Overview: The IMNCI guidelines provide a structured approach to managing HIV in children through systematic assessment, classification, treatment, and counseling. This follows the standard IMNCI process flow: Assess → Classify → Treat → Counsel → Follow-up.

Based on assessment, the child is classified into one of three categories. The management depends entirely on this classification.

• Exposed Children: Follow up monthly to monitor growth and ensure prophylactic medication (Cotrimoxazole/Nevirapine) adherence
• Confirmed Children: Follow up at ART clinic as per schedule (every 2 weeks initially, then monthly)
• Acute Illness: If HIV-positive child has cough or cold, follow up in 5 days rather than waiting, as they deteriorate faster
• Growth Monitoring: Plot weight on growth chart at every visit; flattening curve indicates treatment failure

a) Signs and Symptoms of Some Dehydration in 1-Year-Old (IMCI Classification)

According to the IMCI Chart Booklet 2018, a child with SOME DEHYDRATION must have at least two of the following signs:

1. Restless and irritable behavior: The child is unusually fussy, cries more than normal, cannot be comforted easily, and shows signs of discomfort
2. Sunken eyes: When observed from above, the eyes appear to be deeper in their sockets than normal; the eyes may look hollow or dark circles may appear
3. Drinking eagerly or thirsty: When offered fluids, the child drinks urgently with obvious eagerness, cannot wait, and may reach for the cup
4. Skin pinch goes back slowly: When the skin on the abdomen is pinched and released, it takes 1-2 seconds to return to its original position (longer than normal but less than very slowly)

NOTE: For classification, the child must NOT have any general danger signs (lethargic/unconscious, not able to drink, vomiting everything, convulsions) which would indicate SEVERE DEHYDRATION or VERY SEVERE DISEASE requiring immediate referral.

Additional supporting signs:

• Increased heart rate
• Dry mouth and tongue
• Fewer wet diapers than usual (but still some urine output)
• Mild lethargy but still responsive
• History of watery diarrhea (more water than fecal matter)
• Duration of diarrhea typically less than 14 days (acute)

b) Comprehensive Management of 1-Year-Old with Some Dehydration

Step-by-Step Management Process:

1. Initial Assessment: Confirm some dehydration classification, check for other problems (fever, cough, malnutrition)
2. Calculate ORS Volume: Multiply child's weight (kg) × 75 ml = total ORS for 4 hours
3. ORS Administration Technique:
   • Give frequent small sips from cup or spoon
   • If vomiting occurs, wait 10 minutes, then continue more slowly
   • Offer as much as child wants to drink
   • Continue breastfeeding throughout
4. Zinc Supplementation:
   • Dissolve tablet in small amount of expressed breast milk, ORS, or clean water
   • Give once daily for 10 days (even if diarrhea stops)
5. Feeding During Illness:
   • Increase frequency and duration of breastfeeding
   • Offer favorite soft foods: mashed matoke, potatoes, porridge, eggs
   • Give small, frequent meals (5-6 times/day)
   • After illness, give extra meal daily for one week to help recover weight
6. Monitoring: Observe child during treatment for:
   • Ability to drink and retain fluids
   • Vomiting frequency
   • Stool frequency and consistency
   • Urine output
   • Activity level improvement
7. After 4 Hours: Reassess using the same criteria:
   • If no dehydration → Plan A (home treatment)
   • If still some dehydration → Continue Plan B, may extend 2-4 more hours
   • If severe dehydration → Plan C (IV treatment) or urgent referral

c) Five Health Messages for Caretakers

Comprehensive Counseling Messages:

1. Rule 1: Give Extra Fluid (As Much As The Child Will Take)
   • Continue breastfeeding frequently and for longer at each feed
   • Offer ORS solution, soup, rice water, yogurt drinks between feeds
   • Give 100-200 ml after each loose stool
   • Offer fluids every 5 minutes if child is weak
   • Clean water is essential - boil and cool before use
   • Keep ORS solution covered and use within 24 hours
2. Rule 2: Give Zinc Supplements Daily
   • Give 1 tablet (20 mg) daily for 10 days
   • Dissolve in clean water or breast milk
   • Zinc reduces duration and severity of diarrhea
   • Continue even if child gets better before 10 days
   • Store tablets in dry place away from children
3. Rule 3: Continue Feeding and Increase Breastfeeding
   • Never stop feeding during diarrhea
   • Offer favorite soft foods: mashed banana, eggs, potatoes, porridge
   • Give small amounts more frequently (5-6 times/day)
   • After illness, give one extra meal daily for one week
   • Avoid fasting or giving only plain water/starchy water
   • Continue vitamin A rich foods: liver, eggs, orange vegetables
4. Rule 4: When to Return Immediately (Danger Signs)
   • Child becomes very sleepy, difficult to wake, or unconscious
   • Not able to drink or breastfeed at all
   • Vomits everything that is given
   • Has blood in stool
   • Develops fever (≥38°C)
   • Fast or difficult breathing develops
   • Stops passing urine
   • Skin pinch goes back very slowly (>2 seconds)
   • Child becomes sicker or does not improve after 2 days
5. Rule 5: Prevention of Future Episodes
   • Exclusive breastfeeding for first 6 months of life
   • Wash hands with soap after toilet, before preparing food, before eating
   • Use latrine or bury feces; dispose of baby's stool safely
   • Give measles vaccination at 9 months
   • Continue breastfeeding up to 2 years or beyond
   • Use safe water: boil, chlorinate, or filter drinking water
   • Wash fruits and vegetables thoroughly before eating
   • Avoid giving child uncooked or leftover food
   • Keep child's environment clean
   • Practice proper food storage and handling

Five Specific Prereferral Actions Before Referring 1-Year-Old with General Danger Signs

General Danger Signs (ANY of these requires URGENT referral):

• Not able to drink or breastfeed
• Vomits everything
• Has had convulsions during this illness
• Is lethargic or unconscious
• Is convulsing now

1. Give First Dose of Appropriate Parenteral Antibiotic
   • Medication: Intramuscular Ampicillin (50mg/kg) PLUS Gentamicin (7.5mg/kg)
   • Preparation:
     • Ampicillin: Dilute 500mg vial with 2.1ml sterile water → 500mg/2.5ml
     • Gentamicin: Use 40mg/ml vial, calculate dose by weight
   • Dosage for 10 kg child:
     • Ampicillin: 2 ml (500mg)
     • Gentamicin: 1.8 ml (75mg)
   • Administration: Give deep IM injection in different sites (e.g., each thigh)
   • Rationale: Covers most serious bacterial infections (sepsis, pneumonia, meningitis)
   • Timing: Give immediately, do not delay referral
2. Treat Convulsions (If Present or History)
   • Medication: Diazepam 0.5 mg/kg rectally
   • Preparation: Use diazepam injection solution (10mg/2ml)
   • Dosage for 10 kg child: 1.0 ml (5mg) rectally
   • Technique:
     • Draw up dose in small syringe (without needle)
     • Insert syringe tip 2-3 cm into rectum
     • Position child on side, maintain for 5 minutes
   • Action: Position child appropriately, clear airway, avoid putting things in mouth
   • Repeat: If convulsions have not stopped after 10 minutes, repeat same dose
   • Rationale: Prevent brain damage from prolonged seizures
3. Prevent or Treat Low Blood Sugar (Hypoglycemia)
   • If child able to drink/breastfeed:
     • Ask mother to breastfeed immediately
     • If not breastfed, give expressed breast milk or breast milk substitute
     • Give 30-50 ml of milk before departure
   • If child not able to swallow:
     • Give 20-50 ml expressed breast milk or sugar water by nasogastric tube
   • Sugar water preparation: Dissolve 4 level teaspoons sugar (20g) in 200 ml clean water
   • Rationale: Sick children, especially those not feeding, are at high risk of hypoglycemia
   • Monitoring: Check blood glucose if possible; give glucose if <3 mmol/L
4. Give First Dose of Antimalarial (If Fever Present)
   • Assessment: Check temperature ≥37.5°C AND malaria test positive (if available)
   • Medication Options:
     • Rectal Artesunate: 10 mg/kg (first dose)
     • IM Artesunate: 2.4 mg/kg (if child <20kg) or 3 mg/kg (if ≥20kg)
     • IM Quinine: 10 mg/kg
   • Dosage for 10 kg child:
     • Rectal artesunate: 100 mg suppository
     • IM artesunate: 2.4 mg/kg = 24 mg
     • IM quinine: 100 mg
   • Administration:
     • Rectal: Insert suppository gently into rectum
     • IM: Give deep intramuscular injection (buttock or thigh)
   • Special note: Give first dose even if malaria test not available but fever present in endemic area
5. Keep Child Warm and Prepare for Safe Transport
   • Warmth measures:
     • Dress child in warm clothing including hat and socks
     • Wrap in blanket
     • If available, use skin-to-skin contact with mother during transport
     • Ensure vehicle is warm (no direct cold air)
   • If child has diarrhea with dehydration:
     • Give mother ORS solution to give frequent sips during transport
     • Counsel on continuing breastfeeding during journey
     • Prepare enough ORS for journey (calculate 5 ml/kg/hour)
   • Documentation:
     • Write clear referral note including:
       • Child's name, age, weight
       • All assessments and classifications
       • Pre-referral treatments given (name, dose, time)
       • Reason for referral
       • Vital signs at referral
     • Give copy to mother/caretaker
   • Communication:
     • Explain to mother why referral is necessary
     • Describe what to expect at hospital
     • Ensure transport arrangement (ambulance, vehicle)
     • Ask mother to bring immunization card and any medications

