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Key Features

• The presence of ANY ONE of the listed general danger signs classifies the child as having Very Severe Disease.
• These signs indicate a life-threatening condition requiring immediate action and urgent referral, regardless of the main complaint.

Assessment

• Ask: Is the child able to drink or breastfeed?
• Ask: Does the child vomit everything?
• Ask: Has the child had convulsions during this illness?
• Look/Feel: See if the child is lethargic or unconscious.
• Look/Feel: Is the child convulsing now?

Classification

• Any general danger sign present (Unable to drink/breastfeed OR Vomits everything OR Had convulsions OR Lethargic/unconscious OR Convulsing now) -> VERY SEVERE DISEASE

Management

Non-Pharmacological Management

• Quickly complete the assessment to identify all necessary pre-referral treatments.
• Keep the child warm: Cover the child, ensure no draughts. If possible use skin-to-skin contact.
• Position the child appropriately (e.g., recovery position if unconscious and not convulsing, clear airway).

Pharmacological Treatment

• Specific pharmacological pre-referral treatments depend on associated classifications identified during the rapid assessment (see pre_referral section).

Pre-Referral Treatment

• If convulsing now: Give Diazepam rectally (10mg/2ml solution). Dose: <6m (<5kg) 0.5ml; 6-<12m (5-<10kg) 1.0ml; 1-<3y (10-<15kg) 1.5ml; 4-<5y (15-19kg) 2.0ml. If convulsions continue after 10 minutes, repeat the dose.
• Treat to prevent low blood sugar: If child can breastfeed, ask mother to do so. If not able to breastfeed but able to swallow: Give expressed breast milk OR breastmilk substitute OR sugar water (Dissolve 4 level teaspoons (20g) sugar in 200ml clean water) - give 30-50ml before departure. If child not able to swallow: Give 50ml of milk or sugar water by nasogastric tube.
• Give relevant pre-referral treatment based on quick assessment findings:
• If signs of Severe Pneumonia/Serious Infection: Give first dose Intramuscular Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg). Ampicillin doses (500mg vial diluted to 2.5ml): 4-<6kg: 1ml; 6-<10kg: 2ml; 10-<15kg: 3ml; 15-20kg: 5ml. Gentamicin doses (40mg/ml vial): 4-<6kg: 0.5-1.0ml; 6-<10kg: 1.1-1.8ml; 10-<15kg: 1.9-2.7ml; 15-20kg: 2.8-3.5ml.
• If signs of Very Severe Febrile Disease/Suspected Severe Malaria: Give Rectal Artesunate (10 mg/kg, single dose) OR Intramuscular/IV Artesunate (3 mg/kg if =20kg) OR Intramuscular Quinine (refer to page 11 for detailed dosing based on concentration).
• If signs of Severe Dehydration (Plan C): Start IV fluids immediately if possible OR if child can drink give ORS sips frequently on the way to hospital (refer to page 13).

Monitoring & Follow-Up

• To be managed at the referral hospital facility.

Counselling Points

• Explain clearly to the mother/caregiver why referral is urgent and necessary.
• Explain any pre-referral treatments given and why.
• Advise on how to keep the child warm during transport (e.g., blanket, skin-to-skin).
• Advise on continuing breastfeeding during transport if possible.
• If the child also has dehydration, show how to give frequent sips of ORS on the way.
• Write a referral note detailing assessment findings, classification, treatments given, and reason for referral.

Differential Diagnosis

• Severe Pneumonia
• Meningitis
• Cerebral Malaria
• Severe Dehydration with shock
• Severe Sepsis
• Severe Malnutrition with complications
• Poisoning
• Diabetic Ketoacidosis (rare)

Potential Complications

• Shock (Septic, Hypovolemic)
• Respiratory failure
• Severe metabolic acidosis/electrolyte imbalance
• Organ failure
• Brain damage (from hypoxia, hypoglycemia, infection, convulsions)
• Death

Prevention

• Complete routine childhood immunizations.
• Exclusive breastfeeding for the first 6 months, continued breastfeeding with appropriate complementary feeding.
• Use of insecticide-treated nets (ITNs) in malaria-endemic areas.
• Handwashing and safe water/sanitation.
• Prompt recognition of illness and seeking appropriate care.
• Good maternal health and nutrition.

