As per FBNC module, the case management of children of 2 months to 5 years is described,

1. F IMNCI-Care of sick child 2
Months to 5 Years
B.SUDHA
PROFESSOR
VMCON

2. CASE MANAGEMENT OF A CHILD PRESENTING WITH
COUGH OR DIFFICULT BREATHING
Learning objectives
After completion of this section the participant
should be able to:
• Manage all cases of pneumonia.
• Understand approach to a child presenting with
wheeze.
• Manage acute asthma.
• Understand approach to a child presenting with
stridor.

3. Diagnosis
• Pneumonia is usually identified on the basis of
fever, cough, fast breathing and signs of
respiratory distress.
• Use history, examination and the clinical
findings to arrive at the diagnosis of
pneumonia.

4. Treatment
• Children with wheeze and fast breathing and/or
chest indrawing, particularly those with a past
history of similar attacks should, be given a trial
of rapid acting inhaled bronchodilator (up to 3
cycles).
• Give the rapid-acting bronchodilator by one of
the following methods:
- Nebulized salbutamol, or
- Salbutamol by a metered dose inhaler with spacer
device.

5. Treatment
Treat as pneumonia with antibiotics, only if
there is no response to
bronchodilators(persistence of fast breathing).
Also consider the possibility of tuberculosis in a
child with cough and difficult breathing if:
• Child has fever and cough for more than 2
weeks, and
• Is not responding to appropriate antibiotic
therapy.

6. Treatment of very severe pneumonia
Admit the child in hospital
• Obtain a radiograph.
• Give antibiotics
- Give Injectable Ampicillin (50 mg/kg IM/IV every 6 hours) and
Gentamicin (7.5 mg/kg IM/IV once a day). If the child responds
well, discharge after 5 days with oral Amoxicillin (15 mg/kg per
dose three times a day) plus IM Gentamicin once daily for a
further 5 days.
- Alternatively, give Injectable Chloramphenicol (25 mg/kg IM or
IV every 8 hours) until the child has improved. Then continue the
same drug orally in the same dose for 3 times a day for a total
course of 10 days.

7. Treatment
- If the child does not improve by 48 hours to any one of
these treatments, reassess for complications and switch
• to Injection Ceftriaxone (80 mg/kg IM or I/V once daily)
for 10 days.
• If staphylococcal pneumonia is suspected, add Inj
Cloxacilin (50mg/kg/dose, every 6 hourly) to any of the
above choice of antibiotics.
• When the child improves, continue Cloxacillin orally 4
times a day for a total course of 3 weeks at least.
Children with complicated pneumonia (Empyema)
need longer therapy for 4-6 weeks.

8. Treatment
• Give Oxygen
• Give supportive care
• Monitor the child
• Watch for complications

9. Severe pneumonia
Admit the child to hospital.
• Give antibiotics
Give Benzylpenicillin (50 000 units/kg) or Ampicillin (50 mg/kg) IM or I/V every
6 hourly) for at least 3 days after hospitalization.
• When the child improves, switch to oral amoxicillin (15 mg/kg/dose; q8h).
The total course of treatment is atleast 5 days.
• If the child does not improve within 48 hours, or deteriorates, look for
complications and treat accordingly.
• If there are no apparent complications, switch to Chloramphenicol (25
mg/kg/dose every 8 hours IM or I/V)until the child has improved. Then
continue orally for a total course of 10 days.
• Give Oxygen in children with suspected hypoxia (clinical signs or pulse
oximetry).
• Provide supportive care as for very severe pneumonia.
Monitoring
• The child should be checked by nurses at least every 6 hours .

10. Pleural effusion and empyema
• A child with severe or very severe pneumonia should
be suspected to have pleural effusion or empyema if
anyone of the following is present:
(a) Evidence of staph infection in form of boils, impetigo,
abscesses, etc.
(b) H/o pain chest.
(c) Clinical examination suggestive, eg dull on percussion
and decreased breath sounds
(d) Fever persists despite antibiotics more than 48 hours.
An x-ray is to be done to confirm the presence of fluid in
the chest along with diagnostic pleural tap

11. Treatment of empyema
• a. Chest drainage
• Give antibiotics
• Staphylococcus aureus is a common causative
organism of empyema. Give Cloxacillin ( 50 mg/kg IM
or I/V every 6 hourly) and Gentamicin ( 7.5 mg/kg IM
or I/V once a day).
• Usually, intravenous antibiotic therapy -7-10 days.
• Unlike pneumonia the fever comes down little later by
5-7 days. When the child improves, continue with
Cloxacillin orally, 4 times a day. Continue treatment for
a minimum of 3 weeks.
• c. Supportive therapy

12. Child presenting with wheeze
Asthma
Asthma is a chronic inflammatory condition of
the airways associated with variable airflow
obstruction that is often reversible. It is
characterized by recurrent episodes of
wheezing, cough, and difficulty in breathing,
which respond to treatment with
bronchodilators and anti-inflammatory drugs

13. Treatment of acute asthma
• Mainstay of drug therapy is bronchodilators and steroids.
• Mild attack – (Alert child with no signs of severe respiratory
distress)
• • Rapid-acting bronchodilators: Nebulised Salbutamol 3
doses at 20 min interval OR Salbutamol by metered dose
inhaler (MDI) with spacer: Give 4-5 puffs, spacing out each
at 2-3 min interval.
• This becomes equivalent to a single nebulized dose. Repeat
4-5 puff course as before every 20 min, three times,in this
hour.OR Injection Adrenaline subcutaneously every 20 min
three times.
• Reassess the child after 1 hour:

14. Moderate to severe attack
(Presence of severe respiratory distress or cyanosis)
First dose of steroids (oral Prednisolone 1mg/kg) should be given
promptly, if not started so far.
Nebulized beta agonists and systemic steroids.
• If on reassessment, the response is partial or poor:
- Continue inhaled Salbutamol as before for another hour.
- If available, also add inhaled Ipratropium bromide. This can be
mixed with Salbutamol nebulized solution. Give 3 doses at 20
min interval.
- Continue systemic steroids.
• If the child starts improving or is stable, continue Salbutamol
inhalations 1 or 2 or 4 hourly depending upon the time for which
the response to initial treatment is sustained. Ipratropium
bromide should be continued at 8 hourly intervals.

15. Treatment
• In case of poor or no response after initial
treatment with Salbutamol and Ipratropium
• Magnesium Sulphate
• add Injection Aminophylline
• Antibiotics
• Supportive care
• Monitor the child
• Plan discharge when
• Give follow-up care

16. Conditions presenting with stridor
• Stridor is a harsh noise during inspiration, which
is due to narrowing of the air passage in the
oropharynx, sub glottis or trachea. If the
obstruction is severe, stridor may also occur
during expiration. The major causes of severe
stridor
• viral croup (caused by measles or other viruses),
foreign body, diphtheria, retropharyngeal
abscess, and trauma to the larynx .

17. Mild croup • A hoarse voice
• A barking or hacking
cough
• Stridor that is heard only
when the child is agitated.
• Home care (fluid, feeding, when
to return
Moderate to
Severe croup
• Stridor when the child is
calm
• Rapid breathing and in-
drawing of the lower chest
wall.
• Admit to hospital
• Steroid – Single dose of Inj
Dexamethasone (0.6 mg/kg)
I/M or oral Prednisolone(1-2
mg/kg).
• Epinephrine (adrenaline) –
Nebulized Epinephrine (1:1000
solution) 2ml in 2 ml of normal
saline.
• Antibiotics are not recommended.
• Oxygen therapy
• Intubation or Tracheostomy in
children with incipient obstruction

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