What is the primary management for a child with measles?

Management of Measles in Children

The primary management of measles in children requires immediate isolation, vitamin A supplementation (200,000 IU for children ≥12 months or 100,000 IU for infants <12 months), urgent public health notification, and supportive care for complications. 1

Immediate Actions Upon Diagnosis

Isolation and Infection Control

• Isolate the child immediately for at least 4 days after rash onset, as measles remains contagious from 4 days before through 4 days after rash appearance. 1, 2
• Implement airborne precautions with N95 respirators for all healthcare personnel, regardless of immunity status. 1
• Contact local or state health department immediately—one confirmed measles case constitutes an urgent public health situation requiring prompt investigation. 3, 1

Diagnostic Confirmation

• Collect blood for measles-specific IgM antibody testing during the first clinical encounter, even before laboratory results return. 1
• If IgM is negative within the first 72 hours of rash onset, obtain a second specimen at least 72 hours after rash onset, as IgM may not be detectable early. 1
• Consider molecular characterization of measles virus from urine or nasopharyngeal specimens. 1

Essential Treatment Protocol

Vitamin A Supplementation (The Only Evidence-Based Mortality Reduction Intervention)

Vitamin A supplementation is the cornerstone of measles treatment and the only evidence-based intervention proven to reduce measles mortality. 1, 2

Standard Dosing

• Children ≥12 months: Administer 200,000 IU of vitamin A orally on day 1. 3, 1, 4
• Infants <12 months: Administer 100,000 IU of vitamin A orally on day 1. 3, 4
• Do not delay vitamin A supplementation—administer on day 1 of clinical encounter, as this directly impacts mortality. 1

Complicated Measles (Pneumonia, Otitis, Croup, Diarrhea with Dehydration, or Neurological Problems)

• Administer a second dose on day 2: 200,000 IU for children ≥12 months or 100,000 IU for infants <12 months. 3, 1, 4
• Two doses of vitamin A are associated with an 82% reduction in mortality risk in children under age 2 years and a 67% reduction in pneumonia-specific mortality. 5

Eye Symptoms of Vitamin A Deficiency (Xerosis, Bitot's Spots, Keratomalacia, Corneal Ulceration)

• Administer 200,000 IU (or 100,000 IU for infants <12 months) on day 1. 3, 2
• Administer second dose on day 2. 3, 2
• Administer third dose 1-4 weeks later. 3, 2

Evidence Quality Note

A Cochrane systematic review found that two doses of 200,000 IU vitamin A reduced overall mortality by 64% (RR=0.36; 95% CI 0.14 to 0.82), with greater effect in children under 2 years (82% reduction, RR=0.18; 95% CI 0.03 to 0.61). 5 Single-dose regimens showed no significant mortality benefit. 5

Management of Complications

Bacterial Superinfections

• Treat secondary bacterial infections with appropriate antibiotics, including acute lower respiratory infections and bacterial superinfections. 3, 1, 4
• A Cochrane review suggests antibiotics reduce the incidence of purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72) in children with measles. 6
• While the evidence is from older studies with poor methodology, antibiotics appear beneficial for preventing pneumonia and other bacterial complications. 6

Diarrhea

• Provide oral rehydration therapy for diarrhea. 3, 1, 4
• Vitamin A supplementation reduces the duration of diarrhea by approximately 2 days. 5

Nutritional Support

• Monitor nutritional status and enroll in feeding programs if indicated. 3, 1
• Undernutrition is not a contraindication for measles vaccination but rather a strong indication for vaccination. 3

Critical Long-Term Concern: Neurological Complications

Children who acquire measles before age 5 face elevated risk of subacute sclerosing panencephalitis (SSPE), a fatal degenerative neurological disease that can occur years after measles infection. 1

Measles can cause three separate encephalitic illnesses:

• Acute encephalitis or acute disseminated encephalomyelitis 1
• Subacute encephalopathy 1
• Subacute sclerosing panencephalitis (SSPE) 1

Post-Exposure Prophylaxis for Contacts

Measles Vaccine (Within 3 Days of Exposure)

• Measles vaccine may provide protection or modify disease severity if administered within 3 days of exposure. 3, 1
• For infants aged 6-11 months exposed during outbreaks, monovalent measles vaccine is preferred, but MMR may be used if monovalent is unavailable. 3
• Children vaccinated before 12 months must be revaccinated at 12-15 months and again before school entry. 3

Immune Globulin (IG) for High-Risk Contacts

• Immunocompromised persons: Administer IG 0.5 mL/kg (maximum 15 mL) as soon as possible after exposure, regardless of vaccination status. 1, 2
• Pregnant women: Administer IG 0.25 mL/kg (maximum 15 mL) within 6 days of exposure. 1, 2
• Infants <12 months who are household contacts: IG may be preferred over vaccine, as they are at highest risk for complications. 3
• Persons with contraindications to vaccination: Administer IG 0.25 mL/kg (maximum 15 mL) as soon as possible after exposure. 1

Common Pitfalls to Avoid

• Do not delay vitamin A supplementation waiting for laboratory confirmation—treatment should begin based on clinical diagnosis. 4
• Do not assume vaccination history provides complete protection—approximately 5% of children who receive only one dose of MMR vaccine fail to develop immunity. 1
• Do not use regular surgical masks instead of N95 respirators—measles is highly contagious through aerosols, requiring strict airborne precautions. 1, 2
• Do not stop isolation before 4 days after rash onset—premature discontinuation of isolation can lead to further transmission. 2
• Do not withhold vitamin A due to concerns about toxicity—the standard protocol is safe, as acute toxicity requires >300,000 IU in adults or >60,000 IU in children. 2
• Do not forget that fever, respiratory tract infection, and diarrhea are not contraindications for measles vaccination in outbreak settings. 3

Special Populations

Infants Under 6 Months

• Face particularly high mortality and complication risks because they are too young for routine measles vaccination. 4
• Maternal antibodies may have waned in infants born to vaccinated mothers, increasing their risk of severe complications. 4
• Administer 100,000 IU vitamin A on day 1, with a second dose of 100,000 IU on day 2 for complicated measles. 4

Outbreak Control in Day Care and Schools

• During outbreaks, revaccinate all attendees and siblings who have not received two doses of measles-containing vaccine. 3
• Facility personnel without acceptable evidence of immunity should be vaccinated with MMR. 3
• Persons exempted from vaccination for medical, religious, or other reasons should be excluded from involved institutions until 21 days after rash onset in the last case. 3