Key Features

• Presence of ANY general danger sign automatically classifies as Very Severe Disease.
• Stridor in a CALM child signifies critical upper airway obstruction and is a sign of Very Severe Disease.
• Requires immediate pre-referral antibiotic and treatment for low blood sugar, then urgent referral.

Assessment

• Ask: Does the child have cough or difficult breathing?
• Ask: For how long?
• Check for General Danger Signs (Any ONE: Unable to drink/breastfeed, Vomits everything, Had convulsions, Lethargic/unconscious, Convulsing now).
• Look/Listen: Look and listen for stridor (harsh noise during INspiration) when the child is CALM.

Classification

• Any general danger sign present OR Stridor in a calm child -> SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Management

Non-Pharmacological Management

• Minimize distress; keep the child calm.
• Allow child to assume position of comfort (often sitting up).
• Keep child warm.
• Quickly complete assessment for other pre-referral needs.

Pre-Referral Treatment

• Give first dose of an appropriate intramuscular antibiotic: Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg). Ampicillin doses (500mg vial diluted to 2.5ml): 4-<6kg: 1ml; 6-<10kg: 2ml; 10-<15kg: 3ml; 15-20kg: 5ml. Gentamicin doses (40mg/ml vial): 4-<6kg: 0.5-1.0ml; 6-<10kg: 1.1-1.8ml; 10-<15kg: 1.9-2.7ml; 15-20kg: 2.8-3.5ml.
• Treat to prevent low blood sugar: If child can breastfeed, ask mother to do so. If not able to breastfeed but able to swallow: Give EBM/substitute/sugar water (4 tsp sugar in 200ml water) - 30-50ml. If unable to swallow: Give 50ml milk/sugar water by NG tube.
• Give other pre-referral treatments if indicated (e.g., rectal diazepam for convulsions, pre-referral antimalarial if severe febrile disease also classified).

Monitoring & Follow-Up

• To be managed at the referral hospital facility.

Counselling Points

• Explain the need for urgent referral due to severe breathing problem.
• Explain treatments given (antibiotic, sugar).
• Advise on keeping child warm and calm during transport.
• Advise on continuing breastfeeding if possible.
• Write a detailed referral note.

Differential Diagnosis

• Pneumonia (non-severe)
• Severe Croup (Laryngotracheobronchitis)
• Epiglottitis (rare due to Hib vaccine)
• Foreign body aspiration
• Severe asthma attack
• Anaphylaxis
• Diphtheria (rare)

Potential Complications

• Hypoxemia
• Respiratory failure / arrest
• Airway obstruction
• Sepsis
• Death

Prevention

• Immunization (Hib, PCV, Measles, Pertussis, Diphtheria)
• Good nutrition
• Reducing exposure to indoor/outdoor air pollution
• Exclusive breastfeeding.
• Preventing foreign body aspiration (age-appropriate toys, supervision).

Key Features

• Presence of Chest Indrawing OR Fast Breathing (age-dependent rate).
• Absence of general danger signs and stridor differentiates from Severe Pneumonia.
• Requires treatment with first-line oral antibiotic (Amoxicillin).
• Wheezing requires addition of an inhaled bronchodilator.
• Chest indrawing in HIV exposed/infected child warrants immediate first dose Amoxicillin and referral.

Assessment

• Ask: Does the child have cough or difficult breathing?
• Ask: For how long?
• Confirm absence of General Danger Signs (see IMCI_2M5Y_001).
• Confirm absence of Stridor in a calm child.
• Look: Look for chest indrawing (lower chest wall pulls inwards during INspiration). Child must be calm.
• Listen/Feel: Count breaths in one full minute. Check for fast breathing based on age. Child must be calm. Fast Breathing: Age 2-11 months: >= 50 breaths/minute. Age 12 months - 5 years: >= 40 breaths/minute.
• Look/Listen: Look and listen for wheezing (high-pitched whistling sound during OUTspiration).

