Integrated Management of Neonatal and Childhood Illnesses (IMNCI) – Unit IV | Child Health Nursing I | B.Sc Nursing 5th Semester

Unit – IV
Integrated management
of neonatal and
childhood Illnesses
CHILD HEALTH NURSING
5TH SEMESTER B.Sc NURSING
BY: RAKESH S SAJJAN

Topics
Covere
d
1. Introduction to IMNCI
2. Key Components of IMNCI (Neonatal, Child, Community)
3. Assessment of the Sick Child (danger signs, RR,
dehydration, MUAC, etc.)
4. Classification & Color Coding (Pink/Yellow/Green
decision rules)
5. Treatment Packages (Facility & Home) + Counseling
Checklists
6. Follow-Up Visits (what to reassess; improve/same/worse
actions)
7. Community & Family Practices (feeding, WASH, nets,
prevention)
8. IMNCI Recording Tools & Quality of Care Tips
9. Module-wise Job-Aids (Cough/Breathing, Diarrhea Plans
A/B/C, Fever, Ear, Nutrition, Young Infant)
10. OSCE / Exam Station Drill (RR count, dehydration, MUAC,
ear wicking, ORS, counseling)
11. Drug & Dose Pearls (amoxicillin, paracetamol, zinc, Vit-A,
bronchodilator, Plan C pointers)

Introduction to IMNCI
Definition
• IMNCI = Integrated Management of
Neonatal and Childhood Illnesses (India’s
adaptation of WHO IMCI that includes 0–
7 days neonatal care).
• A standardized, symptom-based
approach for children 0–59 months to
assess, classify (color-code), treat/refer,
counsel, and follow-up.

Scope & Age
Range
• Young infant: 0–2
months (with special
focus on the first 7
days).
• Child: 2 months–5 years
(59 months).
• Applied in facility (OPD,
PHC/CHC, wards) and
community
(home/community
visits).

Rationale
(Why IMNCI?)
• Under-five deaths are largely due
to a few common, often
overlapping illnesses
(pneumonia, diarrhea, sepsis,
malaria, malnutrition, measles).
• Traditional single-disease
guidelines miss co-morbidities;
IMNCI integrates conditions to
avoid missed/unsafe treatments.
• Addresses early neonatal
mortality by adding essential
newborn care and infection
recognition.

Aims/Objectives
• Reduce under-five morbidity
and mortality.
• Standardize case management
with simple, rapid algorithms.
• Improve caregiver practices
(feeding, hygiene, danger-sign
recognition).
• Ensure timely referral for
severe disease.
• Promote rational use of drugs
(antibiotics, antimalarials, ORS,
zinc, Vitamin A).

Guiding
Principles
• Few key questions, focused exam, and
vital signs gathered quickly.
• Color-coded classification (not definitive
diagnosis):
• PINK → Urgent referral (give pre-
referral care if permitted).
• YELLOW → Treat at facility (and
schedule follow-up).
• GREEN → Home care (counsel + return
precautions).
• Assess Classify Identify treatment
→ →
Treat/Counsel Follow-up
→ → (the same
flow for every child).
• Always consider nutrition,
immunization status, and feeding
problems in every visit.

What IMNCI Covers
(High-Level)
• 0–2 months: possible serious
bacterial infection (PSBI), feeding
issues, jaundice triage,
hypothermia/thermal care, local
infections.
• 2–59 months: cough/difficult
breathing (pneumonia), diarrhea
(dehydration plans), fever
(malaria/measles as per area), ear
problems, malnutrition/anemia,
feeding problems, immunization.

Benefits
(for practice & programs)
• Early recognition of danger signs
and prompt pre-referral actions.
• Consistent care across providers
and levels (PHC to district hospital).
• Better caregiver adherence
through structured counseling &
follow-up.
• Supports data and quality
(standard forms/checklists).

Nurse’s Role
• Rapid triage and vital
measurements (RR for full minute,
temp, MUAC, edema check).
• Accurate classification with charts;
first-dose meds/oxygen per
protocol.
• Counsel caregivers (feeding, ORS,
meds, danger signs) and schedule
follow-up.
• Document clearly; coordinate
referral/transport when PINK.

Key
Components
of IMNCI
Neonatal Component (0–2 months; special
focus on first 7 days)
• Purpose: early detection and
management of life-threatening
conditions in young infants.
Core assessment blocks
• General danger signs: unable to feed,
convulsions, RR 60/min, severe chest
≥
indrawing/grunting, fever 37.5°C or
≥
temp <35.5°C, lethargy.
• Local infections: skin/umbilical redness
or pus.
• Jaundice triage: severe if palms/soles
yellow, onset <24 h, or persists >14 days.
• Feeding/weight & thermal care: latch,
frequency (8–12/24 h), dehydration signs;
prevent hypothermia (warm chain/KMC).

Color-coded
classificatio
n action
→
• PINK (Possible Serious Bacterial Infection /
severe jaundice): give pre-referral care
(warmth, airway/breathing, first dose
antibiotics if permitted) and urgent referral.
• YELLOW (local infection, mild/moderate
jaundice, feeding issues): treat at facility
(topical/oral antibiotics as indicated, lactation
support), close follow-up ( 2 days)
≈ .
• GREEN: home care education + routine
follow-up.
Nurse focus: accurate RR count (full minute),
temperature, safe first doses, breastfeeding
support, thermal protection, caregiver
counseling, documentation.

Childhood Component
(2 months–5 years)
• Purpose: integrated management of the common killers with co-morbidity in
mind.
Main symptom modules
• Cough/Difficult breathing:
• Fast breathing thresholds: 2–12 mo >50/min; 12–59 mo >40/min.
• PINK: danger sign/stridor/severe distress oxygen, pre-referral
→
treatment, urgent referral.
• YELLOW: pneumonia (fast breathing only) → oral antibiotic, follow-up 2
days.
• GREEN: no pneumonia home care.
→
• Diarrhea: classify dehydration (Severe / Some / None); apply Plans C/B/A; zinc
14 days for all; dysentery add appropriate antibiotic.
→

Fever (± malaria/measles per area):
• PINK: meningitis signs/high severity urgent referral.
→
• YELLOW: malaria suspected/measles with eye or mouth complications treat per protocol (+ Vitamin A in
→
measles).
• GREEN: home care + antipyretic dosing.
Ear problems: acute infection (oral antibiotic + ear wicking); mastoiditis = PINK.
Malnutrition & anemia: MUAC <11.5 cm or bilateral pedal edema = severe;
manage per severity; counsel on feeding; deworm/iron as indicated.
Feeding problem / low weight: assess age-appropriate diet/breastfeeding; give
precise feeding advice; schedule weight follow-up.
Immunization: check UIP status; give due/overdue vaccines unless
contraindicated; counsel on AEFIs and next visit.
Nurse focus: triage, accurate measurements (RR, temp, MUAC, edema), correct
classification, first doses, ORS demonstration, return-immediately danger signs,
follow-up dates.

Community & Family
Practices (cross-cutting)
• Exclusive breastfeeding (0–6 mo); appropriate
complementary feeding thereafter.
• Hand hygiene, safe water, sanitation, safe food preparation.
• Home management of diarrhea (ORS + zinc), continue
feeding during illness.
• Use of bed nets in malaria areas.
• Immunization completion and recognition of danger signs.
• Timely care-seeking and adherence to follow-up.

Common Process for All
IMNCI Encounters
• Assess (danger signs module-specific signs nutrition/feeding
→ → →
immunization other problems)
→
• Classify (PINK/YELLOW/GREEN)
• Identify treatment (meds/fluids/referral)
• Treat & Counsel (give first doses; teach ORS/feeding/med schedule;
danger signs)
• Follow-up (give specific return date; advise immediate return if any
danger sign)

Assessment of the Sick Child
(IMNCI Case Assessment)
Purpose & Flow
• Rapidly identify life-threatening illness and decide: Assess Classify
→ →
Identify treatment Treat/Counsel Follow-up
→ → .
• Always check: danger signs, main symptoms, nutrition/feeding,
immunization, and other problems.
Infection Control & Preparation
• Hand hygiene, clean equipment (timer, thermometer, MUAC tape, scale).
• Calm, well-lit area; keep infant warm; ensure privacy.

