Most deaths in children under five are from preventable or treatable causes: pneumonia, diarrhoea, malaria, newborn conditions and malnutrition. WHO and UNICEF developed Integrated Management of Childhood Illness (IMCI) so that nurses and other health workers in first-level facilities can assess a sick child systematically, identify who needs urgent referral, and treat the rest correctly. It is used in over 100 countries.
Step 1: Check for general danger signs
For every sick child aged 2 months to 5 years, check first:
- Is the child unable to drink or breastfeed?
- Does the child vomit everything?
- Has the child had convulsions during this illness?
- Is the child lethargic or unconscious?
- Is the child convulsing now?
A child with any general danger sign has a serious problem and needs urgent attention and referral, after pre-referral treatment as per protocol. Don’t keep them waiting in a queue: triage them first.
Step 2: Ask about the main symptoms
Cough or difficult breathing
- Count the breathing rate for a full minute while the child is calm.
- Fast breathing: 50 or more per minute (2–12 months); 40 or more (12 months to 5 years).
- Look for chest indrawing (lower chest wall goes in when breathing in) and listen for stridor in a calm child.
- Check oxygen saturation with a pulse oximeter where available.
- Fast breathing alone suggests pneumonia (oral amoxicillin as per protocol); danger signs or low oxygen mean severe disease needing referral.
Diarrhoea
- For how long? Is there blood in the stool?
- Assess dehydration: general condition, sunken eyes, ability to drink, skin pinch. See our rehydration plans A, B and C.
- Treat with ORS and zinc; continue feeding.
Fever
- In malaria areas, test with a rapid diagnostic test, and treat positives with an ACT.
- Look for a stiff neck (possible meningitis), signs of measles, and other causes.
- Fever with a general danger sign or stiff neck = very severe febrile disease: urgent referral.
Ear problems
Ear pain, discharge, or tender swelling behind the ear (possible mastoiditis, which needs referral).
Step 3: Check nutrition, immunisation and more
- Malnutrition: measure weight-for-length/height and mid-upper arm circumference (MUAC). A MUAC below 11.5 cm, or bilateral pitting oedema of both feet, indicates severe acute malnutrition.
- Anaemia: check for palmar pallor.
- Immunisation status and vitamin A.
- HIV status or exposure in high-prevalence settings.
- Ask about feeding and any other problems.
Classifying with colours
| Colour | Meaning | Action |
|---|---|---|
| Pink | Severe classification | Pre-referral treatment and urgent referral |
| Yellow | Needs specific treatment | Treat at the facility or with home treatment; follow up |
| Green | No serious problem | Home care advice |
Counselling the caregiver
- Show how to give oral medicines and ORS, and check understanding.
- Advise on feeding and fluids during illness.
- Tell them when to return immediately: the child is not able to drink or breastfeed, becomes sicker, develops a fever, has fast or difficult breathing, or has blood in the stool.
- Arrange follow-up.
Young infants (0–2 months)
Young infants have a separate IMCI chart, with signs of possible serious bacterial infection including not feeding well, convulsions, fast breathing (60 or more per minute), severe chest indrawing, fever (37.5°C or more) or low temperature (below 35.5°C), and movement only when stimulated or no movement at all.
Related: Severe malaria · Meningitis · Normal vital signs in children
Based on the WHO/UNICEF IMCI chart booklet and WHO guidance on pneumonia and diarrhoea in children. Educational content: follow your national IMCI guidelines and training.