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 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg

Oral sol. 120 mg/5 ml

3 ml x 34 to 10 ml x 3----
100 mg tab3/4 tab x 31 to 2 tab x 32 to 3 tab x 3---
500 mg tab--½ tab x 3½ to 1 tab x 31½ to 2 tab x 32 tab x 3


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

Age< 2 months2-11 months1-4 years
Weight< 5 kg5-9 kg10-17 kg
Oral susp. 125 mg/5 ml½ tsp x 22 to 3 tsp x 2-
250 mg tab1 tab x 21 to 2 tab x 22 to 3 tab x 2
500 mg tab--1 to 2 tab x 2


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

Age< 6 months6-11 months1 year and over
Weight< 7.5 kg7.5-9 kg10 kg and over
Dose50 000 IU100 000 IU200 000 IU
200 000 IU capsule
(8 drops)
2 drops4 drops1 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)1
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 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg

Oral sol. 120 mg/5 ml

3 ml x 34 to 10 ml x 3----
100 mg tab3/4 tab x 31 to 2 tab x 32 to 3 tab x 3---
500 mg tab--½ tab x 3½ to 1 tab x 31½ to 2 tab x 32 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 kg10-50 kg> 50 kg

Dose to be administered
every 6 hours (in mg)

7.5 mg/kg15 mg/kg1 g

Dose to be administered
every 6 hours (in ml)

0.75 ml/kg1.5 ml/kg100 ml
Dose maximum30 mg/kg/day60 mg/kg/day4 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 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg

Oral susp. 125 mg/5 ml

1½ tsp x 22 to 3 tsp x 2----
250 mg tab1 tab x 21 to 2 tab x 22 to 3 tab x 2---
500 mg tab--1 to 2 tab x 22 to 3 tab x 23 to 4 tab x 24 tab x 2


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

Age< 6 months6-11 months1 year and over
Weight< 7.5 kg7.5-9 kg10 kg and over
Dose50 000 IU100 000 IU200 000 IU
200 000 IU capsule (8 drops)2 drops4 drops1 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

Age1-11 months1-4 years5-10 years11-15 years
Adult
Weight4-9 kg10-17 kg18-32 kg33-47 kg
Dose400 to 900 mg1 to 1.5 g2 to 3 g3 to 4 g4 g

Volume to be injected
(1 g vial /5 ml of diluent)

2 to 5 ml1 to 1½ vial2 to 3 vials3 to 4 vials4 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 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg
Dose200 mg x 4

250 to 400 mg x 4

500 to 750 mg x 4

1 g x 41.5 g x 42 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 43 vials x 44 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 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg

Oral susp. 100 + 12.5 mg/5 ml

8 ml x 212 ml x 2----
500/62,5 mg tab--1 tab x 22 tab x 23 tab x 23 tab x 2

Pneumonia (without signs of severity)

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

Age< 2 months2-11 months1-4 years5-10 years11-15 years
Adult
Weight< 5 kg5-9 kg10-17 kg18-32 kg33-47 kg

Oral susp. 125 mg/5 ml

1½ tsp x 22 to 3 tsp x 2----
250 mg tab1 tab x 21 to 2 tab x 22 to 3 tab x 2---
500 mg tab--1 to 2 tab x 22 to 3 tab x 23 to 4 tab x 24 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 months2-11 months1-4 years3-4 years
Weight< 5 kg5-9 kg10-13 kg14-17 kg
Dose2 mg4 mg8 mg10 mg
Volume to be injected0.5 ml1 ml2 ml2.5 ml


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

Age1 month2 months3 months4-6 months7-9 months10-11 months1-4 years*
Weight4.5 kg5 kg6 kg7 kg8 kg9 kg10-17 kg

Epinephrine
(1 mg/ml ampoule)

2 ml2.5 ml3 ml3.5 ml4 ml4.5 ml5 ml
0.9% NaCl to be added2 ml2 ml1 ml1 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 months6-11 months1 year and over
Weight< 7.5 kg7.5-9 kg10 kg and over
Dose50 000 IU100 000 IU200 000 IU
200 000 IU capsule (8 drops)2 drops4 drops1 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 yearsAdult
Dose50 mg x 4100 mg x 4
50 mg capsule1 cap x 42 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 days1 . 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 months4-11 months1-2 years
Weight< 7 kg7-9 kg10-13 kg
Dose in mg2.5 mg4 mg6 mg
Volume to be administered0.5 ml0.8 ml1.2 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
Ref Notes
1

If not available, 0.25% gentian violet, applied 2 times/day for 5 days maximum.

[ a b ]