Appendix 13. Case management

See Toolbox

 

Case definitions, triage and treatment

Uncomplicated cases (outpatient treatment)

Standard treatment

• Paracetamol PO: 20 mg/kg 3 times daily

  Age	< 2 months	2-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	< 5 kg	5-9 kg	10-17 kg	18-32 kg	33-47 kg
  Oral sol. 120 mg/5 ml	3 ml x 3	4 to 10 ml x 3	–	–	–	–
  100 mg tab	3/4 tab x 3	1 to 2 tab x 3	2 to 3 tab x 3	–	–	–
  500 mg tab	–	–	½ tab x 3	½ to 1 tab x 3	1½ to 2 tab x 3	2 tab x 3

 

• Amoxicillin PO: 25 to 50 mg/kg 2 times daily for 5 days in children under 5 years

  Age	< 2 months	2-11 months	1-4 years
  Weight	< 5 kg	5-9 kg	10-17 kg
  Oral susp. 125 mg/5 ml	½ tsp x 2	2 to 3 tsp x 2	–
  250 mg tab	1 tab x 2	1 to 2 tab x 2	2 to 3 tab x 2
  500 mg tab	–	–	1 to 2 tab x 2

 

• Retinol* (vitamin A) PO: one dose on Day1

  Age	< 6 months	6-11 months	1 year and over
  Weight	< 7.5 kg	7.5-9 kg	10 kg and over
  Dose	50 000 IU	100 000 IU	200 000 IU
  200 000 IU capsule (8 drops)	2 drops	4 drops	1 capsule

* except in pregnant women

 

• Wipe eyes with cotton and clean water.
• Keep nasal passages clear (using a tissue or by nasal lavage with 0.9% sodium chloride if appropriate).
• Depending on the context, for children < 3 or 5 years, food supplement: 500 kcal daily, ready-to use food, 2 weeks.

Treatment of complications

• Pneumonia without severe signs or acute otitis media: amoxicillin PO 5 days
• Purulent conjunctivitis: clean the eyes with clean water + tetracycline eye ointment 1% (2 times daily, 7 days)
• Bitot’s spots: retinol PO one dose on Day1, Day2, Day8
• Oral candidiasis: nystatin 100 000 IU/ml oral suspension (1 ml 4 times daily, 7 days)aCitation a.If not available, 0.25% gentian violet, applied 2 times/day for 5 days maximum.
• Diarrhoea without dehydration: WHO plan A

 

 

Complicated cases (inpatient treatment)

Standard treatment

• Paracetamol PO: 20 mg/kg 3 times daily

  Age	< 2 months	2-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	< 5 kg	5-9 kg	10-17 kg	18-32 kg	33-47 kg
  Oral sol. 120 mg/5 ml	3 ml x 3	4 to 10 ml x 3	–	–	–	–
  100 mg tab	3/4 tab x 3	1 to 2 tab x 3	2 to 3 tab x 3	–	–	–
  500 mg tab	–	–	½ tab x 3	½ to 1 tab x 3	1½ to 2 tab x 3	2 tab x 3

 

• Only in case of high fever in a child who is vomiting repeatedly or whose consciousness is impaired, paracetamol IV, 500 mg vial (10 mg/ml, 50 ml

  Weight	< 10 kg	10-50 kg	> 50 kg
  Dose to be administered every 6 hours (in mg)	7.5 mg/kg	15 mg/kg	1 g
  Dose to be administered every 6 hours (in ml)	0.75 ml/kg	1.5 ml/kg	100 ml
  Dose maximum	30 mg/kg/day	60 mg/kg/day	4 g/day

 

Administer paracetamol IV in 4 doses at 6-hour intervals. Each dose is administered over 15 minutes. Change to oral route as soon as possible.

