Paediatrics chapters
Integrated Management of Newborn and Childhood Illness (IMNCI)
The WHO and UNICEF strategy for sick children under 5 years: general danger signs, colour-coded classification of cough, diarrhoea, fever, ear problems, malnutrition, anaemia and HIV, and the young infant charts.
- IMNCI is a WHO-UNICEF strategy for children under 5 at first-level facilities: assess → classify (pink, yellow, green) → treat → counsel → follow up, treating the whole child with a few clinical signs and essential drugs.
- General danger signs (2 months-5 years): unable to drink or breastfeed, vomits everything, convulsions, lethargic or unconscious, convulsing now; any one means urgent referral.
- Key cut-offs: fast breathing 60 (under 2 months), 50 (2-12 months), 40 (1-5 years); dehydration needs two signs; SAM is MUAC under 115 mm, WFH under −3 Z or oedema of both feet.
On this page
Overview
Integrated Management of Childhood Illness (IMCI) is a WHO and UNICEF strategy to reduce death, illness and disability in children under 5 years. When young-infant (newborn) care was added it became IMNCI, the version used in Pakistan. Akbar's textbook records the IMCI programme as launched in 1997.
It began because five conditions (acute respiratory infection, diarrhoea, measles, malaria and malnutrition) caused about 7 of every 10 child deaths in developing countries, and sick children often have more than one problem at once.
Definition, importance and components
Definition: an integrated approach that assesses and treats the whole sick child for all common killers at once, using a small number of clinical signs, a colour-coded triage, essential drugs and caregiver counselling.
Why it matters:
- Works at first-level health facilities with no costly equipment (no X-ray or microscope needed) and can be used by trained non-specialist health workers.
- Combines treatment with prevention: immunisation, breastfeeding, nutrition counselling, vitamin A, iron and deworming.
- Reduces missed diagnoses and unnecessary antibiotics.
Three components:
- Improving case-management skills of health workers (the charts and training).
- Improving health systems (drugs, supplies, referral, supervision).
- Improving family and community practices (key family practices).
Key family practices include: exclusive breastfeeding to 6 months; complementary feeding from 6 months with breastfeeding to 2 years; micronutrients (vitamin A, iron); safe stool disposal and handwashing; full immunisation before the first birthday; insecticide-treated bed nets in malaria areas; play and communication for development; continued feeding and extra fluids during illness; home treatment; recognising when to seek care; following advice; and antenatal care with tetanus toxoid.
The case-management process
- Assess: ask the mother about the problem, check danger signs, ask about main symptoms, examine, check nutrition, immunisation and other problems.
- Classify each problem with the colour-coded system.
- Identify treatment and give pre-referral treatment if needed.
- Treat (first dose in clinic) and teach the mother to give drugs at home.
- Counsel on feeding, fluids and when to return immediately.
- Follow up on a set day.
| Colour | Meaning |
|---|---|
| Pink | Urgent referral or admission after pre-referral treatment |
| Yellow | Specific outpatient treatment (antibiotic, antimalarial, ORS) and advice |
| Green | Home care and advice only |
IMNCI gives a classification, not a diagnosis. A child can have several classifications at once, and the most severe decides referral.
Child aged 2 months to 5 years
General danger signs
- Not able to drink or breastfeed
- Vomits everything
- Convulsions (in this illness)
- Lethargic or unconscious
- Convulsing now
Any one → very severe disease: complete the assessment quickly, give pre-referral treatment (diazepam if convulsing, prevent low blood sugar, keep warm, first dose antibiotic) and refer urgently.
Cough or difficult breathing
Count breaths for a full minute in a calm child.
| Age | Fast breathing |
|---|---|
| 2 months up to 12 months | 50 or more per minute |
| 12 months up to 5 years | 40 or more per minute |
| Signs | Classification | Treatment |
|---|---|---|
| Any danger sign or stridor in a calm child | Severe pneumonia or very severe disease (pink) | First dose of antibiotic, refer urgently |
| Chest indrawing or fast breathing | Pneumonia (yellow) | Oral amoxicillin twice daily for 5 days; inhaled bronchodilator for 5 days if wheeze; soothe throat; follow up in 3 days |
| Neither | Cough or cold (green) | Soothing remedy; follow up in 5 days if not better |
- Cough for more than 14 days or recurrent wheeze → assess for TB or asthma.
