Doctors Revision

IMCI · Age: 2 months - 5 years

Very Severe Febrile Disease

Classification for a child presenting with fever (or history of fever/feels hot/temp ≥37.5°C) who has any general danger sign OR a stiff neck. This indicates a potentially life-threatening infection (like severe malaria, meningitis, sepsis) 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
  • Stiff neck
  • Impaired consciousness / lethargy
  • Convulsions
  • Signs of shock

Assessment

  • Ask: Does the child have fever (by history, feels hot, or temperature ≥37.5°C)?
  • Check for General Danger Signs (Any ONE: Unable to drink/breastfeed, Vomits everything, Had convulsions, Lethargic/unconscious, Convulsing now).
  • Look/Feel: Look or feel for stiff neck (difficulty or pain when gently flexing the neck forward).

Classification

  • Fever present AND (Any general danger sign OR Stiff neck) -> VERY SEVERE FEBRILE DISEASE

Key features

  • Presence of Fever (current or recent history).
  • Presence of ANY General Danger Sign OR a Stiff Neck.
  • Stiff neck strongly suggests meningitis.
  • Requires immediate pre-referral antimalarial, antibiotic, and hypoglycemia prevention, followed by urgent referral.

Management

Non-pharmacological management

  • Quickly complete assessment.
  • Ensure airway is clear, position appropriately.
  • Keep child warm.

Pre-referral treatment

  • Give 1st dose of pre-referral antimalarial: Rectal Artesunate (10 mg/kg) OR IM/IV Artesunate (3 mg/kg if <20kg; 2.4 mg/kg if >=20kg) OR IM Quinine (see page 11 for specific dosing based on formulation).
  • Give 1st dose of appropriate IM antibiotic: Ampicillin (50 mg/kg) AND Gentamicin (7.5mg/kg) OR alternative based on local guidelines (e.g., Ceftriaxone). See page 12 for Ampicillin/Gentamicin dosing.
  • Treat child to prevent low blood sugar: If child can breastfeed, ask mother. If cannot breastfeed but can swallow, give 30-50ml EBM/substitute/sugar water (4 tsp sugar in 200ml water). If cannot swallow, give 50ml via NG tube.
  • Give one dose of Paracetamol (10-15 mg/kg) if high fever (≥38.5°C axillary). Dosage (500mg tablet): 2-3m (<6kg): 1/4 tab. 4m-3y (6-<14kg): 1/2 tab. 4-5y (14-19kg): 3/4 tab (or 1/2 of 500mg tab from p15). Note: page 15 suggests 10mg/kg for paracetamol, use local guideline preference.
  • If convulsing now, give rectal Diazepam (see page 11 for dose).

Follow-up

  • To be managed at referral hospital facility.

Counselling points

  • Explain the extreme seriousness of the child's condition and the urgent need for hospital care.
  • Explain treatments given (antimalarial, antibiotic, sugar, paracetamol if given).
  • Advise on keeping the child warm during transport.
  • Advise on continuing breastfeeding if possible.
  • Write a detailed referral note listing findings, classifications, and all treatments given (drug, dose, time).

Differential diagnosis

  • Severe Malaria (Cerebral malaria)
  • Bacterial Meningitis
  • Sepsis
  • Severe Pneumonia (may present with fever and danger signs)
  • Typhoid fever (severe)
  • Encephalitis
  • Other severe systemic infections

Complications

  • Coma
  • Permanent neurological damage (from meningitis, cerebral malaria, hypoglycemia)
  • Shock
  • Severe anaemia (malaria)
  • Kidney failure
  • Respiratory failure
  • Death

Prevention

  • Use of Insecticide Treated Nets (ITNs).
  • Prompt diagnosis and treatment of uncomplicated malaria.
  • Immunizations (Hib, Pneumococcal, Meningococcal if available/indicated).
  • Good nutrition.
  • Prompt care seeking for any fever.

References

IMCI Chart Booklet - Page 4, Pages 1, 11, 12, 15

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

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