CRITICAL PRINCIPLE: These actions should be performed RAPIDLY but without delaying referral. The entire pre-referral process should not exceed 30 minutes. If referral transport is delayed, continue treatments every 6-8 hours as indicated.

a) Five Steps in Integrated Case Management of Children (IMNCI)

1. STEP 1: Assessment of the Sick Child
   • Greet caregiver and ask about child's age and main problems
   • Determine if initial or follow-up visit
   • Check for general danger signs (critical first step)
   • Ask about main symptoms: cough/difficult breathing, diarrhea, fever, ear problem
   • Assess nutritional status (weight, height, MUAC, edema)
   • Check for anemia (palmar pallor)
   • Assess immunization and vitamin A status
   • Check for HIV infection and TB exposure
   • Assess feeding practices
   • Check developmental milestones
2. STEP 2: Classification of Illness
   • Use all boxes that match child's symptoms to classify illness
   • Classifications are color-coded:
     • PINK = URGENT (requires referral/hospitalization)
     • YELLOW = Clinic treatment needed
     • GREEN = Home management
   • Possible classifications include:
     • Very severe disease, Severe pneumonia, Pneumonia, Cough or cold
     • Severe dehydration, Some dehydration, No dehydration
     • Severe febrile disease, Malaria, Fever - no malaria
     • Complicated measles, Measles with eye/mouth complications, Measles
     • Mastoiditis, Acute ear infection, Chronic ear infection
     • Severe acute malnutrition, Moderate acute malnutrition
     • Severe anemia, Anemia
3. STEP 3: Identify Treatment
   • Based on classification, identify specific treatments
   • Pre-referral treatments for severe classifications (urgent)
   • Oral medications: antibiotics, antimalarials, ORS, zinc, iron, vitamin A
   • Counseling topics: feeding, home care, when to return
   • Follow-up schedule determination
4. STEP 4: Treat the Child
   • Administer first doses in clinic
   • Teach mother how to give oral medications at home
   • Demonstrate and practice measuring doses
   • Provide ORS and zinc for diarrhea
   • Give vitamin A supplementation
   • Treat local infections (eye, ear, mouth)
   • Immunize if needed
   • Provide RUTF for malnutrition
   • Give preventive treatments (IPT, deworming)
5. STEP 5: Counsel the Mother/Caretaker
   • Assess feeding practices and problems
   • Counsel about feeding recommendations for child's age
   • Teach home care for child's specific condition
   • Explain all medications: name, dose, frequency, duration, purpose
   • Advise when to return for follow-up
   • Teach danger signs requiring immediate return
   • Counsel about mother's own health and nutrition
   • Provide ECD (Early Childhood Development) counseling
   • Discuss family planning and HIV testing if appropriate

