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81
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Table 7.(?<=[.!?])\s+(?=[A-Z0-9])Classifi cation of the severity of pneumonia
Sign or symptom
Classifi cation
Treatment
Cough or diffi culty in
breathing with:
■ Oxygen saturation < 90%
or central cyanosis
■ Severe respiratory distress
(e.g. grunting, very severe
chest indrawing)
■ Signs of pneumonia with
a general danger sign
(inability to breastfeed or
drink, lethargy or reduced
level of consciousness,
convulsions)
Severe
pneumonia
– Admit to hospital.
– Give oxygen if saturation
< 90%.
– Manage airway as
appropriate.
– Give recommended
antibiotic.
– Treat high fever if
present.
■ Fast breathing:
– ≥ 50 breaths/min in a
child aged 2–11 months
– ≥ 40 breaths/min in a
child aged 1–5 years
■ Chest indrawing
Pneumonia
– Home care
– Give appropriate
antibiotic.
– Advise the mother when
to return immediately
if symptoms of severe
pneumonia.
– Follow up after 3 days.
■ No signs of pneumonia or
severe pneumonia
No
pneumonia:
cough or cold
– Home care
– Soothe the throat and
relieve cough with safe
remedy.
– Advise the mother when
to return.
– Follow up after 5 days if
not improving
– If coughing for more than
14 days, refer to chronic
cough (see p.(?<=[.!?])\s+(?=[A-Z0-9])109)
SEVERE PNEUMONIA | 105 | 200 | 0 | WHO-0001 | 1 | who_corpus.pdf | 344 |
82
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Investigations
■Measure oxygen saturation with pulse oximetry in all children suspected
of having pneumonia.
■If possible, obtain a chest X-ray to identify pleural effusion, empyema, pneu-
mothorax, pneumatocoele, interstitial pneumonia or pericardial effusion.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Admit the child to hospital.(?<=[.!?])\s+(?=[A-Z0-9])Oxygen therapy
Ensure continuous oxygen supply, either as cylinders or oxygen concentrator,
at all times.
Give oxygen to all children with oxygen saturation < 90%
Use nasal prongs as the preferred method of oxygen delivery to young
infants; if not available, a nasal or nasopharyngeal catheter may be used.(?<=[.!?])\s+(?=[A-Z0-9])The different methods of oxygen administration and diagrams showing their
use are given in section 10.7, p.(?<=[.!?])\s+(?=[A-Z0-9])312.
Use a pulse oximetry to guide oxygen therapy (to keep oxygen saturation
> 90%).(?<=[.!?])\s+(?=[A-Z0-9])If a pulse oximeter is not available, continue oxygen until the signs
of hypoxia (such as inability to breastfeed or breathing rate ≥ 70/min) are
no longer present.
Remove oxygen for a trial period each day for stable children while continuing
to use a pulse oximeter to determine oxygen saturation. | 106 | 201 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
Discontinue oxygen
if the saturation remains stable at > 90% (at least 15 min on room air).(?<=[.!?])\s+(?=[A-Z0-9])Nurses should check every 3 h that the nasal prongs are not blocked with mucus
and are in the correct place and that all connections are secure.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotic therapy
Give intravenous ampicillin (or benzylpenicillin) and gentamicin.
– Ampicillin 50 mg/kg or benzylpenicillin 50 000 U/kg IM or IV every 6 h
for at least 5 days
– Gentamicin 7.5 mg/kg IM or IV once a day for at least 5 days.
If the child does not show signs of improvement within 48 h and staphylococ-
cal pneumonia is suspected, switch to gentamicin 7.5 mg/kg IM or IV once
a day and cloxacillin 50 mg/kg IM or IV every 6 h (p.(?<=[.!?])\s+(?=[A-Z0-9])83).
Use ceftriaxone (80 mg/kg IM or IV once daily) in cases of failure of fi rst-
line treatment.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE PNEUMONIA | 106 | 202 | 1 | WHO-0001 | 1 | who_corpus.pdf | 295 |
83
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Supportive care
Remove by gentle suction any thick secretions at the entrance to the nasal
passages or throat, which the child cannot clear.
If the child has fever (≥ 39 °C or ≥ 102.2 °F) which appears to be causing
distress, give paracetamol.
If wheeze is present, give a rapid-acting bronchodilator (see p.(?<=[.!?])\s+(?=[A-Z0-9])98), and start
steroids when appropriate.
Ensure that the child receives daily maintenance fl uids appropriate for his
or her age (see section 10.2, p.(?<=[.!?])\s+(?=[A-Z0-9])304), but avoid over-hydration.
– Encourage breastfeeding and oral fl uids.
– If the child cannot drink, insert a nasogastric tube and give maintenance
fl uids in frequent small amounts.(?<=[.!?])\s+(?=[A-Z0-9])If the child is taking fl uids adequately by
mouth, do not use a nasogastric tube as it increases the risk for aspiration
pneumonia and obstructs part of the nasal airway.(?<=[.!?])\s+(?=[A-Z0-9])If oxygen is given by
nasal catheter at the same time as nasogastric fl uids, pass both tubes
through the same nostril.
Encourage the child to eat as soon as food can be taken.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
The child should be checked by a nurse at least every 3 h and by a doctor at
least twice a day. | 107 | 203 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Monitoring
The child should be checked by a nurse at least every 3 h and by a doctor at
least twice a day.(?<=[.!?])\s+(?=[A-Z0-9])In the absence of complications, within 2 days there should
be signs of improvement (breathing slower, less indrawing of the lower chest
wall, less fever, improved ability to eat and drink, better oxygen saturation).(?<=[.!?])\s+(?=[A-Z0-9])Other alternative diagnosis and treatment
■If the child has not improved after 2 days or if the child’s condition has wors-
ened, look for complications (see section 4.3) or alternative diagnoses.(?<=[.!?])\s+(?=[A-Z0-9])If
possible, obtain a chest X-ray.(?<=[.!?])\s+(?=[A-Z0-9])The commonest other possible diagnoses are:
Staphylococcal pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])This is suggested if there is rapid clinical deterio-
ration despite treatment, by a pneumatocoele or pneumothorax with effusion
on chest X-ray, numerous Gram-positive cocci in a smear of sputum or heavy
growth of S. aureus in cultured sputum or empyema fl uid.(?<=[.!?])\s+(?=[A-Z0-9])The presence of
septic skin pustules supports the diagnosis.
Treat with cloxacillin (50 mg/kg IM or IV every 6 h) and gentamicin (7.5 mg/
kg IM or IV once a day). | 107 | 204 | 1 | WHO-0001 | 1 | who_corpus.pdf | 388 |
When the child improves (after at least 7 days of
IV or IM antibiotics), continue cloxacillin orally four times a day for a total
course of 3 weeks.(?<=[.!?])\s+(?=[A-Z0-9])Note that cloxacillin can be replaced by another anti-
staphylococcal antibiotic, such as oxacillin, fl ucloxacillin or dicloxacillin.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE PNEUMONIA | 107 | 205 | 2 | WHO-0001 | 1 | who_corpus.pdf | 120 |
84
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Tuberculosis.(?<=[.!?])\s+(?=[A-Z0-9])A child with persistent cough and fever for more than 2 weeks
and signs of pneumonia after adequate antibiotic treatment should be evaluated
for TB.(?<=[.!?])\s+(?=[A-Z0-9])If another cause of the fever cannot be found, TB should be considered,
particularly in malnourished children.(?<=[.!?])\s+(?=[A-Z0-9])Further investigations and treatment
for TB, following national guidelines, may be initiated and response to anti-TB
treatment evaluated (see section 4.7.2, p.(?<=[.!?])\s+(?=[A-Z0-9])115).(?<=[.!?])\s+(?=[A-Z0-9])The HIV status of all children
suspected of having TB should be confi rmed if not known.(?<=[.!?])\s+(?=[A-Z0-9])HIV infection or exposure to HIV.(?<=[.!?])\s+(?=[A-Z0-9])Some aspects of antibiotic treatment are dif-
ferent for children who are HIV positive or in whom HIV infection is suspected. | 108 | 206 | 0 | WHO-0001 | 1 | who_corpus.pdf | 341 |
Some aspects of antibiotic treatment are dif-
ferent for children who are HIV positive or in whom HIV infection is suspected.(?<=[.!?])\s+(?=[A-Z0-9])Although pneumonia in many of these children has the same etiology as that
in children without HIV, Pneumocystis pneumonia (PCP), often at the age of
4–6 months (see section 8.4, p.(?<=[.!?])\s+(?=[A-Z0-9])244) is an important cause to be suspected
and treated.
Treat as for severe pneumonia above; give ampicillin plus gentamicin IM
or IV for 10 days.
