A child classified as having severe pneumonia or very severe disease is seriously ill. The child needs urgent referral to a hospital for treatments such as oxygen or injectable antibiotics.

If a child has been classified with severe pneumonia or a very severe disease you should give the child the first dose of Cotrimoxazole (see Table 4.2 in Section 4.3.2 below) before the child leaves your health post. The antibiotic helps prevent severe pneumonia from becoming worse.

Then refer the child urgently to the hospital.

Referring a child to the hospital

There are four steps you should follow when referring a child to the hospital:

1. Explain to the mother the need for referral, and get her agreement to take the child. If you suspect that she does not want to take the child, find out why. Possible reasons are:
   • She thinks that hospitals are places where people often die, and she fears that her child will die there too.
   • She does not think that the hospital will help her child.
   • She cannot leave home and tend to her child during a hospital stay because:

   −  there is no one to take care of her other children, or

   −  she is needed for farming, or

   −  she may lose a job.

   • She does not have money to pay for transportation, hospital bills, medicines or food for herself during the hospital stay.
2. Calm the mother’s fears and help her resolve any problem. For example:
   • If the mother fears that her child will die at the hospital, reassure her that the hospital has physicians, supplies and equipment that can help her child.
   • Explain what will happen at the hospital and how that will help her child.
   • If the mother needs help at home while she is at the hospital, ask questions and make suggestions about who could help. For example, ask whether her husband, sister or mother could help with the other children or with meals while she is away.
   • Discuss with the mother how she can travel to the hospital. Help arrange transportation if necessary.

   You may not be able to help the mother solve all her problems and/or be certain that she goes to the hospital. However, it is important to do everything you can to help. If referral is not possible, there are some things you can do for the child at your health post.

3. Write a referral note for the mother to take with her to the hospital. Tell her to give it to the nurse or doctor. In your referral note you should include the following information:
   • the name and age of the child
   • the date and time of referral
   • a description of the child’s problems
   • the reason for referral (the symptoms and signs leading to the severe classification)
   • treatments that you have given
   • any other information that the nurse or doctor at the hospital needs to know in order to care for the child, such as earlier treatment of the illness or immunizations needed
   • your name and the name of your health post.
4. Give the mother any supplies and instructions needed to care for her child on the way to the hospital.
   • If the hospital is far, give the mother additional doses of antibiotics and tell her when to give them to the child during the trip. If you think the mother will not actually go to the hospital, give her the full course of antibiotics, and teach her how to give them at home.
   • Show the mother how to keep the young child warm during the trip.
   • Advise the mother to continue breastfeeding.
   • If the child has some or severe dehydration and can drink, give the mother some oral rehydration solution (ORS) for the child to sip frequently on the way.