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Management of a Child with Measles Dr. Anil Mokashi. MD., DCH., FIAP, PhD. Measles is a disease associated with varied local customs and beliefs, which have a major influence on the management. Management of the CUSTOMS AND BELIEFS is at times more important than the drugs in measles. Harmless practices like a black thread around neck or a visit to temple can be allowed. We should discourage harmful practices like fomenting with hot bricks, instilling cows milk drops in nostrils and eyes, giving him a purge; all in an attempt to bring out the rash completely. Few customs could be encouraged for the benefit of the child e.g. applying oil all over the body or feeding rose jam, groundnuts, curds, black dried grapes. Every mother and grand mother will have different sets of beliefs. A doctor must know local customs and beliefs in that area for successful management of a child with measles. We will discuss the management under 4 headings A. Management in OPD B. Indications for hospitalization C. Management in hospital D. Follow up examination after measles A. Management in OPD: There is no drug available that can act on the measles viruses. Outcome of the disease depends largely on adequate nutrition, fluid intake, symptomatic therapy, early diagnosis and treatment of complications. 1. Fluid Intake: In a sick child fluid intake may be low. There is more evaporative loss due to fever and rapid respiratory rate. Fluid may be lost due to diarrhoea. All these factors in a child, who has only a loti-full of water in his body, make him prone for dehydration. Ensuring adequate fluid intake may be lifesaving. 2. Nutrition: Measles is severe in malnourished children. It is one of the most common infectious diseases precipitating malnutrition. Malnutrition is an important cause of death in measles. Nearly every child, who had measles, loses weight. Appetite is lost during any febrile illness. On the other hand more calories are needed. There is a tendency amongst families to restrict diet during measles. Breast milk is incorrectly stopped during diarrhoea after measles. Unless there is profuse diarrhoea; milk and routine diet is advocated. Adequate nutrition ensures smooth sailing. Diarrhoea: As diarrhoea in measles is directly due to viral infection of the G.I. tract, antibiotics are not going to be useful. Oral rehydration is the mainstay of treatment. Diarrhoea for more than 15 days may be due to lactose intolerance, where withdrawl of milk is necessary or due to secondary bacterial infection, when antibiotics will be curative. Continuing rice-dal-vegetable kanji and breast milk in any diarrhoea is an essential part of treatment. Antibiotics: In disease as severe as measles, it is difficult not to give antibiotics for a sick looking child. It is proved beyond doubts that antibiotics do not prevent bacterial infection. Still everybody of us is always tempted to give an antibiotic.

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Symptomatic Therapy: Paracetamol for fever, chloral hydrate for sedation, cough suppressive, skin lotion like caladryl to reduce itching, steam inhalation to soothen respiratory mucosa and prevention of exposure to bright light if child has photophobia are the symptomatic measures to be taken routinely. Some children develop constipation which may need a soap stick or liquid paraffin. Vitamin C may be given as it is supposed to prevent corneal complications. All children with measles have low vitamin A levels and one oral vitamin A dose ( Govt / inj aquasol given oraly) should be given. B. Indications for hospitalization: The most difficult and vital decision in management of measles is which child needs hospitalization. The guideline given is useful to select at risk children. Optimum care is needed to save these lives. 1. Rash : if there is darkening, desquammation in large plaques or haemorrhages in the rash. 2. Hoarseness of voice particularly if laryngeal obstruction is suspected. 3. Dehydration grade II or more 4. Blood and mucus in stools. 5. More than 10 stools in a day. 6. Convulsion or altered consciousness. 7. Respiratory distress with flaring of alae nasi. 8. Malnourished, underweight children. 9. Infant unable to suck due to soreness of mouth and tongue.

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10. Severe anemia. C. Management in hospital: Investigation: Laboratory and radiology can help the better Management. Investigations should be done for a specific purpose. A routine list of investigations. For every child with measles is unnecessary. Following are the indications and significance of each Diagnostic tool in management of measles. 1. Haemoglobin is done for (a) Pre-existing anemia (b) anemia during measles (bone marrow suppression) (c) anemia after measles (iron and vitamin deficiencies.) 2. 3. Total and differential W.B.C. counts to suspect and diagnose the cause of complications as bacterial. Increased total count with neutrophils suggests bacterial complications. ESR if done 1 month after measles can suggest the possibility of flare up of tuberculosis. A westergren reading of more than 50mm at the end of 1st hour should alert the doctor to search for further evidence of tuberculosis. Tuberculin test is often negative during and for 6 weeks after measles. A routine T.T. is done 6 weeks after in every case of measles at some centers. We should do T.T. if child has fever for more than 15 days duration after measles. C.S.F. examination is indicated if child has altered consciousness or convulsions.