 

• Amoxicillin PO: 25 to 50 mg/kg 2 times daily for 5 days in children under 5 years

  Age	< 2 months	2-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	< 5 kg	5-9 kg	10-17 kg	18-32 kg	33-47 kg
  Oral susp. 125 mg/5 ml	1½ tsp x 2	2 to 3 tsp x 2	–	–	–	–
  250 mg tab	1 tab x 2	1 to 2 tab x 2	2 to 3 tab x 2	–	–	–
  500 mg tab	–	–	1 to 2 tab x 2	2 to 3 tab x 2	3 to 4 tab x 2	4 tab x 2

 

• Retinol (vitamin A) PO: one dose on Day1 and Day2

  Age	< 6 months	6-11 months	1 year and over
  Weight	< 7.5 kg	7.5-9 kg	10 kg and over
  Dose	50 000 IU	100 000 IU	200 000 IU
  200 000 IU capsule (8 drops)	2 drops	4 drops	1 capsule

 

Administer retinol PO in 2 doses (Day1, Day2) to all patients except:

• pregnant women (contra-indicated);
• in the event of corneal lesions or Bitot’s spots (in this case, give 3 doses, on Day1, Day2, Day8).

 

• Wipe eyes with clean water 2 times daily.
• Keep nasal passages clear (using a tissue or by nasal lavage with 0.9% sodium chloride if appropriate).
• Give caloric food, smaller, more frequent meals or breastfeed more frequently.
• Make the child drink regularly.
• Depending on the context, for children < 3 or 5 years, food supplement: 500 kcal daily, ready-to use food, 2 weeks.

Respiratory and ENT complications

Severe pneumonia

• Oxygen if cyanosis or SpO₂ < 90%
• Ceftriaxone slow IV or IM (1 g to be dissolved in 5 ml): 100 mg/kg once daily

  Age	1-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	4-9 kg	10-17 kg	18-32 kg	33-47 kg
  Dose	400 to 900 mg	1 to 1.5 g	2 to 3 g	3 to 4 g	4 g
  Volume to be injected (1 g vial /5 ml of diluent)	2 to 5 ml	1 to 1½ vial	2 to 3 vials	3 to 4 vials	4 vials

 

 

PLUS

 

• Cloxacillin IV infusion over 60 minutes (500 mg to be dissolved in 5 ml water for injection): 25 to 50 mg/kg every 6 hours

  Age	< 2 months	2-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	< 5 kg	5-9 kg	10-17 kg	18-32 kg	33-47 kg
  Dose	200 mg x 4	250 to 400 mg x 4	500 to 750 mg x 4	1 g x 4	1.5 g x 4	2 g x 4
  Volume to be injected (500 mg vial /5 ml)	2 ml x 4	2.5 to 4 ml x 4	1 to 1½ vial x 4	2 vials x 4	3 vials x 4	4 vials x 4

 

Parenteral treatment for at least 3 days then, once the child no longer has fever or clinical signs of severe infection, change to amoxicillin/clavulanic acid PO: 40 mg/kg 2 times daily to complete 7 to 10 days of treatment

 

Pneumonia (without signs of severity)

• Amoxicillin PO: 25 to 50 mg/kg 2 times daily for 5 days

  Age	< 2 months	2-11 months	1-4 years	5-10 years	11-15 years	Adult
  Weight	< 5 kg	5-9 kg	10-17 kg	18-32 kg	33-47 kg
  Oral susp. 125 mg/5 ml	1½ tsp x 2	2 to 3 tsp x 2	–	–	–	–
  250 mg tab	1 tab x 2	1 to 2 tab x 2	2 to 3 tab x 2	–	–	–
  500 mg tab	–	–	1 to 2 tab x 2	2 to 3 tab x 2	3 to 4 tab x 2	4 tab x 2

 

As a second line (treatment failure after 48 hours), amoxicillin/clavulanic acid PO: 40 mg/kg 2 times daily for 7 days (see Severe pneumonia).

Acute otitis media

• Amoxicillin PO: 25 to 50 mg/kg 2 times daily for 5 days (see above)
• If there is discharge from the ear, keep the ear clean by wiping the external auditory canal with dry cotton wool.

