Handout 5Aâ€”Common Signs & Symptoms and Treatment of Childhood

Handout 5A—Common Signs & Symptoms and Treatment of Childhood Febrile Illnesses

Handout 5A—Common Signs & Symptoms and Treatment of Childhood Febrile Illnesses Page | 1

Danger Signs and Signs of Severe Illness

Signs and Symptoms in Children Questions to ASK Treatment Recommendations—Uganda Clinical Guidelines

Respiratory distress and Chest in-drawing

o Difficulty breathing

o Chest draws in on inspiration,

o Stridor

o Lung crepitations (crackles, rales) heard with a stethoscope

o Cyanosis

o Oxygen saturation <95%

Not able to drink, eat or breastfeed

Vomiting everything

Convulsions with present illness

Altered mental state, prostration or extreme weakness

o Unconscious, drowsiness or confusion

o Extreme lethargy, unable to sit or stand

o The child does not respond when you clap or stimulate the sternum

Severe Anemia

o Severe pallor--Palms are white

Severe Dehydration

o Skin pinch test of more than 2 seconds

o Rapid and deep breathing - faster than normal

o Child is drinking poorly

o Fast, weak pulse

o Lethargy or unconsciousness

o Cramping of the arms and legs

How long has the child had difficulty breathing?

Is the child able to drink or breastfeed?

Does the child does not drink when offered water or breast milk?

Is the child able to sit or stand without support?

Describe what happens when you offer your child something to drink.

Does the child vomit everything?

Has the child had convulsions with this current illness?

Does the child seem unusually sleepy or tired?

Pre-referral treatment for severe malaria:

Rectal artesunate shall be used as pre-referral treatment for severe malaria.

When rectal artesunate is not available or contraindicated, intramuscular quinine is the alternative pre-referral treatment.

Dosage of rectal artesunate in children under-5:

Weight (kg)

Age Artesunate dose (mg)

Suppository single dose

5-8.9 0-12 months 50 mg 1 supp (50 mg)

9-19 13-42 months 100 mg 2 supp (50 mg)

20-29 43-60 months 200 mg 1 supp (200 mg)

Pre-referral treatment for chest in-drawing and any general danger signs:

Give 1st dose antibiotic amoxicillin or IM chloramphenicol:

Weight (kg) Age Dose of amoxicillin

4-10 kg 2-12 months 125 mg

10-19 kg 12 months-5 years 250 mg

If unable to swallow Refer urgently

Pre-referral treatment for severe dehydration:

Refer urgently with mother giving frequent sips of ORS on the way.

Advise mother to continue breastfeeding.

If convulsing, give anticonvulsant:

Diazepam 200 micrograms (0.2mg)/ kg (max: 10mg) rectally or IV.



Meningitis


Rapid onset of fever

Neck stiffness or neck pain—(Does the child bend his/her neck easily while looking around? Can the child look easily at his toes or umbilicus?)

Bulging fontanel in children under 18 month

Altered mental state, confusion, or coma

Convulsions

Meningococcal rash (petechial or purpuric)

Severe headache

Failure to feed

Photophobia (older children)

Signs of raised intracranial pressure:

o unequal pupils o rigid posture o focal paralysis in any of the limbs or

trunk o irregular breathing

When did the fever start?

Have you noticed any difficulty with your moving his/her neck?

Has the child had any convulsions? If yes, how often?

Does the child have a rash?

Have you noticed a change in the child’s behavior?

Has the child been eating?

Has the child complained of a headache?

Causative organisms not yet identified HC4:

Ceftriaxone 50-100 mg / kg daily IV or IM daily in 1-2 divided

doses for up to 14 days

Change to cheaper effective antibiotic if and when CNS results

become available.

If ceftriaxone not available, and at HC3 level:

Chloramphenicol 25 mg / kg IV every 6 hours for up to 14

days (use IM if IV not possible).

Once clinical improvement occurs, change to: 25 mg/kg per

dose orally every 6 hours to complete the course.



Uncomplicated Malaria


No danger sign or sign of severe illness

History of fever

Raised body temperature (above 37.5 C as taken from the axilla)

Evidence of parasites in the blood – with a positive RDT (or blood smear), and:

Weakness

Lethargy

Nausea

Vomiting

Loss of appetite

Mild anemia (mild pallor of palms and mucous membranes); occurs commonly in children

Dehydration (dry mouth, coated tongue, and sunken eyes).

