Doctors Revision

IMCI · Age: 2 months - 5 years

Severe Pneumonia or Very Severe Disease

Classification for a child with cough or difficult breathing who presents with any general danger sign OR stridor when calm, indicating a life-threatening respiratory condition requiring immediate pre-referral treatment and urgent referral.

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Care priority and warning signs

Care priority

Refer URGENTLY

Red flags

  • Any general danger sign
  • Stridor in a calm child

Assessment

  • Ask: Does the child have cough or difficult breathing?
  • Ask: For how long?
  • Check for General Danger Signs (Any ONE: Unable to drink/breastfeed, Vomits everything, Had convulsions, Lethargic/unconscious, Convulsing now).
  • Look/Listen: Look and listen for stridor (harsh noise during INspiration) when the child is CALM.

Classification

  • Any general danger sign present OR Stridor in a calm child -> SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Key features

  • Presence of ANY general danger sign automatically classifies as Very Severe Disease.
  • Stridor in a CALM child signifies critical upper airway obstruction and is a sign of Very Severe Disease.
  • Requires immediate pre-referral antibiotic and treatment for low blood sugar, then urgent referral.

Management

Non-pharmacological management

  • Minimize distress; keep the child calm.
  • Allow child to assume position of comfort (often sitting up).
  • Keep child warm.
  • Quickly complete assessment for other pre-referral needs.

Pre-referral treatment

  • Give first dose of an appropriate intramuscular antibiotic: Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg). Ampicillin doses (500mg vial diluted to 2.5ml): 4-<6kg: 1ml; 6-<10kg: 2ml; 10-<15kg: 3ml; 15-20kg: 5ml. Gentamicin doses (40mg/ml vial): 4-<6kg: 0.5-1.0ml; 6-<10kg: 1.1-1.8ml; 10-<15kg: 1.9-2.7ml; 15-20kg: 2.8-3.5ml.
  • Treat to prevent low blood sugar: If child can breastfeed, ask mother to do so. If not able to breastfeed but able to swallow: Give EBM/substitute/sugar water (4 tsp sugar in 200ml water) - 30-50ml. If unable to swallow: Give 50ml milk/sugar water by NG tube.
  • Give other pre-referral treatments if indicated (e.g., rectal diazepam for convulsions, pre-referral antimalarial if severe febrile disease also classified).

Follow-up

  • To be managed at the referral hospital facility.

Counselling points

  • Explain the need for urgent referral due to severe breathing problem.
  • Explain treatments given (antibiotic, sugar).
  • Advise on keeping child warm and calm during transport.
  • Advise on continuing breastfeeding if possible.
  • Write a detailed referral note.

Differential diagnosis

  • Pneumonia (non-severe)
  • Severe Croup (Laryngotracheobronchitis)
  • Epiglottitis (rare due to Hib vaccine)
  • Foreign body aspiration
  • Severe asthma attack
  • Anaphylaxis
  • Diphtheria (rare)

Complications

  • Hypoxemia
  • Respiratory failure / arrest
  • Airway obstruction
  • Sepsis
  • Death

Prevention

  • Immunization (Hib, PCV, Measles, Pertussis, Diphtheria)
  • Good nutrition
  • Reducing exposure to indoor/outdoor air pollution
  • Exclusive breastfeeding.
  • Preventing foreign body aspiration (age-appropriate toys, supervision).

References

IMCI Chart Booklet - Page 2, Pages 1, 11-12

For learning and professional reference. Use current local guidance and clinical judgement.

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