General Danger Signs
(any ONE = urgent referral after first-dose care)
Young Infant (0–2 months)
• Unable to feed or not feeding well; convulsions
• Respiratory rate 60/min, severe chest indrawing, grunting
≥
• Axillary temp 37.5°C or <35.5°C; moves only when
≥
stimulated/lethargic
• Severe jaundice (palms/soles yellow), jaundice <24 h of age, or >14
days
• Umbilical redness extending to skin/pus with fever

Child (2–59 months)
• Not able to drink/breastfeed; vomits everything
• Convulsions; lethargic or unconscious
• Stridor in a calm child or severe respiratory
distress

Main Symptom
Assessment
Cough or Difficult Breathing
• Ask: duration; presence of fast breathing; noisy breathing; feeding difficulty.
• Count respiratory rate for a full minute when the child is calm/asleep.
• <2 months: 60/min (fast)
≥
• 2–12 months: >50/min (fast)
• 12–59 months: >40/min (fast)
• Look: chest indrawing, nasal flaring, grunting, cyanosis.
• Listen: stridor (inspiration), wheeze (expiration).
• Measure SpO₂ if available; note need for oxygen (<90% or clinical hypoxia).

Diarrhea
• Ask: duration; blood in stool; number of stools; vomiting; thirst.
• Look/Feel for dehydration:
• General condition (lethargic/restless), sunken eyes
• Drinking ability (poor/eager)
• Skin pinch on abdomen (returns very slowly/slow/normal)
• Identify type: acute, persistent (>14 days), dysentery (blood).

Fever
(with/without malaria or measles risk)
• Measure axillary temperature.
• Ask: duration; rash; travel/malaria exposure; immunization
for measles.
• Look for meningitis signs (stiff neck, bulging fontanelle in
infants), measles signs (rash with
cough/coryza/conjunctivitis), localizing infections (ear,
throat, skin).

Ear Problem
• Ask: ear pain, discharge, duration.
• Look: discharge (acute <14 d; chronic 14 d),
≥
swelling/tenderness behind ear (mastoiditis).
• Teach ear wicking if discharge present (clean, dry
technique).

Nutrition & Feeding
Assessment
Anthropometry
• Weight: undressed/ light clothing; plot on growth chart if available.
• MUAC (6–59 months): left arm, midpoint between acromion and
olecranon; tape snug.
• <11.5 cm = Severe Acute Malnutrition (SAM)
• 11.5–12.5 cm = Moderate
• ≥12.5 cm = Normal
• Bilateral pitting edema over feet = severe malnutrition.

Feeding History
• <6 months: exclusive breastfeeding? frequency (8–12/24
h)? latch/swallow? problems (thrush, cracked nipples)?
• ≥6 months: diet diversity (staple,
pulses/eggs/fish/meat, veg/fruits, milk), meal frequency,
feeding during illness, extra meal for 2 weeks after
illness.

Immunization Status
• Check MCP/Immunization card against UIP schedule.
• Identify due/overdue vaccines; note any
contraindications; plan catch-up.
Other Problem Check
• Mouth/throat: ulcers, thrush.
• Skin: pustules, cellulitis, measles rash.
• Anemia: palmar pallor (none/mild/severe).
• Wheeze/asthma symptoms; injury/accident history;
dehydration complications.

Measurement Techniques & Normal Ranges (quick reference)
• Respiratory rate: count for 60 seconds; ensure calm state.
• Temperature: axillary; fever 37.5°C; in young infant, <35.5°C = hypothermia.
≥
• SpO₂: aim 90–95% in most settings; <90% consider oxygen and urgent
→
evaluation.
• Skin pinch: vertical pinch on abdominal wall; release and time return.
• MUAC: left arm midpoint; tape flat; read to nearest 0.1 cm.
Documentation (IMNCI Case Form)
• Record: history, vitals (RR, temp, SpO₂), dehydration signs, MUAC/edema,
pallor, immunization.
• Write color-coded classification for each module and overall plan.
• Note first doses given, caregiver counseling points, and a clear follow-up
date.

Common Pitfalls & Tips
• Don’t count RR while the child is crying; wait for calm or sleeping.
• Always re-check any borderline RR or skin pinch findings.
• In infants, prioritize feeding and thermal assessment even if
presenting for other symptoms.
• If any danger sign is present, stop further routine assessment,
give allowed first-dose care, and arrange urgent referral.

IMNCI Classification & Color
Coding (Decision Rules)
How to Classify (the same logic for every child)
• Assess danger signs + main symptom module(s) + nutrition/feeding +
immunization.
• Classify each module using color codes (not a final diagnosis):
• PINK = Severe / very severe URGENT REFERRAL
→ (give allowed first-dose
care before referral)
• YELLOW = Treat at facility (give medicines, counsel, schedule follow-up)
• GREEN = Home care (counsel + return-immediately advice)
• Overall final plan is the most serious color identified in any module.

Decision Rules
•Possible Serious Bacterial Infection (PSBI) — PINK
•Any one of:
• Unable to feed / not feeding well
• Convulsions
• RR 60/min
≥ or severe chest indrawing or grunting
• Axillary temp 37.5°C
≥ or <35.5°C
• Moves only when stimulated / lethargic
Action: Keep warm, clear airway/breathing, give pre-referral first dose antibiotics
if permitted, urgent referral.

Local Bacterial Infection
YELLOW
Pustules/skin infection; umbilical redness
without spreading to abdominal skin; baby
otherwise well
Action: Topical/oral antibiotics as per protocol;
cord/skin hygiene; follow-up in 2 days.

Jaundice — Color-based
• Severe jaundice (PINK): palms/soles yellow OR onset <24 h OR
persists >14 days
Action: Warmth, breastfeeding, urgent referral (possible
phototherapy/exchange).
• Mild–moderate (YELLOW/GREEN): face/eyes ± chest after 24 h;
infant well
Action: Ensure effective feeding; review in 2 days or earlier if worse.

Feeding Problem / Low
Weight — YELLOW/GREEN
• Poor latch, <8 feeds/24 h, thrush, dehydration, or low
weight for age → YELLOW
Action: Lactation support, treat thrush, consider
NG feeds if poor suck; follow-up 2 days.
• Feeding effective, weight appropriate → GREEN with
home advice.

Child (2–59 months) —
Decision Rules
Cough / Difficult Breathing
• Fast breathing cut-offs:
• 2–12 mo >50/min • 12–59 mo >40/min
• PINK (Severe pneumonia/very severe): any danger sign, central cyanosis/SpO₂ low,
stridor in calm child, or severe chest indrawing
Action: Oxygen, first-dose antibiotic if permitted, urgent referral.
• YELLOW (Pneumonia): fast breathing only
Action: Oral antibiotic, soothe cough, follow-up 2 days.
• GREEN (No pneumonia): no fast breathing, no danger signs
Action: Home care; fluids; return if worse.

Diarrhea
(Acute / Persistent / Dysentery)
• Dehydration signs:
• Severe (PINK): lethargic/unconscious, sunken eyes, drinks poorly or
unable, skin pinch very slow
Action: Plan C IV fluids, urgent referral; zinc when able.
• Some (YELLOW): restless/irritable, sunken eyes, drinks eagerly, skin
pinch slow
Action: Plan B ORS 75 ml/kg over 4 h, reassess; zinc 14 days.
• None (GREEN): none of the above
Action: Plan A (home ORS after each stool, continue feeding, zinc 14
days).
• Dysentery (blood in stool) → YELLOW
Action: Appropriate antibiotic per protocol + fluids, hygiene advice.

