Pneumonia — 2 months - 5 years | IMCI

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Care priority and warning signs

Routine Management / Treat at Clinic (unless HIV+ with chest indrawing, then Refer)

Chest indrawing in an HIV exposed/infected child (Requires first dose Amoxicillin and REFERRAL).
Failure to improve after 3 days of appropriate antibiotic treatment.
Development of any danger sign or stridor.
Worsening of respiratory distress.

Ask: Does the child have cough or difficult breathing?
Ask: For how long?
Confirm absence of General Danger Signs (see IMCI_2M5Y_001).
Confirm absence of Stridor in a calm child.
Look: Look for chest indrawing (lower chest wall pulls inwards during INspiration). Child must be calm.
Listen/Feel: Count breaths in one full minute. Check for fast breathing based on age. Child must be calm. Fast Breathing: Age 2-11 months: >= 50 breaths/minute. Age 12 months - 5 years: >= 40 breaths/minute.
Look/Listen: Look and listen for wheezing (high-pitched whistling sound during OUTspiration).

Presence of Chest Indrawing OR Fast Breathing (age-dependent rate).
Absence of general danger signs and stridor differentiates from Severe Pneumonia.
Requires treatment with first-line oral antibiotic (Amoxicillin).
Wheezing requires addition of an inhaled bronchodilator.
Chest indrawing in HIV exposed/infected child warrants immediate first dose Amoxicillin and referral.

Soothe the throat and relieve the cough with a safe remedy (e.g., warm fluids; honey if child is >1 year old). Avoid harmful remedies like codeine.
Continue feeding and encourage fluid intake.
Ensure child is kept warm.

Give oral Amoxicillin twice daily for 5 days. Dosage: Age 2m-<12m (4-<10kg): 250mg dispersible tablet (1 tab) OR 250mg/5ml syrup (5ml) per dose. Age 12m-5y (10-<19kg): 250mg dispersible tablet (2 tabs) OR 250mg/5ml syrup (10ml) per dose.
If wheezing is present (or wheezing was present and disappeared after a trial of bronchodilator): Give inhaled rapid-acting bronchodilator (Salbutamol 100mcg/puff) 2 puffs via spacer, 3 times daily for 5 days.

If chest indrawing is present AND the child is HIV exposed/infected: Give the first dose of oral Amoxicillin (as per dosing above) and REFER the child.

Follow-up in 3 days.
At follow-up (Day 3):
Assess for general danger signs, check for fever, chest indrawing, count breathing rate, assess feeding. Check HIV status.
If danger signs/stridor: Give pre-referral 2nd line antibiotic/chloramphenicol, treat hypoglycemia, refer URGENTLY.
If chest indrawing/fast breathing/fever/eating are same or worse: Change to second-line oral antibiotic recommended locally for treatment failure (treat for 5 days), advise immediate return if worsens, ask to return in 3 days OR Refer (especially if measles within last 3 months or HIV exposed/confirmed).
If breathing slower, less fever, eating better: Continue and complete the 5-day course of Amoxicillin.
If coughing for 14 days or more at any visit, assess for TB (see page 9).

Explain the diagnosis (pneumonia) and the need for antibiotic.
Teach the mother how to give the oral Amoxicillin: correct dose, frequency (twice daily), duration (full 5 days), how to measure syrup or disperse tablet.
If Salbutamol prescribed: Teach how to use the inhaler and spacer correctly (shake inhaler, attach, seal mask/mouthpiece, actuate puff, hold for breaths, repeat for 2nd puff), frequency (3 times daily), duration (5 days).
Teach how to soothe the throat/relieve cough with safe remedies.
Advise to continue feeding and offer extra fluids.
Advise mother WHEN TO RETURN IMMEDIATELY: Breathing becomes difficult, breathing becomes fast, child not able to drink or breastfeed, child becomes sicker.
Advise on follow-up visit in 3 days.

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