General Danger Signs / Very Severe Disease — 2 months - 5 years | IMCI

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Care priority and warning signs

Refer URGENTLY

Any general danger sign present (Unable to drink/breastfeed OR Vomits everything OR Had convulsions OR Lethargic/unconscious OR Convulsing now) -> VERY SEVERE DISEASE

The presence of ANY ONE of the listed general danger signs classifies the child as having Very Severe Disease.
These signs indicate a life-threatening condition requiring immediate action and urgent referral, regardless of the main complaint.

Quickly complete the assessment to identify all necessary pre-referral treatments.
Keep the child warm: Cover the child, ensure no draughts. If possible use skin-to-skin contact.
Position the child appropriately (e.g., recovery position if unconscious and not convulsing, clear airway).

Specific pharmacological pre-referral treatments depend on associated classifications identified during the rapid assessment (see pre_referral section).

If convulsing now: Give Diazepam rectally (10mg/2ml solution). Dose: <6m (<5kg) 0.5ml; 6-<12m (5-<10kg) 1.0ml; 1-<3y (10-<15kg) 1.5ml; 4-<5y (15-19kg) 2.0ml. If convulsions continue after 10 minutes, repeat the dose.
Treat to prevent low blood sugar: If child can breastfeed, ask mother to do so. If not able to breastfeed but able to swallow: Give expressed breast milk OR breastmilk substitute OR sugar water (Dissolve 4 level teaspoons (20g) sugar in 200ml clean water) - give 30-50ml before departure. If child not able to swallow: Give 50ml of milk or sugar water by nasogastric tube.
Give relevant pre-referral treatment based on quick assessment findings:
If signs of Severe Pneumonia/Serious Infection: Give first dose Intramuscular Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg). Ampicillin doses (500mg vial diluted to 2.5ml): 4-<6kg: 1ml; 6-<10kg: 2ml; 10-<15kg: 3ml; 15-20kg: 5ml. Gentamicin doses (40mg/ml vial): 4-<6kg: 0.5-1.0ml; 6-<10kg: 1.1-1.8ml; 10-<15kg: 1.9-2.7ml; 15-20kg: 2.8-3.5ml.
If signs of Very Severe Febrile Disease/Suspected Severe Malaria: Give Rectal Artesunate (10 mg/kg, single dose) OR Intramuscular/IV Artesunate (3 mg/kg if <20kg, 2.4 mg/kg if >=20kg) OR Intramuscular Quinine (refer to page 11 for detailed dosing based on concentration).
If signs of Severe Dehydration (Plan C): Start IV fluids immediately if possible OR if child can drink give ORS sips frequently on the way to hospital (refer to page 13).

Explain clearly to the mother/caregiver why referral is urgent and necessary.
Explain any pre-referral treatments given and why.
Advise on how to keep the child warm during transport (e.g., blanket, skin-to-skin).
Advise on continuing breastfeeding during transport if possible.
If the child also has dehydration, show how to give frequent sips of ORS on the way.
Write a referral note detailing assessment findings, classification, treatments given, and reason for referral.

Complete routine childhood immunizations.
Exclusive breastfeeding for the first 6 months, continued breastfeeding with appropriate complementary feeding.
Use of insecticide-treated nets (ITNs) in malaria-endemic areas.
Handwashing and safe water/sanitation.
Prompt recognition of illness and seeking appropriate care.
Good maternal health and nutrition.

IMCI Chart Booklet - Page 1, Pages 11-13