If the child does not improve within 48 h, switch to ceftriaxone at 80 mg/kg
IV once daily over 30 min.(?<=[.!?])\s+(?=[A-Z0-9])If ceftriaxone is not available, give gentamicin
plus cloxacillin, as above.
For children < 12 months, also give high-dose co-trimoxazole (8 mg/kg
trimethoprim and 40 mg/kg sulfamethoxazole IV every 8 h or orally three
times a day) for 3 weeks.(?<=[.!?])\s+(?=[A-Z0-9])For a child aged 12–59 months, give this treat-
ment only if there are clinical signs of PCP (such as chest X-ray fi ndings of
interstitial pneumonia).
For further management of the child, including PCP prophylaxis, see Chapter
8, p.(?<=[.!?])\s+(?=[A-Z0-9])225). | 108 | 207 | 1 | WHO-0001 | 1 | who_corpus.pdf | 365 |
225).(?<=[.!?])\s+(?=[A-Z0-9])Discharge
Children with severe pneumonia can be discharged when:
•
Respiratory distress has resolved.
•
There is no hypoxaemia (oxygen saturation, > 90%).
•
They are feeding well.
•
They are able to take oral medication or have completed a course of par-
enteral antibiotics.
•
The parents understand the signs of pneumonia, risk factors and when
to return.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE PNEUMONIA | 108 | 208 | 2 | WHO-0001 | 1 | who_corpus.pdf | 127 |
85
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
SEVERE PNEUMONIA
Normal chest X-ray
Lobar pneumonia of the right lower zone
indicated by a consolidation (X-ray)
Staphylococcal pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])Typical
features include pneumatocoeles (right),
and an abscess with an air-fl uid level (left)
(X-ray).(?<=[.!?])\s+(?=[A-Z0-9])Pneumothorax.(?<=[.!?])\s+(?=[A-Z0-9])The right lung (left side
on image) is collapsed towards the hilus,
leaving a transparent margin without lung
structure.(?<=[.!?])\s+(?=[A-Z0-9])In contrast, the right side (normal)
demonstrates markings extending to the
periphery (X-ray).(?<=[.!?])\s+(?=[A-Z0-9])Hyperinfl ated chest.(?<=[.!?])\s+(?=[A-Z0-9])Features are an
increased transverse diameter, ribs running
more horizontally, a small contour of the
heart, and fl attened diaphragm (X-ray).(?<=[.!?])\s+(?=[A-Z0-9])Appearance of miliary tuberculosis:
widespread small patchy infi ltrates
throughout both lungs: “snow storm
appearance” (X-ray). | 109 | 209 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
86
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Follow-up
Children with severe pneumonia may cough for several weeks.(?<=[.!?])\s+(?=[A-Z0-9])As they have
been very sick, their nutrition is often poor.(?<=[.!?])\s+(?=[A-Z0-9])Give the vaccinations that are due,
and arrange follow-up 2 weeks after discharge, if possible, to check the child’s
nutrition.(?<=[.!?])\s+(?=[A-Z0-9])Also address risk factors such as malnutrition, indoor air pollution
and parental smoking.(?<=[.!?])\s+(?=[A-Z0-9])4.2.2 Pneumonia
Diagnosis
Cough or diffi cult breathing plus at least one of the following signs:
■fast breathing: age 2–11 months, ≥ 50/min
age 1–5 years,
≥ 40/min
■lower chest wall indrawing
In addition, either crackles or pleural rub may be present on chest auscultation.(?<=[.!?])\s+(?=[A-Z0-9])Check that there are no signs of severe pneumonia, such as:
– oxygen saturation < 90% on pulse oximetry or central cyanosis
– severe respiratory distress (e.g. grunting, very severe chest indrawing)
– inability to breastfeed or drink or vomiting everything
– convulsions, lethargy or reduced level of consciousness
– auscultatory fi ndings of decreased or bronchial breath sounds or signs
of pleural effusion or empyema. | 110 | 210 | 0 | WHO-0001 | 1 | who_corpus.pdf | 390 |
Treatment
Treat child as outpatient.
Advise carers to give normal fl uid requirements plus extra breast milk or
fl uids if there is a fever.(?<=[.!?])\s+(?=[A-Z0-9])Small frequent drinks are more likely to be taken
and less likely to be vomited
Antibiotic therapy
Give the fi rst dose at the clinic and teach the mother how to give the other
doses at home.
Give oral amoxicillin:
– In settings with high HIV infection rate, give oral amoxicillin at least
40 mg/kg per dose twice a day for 5 days.
– In areas with low HIV prevalence, give amoxicillin at least 40 mg/kg per
dose twice a day for 3 days.(?<=[.!?])\s+(?=[A-Z0-9])PNEUMONIA | 110 | 211 | 1 | WHO-0001 | 1 | who_corpus.pdf | 177 |
87
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Avoid unnecessary harmful medications such as remedies containing
atropine, codeine derivatives or alcohol.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Encourage the mother to feed the child.(?<=[.!?])\s+(?=[A-Z0-9])Advise her to bring the child back after
3 days, or earlier if the child becomes sicker or is unable to drink or breastfeed.(?<=[.!?])\s+(?=[A-Z0-9])When the child returns, check:
•
Whether the breathing has improved (slower), there is no chest indrawing,
less fever, and the child is eating better; complete the antibiotic treatment.
•
If the breathing rate and/or chest indrawing or fever and/or eating have not
improved, exclude a wheeze.(?<=[.!?])\s+(?=[A-Z0-9])If no wheeze, admit to hospital for investiga-
tions to exclude complications or alternative diagnosis.
•
If signs of severe pneumonia are present, admit the child to hospital and
treat as above.
•
Address risk factors such as malnutrition, indoor air pollution and parental
smoking.(?<=[.!?])\s+(?=[A-Z0-9])Pneumonia in children with HIV infection
Admit to hospital and manage as severe pneumonia (see section 4.2.1, p. | 111 | 212 | 0 | WHO-0001 | 1 | who_corpus.pdf | 362 |
Pneumonia in children with HIV infection
Admit to hospital and manage as severe pneumonia (see section 4.2.1, p.(?<=[.!?])\s+(?=[A-Z0-9])80).
For further management of these children, including PCP prophylaxis (see
Chapter 8, p.(?<=[.!?])\s+(?=[A-Z0-9])225).(?<=[.!?])\s+(?=[A-Z0-9])PNEUMONIA
Lower chest wall
indrawing: with
inspiration, the lower
chest wall moves in.
out
in
breathing | 111 | 213 | 1 | WHO-0001 | 1 | who_corpus.pdf | 146 |
88
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
4.3
Complications of pneumonia
Septicaemia is the most common pneumonia complication and occurs when
the bacteria causing pneumonia spreads into the bloodstream (see section 6.5,
p.(?<=[.!?])\s+(?=[A-Z0-9])179).(?<=[.!?])\s+(?=[A-Z0-9])The spread of bacteria can lead to septic shock or metastatic secondary
infections like meningitis especially in infants, peritonitis, and endocarditis
especially in patients with vulvar heart disease or septic arthritis.(?<=[.!?])\s+(?=[A-Z0-9])Other common
complication include pleural effusion, empyema and lung abscess.(?<=[.!?])\s+(?=[A-Z0-9])4.3.1
Pleural effusion and empyema
Diagnosis
A child with pneumonia may develop pleural effusion or empyema.
■On examination, the chest is dull to percussion, and breath sounds are
reduced or absent over the affected area.
■A pleural rub may be heard at an early stage before the effusion is fully
developed.
■A chest X-ray shows fl uid on one or both sides of the chest.