Fever
(± Malaria/Measles per area)
• PINK: meningitis signs (stiff neck, bulging fontanelle), very ill
child, danger signs
Action: Pre-referral care, urgent referral.
• YELLOW: malaria suspected in endemic area or measles with
eye/mouth complications
Action: Treat per local protocol (RDT/ACT where indicated);
Vitamin A for measles; follow-up.
• GREEN: simple fever without danger signs
Action: Home care (fluids, tepid sponging), weight-based
antipyretic, return if worse.

Ear Problem
• PINK: mastoiditis (swelling/tenderness behind
ear) → urgent referral.
• YELLOW: acute ear infection (pain/discharge <14
d) oral antibiotic,
→ ear wicking, pain relief;
follow-up 2 days.
• GREEN: no acute infection; if chronic discharge
14 d
≥ , treat and plan referral/follow-up.

Malnutrition & Anemia
• Severe Acute Malnutrition (SAM) — PINK/YELLOW (depends on
complications):
• MUAC <11.5 cm OR bilateral pitting edema OR visible severe
wasting
Action: Assess for complications; refer/admit if present; initiate
therapeutic feeding per protocol.
• Severe anemia (palmar pallor severe) → PINK (refer).
• Moderate (MUAC 11.5–12.5 cm or mild pallor) → YELLOW (treat +
nutrition/iron/deworming as indicated).
• Normal (MUAC 12.5 cm, no edema/pallor)
≥ → GREEN (reinforce
feeding advice).

Feeding Problem / Low
Weight
• YELLOW: inadequate diet frequency/diversity, poor
feeding during illness, no extra meal in recovery
Action: Give age-specific feeding advice, treat
mouth problems, schedule weight follow-up (1–2
weeks).
• GREEN: adequate diet & weight; reinforce
counseling.

Immunizati
on
YELLOW/GREEN: give
due/overdue vaccines
unless contraindicated;
counsel on AEFIs & next
visit.

First-Dose / Pre-Referral
Bundle (when PINK)
• Airway–Breathing–Circulation: position, clear
airway, oxygen if hypoxic/severe distress.
• Warmth (young infants): dry/wrap; skin-to-skin.
• Fluids: IV for severe dehydration/shock (per Plan C).
• Antibiotic first dose (PSBI, severe pneumonia,
meningitis suspicion) if permitted by your protocol.
• Rapid referral: document vitals, treatments given;
send referral note; keep caregiver informed.

Follow-Up Timing (write on
the card/OPD slip)
• Pneumonia / Acute ear infection → 2 days
• Some dehydration (Plan B) → 5 days (or earlier if not
improving)
• Local infection / Feeding issues (0–2 mo) → 2 days
• Mild–moderate jaundice (0–2 mo) → 2 days
• Malnutrition / Feeding problem (2–59 mo) → 1–2 weeks
• Fever (treated at facility) → 2–3 days or sooner if worse

“Return
Immediately
” Danger
Signs (tell
every caregiver)
• Not able to drink/breastfeed, vomits
everything
• Convulsions, lethargic/unconscious
• Fast/difficult breathing, stridor, severe chest
indrawing
• High fever or low temperature (young infant)
• Diarrhea with drinking poorly, repeated
vomiting, blood in stool
• Worsening jaundice (young infant), umbilical
redness/pus with fever
• Any worsening or new symptom caregiver is
worried about

Treatment Packages (Facility &
Home) + Counseling Checklists
General Treatment Logic
• Treat according to worst color found: PINK >
YELLOW > GREEN.
• Sequence: Give first-dose/initial care Stabilize
→ →
Refer/Observe Counsel Schedule follow-up
→ → .
• Always pair treatment with feeding advice,
immunization check, and return-immediately
danger signs.

PINK Package
(Urgent Referral After First-Dose Care)
Indications: Any danger sign, PSBI, severe
pneumonia, severe dehydration/shock, severe
malnutrition with complications, meningitis signs,
severe jaundice (0–2 mo), mastoiditis.

Actions
before
referral
(as permitted
locally):
• Airway/Breathing: Position, clear
secretions; give oxygen if SpO₂ <90%
or severe distress.
• Circulation: If shock/severe
dehydration start
→ Plan C IV fluids
per protocol.
• Temperature: Keep warm (young
infant: dry/wrap, skin-to-skin/KMC).
• Antibiotic first dose (e.g.,
parenteral ampicillin + gentamicin
or ceftriaxone) per state protocol.
• Glucose if hypoglycemia suspected
(10% dextrose IV).
• Rapid referral: Send referral note
with vitals, treatments given.

YELLOW
Package
(Treat at Facility + Follow-
up)
• Pneumonia (fast breathing only):
• Oral antibiotic (e.g., amoxicillin per
local dose chart).
• Soothe cough (warm fluids, avoid
irritants).
• Follow-up in 2 days.
• Diarrhea—Some Dehydration (Plan B):
• ORS 75 ml/kg over 4 hours at facility;
reassess.
• Zinc 14 days: <6 mo: 10 mg/day; 6–59
mo: 20 mg/day.
• Continue feeding; follow-up in 5 days
(earlier if worse).

•Dysentery (blood in stool):
• Appropriate antibiotic for Shigella per state protocol (e.g.,
cefixime/ciprofloxacin).
• ORS, zinc, hand hygiene counseling; follow-up.
•Fever—Malaria/Measles (non-severe):
• Malaria suspected (endemic area): RDT and ACT per weight band;
antipyretic.
• Measles with eye/mouth complications: eye care, mouth care,
Vitamin A (see below), nutrition.
•Acute Ear Infection (<14 d):
• Oral antibiotic, pain relief, ear wicking technique; follow-up 2
days.

Feeding Problem / Low Weight:
o Correct latch/positioning; treat thrush;
increase frequency;
o Weight review in 1–2 weeks.
Moderate Malnutrition/Anemia:
o Diet counseling, iron/folate and deworming
if indicated, illness screen; close follow-up.

GREEN Package
(Home Care + Return Precautions)
• Cough/Cold without pneumonia: Fluids, rest, honey (>1 yr), avoid
smoke; antipyretic if fever.
• Diarrhea without dehydration (Plan A):
• ORS after each loose stool:
• <2 yrs: 50–100 ml each time
• 2–5 yrs: 100–200 ml each time
• Zinc 14 days (doses as above), continue feeding, extra fluids.
• Simple Fever: Fluids, tepid sponging; paracetamol 15 mg/kg/dose q6–
8h (max 4 doses/day).
• Feeding adequate: reinforce age-appropriate diet, hygiene,
immunization.

Module-Specific Treatment
(High-Yield)
• Vitamin A in measles:
• <12 months: 100,000 IU once daily for 2 days
• ≥12 months: 200,000 IU once daily for 2 days
• (Severe cases: a 3rd dose after 2 weeks if advised)
• Wheeze/Asthma trial: Salbutamol via spacer/nebulizer; if improves →
continue per protocol, teach spacer use.
• Severe Acute Malnutrition (SAM): If complicated (danger signs,
edema + illness, anorexia) → admit/refer; if uncomplicated →
outpatient therapeutic feeding + close follow-up per program.
Important: Exact drug choice/dose varies by state/college protocol. Use
your IMNCI/local dose chart for antibiotics, ACT, and IV fluid rates.

Caregiver Counseling
Checklists (Teach–Show–Do)
Medicines
• Name, dose, time, duration—write a clear schedule.
• Demonstrate measuring with spoon/syringe; confirm caregiver repeat-back.
• Antibiotics: stress full course, not stopping early.
ORS Preparation & Use
• 1 full sachet in 1 liter safe water; mix until fully dissolved.
• Use cup and spoon; no bottle.
• Use within 24 hours; discard leftover.
• Give small, frequent sips; replace losses as per Plan A/B; zinc daily x14 days.