Classification

• Chest indrawing OR Fast breathing -> PNEUMONIA

Management

Non-Pharmacological Management

• Soothe the throat and relieve the cough with a safe remedy (e.g., warm fluids; honey if child is >1 year old). Avoid harmful remedies like codeine.
• Continue feeding and encourage fluid intake.
• Ensure child is kept warm.

Pharmacological Treatment

• Give oral Amoxicillin twice daily for 5 days. Dosage: Age 2m-<12m (4-<10kg): 250mg dispersible tablet (1 tab) OR 250mg/5ml syrup (5ml) per dose. Age 12m-5y (10-<19kg): 250mg dispersible tablet (2 tabs) OR 250mg/5ml syrup (10ml) per dose.
• If wheezing is present (or wheezing was present and disappeared after a trial of bronchodilator): Give inhaled rapid-acting bronchodilator (Salbutamol 100mcg/puff) 2 puffs via spacer, 3 times daily for 5 days.

Pre-Referral Treatment

• If chest indrawing is present AND the child is HIV exposed/infected: Give the first dose of oral Amoxicillin (as per dosing above) and REFER the child.

Monitoring & Follow-Up

• Follow-up in 3 days.
• At follow-up (Day 3):
• Assess for general danger signs, check for fever, chest indrawing, count breathing rate, assess feeding. Check HIV status.
• If danger signs/stridor: Give pre-referral 2nd line antibiotic/chloramphenicol, treat hypoglycemia, refer URGENTLY.
• If chest indrawing/fast breathing/fever/eating are same or worse: Change to second-line oral antibiotic recommended locally for treatment failure (treat for 5 days), advise immediate return if worsens, ask to return in 3 days OR Refer (especially if measles within last 3 months or HIV exposed/confirmed).
• If breathing slower, less fever, eating better: Continue and complete the 5-day course of Amoxicillin.
• If coughing for 14 days or more at any visit, assess for TB (see page 9).

Counselling Points

• Explain the diagnosis (pneumonia) and the need for antibiotic.
• Teach the mother how to give the oral Amoxicillin: correct dose, frequency (twice daily), duration (full 5 days), how to measure syrup or disperse tablet.
• If Salbutamol prescribed: Teach how to use the inhaler and spacer correctly (shake inhaler, attach, seal mask/mouthpiece, actuate puff, hold for breaths, repeat for 2nd puff), frequency (3 times daily), duration (5 days).
• Teach how to soothe the throat/relieve cough with safe remedies.
• Advise to continue feeding and offer extra fluids.
• Advise mother WHEN TO RETURN IMMEDIATELY: Breathing becomes difficult, breathing becomes fast, child not able to drink or breastfeed, child becomes sicker.
• Advise on follow-up visit in 3 days.

Differential Diagnosis

• Severe Pneumonia / Very Severe Disease
• Asthma/Wheezing (often co-exists or primary issue)
• Bronchiolitis (especially in younger infants)
• Tuberculosis
• Cough or Cold (viral URTI)
• Pertussis
• Heart failure (rare)

Potential Complications

• Progression to severe pneumonia
• Treatment failure/Antibiotic resistance
• Pleural effusion / Empyema (less common with non-severe)
• Dehydration (if poor fluid intake)

Prevention

• Immunization (Hib, PCV, Measles, Pertussis)
• Good nutrition, Vitamin A supplementation.
• Reducing exposure to indoor air pollution (smoke).
• Exclusive breastfeeding for first 6 months.
• Handwashing.

Key Features

• Absence of signs of pneumonia (chest indrawing, fast breathing) and very severe disease (danger signs, stridor).
• This is a diagnosis of exclusion after ruling out more severe respiratory conditions.
• Management focuses on symptom relief and home care advice.
• Antibiotics are NOT indicated unless a specific bacterial complication develops (e.g., acute otitis media).