- If a pulse oximeter is available, refer when SpO2 is below 90%.
- Amoxicillin is now first choice because of high cotrimoxazole resistance.
In the current charts, chest indrawing without a danger sign is "pneumonia" treated at home with oral amoxicillin, not automatic referral. Older charts called it severe pneumonia.
Diarrhoea
Ask about duration and blood. Look at the general condition, eyes, thirst and skin pinch.
| Signs (two or more) | Classification | Treatment |
|---|---|---|
| Lethargic or unconscious; sunken eyes; not able to drink or drinking poorly; skin pinch goes back very slowly (over 2 seconds) | Severe dehydration (pink) | Plan C (IV fluids); if another severe classification, refer with ORS sips on the way |
| Restless, irritable; sunken eyes; drinks eagerly, thirsty; skin pinch goes back slowly | Some dehydration (yellow) | Plan B (ORS in clinic), zinc, food; follow up in 5 days if not better |
| Not enough signs | No dehydration (green) | Plan A (home fluids, ORS, zinc, continue feeding) |
Also classify:
| Signs | Classification | Treatment |
|---|---|---|
| Diarrhoea 14 days or more with dehydration | Severe persistent diarrhoea (pink) | Treat dehydration, refer |
| Diarrhoea 14 days or more, no dehydration | Persistent diarrhoea (yellow) | Feeding advice, multivitamins and minerals with zinc for 14 days; review after 5 days |
| Blood in stool | Dysentery (yellow) | Ciprofloxacin for 3 days; follow up in 3 days |
- Give zinc to every child with diarrhoea.
- An antibiotic for cholera only if the child is 2 years or older and cholera is in the area.
Fever
Fever means a history of fever, a hot feel, or a reading of 37.5°C or more. Decide the malaria risk of the area (and recent travel).
| Signs | Classification | Treatment |
|---|---|---|
| Any danger sign or stiff neck | Very severe febrile disease (pink) | First dose of antibiotic; in malaria areas first dose of artesunate (or quinine); prevent low blood sugar; paracetamol for fever 38.5°C or more; refer urgently |
| Malaria test positive | Malaria (yellow) | Oral artemisinin combination (artemether-lumefantrine); follow up in 3 days if fever persists |
| Test negative or no malaria risk | Fever: no malaria (green) | Treat other cause; follow up in 2-3 days if fever persists |
Daily fever lasting over 7 days needs referral for assessment.
Measles now or within the last 3 months:
| Signs | Classification | Treatment |
|---|---|---|
| Danger sign, clouding of the cornea, or deep or extensive mouth ulcers | Severe complicated measles (pink) | Vitamin A, first dose antibiotic, tetracycline eye ointment if eye signs, refer |
| Pus draining from the eye or mouth ulcers | Measles with eye or mouth complications (yellow) | Vitamin A, tetracycline eye ointment, gentian violet for mouth ulcers; follow up in 3 days |
| Measles only | Measles (green) | Vitamin A |
Ear problem
| Signs | Classification | Treatment |
|---|---|---|
| Tender swelling behind the ear | Mastoiditis (pink) | First dose antibiotic, paracetamol, refer |
| Pus draining or discharge for less than 14 days, or ear pain | Acute ear infection (yellow) | Antibiotic for 5 days, paracetamol, dry the ear by wicking; follow up in 5 days |
| Discharge for 14 days or more | Chronic ear infection (yellow) | Wicking plus topical quinolone ear drops for 14 days |
| No pain, no pus | No ear infection (green) | None |
Akbar's Pakistan charts also classify sore throat (throat abscess, streptococcal sore throat treated with benzathine penicillin or amoxicillin, viral sore throat).