Feeding During Illness
 Continue breastfeeding (8–12 times/24 h for
infants).
 Continue usual foods; offer small, frequent, energy-
dense meals.
 After illness: one extra meal daily for 2 weeks.
Fluids & Temperature
 Encourage extra fluids (safe water, soups).
 Tepid sponging for fever; avoid cold baths/alcohol

Hygiene & Prevention
 Handwashing (after toilet, before food/prep, after
cleaning child).
 Safe water, clean utensils; proper food hygiene.
 Bed nets in malaria areas; avoid smoke exposure.
Immunization
 Check card; give due/overdue vaccines unless
contraindicated.
 Explain AEFIs and when to return.

Return-Immediately Danger Signs (re-
teach)
• Not able to drink/breastfeed; vomits everything
• Convulsions; lethargic/unconscious
• Fast/difficult breathing, stridor, severe chest
indrawing
• High fever/very low temp (young infant)
• Worsening diarrhea, blood in stool, poor drinking
• Jaundice worsening (young infant); umbilical

Follow-Up Date
 Pneumonia/Acute ear → 2 days
 Some dehydration (Plan B) → 5 days
 Local infection/Feeding issues (0–2 mo) → 2 days
 Mild–moderate jaundice (0–2 mo) → 2 days
 Malnutrition/Feeding problem → 1–2 weeks
 Fever treated at facility → 2–3 days or earlier if worse

Documentation (brief)
 IMNCI case form: findings, classification,
treatments given, counseling points,
follow-up date.
 Record SpO₂, RR, temp, MUAC/edema,
and any first doses administered.

Follow-Up Visits — What to
Reassess & What To Do (IMNCI)
General Follow-Up Rules
• Reassess fully: danger signs main symptom module(s)
→ →
nutrition/feeding immunization other problems.
→ →
• Compare with baseline: vitals (RR, temp, SpO₂ if available),
hydration, MUAC/edema, weight, symptom counts (stools/day,
cough, fever days).
• Decide: Improved / Same / Worse manage accordingly.
→
• Escalate immediately if any danger sign reappears.

Follow-up timing (typical)
• Local infection / feeding problem / mild–moderate
jaundice: in 2 days (earlier if worse).
• Severe conditions (PSBI, severe jaundice): follow at
referral facility; if seen back in OPD, reassess and
re-refer as needed.

Reassess — checklist
• Feeding: frequency (8–12/24 h), latch/attachment, suck–swallow, vomiting,
dehydration.
• Breathing: RR (full minute), 60/min?
≥ chest indrawing/grunt/apnea.
• Temperature: 37.5 °C or <35.5 °C.
≥
• Activity: moves only when stimulated? lethargy?
• Jaundice: progression (face trunk
→ → palms/soles), onset <24 h or persisting
>14 d.
• Umbilicus/skin: redness, spread to surrounding skin, pus, foul smell.
• Weight trend (if available).

Decide & Act
• Improved (feeds well, RR <60, afebrile, redness reduced, jaundice
not progressing):
→ Continue plan, reinforce breastfeeding/thermal care, complete
medicines, return-immediately advice.
• Same / Not adequate (still poor latch, mild redness persists,
borderline RR):
→ Intensify lactation support, treat oral thrush if present, continue
local therapy; review again in 2 days or sooner if worse.

Worse / New danger sign (RR 60,
≥
chest indrawing, fever/low temp,
lethargy, spreading redness,
palms/soles yellow, jaundice >14 d):
→ Pre-referral care (warmth,
airway/breathing, first-dose antibiotics if
permitted) and urgent referral.

Child (2–59 months)
Pneumonia (fast breathing) — Follow-up in 2 days
•Reassess: RR vs age cut-off (2–12 mo >50; 12–59 mo >40), chest indrawing/stridor,
feeding, fever, SpO₂ (if available).
• Improved (RR below cut-off, distress reduced, feeding better):
→ Complete antibiotic course, home care, return-immediately signs.
• Same (still fast breathing but not worse):
→ Check adherence/dose, teach spacer/humidified inhalation if wheeze; consider
changing antibiotic per protocol; review again in 2 days.
• Worse (danger sign, chest indrawing, hypoxia):
→ Oxygen (if available), first-dose antibiotic if permitted, urgent referral.

•Cough/Cold (no pneumonia) — Return PRN / earlier if worse
• If caregiver returns with worsening: re-classify; manage as pneumonia/severe disease
if thresholds met.
•Diarrhea
• Some dehydration (Plan B) — Follow-up in 5 days (or earlier if symptoms persist):
Reassess: hydration signs, stool/vomit count, thirst/drinking, weight, urine frequency.
• Improved: switch to Plan A, continue zinc 14 days, feeding + fluids.
• Same/Worse: rehydrate again (Plan B/Plan C as indicated), consider referral if
repeated dehydration or poor intake, continue zinc.
• Dysentery — Early review in ~2 days advisable:
• Improved (no blood, fewer stools): complete antibiotics, hygiene advice.
• Not improved / persistent blood or fever: change antibiotic per protocol; refer
if toxic/dehydrated.
• Persistent diarrhea (>14 days) at any visit:
• Assess malnutrition/feeding errors; stool exam if available; refer if weight loss,
dehydration, or systemic illness.

Fever (± malaria/measles as per area)
 Malaria treated with ACT — review 48–72 h:
o Fever resolved/improving: complete regimen.
o Persistent high fever or new danger signs: re-evaluate
(treatment failure/other focus), refer as needed.
 Measles with eye/mouth complications — review 2–3 days:
o Improved: continue eye/mouth care, nutrition, Vitamin A
given.
o Not improved/worse (corneal ulceration, severe
stomatitis, dehydration): urgent referral.

Acute Ear Infection —
Follow-up in 2 days
Reassess: pain, fever, discharge, hearing concern, mastoid area.
• Improved: continue antibiotics/analgesia; keep ear dry
(wicking).
• Not improved: check adherence/resistance; consider change
of antibiotic; re-review.
• Mastoid tenderness/swelling, high fever, toxicity: urgent
referral.

Malnutrition / Feeding
Problem
• Review in 1–2 weeks (earlier if SAM/complications).
Reassess: MUAC, weight (aim positive gain), edema, appetite, intercurrent illness,
diet recall, deworm/iron status.
• Improved (weight gain, MUAC improving, edema resolving): continue plan;
reinforce diet (extra meal ×2 weeks post-illness).
• No gain in 2 consecutive visits / edema persists / anorexia / intercurrent
infection: refer/admit as per SAM protocol; manage infections; adjust feeding
plan.
• Anemia (moderate): recheck in 4 weeks after iron/folate; if severe pallor anytime
→ urgent referral.

Wheeze / Asthma
Trial
• After bronchodilator trial, if improved: continue
as advised; teach spacer/trigger avoidance.
• If no improvement or recurrent severe
episodes: evaluate for pneumonia/foreign
body/asthma; refer.

Immunization / AEFI
• If vaccines given previously: check for AEFIs;
if mild reassure; if severe (anaphylaxis, high
→
fever with lethargy) → urgent referral.
• Ensure catch-up doses planned; write next
due date.

What to Tell the Caregiver
at Every Follow-Up
• What changed since last visit and what to continue/stop.
• Exact medicine schedule (dose, time, duration) and completion of
antibiotics.
• ORS & zinc use (if diarrhea).
• Feeding plan (continue feeds; extra meal ×2 weeks after illness).
• Return-immediately danger signs (repeat list briefly).
• Next follow-up date (write it clearly on card/OPD slip).

Documentation
• Record: vitals, classification now vs prior,
treatment given/changed, caregiver counseling
points, next visit date.
• Note adherence issues and barriers (cost, access,
understanding) and how you addressed them.