Assessment

• Ask: Does the child have cough or difficult breathing?
• Ask: For how long?
• Confirm absence of General Danger Signs (see IMCI_2M5Y_001).
• Confirm absence of Stridor in a calm child.
• Confirm absence of Chest Indrawing.
• Confirm absence of Fast Breathing (Count breaths/min. Not fast if: Age 2-11 months: < 50 breaths/minute. Age 12 months - 5 years: < 40 breaths/minute).
• Look/Listen: Look and listen for wheezing.

Classification

• No signs of Pneumonia or Very Severe Disease -> COUGH OR COLD

Management

Non-Pharmacological Management

• Soothe the throat and relieve the cough with a safe remedy: Encourage breastfeeding. Offer warm drinks like tea with lemon. If child is >1 year old, honey may be given. Avoid harmful remedies (Kabuti, Kisa kya muzadde, codeine, piriton, promethazine).
• Advise mother to continue feeding and encourage fluid intake.
• Clear blocked nose if it interferes with feeding (e.g., saline drops).

Pharmacological Treatment

• If wheezing is present (or was present and disappeared after a trial of bronchodilator): Give inhaled rapid-acting bronchodilator (Salbutamol 100mcg/puff) 2 puffs via spacer, 3 times daily for 5 days.

Monitoring & Follow-Up

• Follow-up in 5 days ONLY IF the child is not improving.
• If coughing for 14 days or more at any visit, assess for TB (History of contact, poor weight gain, persistent fever. Check for GeneXpert/smear if available. See page 9).
• If wheezing is recurrent, refer for asthma assessment.

Counselling Points

• Reassure the mother that the child has a cold and antibiotics are not needed.
• Teach how to soothe the throat and relieve cough using safe home remedies.
• If Salbutamol prescribed for wheezing: Teach correct use of inhaler and spacer (as in Pneumonia counselling).
• Advise to continue feeding and offer extra fluids.
• Advise mother WHEN TO RETURN IMMEDIATELY: Breathing becomes difficult, breathing becomes fast, child not able to drink or breastfeed, child becomes sicker.
• Advise on follow-up in 5 days only if no improvement, or sooner if symptoms worsen.
• Advise to return if cough persists for more than 14 days.

Differential Diagnosis

• Pneumonia (early or mild)
• Asthma/Wheezing (can occur with viral colds)
• Allergic rhinitis
• Bronchiolitis (if wheezing, mainly <2 yrs)
• Tuberculosis (especially if cough > 14 days)
• Pertussis (paroxysmal cough)

Potential Complications

• Acute Otitis Media
• Sinusitis
• Persistent cough
• Exacerbation of underlying asthma (if present)

Prevention

• Frequent handwashing for caregiver and child.
• Avoiding close contact with people who have colds.
• Avoiding exposure to tobacco smoke.
• Good nutrition.
• Exclusive breastfeeding for the first 6 months.

Key Features

• Presence of Fever (current or recent history).
• Presence of ANY General Danger Sign OR a Stiff Neck.
• Stiff neck strongly suggests meningitis.
• Requires immediate pre-referral antimalarial, antibiotic, and hypoglycemia prevention, followed by urgent referral.

Assessment

• Ask: Does the child have fever (by history, feels hot, or temperature 37.5C)?
• Check for General Danger Signs (Any ONE: Unable to drink/breastfeed, Vomits everything, Had convulsions, Lethargic/unconscious, Convulsing now).
• Look/Feel: Look or feel for stiff neck (difficulty or pain when gently flexing the neck forward).

Classification

• Fever present AND (Any general danger sign OR Stiff neck) -> VERY SEVERE FEBRILE DISEASE

Management

Non-Pharmacological Management

• Quickly complete assessment.
• Ensure airway is clear, position appropriately.
• Keep child warm.