■When empyema is present, fever persists despite antibiotic therapy, and the
pleural fl uid is cloudy or frankly purulent.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Drainage
Pleural effusions should be drained, unless they are very small. | 112 | 214 | 0 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Treatment
Drainage
Pleural effusions should be drained, unless they are very small.(?<=[.!?])\s+(?=[A-Z0-9])If effusions
are present on both sides of the chest, drain both.(?<=[.!?])\s+(?=[A-Z0-9])It may be necessary to
repeat drainage two or three times if fl uid returns.(?<=[.!?])\s+(?=[A-Z0-9])See Annex A1.5, p.(?<=[.!?])\s+(?=[A-Z0-9])348,
for guidelines on chest drainage.(?<=[.!?])\s+(?=[A-Z0-9])Subsequent management depends on the character of the fl uid obtained.(?<=[.!?])\s+(?=[A-Z0-9])When
possible, pleural fl uid should be analysed for protein and glucose content,
cell count and differential count, and examined after Gram and Ziehl-Neelsen
staining and bacterial and Mycobacterium tuberculosis culture.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotic therapy
Give ampicillin or cloxacillin or fl ucloxacillin (50 mg/kg IM or IV every 6 h)
and gentamicin (7.5 mg/kg IM or IV once a day).(?<=[.!?])\s+(?=[A-Z0-9])When the child improves
(after at least 7 days of IV or IM antibiotics), continue cloxacillin orally four
times a day for a total course of 3 weeks. | 112 | 215 | 1 | WHO-0001 | 1 | who_corpus.pdf | 397 |
When the child improves
(after at least 7 days of IV or IM antibiotics), continue cloxacillin orally four
times a day for a total course of 3 weeks.(?<=[.!?])\s+(?=[A-Z0-9])Note: Cloxacillin is preferable if staphylococcal infection is suspected; it can be
replaced by another anti-staphylococcal antibiotic such as oxacillin, fl ucloxacillin
COMPLICATIONS OF PNEUMONIA | 112 | 216 | 2 | WHO-0001 | 1 | who_corpus.pdf | 97 |
89
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
or dicloxacillin.(?<=[.!?])\s+(?=[A-Z0-9])Infection with S. aureus is more likely if pneumatocoeles are
also present.(?<=[.!?])\s+(?=[A-Z0-9])Failure to improve
If fever and other signs of illness continue, despite adequate chest drainage
and antimicrobial therapy, test for HIV infection and assess for possible TB.
A trial of anti-TB therapy may be required (see section 4.7.2, p.(?<=[.!?])\s+(?=[A-Z0-9])115).(?<=[.!?])\s+(?=[A-Z0-9])4.3.2 Lung abscess
A lung abscess is a circumscribed, thick-walled cavity in the lung that contains
purulent material resulting from suppuration and necrosis of the involved lung
parenchyma.(?<=[.!?])\s+(?=[A-Z0-9])It frequently develops in an unresolved area of pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])This
could be a result of pulmonary aspiration, diminished clearance mechanisms,
embolic phenomena, or haematogenous spread. | 113 | 217 | 0 | WHO-0001 | 1 | who_corpus.pdf | 328 |
This
could be a result of pulmonary aspiration, diminished clearance mechanisms,
embolic phenomena, or haematogenous spread.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Common signs and symptoms:
■Fever
■Pleuritic chest pain
■Sputum production or haemoptysis
■Weight loss
■On examination: reduced chest movement, decreased breath sounds, dull-
ness to percussion, crackles, and bronchial breathing.
■Chest X-ray: solitary, thick-walled cavity in the lung with or without air
fl uid level.
■Ultrasonography and CT scan: to localize the lesion and guide drainage or
needle aspiration.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
The choice of antibiotic is usually empirical and is based on the underlying
condition of the patient and the presumed etiological agent.
Give ampicillin or cloxacillin or fl ucloxacillin (50 mg/kg IM or IV every 6 h)
and gentamicin (7.5 mg/kg IM or IV once a day).(?<=[.!?])\s+(?=[A-Z0-9])Continue treatment as in
empyema (see section 4.3.1) for up to 3 weeks.
Surgical management is considered in cases of large lung abscess espe-
cially when associated with haemoptysis or clinical deterioration despite
LUNG ABSCESS | 113 | 218 | 1 | WHO-0001 | 1 | who_corpus.pdf | 312 |
90
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
appropriate antibiotic therapy.(?<=[.!?])\s+(?=[A-Z0-9])Drainage is usually through percutaneous
tube drainage or ultrasound guided needle aspiration.(?<=[.!?])\s+(?=[A-Z0-9])4.3.3 Pneumothorax
Pneumothorax is usually secondary to an accumulation of air in the pleural
spaces from alveolar rupture or from infection with gas-producing microor-
ganisms.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
■Signs and symptoms may vary according to the extent of lung collapse,
degree of intrapleural pressure, and rapidity of onset.
■On examination: chest bulging on the affected side if one side is involved,
shift of cardiac impulse away from the site of the pneumothorax, decreased
breath sounds on the affected side, grunting, severe respiratory distress and
cyanosis may occur late in the progression of the complication.
■Differential diagnosis include lung cyst, lobar emphysema, bullae, dia-
phragmatic hernia
■Chest X-ray is crucial in the confi rmation of diagnosis.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Insert needle for urgent decompression, before insertion of an intercostal
chest drain.(?<=[.!?])\s+(?=[A-Z0-9])See Annex A1.5, p.(?<=[.!?])\s+(?=[A-Z0-9])348, for guidelines on chest drainage. | 114 | 219 | 0 | WHO-0001 | 1 | who_corpus.pdf | 389 |
348, for guidelines on chest drainage.(?<=[.!?])\s+(?=[A-Z0-9])4.4
Cough or cold
These are common, self-limited viral infections that require only supportive
care.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotics should not be given.(?<=[.!?])\s+(?=[A-Z0-9])Wheeze or stridor may occur in some
children, especially infants.(?<=[.!?])\s+(?=[A-Z0-9])Most episodes end within 14 days.(?<=[.!?])\s+(?=[A-Z0-9])Cough lasting
14 days or more may be caused by TB, asthma, pertussis or symptomatic HIV
infection (see Chapter 8, p.(?<=[.!?])\s+(?=[A-Z0-9])225).(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Common features:
■cough
■nasal discharge
■mouth breathing
■fever
COUGH OR COLD | 114 | 220 | 1 | WHO-0001 | 1 | who_corpus.pdf | 282 |
91
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
The following are absent:
– general danger signs.
– signs of severe pneumonia or pneumonia
– stridor when the child is calm
Wheezing may occur in young children (see below).(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Treat the child as an outpatient.
Soothe the throat and relieve the cough with a safe remedy, such as a warm,
sweet drink.
Relieve high fever (≥ 39 °C or ≥ 102.2 °F) with paracetamol if the fever is
causing distress to the child.
Clear secretions from the child’s nose before feeds with a cloth soaked in
water that has been twisted to form a pointed wick.(?<=[.!?])\s+(?=[A-Z0-9])Give normal fl uid requirements plus extra breast milk or fl uids if there is fever.(?<=[.!?])\s+(?=[A-Z0-9])Small frequent drinks are more likely to be taken and less likely to be vomited.
Do not give any of the following:
– an antibiotic (they are not effective and do not prevent pneumonia)
– remedies containing atropine, codeine or codeine derivatives, or alcohol
(these may be harmful) or mucolytics
– medicated nose drops.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Advise the mother to:
•
feed the child
•
watch for fast or diffi cult breathing and return if either develops
•
return if the child becomes sicker or is unable to drink or breastfeed. | 115 | 221 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
4.5
Conditions presenting with wheeze
Wheeze is a high-pitched whistling sound on expiration.(?<=[.!?])\s+(?=[A-Z0-9])It is caused by spas-
modic narrowing of the distal airway.(?<=[.!?])\s+(?=[A-Z0-9])To hear a wheeze, even in mild cases,
place your ear next to the child’s mouth and listen to the breathing while the
child is calm, or use a stethoscope.(?<=[.!?])\s+(?=[A-Z0-9])In the fi rst 2 years of life, wheezing is most commonly caused by acute viral
respiratory infections such as bronchiolitis or coughs and colds.(?<=[.!?])\s+(?=[A-Z0-9])After 2 years
CONDITIONS PRESENTING WITH WHEEZE | 115 | 222 | 1 | WHO-0001 | 1 | who_corpus.pdf | 217 |
92
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
CONDITIONS PRESENTING WITH WHEEZE
of age, most wheezing is due to asthma (Table 8, p.(?<=[.!?])\s+(?=[A-Z0-9])93).(?<=[.!?])\s+(?=[A-Z0-9])Some children with
pneumonia present with wheeze.(?<=[.!?])\s+(?=[A-Z0-9])It is important always to consider treatment
for pneumonia, particularly in the fi rst 2 years of life.(?<=[.!?])\s+(?=[A-Z0-9])Children with wheeze but
no fever, chest indrawing or danger signs are unlikely to have pneumonia and
should therefore not be given antibiotics.(?<=[.!?])\s+(?=[A-Z0-9])History
■previous episodes of wheeze
■night-time or early morning shortness of breath, cough or wheeze
■response to bronchodilators
■asthma diagnosis or long-term treatment for asthma
■family history of allergy or asthma
Examination
■wheezing on expiration
■prolonged expiration
■resonant percussion note
■hyperinfl ated chest
■rhonchi on auscultation
■shortness of breath at rest or on exertion
■lower chest wall indrawing if severe. | 116 | 223 | 0 | WHO-0001 | 1 | who_corpus.pdf | 348 |
Response to rapid-acting bronchodilator
If the cause of the wheeze is not clear or if the child has fast breathing or
chest indrawing in addition to wheeze, give a rapid-acting bronchodilator
and assess after 15 min.(?<=[.!?])\s+(?=[A-Z0-9])The response to a rapid-acting bronchodilator helps
to determine the underlying diagnosis and treatment.
