURSE OF TREATMENT, EVEN IF THE INFANT GETS
BETTER
Explain to the mother that if the infant seems better, she should continue to treat the infant.
This is important because the bacteria may still be present even though the signs of disease
are gone.
Advise the mother to keep all medicines out of the reach of children. Also tell her to store
drugs in a dry and dark place that is free of mice and insects.
CHECK THE MOTHERs UNDERSTANDING BEFORE SHE LEAVES THE
CLINIC.
Ask the mother checking questions, such as:
How much will you give each time?
When will you give it? For how many days?
How will you prepare this tablet?
Which drug will you give 3 times per day?
If you feel that the mother is likely to have problems when she gives her infant the drug(s) at
home, offer more information, examples and practice. A child needs to be treated correctly to
get better.
In some clinics, a drug dispenser has the task of teaching the mother to give treatment and
checking the mothers understanding. If this is your situation, teach the skills you are
learning in this section to that dispenser.
ORAL DRUGS
Oral antibiotics. The IMNCI chart shows how many days and how many times each day to
give the antibiotic. Most antibiotics should be given for five days. Only for cholera and
dysentery cases antibiotics are given for three days. The number of times to give the
antibiotic each day varies (two, three or four times per day). Determine the correct dose of
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HAND BOOK ON IMNCI
antibiotic based on the childs weight. If the childs weight is not available, use the childs
age. Always check if the same antibiotic can be used for treatment of different classifications
a child may have. For example, the same antibiotic could be used to treat both pneumonia
and acute ear infection.
Oral antimalarials. Oral antimalarials vary from country to country. Chloroquine is given
for three days .In Bhutan for high risk area ACT is recommended in P. Faciparum confirmed
malaria.
Paracetamol. If a child has a high fever, give one dose of paracetamol in the clinic. If the
child has ear pain, give the mother enough paracetamol for one day, that is, four doses. Tell
her to give one dose every six hours or until the ear pain is gone.
Iron. A child with anaemia needs iron. Give syrup to the child under 12 months of age. If the
child is 12 months or older, give iron tablets. Give the mother enough iron for 14 days. Tell
her to give her child one dose daily for those 14 days. Ask her to return for more iron in 14
days. Also tell her that the iron may make the child's stools black.
Antihelminth drug. An anaemic child who is 1 years of age or older need albendazole if not
given in last six months.
Vitamin A. Vitamin A is given to a child with measles or severe malnutrition. Vitamin A
helps to prevent Xeropthalmia and shedding of epithelial cells that line the lung, gut, mouth
and throat. It may also help the immune system to prevent other infections. Vitamin A is
available in capsule. Use the child's age to determine the dose, and give two doses. Give the
first dose to the child in the clinic. Give the second dose to the mother to give her child on
the next day at home. Each dose of Vitamin A should be recorded because of danger of an
overdose.
Safe remedy for cough and cold. Breast milk alone is a good soothing remedy.
There is no evidence that commercial cough and cold remedies are effective. Simple home
remedies (honey, lemon tea, tulsi leaves) are enough in relieving cough or soothing sore
throat. Suppression of cough is not desirable because cough is a physiological reflex to
eliminate lower respiratory tract secretion.
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Also follow the instructions
listed with each drugs dosage table.
Determine the appropriate drugs and dosage for the childs age or weight.
Tell the mother the reason for giving the drug to the child.
Demonstrate how to measure a dose.
Watch the mother practice measuring a dose by herself.
Ask the mother to give the first dose to her child.
Explain carefully how to give the drug, label and pack the drug.
If more than one drug will be given, collect, count and package each drug separately.
Explain that all the oral tablet or syrup must be used to finish the course of treatment, even if the
child gets better.
Check the mothers understanding before she leaves the clinic.
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HAND BOOK ON IMNCI
Give an appropriate oral antibiotic
FOR PNEUMONIA: ACUTE EAR INFECTION

FIRST LINE ANTIBIOTIC: AMOXICILLIN
SECOND LINE ANTIBIOTIC: COTRIMOXAZOLE
AMOXICILLIN
Give to times daily for 5 days
AGE or WEIGHT
Tablet
250 mg
Syrup
125mg per 5 ml
COTRIMOXAZOLE
(trimethoprim + sulphamethoxazole)
Give two times daily for 5 days
Tablet
Syrup
80 mg trimethoprim 40 mg trimethoprim
+ 400 mg
+200 mg
sulphamethoxazole
sulphamethoxazole
per 5 ml
2 months up to 12
months (4 - <10 kg)
10 ml1
5 ml
12 months up to 5
years (10 - 19 kg)
15 ml
10 ml
FOR DYSENTRY:
FIRST LINE ANTIBIOTIC FOR SHIGELLA: COTRIMOXAZOLE
SECOND LINE ANTIBIOTIC FOR SHIGELLA: CIPROFLOXACIN
COTRIMOXAZOLE
AGE OR WEIGHT
(trimethoprim + sulphamethoxazole)
Give two times daily for 5 days
2 months up to 12 months
(4 - < 10 kg)
SEE DOSE ABOVE
12 months up to 5 years
(10 - 19 kg)
AGE
CIPROFLOXCIN
15mg/kg/day 2 times a day for 3 day

250 MG/TABLET
500 MG/TABET
LESS THAN 6 MONTHS
6 MONTHS UP TO 5
YEARS
CHOLERA: DOXYCYCLINE
AGE OR WEIGHT
Doxycycline: Tablet 100 mg

5mg/kg once a day
2 months up to 12 months (6- < 10 kg)
12 months up to 5 years (10- 19 kg)
1
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HAND BOOK ON IMNCI
Give IRON once daily for 14 days

Iron Syrup
Ferrousfumarate
100mg per 5 ml
20mg elemental
iron per 1ml
2 months up to 4 months 1 ml (<1/4 tsp)
(4 - <6 kg)
4 months up to 12 months 1.25 ml (1/4 tsp)
(6 - <10 kg)
12 months to 3 years(10 - 2 ml (> 1/2 tsp)
<14 kg)
3 years up to 5 years (14 - 2.5 ml (1/2 tsp)
19 kg)
AGE or WEIGHT
IRON/FOLATE
TABLET
Ferrous sulfate 200 mg +
250 mcg Folate
(60 mg elemental iron)
1/2
Give ALBENDAZOLE
Give 400mg Albendazole as a single
dose in clinic if:
The child is 15 months of age
or older, and
If child has not had a dose in
the previous 6 months
1/2
1/2
1
TREATMENT OF LOCAL INFECTIONS
If the child, age 2 months up to 5 years, has a

local infection, the mother or caregiver should be
taught how to treat the infection at home.
Instructions may be given about how to:
Treat eye infection with chloramphnicol eye
ointment;
Dry the ear by wicking to treat ear infection;
Treat mouth ulcers with gentian violet;
Soothe the throat and relieve the cough with a
safe remedy.
Eye Treatment for Children Being Referred

If the child will be referred, and the child needs
treatment with chloromycetin eye ointment,
clean the eye gently. Pull down the lower lid.
Squirt the first dose of tetracycline eye
ointment onto the lower eyelid.
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box.
Watch the mother as she does the first treatment in the clinic (except remedy for cough or sore throat).
Tell her how often to do the treatment at home.
If need for treatment at home, give mother the tube of chloramphenical ointment or a small bottle of
gentian violet.
Check the mothers understanding before she leaves the clinic.
Treat Eye Infection with Chloramphenicol Eye Ointment
Clean both eyes 3 times daily
Wash hands
Ask child to close the eye
Use clean cloth and eater to gently wipe away pus.
Then apply chloramphenical eye ointment in both eye e time daily
o Ask the child to look up
o Squirt a small amount of ointment on the inside of the lower lid
o Wash hands again
Treat until redness is gone
Do not use other eye ointments or drops, or put anything else in the eye
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HAND BOOK ON IMNCI
Dry the ear by wicking at least 3 times daily

