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Measles

Guideline to the management of measles in the paediatric patient

Assessment
Examination
Management
Criteria for Admission
Criteria for Discharge

Assessment

 Any Suspected Measles Case:

Remove from waiting room immediately and isolate the patient. Then triage the patient separately.

Measles is highly contagious.

It is a NOTIFIABLE disease.

REMEMBER TO NOTIFY ALL SUSPECTED MEASLES CASES TO: 
Ms C Jacobs 021-483-3156 (w) /072-3565146 (24hr) 
or 
Ms F Desai 021-483-4266 (w)/082-770-5419 (24hr)

IDENTIFY THE SUSPECT MEASLES CASE:

CLINICAL SUSPICION:

Maculopapular (Blotchy) Rash AND Pyrexia (>38) AND any of the 3 symptoms below:

  1. Cough
  2. Coryza
  3. Conjunctivitis/Photophobia

DIAGNOSTIC CRITERIA:

3-5 day prodrome with Fever >38, runny nose, cough, conjunctivitis

  • Koplik's spots (inner cheek surface - tiny white spots on a red background)
  • Rash begins on head/neck - pale and discrete becoming maculopapular then confluent
  • Rash fades after 3 days leaving temporary pigmentation

Complications: (Especially If fever persists longer than 3 days after onset of rash)

  • Pneumonia
  • Encephalitis
  • Mouth ulcers causing feeding difficulties
  • Severe diarrhoea
  • Corneal ulceration or bacterial conjunctivitis
  • Croup (LTB)
  • DMIST Handover from ambulance
  • Look for IMCI DANGER SIGNS and TRIAGE Patient using SATS
  • Measure and Record Vital Signs

Examination

  • Primary: Assess ABCDE's then Secondary Head to Toe Examination
  • Specifically for Measles:
    • IMCI Danger Signs:
      • Unable to drink or breastfeed OR vomiting everything
      • Rapid or noisy breathing or difficulty in breathing
      • Lethargy or change in the level of consciousness
  • Stigmata of RVD
  • Hydration Status
  • Signs of shock
  • Nutrition Status
  • Signs of Sepsis and Systemic search for any source of infection
  • Evidence of Complications

SAMPLE History

  • Signs/Symptoms: URTI. Onset of Rash, Drinking well?, Vomiting, Fever, Breathing Problems
  • Allergies
  • Medications
  • Past Medical History: RVD Status. Birth History, Growth, Immunisations (RTHC)
  • Events: Contacts

Investigations

  • PLEASE CONFIRM MEASLES DIAGNOSIS WITH URINE AND BLOOD TESTS
  • 2ml in 5ml red-top tube - send specimens to NICD labelled SUSPECTED MEASLES
  • Other investigations depend on acuity and presenting clinical picture: May need CXR/ABG

Management

Stabilise ABCDE's

  • Start Oxygen
  • Check Sugar: Treat if < 3 mmol/l with 5 ml/kg 10 % dextrose IV
  • Weigh child or estimate weight
  • Assess for shock
  • Start IV/IO Fluid boluses if shocked
  • 20 mg/kg IV N/S or Ringers (10 mg/kg if malnourished)

General Management of Measles

  • Antipyretics: Paracetamol 15 mg/kg PO 4-6 hourly
  • Vitamin A PO administer 2 doses to all children with suspected measles:
    • First dose immediately. Second dose after 24 hours.
    • Birth - 6 months: 50 000 units
    • 6 months - 1 year: 100 000 units
    • > 1 year: 200 000 units
  • No prophylactic antibiotics are indicated.

Management of Complications

Gastroenteritis: Follow standard gastroenteritis protocol

Pneumonia:

  • Treat depending on signs of severity: 
    1. Respiratory distress 
    2. O2 dependence 
    3. Focal signs on chest examination.
  • Mild (No signs of severity): Discharge on Amoxil 30mg/kg/dose 8 hrly for 5-10 days
  • Moderate (Some signs of severity): Admit. Oral Ab unless vomiting - then Ampicillin 50mg/kg/dose.
  • Add Gentamicin if < 3 months/HIV/Malnourished
  • Severe/Septic: Admit. Take B/C and FBC/CUE/CRP and CXR. IV Ampicillin/Gentamicin +/- Cloxacillin

Croup:

  • Admit. Keep comfortable on mother's lap.
  • No prednisone: Contraindicated in measles
  • Adrenaline nebs: 2ml adrenaline + 2 ml N/S
  • Ab if systemic infection suspected (T > 38; Toxic, Purulent sputum, Pneumonia)

Mouth Ulcers:

  • Admit if unable to drink. Otherwise D/C on paracetamol and mouth wash (Chlorhexidine or Glycothymol)

Conjunctivitis with Pus:

  • Paracetamol. Avoid light. Clean with boiled water. Chloramphenicol eye ointment to both eyes 6 hrly for 5 days

Otitis Media: 

  • Amoxil 30mg/kg/dose 8 hrly for 5 days

Suspected Encephalitis:

  • Admit. Supportive management.
  • LP to exclude bacterial meningitis (If no contraindications)
  • Cover with 75 mg/kg IV Ceftriaxone

Sepsis: 

  • Manage ABCDE's. IV Ceftriaxone 75mg/kg. Search for source

Criteria for Admission

  1. Any IMCI Danger Criteria
  2. Shocked or Septic
  3. Complications
  4. Poor Social Circumstances

Criteria for Discharge

No Criteria for Admission and Normal Vital Signs.

IF NEEDS AS TRANSFER, CONSULT PAEDIATRIC FLYING SQUAD CRITERIA.

On Discharge

  1. Prescribe Vitamin A
  2. Prevention: Measles Vaccine to all exposed
    • < 6 months: Intragam 0.2-0.25 ml/kg IM within 1 week of exposure
    • 6-8 months: Immunise. Next dose 9 months as usual at the clinic
    • 8-18 months: Immunise if no proof of 2 vaccines. Next dose18 months at clinic
  3. All adults in EC <25 and children within 1m of case should be immunised.

REMEMBER TO NOTIFY ALL SUSPECTED MEASLES CASES TO:

Ms C Jacobs 021-483-3156 (w) /072-3565146 (24hr) 
or
Ms F Desai 021-483-4266 (w)/082-770-5419 (24hr)

Drafted 2010; review January 2014. Ref: Tintinallis. Rosens Emergency Medicine. IMCI guidelines. Western Cape paediatric guidelines: Somerset and Tygerberg Hospitals

Drugs mentioned

NeoHealth® ID 18321 · updated 9/15/2021