This document provides guidelines for classifying and managing illness in children aged 2 months to 5 years for pneumonia. It outlines 4 classifications: very severe disease, severe pneumonia, pneumonia (not severe), and no pneumonia (cough or cold). For each classification, it describes signs, symptoms, and treatment recommendations. Very severe disease requires hospitalization and intravenous antibiotics. Severe pneumonia is treated as inpatients with intramuscular antibiotics. Pneumonia (not severe) is usually treated at home with oral antibiotics. Cough or cold does not require antibiotics. Special considerations for infants under 2 months are also provided.

1. BY
NIKITA V N
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3. CHILD AGED 2 MONTHS TO 5 YEARS
Classifying the illness means making decisions about
the type and severity of disease. The sick child
should be put into one of the four classifications:




VERY SEVERE DISEASE
SEVERE PNEUMONIA
PNEUMONIA(not severe)
NO PNEUMONIA

4. VERY SEVERE DISEASE
The danger signs and possible causes are:
1.
a) Not able to drink: A child who is not able
to drink could have severe pneumonia or
bronchiolotis, septicaemia, throat abscess,
meningitis or cerebral malaria.
b) Convulsions, abnormally sleepy or difficult
to wake: A child with these signs may have
severe pneumonia resulting in hypoxia,
sepsis, cerebral malaria or meningitis.
Meningitis can develop as a complication
of pneumonia or it can occur on its own.

5. c) Stridor in calm child: If a child has stridor
when calm, the child may be in danger of
life threatening obstruction of the air-way
from swelling of larynx, trachea or
epiglottis.
d) Severe malnutrition: A severely
malnourished child is at high risk of
developing and dying from pneumonia. In
addition, the child may not show typical
signs of the illness.

6. 2. SEVERE PNEUMONIA
The most important signs to consider when
deciding if the child has pneumonia are the
child’s respiratory rate, and whether or not
there is chest indrawing may not have fast
breathing if the child becomes exhausted,
and if the efforts needed to expand the
lungs is too great.
In such cases , chest indrawing maybe the
only sign in a child with severe pneumonia.
A child with chest indrawing is at higher
risk of pneumonia than a child with fast
breathing alone.

7. A child classified as having severe pneumonia
also has other signs such as;
. Nasal flaring, when the nose widens as the
child breaths in
. Grunting, the short sounds made with the
voice when the child has difficulty in breathing
and
. Cyanosis, a dark bluish or purplish coloration
of the skin caused by hypoxia
Children who have chest indrawing and a first
episode of wheezing often have severe
pneumonia, however with recurrent wheezing
do not have severe pnuemonia.

8. 3. Pneumonia (not severe)
A child who has fast breathing and no chest
indrawing is classified as having
pneumonia(not severe). Most children are
classified in this category if they are
brought early for treatment. Fever , cough,
tachpnoea, crackles , signs of consolidation
, and constitutional symptoms are the
general clinical features seen in a patient
suffering with pneumonia.

9. 4. No pneumonia: cough or cold
Most children with a cough or difficult
breathing do not have any danger signs or
signs of pneumonia ( chest indrawing or fast
breathing). These children have a simple
cough or cold. They are classified as having
‘no pneumonia: cough or cold’. They do not
need any antibiotic. Majority of such cases
are viral infections where antibiotics are not
effective. Normally a child with cold will get
better within 1-2 weeks.

10. MANAGEMENT OF PNEUMONIA IN A CHILD AGED 2 MONTHS UPTO 5 YEARS

11. Infants less than 2 months of age are referred
to as young infants. They have special
characteristics that must be considered when
their illness is classified. They can become
sick and die very quickly from bacterial
infections, are much less likely to cough with
pneumonia, and frequently have only non
specific signs such as poor feeding, fever or
hypothermia.

