Doctors Revision

Pediatrics & Child Health

IMCI Approach: Fever (2m-5y)

Assessment, classification, and management of fever in children aged 2 months to 5 years using the IMCI approach, focusing on identifying malaria and other severe causes.

Also known as: IMCI Fever Management, Childhood Fever Assessment

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Urgent Referral: Any child classified as Very Severe Febrile Disease OR Severe Complicated Measles. Child with Malaria or Fever-No Malaria who develops danger signs or fails to improve on follow-up. Fever present every day for >7 days. Child with complicated measles (eye/mouth) not improving on follow-up.

Red flags

  • Any General Danger Sign.
  • Stiff neck.
  • Severe complicated measles signs (clouding of cornea, deep mouth ulcers).
  • High fever unresponsive to paracetamol.
  • Signs of shock or severe dehydration.

Signs and symptoms

  • Ask:
  • - Does the child have fever (by history, feels hot, or measured temp >=37.5°C)?
  • - If yes, for how long?
  • - If >7 days, has fever been present every day?
  • - Has the child had measles within the last 3 months?
  • Look and Feel:
  • - Look or feel for stiff neck.
  • - Look for runny nose.
  • - Look for any bacterial cause of fever (local tenderness, oral sores, refusal to use limb, hot tender swelling, red tender skin/boils, abdominal/urinary pain).
  • - Look for signs of MEASLES (Generalized rash AND Cough, Runny nose, or Red eyes).
  • - If Measles now or within 3 months:
  • - Look for mouth ulcers (deep or extensive?).
  • - Look for pus draining from eyes.
  • - Look for clouding of the cornea.

Risk factors

  • Living in or travel to malaria-endemic area.
  • Lack of immunization (Measles, Pneumococcal, Hib).
  • Malnutrition.
  • HIV infection.

Diagnosis

Clinical assessment

Assessment based on presence/absence of general danger signs, stiff neck, malaria test result, duration of fever, presence of localizing signs of bacterial infection, and signs of measles or its complications.

Investigations

  • Malaria Test (RDT or Microscopy): MANDATORY for all fever cases.
  • Temperature measurement.
  • Lumbar Puncture (Referral level, if meningitis suspected based on danger signs/stiff neck).
  • Other investigations based on suspected local cause (e.g., urinalysis, CXR - referral level).

Diagnostic criteria

IMCI Classification based on signs: - Very Severe Febrile Disease: Any General Danger Sign OR Stiff neck. - Malaria: Positive Malaria Test. - Fever - No Malaria: Negative Malaria Test. - Severe Complicated Measles: Measles now or <3m ago AND (Any General Danger Sign OR Clouding of cornea OR Deep/extensive mouth ulcers). - Measles + Eye or Mouth Complications: Measles now or <3m ago AND (Pus draining from eye OR Mouth ulcers). - Measles: Measles now or <3m ago AND none of the above complications.

Management

Non-pharmacological management

  • All Fever: Advise mother on home care (fluids, feeding), when to return immediately (danger signs). Counsel on mosquito net use and environmental sanitation.
  • Measles: Encourage fluid intake, continue feeding.
  • Very Severe Febrile Disease: Keep warm, prevent low blood sugar during referral.

Pharmacological treatment

  • Very Severe Febrile Disease:
  • - Give FIRST DOSE pre-referral antimalarial: Rectal Artesunate (10 mg/kg) OR IM/IV Artesunate (3 mg/kg if <20kg, 2.4 mg/kg if >20kg).
  • - 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).
  • - Give Paracetamol 10-15 mg/kg for high fever (>=38.5°C).
  • - Treat convulsions if present (Rectal Diazepam).
  • - Refer URGENTLY to Hospital.
  • Malaria:
  • - Give first-line oral ACT (Artemether-Lumefantrine - AL) - Dose by weight/age band (See UCG 2.5.2).
  • - Give Paracetamol 10-15 mg/kg for high fever (>=38.5°C).
  • - Treat any identified co-existing bacterial infection.
  • - Follow up in 3 days if fever persists (reassess, check adherence, consider referral/2nd line if needed). Refer if fever >7 days.
  • Fever - No Malaria:
  • - Give Paracetamol 10-15 mg/kg for high fever (>=38.5°C).
  • - Treat identified bacterial infection if present.
  • - If no bacterial cause, reassure, advise paracetamol for fever, follow up in 3 days if fever persists (reassess, repeat malaria test, consider referral). Refer if fever >7 days.
  • Severe Complicated Measles:
  • - Give Vitamin A (Age-appropriate dose - See Nutrition/Vit A section).
  • - Give FIRST DOSE pre-referral antibiotic (as for Very Severe Febrile Disease).
  • - If eye signs (clouding/pus): Apply Tetracycline eye ointment 1%.
  • - Refer URGENTLY to Hospital.
  • Measles + Eye or Mouth Complications:
  • - Give Vitamin A.
  • - If pus from eye: Apply Tetracycline eye ointment 1% TID.
  • - If mouth ulcers: Apply Gentian Violet 0.5% paint BID.
  • - Follow up in 3 days (assess eye/mouth, check treatment, refer if worse/not improving).
  • Measles (Uncomplicated):
  • - Give Vitamin A.
  • - Advise mother on home care.

Monitoring

Follow-up as per classification (usually 3 days if fever persists). Reassess danger signs, temperature, feeding, other symptoms. Monitor response to antimalarials/antibiotics.

Complications

  • Severe malaria.
  • Meningitis.
  • Sepsis.
  • Pneumonia.
  • Dehydration.
  • Febrile convulsions.
  • Complications of measles (pneumonia, diarrhoea, encephalitis, blindness, malnutrition).

Prevention

  • Malaria prevention (LLINs, prompt treatment).
  • Immunization (Measles, PCV, Hib).
  • Good nutrition.
  • Hygiene and sanitation.

Patient education

  • Diagnosis (Malaria vs other fever vs Measles).
  • How to give prescribed medicines (ACT, Paracetamol, antibiotics, Vitamin A, eye ointment, GV paint).
  • Importance of completing full course of treatment.
  • How to manage fever at home (tepid sponging, paracetamol).
  • Need for increased fluids and continued feeding.
  • Danger signs requiring immediate return.
  • Importance of follow-up visit.
  • Malaria prevention (nets) and measles prevention (vaccination).

Uganda-specific notes

Malaria is the most common cause of fever; universal testing (RDT/microscopy) before treatment is policy. Prompt treatment of malaria with ACTs is crucial. Recognizing severe disease needing referral is key. Measles outbreaks still occur. Vitamin A supplementation with measles is vital.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17, Section 17.3.4

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.5.2 (Malaria Treatment)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.3.3 (Measles & Vitamin A)

  • IMCI Chart Booklet, MOH Uganda

    (Fever Algorithm)

Scroll to Top