Pre-Referral Treatment

• Give 1st dose of pre-referral antimalarial: Rectal Artesunate (10 mg/kg) OR IM/IV Artesunate (3 mg/kg if =20kg) OR IM Quinine (see page 11 for specific dosing based on formulation).
• Give 1st dose of appropriate IM antibiotic: Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg) OR alternative based on local guidelines (e.g., Ceftriaxone). See page 12 for Ampicillin/Gentamicin dosing.
• Treat child to prevent low blood sugar: If child can breastfeed, ask mother. If cannot breastfeed but can swallow, give 30-50ml EBM/substitute/sugar water (4 tsp sugar in 200ml water). If cannot swallow, give 50ml via NG tube.
• Give one dose of Paracetamol (10-15 mg/kg) if high fever (38.5C axillary). Dosage (500mg tablet): 2-3m (<6kg): 1/4 tab. 4m-3y (6-<14kg): 1/2 tab. 4-5y (14-19kg): 3/4 tab (or 1/2 of 500mg tab from p15). Note: page 15 suggests 10mg/kg for paracetamol, use local guideline preference.
• If convulsing now, give rectal Diazepam (see page 11 for dose).

Monitoring & Follow-Up

• To be managed at referral hospital facility.

Counselling Points

• Explain the extreme seriousness of the child's condition and the urgent need for hospital care.
• Explain treatments given (antimalarial, antibiotic, sugar, paracetamol if given).
• Advise on keeping the child warm during transport.
• Advise on continuing breastfeeding if possible.
• Write a detailed referral note listing findings, classifications, and all treatments given (drug, dose, time).

Differential Diagnosis

• Severe Malaria (Cerebral malaria)
• Bacterial Meningitis
• Sepsis
• Severe Pneumonia (may present with fever and danger signs)
• Typhoid fever (severe)
• Encephalitis
• Other severe systemic infections

Potential Complications

• Coma
• Permanent neurological damage (from meningitis, cerebral malaria, hypoglycemia)
• Shock
• Severe anaemia (malaria)
• Kidney failure
• Respiratory failure
• Death

Prevention

• Use of Insecticide Treated Nets (ITNs).
• Prompt diagnosis and treatment of uncomplicated malaria.
• Immunizations (Hib, Pneumococcal, Meningococcal if available/indicated).
• Good nutrition.
• Prompt care seeking for any fever.

Key Features

• History of measles (rash + cough/runny nose/red eyes) within last 3 months.
• Presence of ANY General Danger Sign OR Clouding of Cornea OR Deep/extensive mouth ulcers.
• Clouding of cornea indicates severe Vitamin A deficiency and risk of blindness.
• Deep mouth ulcers impair feeding and increase risk of secondary infection/dehydration.
• Requires Vitamin A, pre-referral antibiotic, and urgent referral.

Assessment

• Ask: Does the child have fever?
• Ask: Has the child had measles within the last 3 months? (Look for generalized rash PLUS one of: cough, runny nose, red eyes).
• If Yes to Measles:
• Check for General Danger Signs (Any ONE: Unable to drink/breastfeed, Vomits everything, Had convulsions, Lethargic/unconscious, Convulsing now).
• Look: Look for clouding of the cornea.
• Look: Look for deep or extensive mouth ulcers.

Classification

• Measles now or within last 3 months AND (Any general danger sign OR Clouding of cornea OR Deep/extensive mouth ulcers) -> SEVERE COMPLICATED MEASLES

Management

Non-Pharmacological Management

• Quickly complete assessment.
• Keep child warm.
• Provide supportive care for breathing/airway if needed.

Pharmacological Treatment

• Give Vitamin A treatment dose TODAY (Day 1). Dose: Age 6-11 months: 100,000 IU (Blue capsule). Age 12 months - 5 years: 200,000 IU (Red/Yellow capsule). (Note: Give 2nd dose on Day 2, 3rd dose after 2 weeks if eye signs present - managed at referral).
• Give first dose of appropriate IM antibiotic (e.g., Ampicillin + Gentamicin or Ceftriaxone - see page 12 for doses).
• If clouding of cornea or pus draining from eye: Apply Tetracycline eye ointment (1%) into both eyes.
• Treat to prevent low blood sugar (as per page 12).
• Give other necessary pre-referral treatments (e.g., rectal diazepam, antimalarial if co-existing severe classification).

