Who / when
- Children aged 2 months up to 5 years with cough or difficult breathing.
- Young infants under 2 months: use the sick young infant chart instead.
- Community health workers: treat fast breathing with amoxicillin and refer chest indrawing, unless referral is impossible and national policy lets you treat it.
Red flags: refer now
General danger signs (check in every sick child):
- Not able to drink or breastfeed.
- Vomits everything.
- Has had convulsions, or is convulsing now.
- Lethargic or unconscious.
Also refer urgently: stridor in a calm child; oxygen saturation below 90% (if you have a pulse oximeter); severe malnutrition.
Any of these: severe pneumonia or very severe diseaseDo not delay referral: finish the assessment quickly, give the first dose of an appropriate antibiotic (per your national IMCI chart), keep the child warm and send them.
Assess
- Ask: for how long has the child had cough or difficult breathing?
- The child must be calm. Count breaths for one full minute.
- Look for chest indrawing: the lower chest wall goes in when the child breathes in.
- Look and listen for stridor and for wheeze.
- Pulse oximeter available: measure oxygen saturation. If not, look for a combination of signs of respiratory distress.
- Ask about HIV exposure or infection, and check nutrition.
Wheeze: treat first, then reclassifyIf there is wheeze with fast breathing or chest indrawing, give a rapid-acting inhaled bronchodilator, up to three times 15 to 20 minutes apart. Then count the breaths and look for chest indrawing again, and classify.
Classify
| Age | Fast breathing is |
|---|
| 2 months up to 12 months | 50 breaths per minute or more |
| 12 months up to 5 years | 40 breaths per minute or more |
| Signs | Classify as | Action |
|---|
| Any general danger sign, or stridor in a calm child | Severe pneumonia or very severe disease | First dose of antibiotic; refer urgently |
| Chest indrawing and/or fast breathing | Pneumonia | Oral amoxicillin at home; follow up in 3 days. HIV-exposed or infected child with chest indrawing: first dose and refer |
| No signs of pneumonia or very severe disease | Cough or cold | No antibiotic; soothe the throat; follow up in 5 days if not improving |
Treat
Pneumonia: oral amoxicillin
At least 40 mg/kg per dose, twice daily (80 mg/kg a day). Dispersible tablets are best for children.
Give for 5 days. For fast breathing without chest indrawing in a low-HIV setting, 3 days may be used if your national chart says so.| Age (weight) | Amoxicillin dispersible 250 mg tablets |
|---|
| 2 months up to 12 months (4 to under 10 kg) | 1 tablet twice daily |
| 12 months up to 3 years (10 to under 14 kg) | 2 tablets twice daily |
| 3 years up to 5 years (14 to 19 kg) | 3 tablets twice daily |
- Give the first dose in the clinic and show the carer how to give the rest.
- Wheeze (or wheeze that cleared with the bronchodilator): inhaled bronchodilator for 5 days. Where none is available, oral salbutamol may be tried, but not for severe acute wheeze.
- Soothe the throat and relieve the cough with a safe remedy, such as breast milk for a breastfed infant.
- Cough for more than 14 days, or recurrent wheeze: refer for assessment for TB or asthma.
- Severe pneumonia: injectable treatment happens at the referral facility (ampicillin or penicillin with gentamicin as first line).
Follow-up
Pneumonia: see again after 3 days. Check danger signs and reassess the breathing.
- Any danger sign or stridor: refer urgently.
- Chest indrawing, or breathing rate, fever and eating the same or worse: refer urgently.
- Breathing slower, no chest indrawing, less fever, eating better: finish the 5 days of amoxicillin.
- Cough or cold: see again in 5 days if not improving.
Counsel
- Give every dose of amoxicillin until the course is finished, even if the child seems better.
- Keep breastfeeding and keep offering food and fluids.
- Do not use harmful remedies for the cough.
- Come back at once if the child cannot drink or breastfeed, becomes sicker, develops a fever, or breathes fast or with difficulty.
Give this medicine twice a day for 5 days. Bring your child back in 3 days, or straight away if they cannot drink, get sicker, or breathe fast or with difficulty.
When to refer
- Urgently: any general danger sign, stridor in a calm child, oxygen saturation below 90%, or severe malnutrition.
- Chest indrawing in a child who is HIV-exposed or HIV-infected.
- Not better, or worse, at the 3-day review.
- Not responding to amoxicillin: refer for second-line treatment.
- Cough for more than 14 days, or recurrent wheeze (TB or asthma assessment).
- If referral is not possible: follow the pneumonia section of your national referral guideline or the WHO Pocket Book of hospital care for children.
Sources
World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. World Health Organization. Revised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries. 2014. World Health Organization. Guideline on management of pneumonia and diarrhoea in children up to 10 years of age. 2024.