The treatment for fever or malaria is not based on classification of malaria risk. Therefore once you have classified for fever, the treatment is the same. The exception is where there is no malaria risk when you do not have to treat the child with an antimalarial drug.
Treatment for malaria is described in detail in Study Session 8 of Communicable Diseases, Part 1. All the drugs and dosages are listed there, including for children aged over 4 months, and adults.
6.4.1 Very severe febrile disease or severe malaria
A child with fever and any general danger sign or stiff neck may have meningitis, severe malaria (including cerebral malaria) or sepsis. It is not possible to distinguish between these severe diseases without laboratory tests.
A child classified as having very severe febrile disease needs urgent treatment and referral. Before referring urgently, you should give a dose of paracetamol if the child’s temperature is 38.5°C or above, and prevent low sugar by ensuring the child has food on the journey to hospital. You should administer artesunate rectally as indicated in Table 6.1 below.
Table 6.1 Rectal artesunate treatment for children (aged 0–5 years) and weighing at least 5 kg.
Artesunate dose (mg)
Regimen (single dose)
One 50 mg suppository
One 100 mg suppository
Two 100 mg suppositories
Plasmodium falciparum and Plasmodium vivax are the commonest species of malaria parasite in Ethiopia.
Treat a child over 4 months of age, classified as having P. falciparum malaria, with Coartem (or chloroquine if RDT confirms P. vivax malaria). You should give paracetamol if the child has a fever. If the fever has been present every day for more than seven days, you should refer the child for assessment.
6.4.3 Fever (no malaria)
If the child’s fever is high, give paracetamol. Advise the mother to return for a follow-up visit in two days if the child’s fever persists. If the fever has been present every day for more than seven days, then you should refer the child for assessment.
6.4.4 Follow-up care and treatment for fever or malaria
The follow-up care for high and low risk malaria is set out in Box 6.4. If the child’s fever persists after two days, or returns within 14 days of the initial classification, you should do a full re-assessment of the child. You should consider whether there are other causes of the fever.
Box 6.4 Follow-up care for malaria (low or high risk)
If the fever persists after two days, or returns within 14 days:
Do a full reassessment of the child.
Use the Assess and Classify chart.
Assess for other causes of fever.
If the child has any general danger sign or a stiff neck, treat as very severe febrile disease.
Ask if the child has actually been taking his antimalarial drugs. If he hasn’t, make sure that he takes it.
If the child has any cause of fever other than malaria, provide treatment.
If malaria is the only apparent cause of fever, refer the child to hospital.
6.5 Classifying measles
A child with fever and who has measles, or has had measles within the last three months, should be classified both for fever and for measles.
There are three possible classifications of measles:
Severe complicated measles
Measles with eye or mouth complications
6.5.1 Severe complicated measles
Children with measles may have other serious complications. A child with any general danger sign, clouding of the cornea or deep and extensive mouth ulcers will be classified as ‘severe complicated measles’.
6.5.2 Measles with eye or mouth complications
If the child has pus draining from the eye or mouth ulcers which are not deep or extensive, you should classify the child as having measles with eye or mouth complications. A child with this classification does not need referral.
All children with measles should receive a therapeutic dose of vitamin A.
A child with measles now or within the last three months and with none of the complications listed in the pink or yellow rows is classified as having measles. You should give the child a therapeutic dose of vitamin A to help prevent measles complications from developing. Table 6.2 summarises these classifications and also indicates what treatment should be provided according to the classification.
Table 6.2 Assess and classify table for measles.
You are now going to look at how you treat measles and associated complications.
6.6 Treatment of measles
6.6.1 Severe complicated measles
All children with severe complicated measles should receive urgent treatment and referral. Give the first dose of vitamin A to the child and an appropriate antibiotic and then refer the child urgently. If there is clouding of the cornea, or pus draining from the eye, apply eye ointment.
6.6.2 Measles with eye or mouth complications
Identifying and treating measles complications in infants and children in the early stages of the infection can prevent many deaths. As you read earlier, these children should be treated with vitamin A. It will help decrease the severity of the complications as well as correct any vitamin A deficiency. The mother should be taught how to treat the child’s eye infection or mouth ulcers at home.
Eye infections should be treated as follows:
If pus is still drainingfrom the eye, ask the mother to describe how she has treated the eye infection. If treatment has been given correctly, you should refer the child to hospital. If not, teach the mother the correct treatment; this may help to solve the problem.
If the pus is gone but redness remains, tell the mother to continue the treatment.
If no pus or redness, tell the mother she can stop the treatment.
Mouth ulcers should be treated with gentian violet twice daily as follows:
Clean the child’s mouth with a clean soft cloth wrapped around a clean stick or the end of a spoon and wet with salt water.
Paint the mouth with half strength gentian violet.
Wash hands again.
Treating mouth ulcers helps the child to resume normal feeding more quickly.
6.6.3 Follow-up care for measles with eye or mouth complications
You should give follow-up care to the child after two days: you should look for red eyes and/or pus draining from the eyes and you should check to see whether the child still has the mouth ulcers. If the child’s mouth ulcers are worse, or there is a very foul smell from the mouth, you should refer the child to hospital. If the mouth ulcers are the same or better, you should tell the mother that she must continue to use the gentian violet for a total of five days.
You are now going to do a short activity which will help you to understand the main points that you have covered in this study session.
Activity 6.2 Assess and classify fever (2)
Read Case Study 6.1 and then answer the questions below. You should either have a copy of the Assess and Classify chart to help you with this activity, or you could refer to the sections from the chart that are reproduced in this study session.