Pre-Referral Treatment

• Vitamin A Day 1 dose.
• First dose IM antibiotic.
• Tetracycline eye ointment if eye signs.
• Treat for low blood sugar.
• Other essential pre-referral treatments.

Monitoring & Follow-Up

• To be managed at referral hospital facility.

Counselling Points

• Explain that measles has caused serious complications requiring hospital care.
• Explain treatments given (Vit A, antibiotic, eye ointment).
• Advise on keeping child warm and continuing fluids/breastfeeding if possible during transport.
• Write a detailed referral note mentioning measles, complications found, and all treatments given.

Differential Diagnosis

• Measles with Eye/Mouth complications (less severe)
• Uncomplicated Measles
• Other viral exanthems (e.g., Rubella, Dengue, Enterovirus)
• Kawasaki disease
• Drug reaction
• Severe Vitamin A deficiency (corneal signs)
• Herpetic stomatitis (mouth ulcers)

Potential Complications

• Blindness (from corneal ulceration/scarring)
• Severe Pneumonia
• Encephalitis
• Severe Diarrhoea and Dehydration
• Severe Stomatitis leading to poor intake/malnutrition
• Otitis Media, Mastoiditis
• Sepsis
• Subacute Sclerosing Panencephalitis (SSPE - late complication)
• Death

Prevention

• Measles vaccination (2 doses as per national schedule).
• Vitamin A supplementation (routine).
• Good nutrition.
• Prompt treatment of uncomplicated measles.
• Isolation of cases to prevent spread.

Key Features

• History of measles within last 3 months.
• Presence of Pus draining from eye OR Mouth ulcers (not deep/extensive).
• Absence of severe complications (danger signs, corneal clouding, deep ulcers).
• Requires Vitamin A and specific local treatment for eye/mouth.

Assessment

• Ask: Does the child have fever?
• Ask: Has the child had measles within the last 3 months?
• If Yes to Measles:
• Confirm absence of General Danger Signs.
• Confirm absence of Clouding of Cornea.
• Confirm mouth ulcers are NOT deep or extensive.
• Look: Look for pus draining from the eye.
• Look: Look for mouth ulcers (superficial).

Classification

• Measles now or within last 3 months AND (Pus draining from the eye OR Mouth ulcers) AND No signs of Severe Complicated Measles -> MEASLES WITH EYE OR MOUTH COMPLICATIONS

Management

Non-Pharmacological Management

• Advise on increased fluids and continued feeding.
• For mouth ulcers: Advise soft, non-irritating foods. Avoid spicy, salty, acid foods. Chop foods finely.
• For eye infection: Teach mother how to clean the eyes before applying ointment.

Pharmacological Treatment

• Give Vitamin A treatment dose TODAY (Day 1) and TOMORROW (Day 2). Dose: Age 6-11 months: 100,000 IU daily x 2 days. Age 12 months - 5 years: 200,000 IU daily x 2 days.
• If pus draining from the eye: Treat eye infection with Tetracycline eye ointment (1%). Teach mother to: Wash hands, clean eyes gently with clean cloth/water, apply ointment inside lower lid, 4 times daily until discharge stops. Treat both eyes.
• If mouth ulcers: Treat with Gentian Violet (0.25% aqueous solution - half strength). Teach mother to: Wash hands, wash child's mouth with clean soft cloth wrapped on finger and wet with salt water, paint mouth ulcers with GV using clean applicator, twice daily for 5 days or until 48 hours after ulcers heal. Give Paracetamol for pain relief if needed.

Monitoring & Follow-Up

• Follow-up in 3 days.
• At follow-up (Day 3):
• Reassess eyes and mouth.
• For Eye Infection: If pus worse or same and treatment was correct, refer. If incorrect treatment, teach correct method. If pus gone but redness remains, continue treatment. If no pus/redness, stop treatment.
• For Mouth Ulcers: If worse or very foul smell, refer. If same or better, continue GV for total 5 days.
• Check for other problems.