Acute malnutrition
Look for visible wasting and oedema of both feet, determine weight-for-height/length Z-score, and measure MUAC in children 6 months or older.
| Signs | Classification | Treatment |
|---|---|---|
| Oedema of both feet, or WFH below −3 Z, or MUAC below 115 mm, plus a medical complication, or not able to finish the RUTF test portion, or a breastfeeding problem (under 6 months) | Complicated severe acute malnutrition (pink) | First dose antibiotic, prevent low blood sugar, keep warm, refer urgently |
| WFH below −3 Z or MUAC below 115 mm, able to finish RUTF | Uncomplicated SAM (yellow) | RUTF, oral antibiotic for 5 days, counsel, assess for TB; follow up in 7 days |
| WFH −3 to −2 Z or MUAC 115 to under 125 mm | Moderate acute malnutrition (yellow) | Feeding assessment and counselling; follow up in 30 days |
| WFH −2 Z or more, MUAC 125 mm or more | No acute malnutrition (green) | Feeding advice for under-2s |
Anaemia
| Signs | Classification | Treatment |
|---|---|---|
| Severe palmar pallor | Severe anaemia (pink) | Refer urgently |
| Some palmar pallor | Anaemia (yellow) | Iron; mebendazole if aged 1 year or more and none in the last 6 months; follow up in 14 days |
| No pallor | No anaemia (green) | Feeding advice |
Do not give iron to a child on RUTF (it already contains enough) or in the early treatment of SAM.
HIV infection
Ask whether the mother or child has been tested; test where status is unknown.
| Findings | Classification | Action |
|---|---|---|
| Positive virological test in the child, or positive serological test at 18 months or older | Confirmed HIV infection (pink) | Start ART, cotrimoxazole prophylaxis, TB assessment, regular follow-up |
| Mother HIV-positive and child's virological test negative while breastfeeding (or stopped under 6 weeks ago), child not tested, or positive serology under 18 months | HIV exposed (yellow) | Cotrimoxazole prophylaxis, ARV prophylaxis, virological test, feeding counselling |
| Negative tests | HIV infection unlikely (green) | Treat existing infections |
Under 18 months, a positive antibody test may only reflect maternal antibody, so a virological (PCR) test is needed to confirm infection.
Then check every child for
- Immunisation status (give due vaccines today).
- Vitamin A every 6 months from 6 months of age (100,000 IU at 6-12 months, 200,000 IU from 1 year); an extra dose for measles and persistent diarrhoea.
- Deworming with mebendazole every 6 months from 1 year.
- Feeding problems in children under 2, or with anaemia or malnutrition.
Young infant (birth up to 2 months)
Very severe disease and local infection
| Signs | Classification | Treatment |
|---|---|---|
| Any one of: not feeding well; convulsions; fast breathing 60 or more; severe chest indrawing; fever 37.5°C or above; low temperature below 35.5°C; movement only when stimulated or no movement | Very severe disease (pink) | First dose of IM antibiotics, prevent low blood sugar, keep warm on the way (skin to skin), refer urgently |
| Umbilicus red or draining pus, or skin pustules | Local bacterial infection (yellow) | Oral antibiotic, teach local care; follow up in 2 days |
| None | Severe disease or local infection unlikely (green) | Home care |
Repeat the count if the first is 60 or more.
Jaundice
| Signs | Classification | Treatment |
|---|---|---|
| Any jaundice under 24 hours of age, or yellow palms and soles at any age | Severe jaundice (pink) | Prevent low blood sugar, keep warm, refer urgently |
| Jaundice after 24 hours, palms and soles not yellow | Jaundice (yellow) | Home care; return if palms or soles turn yellow; refer if older than 14 days; follow up in 1 day |
| None | No jaundice (green) | Home care |
Diarrhoea in the young infant
Dehydration is classified as in older children, but the signs are movement only when stimulated or no movement, sunken eyes and skin pinch (no thirst sign). Severe → Plan C or refer; some → Plan B; none → Plan A, with breastfeeding continued.