Community & Family Practices
(Home Care Pillars in IMNCI)
Objectives (for the caregiver & community)
• Promote appropriate feeding, hygiene,
immunization, early care-seeking, and safe home
management of common illnesses.
• Reduce risk of dehydration, pneumonia, malaria,
malnutrition, and injury.

Optimal
Feeding
Practices
Birth–6 months (Young infant)
• Early initiation: within 1 hour of birth; skin-to-
skin.
• Exclusive breastfeeding (EBF): no water,
formula, honey, or animal milk.
• On demand: 8–12 feeds/24 h; correct latch
(areola in mouth, chin touching breast, audible
swallowing).
• Common issues: cracked nipples,
engorgement, thrush—treat early; avoid
bottles (use cup/spoon if needed).
• Illness: continue breastfeeding; if weak,
expressed breast milk by cup/spoon.

6–24 months
(Complementary feeding + continued BF to 2 years or beyond)
• Start thick (not watery) semisolid foods at 6 months; increase variety/texture with age.
• Minimum meal frequency (plus nutritious snacks):
• 6–8 mo: 2–3 meals + 1–2 snacks/day
• 9–11 mo: 3–4 meals + 1–2 snacks/day
• 12–24 mo: 3–4 meals + 1–2 snacks/day (family foods, chopped/mashed)
• Diet diversity daily: staple + pulses/eggs/fish/meat + dairy + two vegetables/fruits +
oil/ghee for energy.
• During illness: small frequent feeds; after illness: one extra meal daily for 2 weeks.
• Avoid bottle feeds and sugary drinks; encourage responsive feeding (patience, no force).

Micronutrients
(per program/prescriber)
• Zinc in any diarrhea 14 days: <6 mo: 10 mg/day; 6–
59 mo: 20 mg/day.
• Iron/folate & deworming as indicated ( 12 months;
≥
follow local protocol).
• Vitamin A when indicated (e.g., measles) as per age-
dose.

Home Management of
Common Symptoms
Diarrhe
a (no danger
signs)
ORS preparation: 1 sachet in 1 L safe water; use within
24 h.
Give after each loose stool:
Zinc daily × 14 days (doses above). Continue
breastfeeding/foods.
Return immediately if: drinking poorly/vomits
everything, blood in stool, lethargy, sunken eyes, very
thirsty or not able to drink, fever, or worse.

Cough/Cold (no pneumonia)
• Fluids, rest, keep child warm; saline nose drops for congestion.
• Paracetamol for fever: 15 mg/kg/dose every 6–8 h (max 4
doses/24 h).
• Honey (>1 year only). No OTC cough/cold syrups for <5 years
unless prescribed.
• Return immediately if fast/difficult breathing, chest indrawing,
stridor, poor feeding, or lethargy.

Fever
• Confirm temperature (axillary). Tepid sponging;
no cold baths/alcohol rub.
• Paracetamol as above; extra fluids; light clothing.
• In malaria areas: seek testing if fever persists or
any danger sign.

Hygiene & WASH
(Water, Sanitation, Hygiene)
• Handwashing with soap (or ash if no soap) at 5 key moments:
• After using toilet/cleaning child
• Before preparing food
• Before feeding child/eating
• After handling animals/soil
• After coughing/sneezing/wiping nose
• Safe water: boil/filter/chlorinate; store covered; pour (don’t dip).
Food hygiene: fresh, thoroughly cooked, served hot; clean utensils; refrigerate
leftovers.
• Sanitation: use latrine; dispose child stools safely; clean play areas.
• Newborn cord care: keep clean and dry; no substances applied unless advised.

Vector &
Environment
al Control
• Sleep under long-lasting
insecticide-treated nets
(LLINs); tuck edges in.
• Reduce mosquito breeding
(cover containers, drain
stagnant water).
• Keep child away from
smoke (tobacco/kitchen);
ventilate cooking areas.

Injury &
Accident
Preventi
on (high-
impact)
• Burns/scalds: keep hot liquids/cookstoves
out of reach; turn pot handles inward.
• Poisoning: lock away kerosene, pesticides,
medicines.
• Falls: don’t leave infants unattended on
beds/tables; use railings.
• Drowning: never leave child alone near
buckets/tubs/ponds; cover wells.
• Road safety: hold hands near traffic; use
age-appropriate restraints.

Immunizati
on
Adherence
(UIP)
• Keep MCP/Immunization card;
check due/overdue vaccines at
every contact.
• Manage common mild AEFIs at
home (local pain/fever with
paracetamol); seek care for
severe reactions (very high
fever, lethargy, breathing
difficulty).
• Note next due date clearly.

Early
Stimulation
&
Responsive
Care
• Talk, sing, play, read daily; floor
time; age-appropriate toys (safe,
clean).
• Encourage social interaction;
praise and comfort.
• Watch developmental milestones;
seek help early if delay suspected.
• Support caregiver mental health;
encourage rest and family
support.

Counseling
Method
(Teach–Show–Do–Repeat–
Write)
• Teach key points in simple
language.
• Show (demo ORS mixing, spacer
use, breastfeeding latch).
• Have caregiver Do and Repeat-
back.
• Write medicine doses/times,
fluids/feeding plan, danger signs,
follow-up date.

Home Care Checklist
• Continue breastfeeding; give thick, diverse foods 6 mo
≥
• ORS + zinc for diarrhea; correct prep, amounts, 14 days zinc
• Paracetamol dosing for fever; no OTC cough syrups (<5 y)
• Handwash at key moments; safe water & food; clean utensils
• LLINs at night; reduce smoke exposure
• Injury prevention: burns/poisoning/falls/drowning/road safety
• Immunization: give due/overdue; note next date
• Return immediately for any danger sign
• Follow-up on the exact date given

Documentation &
Community Links
• Record what was taught, materials given,
and follow-up date on the card/register.
• Coordinate with ASHA/AWW for home visits,
tracking defaulters, nutrition support, and
immunization catch-up.

IMNCI Recording Tools &
Quality of Care Tips
IMNCI Case Recording Form — Sections to Complete
• Identifiers
• Child’s name, age (in months), sex, address, caregiver name/phone, date & time of visit, hospital/OPD ID.
• Reason for Visit & Caregiver Concerns
• Presenting complaints in caregiver’s words; onset/duration (days), prior treatment.
• History (by module + general)
• Cough/breathing: duration, nocturnal worsening, feeding difficulty.
• Diarrhea: days, stool count, blood in stool, vomiting, thirst.
• Fever: days, rash, travel/malaria exposure, measles contact, antipyretics.
• Ear: pain, discharge days, hearing concern.
• Young infant (0–2 mo): feeding frequency, latch/suck, jaundice onset, stool/urine, temperature concerns.
• All: previous illnesses, drug allergies, immunization status.

Examination &
Measurements
• Vitals: RR (count 60 sec), Temp (axillary), SpO₂ (if available), HR (if available).
• Anthropometry: Weight (kg to 0.1), MUAC (cm to 0.1) for 6–59 mo, bilateral
pitting edema.
• General: conscious/lethargic, convulsions, dehydration signs (eyes, drinking,
skin pinch).
• Module signs: chest indrawing, stridor/wheeze, mouth ulcers/thrush, ear
discharge, rash/eye signs, umbilical redness, jaundice to palms/soles (0–2
mo).

1. Color-Coded Classifications (tick/underline)
o Cough/difficult breathing, Diarrhea, Fever, Ear,
Nutrition/Anemia, Feeding problem, Immunization, Other.
o Record the overall plan according to the worst color present.
2. Treatment Given Today
o First doses (drug, mg/kg, route, time), oxygen given (flow,
device), ORS/IV volume, vaccines administered, procedures
(ear wicking, nebulization).
3. Counseling Provided
o Medicine schedule (dose/time/days), ORS preparation & zinc
14 days, feeding advice, hygiene, danger signs, immunization
next due.

oFollow-Up Plan
oExact date/time; what to reassess (e.g., RR; hydration;
ear discharge; weight).
oReferral Details (if PINK)
oReason, pre-referral care given, vitals at transfer,
destination facility, transport mode, caregiver
informed/consent.
oProvider Details
oName, designation, signature.