Enlarged spleen (in acute malaria it may be minimally enlarged, soft and mildly tender)

Does the fever come and go?

Has the child been unusually tired or weak?

Has the child vomited? How many times has he/she vomited since the vomiting began/


Have you given the child any medicine?

Has the child had any convulsions?

Have the convulsions been with this illness?

Treatment of uncomplicated malaria:

The recommended first line medicine is artemether/lumefantrine.

The recommended first line alternative medicine is artesunate /

amodiaquine.

The recommended second line medicine is also an ACT,

dihydroartemisinin piperaquine (DHA-PPQ; 40 mg/320 mg).

The recommended second line alternative medicine is oral quinine

for all patients. WHO recommends that quinine be given with

tetracycline or doxycycline or clindamycin.

Dosage of artemether/lumefantrine 20/120 mg—Coartem tablets:

Weight (kg)

Age Day 1 Day 2 Day 3

5-14 4 months-

3 years

1 tab twice a day / 12

hourly


hourly


hourly

15-24 3-7 years 2 tab twice a day / 12

hourly


hourly


hourly

Dosage of artesunate (AS) tablets:


5-11 months 15 mg

(= 1/2 tab)

15 mg

(= 1/2 tab)

15 mg

(= 1/2 tab)

1-6 years 50 mg 50 mg 50 mg



Dosage of amodiaquine (AQ) tablets:


5-11 months 76 mg

(= 1/2 tab)

76 mg

(= 1/2 tab)

76 mg

(= 1/2 tab)

1-6 years 153 mg

(= 1 tab)

153 mg

(= 1 tab)

153 mg

(= 1 tab)

Dosage of dihydroartemisinin piperaquine (DHA-PPQ) 40 mg/320 mg:

Weight (kg)


5.9.9 6 months-

1 year ½ tab ½ tab ½ tab

10-20 2-7 years 1 tab 1 tab 1 tab



Severe Malaria


Presence of parasitaemia confirmed by positive malaria test and the presence of one or more of the following clinical features:

Impaired consciousness including unrousable coma (danger sign)

Prostration, generalized weakness so that the child unable to sit, stand or walk without assistance (danger sign)

Multiple convulsions: more than two episodes within 24 hours (danger sign)

Deep breathing and respiratory distress, acidotic breathing (danger sign)

Failure to feed (danger sign)

Acute pulmonary oedema and acute respiratory distress syndrome

Circulatory collapse or shock, systolic blood pressure < 50mm Hg in children;

Acute kidney injury

Clinical jaundice plus evidence of other vital organ dysfunction

Abnormal bleeding

Does the fever come and go?

Has the child been unusually tired or weak?

Has the child vomited?


Have you given the child any medicine?

Has the child had any convulsions?

Have the convulsions been with this illness?

Have you noticed any yellow in the eyes?

Treatment of severe and complicated malaria:

Intravenous artesunate is the recommended first line

medicine for severe malaria.

Intravenous quinine or intramuscular artemether is the

alternative to be used when artesunate is not available.

Once the patient is able to take orally after at least 24 hours

of parenteral treatment, treatment should be completed with a

treatment, treatment should be completed with a full course of

oral first line ACT.

Dosage of intravenous artesunate for severe malaria: 2.4 mg/kg:

Dose Time of administration

First dose on admission At 0 hours

Second dose At 12 hours

Third dose At 24 hours

Then once a day until patient is able to tolerate oral medication

If convulsing, give anticonvulsant:

Diazepam 200 micrograms (0.2mg)/ kg (max: 10mg) rectally or IV



Pneumonia (non-severe)


No danger sign or sign of severe illness

Tachypnoea (rapid breathing):

o 0-2 months >60 /min



Nasal flaring

Stridor (high pitched wheezing sound when the child breathes)

Cough

Lethargy

High pulse rate

Is the child having difficulty breathing?

Does the child have a cough? If yes, how long has the child had a cough?

What is the quality of the cough? Dry? Productive?

When did you first notice the child breathing fast?

Has the child been tired or weak?

Have you noticed any harsh noises when the child breathes in?

