IMCI Handbook Search Tool

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

• Fever (current or recent history).
• Positive malaria diagnostic test.
• Absence of any general danger sign or stiff neck.
• Requires treatment with oral Artemisinin-based Combination Therapy (ACT).

Assessment

• Ask: Does the child have fever (by history, feels hot, or temperature 37.5C)?
• Confirm absence of General Danger Signs.
• Confirm absence of Stiff Neck.
• Perform Malaria Test (RDT or Microscopy) - Result is POSITIVE.

Classification

• Fever present AND Malaria test POSITIVE AND No signs of Very Severe Febrile Disease -> MALARIA

Management

Non-Pharmacological Management

• Advise adequate fluid intake.
• Advise tepid sponging for comfort if high fever (optional, do not use cold water).
• Continue feeding.

Pharmacological Treatment

• Give first-line oral Artemisinin-based Combination Therapy (ACT): Artemether-Lumefantrine (AL) OR Artesunate-Amodiaquine (AS+AQ).
• AL Dosing (Coartem 20/120mg tablets, give dose twice daily for 3 days at 0, 8, 24, 36, 48, 60 hours): Weight 5-<15kg (Age 4m-<3y): 1 tablet per dose. Weight 15-<25kg (Age 3-<9y): 2 tablets per dose. Weight 25-<35kg (Age 9-=35kg (Age >14y): 4 tablets per dose. Give with food/fatty drink.
• AS+AQ Dosing (Fixed dose combination, give once daily for 3 days): Refer to specific product dosing based on age/weight bands.
• Give Paracetamol (10-15 mg/kg) if high fever (38.5C axillary) - see dosage on page 15.
• If fever persists every day for more than 7 days, refer for further assessment.

Monitoring & Follow-Up

• Follow-up in 3 days IF fever persists.
• At follow-up: Reassess child fully. If danger signs or stiff neck, treat as Very Severe Febrile Disease and refer. If malaria is only cause of persistent fever, treat with second-line antimalarial (e.g., Quinine) or refer. If other cause identified, treat accordingly.
• If fever has been present > 7 days total, refer for assessment.

Counselling Points

• Explain the diagnosis (malaria) and the need for antimalarial tablets.
• Teach how to give the full course of ACT correctly: dose, timing (especially for AL's 8-hour second dose), duration (3 days), importance of giving with food for AL.
• Teach how to give Paracetamol for high fever.
• Advise on increasing fluids and continuing feeding.
• Advise WHEN TO RETURN IMMEDIATELY: Develops danger signs (cannot drink, vomits everything, convulsions, lethargy), develops stiff neck, becomes sicker.
• Advise to return in 3 days if fever persists, or sooner if condition worsens.

Differential Diagnosis

• Very Severe Febrile Disease (especially Severe Malaria)
• Fever - No Malaria (viral illness, other bacterial infection)
• Pneumonia
• Urinary Tract Infection
• Typhoid fever
• Other febrile illnesses

Potential Complications

• Progression to severe malaria
• Anaemia
• Febrile convulsions
• Dehydration

Prevention

• Sleeping under an Insecticide Treated Net (ITN) every night.
• Indoor residual spraying (IRS) where implemented.
• Prompt diagnosis and effective treatment of malaria episodes.
• Intermittent Preventive Treatment in pregnancy (IPTp) and infancy (IPTi)/Seasonal Malaria Chemoprevention (SMC) where applicable.

Key Features

• Fever (current or recent history).
• Malaria test is negative (or not done but malaria unlikely/ruled out clinically where appropriate).
• Absence of any general danger sign or stiff neck.
• Need to search for and treat other potential causes of fever.
• If no cause found, likely viral, manage symptomatically.

Assessment

• Ask: Does the child have fever (by history, feels hot, or temperature 37.5C)?
• Confirm absence of General Danger Signs.
• Confirm absence of Stiff Neck.
• Perform Malaria Test (RDT or Microscopy) - Result is NEGATIVE OR test not done.
• Look for other causes of fever (e.g., signs of pneumonia, ear infection, UTI symptoms, skin infection, throat infection).