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X-Ray chest during the attack of measles, X-Ray chest can show (a) bronchopnemonia or pneumonia following secondary bacterial infection. (b) Bronchilolitis diagnosed by the findings of emphysema, rhonchii and breathlessness. (c) Pre-existing tuberculosis, X-Ray chest 1 month after measles can suggest the flare up of tuberculosis. Treatment: As described above SYMPTOMATIC CARE is essential. In a child with respiratory distress, OXYGEN and suction of the oropharynx is the first step in bringing the disturbed physiology to normalcy. GENTION VIOLET application for soreness of mouth and tongue prevents fungal overgrowth. Codein is given to suppress the distressing hacking cough. INTRAVENOUS FLUIDS are required for correction of dehydration and for maintenance. Electrolyte imbalance can complicate the picture. Generally a second drip of polyelectrolyte solution like Isolyte or DLRP serves the purpose. Sodium bicarbonate is diluted and pushed I.V. if signs of acidosis like deep rapid respiration are noted. ANTIBIOTICS are given if child has bronchopneumonia, otitis media, pyoderma or diarrhoea after subsidance of the rash. Antibiotic therapy is tailored to suit the economic status of the parents. Omnatax, mikacin are good in hospitalised children. In poor patients penicillin injection or septran is the cheapest and best treatment. STEROIDS Is a double edged weapon in the management of measles. In an uncomplicated disease in initial stages steroids are harmful while in some complications they are life saving. In active phase of viremia steroids will suppress the immunological responses and the disease will be more severe. So steroids are contraindicated when rash is in active phase. If a child with measles has tuberculosis already, and is not on antitubercular drugs, steroids will surely flare up the tuberculosis. Steroids are indicated in encephalitis and toxemia with bronchopneumonia. Dexamethasone is preferred over other steroids. So steroids should be used more as a life saving measure than a routine measure in the management of measles. GAMMAGLOBULINS attenuate the severity of measles and are supposed to prevent complication. In a serious child it should be given. Even though the efficacy is not proved, it surely will not harm. Dose is 0.2 to 0.3 ml 10% gammaglobulin subcutaneous or IM injection. The maximum efficacy is observed if given within 5 days of exposure to measles. If the child has (1) anemia with HB less than 5 gm% (2) toxemia or septicemia (3) haemorrhagic complications, BLOOD TRANSFUSION many be needed. The dose is 20 ml/kg/day. Many times in seriously ill

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children, blood transfusion alters the picture. In case of respiratory distress with predominant rhonchiri, BRONCHODILATORS nebuliser, aminophylline 4 mg./kg/dose every 6-8 hourly helps in clearing the respiratory passage. LANOXIN is indicated in C.C.F. diagnosed by anxiety, heart rate above 200/minute, liver and spleeen palpable and mottled skin appearance. VITAMINS AND MINERALS are given if there is pre-existing deficiency and to meet the increased demands during illness. Vitamin C is supposed to be useful in corneal lesions. Vitamin A is given if skin complications arise. B Vitamins are given to ensure adequate marrow function which is suppressed by measles. Vitamins can be given in injectable form during hospital stay, or orally in the form of multivitamin C or AD drops. Adequate nutrition must be established. Concentrated glucose given I.V. does not supply adequate calories. 10 ml of 50% glucose will give hardly 20 calories. We have to give calories in thousands (1200 to 1500). If required ryles tube feeding is given for first 2-3 days. A doctor should not be much worried about child's digestive power. Cereals + pulses +fats + milk as semisolid paste (not liquid) is the most suitable food. This type of kanji meets the social, cultural, economic, nutritional requirements. A proper RECORD OF PROGRESS is valuable in evaluating therapy. As temperature, respiratory rate, number of stools settle down, it surely gives an indications to a successful outcome. If weight is recorded at admission and 15 days later, we can easily diagnose malnutrition at an earlier stage. D. Follow up Examination at 1 month After 1 month of illness child should be re-examined for 1) otitis media 2) chronic diarrhoea 3) weight loss or inadequate gain 4) flare up of tuberculosis 5) neurological signs & symptoms 6) pyoderma 7) residual respiratory complications 8) nutritional anemias.