How to Fill Accurately
• Use BLOCK letters, avoid blanks; write units (°C, /min, %, kg, cm).
• RR: count for full 60 seconds when calm/asleep.
• Temp: axillary digital; note fever 37.5°C
≥ ; infant low temp <35.5°C.
• MUAC: left arm, midpoint; tape flat; read to 0.1 cm.
• Weight: remove shoes/heavy clothes; to 0.1 kg.
• Circle/tick color classifications clearly; do all relevant modules (co-
morbidity).
• Time-stamp first doses, oxygen start/stop, and fluids.

Triage & Patient Flow
(Time Targets)
• Triage within 5 min of arrival; identify danger signs
immediately.
• If PINK: start pre-referral care within 10 min (oxygen, first
dose antibiotics/IV fluids as permitted).
• Plan B ORS: begin within 10 min for some dehydration.
• Keep young infants warm (skin-to-skin, cap, wrap)
throughout.

Measurement “Gold
Standards”
• RR: observe abdomen/chest; avoid counting during crying; repeat if
borderline.
• Skin pinch: abdominal wall; release—note slow/very slow.
• SpO₂: clean warm finger/toe; good waveform; aim 90–95%; avoid
prolonged hyperoxia.
• Jaundice (0–2 mo): document cephalocaudal progression;
palms/soles = severe.
• Edema: press both feet for 3 sec; pitting = SAM.

Quality & Safety Checks
• Six rights of medication + mg/kg pediatric dosing; double-check math.
• Oxygen: correct prong size; monitor SpO₂ and work of breathing;
reassess need.
• IV fluids (Plan C): right fluid, rate, monitor for overload (lungs, edema).
• Antibiotics: note dose, route, time; ensure full course instruction.
• Infection prevention: hand hygiene, equipment cleaning, safe sharps
disposal.

Common Errors & How to
Avoid
• Counting RR while crying wait for calm/sleep.
→
• Misclassifying dehydration by one sign use
→ combined signs.
• Missing bilateral pedal edema always check feet.
→
• Skipping palms/soles in neonatal jaundice assessment.
• Not giving first dose before referral in PINK cases (when permitted).
• Forgetting to write follow-up date or danger-sign list on the card.
• Incomplete referral note (no vitals/treatments/time).

Micro-Audit Checklist
• Case form complete; all vitals recorded (RR, Temp, SpO₂*).
• MUAC/edema documented; weight charted.
• All modules classified; worst color drives plan.
• First doses/oxygen/fluids charted with time.
• ORS + zinc prescribed for diarrhea; antibiotic for pneumonia/dysentery as per protocol.
• Counseling: meds schedule, ORS mixing, feeding, danger signs, follow-up date.
• Stocks available: ORS, zinc, amoxicillin, paracetamol, Vitamin A, malaria RDT/ACT (if
endemic), ear wicks, syringes, MUAC tape.
• Equipment working: timer, thermometer, scale, pulse oximeter, nebulizer/spacer.

Safe Referral & Transport
(Young Infant priority)
• Maintain warm chain (dry, wrap, skin-to-skin, cap, warm
transport).
• Continue oxygen during transfer if needed; secure IV line.
• Send referral note with vitals, times, doses, and treatments
given.
• Caregiver understands where to go and why; transport
arranged.

Using Data for
Improvement (Facility QI)
• Monthly tallies: case mix, pneumonia recovery,
diarrhea re-attendance, antibiotic use, referral
times.
• Identify gaps (e.g., missing RR, no zinc) → plan–do–
study–act cycles.
• Feedback to team; refresh IMNCI drills.

Legal & Ethical Points
• Informed consent for procedures/referral;
maintain confidentiality.
• Communicate in caregiver’s preferred
language; use visual job-aids.

Handover Format (SBAR) —
for ward/transport
• Situation: child age, main problem, color classification.
• Background: brief history; key vitals; co-morbid modules.
• Assessment: what you found (RR, dehydration grade,
MUAC, SpO₂).
• Recommendation: ongoing treatments, what to do next,
follow-up needs.

End-of-Day Quality
Routine
• Check drug stocks, ORS/zinc supply,
functioning equipment.
• Vaccines/cold-chain (if applicable); clean
& disinfect equipment; replenish forms.

Module-
Wise Job-
Aids (Quick
Rules Sheet)
Keep the color
code in mind:
PINK = urgent
referral,
YELLOW = treat
at facility,
GREEN = home
care.

Cough / Difficult Breathing
(2–59 months)
Fast breathing cut-offs (count RR for full 60 sec, child calm):
• 2–12 months: > 50/min
• 12–59 months: > 40/min
Classify & act
• PINK (Severe pneumonia/very severe disease): any danger sign, stridor at rest, severe chest indrawing,
central cyanosis/SpO₂ <90%
→ Oxygen, first-dose antibiotic if permitted, urgent referral.
• YELLOW (Pneumonia): fast breathing only
→ Oral antibiotic per protocol, soothe cough, follow-up 2 days.
• GREEN (No pneumonia): none of the above
Home care (fluids, rest, avoid smoke), return if worse.
→
Wheeze rule (any age): give bronchodilator trial (spacer/nebulizer). If improves continue per protocol; if not
→ →
reassess for pneumonia/foreign body.
Caregiver messages: fast/difficult breathing, chest indrawing, stridor, poor feeding = come back immediately.

Diarrhea
(Acute, Persistent, Dysentery)
• Dehydration signs
• Severe (PINK): lethargic/unconscious; sunken eyes; drinks
poorly/unable; skin pinch very slow
→ Plan C IV fluids per protocol, urgent referral; zinc when
able.
• Some (YELLOW): restless/irritable; sunken eyes; drinks
eagerly/thirsty; skin pinch slow
→ Plan B: ORS 75 ml/kg over 4 h, reassess; zinc 14 days.
• None (GREEN): none of the above
→ Plan A at home, zinc 14 days.

Zinc dose (14 days):
• <6 months: 10 mg/day
• 6–59 months: 20 mg/day
• Plan A amounts after each loose stool:
• Dysentery (blood in stool): YELLOW appropriate
→ antibiotic per
protocol, ORS, zinc, hygiene advice.
Persistent diarrhea (>14 days): assess malnutrition, feeding errors;
refer if weight loss or dehydration.
• Follow-up: Some dehydration → 5 days (earlier if worse).

Fever
(± malaria/measles as per area)
•Always check duration, rash, travel/malaria risk, measles vaccination.
Classify & act
• PINK: meningitis signs (stiff neck, bulging fontanelle), very ill/danger sign
Pre-referral care,
→ urgent referral.
• YELLOW: malaria suspected in endemic area or measles with eye/mouth complications
→ RDT/ACT per local guidance (malaria); Vitamin A & eye/mouth care (measles).
• GREEN: simple fever without danger signs
Fluids,
→ paracetamol 15 mg/kg/dose q6–8h (max 4 doses/day), tepid sponging.
Vitamin A in measles:
• <12 months: 100,000 IU day 1 & day 2
• ≥12 months: 200,000 IU day 1 & day 2
Return immediately: persistent high fever, convulsion, lethargy, neck stiffness, breathing
difficulty, poor drinking.

