Imci diarrhoea all
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IMCI - Diarrhoea: Complete Coverage
Source: Park's Textbook of Preventive and Social Medicine (IMCI Chapter)
IMCI Case Management Process (Overview)
IMCI applies to children aged 1 week up to 5 years. Illness classification uses a colour-coded triage system:
- 🔴 PINK = Urgent hospital referral
- 🟡 YELLOW = Specific outpatient treatment
- 🟢 GREEN = Home management
STEP 1: ASSESS - Does the Child Have Diarrhoea?
Ask:
- For how long has diarrhoea been present?
- Is there blood in the stool?
Look and Feel:
- Child's general condition: lethargic/unconscious? Restless and irritable?
- Sunken eyes
- Offer fluid - is the child not able to drink or drinking poorly? OR drinking eagerly/thirsty?
- Skin pinch of abdomen: goes back very slowly (>2 seconds)? Or slowly?
STEP 2: CLASSIFY DIARRHOEA
A) Classify for DEHYDRATION
Child (2 months - 5 years):
| Signs | Classification | Treatment |
|---|---|---|
| Two of: Lethargic/unconscious; Sunken eyes; Not able to drink/drinking poorly; Skin pinch goes back very slowly | 🔴 PINK: SEVERE DEHYDRATION | If no other severe classification: Plan C. If also has another severe classification: Refer URGENTLY with ORS sips en route. If child ≥2 years and cholera in area: give antibiotic for cholera. |
| Two of: Restless/irritable; Sunken eyes; Drinks eagerly/thirsty; Skin pinch goes back slowly | 🟡 YELLOW: SOME DEHYDRATION | Plan B (ORS in clinic over 4 hours). If severe classification: refer urgently with ORS. Follow-up in 2 days if not improving. |
| Not enough signs for some or severe dehydration | 🟢 GREEN: NO DEHYDRATION | Plan A (home treatment). Advise when to return. Follow-up in 2 days if not improving. |
Young Infant (up to 2 months) - same signs apply but:
- Infant movement (on own / only when stimulated / not at all) is assessed instead of drinking
- "Very slowly" criterion for skin pinch same as above
B) Classify for PERSISTENT DIARRHOEA (if diarrhoea ≥14 days)
| Signs | Classification | Treatment |
|---|---|---|
| Dehydration present | 🔴 PINK: SEVERE PERSISTENT DIARRHOEA | Treat dehydration before referral. Refer to hospital. |
| No dehydration | 🟡 YELLOW: PERSISTENT DIARRHOEA | Advise on feeding; give multivitamins and minerals (including zinc) for 14 days. Follow-up in 5 days. |
C) Classify for DYSENTERY (if blood in stool)
| Signs | Classification | Treatment |
|---|---|---|
| Blood in the stool | 🟡 YELLOW: DYSENTERY | Give ciprofloxacin for 3 days. Follow-up in 3 days. |
STEP 3: TREATMENT PLANS
PLAN A - Treat Diarrhoea at Home (No Dehydration)
4 Rules of Home Treatment:
1. Give Extra Fluid (as much as the child will take):
- Breastfed infants: breastfeed frequently + longer at each feed
- Exclusively breastfed: ORS or clean water in addition to breast milk
- Not exclusively breastfed: ORS, food-based fluids (soup, rice water, yoghurt drinks), or clean water
ORS amounts after each loose stool:
| Age | ORS after each loose stool |
|---|---|
| Up to 2 years | 50-100 ml |
| 2 years or more | 100-200 ml |
- Give frequent small sips from a cup
- If vomits: wait 10 min, then continue more slowly
- Continue until diarrhoea stops
- Give mother 2 packets of ORS to take home
2. Give Zinc (age 2 months up to 5 years) - 20 mg tablet:
| Age | Dose | Duration |
|---|---|---|
| 2 months up to 6 months | ½ tablet (10 mg) daily | 14 days |
| 6 months up to 5 years | 1 tablet (20 mg) daily | 14 days |
- Infants: dissolve tablet in small amount of expressed breast milk, ORS, or clean water
- Older children: tablet can be chewed or dissolved in small amount of water
3. Continue Feeding (exclusive breastfeeding if age <6 months)
4. When to Return - advise caregiver to return immediately if child gets worse
PLAN B - Treat Some Dehydration with ORS (in clinic, over 4 hours)
ORS amounts in the first 4 hours:
| Weight | Age | ORS (ml) |
|---|---|---|
| <6 kg | Up to 4 months | 200-450 ml |
| 6-<10 kg | 4 months up to 12 months | 450-800 ml |
| 10-<12 kg | 12 months up to 2 years | 800-960 ml |
| 12-19 kg | 2 years up to 5 years | 960-1600 ml |
Formula: approximate amount (ml) = weight (kg) × 75
- Give more if child wants more
- Infants <6 months not breastfed: also give 100-200 ml clean water (not needed with low osmolarity ORS)
- Continue breastfeeding whenever child wants
- After vomiting: wait 10 min, then continue more slowly
After 4 hours: Reassess, reclassify dehydration, choose appropriate plan, begin feeding in clinic.
If mother must leave before completing: Show her how to prepare ORS and how much to give to finish 4-hour treatment at home. Explain the 4 Rules.
PLAN C - Treat Severe Dehydration Quickly
Summary of Plan C (follow arrows):
If IV fluids available immediately → YES:
- Start IV fluid immediately: 100 ml/kg Ringer's Lactate (or normal saline if RL unavailable)
Patient First give 30 ml/kg in: Then give 70 ml/kg in: Infants (<12 months) 1 hour* 5 hours Children (12 months - 5 years) 30 minutes* 2½ hours *Repeat once if radial pulse still very weak or not detectable - Reassess every 1-2 hours; if not improving, speed up drip
- Also give ORS ~5 ml/kg/hour as soon as child can drink (after 3-4 hours in infants, 1-2 hours in children)
- Reassess: infant after 6 hours, child after 3 hours. Classify dehydration. Choose appropriate plan.
If IV not available but available nearby (within 30 min) → YES:
- Refer URGENTLY to hospital
- Give ORS or ORS by NG tube en route
If trained to use NG tube → YES:
- Start ORS via NG tube/mouth: 20 ml/kg/hour for 6 hours (total 120 ml/kg)
- Reassess every 1-2 hours
- If repeated vomiting or increasing abdominal distension: give fluid more slowly
- If hydration not improving after 3 hours: send for IV therapy
If child can drink → YES: same NG protocol applies
If none of the above → NO: Refer URGENTLY for IV or NG treatment
NOTE: If child is not referred, observe at least 6 hours after rehydration to confirm mother can maintain hydration with oral ORS.
Key Points to Remember
| Feature | Detail |
|---|---|
| Diarrhoea definition (young infant) | Stools changed from usual, many and watery (more water than faecal matter). Normal frequent/semi-solid stools of a breastfed baby are NOT diarrhoea. |
| Persistent diarrhoea | Diarrhoea ≥ 14 days |
| Dysentery | Blood in stool - treat with ciprofloxacin 3 days |
| Zinc supplementation | 2 months - 5 years, 14 days course in ALL cases of diarrhoea |
| Cholera antibiotic | Only if child ≥2 years AND cholera in your area (in severe dehydration) |
| Breastfeeding | Must be continued in all plans - never stop |
| Follow-up: no dehydration | 2 days if not improving |
| Follow-up: persistent diarrhoea (yellow) | 5 days |
| Follow-up: dysentery | 3 days |
- Park's Textbook of Preventive and Social Medicine, IMCI Chapter (block 9)
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