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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

• 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

• Fast breathing (>= 60 breaths/minute) is the key sign.
• Applies ONLY to infants aged 7 days to 59 days.
• Absence of severe chest indrawing and other signs of PSBI/Very Severe Disease is crucial for this classification.
• Requires treatment with oral Amoxicillin.

Assessment

• Confirm Age is 7 days up to 2 months (59 days).
• Look/Feel: Count the breaths in one minute. Repeat if >= 60. Ensure infant is calm/quiet.
• Confirm absence of Severe Chest Indrawing.
• Confirm absence of all signs listed for PSBI / Very Severe Disease (feeding problem, convulsions, fever, low temp, abnormal movement).

Classification

• Fast breathing (>= 60 breaths/minute) AND Age 7 days to 59 days AND No severe chest indrawing AND No other signs of PSBI/Very Severe Disease -> PNEUMONIA

Management

Non-Pharmacological Management

• Advise mother on keeping infant warm.
• Advise on continued exclusive breastfeeding.
• Advise on clearing blocked nose if interfering with feeding.
• Advise mother on signs to return immediately.

Pharmacological Treatment

• Give oral Amoxicillin twice daily for 7 days. Dosage (using 75-100mg/kg/day range, divided twice daily): Weight 1.5-2.4kg: 125mg per dose (1/2 of 250mg DT or 2.5ml of 250mg/5ml syrup). Weight 2.5-3.9kg: 125mg per dose (1/2 of 250mg DT or 2.5ml of 250mg/5ml syrup). Weight 4.0-5.9kg: 250mg per dose (1 of 250mg DT or 5ml of 250mg/5ml syrup). (Note: Dosages derived from page 42, aiming for mid-range).
• Give Paracetamol if fever >=38C (Dosing needs careful calculation for neonates, often 10-15mg/kg/dose q6-8h - refer to specific neonatal dosing guidelines, IMCI chart doesn't specify neonatal paracetamol dose here).

Monitoring & Follow-Up

• Follow up on day 4 (Page 47).
• At follow-up (Day 4): Reassess for PSBI/VSD signs, pneumonia signs. Check feeding.
• If PSBI/VSD signs develop -> Refer URGENTLY.
• If improving (breathing slower, feeding well): Continue Amoxicillin to complete 7 days.
• If not improving or worse: Refer URGENTLY (consider treatment failure/alternative diagnosis).

Counselling Points

• Explain the diagnosis (pneumonia) and the need for antibiotic.
• Teach mother how to give oral Amoxicillin: correct dose (demonstrate measurement), frequency (twice daily), full duration (7 days).
• Advise on keeping infant warm.
• Advise on exclusive breastfeeding.
• Advise on WHEN TO RETURN IMMEDIATELY: Breathing becomes difficult, breathing becomes faster, feeding poorly, becomes sicker, develops fever or feels cold.
• Advise on follow-up visit on day 4.

Differential Diagnosis

• Possible Serious Bacterial Infection / Very Severe Disease (if any severe signs present)
• Transient Tachypnea of the Newborn (usually resolves <72 hours)
• Bronchiolitis (often associated with wheeze, cough)
• Congenital heart disease
• Aspiration
• Metabolic acidosis

Potential Complications

• Progression to severe pneumonia/PSBI
• Respiratory failure
• Apnea
• Treatment failure

Prevention

• Maternal health (immunization, nutrition).
• Exclusive breastfeeding.
• Avoiding exposure to smoke and sick contacts.
• Handwashing.

Key Features

• Absence of any sign classifying as PSBI/VSD, Pneumonia, or Local Bacterial Infection.
• Indicates low likelihood of significant bacterial infection requiring antibiotics.
• Focus is on home care advice and monitoring.

Assessment

• Confirm absence of all signs listed for PSBI / Very Severe Disease.
• Confirm absence of Fast Breathing (if age 7-59 days).
• Confirm absence of Severe Chest Indrawing.
• Confirm absence of Umbilical redness/pus.
• Confirm absence of Skin pustules.

Classification

• No signs of PSBI/Very Severe Disease AND No signs of Local Bacterial Infection AND No Fast Breathing (if 7-59 days) -> INFECTION UNLIKELY

Management

Non-Pharmacological Management

• Advise mother on home care for the young infant:
• Keep infant warm (skin-to-skin, appropriate clothing/wrapping).
• Exclusively breastfeed frequently, day and night.
• Ensure good hygiene (handwashing).
• Advise on signs requiring immediate return.

Pharmacological Treatment

• No antibiotics needed.

Monitoring & Follow-Up

• No specific follow-up needed unless another problem identified.
• Advise return immediately if any danger signs develop.

Counselling Points

• Reassure mother that the infant does not show signs of serious infection.
• Provide counselling on essential newborn care: warmth, exclusive breastfeeding, hygiene.
• Advise WHEN TO RETURN IMMEDIATELY: Difficulty feeding, becomes sicker, develops fever, feels cold, fast breathing, difficult breathing.
• Address any other concerns the mother has.

Differential Diagnosis

• Consider other non-infectious issues if infant has symptoms (e.g., colic, feeding difficulties not meeting PSBI criteria, mild jaundice).

Prevention

• Essential newborn care (warmth, breastfeeding, hygiene).
• Prompt care seeking if illness develops.