# Situation: A nurse handles the under-five clinic of a Barangay Health Station (BHS). An 11-month-old infant is brought in for a 3-day cough. The infant is alert and feeding well, has no general danger signs, no chest indrawing, and no stridor, and has a respiratory rate of 48 breaths per minute. How should the nurse classify the illness according to Integrated Management of Childhood Illness (IMCI)?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627056  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A nurse handles the under-five clinic of a Barangay Health Station (BHS).

An 11-month-old infant is brought in for a 3-day cough. The infant is alert and feeding well, has no general danger signs, no chest indrawing, and no stridor, and has a respiratory rate of 48 breaths per minute. How should the nurse classify the illness according to Integrated Management of Childhood Illness (IMCI)?

## 보기

1. Pneumonia (yellow)
2. Severe pneumonia or very severe disease (pink)
3. Cough or cold (green) **✔ 정답**
4. Pneumonia (pink)

**정답: 3**

## 해설

The fast-breathing cut-off depends on age: 50 breaths per minute or more from 2 months up to 12 months, and 40 or more from 12 months up to 5 years. At 11 months, a rate of 48 is below 50, so there is no fast breathing. With no chest indrawing, no stridor, and no danger signs, the classification is cough or cold (green).

## 심화 해설

The IMCI assessment for a child with cough follows a structured sequence: first check for general danger signs, then examine for chest indrawing and stridor, and finally count the respiratory rate to determine whether fast breathing is present. In this 11-month-old infant, none of the danger signs are present, there is no chest indrawing, and no stridor is noted. The remaining question is whether the respiratory rate of 48 breaths per minute meets the threshold for fast breathing.

The fast-breathing cut-off is age-specific. For infants aged 2 months up to 12 months, fast breathing is defined as 50 breaths per minute or more. For children aged 12 months up to 5 years, the threshold is 40 breaths per minute or more. Because this infant is 11 months old, the applicable cut-off is 50. A rate of 48 is below that threshold, so fast breathing is not present.

With no general danger signs, no chest indrawing, no stridor, and no fast breathing, the illness is classified as cough or cold (green). The green classification indicates that the child can be managed at home with supportive care, such as a safe remedy for cough, continued feeding, and instructions on when to return immediately.

Key point! The age-based respiratory rate cut-off is the single most important discriminator between the green and yellow classifications in a child with cough but no chest indrawing. At 11 months, 48 is still normal-range for IMCI purposes.

The revised WHO guidance and IMCI protocol classify pneumonia based on fast breathing and/or chest indrawing in children aged 2–59 months . In this infant, neither finding is present. Chest indrawing is absent, and the respiratory rate does not reach the fast-breathing threshold for the infant’s age. Therefore, pneumonia is not classified.

Watch out! A common error is applying the 40 breaths per minute cut-off to an infant under 12 months. That threshold applies only from 12 months onward. Using it here would incorrectly suggest fast breathing and lead to a pneumonia classification.

The IMCI algorithm does not include routine lung auscultation by non-physician health workers in low-resource settings, partly because of concerns about feasibility and reliability . Classification relies on the clinical signs assessed in this scenario: danger signs, chest indrawing, stridor, and respiratory rate. In this infant, all findings point to a simple cough or cold.

| Age group | Fast breathing threshold | This infant |
| --- | --- | --- |
| 2 months up to 12 months | 50 breaths/min or more | 48 breaths/min — not fast breathing |
| 12 months up to 5 years | 40 breaths/min or more | Not applicable at 11 months |

The correct classification is cough or cold (green), because the respiratory rate of 48 at 11 months of age is below the 50 breaths per minute threshold for fast breathing, and no other pneumonia-defining signs are present.

## 임상 시나리오

IMCI Cough Classification: Age-Based Fast Breathing Cutoff11-month-old with RR 48 and no danger signs
For an infant aged 2 months up to 12 months, fast breathing is defined as 50 breaths/min or more. At 11 months, a respiratory rate of 48 is below the threshold, so fast breathing is absent.

With no general danger signs, no chest indrawing, no stridor, and no fast breathing, the correct IMCI classification is cough or cold (green). The child can be managed at home with supportive care and return precautions.

CautionThe cutoff changes at 12 months: from 12 months up to 5 years, fast breathing is 40 breaths/min or more. Always verify the child's exact age before applying the threshold—misclassifying by even one month can change the management plan.

## 핵심 개념

- **Fast breathing** — Age-specific respiratory rate threshold: 50/min or more for 2–11 months, 40/min or more for 12 months–5 years.
- **Cough or cold (green)** — IMCI classification for cough with no danger signs, no chest indrawing, no stridor, and no fast breathing; managed at home.
- **Pneumonia (yellow)** — IMCI classification for cough with fast breathing but no danger signs, chest indrawing, or stridor; requires oral antibiotics.
- **Severe pneumonia or very severe disease (pink)** — IMCI classification for cough with any general danger sign, chest indrawing, or stridor; requires urgent referral.
- **General danger signs** — Inability to drink or breastfeed, vomiting everything, convulsions, lethargy or unconsciousness; checked first in IMCI.

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