5.4 Treatment of complicated cases

A complicated case is a patient who has one or more major complications; these patients are hospitalised.

Measles patients should be hospitalised in an area separate from other patients, with dedicated staff and equipment to prevent any transmission within the health care facility. Patients need to be isolated for 4 days after the rash first appears.

Treatment for complicated cases consists of the standard treatment AND treatment for one or more existing complications.
 

5.4.1 Routine standard treatment

See Section 5.3

• Antipyretic: paracetamol
  • Paracetamol should be given orally, if possible.
  • The IV route is used only in case of high fever in a child who is vomiting repeatedly or whose consciousness is impaired (lethargy or coma). IV paracetamol is no more effective than oral paracetamol and is more complicated to administer (infusion every 6 hours).

5.4.2 Treatment of severe pulmonary and ENT complications

In all cases of severe respiratory complications:
 

A – Clear the airways and remove secretions. Respect the position the patient chooses for breathing – usually sitting or half-sitting; for example, for an infant, on the parent/carer’s lap. Do not lay them down if they are having trouble breathing.

B – Start oxygen therapy and monitor oxygen saturation: oxygen mask; in the event of cyanosis or laboured breathing (nasal flaring, etc.), ensure sufficient flow to bring the  SpO₂ back above 94-98%.

C – Place an IV line and assess/treat any shock.

D – Check the blood glucose and do a rapid test for malaria.

E – Check for signs of septicaemia. Prevent and manage hypothermia. Start treating fever once the above procedures have been started.

In the event of audible wheezing (with or without a stethoscope), see the protocol Asthma in the Clinical Guidelines.

Severe pneumonia aCitation a.In this context, for children under 5 years, this antibiotic treatment directly replaces the routine 
amoxicillin therapy.

Amoxicillin 1 g / clavulanic acid 200 mg powder, IV or ceftriaxone IV or IM (replaces oral amoxicillin) bCitation b.During an outbreak, ceftriaxone may be considered a first-line treatment because it is easier to use, as it can be administered once daily and, if necessary, by IM.  

Then:

• If improvement, switch to oral amoxicillin/clavulanic acid to complete 7 days of treatment.
• If no improvement after 48 to 72 hours, consider the risk of empyema (or pleuropulmonary staphylococcal infection).
  • If treatment was started with ceftriaxone IV or IM, add clindamycin IV.
  • If treatment was started with amoxicillin/clavulanic acid, switch to ceftriaxone + clindamycin IV.
    In all cases, close monitoring is required.
     
• Moderate or severe croup
  • Place the child under intensive monitoring until symptoms resolve.
  • Keep the child calm and reassured, place in the parent’s arms or in a sitting position to help breathing, as agitation and crying worsen the symptoms.
  • O₂ if SpO₂ < 92% or severe respiratory distress.
  • Administer one dose of dexamethasone PO or prednisolone PO. 
  • Administer by IV or IM route if the child cannot tolerate the oral route. The anti-inflammatory effect begins in 30 minutes to 2 hours and lasts about 24 hours. One dose generally suffices.
  • Administer nebulised epinephrine (adrenaline) if needed and repeat every 20 minutes. It is used to relieve symptoms while waiting for the steroids to take effect. It relieves symptoms rapidly (in 10 to 30 minutes), but the effect is short-lived (about 2 hours). Note: if severe tachycardia (heart rate (HR) > 200/min.) occurs, stop epinephrine until the HR returns to normal (Appendix 16).
  • Give the standard symptomatic treatment: hydration, antipyretic, decongestion, etc.
     
• Acute otitis media that is not responding after 48 hours to the first well-administered outpatient treatment with oral amoxicillin:
  • Re-evaluate the child and look for signs suggesting mastoiditis: fever and persistent, throbbing ear pain and sometimes purulent otorrhoea. Redness, swelling, pain and fluctuance may develop in the mastoid region; the pinna is typically displaced laterally and inferiorly.
  • If no mastoiditis: amoxicillin/clavulanic acid PO for 5 to 7 days. If mastoiditis is suspected, hospitalise urgently and refer to the Chronic suppurative otitis media protocol in MSF Clinical Guidelines.
  • Keep the ear clean by wiping the external auditory canal with dry cotton if there is external discharge.

5.4.3 Treatment of ocular complications

• Corneal involvement (opacification, Bitot’s spot, corneal ulcer)
• Cleaning the eyes with clean water 
  + tetracycline 1% eye ointment for 7 days 
  + vitamin A: retinol PO one dose on D1 and D2 and third dose 4 to 6 weeks later cCitation c.For pregnant women (ask the patient), give 25,000 IU/week for at least 4 weeks.
  + for ocular pain: eye protection +

  • if > 12 years: tramadol PO

  • if ≤12 years: morphine PO

• No topical corticosteroids.

5.4.4 Treatment of gastrointestinal complications 

• Watery diarrhoea (See Appendix 14):
  • Without dehydration: oral rehydration according to WHO Plan A
  • With dehydration: rehydration according to WHO Plan B or C 

+  for all watery diarrhoea: zinc sulfate* PO 1 dose/day for 10 days

*Zinc supplementation is unnecessary if the child is receiving nutritional care with F-75®
or F-100® milk, Plumpy'nut® or BP-100®.
 

• Oral candidiasis
  • Nystatin PO for 7 days  
    + if stomatitis that prevents eating:  nasogastric tube feeding until the child can eat. Check daily to see if the tube is still necessary; remove it as soon as possible.

5.4.5 Malnutrition

• Treatment of acute malnutrition, if present 
  Follow the protocol for managing acute malnutrition with therapeutic milk or RUTF, depending on the clinical status, and transfer the child to a feeding programme upon discharge from the measles treatment centre.  
   
• Prevention of post-measles malnutrition 
  If the situation justifies it (food insecurity or activity deemed operationally pertinent), children under 5 years receive nutritional supplementation in the form of RUSF or RUTF, 500 kcal per day during the hospital stay and for 2 weeks after discharge.

5.4.6 Treatment for other complications

• Seizures  
  If the patient is having a generalised seizure, take the usual measures (protect from injury, lay on their side), note the time, and assess the five ABCDE points:
  
  A – Clear the airways and remove secretions. Do not force the mouth open if tonic-clonic seizure.
  
  B – Start oxygen therapy and monitor oxygen saturation (target SpO₂ > 94%).
  
  C – Place an IV line and assess/treat any shock.
  
  D – Check the blood glucose and do a rapid test for malaria.
  
  E – Check for signs of septicaemia. Prevent and manage hypothermia; start treating fever once the above procedures have been started.
  
  Most febrile seizures resolve in 5 minutes. If generalised seizures do not resolve quickly on their own, use intrarectal diazepam or buccal midazolam.
   
• Malaria  
  Antimalarial treatment effective in the region.

5.4.7 Starting treatment and additional information

For dosage by weight and age, see Appendix 13.
 

Always send the patient with a transfer form indicating the reason for the referral and the treatments administered.