5.4 Treatment of complicated cases


Standard treatment aimed at treating the fever and preventing the most common complications.
Added to this standard treatment is the treatment of complications found on clinical examination (Appendix 13).

Standard treatment

− Antipyretic: paracetamol PO (IV only if oral route impossible)
− Antibiotherapy: amoxicillin PO for 5 days in children < 5 years, unless severe pneumonia (see below Treatment for pulmonary complications)
− Vitamin A: retinol PO on D1 and D2, unless corneal involvement (see below Treatment for ocular complications)
− Cleaning the eyes with clean water
− Decongestion of the nasopharynx
− Hydration, caloric feeding, divided meals (every 2 to 3 hours) or more frequent breastfeeding
− Depending on the context, nutritional supplements in children < 3 or 5 years

AND

Treatment for pulmonary and ENT complications
if any

Severe pneumonia:
ceftriaxone IV or IM + cloxacillin IV for 3 days then, if improvement, change to amoxicillin/clavulanic acid PO to complete 7 to 10 days of treatment
+ oxygen if cyanosis or SpO2 < 90%
+ salbutamol if expiratory wheezing and sibilant rales on auscultation
If suspect staphylococcal pneumonia: cloxacillin IV + gentamicin IM
In all cases, close monitoring.

Pneumonia with no severity criteria or acute otitis media:
amoxicillin PO for 5 days
Use amoxicillin/clavulanic acid PO for 5 to 7 days only if amoxicillin alone fails (worsening or lack of improvement after 48 hours of properly-conducted treatment).

Croup:
• Inpatient monitoring (risk of worsening) and supportive therapy
• Severe croup: dexamethasone IM single dose + nebulised epinephrine (adrenaline) (Appendix 16) and intensive monitoring

AND

Treatment for ocular complications
if any

Purulent conjunctivitis (no corneal lesions):
Cleaning the eyes with clean water
+ tetracycline 1% eye ointment for 7 days

Corneal involvement (corneal opacification or ulcer):
Cleaning the eyes with clean water
+ tetracycline 1% eye ointment for 7 days
+ retinol PO one dose on D1, D2 and D8
+ for ocular pain: eye protection and tramadol PO from age 12 years. No topical corticosteroids.

AND

Treatment for gastrointestinal complications
if any

Watery diarrhoea:
• Without dehydration: oral rehydration according to WHO Plan A
• With dehydration: rehydration according to WHO Plan B or C + zinc sulfate PO for 10 days (Appendix 14)

Oral candidiasis:
nystatin PO for 7 days1
If necessary, gastric tube feeding.

AND

Treatment of
malnutrition
if any

Follow the protocol for managing malnutrition (RUTF).

AND

Treatment for other complications
if any

Seizures:
diazepam if generalised seizures

Malaria:
Antimalarials that are effective in the region.

See Appendix 13 for doses according to weight or age.

5.4.1 Standard treatment

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).

Five-day antibiotherapy (amoxicillin PO, except if resistance is known in the area) is given to children under 5 years, to prevent potential complications. If a child under 5 years has nonsevere pneumonia or acute otitis media, there is no change in therapy since the first-line  treatment for these infections is the same as the standard antibiotic therapy already routinely administered. For severe pneumonia, replace amoxicillin with the ceftriaxone + cloxacillin combination.

Clearing the upper airways: blow the child’s nose to prevent congestion and secondary respiratory infection and improve the child’s comfort (especially during breastfeeding) and
sleep. Nasal lavages with 0.9% sodium chloride solution may be used in the event of significant nasal discharge (Appendix 15).

Patients without ocular involvement should receive one dose of vitamin A on 2 consecutive days except pregnant women (ask the patient).

If the patient has corneal involvement or Bitot’s spots, give 3 doses of vitamin A, rather than 2 (the third dose is administered some time after the first two doses, on D8).

When appropriate to the situation, give children under 3 or 5 years who are not malnourished ready-to-use food (500 kcal daily) during their hospitalisation and for 2 weeks after discharge.

