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

• Presence of Some Palmar Pallor.
• Absence of Severe Palmar Pallor.
• Requires malaria testing.
• Requires iron treatment (unless contraindicated by confirmed SCD + RUTF, or SAM + RUTF).
• Requires assessment for underlying causes, including SCD.

Assessment

• Look/Feel: Look at the child's palms. Are they pale? (Some Palmar Pallor).
• Confirm absence of Severe Palmar Pallor.
• If palmar pallor (some or severe) is present, assess for history and symptoms suggestive of Sickle Cell Disease (SCD):
• Ask: Family history of SCD or sibling death from anaemia?
• Ask: History of painful joints/bones, episodes of severe pain (abdomen, chest, bones)?
• Ask: History of previous blood transfusion?
• Look/Feel: Swelling of hands & feet (dactylitis, esp. in infants)?
• Look/Feel: Features suggestive of stroke (weakness of one side)?
• Look/Feel: Bossing (prominence) of skull?

Classification

• Some palmar pallor -> ANAEMIA

Management

Non-Pharmacological Management

• Counsel on iron-rich foods.
• If SCD confirmed, provide specific counselling and link to care.

Pharmacological Treatment

• Do Malaria Test (RDT or Microscopy). Treat if positive (see Malaria classification).
• Give Iron: Provide Iron/Folate supplement (e.g., Ferrous sulfate 200mg + Folic acid 250mcg tablet, containing ~60mg elemental iron) or Iron Syrup (e.g., Ferrous fumarate 100mg/5ml, containing ~20mg elemental iron/5ml) once daily for 14 days initially. Syrup Dose: 2-3m (<6kg): 1.0ml (<1/4 tsp). 4m-<12m (6-<10kg): 1.25ml (1/4 tsp). 12m-<3y (10-<14kg): 2.0ml (<1/2 tsp). 3y-5y (14-19kg): 2.5ml (1/2 tsp). Tablet Dose: 12m-<3y: 1/2 tablet. 3y-5y: 1/2 tablet. (Note: Doses match syrup/tab given on page 17, continue for 14 days initially).
• Give Folic Acid (5mg tablet) if giving plain iron (not iron+folate compound). Dose: 1/2 tablet daily for 2-3m, 1 tablet daily for 4m-5y.
• **IMPORTANT Iron Contraindications:** If child has confirmed Sickle Cell Disease AND/OR Severe Acute Malnutrition AND is receiving RUTF, DO NOT give iron supplement. Give Folic Acid instead.
• Give Mebendazole 500mg single dose if child >= 1 year and not dewormed in past 6 months (Page 20).
• If child has history or symptoms suggestive of SCD: Recommend testing for SCD (e.g., Hb electrophoresis). If child already confirmed with SCD and has pallor/illness, REFER.

Pre-Referral Treatment

• If referring due to confirmed SCD needing assessment: Manage pain, ensure hydration.

Monitoring & Follow-Up

• Follow-up in 14 days.
• At follow-up (Day 14): Reassess palmar pallor. If still some pallor, continue giving iron daily for 2 months total. If severe pallor, refer urgently. If no pallor, stop iron.
• Advise mother when to return immediately (develops severe pallor, danger signs).

Counselling Points

• Explain the child has anaemia (pale blood) and needs iron medicine.
• Teach how to give iron supplement correctly (dose, frequency, duration - 14 days initially, then reassess).
• Advise iron can make stools black.
• Advise on iron-rich foods.
• Explain importance of deworming (Mebendazole).
• If SCD suspected: Explain the need for testing and potential for inherited condition.
• If SCD confirmed: Provide specific counselling (link to SCD clinic, avoid iron unless prescribed, importance of folic acid, recognize crisis signs).
• Advise when to return immediately (severe pallor, danger signs).
• Advise on follow-up in 14 days.

Differential Diagnosis

• Severe Anaemia
• No Anaemia
• Causes of anaemia: Iron deficiency, Malaria, Hookworm, Sickle Cell Disease, Other haemoglobinopathies, Chronic infection/inflammation, Malnutrition.

Potential Complications

• Progression to severe anaemia
• Impaired cognitive development (iron deficiency)
• Reduced exercise tolerance
• Increased susceptibility to infection
• Complications related to underlying cause (e.g., SCD crisis)

Prevention

• Malaria prevention.
• Routine iron supplementation in high-risk populations/ages.
• Deworming.
• Diet rich in iron and enhancers of iron absorption (Vitamin C).
• Delayed cord clamping at birth.
• Newborn screening and management for SCD.