Give the rapid-acting bronchodilator by one of the following methods:
– nebulized salbutamol
– salbutamol by a metered dose inhaler with spacer device
– if neither of the above methods is available, give a subcutaneous injec-
tion of adrenaline.(?<=[.!?])\s+(?=[A-Z0-9])For details of administering the above, see pp.(?<=[.!?])\s+(?=[A-Z0-9])98–99.
■Assess the response after 15 min.(?<=[.!?])\s+(?=[A-Z0-9])Signs of improvement are:
– less respiratory distress (easier breathing) | 116 | 224 | 1 | WHO-0001 | 1 | who_corpus.pdf | 259 |
93
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
CONDITIONS PRESENTING WITH WHEEZE
Table 8.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with wheeze
Diagnosis
In favour
Asthma
– History of recurrent wheeze, chest tightness, some
unrelated to coughs and colds or induced by exercise
– Hyperinfl ation of the chest
– Prolonged expiration
– Reduced air entry (if very severe, airway obstruction)
– Good response to bronchodilators, unless very severe
Bronchiolitis
– First episode of wheeze in a child aged < 2 years
– Wheeze episode at time of seasonal bronchiolitis
– Hyperinfl ation of the chest
– Prolonged expiration
– Reduced air entry (if very severe, airway obstruction)
– Poor or no response to bronchodilators
– Apnoea in young infants, especially if born preterm
Wheeze
associated with
cough or cold
– Wheeze always related to coughs and colds
– No family or personal history of asthma, eczema,
hay-fever
– Prolonged expiration
– Reduced air entry (if very severe, airway obstruction)
– Good response to bronchodilators
– Tends to be less severe than wheeze associated with
asthma
Foreign body
– History of sudden onset of choking or wheezing
– Wheeze may be unilateral
– Air trapping with hyper-resonance and mediastinal shift
– Signs of lung collapse: reduced air entry and impaired
breathing
– No response to bronchodilators
Pneumonia
– Fever
– Coarse crackles
– Grunting | 117 | 225 | 0 | WHO-0001 | 1 | who_corpus.pdf | 324 |
94
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
– less lower chest wall indrawing
– improved air entry.
Children who still have signs of hypoxia (central cyanosis, low oxygen
saturation ≤ 90%, unable to drink due to respiratory distress, severe lower
chest wall indrawing) or have fast breathing should be given a second dose
of bronchodilator and admitted to hospital for further treatment.(?<=[.!?])\s+(?=[A-Z0-9])4.5.1
Bronchiolitis
Bronchiolitis is a lower respiratory viral infection, which is typically most
severe in young infants, occurs in annual epidemics and is characterized by
airways obstruction and wheezing.(?<=[.!?])\s+(?=[A-Z0-9])It is most commonly caused by respiratory
syncytial virus.(?<=[.!?])\s+(?=[A-Z0-9])Secondary bacterial infection may occur.(?<=[.!?])\s+(?=[A-Z0-9])The management of
bronchiolitis associated with fast breathing or other sign of respiratory distress
is therefore similar to that of pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])Episodes of wheeze may occur for
months after an attack of bronchiolitis, but will eventually stop. | 118 | 226 | 0 | WHO-0001 | 1 | who_corpus.pdf | 322 |
Episodes of wheeze may occur for
months after an attack of bronchiolitis, but will eventually stop.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Typical features of bronchiolitis, on examination, include:
■wheezing that is not relieved by up to three doses of a rapid-acting bron-
chodilator
■hyperinfl ation of the chest, with increased resonance to percussion
■lower chest wall indrawing
■fi ne crackles and wheeze on auscultation of the chest
■diffi culty in feeding, breastfeeding or drinking owing to respiratory distress
■nasal discharge, which can cause severe nasal obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Most children can be treated at home, but those with the following signs of
severe pneumonia (see section 4.2.1) should be treated in hospital:
■oxygen saturation < 90% or central cyanosis.
■apnoea or history of apnoea
■inability to breastfeed or drink, or vomiting everything
■convulsions, lethargy or unconsciousness
■gasping and grunting (especially in young infants).(?<=[.!?])\s+(?=[A-Z0-9])BRONCHIOLITIS | 118 | 227 | 1 | WHO-0001 | 1 | who_corpus.pdf | 293 |
95
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
BRONCHIOLITIS
Oxygen
Give oxygen to all children with severe respiratory distress or oxygen satu-
ration ≤ 90% (see section 4.2.1).(?<=[.!?])\s+(?=[A-Z0-9])The recommended method for delivering
oxygen is by nasal prongs or a nasal catheter (see p.(?<=[.!?])\s+(?=[A-Z0-9])312).
The nurse should check, every 3 h, that the prongs are in the correct position
and not blocked with mucus, and that all connections are secure.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotic treatment
If the infant is treated at home, give amoxicillin (40 mg/kg twice a day) orally
for 5 days only if the child has signs of pneumonia (fast breathing and lower
chest wall indrawing).
If there are signs of severe pneumonia, give ampicillin at 50 mg/kg or
benzylpenicillin at 50 000 U/kg IM or IV every 6 h for at least 5 days and
gentamicin 7.5 mg/kg IM or IV once a day for at least 5 days (see p.(?<=[.!?])\s+(?=[A-Z0-9])82). | 119 | 228 | 0 | WHO-0001 | 1 | who_corpus.pdf | 321 |
82).(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
If the child has fever (≥ 39 °C or ≥ 102.2 °F) that appears to be causing
distress, give paracetamol.
Ensure that the hospitalized child receives daily maintenance fl uids appropri-
ate for age (see section 10.2, p.(?<=[.!?])\s+(?=[A-Z0-9])304), but avoid overhydration.(?<=[.!?])\s+(?=[A-Z0-9])Encourage
breastfeeding and oral fl uids.
Encourage the child to eat as soon as food can be taken.(?<=[.!?])\s+(?=[A-Z0-9])Nasogastric feeding
should be considered in any patient who is unable to maintain oral intake or
hydration (expressed breast milk is the best).
Gentle nasal suction should be used to clear secretions in infants where
nasal blockage appears to be causing respiratory distress.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
A hospitalized child should be assessed by a nurse every 6 h (or every 3 h
if there are signs of very severe illness) and by a doctor at least once a day.(?<=[.!?])\s+(?=[A-Z0-9])Monitor oxygen therapy as described on p.(?<=[.!?])\s+(?=[A-Z0-9])314. | 119 | 229 | 1 | WHO-0001 | 1 | who_corpus.pdf | 359 |
Monitor oxygen therapy as described on p.(?<=[.!?])\s+(?=[A-Z0-9])314.(?<=[.!?])\s+(?=[A-Z0-9])Watch for signs of respiratory
failure, i.e. increasing hypoxia and respiratory distress leading to exhaustion.(?<=[.!?])\s+(?=[A-Z0-9])Complications
If the child fails to respond to oxygen therapy or the child’s condition worsens
suddenly, obtain a chest X-ray to look for evidence of pneumothorax.(?<=[.!?])\s+(?=[A-Z0-9])Tension pneumothorax associated with severe respiratory distress and shift of
the heart requires immediate relief by placing a needle to allow the air that is | 119 | 230 | 2 | WHO-0001 | 1 | who_corpus.pdf | 189 |
96
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
under pressure to escape (needle thoracocentesis).(?<=[.!?])\s+(?=[A-Z0-9])Following this, a continuous
air exit should be assured by inserting a chest tube with an underwater seal until
the air leak closes spontaneously and the lung expands (see Annex A1.5, p.(?<=[.!?])\s+(?=[A-Z0-9])348).(?<=[.!?])\s+(?=[A-Z0-9])If respiratory failure develops, continuous positive airway pressure may be
helpful.(?<=[.!?])\s+(?=[A-Z0-9])Infection control
Bronchiolitis is very infectious and dangerous to other young children in hospital
with other conditions.(?<=[.!?])\s+(?=[A-Z0-9])The following strategies may reduce cross-infection:
■hand-washing by personnel between patients
■ideally isolate the child, but maintain close observation
■during epidemics, restrict visits to children by parents and siblings with
symptoms of upper respiratory tract infection.(?<=[.!?])\s+(?=[A-Z0-9])Discharge
An infant with bronchiolitis can be discharged when respiratory distress and hy-
poxaemia have resolved, when there is no apnoea and the infant is feeding well.(?<=[.!?])\s+(?=[A-Z0-9])Infants are at risk for recurrent bronchiolitis if they live in families where adults
smoke or if they are not breastfed. | 120 | 231 | 0 | WHO-0001 | 1 | who_corpus.pdf | 399 |
Infants are at risk for recurrent bronchiolitis if they live in families where adults
smoke or if they are not breastfed.(?<=[.!?])\s+(?=[A-Z0-9])So, advise the parents against smoking.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Infants with bronchiolitis may have cough and wheeze for up to 3 weeks.(?<=[.!?])\s+(?=[A-Z0-9])As
long as they are well with no respiratory distress, fever or apnoea and are
feeding well they do not need antibiotics.(?<=[.!?])\s+(?=[A-Z0-9])4.5.2 Asthma
Asthma is a chronic infl ammatory condition with reversible airways obstruc-
tion.(?<=[.!?])\s+(?=[A-Z0-9])It is characterized by recurrent episodes of wheezing, often with cough,
which respond to treatment with bronchodilators and anti-infl ammatory drugs.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotics should be given only when there are signs of pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
History of recurrent episodes of wheezing, often with cough, diffi culty in
breathing and tightness in the chest, particularly if these are frequent and
recurrent or are worse at night and in the early morning. Findings on examina-
tion may include:
■rapid or increasing respiratory rate
■hyperinfl ation of the chest
ASTHMA | 120 | 232 | 1 | WHO-0001 | 1 | who_corpus.pdf | 391 |
97
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
■hypoxia (oxygen saturation ≤ 90%)
■lower chest wall indrawing
■use of accessory muscles for respiration (best noted by feeling the neck
muscles)
■prolonged expiration with audible wheeze
■reduced or no air intake when obstruction is life-threatening
■absence of fever
■good response to treatment with a bronchodilator.(?<=[.!?])\s+(?=[A-Z0-9])If the diagnosis is uncertain, give a dose of a rapid-acting bronchodilator (see
salbutamol, p.(?<=[.!?])\s+(?=[A-Z0-9])98).(?<=[.!?])\s+(?=[A-Z0-9])A child with asthma will often improve rapidly with such
treatment, showing signs such as slower respiratory rate, less chest wall in-
drawing and less respiratory distress.(?<=[.!?])\s+(?=[A-Z0-9])A child with severe asthma may require
several doses in quick succession before a response is seen (see below).(?<=[.!?])\s+(?=[A-Z0-9])Treatment
A child with a fi rst episode of wheezing and no respiratory distress can
usually be managed at home with supportive care. | 121 | 233 | 0 | WHO-0001 | 1 | who_corpus.pdf | 336 |
Treatment
A child with a fi rst episode of wheezing and no respiratory distress can
usually be managed at home with supportive care.(?<=[.!?])\s+(?=[A-Z0-9])A bronchodilator is not
necessary.