b) Six Conditions to Check Before Child Leaves IMNCI Clinic

c) Assessment of General Danger Signs Using IMNCI Approach

General danger signs are assessed FIRST in IMNCI before asking about main symptoms. ANY danger sign requires urgent referral.

ASSESSMENT SEQUENCE:

1. Quickly observe child as they enter/consultation begins
2. Ask mother directly about danger signs
3. Verify questionable responses by observing child
4. Assess breathing in calm child (wait if child is crying)
5. If any danger sign present, complete assessment rapidly but do not delay pre-referral treatment

CRITICAL: If ANY general danger sign is present, child is classified as having VERY SEVERE DISEASE and requires URGENT referral after pre-referral treatment.

Classification

Comprehensive Management (10 Marks)

The management follows urgent pre-referral treatment and immediate referral protocol.

Additional Critical Management Points:

1. Positioning during transport:
   • Keep child upright or semi-upright to ease breathing
   • Avoid lying flat
   • Keep airway clear
   • If vomiting, place on side
2. Do NOT give oral antibiotics alone:
   • Stridor with fast breathing indicates severe disease
   • Oral treatment is insufficient
   • IM/IV antibiotics needed
3. Do NOT give cough syrups or codeine:
   • May suppress breathing
   • Not recommended in IMCI
   • Can worsen respiratory depression
4. Do NOT attempt oral rehydration if child unable to drink:
   • Assess ability to swallow first
   • If cannot drink, treat as severe dehydration with IV/NG
5. Monitor during pre-referral period:
   • Check breathing every 15 minutes
   • If respiratory distress worsens, expedite referral
   • Watch for cyanosis (bluish lips/fingers)
6. Mother counseling before departure:
   • Explain child is very ill and needs hospital care
   • Describe what will happen at hospital (oxygen, IV medications)
   • Encourage mother to remain calm and keep child calm
   • Advise to keep child warm during journey
   • Give hope but emphasize urgency

Prognosis: Without prompt treatment, mortality rate for severe pneumonia with stridor in infants is high (10-20%). With timely referral and hospital care (oxygen, IV antibiotics, supportive care), survival improves to >90%.

Classification

Comprehensive Management (15 Marks)

This complex case requires simultaneous management of both life-threatening conditions.

HOSPITAL MANAGEMENT REQUIREMENTS (What Referral Hospital Should Do):

