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Management of pneumonia based on IMNCI classification

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IMNCI pneumonia classification management amoxicillin dose fast breathing chest indrawing severe pneumonia

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"pneumonia"[MeSH Terms] AND "Integrated Management of Childhood Illness"

Let me read the Park's IMNCI section.
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https://nhm.hp.gov.in/storage/app/media/uploaded-files/Train…

Management of pneumonia by IMNCI classification (children 2 months to 5 years)

The IMNCI approach is to check for general danger signs first. Then ask about cough or difficult breathing, count the breaths in one minute (the child must be calm), and look for chest indrawing, stridor and wheeze. Classify by colour and treat accordingly (Park's Textbook of Preventive and Social Medicine, IMNCI chart, Block 9).
Fast breathing cut-offs
  • 2 to 12 months: 50 breaths/min or more
  • 12 months to 5 years: 40 breaths/min or more
If the child is wheezing and also has fast breathing or chest indrawing, give a rapid-acting inhaled bronchodilator up to 3 times, 15 to 20 minutes apart. Then recount the breaths, look for chest indrawing again, and classify.

1. Pink: Severe pneumonia or very severe disease

Signs: any general danger sign, or stridor in a calm child. General danger signs are:
  • unable to drink or breastfeed
  • vomits everything
  • convulsions
  • lethargic or unconscious
Management (Park's):
  • Give the first dose of an appropriate antibiotic.
  • Refer urgently to hospital.
  • Give diazepam if the child is convulsing now.
  • Treat to prevent low blood sugar.
  • Keep the child warm.
Updated national guidance (this comes from a state NHM training module, so check your own programme's version): the pre-referral antibiotics are oral amoxicillin plus intramuscular gentamicin. If oxygen saturation is below 90%, give oxygen while arranging referral. Hospital treatment (injectable antibiotics, oxygen) is then given at the referral facility.

2. Yellow: Pneumonia

Signs: fast breathing and/or chest indrawing, with no danger sign or stridor.
Management (Park's):
  • Give oral amoxicillin for 5 days.
  • If wheezing, give an inhaled bronchodilator for 5 days. This also applies if the wheeze disappeared after the trial dose.
  • Soothe the throat and relieve the cough with a safe remedy.
  • If the child has coughed for more than 14 days, or has recurrent wheeze, refer to assess for TB or asthma.
  • If the child has chest indrawing and is HIV exposed or infected, give the first dose of amoxicillin and refer.
  • Advise the mother on when to return immediately.
  • Follow up in 3 days (Park's chart). The newer NHM module says 2 days, so use whichever your programme specifies.
Amoxicillin dose, twice daily for 5 days (NHM IMNCI training module). The standard WHO dose is about 40 mg/kg per dose, twice daily.
Age (weight)Syrup 125 mg/5 mlDispersible tablet 250 mg
2 to <4 months (4 to <6 kg)5 ml½
4 to <12 months (6 to <10 kg)10 ml1
12 months to <3 years (10 to <14 kg)15 ml1½
3 to <5 years (14 to <20 kg)-2
Follow-up at 2 to 3 days
  • If the child is improving, complete the 5 days.
  • If the child is worse or not improving, refer for hospital care.
Advise the mother to return immediately if the child:
  • becomes sicker
  • cannot drink or breastfeed
  • has fast or difficult breathing
  • develops fever

3. Green: Cough or cold (no pneumonia)

Signs: no fast breathing, no chest indrawing, no danger signs.
Management:
  • No antibiotic.
  • Give an inhaled bronchodilator if the child is wheezing.
  • Soothe the throat with a safe remedy such as warm fluids, honey or tulsi, and avoid harmful remedies.
  • Advise home care: continue feeding and fluids, keep the child clothed and warm, and clear a blocked nose.
  • Review in 5 days if not improving.
  • Refer if the cough has lasted more than 14 days.

Young infants (under 2 months): different classification

Pneumonia is not classified separately here. Fast breathing is 60 breaths/min or more.
  • Possible serious bacterial infection (PSBI) or very severe disease includes any of the following:
    • fast breathing (60 or more)
    • severe chest indrawing
    • fever (37.5°C or above) or low temperature (<35.5°C)
    • convulsions
    • not feeding well
    • movement only when stimulated, or no movement
    • grunting
  • Pre-referral treatment:
    • First dose of oral amoxicillin plus IM gentamicin (5 mg/kg once daily).
    • Prevent low blood sugar.
    • Warm the infant with skin-to-skin contact.
    • Refer urgently.
  • If referral is refused or not possible, give gentamicin once daily and amoxicillin twice daily for 7 days.

Evidence update

I searched PubMed for recent meta-analyses and found nothing that contradicts these protocols. A 2025 systematic review (PMID 40537056) supports community-level management of chest indrawing pneumonia in children aged 2 to 59 months. The WHO revision moved chest indrawing pneumonia from injectable treatment to oral amoxicillin at home.

Caveats

  • Park's chart is the older version. Newer national modules add oxygen saturation (<90% means severe) and a 2-day follow-up.
  • Check your national or state programme version before applying it clinically.
  • I did not find the pre-referral gentamicin volumes cleanly in the sources, so I left them out.
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