Ear Problems
Classify & act
• PINK (Mastoiditis): tender swelling behind ear, protruding pinna, high
fever/toxic
→ Urgent referral.
• YELLOW (Acute ear infection <14 d): ear pain/discharge, fever
→ Oral antibiotic per protocol, ear wicking (dry technique), pain relief;
follow-up 2 days.
• Chronic discharge 14 d:
≥ treat per protocol; plan referral if persistent.
• GREEN: no infection hygiene/avoid water entry.
→
Teach ear wicking: wash hands twist clean absorbent wick gently insert
→ →
to absorb discharge change until dry no probing.
→ →

Nutrition & Anemia
(6–59 months)
Quick measurements
• MUAC:
• <11.5 cm = Severe Acute Malnutrition (SAM)
• 11.5–12.5 cm = Moderate
• ≥12.5 cm = Normal
• Bilateral pitting edema of feet = Severe malnutrition.
• Palmar pallor: none / some / severe.
Decide & act
• SAM with complications (danger signs, edema + illness, anorexia, hypoglycemia) → Refer/admit.
• Uncomplicated SAM/Moderate malnutrition: outpatient nutrition plan, illness screen, deworming/iron
as indicated, close follow-up (1–2 wks).
• Severe pallor: refer; moderate iron/folate as per protocol.
→
Feeding counseling keys: age-appropriate meal frequency, diet diversity, extra meal ×2 weeks after illness;
continue breastfeeding.

— PSBI & Jaundice
Danger signs (any = PINK):
• Unable to feed/not feeding well; convulsions
• RR 60/min
≥ , severe chest indrawing, grunting
• Temp 37.5°C or <35.5°C
≥
• Moves only when stimulated/lethargic
• Severe jaundice: palms/soles yellow, onset <24 h, or persists
>14 d
• Umbilical infection spreading to skin ± fever

Action for PINK: keep warm (dry/wrap/skin-to-skin), ensure
airway/breathing, first-dose parenteral antibiotic if permitted, urgent
referral.
Local bacterial infection (YELLOW): umbilical redness without spread /
skin pustules topical/oral antibiotic as indicated,
→ cord/skin hygiene,
follow-up 2 days.
Feeding/Thermal care (all young infants):
 8–12 feeds/24 h, correct latch/attachment, treat thrush; cup/spoon
EBM if poor suck.
 Maintain warm chain; delay bathing; cap/socks; KMC if stable.
Caregiver messages: poor feeding, fever/low temp, fast
breathing/grunting, jaundice spreading to palms/soles, umbilical
redness/pus with fever = come immediately.

Immunization Check
(all visits)
• Review MCP/Immunization card; give
due/overdue vaccines (no unnecessary
delay during minor illness).
• Explain AEFIs (mild fever/pain common;
severe reaction rare seek care).
→
• Write next due date clearly.

Standard Add-Ons
(use everywhere)
• ORS + Zinc in any diarrhea episode (doses above).
• Paracetamol for fever/pain (15 mg/kg/dose q6–
8h; max 4 doses/day).
• Oxygen if SpO₂ <90% or severe respiratory
distress.
• First-dose antibiotic before referral in PINK cases
(as permitted by your protocol).

Follow-up dates
(write on card):
• Pneumonia / Acute ear → 2 days
• Some dehydration → 5 days
• Young infant local infection/feeding/jaundice (non-
severe) → 2 days
• Malnutrition/feeding problem → 1–2 weeks
• Fever (treated) → 2–3 days or sooner if worse

Danger-Sign Card
(give to caregiver)
• Not able to drink/breastfeed, vomits everything
• Convulsions, very sleepy/lethargic
• Fast/difficult breathing, chest indrawing, stridor
• High fever/very low temperature (young infant)
• Worsening diarrhea, blood in stool, poor drinking
• Jaundice spreading to palms/soles (young infant), umbilical
redness/pus with fever
• Any new/worsening symptom — come back immediately

OSCE / Exam Station Drill
(IMNCI Skills)
•Counting Respiratory Rate (RR) — 2–59 months
•Steps
• Hand hygiene greet caregiver get consent.
→ →
• Position child calm/asleep, expose chest/abdomen.
• Watch abdominal/chest rise–fall cycles; count for full 60 sec.
• Re-count if crying/moving; document RR/min and effort (indrawing/stridor/wheeze).
• Classify using cut-offs: 2–12 mo >50/min; 12–59 mo >40/min.
• Check SpO₂ if available.
• Common errors: counting 30 sec ×2; counting during crying; clothing covering chest.
Viva: “Fast breathing cut-offs: >50 (2–12 mo), >40 (12–59 mo).”

Dehydration Grading
(Diarrhea)
Steps
• Ask: days, stool count, vomiting, thirst/drinking.
• Look: general condition (lethargic/restless), sunken eyes.
• Offer fluid: drinks poorly/eagerly?
• Skin pinch on abdomen: very slow/slow/normal.
Classify:
• Severe: lethargic/unconscious + drinks poorly/unable + very slow pinch → Plan C.
• Some: restless/irritable + drinks eagerly + slow pinch → Plan B.
• None: none of the above → Plan A.
Start plan; Zinc 14 days for all diarrhea.
•Viva: “Plan B = ORS 75 ml/kg in 4 h; Plan A amounts after each stool: <2 y 50–100 ml, 2–5 y 100–200 ml.”

MUAC (6–59 months) &
Edema
Steps
• Left arm; find midpoint (acromion–olecranon).
• Wrap MUAC tape snug, not tight; read to 0.1 cm.
• Press both feet 3 sec for bilateral pitting edema.
• Interpret: <11.5 cm = SAM; 11.5–12.5 = Moderate; 12.5 = Normal
≥ .
Viva: “Bilateral pitting edema = severe malnutrition regardless of
MUAC.”

Ear Wicking
(Acute otorrhea)
Steps
• Hand hygiene; explain; good light.
• Twist clean absorbent wick (gauze/cotton on applicator).
• Gently insert into canal mouth; absorb, replace till dry.
• Do not probe deep; teach caregiver dry-ear technique; give oral
antibiotic/analgesic per protocol.
Viva: “Mastoiditis signs (post-auricular swelling/tenderness) → urgent
referral.”

ORS Mixing &
Administration
Steps
• 1 full sachet → 1 L safe water; stir till dissolved.
• Use cup & spoon; no bottles; use within 24 h.
• Give small, frequent sips; replace after each stool (Plan A amounts).
• Start Zinc 14 days (10 mg <6 mo; 20 mg 6–59 mo).
• Demonstrate; ask teach-back.
Viva: “Reasons to return immediately: drinks poorly/vomits everything, blood in
stool, lethargy.”

Caregiver Counseling (Teach–
Show–Do–Repeat–Write)
Script
• Explain illness & plan in simple words.
• Show: dose measurement, ORS mixing, spacer use or latch.
• Ask caregiver to Do and repeat-back the steps.
• Write: dose–time–days, ORS amounts, danger signs, follow-up date.
• Encourage extra fluids and continue feeding; extra meal × 2 weeks
after illness.
Viva: “3 medication must-dos: correct dose, full course, don’t stop early.”

Spacer / Bronchodilator
Demo (Wheeze)
Steps
• Assemble inhaler + spacer; shake inhaler.
• Child seated; seal mouth on spacer mouthpiece (or mask).
• 1 puff 5–6 slow breaths
→ ; wait ~1 min; repeat as advised.
• Rinse mouth if steroid inhaler used.
Viva: “If improves after trial, continue per protocol; if no
improvement, reassess for pneumonia/foreign body.”

Breastfeeding Attachment
& Position (Young Infant)
Good attachment signs (4)
• More areola visible above than below.
• Mouth wide open.
• Chin touching breast.
• Lower lip everted; audible swallowing.
Position tips: mother relaxed; baby tummy-to-tummy, ear-shoulder-hip aligned, whole
body supported, bring baby to breast, not breast to baby; feed 8–12 times/24 h.
Viva: “If poor latch → re-position; manage thrush; consider cup/spoon EBM if weak suck.”

Neonatal Jaundice Triage
(0–2 months)
Steps
• Good light; press skin on forehead/chest; watch yellowing.
• Cephalocaudal spread? Check palms/soles.
• Severe if: palms/soles yellow, onset <24 h, or persists >14
d.
• Assess feeding, weight, temp, activity.

