IMCI Case Management

Focused Assessment Classification

Danger signs
Need to Refer
Main Symptoms
Nutritional status
Immunization status Specific treatment
Vitamin A status
Deworming
Home
Feeding Problem
Other problems management

Counsel & Follow-up Treatment

Counsel caretakers Identify treatment

Follow-up Treat
 Check for general danger signs

• Not able to drink or breastfeed, or

• Vomits everything, or
• Convulsions, or
• Abnormally sleepy or difficult
to awaken

If YES: URGENT REFERRAL is needed

 Ask about the main symptoms

• Cough or difficulty in breathing

• Diarrhea
• Fever
• Ear problem
 Cough or difficulty in breathing

Look for:
•Count RR The child
•Chest indrawing must be
Listen for Stridor calm & not
Listen for wheezing eating
 If with:
- Any general danger sign or
- Chest indrawing or
- Stridor

SEVERE PNEUMONIA OR
VERY SEVERE
DISEASE

 1st dose of antibiotic

 Vitamin A
 URGENT REFERRAL
 Prevent low blood sugar
 If Fast breathing only:
2 – 12 months old: ≥ 50/minute
1 year or older: ≥ 40/minute
Note: Exactly 12 mos: 40

PNEUMONIA

 Antibiotic for 3 days (Amoxycillin)

 safe throat remedy
(calamansi, breast milk)
Follow-up in 2 days

•If wheezing, give trial of rapid-acting inhaled

bronchodilator (up to three cycles for up to 15-20 minutes
apart)
 If No signs of pneumonia
or a very severe disease

NO PNEUMONIA: COUGH OR COLD

 If cough ≥ 30 days
 refer to hospital for assessment
 safe throat remedy
 Follow-up in 5 days.

• If wheezing, give inhaled bronchodilator for 5 days

If with Diarrhea, then classify

For dehydration

If persistent

If with blood in the stool

 Classify for 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 (↑2 sec)

If with no other
severe classification:
Plan C- IVF in RHU
SEVERE DEHYDRATION
If less than 2 yrs & there is cholera
In the area, give TETRACYCLINE
 Classify for dehydration

2 of the following:
- Restless, irritable
- Sunken eyes
- Drinks eagerly, thirsty
- Skin pinch goes back slowly (↓2 sec)

Plan B : ORS,
SOME DEHYDRATION zinc supplement
inRHU
 Classify for dehydration

Not enough signs to classify as

SEVERE DEHYDRATION or
SOME DEHYDRATION

• Plan A: Extra Fluids

NO DEHYDRATION Give Zinc supplement
• Follow-up in 5 days
 Persistent diarrhea: 14 days or more

Dehydration present- severe persistent

diarrhea

• Treat dehydration
• Give Vitamin A
• REFER to hospital
 Persistent diarrhea: 14 days or more

No dehydration- persistent diarrhea

• Advise regarding feeding

• Give Vitamin A
• Give multivitamins & minerals
with zinc for 14 days
• Follow-up in 5 days
 If with blood in the stool - dysentery

• Oral antibiotic- CIPROFLOXACIN for 3

days
• Follow-up in 2 days
 If with fever?

Determine: Malaria risk?

Measles now or w/in last 3 mos

Dengue risk?
 Fever: Ask about malaria risk

• Residing in endemic area?

• OR:
• Travel & overnight
w/in past
stay in endemic area 4 weeks

If YES, then do a blood smear.

 If with Malaria risk:
& with any general danger sign or stiff
neck

Very severe febrile disease/malaria

• Quinine (under med. supervision)

• 1st dose of antibiotic, Paracetamol
• Prevent low blood sugar
• Send the blood smear with patient
• URGENT REFERRAL
 If Malaria risk
(+) blood smear

Malaria

• Oral antimalarial
• Paracetamol for fever
• Follow-up in 2 days
 If Malaria risk
(-) blood smear

Fever, malaria
unlikely

• Paracetamol for fever

• Treat other causes of fever
• Follow-up in 2 days
 If no malaria risk but with
Any general danger sign or stiff neck

Very severe febrile disease

• One dose of antibiotic, Paracetamol

• Treat to prevent low blood sugar
• URGENT REFERRAL
 If no malaria risk & NO sign of very
severe febrile disease