Treat with antibiotics:

Amoxicillin every 8 hours for 5 days

Age Weight (kg) Dose

2-12 months 4-10 125 mg

12 months-5 years 10-19 250 mg

If amoxicillin is not available, give Cotrimoxazole 24 mg/kg every 12 hours for 5 days or PPF 50,000 IU/kg IM daily for at least 3 days

Give vitamin A to all children with pneumonia:

6-11 months: 100,000 IU single dose

1-6 years: 200,000 IU single dose

Manage fever:

Paracetamol 10 mg/kg every 8 hours for 3 days.

If wheezing is present:

Salbutamol 100 micrograms (0.1 mg)/kg every 8 hours until wheezing stops HC3

Reassess child for progress; if no improvement in 2 days or condition deteriorates:

Switch to chloramphenicol 25 mg/kg IV every 6 hours until the child improves then continue with oral chloramphenicol for a total of 10 days HC4.



Gastroenteritis / Dysentery


4 to 10 loose stools a day

Blood or mucus in the stool

Abdominal pain

Nausea and vomiting

Loss of appetite

Signs of dehydration:

Dryness of the mouth and tongue

Child is thirsty and drinks eagerly or not able to drink or drinking poorly.

Sunken eyes

Irritability, restlessness, weakness, and dizziness

Skin pinch test of 1 second

Crying with few or no tears

Passing very little urine which is often dark

Headache

Has the child had any watery stools?

How many lose stools does the child have in one day?

How many days has the child had diarrhea?

Is there blood in the stool?

Has the child been vomiting?

Has the child been very thirsty?

When was the last time the child urinated?

Is the child eating?

Has the child complained of abdominal pain?

Treatment for diarrhoea and dehydration:

Oral rehydration salts (ORS) for 3 days. Give small but frequent sips.

Age (Months) Weight (kg) ORS (mL)

<4 <6 200-400

4-12 6-9.9 400-700

13-24 10-11.9 700-900

25-60 12-19 900-1400

Zinc (10-20 mg) daily for 10 days:

Age Dose

<6 months 10 mg daily x 10 days

>6 months 20 mg daily x 10 days

Vitamin A

o 6-11 months: 100,000 IU

o 1-6 years: 200,000 IU

Continue breastfeeding, giving fluids and feeding

Follow up in 5 days

Treatment of dysentery (shigellosis—bloody diarrhoea) child >3 month:

Cotrimoxazole 24 mg/kg every 12 hours for 5 days

or

ciprofloxacin 30 mg/kg twice daily for 3 days

or

nalidixic acid 15 mg/kg per dose

Follow up in 3 days



Measles


Generalized rash without pustules or vesicles (which began behind the ears and on the neck) and one of these:

o Cough

o Runny nose

o Conjunctivitis (red eyes)

Barking cough

Recent exposure to a measles case

Koplik’s spots (grey white spots inside the mouth)

No documented measles immunization

Anorexia and vomiting

Mouth ulcers (severe measles)

Pus draining from eye (severe measles)

Clouding of the cornea (severe measles)

If the child has had fever for more than 7 days, has the fever been present every day?

Has the child had measles within the last 3 months?

Has the child been vaccinated for measles?

Does the child have a rash?

When did you first notice the rash?

Where did you first notice the rash?

Does the rash itch?

Does the child have a cough?

How long has the child had a runny nose?

Have you noticed any drainage from the eyes?

Have you noticed any sores in the child’s mouth?

How long has the child had clouding in the eyes?

Management (symptomatic) HC2:

Apply tetracycline eye ointment 1% every 12 hours for 5 days

Increase fluid intake

Give vitamin A 200,000 IU

o 1st dose: At diagnosis

o 2nd dose: The next day

o 3rd dose: 2-4 weeks later

Management of mouth ulcers:

Paint the mouth with gentian violet aqueous paint 0.5%

twice daily

Management of eye infection:

Clean both eyes 3 times daily:

o Wash hands

o Ask child to close eyes

o Use clean cloth with clean water to gently remove pus

o Use a different part of the cloth for each eye

o Clean each eye from nose-side to ear-side to avoid passing the infection from one eye to the other

Apply tetracycline eye ointment 1% to each eye

o Ask the child to look up

o Squirt a small amount (5 mm length) on the inside of the lower eyelid

o Wash hands again

Continue application until the redness has gone

Do not put anything else into the eye



Acute Otitis Media (Ear Infection)


Pus drainage from ear

Ear pain

Child repeatedly tugging or touching the infected ear

Tenderness or swelling behind the ear

Swollen lymph nodes in anterior neck

Red tympanic membrane on otoscopy

Have you noticed any drainage from the child’s ears?