If the child is in respiratory distress (acute severe asthma) or has recur-
rent wheezing, give salbutamol by metered-dose inhaler and spacer device
or, if not available, by nebulizer (see below for details).(?<=[.!?])\s+(?=[A-Z0-9])If salbutamol is not
available, give subcutaneous adrenaline.
Reassess the child after 15 min to determine subsequent treatment:
– If respiratory distress has resolved, and the child does not have fast
breathing, advise the mother on home care with inhaled salbutamol from
a metered dose inhaler and spacer device (which can be made locally
from plastic bottles).
– If respiratory distress persists, admit to hospital and treat with oxygen,
rapid-acting bronchodilators and other drugs, as described below.(?<=[.!?])\s+(?=[A-Z0-9])Severe life-threatening asthma
If the child has life-threatening acute asthma, is in severe respiratory distress
with central cyanosis or reduced oxygen saturation ≤ 90%, has poor air entry
(silent chest), is unable to drink or speak or is exhausted and confused, admit
to hospital and treat with oxygen, rapid-acting bronchodilators and other
drugs, as described below.(?<=[.!?])\s+(?=[A-Z0-9])ASTHMA | 121 | 234 | 1 | WHO-0001 | 1 | who_corpus.pdf | 362 |
98
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
In children admitted to hospital, promptly give oxygen, a rapid-acting
bronchodilator and a fi rst dose of steroids.(?<=[.!?])\s+(?=[A-Z0-9])Oxygen
Give oxygen to keep oxygen saturation > 95% in all children with asthma
who are cyanosed (oxygen saturation ≤ 90%) or whose diffi culty in breathing
interferes with talking, eating or breastfeeding.(?<=[.!?])\s+(?=[A-Z0-9])Rapid-acting bronchodilators
Give the child a rapid-acting bronchodilator, such as nebulized salbutamol
or salbutamol by metered-dose inhaler with a spacer device.(?<=[.!?])\s+(?=[A-Z0-9])If salbutamol
is not available, give subcutaneous adrenaline, as described below.(?<=[.!?])\s+(?=[A-Z0-9])Nebulized salbutamol
The driving source for the nebulizer must deliver at least 6–9 litres/min.(?<=[.!?])\s+(?=[A-Z0-9])Rec-
ommended methods are an air compressor, ultrasonic nebulizer or oxygen
cylinder, but in severe or life-threatening asthma oxygen must be used.(?<=[.!?])\s+(?=[A-Z0-9])If these
are not available, use an inhaler and spacer. | 122 | 235 | 0 | WHO-0001 | 1 | who_corpus.pdf | 371 |
If these
are not available, use an inhaler and spacer.(?<=[.!?])\s+(?=[A-Z0-9])An easy-to-operate foot pump may
be used but is less effective.
Put the dose of the bronchodilator solution in the nebulizer compartment,
add 2–4 ml of sterile saline and nebulize the child until the liquid is almost
all used up.(?<=[.!?])\s+(?=[A-Z0-9])The dose of salbutamol is 2.5 mg (i.e.(?<=[.!?])\s+(?=[A-Z0-9])0.5 ml of the 5 mg/ml
nebulizer solution).
If the response to treatment is poor, give salbutamol more frequently.
In severe or life-threatening asthma, when a child cannot speak, is hypoxic or
tiring with lowered consciousness, give continuous back-to-back nebulizers
until the child improves, while setting up an IV cannula.(?<=[.!?])\s+(?=[A-Z0-9])As asthma improves,
a nebulizer can be given every 4 h and then every 6–8 h.(?<=[.!?])\s+(?=[A-Z0-9])Giving salbutamol by metered-dose inhaler with a spacer device
Spacer devices with a volume of 750 ml are commercially available.
Introduce two puffs (200 µg) into the spacer chamber.(?<=[.!?])\s+(?=[A-Z0-9])Then, place the child’s
mouth over the opening in the spacer and allow normal breathing for three to
fi ve breaths. | 122 | 236 | 1 | WHO-0001 | 1 | who_corpus.pdf | 392 |
Then, place the child’s
mouth over the opening in the spacer and allow normal breathing for three to
fi ve breaths.(?<=[.!?])\s+(?=[A-Z0-9])This can be repeated in rapid succession until six puffs of the
drug have been given to a child < 5 years, 12 puffs for > 5 years of age.(?<=[.!?])\s+(?=[A-Z0-9])After
6 or 12 puffs, depending on age, assess the response and repeat regularly
until the child’s condition improves.(?<=[.!?])\s+(?=[A-Z0-9])In severe cases, 6 or 12 puffs can be
given several times an hour for a short period.(?<=[.!?])\s+(?=[A-Z0-9])ASTHMA | 122 | 237 | 2 | WHO-0001 | 1 | who_corpus.pdf | 207 |
99
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Some infants and young children
cooperate better when a face
mask is attached to the spacer
instead of the mouthpiece.(?<=[.!?])\s+(?=[A-Z0-9])If commercial devices are not
available, a spacer device can be
made from a plastic cup or a 1-
litre plastic bottle.(?<=[.!?])\s+(?=[A-Z0-9])These deliver
three to four puffs of salbutamol,
and the child should breathe from
the device for up to 30 s.(?<=[.!?])\s+(?=[A-Z0-9])Subcutaneous adrenaline
If the above two methods of
delivering salbutamol are not
available, give a subcutaneous
injection of adrenaline at 0.01
ml/kg of 1:1000 solution (up to
a maximum of 0.3 ml), meas-
ured accurately with a 1-ml sy-
ringe (for injection technique,
see p.(?<=[.!?])\s+(?=[A-Z0-9])336).(?<=[.!?])\s+(?=[A-Z0-9])If there is no improvement after 15 min, repeat the dose once.(?<=[.!?])\s+(?=[A-Z0-9])Steroids
If a child has a severe or life-threatening acute attack of wheezing (asthma),
give oral prednisolone, 1 mg/kg, for 3–5 days (maximum, 60 mg) or 20 mg
for children aged 2–5 years. | 123 | 238 | 0 | WHO-0001 | 1 | who_corpus.pdf | 392 |
If the child remains very sick, continue the
treatment until improvement is seen.(?<=[.!?])\s+(?=[A-Z0-9])Repeat the dose of prednisolone for children who vomit, and consider IV steroids
if the child is unable to retain orally ingested medication.(?<=[.!?])\s+(?=[A-Z0-9])Treatment for up to
3 days is usually suffi cient, but the duration should be tailored to bring about
recovery.(?<=[.!?])\s+(?=[A-Z0-9])Tapering of short courses (7–14 days) of steroids is not necessary.(?<=[.!?])\s+(?=[A-Z0-9])IV hydrocortisone (4 mg/kg repeated every 4 h) provides no benefi t and should
be considered only for children who are unable to retain oral medication.(?<=[.!?])\s+(?=[A-Z0-9])Magnesium sulfate
Intravenous magnesium sulfate may provide additional benefi t in children with
severe asthma treated with bronchodilators and corticosteroids.(?<=[.!?])\s+(?=[A-Z0-9])Magnesium
sulfate has a better safety profi le in the management of acute severe asthma
ASTHMA
Use of spacer device and face mask to give
bronchodilator treatment.(?<=[.!?])\s+(?=[A-Z0-9])A spacer can
be made locally from a plastic soft-drink
bottle. | 123 | 239 | 1 | WHO-0001 | 1 | who_corpus.pdf | 357 |
100
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
than aminophylline.(?<=[.!?])\s+(?=[A-Z0-9])As it is more widely available, it can be used in children
who are not responsive to the medications described above.