Give tropical quinolone ear drop three times a day for 14 days
Roll clean absorbent cloth or soft, strong tissue paper into a wick
Place the wick in the childs ear
Remove the wick when wet.
Treat Mouth Ulcers with Gentain Violet twice daily
Wash hands
Wash the childs mouth with wet clean soft cloth wrapped around the finger
Paint the mouth with half-strength gentian violet
Wash hands again.
Soothe the Throat, Relieve the Cough with a Safe Remedy

Safe remedies to recommend:
o Breast milk for exclusively breastfed infant
o Warm tea with sugar or honey
o Warm ginger tea
Harmful remedies to discourage:
o Syrup containing codeine, sedatives or anti-histamine
Chart 3. TREATMENT IN THE OUTPATIENT HEALTH FACILITY OF THE SICK

CHILD FROM AGE 2 MONTHS UP TO 5 YEARS
Classification
TREATMENT
PNEUMONIA
a) Give appropriate antibiotic for five days.

The choice of antibiotic is based on the fact that most childhood
pneumonia of bacterial origin is due to Streptococcus pneumonia or
Haemophilus influenzae. Non-severe cases of Pneumonia can be treated
with either oral cotrimoxazole or amoxicillin for 5 days. These two oral
antibiotics are usually effective against these two bacteria, both are
relatively inexpensive, widely available, and are on the essential drug list
of most countries.
b) Soothe the throat and relieve the cough with a safe remedy
c) Advise mother when to return immediately
d)Follow-up in 2 days
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HAND BOOK ON IMNCI
NO PNEUMONIA
COUGH
OR
COLD
a) Soothe the throat and relieve the cough with a safe remedy.
c) Advise mother when to return immediately
d) Follow-up in 5 days
SOME
DEHYDRATION
WHO Treatment Plan B

Give initial treatment with ORS over a period of four hours. The
approximate amount of ORS required is 75ml/kg; during these four hours,
the mother slowly gives the recommended amount of ORS by spoonfuls
or sips.
Note: i) If the child is breast-fed, breast-feeding should continue.
Children under 6 months who, are not breastfed- should be given 100-200
ml plain water during this period to prevent hypernatraemia.
ii) If the child vomits, wait for 10 minutes and then give more slowly.
iii) If the child wants more give more ORS solution.
After four hours, the child is reassessed and reclassified for dehydration,
and feeding should begin. When there are no signs of dehydration, the
child is put on Plan A. If there is still some dehydration, Plan B should be
repeated. If the child now has severe dehydration, the child should be put
on Plan C.
NO
DEHYDRATION
WHO Treatment Plan A

Plan A focuses on the three rules of home treatment: give extra fluids,
continue feeding, and advice the caregiver when to return (if there is
blood in the stool, the child drinks poorly, becomes sicker, or is not
getting better in two days).
Fluids should be given as soon as diarrhoea starts; the child should take as
much as s/he wants. Correct home therapy can prevent dehydration in
many cases. ORS may be used at home to prevent dehydration. However,
other fluids that are commonly available in the home may be less costly,
more convenient and effective especially when given with food e.g.
Cooked rice water.
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HAND BOOK ON IMNCI
Note : Fluids which should be avoided

Very sweet tea, soft drinks, and sweetened fruit drinks should be avoided.
They can cause osmotic diarrhoea and hypenatremia. Fluids with
purgative action and stimulants (e.g., coffee, some medicinal teas or
infusions)
also
to
be
avoided.
Feeding - Encourage mother to continue breast-feeding and family food
according to age. Recommended home fluid should be:
Easy to prepare. The recipe should be familiar and its preparation should
not require much effort or time. The required ingredients and measuring
utensils should be readily available and inexpensive.
Acceptable. The fluid should be one that are culturally acceptable and the
mother is willing to give freely to a child with diarrhoea and that the child
will readily accept.
Effective. Fluids that are safe are also effective. Most effective fluids are
those containing carbohydrates, protein and some salt. However, nearly
the same result is obtained when fluids are given freely along with
weaning foods that contain salt.
PERSISTENT
Encourage the mother to continue breastfeeding. If the child is artificially
DIARRHOEA
fed with animal milk, limit it to of the previous amount, what the child
was taking, greater amount may aggravate the diarrhoea.
Other foods according to age should be given in frequent, small meals, at
least six times a day. All children with persistent diarrhoea should receive
supplementary multivitamins and minerals (iron, magnesium, zinc) each
day for two weeks.
Diarrhoea is a serious and often fatal event in children with severe
malnutrition. For management of dehydration in severely malnourished
children. (i) Full-strength ORS solution should not be used for oral or
NG rehydration. It provides too much sodium and too little potassium. A
suitable oral solution can be prepared by:
Give Re-SoMal, Dissolving a ORS (containing 75 mEq/l of Sodium)
packet into 2 litres of clean water
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HAND BOOK ON IMNCI
Adding 45 ml of potassium chloride solution (from stock solution

containing 100g KCL/l) and
Adding 50g sucrose
This modified solution provide less sodium (37.5 mmol/) more potassium
(40 mmol/l) and added sugar (25 g/l), which is appropriate for severely
malnourished children with diarrhoea.
DYSENTERY
The four key elements of dysentery treatment are:

Antibiotics
Fluids
Feeding
Follow-up: Selection of an antibiotic is based on sensitivity patterns of
strains of Shigella isolated in the area (Cotrimoxazole is the drug of
choice; ciprofloxacin is the drug of 2nd choice). Recommended duration
of treatment is five days. If after two days (during follow-up) there is no
improvement, the antibiotic should be stopped and a second line of drug
should be used.
Give an oral antimalarial drug.
Give one dose of paracetamol for high fever (101.3F or above).
MALARIA
FEVER
Give one dose of paracetamol for high fever (101.3F or above).

Treat other obvious causes of fever.
MALARIA
UNLIKELY
WITH
Give first dose of Vitamin A. If clouding of cornea or pus draining from
EYE OR MOUTH
the eye is present, apply cloramphenicol eye ointment. If mouth ulcers,

treat with gentian violet (see chart booklet page-9).
MEASLES
COMPLICATION
S
MEASLES
Give first dose of Vitamin A.
(CURRENTLY
OR WITHIN THE
LAST 3
MONTHS)
ACUTE EAR
INFECTION
Give appropriate antibiotic for five days.