FEVER, NO MALARIA

• One dose Paracetamol

• If with fever every day for more than 7
days, REFER for assessment
 If with Measles & with clouding of
cornea or
with deep or extensive mouth ulcers or
ANY danger sign

Severe complicated measles

• 1st dose of antibiotic, Vitamin A

• tetracycline eye ointment
• Urgent referral
Measles now or w/in last 3 mos
Pus draining from the eye or
Mouth ulcers

Measles with eye or

Mouth complications

• Vitamin A
• Tetracycline eye ointment
• Gentian violet
• Follow up in 2 days
Measles now or w/in last 3 mos
No other signs

Measles

• Vitamin A
• Advise mother when
to return immediately
 Assess Dengue risk

Bleeding gums, nose, in vomitus or

stools ,or
Persistent vomiting & abdominal pain,
Skin petechiae, or
Cold clammy extremities, or
Slow capillary refill (more than 3
secs)
+ Tourniquet test
 Any of the mentioned symptoms

Severe Dengue hemorrhagic fever

• Plan C if with + bleeding

• Plan B if with either abdominal plain,
or skin petechia, or + torniquet test
• Do not give aspirin
• Treat to prevent low blood sugar.
• URGENT REFERRAL
 If No sign of Severe Dengue
Hemorrhagic Fever

FEVER, DHF UNLIKELY

• DO NOT GIVE ASPIRIN

• Follow-up in 2 days
 Classify Ear problem:
Tender swelling behind
ear

Mastoiditis

• 1st dose of antibiotic

• Paracetamol for pain
• URGENT REFERRAL
If with ear problem: with ear discharge
< 14 days

Acute ear infection

• Antibiotic for 5 days

• Paracetamol for pain
• Wicking
• Follow-up in 5 days
Ear discharge for 14 days or more

Chronic ear infection

• Wicking
• Quinolone ear drops for 2 weeks
• Follow-up in 5 days
Then check for malnutrition
& anemia
Look for:
• Visible severe wasting
• Edema of both feet
• Palmar pallor
• If 6 months or older, determine if
MUAC (Mid-upper Arm Circumference)
is less tha 115 mm.

Determine weight for age

If up to 6 months and:
Visible severe wasting or
Edema on both feet
If 6 mos & above: Above symptoms &
MUAC is less than 115 mm

Severe malnutrition

• Vitamin A
• Treat to prevent low blood sugar
• URGENT REFERRAL
 Very low weight for age

Very low weight

• Assess for feeding problem

• Counsel the mother on feeding
• Vitamin A
 Severe palmar pallor

Severe anemia

• URGENT REFERRAL
 Some palmar pallor or

Anemia

• Assess for feeding problem / counsel mother

• Give iron & Albendazole (if 1 yr old & older)
 Then CHECK CHILD’S IMMUNIZATION
STATUS

Birth BCG HepB1

6 weeks OPV1 HepB2 DPT1 Hib1
10 weeks
OPV2 DPT2 Hib2
14 weeks OPV3 HepB3 DPT3 Hib3
9 months Measles
15 months MMR
 New Immunization Schedule

Birth BCG HepB0

6 weeks Pentavalent1 OPV1 RTV1* PCV1*

10 weeks Pentavalent2 OPV2 RTV2* PCV2*
14 weeks Pentavalent3 OPV3 RTV3* PCV3*
9 months Measles
12 months MMR

RTV*PCV* - in selected areas only due to limited

supplies
Pentavalent vaccine includes DPT, HIB, HepB
 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 of urgent
pre-referral treatment.
 Then check the child’s DEWORMING
status

• ROUTINE WORM TREATMENT:

Give every child ALBENDAZOLE/
MEBENDAZOLE every 6 months
from the age of one year.
 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
•Child less than 6 months taking other milk/ food
•Use of breastmilk substitute/ cow’s milk, evap
•Use of feeding bottles
•Child 6 months above not yet given complementary
food
 ASSESS CARE DEVELOPMENT:

• Ask questions about how the mother

cares for her child. ASK
- How does she play with your
child?
- How does she communicate
with
the child?
Then ASSESS OTHER PROBLEMS