Give 50% magnesium sulfate as a bolus of 0.1 ml/kg (50 mg/kg) IV over
20 min.(?<=[.!?])\s+(?=[A-Z0-9])Aminophylline
Aminophylline is not recommended in children with mild-to-moderate acute
asthma.(?<=[.!?])\s+(?=[A-Z0-9])It is reserved for children who do not improve after several doses of
a rapid-acting bronchodilator given at short intervals plus oral prednisolone.(?<=[.!?])\s+(?=[A-Z0-9])If indicated in these circumstances:
Admit the child ideally to a high-care or intensive-care unit, if available, for
continuous monitoring.
Weigh the child carefully and then give IV aminophylline at an initial loading
dose of 5–6 mg/kg (up to a maximum of 300 mg) over at least 20 min but
preferably over 1 h, followed by a maintenance dose of 5 mg/kg every 6 h. | 124 | 240 | 0 | WHO-0001 | 1 | who_corpus.pdf | 320 |
IV aminophylline can be dangerous at an overdose or when given too rapidly.
•
Omit the initial dose if the child has already received any form of aminophyl-
line or caffeine in the previous 24 h.
•
Stop giving it immediately if the child starts to vomit, has a pulse rate > 180/
min, develops a headache or has a convulsion.(?<=[.!?])\s+(?=[A-Z0-9])Oral bronchodilators
Use of oral salbutamol (in syrup or tablets) is not recommended in the treatment
of severe or persistent wheeze.(?<=[.!?])\s+(?=[A-Z0-9])It should be used only when inhaled salbutamol
is not available for a child who has improved suffi ciently to be discharged home.(?<=[.!?])\s+(?=[A-Z0-9])Dosage:
– Age 1 month to 2 years: 100 µg/kg (maximum, 2 mg) up to four times daily
– Age 2–6 years: 1–2 mg up to four times daily
Antibiotics
Antibiotics should not be given routinely for asthma or to a child with asthma
who has fast breathing without fever.(?<=[.!?])\s+(?=[A-Z0-9])Antimicrobial treatment is indicated,
however, when there is persistent fever and other signs of pneumonia (see
section 4.2, p.(?<=[.!?])\s+(?=[A-Z0-9])80).(?<=[.!?])\s+(?=[A-Z0-9])ASTHMA | 124 | 241 | 1 | WHO-0001 | 1 | who_corpus.pdf | 376 |
101
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Supportive care
Ensure that the child receives daily maintenance fl uids appropriate for his
or her age (see p.(?<=[.!?])\s+(?=[A-Z0-9])304).(?<=[.!?])\s+(?=[A-Z0-9])Encourage breastfeeding and oral fl uids.(?<=[.!?])\s+(?=[A-Z0-9])Encour-
age adequate complementary feeding for the young child, as soon as food
can be taken.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
A hospitalized child should be assessed by a nurse every 3 h or every 6 h as
the child shows improvement (i.e. slower breathing rate, less lower chest
wall indrawing and less respiratory distress) and by a doctor at least once a
day.(?<=[.!?])\s+(?=[A-Z0-9])Record the respiratory rate, and watch especially for signs of respiratory
failure – increasing hypoxia and respiratory distress leading to exhaustion.(?<=[.!?])\s+(?=[A-Z0-9])Monitor oxygen therapy as described on p.(?<=[.!?])\s+(?=[A-Z0-9])314. | 125 | 242 | 0 | WHO-0001 | 1 | who_corpus.pdf | 343 |
Monitor oxygen therapy as described on p.(?<=[.!?])\s+(?=[A-Z0-9])314.(?<=[.!?])\s+(?=[A-Z0-9])Complications
If the child fails to respond to the above therapy, or the child’s condition
worsens suddenly, obtain a chest X-ray to look for evidence of pneumothorax.(?<=[.!?])\s+(?=[A-Z0-9])Be very careful in making this diagnosis as the hyperinfl ation in asthma
can mimic a pneumothorax on a chest X-ray.(?<=[.!?])\s+(?=[A-Z0-9])Treat as described on p.(?<=[.!?])\s+(?=[A-Z0-9])90.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up care
Asthma is a chronic and recurrent condition.
Once the child has improved suffi ciently to be discharged home, inhaled
salbutamol through a metered dose inhaler should be prescribed with a
suitable (not necessarily commercial) spacer and the mother instructed
on how to use it.
A long-term treatment plan should be made on the basis of the frequency
and severity of symptoms.(?<=[.!?])\s+(?=[A-Z0-9])This may include intermittent or regular treatment
with bronchodilators, regular treatment with inhaled steroids or intermittent
courses of oral steroids. | 125 | 243 | 1 | WHO-0001 | 1 | who_corpus.pdf | 359 |
This may include intermittent or regular treatment
with bronchodilators, regular treatment with inhaled steroids or intermittent
courses of oral steroids.(?<=[.!?])\s+(?=[A-Z0-9])Up-to-date international or specialized national
guidelines should be consulted for more information.(?<=[.!?])\s+(?=[A-Z0-9])4.5.3 Wheeze with cough or cold
Most fi rst episodes of wheezing in children aged < 2 years are associated with
cough and cold.(?<=[.!?])\s+(?=[A-Z0-9])These children are not likely to have a family history of atopy
(e.g. hay-fever, eczema, allergic rhinitis), and their wheezing episodes become
less frequent as they grow older.(?<=[.!?])\s+(?=[A-Z0-9])The wheezing, if troublesome, may be treated
with inhaled salbutamol at home.(?<=[.!?])\s+(?=[A-Z0-9])WHEEZE WITH COUGH OR COLD | 125 | 244 | 2 | WHO-0001 | 1 | who_corpus.pdf | 261 |
102
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
4.6
Conditions presenting with stridor
Presenting sign is stridor
Stridor is a harsh noise during inspiration, which is due to narrowing of the air
passages in the oropharynx, subglottis or trachea.(?<=[.!?])\s+(?=[A-Z0-9])If the obstruction is below
the larynx, stridor may also occur during expiration.(?<=[.!?])\s+(?=[A-Z0-9])The major causes of severe stridor are viral croup (commonly caused by
measles or other viruses), foreign body inhalation, retropharyngeal abscess,
diphtheria and trauma to the larynx (Table 9).(?<=[.!?])\s+(?=[A-Z0-9])It may also occur in early infancy
due to congenital abnormalities.(?<=[.!?])\s+(?=[A-Z0-9])History
■fi rst episode or recurrent episode of stridor
■history of choking
■stridor present soon after birth
4.6.1
Viral croup
Croup causes obstruction of the upper airway, which, when severe, can be
life-threatening.(?<=[.!?])\s+(?=[A-Z0-9])Most severe episodes occur in children ≤ 2 years of age.(?<=[.!?])\s+(?=[A-Z0-9])This
section deals with croup caused by various respiratory viruses. | 126 | 245 | 0 | WHO-0001 | 1 | who_corpus.pdf | 380 |
This
section deals with croup caused by various respiratory viruses.(?<=[.!?])\s+(?=[A-Z0-9])For croup
associated with measles, see p.(?<=[.!?])\s+(?=[A-Z0-9])175.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Mild croup is characterized by:
■fever
■a hoarse voice
■a barking or hacking cough
■stridor that is heard only when the child is agitated.(?<=[.!?])\s+(?=[A-Z0-9])Severe croup is characterized additionally by:
■stridor even when the child is at rest
■rapid breathing and lower chest indrawing
■cyanosis or oxygen saturation ≤ 90%.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Mild croup can be managed at home with supportive care, including encourag-
ing oral fl uids, breastfeeding or feeding, as appropriate.(?<=[.!?])\s+(?=[A-Z0-9])CONDITIONS PRESENTING WITH STRIDOR | 126 | 246 | 1 | WHO-0001 | 1 | who_corpus.pdf | 293 |
103
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
VIRAL CROUP
Table 9.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with stridor
Diagnosis
In favour
Viral croup
– Barking cough
– Respiratory distress
– Hoarse voice
– If due to measles, signs of measles (see p.(?<=[.!?])\s+(?=[A-Z0-9])175)
Retropharyngeal
abscess
– Soft tissue swelling in back of the throat
– Diffi culty in swallowing
– Fever
Foreign body
– Sudden history of choking
– Respiratory distress
Diphtheria
– Bull neck appearance due to enlarged cervical
nodes and oedema
– Red throat
– Grey pharyngeal membrane
– Blood-stained nasal discharge
– No evidence of DPT vaccination
Epiglottitis
– Soft stridor
– ‘Septic’ child
– Little or no cough
– Drooling of saliva
– Inability to drink
Congenital anomaly
– Stridor present since birth
Anaphylaxis
– History of allergen exposure
– Wheeze
– Shock
– Urticaria and oedema of lips and face
Burns
– Swollen lips
– Smoke inhalation
A child with severe croup should be admitted to hospital.(?<=[.!?])\s+(?=[A-Z0-9])Try to avoid invasive
procedures unless undertaken in the presence of an anaesthetist, as they may
precipitate complete airway obstruction.