Give one dose of paracetamol for pain.
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HAND BOOK ON IMNCI
CHRONIC
EAR
IINFECTION
WEIGHT
Assess the childs feeding and counsel the mother accordingly on feeding.
If pallor is present: give iron; give oral antimalarial if high malaria risk.
Give Albendazole if the child is 15 months or older and has not had a
dose in the previous six months (see chart booklet page-8).
NO ANAEMIA
If the child is less than 2 years old, assess the childs feeding and counsel
AND NOT VERY
the mother accordingly on feeding.
ANAEMIA
OR
VERY LOW
LOW WEIGHT
COUNSELLING A MOTHER OR CAREGIVER
A child who is seen at the clinic needs to continue treatment, feeding and fluids at home. The
child's mother or caregiver also needs to recognize when the child is not improving, or is
becoming sicker. The success of home treatment depends on how well the mother or
caregiver knows how to give treatment, understands its importance and knows when to
return to a health care provider.
The steps to good communication were listed earlier. Some advice is simple; other advice
requires teaching the mother or caregiver how to do a task. When you teach a mother how
to treat a child, use three basic teaching steps: give information; show an example; let her
practice.
During teaching the mother or caregiver: (1) use words that s/he understands; (2) Use
Mothers card; (3) give feedback when s/he practices, praise what was done well and make
corrections; (4) allow more practice, if needed; and (5) encourage the mother or caregiver to
ask questions and then answer all questions. Finally, it is important to check the mothers or
caregiver's understanding by good checking questions.
The content of the actual advice will depend on the childs condition and classifications.
Below are essential elements that should be considered when counselling a mother or care
taker:
Advise to continue feeding and increase fluids during illness;

Teach how to give oral drugs or to treat local infection;
Counsel to solve feeding problems (if any);
Advise when to return.
Advice to continue feeding and increase fluids: The IMCI guidelines (See Mothers card in
the chart booklet) give feeding recommendations for different age groups. These feeding
recommendations are appropriate both when the child is sick and when the child is healthy.
During illness, childrens appetite and thirst may be decreased. However, mother and
caregiver should be counselled to increase fluids and to offer the types of food recommended
for the child's age, as often as recommended, even though a child may take small amount at
each feeding. After each episode of illness, good feeding helps make up for weight loss and
helps prevent malnutrition. When the child is well, good feeding helps prevent future illness.
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HAND BOOK ON IMNCI
Teach how to give oral drugs or to treat local infection at home: Simple steps should be
followed when teaching a mother or caregiver how to give oral drugs or treat local
infections. These steps include: (1) determine the appropriate drugs and dosage for the child's
age or weight; (2) tell the mother or caregiver what the treatment is and why it should be
given; (3) demonstrate how to measure a dose; (4) describe the treatment steps; (5) watch the
mother or caregiver practise measuring a dose; (6) ask the mother or caregiver to give the
dose to the child; (7) explain carefully how, and how often, to do the treatment at home; (8)
explain that All oral drug (tablets or syrups) must be used to finish the course of treatment,
even if the child gets better; (9) check the mother's or caregiver's understanding.
Counsel to solve feeding problems (if any): Based on the type of problems identified, it is
important to give correct advice about the nutrition of the young child both during and after
illness. Give proper advice that promotes breastfeeding, improved weaning practices with
locally appropriate energy- and nutrient-rich foods. Specific and appropriate complementary
foods should be recommended and the frequency of feeding by age should be explained
clearly. Encourage exclusive breastfeeding for the first six months. Discourage use of
feeding bottles for children of any age; and provide guidance on how to solve problems with
breastfeeding. The latter includes assessing the adequacy of attachment and suckling.
Specific feeding recommendations should be provided for children with persistent diarrhoea.
Feeding counselling relevant to identify feeding problems is described in the Mothers card.
Advice when to return: During counselling every mother or caregiver needs to be advised
about when to return to a health facility.
The health care provider should:
a. teach signs that mean to return immediately for further care;
b. advise when to return for a follow-up visit; and
c. determine the schedule of the next well-child or immunization visit. The table below
lists the specific times to advise a mother or caregiver to return to a health facility.
d.
A) IMMEDIATELY
Advise to return immediately if the child has any of these signs.
Any sick child
Not able to drink or breastfeed
Becomes sicker
Develops a fever
If child has no PNEUMONIA: COUGH OR Fast breathing
COLD, also return if:
Difficult breathing
If child has diarrhoea, also return if:
Blood in stool
Drinking poorly
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HAND BOOK ON IMNCI
B) FOR FOLLOW-UP VISIT

If the child has:
PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVER MALARIA UNLIKELY if fever
MEASLES
WITH
EYE
OR
COMPLICATIONS
MEASLES, IF MEASLES NOW
PERSISTENT DIARRHOEA
ACUTE EAR INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not
Return for follow-up not later than:
persists
MOUTH
2 days
5 days
improving
ANAEMIA
VERY LOW WEIGHT FOR AGE
14 days
30 days
C) NEXT WELL-CHILD VISIT

Advice mother when to return for the next immunization according to the schedule.
FOLLOW-UP CARE
Some sick children will need to return for follow-up care. At a follow-up visit, see if the
child is improving on the drug or other treatment that was prescribed. Some children may not
respond to a particular antibiotic or antimalarial, and may need to try a second-line drug.
Children with persistent diarrhoea also need follow-up to be sure that the diarrhoea has
stopped. Children with fever or eye infection need to be seen if they are not improving.
Follow-up is especially important for children with a feeding problem to ensure they are
being fed adequately and are gaining weight.
When a child comes for follow-up of an illness, ask the mother or caregiver if the child has
developed any new problems. If she answers yes, the child requires a full assessment: check
for general danger signs and assess all the main symptoms and the child's nutritional status.
If the child does not have a new problem, use the IMNCI follow-up instructions for each
specific problem:
Assess the child according to the instructions;
Use the information about the child's signs to select the appropriate treatment;
Give the treatment.
Note: If a child who comes for follow-up has several problems and is getting worse, or
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HAND BOOK ON IMNCI
returns repeatedly with chronic problems that do not respond to treatment, the child should
be referred to a hospital.
The IMNCI charts contain detailed instructions on how to conduct follow-up visits for
different diseases. Follow-up visits are recommended for sick children classified as having:
Pneumonia
Persistent diarrhoea Dysentery
Malaria (High or Low Malaria Risk)
Fever Malaria Unlikely, if fever persists
Fever-no malaria (No Malaria Risk)
Measles with eye or mouth complications
Acute ear infection
Chronic ear infection
Feeding problem
Pallor
Very low weight for age
Any other illness, if not improving
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HAND BOOK ON IMNCI
CHAPTER 3
3
3.1
OUTPATIENT MANAGEMENT OF SICK YOUNG INFANTS UP TO 2

MONTHS
LEARNING OBJECTIVES
This Section of the handbook will describe the following tasks and allow the students to
practice some of them (some will be practiced in the clinic):
Assessing and classifying an young infant for very severe disease and local bacterial
infection
Assessing and classifying an young infant for jaundice
Assessing and classifying an young infant with diarrhoea
Checking for a feeding problem or malnutrition, assessing breastfeeding and classifying