Severe laryngotracheobronchitis (croup)

• Dexamethasone (1 ml ampoule, 4 mg/ml) IM: 0.6 mg/kg single dose

  Age	< 2 months	2-11 months	1-4 years	3-4 years
  Weight	< 5 kg	5-9 kg	10-13 kg	14-17 kg
  Dose	2 mg	4 mg	8 mg	10 mg
  Volume to be injected	0.5 ml	1 ml	2 ml	2.5 ml

 

• Nebulized epinephrine (1 mg ampoule, 1 mg/ml): 0.5 ml/kg per dose

  Age	1 month	2 months	3 months	4-6 months	7-9 months	10-11 months	1-4 years*
  Weight	4.5 kg	5 kg	6 kg	7 kg	8 kg	9 kg	10-17 kg
  Epinephrine (1 mg/ml ampoule)	2 ml	2.5 ml	3 ml	3.5 ml	4 ml	4.5 ml	5 ml
  0.9% NaCl to be added	2 ml	2 ml	1 ml	1 ml	–	–	–

 

* In children > 4 years or > 17 kg, the dose should not exceed 5 ml.

 

• Oxygen if cyanosis or SpO₂ < 90%

Ocular complications

Corneal lesions (opacification, ulcer)

• Retinol (vitamin A) PO: one dose on Day1, Day2, Day8

  Age	< 6 months	6-11 months	1 year and over
  Weight	< 7.5 kg	7.5-9 kg	10 kg and over
  Dose	50 000 IU	100 000 IU	200 000 IU
  200 000 IU capsule (8 drops)	2 drops	4 drops	1 capsule

 

• Tramadol PO if ocular pain:
  • Child over 12 years and adult: 50 to 100 mg every 6 hours (max. 400 mg daily)

    Age	> 12 years	Adult
    Dose	50 mg x 4	100 mg x 4
    Gél 50 mg	1 cap x 4	2 cap x 4

 

• Keep the eye clean: clean with 0.9% sterile sodium chloride and apply tetracycline eye ointment 1%, 2 times daily, to prevent or treat bacterial superinfection.
• Protective dressing as long there is photophobia.

Bitot’s spots

• Retinol (vitamin A) PO: one dose on Day1, Day2 and Day8, as above

Purulent conjunctivitis

• Clean the eyes with clean water 2 times daily.
• Tetracycline eye ointment 1%: one application 2 times daily for 7 days

Gastrointestinal complications

Oral candidiasis

• Nystatin PO: 1 ml of oral suspension (100 000 IU) 4 times daily for 7 daysbCitation b.If not available, 0.25% gentian violet, applied 2 times/day for 5 days maximum. . If there is no improvement after 3 days, increase the dose to 200 000 IU 4 times daily.

Diarrhoea without dehydration

WHO treatment plan A

Diarrhoea with dehydration

• Rehydration:

Moderate (some) dehydration: WHO treatment plan B

Severe dehydration: WHO treatment plan C

+

• Zinc sultate (20 mg dispersible tablet):
  • Child under 6 months: 10 mg once daily for 10 days (= ½ tab daily)
  • Child from 6 months to 5 years: 20 mg daily for 10 days (= 1 tab daily)

In infants: place ½ or 1 tablet in a teaspoon and add a bit of water to dissolve it.

In children over 2 years: tablets may be chewed or dissolved.

Ask the parents not to remove the tablets from the blister-pack. Once a tablet is removed from the blister-pack, it must be administered immediately.

Other complications

Acute malnutrition

Follow the protocol for managing malnutrition (RTUF).

Seizures

Generalised seizure lasting > 3 minutes:

• diazepam: 10 mg ampoule (5 mg/ml, 2 ml)

Child: 0.5 mg/kg rectally, without exceeding a total dose of 10 mg

• For intrarectal administration, use a 1 ml-syringe graduated in 0.01 ml (with no needle). Introduce the tip of the syringe into the rectum (1.5 to 4 cm depending on age).

  Age	< 4 months	4-11 months	1-2 years
  Weight	< 7 kg	7-9 kg	10-13 kg
  Dose in mg	2.5 mg	4 mg	6 mg
  Volume to be administered	0.5 ml	0.8 ml	1.2 ml

 

If seizures persist after 5 minutes after the first dose, repeat the same dose once.

If the patient is to be transferred to a hospital

• Administer the first dose of amoxicillin PO and paracetamol PO.
• Severe dehydration: place a IV line and transfer the patient when stable.
• Moderate (some) dehydration: the patient should be able to drink ORS while being transferred.
• Corneal lesion: protect the eye with a dry dressing.
• Send the patient with a transfer form indicating the reason for the referral and treatments administered.