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Referral and warning signs
When to refer
Urgent Referral: Any child classified as Severe Pneumonia or Very Severe Disease. Child with Pneumonia who is HIV exposed/infected and has chest indrawing. Child with Pneumonia or Cough/Cold who worsens or fails to improve on follow-up. Child with cough >14 days or recurrent wheeze (for TB/Asthma assessment).
Red flags
- Any General Danger Sign.
- Stridor when calm.
- Severe chest indrawing.
- Cyanosis.
- SpO2 <90%.
- Grunting.
- Failure to improve after 48-72h of appropriate antibiotic for Pneumonia.
Signs and symptoms
- Ask:
- - Does the child have cough or difficult breathing?
- - If yes, for how long?
- Look, Listen, Feel (Child must be calm):
- - Count breaths in one full minute. (Fast breathing if: Age 2-12m: >=50/min; Age 1-5y: >=40/min).
- - Look for chest indrawing (lower chest wall goes IN when child breathes IN).
- - Look and listen for stridor (harsh noise on INspiration when calm).
- - Look and listen for wheezing (high-pitched noise, usually on OUTspiration).
- - Check SpO2 if available (Refer if <90%).
Risk factors
- Malnutrition.
- Lack of immunization (Hib, PCV, Measles).
- Indoor air pollution.
- HIV infection.
- Low birth weight.
Diagnosis
Clinical assessment
Assessment based on presence/absence of general danger signs, stridor, chest indrawing, and fast breathing (age-specific cutoffs).
Investigations
- Clinical assessment using IMCI algorithm is primary.
- Chest X-ray (usually at referral level for severe/complicated cases).
- Pulse oximetry (SpO2) if available.
Diagnostic criteria
IMCI Classification based on signs: Severe Pneumonia or Very Severe Disease: Any General Danger Sign OR Stridor in calm child OR SpO2 <90%. Pneumonia: Chest indrawing OR Fast breathing. Cough or Cold (No Pneumonia): No signs of severe disease or pneumonia.
Management
Non-pharmacological management
- All Classifications: Soothe throat/relieve cough with safe remedy (breastmilk, warm tea with honey). Counsel mother on danger signs and when to return immediately. Counsel on home care (fluids, feeding).
- Cough or Cold: Advise follow-up in 5 days if not improving.
- Pneumonia: Advise follow-up in 3 days.
- Severe Pneumonia: Keep child warm, prevent low blood sugar during referral.
Pharmacological treatment
- Severe Pneumonia or Very Severe Disease:
- - Give FIRST DOSE pre-referral antibiotic:
- - Ampicillin 50 mg/kg IM + Gentamicin 7.5 mg/kg IM (HC3+).
- - OR Benzylpenicillin 50,000 IU/kg IM (HC2).
- - OR Amoxicillin DT 40 mg/kg PO if parenteral not available.
- - If SpO2 <90%, give Oxygen.
- - Refer URGENTLY to Hospital.
- - If referral impossible: Continue Ampicillin Q6H + Gentamicin OD for 5 days.
- Pneumonia:
- - Give oral Amoxicillin dispersible tablet (DT) 40 mg/kg PO BID for 5 days (First line).
- - Dose (DT 250mg): 2-12m (4-9kg): 1 tab BID; 1-3y (10-13kg): 2 tabs BID; 3-5y (14-19kg): 3 tabs BID.
- - If wheezing: Give inhaled rapid-acting bronchodilator (Salbutamol inhaler with spacer) 2 puffs Q3-4H PRN for 5 days.
- - If cough >14 days or recurrent wheeze: Refer for TB/Asthma assessment.
- - If HIV exposed/infected with chest indrawing: Give first dose Amoxicillin DT and Refer.
- Cough or Cold (No Pneumonia):
- - NO ANTIBIOTIC NEEDED (likely viral).
- - If wheezing: Give inhaled Salbutamol (as above) for 5 days.
- - If cough >14 days or recurrent wheeze: Refer for TB/Asthma assessment.
Monitoring
Follow-up as indicated by classification (3 days for Pneumonia, 5 days if Cough/Cold not improving). Reassess breathing, feeding, fever, danger signs. If worsening or not improving, refer.
Complications
- Respiratory failure.
- Sepsis.
- Pleural effusion / Empyema.
- Lung abscess.
- Death.
Prevention
- Immunization (PCV, Hib, Measles).
- Exclusive breastfeeding.
- Good nutrition.
- Reducing exposure to indoor air pollution.
- Handwashing.
- Zinc supplementation (reduces incidence).
Patient education
- Diagnosis and reason for treatment (antibiotics only if Pneumonia).
- How to give oral Amoxicillin correctly (dose, frequency, full 5-day course).
- How to use Salbutamol inhaler with spacer if prescribed.
- Importance of safe cough remedies (soothing).
- Need for increased fluids and continued feeding.
- Danger signs requiring immediate return.
- Importance of follow-up visit.
- Prevention measures (immunization, nutrition).
Uganda-specific notes
Pneumonia is a leading cause of child mortality. IMCI algorithm using age-specific respiratory rate cutoffs and chest indrawing is standard for diagnosis and classification at primary level. Amoxicillin DT is first-line for non-severe pneumonia. Recognize need for referral for severe cases and potential TB/Asthma.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.3.2
- IMCI Chart Booklet, MOH Uganda
(Cough or Difficult Breathing Algorithm)