Classification

• Fever present AND Malaria test NEGATIVE (or not done/available) AND Other cause of fever PRESENT -> FEVER - NO MALARIA (Treat the identified cause)
• Fever present AND Malaria test NEGATIVE (or not done/available) AND No other cause of fever identified -> FEVER - NO MALARIA (Likely Viral)

Management

Non-Pharmacological Management

• Advise adequate fluid intake.
• Continue feeding.
• Advise tepid sponging for comfort if high fever (optional).

Pharmacological Treatment

• Give one dose of Paracetamol (10-15 mg/kg) in the clinic if high fever (38.5C axillary) - see dosage on page 15.
• If an identified bacterial cause of fever is present (e.g., Pneumonia, Acute Ear Infection, Dysentery): Give appropriate antibiotic treatment for that condition (refer to relevant sections/pages for drug, dose, duration - e.g., Amoxicillin for Pneumonia/AOM, Ciprofloxacin for Dysentery).
• If fever is present every day for > 7 days, refer for further assessment.
• If fever is present for > 14 days, check for TB (assess symptoms, contact history - see page 9).

Monitoring & Follow-Up

• Follow-up in 3 days IF fever persists.
• At follow-up: Reassess child fully (check danger signs, stiff neck, source of fever). If danger signs/stiff neck, treat as Very Severe Febrile Disease and refer. If fever persists without source, reassess carefully, consider referral if >7 days total or child unwell. If another cause identified, treat. If improving, reassure.
• Advise mother when to return immediately.

Counselling Points

• If bacterial cause identified: Explain diagnosis and need for antibiotic. Teach how to give antibiotic correctly.
• If no bacterial cause identified: Explain likely viral cause, reassure that antibiotics are not needed. Explain that fever may last a few days.
• Teach how to give Paracetamol for high fever at home (correct dose, frequency max every 6 hours).
• Advise on increasing fluids and continuing feeding.
• Advise WHEN TO RETURN IMMEDIATELY: Develops danger signs, develops stiff neck, becomes sicker, fever persists > 3 days without improving at all, or develops localizing signs.
• Advise to return in 3 days if fever persists.

Differential Diagnosis

• Viral URTI / LRTI (Flu, adenovirus etc.)
• Pneumonia
• Acute Otitis Media
• Urinary Tract Infection (UTI)
• Tonsillitis/Pharyngitis (Bacterial or Viral)
• Skin and soft tissue infection (abscess, cellulitis)
• Gastroenteritis (may have fever)
• Typhoid fever
• Tuberculosis (if prolonged fever)
• Other less common infections (e.g., Brucellosis, Rickettsial)
• Non-infectious causes (rare in this context - e.g., Kawasaki disease)

Potential Complications

• Febrile convulsions
• Dehydration
• Complications related to the underlying cause of fever (e.g., mastoiditis from ear infection, pyelonephritis from UTI).

Prevention

• Immunizations.
• Handwashing, hygiene.
• Good nutrition.
• Malaria prevention (reduces malaria as cause, helps focus on other causes).
• Prompt care seeking.

Key Features

• Diagnosis often based on a combination of symptoms, contact history, and signs, especially in young children where bacteriological confirmation is difficult.
• Criteria differ slightly based on HIV status: >=2 symptoms/signs if HIV Neg, >=1 symptom/sign if HIV Pos.
• Positive contact history is significant.
• Positive GeneXpert or smear microscopy confirms TB.
• Requires multi-drug anti-TB treatment regimen.

Assessment

• Ask (Symptoms suggestive of TB):
• Has the child been coughing for 14 days or more?
• Has the child had persistent fever (14 days)?
• Has the child had poor weight gain in the last month? (Defined as: Weight loss >5% since last visit OR Weight-for-age < -3 Z-score OR Weight-for-age < -2 Z-score OR Growth curve flattening OR Red/Yellow MUAC colour code).
• Ask (History of contact):
• Has the child had contact with a person with Pulmonary TB or chronic cough?
• Look/Feel (Physical signs suggestive of TB):
• Look/Feel for swellings in the neck or armpit (lymphadenopathy).
• Look/Feel for swelling on the back (e.g., gibbus).
• Look/Feel for stiff neck.
• Listen for persistent wheeze not responding to bronchodilators.
• Check HIV status (HIV positive status increases suspicion/risk).
• Review available diagnostic tests: Collect sample for GeneXpert or smear microscopy if available. Chest X-Ray results if available.

