At the start of a sick child (2 months to 5 years) consultation Ask the mother what the child’s problems are. Determine if this is an initial or follow- up visit for this problem.

IMCI Case Management Danger signs Main Symptoms Nutritional status Immunization status Other problems Need to Refer Specific treatment Home management Classification Focused Assessment Identify treatment Treat Counsel caretakers Follow-up TreatmentCounsel & Follow-up

Check for general danger signs Ask: Not able to drink or breastfeed, Vomits everything, Convulsions, or Look: Abnormally sleepy or difficult to awaken Need to Refer (except in severe dehydration)

Ask about the main symptoms Cough or difficulty in breathing Diarrhea Fever Ear problem

Cough or difficulty in breathing Ask: For how long? Look: Count RR Chest indrawing Stridor The child must be calm.

SEVERE PNEUMONIA OR VERY SEVERE DISEASE  1 st dose of antibiotic  Vitamin A  Breastfeeding/sugar water  URGENT REFERRAL Any general danger sign or Chest indrawing or Stridor

PNEUMONIA  Antibiotic for 5 days  Relieve cough with safe remedy  Advise mother on danger signs  Follow up in 2 days Fast breathing 2 – 12 months old: ≥ 50/minute 1 year or older: ≥ 40/minute

NO PNEUMONIA: COUGH OR COLD  If cough ≥ 30 days  refer to hospital for assessment  Relieve cough with safe remedy  Advise mother on danger signs  Follow up in 5 days if no improvement No signs of pneumonia or a very severe disease

Diarrhea: Classify For dehydration Persistent diarrhea Blood in the stool

SEVERE DEHYDRATION 2 or more of the following: Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly Classify for dehydration Plan C

IV treatment within 30 minutes IV fluid: LRS 100 ml/kg body weight (in 6 hrs for infants; 3 hrs for children) Plan C: To treat dehydration quickly NO Oresol/NGT

Oresol p.o. Plan C: To treat dehydration quickly NO Oresol/NGT URGENT REFERRAL

SOME DEHYDRATION 2 of the following: Restless, irritable Sunken eyes Skin pinch goes back slowly Classify for dehydration Plan B

Age< 4 mos4-12 mos Amount Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart. Plan B: Treat some dehydration with ORS

Age12 mos-2 yrs2-5 yrs Amount Determine the amount (in ml) of Oresol to be given in 4 hours = weight of the child (in kg) X 75, or if weight is unknown, use this chart. Plan B: Treat some dehydration with ORS

 Show the mother how to give Oresol to the child: frequent sips from a cup  If the child vomits, wait for 10 minutes. Then continue, but more slowly.  Continue breastfeeding if the child wants to breastfeed.  If the child develops puffy eyelids, stop ORS. Plan B: Treat some dehydration with ORS

After 4 hours:  Reassess the child & classify for dehydration.  Select appropriate plan.  Begin feeding the child in the health center. Plan B: Treat some dehydration with ORS

NO DEHYDRATION Not enough signs to classify as SEVERE DEHYDRATION or SOME DEHYDRATION Classify for dehydration Plan A

 Give extra fluid. Plan A: Treat diarrhea at home Up to 2 yrs50 – 100 ml after each LBM 2 -4 yrs100 – 200 ml after each LBM  Continue feeding.  Know when to return.

Persistent diarrhea: 14 days or more Treat dehydration Give Vitamin A Refer to hospital + Dehydration=severe persistent diarrhea

Persistent diarrhea: 14 days or more Advise regarding feeding Give Vitamin A Follow up in 5 days No dehydration=persistent diarrhea

Blood in the stool = dysentery Oral antibiotic for shigella for 5 days Follow up in 2 days

Fever: (history/temperature 37.5°C or above) Malaria risk? Measles now or w/in last 3 mos Dengue risk?

Fever: Ask about malaria risk Residing in endemic area? OR: Travel & overnight stay in endemic area, or Blood transfusion w/in past 6 mos

Malaria risk + Blood smear Ask: Duration of fever? Present everyday? Look:Stiff neck Runny nose Other signs of measles

Malaria risk + any general danger sign or stiff neck Quinine (under med. supervision) 1 st dose of antibiotic, Paracetamol Urgent referral Very severe febrile disease/malaria

Malaria risk +, blood smear + No runny nose, no measles Oral antimalarial Paracetamol Follow up in 2 days > 7 days fever  hospital for assessment Malaria

No malaria risk Any general danger sign or stiff neck 1 st dose of antibiotic, Paracetamol Urgent referral Very severe febrile disease

Measles now or w/in last 3 mos Clouding of cornea or Deep or extensive mouth ulcers 1 st dose of antibiotic, Vitamin A Urgent referral Severe complicated measles

Measles now or w/in last 3 mos Pus draining from the eye or Mouth ulcers Vitamin A Tetracycline eye ointment Gentian violet Follow up in 2 days Measles with eye or Mouth complications

Measles now or w/in last 3 mos No other signs Vitamin A Measles

If there is Dengue risk Bleeding gums, nose, in vomitus or stools Black vomitus or stools Persistent abdominal pain Persistent vomiting Skin petechiae Slow capillary refill No signs, but fever > 3 days  Tourniquet test

Any of the danger signs or + tourniquet test If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS Any other signs of bleeding  Plan C Urgent referral Do not give aspirin Severe Dengue hemorrhagic fever

Ear problem: tender swelling behind ear 1 st dose of antibiotic Paracetamol for pain Urgent referral Mastoiditis

Ear discharge < 14 days or Ear pain Antibiotic for 5 days Paracetamol for pain Wicking Follow up in 5 days Acute ear infection

Ear discharge for 14 days or more Wicking Follow up in 5 days Chronic ear infection

Visible severe wasting or Edema on both feet or Severe palmar pallor Vitamin A Urgent referral Severe malnutrition or severe anemia

Some palmar pallor or Very low weight for age Assess for feeding problem Pallor: iron & Albendazole Wt for age very low: Vitamin A Anemia or very low weight for age

Then CHECK CHILD’S IMMUNIZATION STATUS BCG DPT 1, 2, 3 OPV 1,2, 3 HEP B 1, 2, 3 MEASLES

Then CHECK VITAMIN A SUPPLEMENTATION STATUS (for children 6 months or older) Given if child was not given in the past 6 months. May be given even if given one in the past 6 months if Vit. A is part or urgent pre-referral treatment.

Then ASSESS THE CHILD’S FEEDING If the child has ANEMIA or VERY LOW WEIGHT or LESS THAN 2 YEARS OLD. Examples of feeding problems: Difficulty in breastfeeding Use of feeding bottles Lack of active feeding Not feeding well during illness Not giving protein source of food Improper handling and use of breast milk substitute

Then ASSESS OTHER PROBLEMS