feeding, immunization
3.2
ASSESSMENT OF SICK YOUNG INFANTS
While there are similarities in the management of sick young infants (age up to 2 months)
and children (age 2 months up to 5 years), some clinical signs observed in young infants
differ from those in older children. Young infants have special characteristics that must be
considered when classifying their illnesses. They can become sick and die very quickly from
severe diseases. They frequently have only general danger signs like, less movements, fever
or low body temperature, poor feeding. Mild chest in drawing is normal in young infants
because their chest wall is soft. For these reasons, assessment, classification and treatment of
the sick young infants are different from an older infant or young child.
The assessment procedure for this age group, as for the older children, also includes a
number of important steps that must be taken by the health care provider, these includes:
History taking and communicating with the caregiver about the young infants problem
Checking for very severe diseases and local bacterial infection
Checking for jaundice
Assessing if the young infant has diarrhoea
Checking for feeding problems or low weight
Assess breastfeeding
Checking the young infants immunization status
Assessing other problems.
The importance of good communication with the mother or caregiver of a young child has
already been discussed under 2.2.1. Good communication techniques and an integrated
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HAND BOOK ON IMNCI
assessment are required to ensure that common problems or signs of disease or malnutrition
are not overlooked. Proper communication helps to reassure the mother or caregiver that the
infant will receive appropriate care. In addition, the success of home treatment depends on
how well the mother or caregiver knows about giving the treatment and understands its
importance. The steps of good communication have also been discussed under 2.2.1
The remainder of this chapter covers
instances where the management of young
infants differs from that of the small child.
For example, it is essential to pay attention
to the following clinical signs as an
infants illness can progress rapidly to
death.
While the signs of pneumonia and other
serious bacterial infections cannot be
easily distinguished in this age group, it is
recommended that all sick young infants
should be assessed first for signs of very
severe disease.
History taking
Checking for:
Very severe disease or local bacterial infection
Jaundice
Diarrhoea
Feeding problems or Low weight
Immunizations status
Other problems
The sick young infants should be assessed using the Young Infant Recording Form:
The information needs to be recorded on Young Infant Recording Form.
The top lines on the form are for recording name, age, weight, temperature, the infants
problems and whether this is an initial or follow up visit.
Part of a Sick Young Infant Recording Form is given below.
EXAMPLE: Sonam is 6 weeks old. He weighs 4.5 kg. His temperature is 98.60F. The health
worker asked What are the infants problems? The mother said Sonam has diarrhoea and
a skin rash for the last 3 days. This is the initial visit for this illness.
MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS

Name: Sonam Age: 6 weeks Weight: 4.5 kg Temperature: 98.60 F
Ask: What are the infants problems? Diarrhoea and rash. Initial visit Follow-up visit __
CLINICAL ASSESSMENT
Many clinical signs point to very severe disease in sick young infants. The most informative
and easy to check signs are:
Convulsion (as part of the current illness). All children who have had convulsions during the
present illness should be considered seriously ill.
Not feeding well. Ask the mother this question. Any difficulty mentioned by the mother is
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HAND BOOK ON IMNCI
important. A newborn who has not been able to feed since birth may be premature or may
have complications such as birth asphyxia. A young infant who was feeding well earlier but
is not feeding well now may have a serious infection. These infants who are either not able
to feed or are not feeding well should be referred urgently to hospital. The mother may also
mention difficulties like: her infant feeds too frequently, or not frequently enough; she does
not have enough milk; her nipples are sore; or she has flat or inverted nipples. You will assess
these difficulties later during breastfeeding assessment.
This is the most important and earliest sign of infection in young infants.
Fast breathing. Young infants usually breathe faster than older children do. The breathing
rate of a healthy young infant is commonly more than 50 breaths per minute. Therefore, 60
breaths per minute is the cut-off rate to identify fast breathing in this age group. If the count
is 60 breaths or more, the count should be repeated, because the breathing rate of a young
infant is often irregular. The young infant will occasionally stop breathing for a few seconds,
followed by a period of faster breathing. If the second count is also 60 breaths or more, the
young infant has fast breathing.
Severe chest indrawing. Mild chest in drawing is normal in a young infant because of
softness of the chest wall. Severe chest in drawing is very deep and easy to see. It is a sign of
pneumonia or other serious bacterial infection in a young infant.
Grunting (when an infant breathes out) is an indication of troubled breathing and possible
pneumonia.
Temperature (fever or hypothermia) may equally indicate bacterial infection. Fever
(axillary temperature more than 98 F) is uncommon in the first two months of life. Fever in
a young infant may indicate a serious bacterial infection, and may be the only sign of a
serious bacterial infection. Young infants can also respond to infection by dropping their
body temperature (Hypothermia) to below 97.4F.
Movement only when stimulated or No movement at all also indicate a serious
condition.
Young infants often sleep most of the time, and this is not a sign of illness. If a young infant
does not wake up during the assessment, ask the mother to wake him. An awake young
infant will normally move his arms or legs or turn his head several times in a minute if you
watch him closely.
Observe the infant's movements while you do the assessment.
If the infant is awake but has no spontaneous movements, gently stimulate the young infant.
If the infant moves only when stimulated and then stops moving, or does not move even
when stimulated, it is a sign of severe disease.
Redness of the umbilicus or draining pus are signs of umbilical infection. Early
recognition and treatment of an infected umbilicus are essential to prevent sepsis.
Skin pustules Examine the skin on the entire body. Skin pustules are red spots or blisters
which contain pus.
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HAND BOOK ON IMNCI
3.2.1 CLASSIFICATION OF VERY SEVERE DISEASE

A sick young infant with VERY SEVERE DISESE is one who has any of the following
signs:
Not feeding well or
Convulsions or
Fast breathing (60 breaths
per minute or more) or
Severe chest indrawing or
Give first dose of intramuscular

antibiotics.
Treat the young infant to prevent

low blood sugar.
Advise mother how to keep the

infant warm on the way to the
hospital.
Grunting or
Fever (37.5C* or above or
feels hot) or low body
temperature (less than
35.5C* or feels cold) or
VERY SEVERE
DISEASE
Severe skin pustule or

umbilical redness extending
upto skin
Movement
only
Not
feeding well,
fast when
breathing, severe chest indrawing, grunting, convulsions, fever,
stimulated severe
or skin pustules,
No
hypothermia,
movement only when stimulated or no movement at all.
movement
at
all
This infant should be referred urgently to the hospital after being given intramuscular
Ampicillin plus Gentamicin, treatment to prevent hypoglycaemia, and advice to the mother
on keeping the young infant warm. With this classification a young infant may have
meningitis, pneumonia, sepsis or hypothermia.
A sick young infant with LOCAL BACTERIAL INFECTION is one who has red umbilicus or
umbilicus draining pus or some skin pustules . This infant may be treated at home with oral
antibiotics but should be seen in follow-up in two days.
Umbilicus
red
draining pus or
Skin pustules
or
LOCAL BACTERIAL
INFECTION
Give an
antibiotic.
Teach mother to treat local skin

infection at home.
Advice mother to give home

care to the young infant.
Follow up in 2 days
appropriate
oral
A Young infants with the classification SEVERE DISEASE OR LOCAL

INFECTION UNLIKELY has none of the signs of very severe disease and local
bacterial infection. Advise the mother to give homecare to the young infant.
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None of the signs of very
SEVERE DISEASE
sever disease or local bacterial

infection
OR LOCAL
Advise mother to give

home care for the young
infant.
INFECTION
UNLIKELY
3.2.2 CHECK FOR JAUNDICE.

