What is the appropriate management for a 16‑month‑old child with measles presenting with two days of diarrhea, cough and upper‑respiratory symptoms?

Management of Measles in a 16-Month-Old Child with Diarrhea and Respiratory Symptoms

This child requires immediate vitamin A supplementation (100,000 IU orally on day 1 and a second 100,000 IU dose on day 2), supportive care with oral rehydration therapy for diarrhea, and close monitoring for signs of severe complications requiring hospitalization. 1

Immediate Vitamin A Supplementation Protocol

For this 16-month-old child with complicated measles (presenting with diarrhea and respiratory symptoms), administer 200,000 IU of oral vitamin A on day 1, followed by a second identical dose of 200,000 IU on day 2. 1, 2 The two-dose regimen is specifically indicated because this child has complications (diarrhea and cough), and this protocol reduces overall mortality by 64% and pneumonia-specific mortality by 67%. 3, 4

• Vitamin A is the only evidence-based intervention proven to reduce measles mortality in children, with an 82% mortality reduction in children under 2 years of age when given as two doses. 1, 3
• Do not delay vitamin A administration waiting for laboratory confirmation—treatment should begin based on clinical diagnosis. 1
• The standard dose for children ≥12 months is 200,000 IU (not 100,000 IU), provided the child has not received vitamin A in the preceding month. 2, 5

Management of Diarrhea

Initiate oral rehydration therapy (ORT) immediately for the diarrhea. 1, 2

• Assess hydration status carefully—if moderate to severe dehydration is present, this further justifies the two-dose vitamin A regimen. 2
• Vitamin A supplementation reduces the duration of diarrhea by approximately 2 days in measles patients. 3, 6
• Monitor nutritional status and consider enrollment in feeding programs if indicated. 2, 5

Management of Respiratory Symptoms (Cough and Colds)

Assess for signs of pneumonia or acute lower respiratory infection, which would require antibiotic therapy. 1, 2

• Look specifically for: markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs, or cyanosis. 7
• If pneumonia or bacterial superinfection is suspected, initiate standard antibiotic therapy according to local protocols. 1, 2
• Vitamin A reduces the incidence of croup by 47% and may reduce pneumonia-specific mortality. 3, 6

Criteria for Hospital Admission

Refer for immediate hospital assessment if any of the following danger signs develop: 7

• Respiratory distress: markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs 7
• Cyanosis 7
• Severe dehydration (from ongoing diarrhea) 7
• Altered conscious level 7
• Signs of septicemia: extreme pallor, hypotension, floppy infant 7

Infection Control Measures

Isolate the child immediately for at least 4 days after rash onset to prevent transmission. 1, 5

• The child is contagious from 4 days before rash onset through 4 days after rash onset. 2, 5
• Keep the child away from other children, especially unvaccinated infants and immunocompromised individuals. 5

Supportive Care

• Antipyretics: Use acetaminophen or ibuprofen for fever control (never aspirin in children under 16 years). 7, 2
• Fluids: Ensure adequate hydration, especially given the diarrhea. 7
• Nutritional monitoring: Assess and monitor nutritional status throughout the illness. 2

Critical Pitfalls to Avoid

• Do not use a single dose of vitamin A—the evidence shows that a single 200,000 IU dose is not associated with reduced mortality (RR 0.77), whereas two doses significantly reduce mortality (RR 0.36). 3, 4
• Do not withhold vitamin A due to concerns about toxicity—the standard two-dose protocol is safe, as acute toxicity requires >300,000 IU in adults or >60,000 IU in children within hours/days. 2
• Do not assume mild symptoms will remain mild—infants under 2 years face particularly high mortality and complication risks from measles. 1
• Do not forget to assess for bacterial superinfections—secondary bacterial pneumonia and otitis media are common complications requiring antibiotic therapy. 2

Follow-Up Considerations

• If eye symptoms develop (xerosis, Bitot's spots, keratomalacia, or corneal ulceration), administer a third dose of 200,000 IU vitamin A 1-4 weeks later. 2, 5
• In at-risk populations, continue routine vitamin A supplementation every 3 months after completing acute measles treatment. 1, 2