12. 1) Further mild chest indrawing is normal in
young infants because their chest wall bones
are soft. The presence of these characteristics
means that they will be classified and treated
differently from older children.
2) Many of the cases may have added risk
factor of low birth weight. Such children are
very susceptible to temperature changes and
even in tropical climates, death due to cold
stress or hypothermia are common.
3) In young infants the cut off point for fast
breathing is 60 breaths per minute. Any
pneumonia in young infants is considered to
be severe.

13. Some of the danger signs of very severe
disease are:
a. convulsions, abnormally sleepy or difficult to
wake: a young infant with these signs may
have hypoxia from pneumonia, sepsis or
meningitis. Malaria infection is unusual in
children of this age, so antimalarial
treatment is not advised.
b. Stridor when calm: infections causing stridor
viz diphtheria, bacterial tracheitis, measles
or epiglottitis are rare in young infants. A
young infant who has stridor should be
classified as having very severe disease.

14. c. Stopped feeding well : a young infant who
stops feeding well(i.e takes less than half of
the usual amount of milk) may have a serious
infection and should be classified as having
very severe disease.
d. wheezing: it is uncommon in infants and is
usually associated with hypoxia.
e. Fever or low body temperature: fever(38
degree or more) is uncommon in young
infants and more often means a serious
bacterial infection. It may be the only sign of
serious bacterial infection. Sometimes
infection can cause hypothermia.

15. CLASSIFICATION AND MANAGEMENT OF ILLNESS IN YOUNG INFANTS

17. A. TREATMENT FOR CHILDREN
AGED 2 MONTHS UPTO 5 YEARS
.PNEUMONIA (child with cough and fast
breathing)
cotrimoxazole is the drug of choice for
the treatment of pneumonia. Cure
rates are 95%. It is less expensive with
few side effects and can be used safely
by health workers at the peripheral
health facilities and at home by the
mothers.

18. 



The condition of the child should be assessed
after 48 hours.
Cotrimoxazole should be continued for
another 3 days in children who show
improvement in clinical condition.
If there is no improvement in the condition
then it should be continued for 48 hours and
then reassesed.
If at 48 hours or earlier the condition
worsens, the child should be hospitalised
immediately.

19. 
Severe pneumonia (chest indrawing)
Children with severe pneumonia should be
treated as inpatients with intramuscular
injections of benzylpenicilline(after test dose)
ampicillin or chloramphenicol.
The condition of the child must be monitored
everyday and reviewed after 48hrs for
antibiotic therapy.
Antibiotic therapy must be given for a
minimum of 5 days and continued for atleast
3 days after the child gets well.

20. Very severe disease
-Children with signs of very severe disease are
in imminent danger of death and should be
treated in a health facility, with provision of
oxygen therapy and intensive monitoring.
-Chloramphenicol IM is the doc in all such
cases. Treat for 48 hrs ,if conditons improve
switch over to oral chloramphenicol. It should
be given for a total of 10 days.
-If condition worsens or does not improve after
48hrs switch to IM injections of cloxacillin
and gentamicin.


21. B. PNEUMONIA IN YOUNG INFANTS UNDER 2
MONTHS OF AGE
The treatment in these condition is basically
the same.
1.The child must be hospitaised.
2.Treatment with cotrimoxazole maybe started
by the health worker before referring the
child.
3. If pneumonia is suspected in the child
should be treated with IM injection of
bezylpenicilline or ampicillin, along with
injection gentamycin.

22. 
Besides antibiotics, therapy for the associated
conditions if any, must be instituted
immediately. The child must be kept warm
and dry. Breast feeding must be promoted
strongly as the child who is not breast fed is
at a much higher risk of diarrhoea.

23. Management of AURI (no pneumonia)
-> Many children with presenting symptoms
of cough, cold and fever do not have
pnenumonia and do not require treatment
with antibiotics.
->They are not recommended as majority of
cases are caused by viruses and antibiotics
are not effective, they increase resistant
strains and cause side effects while providing
no clinical benefit, and are wasteful
expenditure.
->Symptomatic treatment and care at home is
generally enough for such cases.
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