Basic facts

• About 20% of all deaths in children under 5 years are due to Acute Lower Respiratory Infections (ALRIs - pneumonia, bronchiolitis and bronchitis); 90% of these deaths are due to pneumonia. Early recognition and prompt treatment of pneumonia is life saving.
• Causative organisms may be bacterial (most commonly Streptococcus pneumoniae and Haemophilus influenzae) or viral. However, it is not possible to differentiate between bacterial and viral ARIs based on clinical signs or radiology.
• Low birth weight, malnourished and non-breastfed children and those living in overcrowded conditions are at higher risk of getting pneumonia. These children are also at a higher risk of death from pneumonia.

Case management of ARI in children 2 month to 5 years

• Assessment, classification and treatment of ARI are summarized on the attached charts. All children presenting with cough or difficult breathing should be assessed according to these charts.
• All children should also be assessed for signs of severe malnutrition - visible severe wasting and oedema of both feet. Children with any of these signs must be referred to a hospital as they are at a very high risk of death from pneumonia.
• Children with danger signs should be referred to a hospital after a single dose of IM chloramphenicol. In situations where referral is not possible, twice daily injections of IM chloramphenicol should be continued for 5 days, followed by oral antibiotic therapy for another 5 days.
• Children with severe pneumonia should be referred to a hospital for treatment with IM ampicillin/penicillin. In situations where referral is not possible, these children can be treated with oral amoxicillin given thrice daily for 7 days. Oral amoxicillin has recently been shown to be effective in treatment of severe pneumonia.
• Children with non-severe pneumonia should be given antibiotics for 5 days. The new Emergency Health kits contain co-trimoxazole, which is a low-cost broad spectrum antimicrobial. An alternative is oral amoxicillin.
• Supportive measures include increased oral fluids to prevent dehydration, continued feeding to avoid malnutrition and anti-pyretics to reduce high fever.

Case management of ARI in young infants 0-2 months

• Signs of pneumonia, sepsis and meningitis are difficult to differentiate in a young infant less than 2 months of age.
• Young infants with fast breathing or chest indrawing should be suspected to have serious bacterial infection. These infants should be referred to a hospital and treated with IM ampicillin/penicillin and gentamicin for 10 days. In situations where referral is not possible, oral amoxicillin or co-trimoxazole twice daily with IM gentamicin once daily should be given for 10 days.
• Supportive measures include frequent breastfeeding and keeping the young infant warm.

Please send questions or comments to CAH@who.int or by fax +41 22 791 4853.