Appendix 13. Case management

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    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) a Citation a. If not available, 0.25% gentian violet, applied 2 times/day for 5 days maximum.
    Diarrhoea without dehydration: WHO plan A

     

    – Administer the first dose of treatments during the consultation.
    – Advice to parents:
    • Make the child drink, give smaller, more frequent meals or breastfeed more frequently.
    • Keep the eyes clean, blow the child’s nose frequently.
    • Bring the child back in if: his consciousness is impaired or in case of seizures, if he cannot drink or nurse, or is vomiting, if diarrhoea appears or worsens, if he has respiratory problems or ear pain or if fever persists after 2 days.
    • Family members with symptoms of measles should also come for consultation.

    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

     

     

    IV injection:
     When ceftriaxone is administered by IV route, the powder (1 g) must be dissolved in 5 ml of water for injection.

     

    IM injection:
    Vials of ceftriaxone for IM injection are provided with a specific diluent containing lidocain. Once reconstituted with this diluent, ceftriaxone can be administered by IM route only, NEVER BY IV ROUTE. Doses (in ml or vials) in the table above are based on a ceftriaxoneconcentration of 1 g diluted in 5 ml of diluent with lidocain. Always verify the dosage and the volume of diluent as they can vary according to the manufacturers (500 mg/2 ml, 500 mg/5 ml, 1 g/5 ml, 1 g/10 ml, etc.). All of the diluent must be used for reconstitution. If the volume to be injected is large, administer half the dose into each buttock.

     

    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

     

    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.

    100 + 12.5 mg/5 ml

    8 ml

    x 2

    12 ml

    x 2

    - - - -
    500/62,5 mg tab - -

    1 tab

    x 2

    2 tab

    x 2

    3 tab

    x 2

    3 tab

    x 2

     

    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 (a) Citation a. In children > 4 years or > 17 kg, the dose should not exceed 5 ml.
    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 - - -

    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
    50 mg capsule 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 days a Citation a. 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.

     

    Footnotes
    • (a) If not available, 0.25% gentian violet, applied 2 times/day for 5 days maximum.
    • (a)In children > 4 years or > 17 kg, the dose should not exceed 5 ml.