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Pediatrics & Child Health

IMCI Approach: Cough or Difficult Breathing (2m-5y)

Assessment, classification, and management of cough or difficult breathing in children aged 2 months to 5 years using the IMCI approach.

Also known as: IMCI Pneumonia Assessment

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Referral and warning signs

When to refer

Urgent Referral: Any child classified as Severe Pneumonia or Very Severe Disease. Child with Pneumonia who is HIV exposed/infected and has chest indrawing. Child with Pneumonia or Cough/Cold who worsens or fails to improve on follow-up. Child with cough >14 days or recurrent wheeze (for TB/Asthma assessment).

Red flags

  • Any General Danger Sign.
  • Stridor when calm.
  • Severe chest indrawing.
  • Cyanosis.
  • SpO2 <90%.
  • Grunting.
  • Failure to improve after 48-72h of appropriate antibiotic for Pneumonia.

Signs and symptoms

  • Ask:
  • - Does the child have cough or difficult breathing?
  • - If yes, for how long?
  • Look, Listen, Feel (Child must be calm):
  • - Count breaths in one full minute. (Fast breathing if: Age 2-12m: >=50/min; Age 1-5y: >=40/min).
  • - Look for chest indrawing (lower chest wall goes IN when child breathes IN).
  • - Look and listen for stridor (harsh noise on INspiration when calm).
  • - Look and listen for wheezing (high-pitched noise, usually on OUTspiration).
  • - Check SpO2 if available (Refer if <90%).

Risk factors

  • Malnutrition.
  • Lack of immunization (Hib, PCV, Measles).
  • Indoor air pollution.
  • HIV infection.
  • Low birth weight.

Diagnosis

Clinical assessment

Assessment based on presence/absence of general danger signs, stridor, chest indrawing, and fast breathing (age-specific cutoffs).

Investigations

  • Clinical assessment using IMCI algorithm is primary.
  • Chest X-ray (usually at referral level for severe/complicated cases).
  • Pulse oximetry (SpO2) if available.

Diagnostic criteria

IMCI Classification based on signs: Severe Pneumonia or Very Severe Disease: Any General Danger Sign OR Stridor in calm child OR SpO2 <90%. Pneumonia: Chest indrawing OR Fast breathing. Cough or Cold (No Pneumonia): No signs of severe disease or pneumonia.

Management

Non-pharmacological management

  • All Classifications: Soothe throat/relieve cough with safe remedy (breastmilk, warm tea with honey). Counsel mother on danger signs and when to return immediately. Counsel on home care (fluids, feeding).
  • Cough or Cold: Advise follow-up in 5 days if not improving.
  • Pneumonia: Advise follow-up in 3 days.
  • Severe Pneumonia: Keep child warm, prevent low blood sugar during referral.

Pharmacological treatment

  • Severe Pneumonia or Very Severe Disease:
  • - Give FIRST DOSE pre-referral antibiotic:
  • - Ampicillin 50 mg/kg IM + Gentamicin 7.5 mg/kg IM (HC3+).
  • - OR Benzylpenicillin 50,000 IU/kg IM (HC2).
  • - OR Amoxicillin DT 40 mg/kg PO if parenteral not available.
  • - If SpO2 <90%, give Oxygen.
  • - Refer URGENTLY to Hospital.
  • - If referral impossible: Continue Ampicillin Q6H + Gentamicin OD for 5 days.
  • Pneumonia:
  • - Give oral Amoxicillin dispersible tablet (DT) 40 mg/kg PO BID for 5 days (First line).
  • - Dose (DT 250mg): 2-12m (4-9kg): 1 tab BID; 1-3y (10-13kg): 2 tabs BID; 3-5y (14-19kg): 3 tabs BID.
  • - If wheezing: Give inhaled rapid-acting bronchodilator (Salbutamol inhaler with spacer) 2 puffs Q3-4H PRN for 5 days.
  • - If cough >14 days or recurrent wheeze: Refer for TB/Asthma assessment.
  • - If HIV exposed/infected with chest indrawing: Give first dose Amoxicillin DT and Refer.
  • Cough or Cold (No Pneumonia):
  • - NO ANTIBIOTIC NEEDED (likely viral).
  • - If wheezing: Give inhaled Salbutamol (as above) for 5 days.
  • - If cough >14 days or recurrent wheeze: Refer for TB/Asthma assessment.

Monitoring

Follow-up as indicated by classification (3 days for Pneumonia, 5 days if Cough/Cold not improving). Reassess breathing, feeding, fever, danger signs. If worsening or not improving, refer.

Complications

  • Respiratory failure.
  • Sepsis.
  • Pleural effusion / Empyema.
  • Lung abscess.
  • Death.

Prevention

  • Immunization (PCV, Hib, Measles).
  • Exclusive breastfeeding.
  • Good nutrition.
  • Reducing exposure to indoor air pollution.
  • Handwashing.
  • Zinc supplementation (reduces incidence).

Patient education

  • Diagnosis and reason for treatment (antibiotics only if Pneumonia).
  • How to give oral Amoxicillin correctly (dose, frequency, full 5-day course).
  • How to use Salbutamol inhaler with spacer if prescribed.
  • Importance of safe cough remedies (soothing).
  • Need for increased fluids and continued feeding.
  • Danger signs requiring immediate return.
  • Importance of follow-up visit.
  • Prevention measures (immunization, nutrition).

Uganda-specific notes

Pneumonia is a leading cause of child mortality. IMCI algorithm using age-specific respiratory rate cutoffs and chest indrawing is standard for diagnosis and classification at primary level. Amoxicillin DT is first-line for non-severe pneumonia. Recognize need for referral for severe cases and potential TB/Asthma.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17, Section 17.3.2

  • IMCI Chart Booklet, MOH Uganda

    (Cough or Difficult Breathing Algorithm)

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