There are three possible classifications for jaundice.
A sick young infant with SEVERE JAUNDICE is one who has yellow palms and soles
or has jaundice at age < 24 hours or at age 14 days or more. This infant should be
referred urgently to the hospital after being given treatment to prevent hypoglycemia and
advice to the mother on keeping the young infant warm while arranging referral.
Any jaundice if age less
Treat the young infant to prevent low blood

sugar.
Advise mother how to keep the infant warm on

the way to the hospital.
than 24 hours or
Yellow palms and soles
at any age
SEVERE
JAUNDICE
A sick young infant with JAUNDICE is one who has jaundice which appeared after 24
hours of age and the palms and soles are not yellow. This infant should be given home
care, but mother should be advised when to return immediately and should be seen in
follow-up in two days.
Jaundice appearing
after 24 hours of age
and
Palms and soles not

yellow
JAUNDICE
Advise the mother to give home care for the

young infant.
Advice mother to return immediately if palms

and soles appear yellow.
If the young infant is older than 3 weeks, refer to

a hospital for assessment.
Follow-up in 1 day.
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A young infant with the classification NO JAUNDICE has none of the signs of
severe jaundice and Jaundice. Advise the mother to give homecare to the young
infant..
No jaundice
NO JAUNDICE
Advise the mother to give home care

for the young infant.
EXAMPLE OF THE TOP SECTION OF THE YOUNG INFANT CASE

RECORDING FORM
CASE:
Sonam is 6 weeks old. He weighs 4.5 kg. His temperature is 98.60 F. The health worker
asked What are the infants problems? The mother said Sonam has diarrhoea and a skin
rash for the last 3 days. This is the initial visit for this illness.
The health worker checks the young infant for signs of severe infection /jaundice. His mother
says that Sonam did not have convulsions. The health worker counts 55 breaths per minute.
He finds no chest indrawing. Sonam has no grunting. The umbilicus is normal. There are
skin pustules. Sonam is not lethargic or unconscious, and his movements are normal. He
does not have jaundice.
Name: Sonam Age: 6 weeks Weight: 4.5 kg Temperature: 98.60 F
Ask: What are the infants problems ? Diarrhoea and rash Initial visit Follow-up visit__
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CLASSIFY
CHECK FOR VERY SEVERE DISEASE/JAUNDIC

Has
the
convulsions?
infant
had
Yes _____ No ____

Is the infant feeding well?
Yes ____ No ___
Count the breaths in one minute 55

breaths per minute. Repeat if
elevated ________Fast breathing?
Look and listen for grunting.
Look for severe chest in-drawing.
Fever (temperature 37.50C or
above)
Low body temperature (less than
35.50C)
Local Bacterial
Look for severe skin pustules
Red umbilicus/draining pus from it Infection
Redness extending up to the skin
Look at young infants movements
Does the infant move only when
only stimulated?
Does the infant not move at all?
Does the infant move only when
stimulated
3.2.3 DIARRHOEA
All sick young infants should be checked for diarrhoea.
CLINICAL ASSESSMENT AND CLASSIFICATION OF DIARRHOEA
Assessment, classification and management of diarrhoea in sick young infants are similar to
those in older children. However, assessing thirst by offering a drink is not reliable.
Note that there is no classification for persistent diarrhoea and dysentery in young infant.
This is because any young infant who has persistent diarrhoea should be referred.
Young infants with blood in the stool are usually severely ill and are referred urgently to the
hospital. Dysentery is uncommon in young infants, so blood in the stool may be not due to a
shigella infection. In this age group, blood in the stool is just as likely to be caused by a
problem which may require surgery, so urgent referral is needed.
CASE: Sonam is 6 weeks old. He weighs 4.5 kg. His temperature is 98.6 0 F. The health
worker health worker asked What are the infants problems? The mother said Sonam has
diarrhoea and a skin rash for the last 3 days. This is the initial visit for this illness.
The health worker health worker checks the young infants for signs of very severe
disease/local bacterial infection. His mother says that Sonam has not had convulsions. The
health worker health worker counts 55 breaths per minute. He finds no chest indrawing.
Sonam has no grunting. The umbilicus is normal. The body temperature is normal. There are
skin pustules. Sonam is not lethargic or unconscious, and his movements are normal. He
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does not have jaundice.

When the health worker health worker asks the mother about Sonams diarrhoea, the mother
replies that it began 3 days ago. Sonam is crying. He stopped once when his mother put him
to the breast. He began crying again when she stopped breastfeeding. His eyes look normal,
not sunken. When the skin of his abdomen is pinches, it goes back slowly, and the skin looks
normal.
EXAMPLE OF THE TOP THREE SECTIONS OF THE YOUNG INFANT CASE
RECORDING FORM
Name: Sonam Age: 6 weeks
Weight: 4.5 kg Temperature 98.60F
Date:17/7/2011
ASK: What are the infants problems? Diarrhoea and rash Initial visit? Follow-up visit?
______
CLASSIFY

* Has the infant had
convulsion?
* Is the infant having
difficulty feeding?
THEN CHECK FOR

JAUNDICE
If
jaundice
is
present, when did
jaundice
first
appear?
DOES
YOUNG
THE
INFANT
HAVE
DIARRHOEA?
Count the breaths in one minute 55 breaths

per minute. Repeat if elevated ________Fast
breathing?
Fever (temperature 37.50C or above)
Low body temperature (less than 35.50C)
Red umbilicus/draining pus from it
Does the infant move only when only
Local Bacterial
stimulated?
Infection
Yes ______ No __ ___
Look for jaundice (yellow eyes or skin)
Look at the young infants palms and soles.
Are they yellow? Yes _ __ No ___
Look at the young infants general condition.
Does the infant move only when stimulated?
Is the infant restless or irritable?
Some Dehydration
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* For how long?

_3___ Days
Is there blood in the

stool?
Look for sunken eyes

Pinch the skin of the abdomen. Does it goes
back slowly (longer than 2 seconds)?
Slowly
Yes ___ No ____
3.2.4 FEEDING PROBLEMS OR LOW WEIGHT

All sick young infants seen in outpatient health facilities should be assessed for weight and
adequate feeding, as well as for breast-feeding technique.
CLINICAL ASSESSMENT
Assessment of feeding. Assessment of feeding in young infants has two parts. In the first part
you ask the mother questions to determine if she is having difficulty feeding the infant, what
the young infant is fed and how often or being given other foods or drinks, or low weight for
age. You also determine weight for age.
In the second part, breastfeeding should be assessed. Assessment of breastfeeding in young
infants includes checking if the infant is able to attach, if the infant is suckling effectively
(slow, deep sucks, with some pausing), and if there are ulcers or white patches in the mouth
(thrush).
Part 1
Is there any feeding difficulty? Any difficulty mentioned by the mother is important. This
mother may need counselling or specific help with a difficulty. If a mother says that the
infant is not able to feed, assess breastfeeding or watch her try to feed the infant with a cup to
see what she means by this. An infant who is not able to feed may have a serious infection or
other life-threatening problem and should be referred urgently to hospital.
Is the infant breastfed? If yes, how many times in 24 hours? The recommendation is that
the young infant be breastfed as often and for as long as the infant wants, day and night. This
should be 8 or more times in 24 hours.
Does the infant usually receive any other foods or drinks? If yes, how often? A young
infant should be exclusively breastfed. Find out if the young infant is receiving any other
foods or drinks such as other milk, juice, tea, thin porridge, dilute cereal, or even water. Ask
how often he receives it and the amount. You need to know if the infant is mostly fed on
other foods.
What do you use to feed the infant? If an infant takes other foods or drinks, find out if the
mother uses a feeding bottle or cup.
Determine weight for age. Weight for age compares the young infant's weight with the
infants of the same age in the reference population (WHO-NCHS reference). The VERY
LOW WEIGHT FOR AGE LINE identifies children whose weight is 3 standard deviations
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below the mean weight of infants in the reference population (Z score <-3). The LOW
WEIGHT FOR AGE LINE identifies children whose weight is 2 standard deviations below
the mean weight of infants in the reference population (Z score <-2).
Infants who are Very Low Weight for Age should be referred to a hospital. Infants who are
Low Weight for Age need special attention to how they are fed and on keeping them warm.
The age of a young infant is usually stated in weeks.
Part 2
Assessment of breast feeding
Assessment of breastfeeding in young infants includes checking if the infant is able to attach,
if the infant is suckling effectively (slow, deep sucks, with some pausing), and if there are
Breastfeeding: Signs of Good Attachment
Breastfeeding: Signs of Good Positioning
Chin touching breast;
Straight head and body
Mouth wide open;
Body close to the mother
Lower lip turned outward; and
The whole body fully supported
More areola visible above than below the

mouth.
Facing breast, nose opposite to nipple
ulcers or white patches in the mouth (thrush).
CLASSIFICATION OF FEEDING PROBLEMS OR LOW WEIGHT