What colour is the drainage?

When did you first notice the ear drainage?

Has the child been pulling at one ear?

Has the child had an ear infection before?

Treat with antibiotics::

Amoxicillin every 8 hours for 5 days

Age Weight (kg) Dose

2-12 months 4-10 125 mg

12 months-5 years 10-19 250 mg

Dry the ear at least 3 times daily:

Dry ear by wicking Roll clean absorbent cloth or soft gauze into a wick

Place this in the ear and remove when wet

Replace wick with a clean one

Repeat this process until the ear is dry

Manage pain:

Paracetamol 10 mg/kg every 8 hours for 3 days



Pharyngitis / Tonsillitis (Sore Throat)


Pain and difficulty in swallowing

Drooling of saliva

Mild cough

Swollen lymph nodes in the anterior neck

Red and inflamed tonsils

White coating over the throat or tonsils

Has the child complained of a sore throat?

Has the child had pain or difficulty swallowing?

Have you notice any swelling or tenderness of the neck?

Does the child have a cough?

If streptococcal pharyngitis suspected:

Benzathine penicillin 1.2 MU IM single dose

o Child: <30 kg: 30,000 IU/kg

or

PPF 20,000 IU/kg IM daily for 10 days

or

Phenoxymethyl penicillin 12.5 mg/kg every 6 hours for 10 days

If allergic to penicillin:

Erythromycin 12.5 mg/kg per dose every 6 hours for 10 days

Note:

If not properly treated, streptococcal pharyngitis may lead to

acute rheumatic fever and retropharyngeal or peritonsillar

abscess. Therefore. ensure that the full 10-day courses of

antibiotics are completed where applicable

Cotrimoxazole is not effective for the treatment of

streptococcal pharyngitis, and it should not be used.



Typhoid


Fever rises in steps

Gradual onset of chills and weakness

Headache

Anorexia (failure to feed)

Epistaxis (nose bleed)

Backache and constipation

Abdominal pain and tenderness

Bradycardia (very slow heart rate)

Confusion, delirium and stupor

Tender splenomegaly

Seriously and obviously ill with no apparent cause

Is the child eating?

Has the child complained of a headache?

Has the child complained of abdominal pain?

Has the child had a nose bleed?

Has the child been confused?

Does the child been very tired?


Chloramphenicol 25 mg/kg IV or oral every 6 hours for 10-14 days

or

Ciprofloxacin 10-15 mg/kg every 12 hours for 5-14 days

or

Cotrimoxazole 24 mg/kg every 12 hours for 3 days dose

or

Amoxicillin 25 mg/kg every 8 hours

Cystitis (Urinary Tract Infection)


Crying when passing urine

Urinary frequency or dysuria

Urgency which manifests as incontinence in previously continent child

Dark or foul smelling urine

Blood in the urine

Vomiting

Poor feeding

Lethargy and/or irritability

Lower abdominal tenderness

Costo-vertebral angle or suprapubic tenderness

Does the child cry when passing urine?

Have you noticed the child urinating more than usual?

Have you noticed any blood in the urine?

Does the urine smell unusually bad?


Have you noticed the child has had accidents urinating?

Has the child been very tired?


Cotrimoxazole 48 mg/kg single dose

or

Ciprofloxacin 10-15 mg/kg single dose

Ensure high fluid intake



Chicken Pox (varicella zoster)


Low grade temperature

Sore throat

Itchy rash on the head and torso

Vesicular rash with superficial blister in centre which erupts and forms a crust.

Papules may ooze clear fluid or be dry

Rash with pus like discharge is a sign of sepsis

Complications may include septicaemia, pneumonia, fulminating haemorrhagic varicella, and meningoencephalitis

When did the rash begin?

Are there other children in the community with similar rash?

What have you given the child to stop the itching?

When did the rash begin to dry up?

Relieve pain and itching from rash:

Apply Calamine lotion every 12 hours plus chlorphenamine 4 mg every 12 hours for 3 days

Paracetamol 1 mg every 12 hours for 3 days

Prevent spread of infection:

Advise to avoid contact between infected persons and immunosuppressed persons.

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Handout 5Aâ€”Common Signs & Symptoms and Treatment of Childhood