Action
• Severe PINK
→ : keep warm, support feeding,
urgent referral (phototherapy/exchange).
• Mild/moderate with good feeding review
→ in
2 days.
Viva: “Palms/soles yellow = severe jaundice.”

Axillary Temperature
(Young Infant priority)
Steps
• Dry axilla; place digital thermometer high in axilla; hold arm against
chest.
• Wait for beep; read & record.
• Fever 37.5°C
≥ ; low temp <35.5°C (hypothermia warm chain/KMC).
→
Viva: “Young infant fever/low temp with poor feeding = PSBI until
proven otherwise.”

Pre-Referral Bundle
(PINK)
Steps (as protocol permits)
• Airway–Breathing: position, clear secretions, oxygen if SpO₂ <90% or severe distress.
• Circulation: shock/severe dehydration → Plan C IV fluids; treat hypoglycemia (10%
dextrose).
• Warmth: dry/wrap; skin-to-skin (cap/socks).
• First-dose parenteral antibiotic (PSBI/severe pneumonia/meningitis suspicion).
• Referral note: vitals, times, doses, IV/oxygen, what to monitor; arrange transport;
counsel caregiver.
Viva: “Worst color drives the plan—if any PINK, treat & refer.”

Quick Scoring Templates
(Exam Checklist bullets)
• RR Station: calm child, full 60 sec, thresholds stated, documentation → 4/4.
• Dehydration: asked key history, checked 4 signs, correct plan (A/B/C) → 4/4.
• MUAC/Edema: correct midpoint, snug tape, read value, edema check,
correct category → 5/5.
• ORS: correct mix, amounts by age, zinc dose, discard after 24 h → 4/4.
• Counseling: Teach–Show–Do–Repeat–Write, danger signs & follow-up
written → 5/5.
• Pre-referral: ABC, warmth, first dose, referral note → 4/4.

Viva One-Liners
• U5 danger signs: Not drinking, Vomits everything, Convulsions, Lethargic/Unconscious,
Stridor/severe distress.
• RR cut-offs: >50 (2–12 mo), >40 (12–59 mo); 60
≥ for <2 mo.
• Zinc in diarrhea: 10 mg <6 mo, 20 mg 6–59 mo × 14 days.
• Plan B: ORS 75 ml/kg in 4 h.
• Measles Vitamin A: 100,000 IU (<12 mo); 200,000 IU ( 12 mo)
≥ on Day 1 & 2.
• MUAC <11.5 cm = SAM.
• Neonatal hypothermia: <35.5°C (axillary).
• Severe jaundice flags: palms/soles, <24 h onset, >14 d.
• Mastoiditis → urgent referral.
• Worst color present determines final plan.

Drug & Dose Pearls
Universal Pediatric Rules
• Dose by mg/kg (or by age band only).
• Weigh the child; if unknown, estimate conservatively.
• Re-check units (mg vs mL; elemental iron vs salt).
• Write the schedule (dose–time–days) and teach caregiver
measurement (syringe/spoon).
• In any PINK case: give first dose (if permitted) before referral.

Core Outpatient
Medicines
Amoxicillin (pneumonia – fast breathing)
• Dose: 40–50 mg/kg per dose PO every 12 h × 5 days.
• Worked examples:
• 6 kg: 6 × 40 = 240 mg per dose (≈ 10 mL of 125 mg/5 mL syrup).
• 10 kg: 10 × 40 = 400 mg per dose (≈ 16 mL of 125 mg/5 mL OR 8 mL
of 250 mg/5 mL).
• 15 kg: 15 × 40 = 600 mg per dose (≈ 12 mL of 250 mg/5 mL).
• Counsel: full 5-day course; don’t stop early.

Paracetamol (fever/pain)
 Dose: 15 mg/kg per dose every 6–8 h (max 4
doses/24 h).
 Example: 12 kg 12 × 15 =
→ 180 mg (~ 3.6 mL of 250
mg/5 mL).
Zinc (all diarrhea episodes)
 <6 months: 10 mg once daily × 14 days.
 6–59 months: 20 mg once daily × 14 days.
 Form: syrup or dispersible tablet (dissolve in breast
milk/water).

Vitamin A
(measles)
• <12 months: 100,000 IU on Day 1 & Day 2.
• ≥12 months: 200,000 IU on Day 1 & Day 2.
• Consider a third dose after 2 weeks if
advised.

Bronchodilator
(Salbutamol) for wheeze
• Spacer (MDI): typically 2 puffs, each puff followed by
5–6 breaths; reassess response.
• Nebulization: common dose ≈ 0.15 mg/kg (min 2.5
mg) with normal saline; per local protocol.
• If improves, continue; if no improvement, reassess
for pneumonia/foreign body.

Iron (elemental) for anemia
(non-severe; if no acute infection)
• Dose: ~ 3 mg/kg/day elemental iron, usually once
daily for ~12 weeks (per program).
• Example: 10 kg → 30 mg elemental iron/day
(check syrup label for elemental content).
• Add folic acid as per local schedule; deworm if
due.

Dysentery antibiotic
• Choose per local resistance/IMNCI
table (e.g., ciprofloxacin or cefixime).
• Give correct mg/kg dose for 3–5 days
as per protocol; ORS + zinc mandatory.

Pre-Referral (PINK)
Antibiotics & Rescue
Give only if your setting permits; do not delay referral.
Young Infant (0–2 months) – PSBI
• Gentamicin IM/IV: 7.5 mg/kg once daily (simplified outpatient regimens
use this).
• + Amoxicillin PO: 50 mg/kg per dose every 12 h, or
• Ampicillin IM/IV: 50 mg/kg every 6 h (facility protocols).
• Alternative single-dose option in some settings: Ceftriaxone 50 mg/kg
IM/IV once before referral.

Severe Pneumonia / Meningitis suspicion (2–59
months)
 First dose per local protocol (e.g., Ceftriaxone
50 mg/kg IM/IV), oxygen if hypoxic, then
urgent referral.
Hypoglycemia rescue
 10% Dextrose IV bolus: 2 mL/kg (check blood
glucose if feasible); start maintenance as
advised.

Fluids: Diarrhea Plans &
Shock
Plan A (home)
• ORS after each stool:
• <2 years: 50–100 mL
• 2–5 years: 100–200 mL
• Plus zinc 14 days; continue feeding.
Plan B (some dehydration)
 ORS 75 mL/kg over 4 hours at facility; reassess; start zinc.

Plan C (severe
dehydration/shock) (WHO
schedule)
• If <12 months: 30 mL/kg in 1 h, then 70 mL/kg in 5 h.
• If 12 months
≥ : 30 mL/kg in 30 min, then 70 mL/kg in
2.5 h.
• Monitor pulse, breathing, lungs; switch to ORS when
able; give zinc.

Oxygen (when &
how)
• Indications: SpO₂ <90% or severe respiratory
distress/central cyanosis.
• Delivery: nasal prongs/hood; titrate to SpO₂ 90–
95%; avoid prolonged hyperoxia.
• Document flow rate, start time, and SpO₂ trend.

Safe Calculation Tips
(avoid exam/ward errors)
• Convert mg mL
↔ using syrup strength (e.g., 125 mg/5
mL = 25 mg/mL).
• Write the exact mL and spoon/syringe size.
• Confirm allergies; check drug–drug overlaps; renal
cautions (e.g., gentamicin).
• For dispersible tablets: dissolve fully; give the fraction
required.

Documentation &
Counseling (must do)
• Record drug, dose (mg/kg), route, time, and first dose
given.
• Provide written schedule to caregiver; demonstrate
measurement.
• Reinforce full course, ORS + zinc, danger signs, and follow-
up date.

Integrated Management of Neonatal and Childhood Illnesses (IMNCI) – Unit IV | Child Health Nursing I | B.Sc Nursing 5th Semester

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