Feeding problem or low weight
Ask about breastfeeds in 24 hours, other foods or drinks and what is used to feed. Determine weight for age, look for thrush, and observe a breastfeed for 4 minutes.
| Signs | Classification | Treatment |
|---|---|---|
| Not well attached, not suckling effectively, fewer than 8 breastfeeds in 24 hours, receives other food or drinks, low weight for age, or thrush | Feeding problem or low weight (yellow) | Teach positioning and attachment; express milk and cup-feed if needed; feed more often, day and night; stop other feeds; treat thrush (nystatin); advise how to keep a low-weight baby warm; follow up feeding problems or thrush in 2 days, low weight in 14 days |
| None | No feeding problem (green) | Praise the mother |
- Not breastfeeding at all → refer for breastfeeding counselling and possible relactation; teach safe replacement feeds by cup.
- For an HIV-positive mother using replacement feeds, look for unsafe preparation, bottle use or mixing breast and other feeds before 6 months.
Low birth weight
Babies with low weight need warmth (kangaroo mother care, skin to skin), frequent breastfeeds (at least every 2-3 hours, waking the baby), and close weight follow-up.
HIV in the young infant
Ask about the mother's HIV status. An exposed infant needs virological testing, ARV prophylaxis and cotrimoxazole prophylaxis according to the national programme, and the mother needs feeding counselling (exclusive breastfeeding with ART rather than mixed feeding).
Pre-referral treatments
- Convulsions: turn on side, nothing in the mouth, rectal diazepam 0.5 mg/kg; repeat after 10 minutes if still fitting.
- Prevent low blood sugar: breastfeed, or give expressed milk or sugar water (4 level teaspoons (20 g) of sugar in 200 mL of water), 30-50 mL before departure; by nasogastric tube if unable to swallow.
- First dose of antibiotic (IM for young infants and children who cannot drink).
- Keep warm.
- Severe malaria: IM or rectal artesunate (or IM quinine) before referral.
Expect: the meaning of IMNCI and its three components; the five conditions behind most child deaths; the pink, yellow and green system; the five general danger signs; fast-breathing cut-offs (60, 50, 40); pneumonia with chest indrawing treated with oral amoxicillin for 5 days; signs of severe versus some dehydration and Plans A, B and C; persistent diarrhoea at 14 days; ciprofloxacin for dysentery; very severe febrile disease with stiff neck; vitamin A in measles; mastoiditis and chronic ear infection with 14-day cut-off; MUAC 115 and 125 mm, oedema and the RUTF appetite test; severe palmar pallor; HIV-exposed versus confirmed infection and the 18-month serology rule; young infant very severe disease signs, temperature cut-offs, severe jaundice and the four attachment signs.
Quick revision
- Assess → classify → treat → counsel → follow up; pink refer, yellow treat, green home.
- Danger signs: cannot drink, vomits everything, convulsions, lethargic or unconscious, convulsing now.
- Fast breathing: 60 (under 2 months), 50 (2-12 months), 40 (1-5 years).
- Pneumonia (indrawing or fast breathing): oral amoxicillin 5 days, review in 3 days.
- Dehydration needs two signs; persistent diarrhoea 14 days; dysentery → ciprofloxacin 3 days.
- Ear: mastoiditis refer; acute under 14 days antibiotic; chronic 14 days or more wick and quinolone drops.
- SAM: MUAC under 115 mm, WFH under −3 Z or bilateral oedema; MAM: MUAC 115-125 mm.
- Young infant: temperature 37.5°C or above, or below 35.5°C, fast breathing 60, severe indrawing → refer.
- Severe jaundice: under 24 hours or yellow palms and soles.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Park's Preventive and Social Medicine).
FAQ
What does each IMNCI colour mean?
Pink means urgent referral after pre-referral treatment, yellow means specific outpatient treatment, and green means home care with advice.
How is fast breathing defined in IMNCI?
60 or more per minute under 2 months, 50 or more from 2 to 12 months, and 40 or more from 12 months to 5 years.
When is a young infant classified as having very severe disease?
When there is poor feeding, convulsions, fast breathing of 60 or more, severe chest indrawing, fever of 37.5°C or more, temperature below 35.5°C, or movement only when stimulated or none.
Why is a positive HIV antibody test not enough under 18 months?
Maternal antibodies cross the placenta and can persist, so infection must be confirmed with a virological test.