Case Study 6.1 Pawlos’s story
Pawlos is ten-months-old. He weighs 8.2 kg. His temperature is 37.5°C. His mother says he has a rash and cough.
The health worker checked Pawlos for general danger signs. Pawlos was able to drink, was not vomiting, did not have convulsions and was not lethargic or unconscious.
The health worker next asked about Pawlos’s cough. The mother said Pawlos had been coughing for five days. The health worker counted 43 breaths per minute. She did not see chest in-drawing nor hear stridor. Pawlos did not have diarrhoea.
The mother said Pawlos had felt hot for two days and that they lived in a high malaria risk area. Pawlos did not have a stiff neck. He has had a runny nose with this illness.
Pawlos had a rash covering his whole body. Pawlos’s eyes were red. The health worker checked the child for complications of measles. There were no mouth ulcers. There was no pus draining from the eye and no clouding of the cornea.
Does Pawlos have severe febrile disease? Write down your reasons for your answer.
What malaria classification would you record on Pawlos’s form and why?
How would you classify Pawlos’s measles? Write down reasons for your answer.
To help you understand the process of classification for Pawlos, we have set out below how the health worker classified Pawlos’s fever, using the table for classifying fever when there is a high malaria risk. (If you have your chart booklet with you, you should open it on page 24.)
First, the health worker checked to see if Pawlos had any of the signs in the pink row. She thought, ‘Does Pawlos have any general danger signs or a stiff neck? No, he does not. Pawlos does not have any signs of severe febrile disease.’
Next, the health worker looked at the yellow row. She thought, ‘Pawlos has a fever. His temperature measures 37.5°C. He also has a history of fever because his mother says Pawlos felt hot for two days. He is from a high malaria risk area’. She classified Pawlos as having malaria.
Because Pawlos had a generalised rash and red eyes, Pawlos has signs suggesting measles. To classify Pawlos’s measles, the health worker looked at the classification table for classifying measles.
She checked to see if Pawlos had any of the signs in the pink row. She thought, ‘Pawlos does not have any general danger signs. The child does not have clouding of the cornea. There are no deep or extensive mouth ulcers. Pawlos does not have severe complicated measles.’
Next the health worker looked at the yellow row. She thought, ‘Does Pawlos have any signs in the yellow row? He does not have pus draining from the eye. There are no mouth ulcers. Pawlos does not have measles with eye or mouth complications.’
Finally the health worker looked at the green row. Pawlos has measles, but he has no signs in the pink or yellow row. The health worker classified Pawlos as having measles.
End of discussion
In this study session you have learned about assessing fever in children. As you read earlier, fever may be caused by a serious illness such as malaria, measles or meningitis, and therefore it is critical that you are able to classify these conditions and ensure the sick child receives the correct treatment as quickly as possible.
Summary of Study Session 6
In Study Session 6, you have learned that:
Fever is a symptom of both simple and serious diseases.
Identifying serious disease is very important to prevent death among children.
To assess for fever you need to determine the malaria risk, ask about the duration of any fever, ask about and look for measles, look and check for signs of meningitis.
Malaria, measles and other severe febrile diseases like meningitis should be classified to give appropriate and prompt treatment.
Infants and children with severe febrile diseases and severe complicated measles should be referred urgently.
Malaria and measles with eye or mouth complications can be treated at the health post, while measles and fever with no malaria can be treated at home.
Self-Assessment Questions (SAQs) for Study Session 6
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the notes on the Self-Assessment Questions at the end of this Module.
SAQ 6.1 (tests Learning Outcomes 6.1 and 6.2)
If a child is brought to the health post with a fever, what would you need to do immediately and why?
You need to decide the cause of the fever: whether it is due to malaria, meningitis, measles, or another cause. This is because the treatment you give in each case will be different and may involve urgent referral.
End of answer
Read Case Study 6.2 and then answer the questions below.
Case Study 6.2 for SAQ 6.2
Abdi is three years old. He weighs 9.4 kg. He feels hot and has also had a cough for three days. Abdi is able to drink, has not vomited, has not had convulsions, and has not been lethargic or unconscious during the visit to the health post. His breathing rate is 51 a minute. The health worker did not see chest in-drawing or hear stridor when he is calm. Abdi does not have diarrhoea.
The mother says Abdi has felt hot for five days. The risk of malaria is high.
Abdi has not had measles within the last three months. He does not have a stiff neck; there is no runny nose, and no generalised rash.
SAQ 6.2 (tests Learning Outcomes 6.2 and 6.3)
What are the child’s signs?
How would you classify his illness?
You should have noted that the signs present in Abdi’s case are: fever, cough and fast breathing.
Therefore you should have classified his illness as pneumonia because he has cough and fast breathing. And malaria because he has fever and he is living in a high risk malaria area.
End of answer
Read Case Study 6.3 and answer the questions below.
Case Study 6.3 for SAQ 6.3
Lemlen is three years old. She weighs 10 kg. Her temperature is 38°C. She has been coughing for two days, has a generalised rash and has felt hot for three days. She is able to drink, has not been vomiting and does not have convulsions. She is not lethargic. The health worker counts 42 breaths per minute. There is no chest in-drawing or stridor when she is calm. She has no diarrhoea. She does not have a stiff neck or runny nose, or mouth ulcers or pus draining from the eye. There is no clouding of the cornea.
SAQ 6.3 (tests Learning Outcomes 6.1, 6.2, 6.3 and 6.4)
How would you classify Lemlen’s illness?
How would you treat her illness?
You should have classified Lemlem’s illness as pneumonia because she has a cough and fast breathing; and measles because she has fever, generalised rash and red eyes.