Classification

• Criteria for TB Classification:
• (HIV Negative Child): Two or more of the following: (Cough 14d) OR (Fever 14d) OR (Poor weight gain*) OR (Positive contact history) OR (Suggestive physical sign: neck/axilla/back swelling, stiff neck, persistent wheeze).
• (HIV Positive Child): One or more of the following: (Cough 14d) OR (Fever 14d) OR (Poor weight gain*) OR (Positive contact history) OR (Suggestive physical sign).
• OR A positive GeneXpert or smear microscopy test.
• -> Classify as TB

Management

Non-Pharmacological Management

• Provide nutritional support counselling.
• Counsel on adherence to long-term treatment.
• Trace contacts of the child (especially the source case) for screening.

Pharmacological Treatment

• Initiate TB treatment using appropriate regimen based on national guidelines (typically involves Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), +/- Ethambutol (E) in intensive phase, followed by HR in continuation phase).
• Use weight-band dosing for fixed-dose combinations (FDCs) if available (See Page 19 for RHZ 75/50/150 and E100 weight bands: 4-7kg: 1 tab RHZ, 1 tab E; 8-11kg: 2 tabs RHZ, 2 tabs E; 12-15kg: 3 tabs RHZ, 3 tabs E; 16-24kg: 4 tabs RHZ, 4 tabs E).
• Intensive Phase (First 2 months): Typically 2RHZE or 2RHZ.
• Continuation Phase (Next 4 or 10 months): Typically 4RH or 10RH (longer for TB meningitis/bone TB). See Page 19: 4RH for most forms, 10RH for TB meningitis/osteoarticular TB.
• Link the child to the nearest TB clinic for registration, ongoing treatment, monitoring, and follow-up.
• If GeneXpert or smear microscopy test is not available or negative, but clinical suspicion is high based on criteria, initiate treatment and refer for further assessment/confirmation.
• Treat, counsel, and follow up any co-infections (e.g., HIV, malnutrition).
• If available, give Pyridoxine (Vitamin B6) 12.5mg/day for children <5 years on Isoniazid to prevent neuropathy (absence should not delay starting TB meds).

Pre-Referral Treatment

• If signs of severe TB (meningitis, respiratory distress) or other severe classification present, provide appropriate pre-referral treatments (antibiotics, manage danger signs) before urgent referral to hospital (TB treatment may be initiated at hospital).

Monitoring & Follow-Up

• Requires regular follow-up at the TB clinic (e.g., monthly) for monitoring treatment response, side effects, adherence, and weight gain.
• Contact tracing follow-up.

Counselling Points

• Explain the diagnosis (TB) and the need for long-term treatment (usually 6 months).
• Explain the importance of taking medications every day exactly as prescribed.
• Teach how to give the TB medicines (crushing/dispersing tablets if needed).
• Explain potential side effects and when to return if they occur (e.g., yellow eyes, skin rash).
• Counsel on good nutrition to support recovery.
• Explain importance of follow-up visits at TB clinic.
• Discuss infection control measures within the household (e.g., cough hygiene, ventilation) if relevant.
• Ask about the caregiver's health (possible source case) and advise screening if needed.
• Counsel on contact tracing for other household members, especially young children.

Differential Diagnosis

• Persistent bacterial pneumonia
• Asthma (persistent wheeze)
• Chronic lung disease
• Lymphoma or other malignancy (lymphadenopathy)
• HIV-related complications (poor weight gain, fever)
• Malnutrition (poor weight gain)
• Other chronic infections

Potential Complications

• TB Meningitis
• Miliary TB
• Spinal TB (Pott's disease)
• Pleural effusion
• Bronchiectasis
• Treatment failure / Drug resistance
• Drug toxicity (e.g., hepatitis, neuropathy)
• Malnutrition
• Death

Prevention

• BCG vaccination at birth (protects mainly against severe forms like meningitis).
• Isoniazid Preventive Therapy (IPT) for eligible contacts (especially HIV+ children and children <5y who are close contacts) - see TB Exposure classification.
• Early diagnosis and treatment of infectious TB cases (source control).
• Infection control measures (ventilation, cough hygiene).
• HIV prevention and treatment (reduces TB risk).