1. Immediate Stabilization (First 6-24 hours):
   • Hypoglycemia screen & treatment: Check blood glucose. If <3 mmol/L, give 5 ml/kg of 10% glucose IV bolus
   • Hypothermia management: Rewarm gradually using warm room, blankets, warm IV fluids
   • Dehydration assessment: Rehydrate cautiously (5-10 ml/kg/hour) as SAM children prone to heart failure
   • Continue broad-spectrum antibiotics: IV ampicillin + gentamicin for 5-7 days
   • Vitamin A: If not given pre-referral, give 200,000 IU on day 1, 2, and 15
   • Folic acid: 5 mg daily (do NOT give iron initially in SAM)
2. Severe Anemia Management:
   • Hemoglobin confirmation: Take blood for Hb, blood group, cross-match
   • Blood transfusion criteria:
     • Hb <6 g/dL OR
     • Hb 6-10 g/dL with respiratory distress or shock
   • Transfusion protocol:
     • packed cells 10 ml/kg over 3 hours
     • Or whole blood 20 ml/kg over 3-4 hours
     • Give frusemide 1 mg/kg IV at start of transfusion if risk of heart failure
     • Monitor for transfusion reactions every 15 minutes
   • Post-transfusion: Re-check Hb after 4 hours
   • If transfusion not immediately available:
     • Keep child at complete rest
     • Give oxygen if respiratory distress
     • Delay therapeutic feeding until after transfusion
3. Therapeutic Feeding for SAM:
   • Phase 1 (Day 1-7):
     • Start F-75 therapeutic milk (75 kcal/100ml)
     • Give 130 ml/kg/day divided every 3 hours
     • Do NOT exceed 100 ml/kg/day if child has severe edema
     • Monitor for hypoglycemia, hypothermia daily
     • Re-feeding syndrome risk: watch for fluid overload
   • Transition Phase (Day 3-7):
     • Child shows appetite improvement
     • Gradually introduce F-100 (100 kcal/100ml)
     • Increase volume as tolerated
   • Rehabilitation Phase (Day 8+):
     • Give F-100 or RUTF (Ready-to-Use Therapeutic Food)
     • 200 kcal/kg/day
     • Allow child to eat as much as wants
     • Continue until weight-for-height ≥-2 z-scores
4. Monitoring and Complication Management:
   • Daily monitoring: Temperature, pulse, respiratory rate, weight, fluid intake/output
   • Electrolytes: Check sodium, potassium if possible (risk of deficiency)
   • Infection surveillance: Watch for septic shock, pneumonia, urinary tract infection
   • Heart failure: Watch for fast breathing, enlarged liver, edema; treat with diuretics
   • Skin care: Treat pressure sores, diaper rash
5. Iron Therapy Timing:
   • DO NOT give iron during Phase 1 (first week) of SAM treatment
   • Start iron only after appetite returns (usually day 8-10)
   • Give iron-folate 2 mg/kg daily for 3 months
   • Monitor for side effects (dark stools, constipation)

If Referral is REFUSED or NOT POSSIBLE:

Community-based management (only if no complications):

1. Give ready-to-use therapeutic food (RUTF):
   • 92 g packets (500 kcal each)
   • Give 4-5 packets daily for 3-year-old (divide into 5-6 meals)
   • Allow child to eat at own pace
   • Continue breastfeeding
   • Offer clean water between feeds
2. Give oral antibiotics:
   • Amoxicillin twice daily for 5 days (even if no fever)
   • SAM children have high infection risk even without symptoms
3. Manage severe anemia:
   • Refer urgently if possible despite initial refusal
   • If transfusion impossible, give:
     • Iron 6 mg/kg daily
     • Folic acid 5 mg daily
     • Antimalarial if malaria endemic
     • Albendazole if worms likely
     • Full rest, avoid exertion
   • Follow-up weekly; refer immediately if condition worsens
4. Daily home visits for first week:
   • Check for danger signs
   • Weigh child daily
   • Assess intake
   • Support mother

Expected Outcomes with Proper Treatment:
• Mortality: <5% with hospital care
• Weight gain: 10-15 g/kg/day during rehabilitation
• Anemia correction: Hb rises 0.5-1.0 g/dL per week with iron
• Duration: Hospital stay typically 2-4 weeks, then outpatient follow-up

Classification

Management (10 Marks)

Five Complications Likely to Get (5 Marks)