5.4.2 Management of complications

See also the: Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. World Health Organization, 2005.
http://whqlibdoc.who.int/publications/2005/9241546700.pdf

Respiratory complications

– In all cases:
• check to make sure that the upper airway is clear;
• respect the position the patient chooses for breathing – usually sitting or half-sitting. Do not lay him down while he is having trouble breathing;
• set up a pulse oximeter, if available.

– In the event of cyanosis, laboured breathing (e.g., nasal flaring), or SpO2 < 90%: oxygen mask with sufficient flow to bring the SpO2 back above 90%.

– In the event of audible wheezing (with or without a stethoscope): aerosol bronchodilator (salbutamol).

– In the event of severe pneumonia: immediately start parenteral antibiotics.

– In the event of benign or moderate croup:
• monitor the child for signs of worsening (regular assessment of respiratory rate, indrawing?, stridor?);
• agitation and crying exacerbate the symptoms: keep the child calm, reassure him, place him in his parent’s arms or in a seated position to help him breath;
• the symptomatic treatment is standard: hydration, antipyretic, decongestion, etc.

– In the event of severe croup:
• the child is placed under intensive monitoring until symptoms resolve;
• administer one dose of dexamethasone IM. The anti-inflammatory effect begins in 30 minutes to 2 hours, and lasts about 24 hours. Give only a single dose;
• nebulised epinephrine (adrenaline) is used to relieve symptoms while waiting for the steroids to take effect. It rapidly improves symptoms (in 10 to 30 minutes), but effect does not last long (about 2 hours). Symptoms may recur (rebound effect). Nebulisation can be repeated once, on medical prescription only. See Appendix 16 for administration and monitoring;
• standard symptomatic treatment: hydration, antipyretic, decongestion, etc.;
• keep the child calm, in his parent’s arms, to reassure him and help him breath.

Acute otitis media

If there is discharge from the ear, keep the ear clean by wiping the external auditory canal with dry cotton wool.

Stomatitis that prevents eating

Gastric tube feeding (F-100 milk) is needed as long as the child cannot eat. Check daily to see if the tube is still necessary; remove it as soon as possible.

Seizures

– If the patient is having a generalised seizure, take the usual measures (protect him from injury, lay him on his side). Use intrarectal diazepam if the seizures do not resolve spontaneously.
– Look for the cause of possible the seizures (e.g. hyperthermia, hypoglycaemia, severe malaria in endemic areas [perform a rapid test]) and assess the risk of recurrence.

See Appendix 13 for doses according to weight or age.

5.4.3 Patients transferred to a hospital

Depending on the distance, the time needed for the transfer, and the complications identified at the examination:
– Administer the first dose of amoxicillin PO2 .
– Administer the first dose of paracetamol PO, especially if the fever is high, or if the child had a seizure.
– If the patient is dehydrated, he should be able to drink ORS while being transferred.
– If the patient is severely dehydrated, place a IV line and transfer the patient when stable.
– If the patient has a corneal lesion: protect the eye with a dry dressing.

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

5.4.4 Advice for parents on hospital discharge

1) Ask parents to:
− make the child drink, and give smaller, more frequent meals or breastfeed more frequently;
− keep his eyes clean, blow his nose frequently.

2) Instruct parents on how to use the medications and nutritional supplements. Make sure that they understand the instructions. Provide the drugs, supplies (cotton), supplements needed to do the rest of the treatment at home.

3) Ask them to bring the child back in if his condition worsens; for example, if he cannot drink or nurse, or is vomiting, if his consciousness is impaired (he is difficult to awaken), if he has respiratory problems, or if the diarrhoea recurs.

4) Explain that after measles, complications can still occur and that they should bring the child back in right away if he does not recover completely.



Footnotes
Ref Notes
1 If nystatin is not available, gentian violet 0.25% may be applied 2 times daily for maximum of 5 days.
2 If the patient has severe pneumonia and ceftriaxone and cloxacillin are available peripherally, administer the first dose before transferring the patient.