Table 2. Major changes in ALMANACH as compared to IMCI algorithm based on evidence and experts’ opinion.

Location	Topic	IMCI	ALMANACH	Rationale
Management of very severe diseases section	Very severe diseases	“A child with any general danger signs needs URGENT attention; complete the assessment and pre-referral treatment immediately so that referral is not delayed”	If the child has any general danger sign, HWs are not asked to complete the assessment of all symptoms, but rather to “Give pre-referral treatment and REFER URGENTLY”	To complete the assessment would delay pre-referral treatment, and impair prognosis. In presence of general danger sign, the priority is to give rapidly presumptive AB/AM treatment[42,43] and to refer to hospital, where further etiological investigations will allow adapting the treatment.
	List of general danger signs	“Lethargic; Convulsing; Unable to drink/breastfeed; Vomits everything; History of convulsion”	“Convulsing; Lethargic; Unable to drink/breastfeed; Vomits everything; History of convulsion; Jaundice; Cyanosis; Stiff neck; Severe pallor; Severe wasting”	Stiff neck, severe pallor, and severe wasting (assessed later on in IMCI) are part of the ALMANACH initial assessment, in order to facilitate and fasten the detection and management of very severe diseases. Jaundice and cyanosis that are strong predictors for serious bacterial diseases and severe respiratory conditions [15], have been added to the general danger signs.
	Pre-referral treatment	Available in the “TREAT THE CHILD” section in the middle of the booklet	Available in the “Management of very severe diseases” section in the first pages of the booklet	To facilitate and fasten the management of severe patients, the first section “Management of very severe diseases” has all assessment, classification and treatment charts together.
Management of children with no general danger signs	Fever §	Fever § is one of the 4 “Main symptoms”.	Fever is a crossing point in ALMANACH: different recommendations are made for children (non-severe) with or without fever § .	In children having no underlying chronic condition, and no danger signs, only few bacterial infections should be considered. Apart from dysentery and soft tissue infection, antibiotics are not recommended in the treatment of non-severe non-febrile conditions in ALMANACH.
	Fever	Classifications considered in the Fever chart are: “Very severe disease”, “Malaria” and “Measles”. Additional classification in low malaria risk contexts: “Fever, malaria unlikely”	Classifications considered in the Fever algorithm: “Malaria”, Acute respiratory infections, including “Pneumonia”; Diarrhea related classifications; Ear related classification; Measles; Skin infections; “UTI”, “Typhoid fever”, “Likely viral infection”	Designing a specific chart for patients with fever allows considering more fever related classifications than in IMCI, thus to address relevant non-malaria fever. This design allow also to consider “Likely Viral infections” after having excluded potentially life threatening conditions
Febrile chart	Malaria	Presumptive diagnosis of malaria for all children with fever in high malaria risk contexts	Test-based malaria diagnosis is recommended, using mRDTs in all children with fever. Antimalarials only recommended in test positive patients	The accuracy, the performance and the safety[7] of a diagnostic strategy based on mRDTs have been evaluated and demonstrated in U5.
FebrileCough chart	Pneumonia	Pneumonia diagnosis rely on increased respiratory rate (RR) above age specific threshold: 50 breath/min if aged 2–11 months; 40/min if aged 12–59 months	Pneumonia is considered in children aged 2–59 months, if they report the presence of fever and have a RR above 50 breaths/min	The need of antibiotics in children aged 2–59 months with non-severe pneumonia as defined in IMCI is questioned[76]. In children aged 12–59 months the gain in sensitivity doesn’t balance the loss of specificity for the diagnosis of pneumonia when using the threshold 40 instead of 50 breath/min. (see results section)
Ear problem chart	Acute ear infection	Oral antibiotics are recommended for “Acute ear infection” defined as either “ear pain” or “ear pus/ discharge for less than 14 days”	Oral antibiotics are only recommended for children with fever and “ear pus/ discharge for less than 14 days”	The need for antibiotics for otitis media is questioned[56]. Ear pain is a weak predictor of otitis media[53,55,77] especially in children below 2 years of age. AB are most useful for children with otitis media and ear discharge[56].
Skin problem chart	Skin and soft tissue infections	Some guidance provided in an annex and not integrated with the complaints of the main algorithm	Referral to hospital is recommended for febrile skin lesions with a size >4 cm or associated with red streaks or tender nodes, and for multiple abscesses. Local treatment and home management is recommended for impetigo and minor abscesses	Severe soft tissue infections require in hospital treatment and injectable antibiotics. Limited skin infections can be safely managed by topical treatment.
Febrile chart for “Fever with no identified cause” after symptom charts assessment	Urinary tract infection	Not considered in IMCI	Considered in non-severe febrile children, under 2 years of age, with no primary focus identified; and in children, above 2 years of age, with dysuria. Urinalysis using a dipstick is recommended for the diagnostic.	UTI is most frequent in children under 2 years of age. Above 2 years of age, the specificity of dysuria symptoms is low. The accuracy and performance of dipstick for UTI diagnosis have been demonstrated. Dipsticks for pregnancy follow-up were already broadly available in PHCFs in Tanzania; dipsticks for urinalyses were available in Health Centers.
	Typhoid fever	Not considered in IMCI	In non-severe febrile children above 2 years of age, with no primary focus identified, abdominal palpation is recommended. In presence of tenderness, a presumptive treatment for typhoid fever and invasive intestinal bacterial infections is recommended.	Typhoid fever and other invasive enteric infections are life threatening conditions. In low resource care facilities, HWs fear to miss these diagnoses and tend to overprescribe antibiotics to children with no identified causes of fever. In the Tanzanian fever study, abdominal tenderness was associated with invasive bacterial infections and typhoid[15], in children above 2 years of age.

AB: antibiotics, AM: antimalarials, HW: health worker, IMCI: Integrated Management of Childhood Illness, PHCF: primary health care facility, U5: children under 5 years of age, UTI: urinary tract infection.

^§Fever is defined by either history of fever or axillary temperature above 37.5°C or child feels hot.