Revised WHO classification and treatment

of childhood pneumonia at health facilities

QUICK REFERENCE GUIDE
Pneumonia kills more children under CHANGE 1 CHANGE 2
the age of five years than any other RE-CLASSIFICATION TO TWO ORAL AMOXICILLIN REPLACES
disease. In 2013, it took the lives of CATEGORIES OF PNEUMONIA ORAL COTRIMOXAZOLE AS
over one million children around the FIRST-LINE TREATMENT OF
The two new classification categories
world, most in resource-poor settings. PNEUMONIA
WHO and UNICEF have developed the are:
n For children 2–59 months of age
integrated Global Action Plan for the n pneumonia* treated with oral
Treatment and Control of Pneumonia diagnosed with pneumonia and
amoxicillin and home care advice
and Diarrhoea (GAPPD) aimed at ending presenting “fast breathing” and “chest
preventable deaths from these two n severe pneumonia requiring indrawing” clinical signs, oral amoxicillin
major killers by 2025. The GAPPD gives injectable antibiotics. is the first line of treatment, delivered
guidance to governments to develop a on an outpatient basis.
* The classification “pneumonia”
plan to protect against, treat and control includes the previously classified ‘fast n Dosage: New guidance is available on
pneumonia and diarrhoea in young breathing’ pneumonia and ‘chest appropriate dosages of oral amoxicillin
children. indrawing’ pneumonia. They can per age of the child (see Table, over­
Currently, only 60% of child caregivers both be treated effectively with oral leaf). Amoxicillin is recommended for
seek appropriate care for suspected amoxicillin and home care advice (see use in a child-friendly dispersible tablet
pneumonia; proper antibiotic treatment Figure and Change 2). formulation that is dissolvable in breast
is given only in about one-third of milk or water, making it easy to swallow.
WHY THIS CHANGE? The tablets are also easier to distribute,
pneumonia cases.1
The new approach will: store and dispense than suspension
With the goal of getting appropriate forms.
treatment to more children, the WHO — simplify the management of
guidance for classifying and treating pneumonia at outpatient level WHY THIS CHANGE?
childhood pneumonia at the first- — reduce substantially the number of — Oral amoxicillin is the most effective
level health facility and outpatient referrals for hospitalization treatment for both fast breathing
department has been revised.2,3 and chest indrawing pneumonia.
— achieve better treatment outcomes.

FIGURE. Comparison of previous and revised classification and treatment of childhood pneumonia at health facility

Previous classification and treatment Availability Revised classification and treatment for
of new
of childhood pneumonia evidence
childhood pneumonia at health facility

Cough and cold:

Home care advice Cough and cold:
no pneumonia Home care advice
no pneumonia

Oral cotrimoxazole
Fast breathing: and home care Fast breathing and/
Child age pneumonia Child age Oral amoxicillin and
2–59 months advice 2–59 months or chest indrawing:
pneumonia home care advice
with cough with cough
and/or and/or
difficult Chest indrawing: difficult
severe pneumonia First dose
breathing breathing First dose
antibiotic and
General danger antibiotic and
referral to facility
General danger signs:† severe referral to facility
for injectable
signs:† severe pneumonia or very for injectable
antibiotic/
pneumonia or very severe disease antibiotic/
supportive therapy
severe disease supportive therapy

† Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition.

1 UNICEF. State of the World’s Children. UNICEF New York 2014.

2 Integrated Management of Childhood Illness (IMCI) (revised). Geneva, World Health Organization/The United Nation Children’s Fund
(UNICEF), 2014.
3 WHO. Recommendations for management of common childhood conditions: Evidence for technical update of pocket book
recommendations. Geneva, WHO, 2012. http://www.who.int/maternal_child_adolescent/documents/management_childhood_
conditions/en/index.html
TABLE. Doses of amoxicillin for children 2–59 months of age with pneumonia
CATEGORY OF DOSAGE OF AMOXICILLIN DISPERSIBLE
TOOLS AGE/WEIGHT OF CHILD
PNEUMONIA TABLETS (250 mg)

iCCM tool for community Fast breathing 2 months up to 12 months (4–<10 kg)  1 tab twice a day x 5 days (10 tabs)
health workers: no change pneumonia 12 months up to 5 years (10–19 kg) 2 tabs twice a day x 5 days (20 tabs)

Fast breathing 2 months up to 12 months (4–<10 kg) 1 tab twice a day x 5 days (10 tabs)
IMCI tool for professional
and chest
health workers at health 12 months up to 3 years (10–<14 kg) 2 tabs twice a day x 5 days (20 tabs)
indrawing
facilities: revised
pneumonia 3 years up to 5 years (14–19 kg) 3 tabs twice a day x 5 days (30 tabs)

TO NOTE
n An HIV positive child with chest ADVANTAGES OF REVISED WHO PNEUMONIA RECOMMENDATIONS
indrawing will still need to be referred n Increased access to antibiotic treatment closer to home
to the hospital for inpatient treatment. 4
n One oral antibiotic for the treatment of both fast breathing pneumonia and
n Guidance for community case chest indrawing pneumonia
management of pneumonia does not
n Decreased need for referrals to higher level facilities
change:
n Simplified pneumonia classification and management (two categories
—­ Community health workers (CHWs)
will continue to refer children with instead of three)
chest indrawing and/or general n Simplified training of health workers
danger signs to health facilities
where a higher level of care can be n Cost benefits at individual, household, community and health facility levels
provided. n Decreased probability of hospitalization and thus the risk of hospital-acquired
—­ CHWs will continue to dispense and injection-borne diseases
oral amoxicillin at existing dosages n Reduced probability of increasing antimicrobial resistance, due to better
for children 2 to 59 months of age adherence to simplified treatment
with fast breathing pneumonia as
indicated in the WHO/UNICEF iCCM
guidelines.5

CHANGES TO POLICY AND PRACTICE FOR PNEUMONIA TREATMENT

For further reading
n WHO recommends that national programmes switch to oral amoxicillin as
Pocket book of hospital care for children:
the first-line treatment for pneumonia and to the simplified two categories
Guidelines for the management of
for classification of pneumonia.
common illnesses. Second edition. Geneva:
World Health Organization; 2013. n National essential medicine lists will need revision to recommend oral
amoxicillin.
Revised WHO classification and treatment
of childhood pneumonia at health n In order to reap the full benefits of the new scientific evidence, further local
facilities. Evidence summaries. Geneva, adaptations will need to be carried out and health workers will need to be
World Health Organization, 2014. re-trained according to the new guidelines.

Revised WHO classification and

treatment of childhood pneumonia at
health facilities. Implications for policy
and implementation. World Health
Organization, 2014.

4 WHO recommendations on the For more information please contact:

management of diarrhoea and Department of Maternal, Newborn, Child and Adolescent Health (MCA)
pneumonia in HIV-infected infants World Health Organization
and children. Geneva: World Health 20 Avenue Appia, 1211 Geneva 27, Switzerland
Organization; 2010 (http://www.
who.int/maternal_child_adolescent/ Tel: + 41 22 791 32 81
documents/9789241548083/en) Fax: + 41 22 791 48 53
5 Caring for a sick child in the community. E-mail: [email protected]
Manual for community health workers. Website: http://www.who.int/maternal_child_adolescent
Geneva, World Health Organization/The
United Nation Children’s Fund (UNICEF),
2013. © World Health Organization 2014   WHO/FWC/MCA/14.9