Counselling Points

• Explain the complication (eye or mouth) and the need for Vitamin A and local treatment.
• Teach how to give Vitamin A (correct dose, 2 days).
• If eye infection: Teach how to clean eyes and apply Tetracycline ointment correctly, frequency (4x/day), duration.
• If mouth ulcers: Teach how to clean mouth and apply Gentian Violet correctly, frequency (2x/day), duration. Advise on soft foods.
• Advise on continuing feeding and fluids.
• Advise when to return immediately (danger signs, eye/mouth problem worsening, corneal clouding).
• Advise on follow-up visit in 3 days.

Differential Diagnosis

• Severe Complicated Measles
• Uncomplicated Measles
• Bacterial conjunctivitis (non-measles)
• Viral conjunctivitis (non-measles)
• Herpetic gingivostomatitis
• Aphthous ulcers
• Hand, foot, and mouth disease

Potential Complications

• Progression to severe eye complications (corneal ulcer/scarring) if eye infection untreated/severe.
• Secondary bacterial infection of mouth ulcers.
• Poor feeding and malnutrition due to mouth pain.
• Dehydration.

Prevention

• Measles vaccination (2 doses).
• Vitamin A supplementation (routine).
• Good nutrition.
• Good hygiene practices.

Key Features

• Presence of bilateral pitting oedema (any grade) automatically classifies as SAM.
• OR WFH/L Z-score < -3.
• OR MUAC = 6 months).
• AND Presence of ANY of the following indicates COMPLICATED SAM: Any medical complication (General danger sign, severe classification, pneumonia w/ chest indrawing) OR Failed appetite test (for child >= 6 months) OR Breastfeeding problem (for child < 6 months).

Assessment

• Look/Feel: Look for oedema of both feet (Check by pressing thumb gently for 3 seconds).
• Look/Feel: Determine Weight-for-Height/Length (WFH/L) Z-score using WHO growth charts.
• Look/Feel: Measure Mid-Upper Arm Circumference (MUAC) in mm (for children 6 months or older).
• Check for Medical Complications: Any General Danger Sign (see IMCI_2M5Y_001)? Any Severe Classification (e.g., Severe Pneumonia, Severe Dehydration)? Pneumonia with chest indrawing?
• Check Appetite (only if SAM criteria met AND child >= 6 months AND no other medical complication present): Offer Ready-to-Use Therapeutic Food (RUTF). Is the child able to finish the prescribed amount based on weight?
• Check Breastfeeding (only if SAM criteria met AND child < 6 months AND no other medical complication present): Assess breastfeeding (attachment, suckling). Does the child have a breastfeeding problem?

Classification

• (Oedema of both feet) OR (WFH/L < -3 Z-score) OR (MUAC =6m]) AND [ (Any medical complication present) OR (Not able to finish RUTF [if >=6m]) OR (Breastfeeding problem [if COMPLICATED SEVERE ACUTE MALNUTRITION

Management

Non-Pharmacological Management

• Keep the child warm (prevent/treat hypothermia).
• Handle gently.
• Quickly complete assessment for other pre-referral needs.

Pre-Referral Treatment

• Give first dose of an appropriate IM antibiotic (e.g., Ampicillin 50mg/kg + Gentamicin 7.5mg/kg or Ceftriaxone - see page 12 for doses). Assume infection even if not obvious.
• Treat to prevent low blood sugar (Hypoglycemia): Give 50ml of 10% glucose/sucrose solution (or usual sugar water: 4 tsp sugar in 200ml water) orally or by NG tube. If possible, check blood sugar. Follow with feeding.
• Give Vitamin A dose if child is >= 6 months (unless given in last month). Dose: Age 6-11m: 100,000 IU. Age 12m-5y: 200,000 IU (Page 20). Do NOT give Vitamin A if oedema is present (often given during stabilization phase under supervision). Check local inpatient protocol.
• Do NOT give iron in the initial phase.
• Provide rehydration fluid carefully if dehydration present (use ReSoMal if available, or half-strength ORS with added potassium/glucose as per inpatient protocols; standard ORS can worsen electrolyte imbalance in SAM). Give fluids slowly, orally or NG. Avoid IV fluids unless signs of shock are present, give cautiously.