Steroid treatment.(?<=[.!?])\s+(?=[A-Z0-9])Give one dose of oral dexamethasone (0.6 mg/kg) or
equivalent dose of some other steroid: dexamethasone (see p. | 127 | 247 | 0 | WHO-0001 | 1 | who_corpus.pdf | 375 |
Give one dose of oral dexamethasone (0.6 mg/kg) or
equivalent dose of some other steroid: dexamethasone (see p.(?<=[.!?])\s+(?=[A-Z0-9])361) or
prednisolone (p.(?<=[.!?])\s+(?=[A-Z0-9])369).(?<=[.!?])\s+(?=[A-Z0-9])If available, use nebulized budesonide at 2 mg.(?<=[.!?])\s+(?=[A-Z0-9])Start
the steroids as soon as possible.(?<=[.!?])\s+(?=[A-Z0-9])It is preferable to dissolve the tablet in a
spoonful of water for children unable to swallow tablets.(?<=[.!?])\s+(?=[A-Z0-9])Repeat the dose
of steroid for children who vomit. | 127 | 248 | 1 | WHO-0001 | 1 | who_corpus.pdf | 240 |
104
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Adrenaline.(?<=[.!?])\s+(?=[A-Z0-9])As a trial, give the child nebulized adrenaline (2 ml of 1:1000
solution).(?<=[.!?])\s+(?=[A-Z0-9])If this is effective, repeat as often as every hour, with careful
monitoring.(?<=[.!?])\s+(?=[A-Z0-9])While this treatment can lead to improvement within 30 min in
some children, it is often temporary and may last only about 2 h.
Antibiotics.(?<=[.!?])\s+(?=[A-Z0-9])These are not effective and should not be given.
Monitor the child closely and ensure that facilities for an emergency intuba-
tion and/or tracheostomy are immediately available if required, as airway
obstruction can occur suddenly.(?<=[.!?])\s+(?=[A-Z0-9])In a child with severe croup who is deteriorating, consider the following:
Intubation and/or tracheostomy: If there are signs of incipient complete
airway obstruction, such as severe lower chest wall indrawing and restless-
ness, intubate the child immediately.
If this is not possible, transfer the child urgently to a hospital where intuba-
tion or emergency tracheostomy can be done.(?<=[.!?])\s+(?=[A-Z0-9])Tracheostomy should be done
only by experienced staff.
Avoid using oxygen unless there is incipient airway obstruction. | 128 | 249 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Tracheostomy should be done
only by experienced staff.
Avoid using oxygen unless there is incipient airway obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Signs such
as severe lower chest wall indrawing and restlessness are more likely to
indicate the need for intubation or tracheostomy than oxygen.(?<=[.!?])\s+(?=[A-Z0-9])Nasal prongs
or a nasal or nasopharyngeal catheter can upset the child and precipitate
obstruction of the airway.
However, oxygen should be given if there is incipient complete airway ob-
struction and intubation or tracheostomy is deemed necessary.(?<=[.!?])\s+(?=[A-Z0-9])Call for help
from an anaesthetist and surgeon to intubate or perform a tracheostomy.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
Keep the child calm, and avoid disturbance as much possible.
If the child has fever (≥ 39 °C or ≥ 102.2 °F) that appears to be causing
distress, give paracetamol.
Encourage breastfeeding and oral fl uids.(?<=[.!?])\s+(?=[A-Z0-9])Avoid parenteral fl uids, as this in-
volves placing an IV cannula, which can cause distress that might precipitate
complete airway obstruction.
Encourage the child to eat as soon as food can be taken.(?<=[.!?])\s+(?=[A-Z0-9])Avoid using mist tents, which are not effective, which separate the child from
the parents and which make observation of the child’s condition diffi cult. | 128 | 250 | 1 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Avoid using mist tents, which are not effective, which separate the child from
the parents and which make observation of the child’s condition diffi cult.(?<=[.!?])\s+(?=[A-Z0-9])Do
not give sedatives or antitussive medicines.(?<=[.!?])\s+(?=[A-Z0-9])VIRAL CROUP | 128 | 251 | 2 | WHO-0001 | 1 | who_corpus.pdf | 96 |
105
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Monitoring
The child’s condition, especially respiratory status, should be assessed by
nurses every 3 h and by doctors twice a day.(?<=[.!?])\s+(?=[A-Z0-9])The child should occupy a bed
close to the nursing station, so that any sign of incipient airway obstruction
can be detected as soon as it develops.(?<=[.!?])\s+(?=[A-Z0-9])4.6.2 Diphtheria
Diphtheria is a bacterial infection, which can be prevented by immunization.(?<=[.!?])\s+(?=[A-Z0-9])Infection in the upper airway or nasopharynx produces a grey membrane, which,
when present in the larynx or trachea, can cause stridor and obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Nasal
involvement produces a bloody discharge.(?<=[.!?])\s+(?=[A-Z0-9])Diphtheria toxin causes muscular paralysis
and myocarditis, which are associated with
mortality.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
■Carefully examine the child’s nose and
throat and look for a grey, adherent
membrane.(?<=[.!?])\s+(?=[A-Z0-9])Great care is needed when
examining the throat, as the examination
may precipitate complete obstruction
of the airway. | 129 | 252 | 0 | WHO-0001 | 1 | who_corpus.pdf | 378 |
Great care is needed when
examining the throat, as the examination
may precipitate complete obstruction
of the airway.(?<=[.!?])\s+(?=[A-Z0-9])A child with pharyngeal
diphtheria may have an obviously swol-
len neck, termed a ‘bull neck’.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Antitoxin
Give 40 000 U diphtheria antitoxin (IM
or IV) immediately, because delay can
increase the risk for mortality.(?<=[.!?])\s+(?=[A-Z0-9])As there
is a small risk for a serious allergic reac-
tion to the horse serum in the antitoxin, an initial intradermal test to detect
hypersensitivity should be carried out, as described in the instructions, and
treatment for anaphylaxis should be available (see p.(?<=[.!?])\s+(?=[A-Z0-9])108).(?<=[.!?])\s+(?=[A-Z0-9])Antibiotics
Any child with suspected diphtheria should be given a daily deep IM injection
of procaine benzylpenicillin at 50 mg/kg (maximum, 1.2 g) daily for 10 days.(?<=[.!?])\s+(?=[A-Z0-9])This drug should not be given IV.(?<=[.!?])\s+(?=[A-Z0-9])DIPHTHERIA
Pharyngeal membrane
of diphtheria.(?<=[.!?])\s+(?=[A-Z0-9])Note: the
membrane extends beyond
the tonsils and covers the
adjacent pharyngeal wall. | 129 | 253 | 1 | WHO-0001 | 1 | who_corpus.pdf | 398 |
106
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Oxygen
Avoid using oxygen unless there is incipient airway obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Signs such as severe lower chest wall indrawing and restlessness are more likely
to indicate the need for tracheostomy (or intubation) than oxygen.(?<=[.!?])\s+(?=[A-Z0-9])Moreover, the
use of a nasal or nasopharyngeal catheter can upset the child and precipitate
obstruction of the airway.