Based on an assessment of feeding and weight, a sick young infant may be classified into
two categories:
Infants with FEEDING PROBLEMS OR LOW WEIGHT are those infants who present with
feeding problems like not attaching well to the breast, not suckling effectively, getting
breast milk less than eight times in 24 hours, receiving other foods or drinks than breast
milk, or those who have low weight for age or have thrush (ulcers/white patches in
mouth).
Appropriate counselling of the mother should be based on the identified feeding problem: (a)
if the infant is not well-attached or not suckling effectively, teach correct positioning and
attachment; (b) if the infant is breastfeeding fewer than eight times in 24 hours, advise the
mother to increase frequency of feeding; (c) if the infant receives other food or drinks,
counsel the mother about breastfeeding more, reducing other foods or drinks, and using a
cup; (d) if the mother is not breastfeeding at all, refer for breastfeeding counselling and
possible relactation. In infants with thrush, teach the caregiver how to treat thrush at home
using gentian violet. Ensure follow-up for any feeding problem or thrush in two days and
follow-up low weight for age in 14 days.
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Not well attached to breast

or
If not well attached or not suckling effectively, teach

correct positioning and attachment.
Not suckling effectively or
If not able to attach well immediately, teach the

mother to express breast milk and feed by a cup.
If breastfeeding less than 8 times in 24 hours,
advise to increase frequency of feeding. Advise her to
breastfeed as often and for as long as the infant
wants, day and night.
Less than 8 breastfeeds in

24 hours or
If was receiving other foods or drinks, counsel mother

about breastfeeding more, reducing other foods or
drinks, and using a cup.
FEEDING
Receives other foods or

drinks or
Low weight for age or
PROBLEM
OR
LOW WEIGHT
FOR AGE
If not breastfeeding at all:

- Refer for breastfeeding counselling and possible
relactation.
- Advise about correctly preparing breast milk
substitutes and using a cup.
If thrush, teach the mother to treat thrush at home.
Advise mother to give home care for the young infant.
Follow-up any feeding problem or thrush in 2 days.
Thrush (ulcers or white

patches in mouth)
Follow-up low weight for age in 14 days.
Infants with NO FEEDING PROBLEMS are those who are breastfed exclusively at least
eight times in 24 hours and whose weight is not classified as low weight for age
according to standard measures
Not low weight for age

and no other signs of
inadequate feeding
Advise mother to give home

care for the young infant
NO FEEDING
PROBLEM
Praise the mother for

feeding the infant well
3.2.5 CHECKING IMMUNIZATION STATUS

As for older children, immunization status should be checked in all sick young infants.
Equally, illness is not a contraindication to immunization.
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At Birth: BCG, Hep B-0 and OPV-0 shall be given
Do not give OPV 0 to an infant who is more than 14 days old. If an infant has not
received OPV 0 by the time s/he is 15 days old, OPV should be given at 6 weeks of age
as OPV 1.
3.2.6 ASSESSING OTHER PROBLEMS

As for older children, all sick young infants need to be assesses for other potential problems
mentioned by the mother or observed during the examination. If a potentially serious
problem is found or there is no means in the clinic to help the infants, s/he should be referred
to hospital.
EXAMPLE:
Sonam is 6 weeks old. He weighs 4.5 kg. His temperature is 98.60F. The health worker asked
What are the infants problems? The mother said Sonam has diarrhoea and skin rash for
the last 3 days. This is the initial visit for this illness.
The health worker checks the young infants for signs of very severe disease and local
bacterial infection. His mother says that Sonam has not had convulsions. The health worker
counts 55 breaths per minute. He finds no chest indrawing or grunting. The umbilicus is
normal. The body temperature is normal. There are 2 skin pustules on abdomen. Sonam is
not lethargic or unconscious, and his movements are normal. He does not have jaundice.
When the health worker asks the mother about Sonams diarrhoea, the mother replies that it
began 3 days ago. Sonam is crying. He stopped once when his mother put him to the breast.
He began crying again when she stopped breastfeeding. His eyes look normal, not sunken.
When the skin of his abdomen is pinches, it goes back slowly.
Sonams mother says that he has no difficulty feeding him. He breastfeeds about 5 times in
24 hours. She gives him other foods and drinks 2-3 times a day with cup and spoon. The
health worker uses weight for Age chart and determines that Sonams weight (4.5 kg.) is not
low for his age (6 weeks).
Since Sonam is breastfeeding less than 8 times in 24 hours and is taking other foods or
drinks. The health worker decides to assess breastfeeding. Sonams mother agrees to
breastfeed now. The health worker observes that Sonams chin is touching the breast. His
mouth is wide open and his lower lip is turned outward. More areola is visible above than
below the mouth. His sucks are deep and slow. When Sonam stops breastfeeding, the health
worker looks in his mouth. He sees no ulcers or white patches in his mouth.
EXAMPLE OF THE TOP FOUR SECTIONS OF THE YOUNG INFANT CASE
RECORDING FROM
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Name:
Sonam
Age:
Date:_____________________
weeks
Weight:
4.5
kg
98.60F
Temperature:
ASK: What are the infants problems? Diarrhoea and rash Initial visit Follow-up visit ______
CLASSIFY

* Has the infant had
convulsion?
* Is the infant having
difficulty feeding?
Count the breaths in one minute 55 breaths per

minute. Repeat if elevated ________Fast
breathing?
Fever (temperature 37.50C or above)
Low body temperature (less than 35.50C)
Red umbilicus/draining pus from it
Does the infant move only when only stimulated?
Local
Bacterial
Infection
THEN CHECK FOR Yes ______ No __ ___

JAUNDICE
Look for jaundice (yellow eyes or skin)
If jaundice is present, Look at the young infants p they palms and soles.
when did jaundice
Are they yellow?
first appear?
DOES THE YOUNG Yes No ___
INFANT
HAVE Movement only when stimulated or no movement
DIARRHOEA?
at all?
* For how long? 3
Days
Restless and irritable?

Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
Some
Dehydration
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THEN CHECK FOR FEEDING PROBLEM & MALNUTRITION
Is there any difficulty feeding? Yes No * Determine weight for age.
Is the infant breastfed? yes No _
Very low weight ___Not Low
Feeding
problem
If yes, how many times in 24 hours? 5 times
Does the infant usually receive any other foods or drinks? Yes No If Yes, 0r
how often? 2-3 times
Low weight
What do you use to feed the infant? Cup and spoon
ASSESS
BREASTFEEDING :
* Has the infant breastfed
If infant has not fed in the previous hour, ask the

mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
in the previous hour?
Is the infant able to attach? To check

attachment, look for:
Chin touching breast yes No __
Mouth wide open
Lower lip turned outward Yes No __
More areola above than below the mouth

Yes No -
Not well attached
yes No __
Well attached
Is the infant suckling effectively (that is, slow

deep sucks, sometimes pausing)?
Not suckling effectively Sucking effectively
3.3
Look for ulcers or white patches in the mouth

(thrush).
TREATMENT PROCEDURES FOR SICK INFANTS
3.3.1 REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS

THE
FIRST STEP IS TO GIVE URGENT PRE-REFERRAL TREATMENT(S).