Monitoring & Follow-Up

• To be managed in an inpatient therapeutic feeding center / hospital stabilization phase.

Counselling Points

• Explain that the child is very severely malnourished and has complications requiring urgent hospital treatment.
• Explain treatments given (antibiotic, sugar solution, Vit A if given).
• Advise on keeping child warm during transport.
• Reassure mother about therapeutic feeding program.
• Write a detailed referral note indicating Complicated SAM, specific complications, WFH/L or MUAC/oedema status, and treatments given.

Differential Diagnosis

• Uncomplicated Severe Acute Malnutrition
• Moderate Acute Malnutrition
• Stunting (Chronic malnutrition - low Height-for-Age)
• Oedema due to other causes (renal disease, heart failure - less common, clinical context important)

Potential Complications

• Hypoglycemia
• Hypothermia
• Dehydration / Shock
• Severe electrolyte imbalance
• Infection / Sepsis
• Heart failure (especially during refeeding)
• Severe anaemia
• Vitamin/Mineral deficiencies (esp. Vit A, Zinc, Potassium, Phosphate, Magnesium)
• Refeeding syndrome

Prevention

• Improved infant and young child feeding practices (exclusive breastfeeding, appropriate complementary feeding).
• Prevention and prompt management of childhood illnesses.
• Micronutrient supplementation.
• Food security.
• Maternal health and nutrition.

Key Features

• Presence of ANY symptom suggestive of TB (persistent cough/fever, non-responsive pneumonia, contact history) OR Very low weight (<1.5kg or WFA<-3Z) triggers suspicion.
• Diagnosis is challenging in this age group; high index of suspicion needed.
• Requires referral for specialized investigation (e.g., gastric aspirates, X-ray, GeneXpert) and management.
• Young infants with danger signs also warrant TB consideration and referral.

Assessment

• Ask: History of contact with a person with PTB or chronic cough?
• Ask: Persistent fever (>14 days)?
• Ask: Persistent cough (>14 days)?
• Check: Does infant have pneumonia not responding to standard therapy?
• Check: Weight for age. Is it <1.5kg? Is WFA Z-score < -3?
• Check: Presence of ANY danger sign (implies severe illness, increasing TB suspicion if other symptoms present).

Classification

• Presence of ANY of the symptoms and signs suggestive of TB (contact Hx, cough>14d, fever>14d, non-responsive pneumonia) OR Weight less than 1.5kg OR WFA PRESUMPTIVE TB

Management

Non-Pharmacological Management

• Keep infant warm.
• Support feeding.
• Refer to hospital for further assessment and management.

Pharmacological Treatment

• If danger signs also present, provide pre-referral treatment for PSBI/VSD (Antibiotics, prevent hypoglycemia - Page 40) before referral.
• TB treatment is typically initiated at referral center after investigation.

Pre-Referral Treatment

• Manage any danger signs (PSBI/VSD treatment - Page 40).
• Keep warm.
• Support feeding.

Monitoring & Follow-Up

• To be managed at referral hospital / TB clinic.

Counselling Points

• Explain that the baby has signs that might indicate TB and needs further tests at the hospital.
• Explain any pre-referral treatments given.
• Advise on keeping infant warm and continuing feeding during transport.
• Ask about caregiver's health (possible TB source) and advise testing if needed.
• Write a detailed referral note listing signs, symptoms, weight, and reason for TB suspicion.

Differential Diagnosis

• PSBI / Sepsis
• Severe Pneumonia (bacterial/viral)
• Congenital infection
• Malnutrition / Failure to thrive (non-TB causes)
• Congenital lung/airway anomalies

Potential Complications

• Disseminated TB (miliary, meningitis)
• Severe pneumonia
• Death

Prevention

• BCG vaccination at birth.
• Early identification and treatment of infectious TB cases in household.
• IPT for eligible exposed infants (though usually started >2 months).