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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