REFERRAL TREATMENTS INCLUDE:
First dose of Iintramuscular antibiotics
Keeping the infant warm on the way to the hospital
Prevention of hypoglycaemia with breast milk or sugar water
Frequent sips of ORS solution on the way to the hospital
POSSIBLE
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Chart 4. URGENT PRE-REFERRAL TREATMENTS FOR SICK YOUNG INFANTS

UP TO 2 MONTHS FOR VERY SEVERE DISEASES
Classification
TREATMENT
For all infants before referral:
Prevent low blood sugar by giving breast milk or sugar water.
Advise mother how to keep the infant warm on the way to the
hospital.
CONVULSION
If the young infant is convulsing, give Phenobarbital, (200 mg/ml

solution) in a dose of 20 mg/ kg IM; alternatively injection diazepam
( 10 mg/ 2ml solution) in dose or 0.5ml /kg / dose rectally can be
given. If convulsion continues, the dose of anticonvulsant can be
repeated after 10 minutes.
VERY
SEVERE
Give first dose of intramuscular antibiotics. The recommended
DISEASES AND/OR
choices are Ampicillin and Gentamycin
NOT ABLE TO FEED
BLOOD IN STOOL /
SEVERE
PERSISTENT
DIARRHOEA
Give first dose of intramuscular antibiotic and then refer.

Advice the mother to keep the infant warm on the way to the hospital
IF THE YOUNG INFANT IS LESS THAN TWO WEEKS OF AGE

Encourage breastfeeding
SEVERE JAUNDICE
If breastfeeding poorly, give extra fluid by cup and spoon
SERIOUS
Give first dose of appropriate intramuscular antibiotic
UMBILICAL
INFECTION
Treat to prevent low blood sugar

Advice mother how to keep the infant warm on the way to the
hospital
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3.3.2 TREATMENT IN OUTPATIENT CLINICS

The treatment instructions for a young infant are given in IMNCI guidelines. The antibiotics
and dosages are different than those for older children. Exceptions are the fluid plans for
treating diarrhoea and the instructions for preventing low blood sugar. WHO Plans A, B, and
C and the guidelines on how to prevent low blood sugar are used for young infants as well as
older infants and young children.
Chart 5. TREATMENT IN THE OUTPATIENT CLINIC FOR SICK YOUNG
INFANTS UP TO 2 MONTHS
Classification
TREATMENT
LOCAL SKIN INFECTION
Give an appropriate oral antibiotic. The recommended

choices are cotrimoxazole or amoxicillin.
Treat local infections and teach the mother to do it at
home. (see chart booklet)
SOME DEHYDRATION
Treat according to plan B (see chart booklet)
NO DEHYDRATION
Treat according to Plan A (see chart booklet)
LOCAL
INFECTION
FEEDING
WEIGHT
UMBILICAL Same as in local skin infection
PROBLEM
OR
LOW
Give appropriate feeding advice.

( including correct position and attachment )
If thrush, teach the mother to treat thrush at home (See
chart booklet).
ORAL DRUGS
The first dose of oral drugs for a young infant should always be given in the clinic. In
addition, the mother or caregiver should be taught how to give an oral antibiotic at home.
That is, teaching how to measure a single dose, showing how to crush a tablet (if syrup is not
available) and mix it with breast milk, and teaching the treatment schedule.
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Note: Avoid giving Cotrimoxazole to a young infant less than 1 month of age who is
premature or jaundiced. Give this infant Amoxicillin.
COUNSELLING A MOTHER OR CAREGIVER
As with older children, the success of home treatment depends on how well the mother or
caregiver knows how to give the treatment, understands its importance, and knows when to
return to a health care provider.
Counselling the mother or caregiver of a sick young infant includes the following essential
elements:
Ask and Listen to find out what the infants problems are and what the mother is
already doing for the infant
Praise the mother for what she has done well
Advise her how to care for her infant at home
Check the mothers understanding with good checking questions
Note: Avoid asking leading questions (that is questions which suggests the right answer) and
questions that can be answered with a simple yes or no.
Example of a good checking question: what foods will you give to your child? or How
often should you breastfeed your child?
During teaching a mother 3 basic steps needs to be followed:
1. Give information
2. Show an example
3. Let her practice
When teaching the mother:
Use words that she understands
Use teaching aids that are familiar
Give feed-back when she practices. Praise what was done well and make corrections
Allow more practice if needed
Encourage the mother to ask questions
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CHECK THE MOTHERS UNDERSTANDING

Ask questions to find out what the mother understands and what needs further explanation.
Avoid asking leading questions (that is, questions which suggest the right answer) and
questions that can be answered with a simple yes or no.
GOOD CHECKING QUESTIONS
POOR QUESTIONS
How will you prepare the ORS solution?
Do you remember how to mix the ORS?
How often should you breastfeed your Should you breastfeed your child?
child?
On what part of the eye do you apply the Have you used ointment on your child
ointment?
before?
How much extra fluid will you give after Do you know how to give extra fluids?
each loose stool?
Why is it important for you to wash your Will you remember to wash your hands?
hands?
When checking the mothers understanding:
Ask questions that require the mother to explain what, how, how much, how many,
when, or why. Do not ask questions that can be answered with just a yes or no.
Give the mother time to think and then answer.
Praise the mother for correct answers.
If she needs it, give more information, examples or practice
Counselling the mother or caretaker of a sick young infant includes the following essential
elements:
Teach how to give oral drugs
Teach how to treat local infection.
Teach how to manage breast or nipple problem
Teach correct positioning and attachment for breastfeeding.
Counsel on other feeding problems.
Advise when to return.

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Counsel the mother about her own health
Teach correct positioning and attachment for breastfeeding:
Show the mother how to hold her infant, so that