Key Features

• ANY ONE of the specified signs indicates PSBI or Very Severe Disease.
• Signs include severe feeding problems, convulsions, respiratory distress (severe chest indrawing or fast breathing <7d), temperature instability (high or low), or significantly reduced movement.
• This is a life-threatening emergency in young infants.

Assessment

• Ask: Is the infant having difficulty in feeding?
• Ask: Has the infant had convulsions?
• Look/Feel: Count the breaths in one minute. Repeat if >= 60.
• Look/Feel: Look for SEVERE chest indrawing.
• Look/Feel: Measure axillary temperature. Is it 38C or <35.5C?
• Look/Feel: Look at the young infant's movements. Does the infant move on his/her own? Stimulate if not moving. Does the infant move only when stimulated? Does the infant not move at all?
• Check specific signs listed in classification criteria.

Classification

• Any ONE of the following signs:
• Not able to feed since birth, stopped feeding well, or not feeding at all
• Convulsions
• Severe chest indrawing
• Fast breathing (>= 60 breaths/minute) in infants LESS THAN 7 DAYS OLD
• Fever (>= 38C axillary)
• Low body temperature (< 35.5C axillary)
• Movement only when stimulated or no movement at all
• -> POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE

Management

Non-Pharmacological Management

• Quickly complete assessment for all necessary pre-referral treatments.
• Keep the infant warm: Initiate skin-to-skin contact (Kangaroo Mother Care) if possible OR wrap infant in warm, dry clothes, including hat/socks, cover with blanket. Ensure no draughts.
• Handle gently.

Pre-Referral Treatment

• Give first dose of intramuscular antibiotic: Gentamicin (5 mg/kg, or 4 mg/kg if low birth weight concentration becomes 20mg/ml. Dose based on weight (refer to local dosing charts or calculate carefully). Ampicillin (prepare 500mg vial): Dose based on weight. (Refer to Page 40 for general statement, precise dosing usually requires local protocol/weight chart).
• Treat to prevent low blood sugar (Hypoglycemia): If infant can breastfeed, ask mother. If cannot feed but can swallow, give 20-50ml (approx 10ml/kg) EBM. If cannot swallow, give EBM via NG tube. (Sugar water is not the first option for neonates, EBM preferred, page 40 focuses on EBM).
• If referral is refused or not possible: Continue antibiotic treatment (e.g., Gentamicin OD + Ampicillin BD/QDS based on protocol) for 7 days. Continue warmth, feeding support (NG if needed), oxygen if available/indicated. This is high-risk care outside referral center.

Monitoring & Follow-Up

• To be managed at referral hospital facility.

Counselling Points

• Explain that the baby is very sick and needs urgent hospital care.
• Explain treatments given (antibiotics, sugar/milk).
• Teach the mother how to keep the infant warm on the way to the hospital (skin-to-skin contact or warm wrapping).
• Advise mother to continue trying to breastfeed if possible.
• Write a detailed referral note including all signs, classification, and treatments given (drug, dose, time).

Differential Diagnosis

• Neonatal Sepsis
• Bacterial Meningitis
• Severe Pneumonia
• Birth Asphyxia complications
• Congenital Heart Disease
• Metabolic disorders
• Hypoglycemia
• Severe Jaundice complications (kernicterus)

Potential Complications

• Septic shock
• Meningitis with neurological sequelae
• Respiratory failure
• Apnea
• Hypoglycemia complications (brain damage)
• Hypothermia complications
• Death

Prevention

• Clean delivery practices.
• Maternal health (screening/treatment of infections like GBS).
• Early and exclusive breastfeeding.
• Thermal care at birth.
• Handwashing.
• Prompt recognition and care seeking for newborn illness.
• Cord care (clean and dry, or chlorhexidine where recommended).

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).