Who this is for: GPs and medical officers assessing cough or difficult breathing in children under 5 in the OPD, applying WHO IMCI classification and the revised outpatient antibiotic rules.

Epidemiology in Pakistan

Pneumonia is the single largest infectious killer of children under 5 in Pakistan, responsible for an estimated 15 to 20 percent of under-5 deaths, tens of thousands of children each year. Risk concentrates in infants, the unvaccinated, the malnourished, and households with indoor smoke exposure. Pneumococcal conjugate vaccine has been in the EPI schedule since 2012 and Hib vaccine since 2009, but coverage gaps persist, and late presentation to care remains the deadliest pattern. Correct OPD classification plus oral amoxicillin prevents most of these deaths.

Assessment: count, look, listen

For every child with cough or difficult breathing, ask duration, then check the IMCI general danger signs: unable to drink or breastfeed, vomits everything, convulsions, lethargic or unconscious. Then, with the child calm:

  1. Count the respiratory rate for a full minute. Fast breathing thresholds by age band: under 2 months, 60 breaths per minute or more; 2 to 11 months, 50 or more; 12 to 59 months, 40 or more.
  2. Look for lower chest wall indrawing (inward movement of the lower chest on inspiration; not intercostal recession alone).
  3. Look and listen for stridor in a calm child, and for audible wheeze.
  4. Check SpO2 wherever a pulse oximeter exists; below 90 percent means severe disease. A basic oximeter is one of the highest-value purchases a Pakistani GP clinic can make.

Classification per IMCI (2014 revision):

  • Cough or cold: no fast breathing, no indrawing, no danger signs. Home care, no antibiotic.
  • Pneumonia: fast breathing or chest indrawing, without danger signs, stridor or hypoxia. Oral amoxicillin as an outpatient. The 2014 revision moved chest indrawing from the referral category to outpatient treatment, provided SpO2 is adequate and the child can feed and return for review.
  • Severe pneumonia or very severe disease: any general danger sign, stridor in a calm child, or SpO2 below 90 percent. First dose of antibiotic, then urgent referral.

Infants under 2 months are a separate universe: any fast breathing, indrawing or danger sign classifies as possible serious bacterial infection; give the pre-referral dose and refer. Do not manage neonatal pneumonia as an outpatient.

Differentials: bronchiolitis (under 12 months, wheeze-predominant, antibiotics do not help; supportive care and oximetry-guided referral), asthma or reactive airways (recurrent wheeze responding to bronchodilator; give a salbutamol trial and recount the respiratory rate before classifying), foreign body (sudden onset, unilateral signs), tuberculosis (cough over 2 weeks, contact, failure to thrive; see the TB pathway), croup (barking cough with stridor), and malaria or sepsis presenting with fast breathing from fever and acidosis. Recounting the rate after paracetamol and a bronchodilator, once the fever is down, avoids a lot of over-classification.

Treatment

Outpatient pneumonia (fast breathing or chest indrawing):

  • Oral amoxicillin 40 mg per kg per dose twice daily for 5 days (WHO IMCI; 80 mg per kg per day). Dispersible tablets are the WHO-preferred formulation and cheap in Pakistan; syrup brands vary in concentration, so write the mg dose and confirm the measuring device with the caregiver. Some programmes permit 3 days for fast-breathing pneumonia in low-HIV settings; follow your provincial IMCI protocol.
  • Wheeze present: inhaled salbutamol via spacer (a homemade bottle spacer works) or nebuliser.
  • Fever: paracetamol 15 mg per kg per dose.
  • Continue feeding and breastfeeding; small frequent feeds if breathless.
  • Do not prescribe cough syrups, sedating antihistamines or codeine-containing remedies; they add risk and no benefit.
  • Counsel return-immediately signs: breathing becoming faster or harder, unable to drink, worsening fever, bluish lips.

Pre-referral treatment for severe pneumonia: first dose of oral amoxicillin (or IM ampicillin plus gentamicin where injectables and skills exist per referral protocol), the first dose of oxygen if you have a concentrator or cylinder, keep the child warm and breastfeeding en route, and treat hypoglycaemia risk in the toxic infant with breastmilk or sugar water per IMCI.

Amoxicillin failure at 3 days (persistent fast breathing without improvement) means reassess fully: recheck for empyema signs, consider staphylococcal disease after measles or with skin boils, consider TB and asthma, then refer or escalate rather than adding random second antibiotics.

Red flags: refer urgently

Any general danger sign; SpO2 below 90 percent; stridor at rest; severe acute malnutrition with cough; age under 2 months with any respiratory sign; grunting, head nodding or cyanosis; failure of outpatient treatment at 3-day review; recurrent pneumonia (think TB, foreign body, congenital heart disease).

Follow-up schedule

Review every outpatient pneumonia at 3 days (sooner if worse): improving means complete the 5 days; not improving means the reassessment pathway above. A follow-up visit at the end of treatment doubles as a vaccination catch-up and nutrition check; weigh the child every visit. MyPatient AI-prepared intakes capture respiratory rate history, vaccination status and prior antibiotic use before the consult, so the clinician can spend the visit counting breaths rather than reconstructing the story. Give caregivers the patient guide to share covering danger signs at home.

Key points

  • Count a full minute: fast breathing is 60 or more under 2 months, 50 or more at 2 to 11 months, 40 or more at 12 to 59 months.
  • Fast breathing or chest indrawing without danger signs equals outpatient pneumonia: amoxicillin 40 mg per kg twice daily for 5 days.
  • Danger signs, stridor or SpO2 below 90 percent equal severe disease: first dose plus urgent referral.
  • All symptomatic infants under 2 months are referrals, not outpatients.
  • Trial of bronchodilator and antipyretic before classifying the wheezy febrile child.
  • Mandatory review at day 3; treatment failure triggers reassessment for TB, empyema and asthma, not a random antibiotic switch.

References

  • Integrated Management of Childhood Illness (IMCI) Chart Booklet. World Health Organization and UNICEF, 2014.
  • Revised WHO Classification and Treatment of Childhood Pneumonia at Health Facilities. World Health Organization, 2014.
  • Pocket Book of Hospital Care for Children, 2nd edition. World Health Organization, 2013.
  • Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025 (GAPPD). WHO and UNICEF, 2013.
  • Fever in Under 5s: Assessment and Initial Management, NG143. National Institute for Health and Care Excellence, 2019 (updated 2021).

Clinical judgement and local protocols take precedence.