a. Supporting infants whole body, not just neck and shoulders.
b. with the infants head and body straight
c. facing her breast, with infants nose opposite her nipple
d. with infants body close to her body
Baby's body close, facing breast
Baby's body away from mother, neck twisted
Show her how to help the infant to attach. Signs of good attachment are:
a. Chin of the baby touching breast
b. mouth is opening wide
c. lower lip turned outward
d. more areola visible above than below the mouth
Look for signs of good attachment and effective suckling. If the attachment or suckling is
not good, try again.
Teach the mother to express breast milk and feed with a cup and spoon
Expression of breast milk is usually required for feeding infants who do not suck effectively
but are able to swallow effectively (as in the case of low birth weight babies) or when there
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are breast or nipple problems. The expressed breast milk is usually fed with a cup and spoon.
The mother is made to sit comfortably and hold the cup near her breast with one hand. With
the other hand, the mother is asked to place her thumb above and her first finger below the
nipple and areola. Then she is asked to push her thumb and finger slightly inwards towards
the chest wall and then press the nipple between the thumb and finger. She must repeatedly
press and release. This repeated action would allow to milk to drip out. She must repeat this
action also from the sides of the areola to make sure that milk is expressed from all
quadrants. Expression must be continued for 3-5 minutes until the milk flow slows down.
The mother must perform the expression form both breasts and it may take her about 15-20
minutes to express both breasts completely.
For feeding the baby small amounts of the expressed breast milk are taken into the spoon or
paladai and directly poured from the angle of the mouth. One must wait for the baby to
swallow the milk before more milk is poured into the mouth.
Treat thrush with gentian violet. Teach the mother to treat thrush with half-strength gentian
violet (0.25%). Tell the mother that her infant will start feeding normally sooner if she paints
the mouth ulcers in her infants mouth. Ask her to use a clean cloth or a cotton-tipped stick to
paint gentian violet on the mouth ulcers and put a small amount of gentian violet on the cloth
or stick. Tell the mother the frequency and duration of treatment
Show the mother how to paint half of the infants mouth with half-strength gentian violet.
Ask the mother to practice. Watch her paint the rest of the mouth with gentian violet.
Comment on the steps she did well and those that need to be improved.
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Give the mother a bottle of half-strength gentian violet to take home. Before the mother
leaves, ask checking questions. If she anticipates any problems providing the treatment, help
her to solve them.
Teach the mother to manage breast and nipple problems
During the first few weeks after birth, breast and nipple problems can be important causes of
feeding problems and poor growth in young infants. Some of the common problems are flat
or inverted nipples, sore nipples or breast abscess in the mother.
Flat or inverted nipples: If the mother has flat or inverted nipples, the baby can have
difficulty in attaching to the breast, which can result in decreased lactation and poor weight
gain in the infant. The nipple should be everted with fingers before the infant is put to breast
during a feed. This will help the infant to attach well onto the breast. After a few days the
nipples will remain everted.
Sore nipples: Sore nipples are almost always due to faulty attachment of the infant onto the
mothers breast. The mother should be helped to ensure that attachment and position are
correct. To alleviate the discomfort due to soreness, the mother should be advised to apply
breast milk on the affected nipple. If the babys sucking causes a lot of discomfort to the
mother inspite of correct positioning, the mother should be advised to express the breast milk
and feed it with a cup and spoon to the infant, till she is able once again able to breast feed
the infant without much discomfort (this would usually take about 1-2 days).
Engorged breasts and Breast abscess: Engorged breasts are swollen, hard and tender.
Breast abscess is often due to breast engorgement and rarely due to primary infection of the
breast. The mother should be encouraged to feed from the unaffected breast and referred to a
health facility for treatment of the abscess. If the amount of milk from a single breast is
inadequate, then undiluted animal milk with added sugar can be fed with cup and spoon.
Counselling about Other Feeding Problems
If a mother is breastfeeding her infant less than 8 times in 24 hours, advise her to increase
the frequency of breastfeeding. Breastfeed as often and for as long as the infant wants,
day and night.
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If the infant receives other foods or drinks, counsel the mother about breastfeeding more,
reducing the amount of the other foods or drinks, and if possible, stopping altogether.
Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle.
If the mother does not breastfeed at all, consider referring her for breastfeeding
counselling and possible re-lactation. If the mother is interested, a breastfeeding
counsellor may be able to help her to overcome difficulties and begin breastfeeding
again.
Advise a mother who does not breastfeed about choosing and correctly preparing
dairy/locally appropriate animal milk. Also advise her to feed the young infant with a cup,
and not from a feeding bottle.
Follow-up any young infant with a feeding problem in 2 days. This is especially important if
you are recommending a significant change in the way the infant is fed.
Advice about food and fluids: advise to breastfeed frequently, at least 8 times/24 hrs as
often as possible and for as long as the infant wants, day and night, during sickness and
health.
Advise when to return:
A) IMMEDIATELY
Advise to return immediately if the infant has any

of these signs:
Breastfeeding or drinking poorly
Becomes sicker
Develops a fever
Fast breathing
Difficult breathing
Blood in stool
B) FOR FOLLOW-UP VISIT

If the infant has:
Jaundice
Return for followup not later than:

1 Day
Local skin/umbilical infection

Any feeding problem
Oral thrush
2 days
14 days
LOW WEIGHT FOR AGE
83
HAND BOOK ON IMNCI
C) NEXT WELL-CHILD VISIT
Advise when to return for the next immunization according to immunization schedule.
FOLLOW-UP CARE
Follow-up visits are recommended for young infants who are classified as:
Local bacterial local infection
Jaundice
Diarrhoea
Feeding problem
Low weight
Thrust
84
HAND BOOK ON IMNCI
3.4 RECORDING FORM
85
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HAND BOOK ON IMNCI

HAND BOOK ON IMNCI

HAND BOOK ON IMNCI

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ................................ 1

1.2 RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TO

COMPONENTS OF THE INTEGRATED APPROACH .................................... 3

THE PRINCIPLES OF INTEGRATED CARE ................................................... 3

THE IMNCI CASE MANAGEMENT PROCESS ............................................... 4

2 OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO YEARS 7

LEARNING OBJECTIVES .................................................................................. 7

ASSESSMENT OF SICK CHILDREN ................................................................ 7

2.2.1 History taking- COMMUNICATING WITH THE PARENTS OR

CHECKING FOR GENERAL DANGER SIGNS ........................................... 9

CHECKING MAIN SYMPTOMS ................................................................. 11

2.2.3.1 COUGH OR DIFFICULT BREATHING .................................................. 11

2.2.3.3 FEVER ........................................................................................................ 21

CHECKING NUTRITIONAL STATUS - MALNUTRITION AND

CHECKING IMMUNIZATION, VITAMIN A and DEWORMING STATUS

ASSESSING THE CHILD'S FEEDING ........................................................ 41

ASSESSING OTHER PROBLEMS ............................................................... 44

identify treatments FOR SICK CHILDREN....................................................... 45

REFERRAL OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS ............. 45

TREATMENT IN OUTPATIENT CLINICS ................................................. 48

2.3.2.1 ORAL DRUGS ........................................................................................... 48

HAND BOOK ON IMNCI

2.3.2.2 TREATMENT OF LOCAL INFECTIONS ........................................... 53

OUTPATIENT Management of SICK Young Infants Up to 2 Months ..................... 62

Learning Objectives ............................................................................................ 62

ASSESSMENT OF sick YOUNG INFANTS .................................................... 62

Classification of very severe disease............................................................... 65

Check for jaundice. ......................................................................................... 66

FEEDING PROBLEMS OR LOW WEIGHT ................................................ 70

CHECKING IMMUNIZATION STATUS .................................................... 72

ASSESSING OTHER PROBLEMS ............................................................... 73

Treatment Procedures for SICK Infants .............................................................. 75

REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS ........................... 75

TREATMENT IN OUTPATIENT CLINICS ................................................. 77

3.3.2.1 ORAL DRUGS ........................................................................................... 77

HAND BOOK ON IMNCI

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Acute respiratory infection

Under-nutrition is common among children

Tuberculosis and malaria are the other major health problems.

Improvements in child health

HAND BOOK ON IMNCI

of under five children.

RATIONALE FOR AN EVIDENCE-BASED SYNDROMIC APPROACH TO

IMNCI as a key strategy for Improving child health

Other disease prevention

HAND BOOK ON IMNCI

Health problem(s) the child may have;

Severity of the childs condition

Appropriate feeding practices

COMPONENTS OF THE INTEGRATED APPROACH

Improvements in the case-management skills of health care providers.

Improvements in the overall health system required for effective management of

Improvements in family and community health care practices.

THE PRINCIPLES OF INTEGRATED CARE

The IMNCI guidelines are based on the following principles:

HAND BOOK ON IMNCI

A combination of individual signs leads to a childs classification(s) rather than a

IMNCI management procedures use a limited number of essential drugs and