What is the best course of treatment for my 18-month-old baby boy with persistent fever, productive cough, and exposure to infectious children, currently on paracetamol (PCM), rantidine, cough syrup, P-250 (possibly a vitamin supplement), nasal drops, and ondansetron, with minimal acceptance of solid food and only breast feeding?

Management of an 18-Month-Old with Fever, Cough, and Respiratory Findings

For an 18-month-old with persistent fever, productive cough, and right lung crackles, amoxicillin (90 mg/kg/day in 2 divided doses) should be started as first-line therapy for presumed community-acquired pneumonia, while continuing supportive care with paracetamol for fever management.

Assessment of Current Condition

Your child appears to have symptoms consistent with community-acquired pneumonia (CAP):

• Persistent fever (101°F/38.3°C) despite paracetamol
• Productive cough (though unable to expectorate)
• Right lung crackles on auscultation
• Recent exposure to infectious children
• Decreased appetite (accepting only breast milk, minimal solid food)
• Active when temperature decreases

Antibiotic Recommendations

First-line Treatment

• Amoxicillin 90 mg/kg/day divided into 2 doses 1
  • This is the recommended first-line treatment for children under 5 years with presumed pneumococcal pneumonia
  • Duration: 5-7 days for uncomplicated pneumonia 1

Alternative Options (if no improvement in 48-72 hours)

• Amoxicillin-clavulanate
• Consider macrolide (azithromycin) if atypical pneumonia is suspected 1

Supportive Care Recommendations

Fever Management

• Continue paracetamol (15 mg/kg/dose) every 4-6 hours as needed, not exceeding 4 doses in 24 hours 2
• Consider adding ibuprofen (10 mg/kg/dose) every 6-8 hours if fever persists, not exceeding 3 doses in 24 hours 2
  • Using both medications can provide longer fever-free periods (additional 2.5 hours over 24 hours) 2
  • If using both medications, carefully record all dose times to avoid exceeding maximum doses 2
• Continue tepid sponging as an adjunct to medication for fever management

Respiratory Support

• Ensure adequate hydration through continued breastfeeding
• Elevate the head of the bed to improve breathing comfort
• Maintain a humidified environment to help with cough

Nutrition

• Continue breastfeeding as the primary source of nutrition and hydration
• Offer small, frequent meals of easily digestible foods
• Prioritize hydration over solid food intake until fever resolves

Monitoring and Follow-up

Signs of Improvement (expect within 48-72 hours)

• Decreased fever
• Reduced respiratory rate
• Improved appetite
• Decreased cough
• Increased activity level

Warning Signs Requiring Immediate Medical Attention

• Oxygen saturation <92% or cyanosis
• Respiratory rate >50 breaths/minute
• Increased difficulty breathing or grunting
• Dehydration (dry mouth, decreased urination, no tears when crying)
• No improvement after 48 hours of antibiotic treatment 1

Medication Adjustments

Current Medications to Continue

• Paracetamol for fever management
• Nasal drops for nasal congestion

Medications to Consider Discontinuing

• Ranitidine (not indicated for respiratory infections)
• Ondansetron (unless actively vomiting)

Regarding Cough Syrup

• Most pediatric guidelines do not recommend routine use of cough suppressants in young children 1
• Focus on hydration and humidity instead

Regarding Antiviral Treatment (Fluvir)

• Oseltamivir (Fluvir) is only indicated if influenza is confirmed or strongly suspected
• Given the clinical presentation and physical findings suggesting bacterial pneumonia, oseltamivir is not recommended at this time

Conclusion

Monitor your child closely over the next 48-72 hours while implementing the recommended antibiotic therapy and supportive care. If there's no improvement within this timeframe or if any warning signs develop, seek immediate medical attention.