1. Pneumonia (Post-Measles Pneumonia)
   • Most common complication (5-10% of measles cases)
   • Presents with fast breathing, chest indrawing, fever
   • Caused by secondary bacterial infection (Staph aureus, Strept pneumoniae)
   • High mortality if untreated
   • Prevented by amoxicillin prophylaxis
2. Diarrhea with Dehydration
   • Occurs in 10-15% of measles cases
   • Due to measles virus damaging gut lining
   • Risk of severe dehydration and death
   • Exacerbated by malnutrition
   • Treat with ORS and zinc supplementation
3. Blindness from Eye Complications
   • Corneal ulcer can perforate leading to blindness
   • Xerophthalmia (dry eyes) from vitamin A deficiency
   • Secondary bacterial infection worsens damage
   • Preventable with vitamin A and tetracycline eye ointment
   • Leading cause of childhood blindness in Africa
4. Acute Malnutrition
   • Measles causes increased metabolic needs
   • Loss of appetite during illness
   • Diarrhea reduces nutrient absorption
   • Child can deteriorate from well-nourished to malnourished in 2-3 weeks
   • Requires therapeutic feeding intervention
5. Acute Encephalitis
   • Rare but serious complication (1-3 per 1000 cases)
   • Occurs 2-7 days after rash onset
   • Presents with convulsions, drowsiness, coma
   • High mortality (10-20%) and neurological sequelae
   • Requires hospital intensive care

Teaching Mother on Prevention of Measles Transmission (5 Marks)

Comprehensive Prevention Counseling:

1. Measles Vaccination
   • Primary prevention: Give measles vaccine at 9 months of age
   • Second dose: At 18 months for full protection
   • Catch-up: Any unvaccinated child should be immunized immediately
   • Vaccine efficacy: 85-90% after first dose, 95% after second dose
   • Bring vaccination card to every visit
   • Check siblings' immunization status
2. Isolation During Illness
   • Keep child at home during illness
   • Avoid contact with other children for 7 days after rash appears
   • Measles is most contagious 2 days before to 4 days after rash
   • Do not take to market, school, clinic waiting areas
   • Inform neighbors so they can check their children's immunity
   • Unvaccinated contacts should be immunized within 72 hours
3. Vitamin A Supplementation
   • Give vitamin A every 6 months from 6 months of age
   • 200,000 IU dose for children >1 year
   • Reduces measles risk and severity
   • Prevents eye complications and blindness
   • Strengthens immune system
   • Mark dose on child's health card
4. Respiratory Hygiene
   • Cover mouth and nose when coughing/sneezing
   • Use tissue or cloth, then wash hands
   • Dispose of used tissues safely (burn or bury)
   • Ventilate living areas (open windows)
   • Avoid overcrowding
   • Wash child's face and hands frequently
   • Keep child's environment clean
5. Community Protection (Herd Immunity)
   • Encourage all community members to vaccinate children
   • 95% vaccination coverage prevents measles outbreaks
   • Participate in immunization campaigns
   • Identify and vaccinate unreached children
   • Support health education in community
   • Report measles cases to health authorities for outbreak response

Additional points to emphasize:
• Malnutrition increases measles risk and severity - ensure good nutrition
• HIV-exposed children need extra doses of measles vaccine
• Breastfeeding provides some protection (antibodies)
• Early treatment reduces transmission period

Classification

Management (10 Marks)

Hospital Management (What Facility Should Do):

Upon arrival, hospital should:

1. Emergency assessment: ABC (Airway, Breathing, Circulation)
2. Immediate IV antibiotics:
   • Ceftriaxone 100 mg/kg IV 12-hourly (preferred for meningitis)
   • PLUS Gentamicin 7.5 mg/kg IV daily
   • OR Benzyl penicillin 60 mg/kg 4-hourly if ceftriaxone unavailable
3. Lumbar puncture: Within 1 hour (if no contraindications)
   • CSF analysis: cell count, protein, glucose, gram stain, culture
   • Blood glucose simultaneously
   • Distinguish bacterial vs. viral meningitis
4. Supportive care:
   • IV fluids: maintain hydration, avoid overload
   • Oxygen if SpO2 <90%< /li>
   • Continue antimalarial if started
   • Paracetamol for fever 6-hourly
   • NG tube feeding if unable to swallow
5. Monitoring:
   • Hourly: pulse, BP, RR, temperature
   • Neurological status: Glasgow coma scale
   • Fluid balance: input/output chart
   • Repeat blood glucose if <3 mmol/L
6. Adjust antibiotics: Based on CSF results after 48 hours

Differential Diagnoses to Consider:

• Bacterial meningitis: Most urgent, needs immediate antibiotics
• Viral meningitis/encephalitis: Supportive care, may need acyclovir if HSV suspected
• Tuberculous meningitis: If slow onset, history of TB contact
• Cerebral malaria: Even with negative RDT, consider if severe malaria area
• Brain abscess: If focal neurological signs

Prognosis: With prompt antibiotics, mortality from bacterial meningitis is 5-10%. Without treatment, mortality is 50-90%. Neurological sequelae occur in 10-30% of survivors (deafness, seizures, developmental delay).

a) Three Main Symptoms Joel Presented With (3 Marks)

Marking: 1 mark per correct symptom, must include duration and correct system identification.

b) One General Danger Sign Joel Presented With (1 Mark)

Rationale: Stiff neck is a clear general danger sign indicating possible meningitis or severe febrile disease. It is assessed during the fever check (look and feel for stiff neck) and requires urgent referral. The history of convulsions also qualifies as a general danger sign.

Marking: 1 mark for identifying ONE correct danger sign (stiff neck, convulsions, or drinks poorly/but this is assessed under dehydration). STIFF NECK is the most definitive.

c) Three Classifications of Joel's Illnesses (3 Marks)

Marking: 1 mark per correct classification. Must be specific (Pneumonia, Some Dehydration, Very Severe Febrile Disease). Do not accept generic terms like "severe disease" only.

d) Management of Joel (18 Marks)

Joel has multiple severe conditions requiring URGENT PRE-REFERRAL TREATMENT and IMMEDIATE REFERRAL to hospital. This is a life-threatening situation.

Hospital Management (What Referral Hospital Should Do):

1. Emergency Triage (Within 5 minutes of arrival):
   • Rapid ABC assessment
   • Check vital signs: pulse, BP, temperature, RR
   • Assess level of consciousness (AVPU scale)
   • Check for signs of shock (cold hands, weak pulse, capillary refill)
   • Provide oxygen if respiratory distress
2. Lumbar Puncture (Within 1 hour if no contraindications):
   • Check for signs of raised intracranial pressure first
   • Contraindications: coma, focal neurological signs, severe respiratory distress
   • If contraindicated, start antibiotics empirically
   • CSF analysis: cell count, glucose, protein, Gram stain, culture
   • Blood glucose simultaneously
3. IV Antibiotics (Continue/Upgrade):
   • If meningitis suspected: Ceftriaxone 100 mg/kg IV 12-hourly
   • PLUS Gentamicin 7.5 mg/kg IV daily
   • Duration: 10-14 days for meningitis
   • Adjust based on culture results
4. Supportive Care:
   • Fluids: IV maintenance fluids (80% of normal due to SAM risk)
   • Monitoring: Hourly vitals, neurological checks
   • Feeding: NG tube feeding if unable to swallow (F-75 formula)
   • Convulsion management: If recurs, give IV diazepam 0.3 mg/kg slowly
   • Steroids: NOT recommended for bacterial meningitis in children
   • Glycerol: May reduce neurological sequelae (5 ml/kg every 6 hours)
5. Continue Other Treatments:
   • Continue ORS if still dehydrated
   • Continue zinc supplementation
   • Continue paracetamol for fever
   • Monitor for and treat hypoglycemia
   • HIV test if status unknown
6. Complication Surveillance:
   • Septic shock: Watch for cold extremities, weak pulse
   • Cerebral edema: Watch for irregular breathing, bradycardia
   • Subdural effusion: Persistent fever, bulging fontanelle
   • Hearing loss: Test before discharge and at follow-up
   • Neurological sequelae: Assess motor function, cognitive development

Follow-up Care After Discharge:

• Reassessment: After 5 days for pneumonia, 3 days for fever, 14 days for anemia
• Developmental monitoring: Every 2 weeks for first 3 months post-meningitis
• Hearing test: At discharge, 1 month, 3 months
• Immunization: Catch up on missed vaccines after recovery
• Nutritional support: RUTF if SAM develops