However, oxygen should be given if there is incipient airway obstruction and
intubation or a tracheostomy is deemed necessary.(?<=[.!?])\s+(?=[A-Z0-9])Tracheostomy/intubation
Tracheostomy should be performed, only by experienced staff, if there are
signs of incipient complete airway obstruction, such as severe lower chest
wall indrawing and restlessness.(?<=[.!?])\s+(?=[A-Z0-9])If obstruction occurs, an emergency
tracheostomy should be carried
out.(?<=[.!?])\s+(?=[A-Z0-9])Orotracheal intubation is an
alternative but may dislodge the
membrane and fail to relieve the
obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
If the child has fever (≥ 39 °C
or ≥ 102.2 °F) that appears to
be causing distress, give par-
acetamol.
Encourage the child to eat and
drink. | 130 | 254 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
Supportive care
If the child has fever (≥ 39 °C
or ≥ 102.2 °F) that appears to
be causing distress, give par-
acetamol.
Encourage the child to eat and
drink.(?<=[.!?])\s+(?=[A-Z0-9])If the child has diffi culty in
swallowing, nasogastric feeding
is required.(?<=[.!?])\s+(?=[A-Z0-9])The nasogastric tube
should be placed by an experi-
enced clinician or, if available,
an anaesthetist (see p.(?<=[.!?])\s+(?=[A-Z0-9])345).(?<=[.!?])\s+(?=[A-Z0-9])Avoid frequent examinations and invasive procedures when possible or disturb-
ing the child unnecessarily.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
The child’s condition, especially respiratory status, should be assessed by a
nurse every 3 h and by a doctor twice a day.(?<=[.!?])\s+(?=[A-Z0-9])The child should occupy a bed
close to the nursing station, so that any sign of incipient airway obstruction
can be detected as soon as it develops.(?<=[.!?])\s+(?=[A-Z0-9])DIPHTHERIA
‘Bull neck’: a sign of diphtheria, due
to enlarged lymph nodes in the neck | 130 | 255 | 1 | WHO-0001 | 1 | who_corpus.pdf | 359 |
107
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Complications
Myocarditis and paralysis may occur 2–7 weeks after the onset of illness.
■Signs of myocarditis include a weak, irregular pulse and evidence of heart
failure.(?<=[.!?])\s+(?=[A-Z0-9])Refer to standard paediatric textbooks for details of the diagnosis
and management of myocarditis.(?<=[.!?])\s+(?=[A-Z0-9])Public health measures
The child should be nursed in a separate room by staff who are fully vac-
cinated against diphtheria.
Give all vaccinated household contacts a diphtheria toxoid booster.
Give all unvaccinated household contacts one dose of benzathine penicillin
(600 000 U for those aged ≤ 5 years, 1 200 000 U for those > 5 years).(?<=[.!?])\s+(?=[A-Z0-9])Give
them diphtheria toxoid, and check daily for 5 days for any signs of diphtheria.(?<=[.!?])\s+(?=[A-Z0-9])4.6.3 Epiglottitis
Epiglottitis is a medical emergency that may result in death if not treated
quickly.(?<=[.!?])\s+(?=[A-Z0-9])It is mainly caused by the bacteria H. infl uenzae type b but may also
be caused by other bacteria or viruses associated with upper respiratory infec-
tions. | 131 | 256 | 0 | WHO-0001 | 1 | who_corpus.pdf | 360 |
It is mainly caused by the bacteria H. infl uenzae type b but may also
be caused by other bacteria or viruses associated with upper respiratory infec-
tions.(?<=[.!?])\s+(?=[A-Z0-9])Epiglottitis usually begins as an infl ammation and swelling between the
base of the tongue and the epiglottis.(?<=[.!?])\s+(?=[A-Z0-9])The swelling may obstruct the airway.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
■sore throat with diffi culty in speaking
■diffi culty in breathing
■soft stridor
■fever
■drooling of saliva
■diffi culty in swallowing or inability to drink.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Treatment of patients with epiglottitis is directed to relieving the airway
obstruction and eradicating the infectious agent.
Keep the child calm, and provide humidifi ed oxygen, with close monitoring.
Avoid examining the throat if the signs are typical, to avoid precipitating
obstruction.(?<=[.!?])\s+(?=[A-Z0-9])EPIGLOTTITIS | 131 | 257 | 1 | WHO-0001 | 1 | who_corpus.pdf | 301 |
108
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Call for help and secure the airway as an emergency because of the danger
of sudden, unpredictable airway obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Elective intubation is the best
treatment if there is severe obstruction but may be very diffi cult; consider
the need for surgical intervention to ensure airway patency.
Give IV antibiotics when the airway is safe: ceftriaxone at 80 mg/kg once
daily for 5 days.(?<=[.!?])\s+(?=[A-Z0-9])4.6.4 Anaphylaxis
Anaphylaxis is a severe allergic reaction, which may cause upper airway ob-
struction with stridor, lower airway obstruction with wheezing or shock or all
three.(?<=[.!?])\s+(?=[A-Z0-9])Common causes include allergic reactions to antibiotics, to vaccines,
to blood transfusion and to certain foods, especially nuts.(?<=[.!?])\s+(?=[A-Z0-9])Consider the diagnosis if any of the following symptoms is present and there
is a history of previous severe reaction, rapid progression or a history of
asthma, eczema or atopy. | 132 | 258 | 0 | WHO-0001 | 1 | who_corpus.pdf | 296 |
Consider the diagnosis if any of the following symptoms is present and there
is a history of previous severe reaction, rapid progression or a history of
asthma, eczema or atopy.(?<=[.!?])\s+(?=[A-Z0-9])ANAPHYLAXIS
Severity
Symptoms
Signs
Mild
– Itching mouth
– Nausea
– Urticaria
– Oedema of the face
– Conjunctivitis
– Red throat
Moderate
– Cough or wheeze
– Diarrhoea
– Sweating
– Wheeze
– Tachycardia
– Pallor
Severe
– Diffi culty in breathing
– Collapse
– Vomiting
– Severe wheeze with poor air entry
– Oedema of the larynx
– Shock
– Respiratory arrest
– Cardiac arrest
This situation is potentially life-threatening and may result in a change in level
of consciousness, collapse, or respiratory or cardiac arrest.
Assess the airways, breathing and circulation.
– If the child is not breathing, give fi ve rescue breaths with a bag-valve
mask and 100% oxygen and assess circulation.
– If no pulse, start basic life support. | 132 | 259 | 1 | WHO-0001 | 1 | who_corpus.pdf | 208 |
109
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Treatment
Remove the allergen as appropriate.
For mild cases (just rash and itching), give oral antihistamine and oral
prednisolone at 1 mg/kg.
For moderate cases with stridor and obstruction or wheeze:
– Give adrenaline at 0.15 ml of 1:1000 IM into the thigh (or subcutaneous);
the dose may be repeated every 5–15 min.
For severe anaphylactic shock:
– Give adrenaline at 0.15 ml of 1:1000 IM and repeat every 5–15 min.
– Give 100% oxygen.
– Ensure stabilization of the airway, breathing, circulation and secure IV
access.
– If the obstruction is severe, consider intubation or call an anaesthetist
and surgeon to intubate or create a surgical airway.
– Administer 20 ml/kg normal saline 0.9% or Ringer’s lactate solution IV as
rapidly as possible.(?<=[.!?])\s+(?=[A-Z0-9])If IV access is not possible, insert an intraosseous line.(?<=[.!?])\s+(?=[A-Z0-9])4.7
Conditions presenting with chronic cough
A chronic cough is one that lasts ≥ 14 days.(?<=[.!?])\s+(?=[A-Z0-9])Many conditions may present with
a chronic cough such as TB, pertussis, foreign body or asthma (see Table 10). | 133 | 260 | 0 | WHO-0001 | 1 | who_corpus.pdf | 340 |
Many conditions may present with
a chronic cough such as TB, pertussis, foreign body or asthma (see Table 10).(?<=[.!?])\s+(?=[A-Z0-9])History
■duration of coughing
■nocturnal cough
■paroxysmal cough or associated severe bouts ending with vomiting or
whooping
■weight loss or failure to thrive (check growth chart, if available),
■night sweats
■persistent fever
■close contact with a known case of sputum-positive TB or pertussis
■history of attacks of wheeze and a family history of allergy or asthma
■history of choking or inhalation of a foreign body
■child suspected or known to be HIV-infected
■treatment given and response.(?<=[.!?])\s+(?=[A-Z0-9])CONDITIONS PRESENTING WITH CHRONIC COUGH | 133 | 261 | 1 | WHO-0001 | 1 | who_corpus.pdf | 194 |
110
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
CONDITIONS PRESENTING WITH CHRONIC COUGH
Table 10.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with chronic cough
Diagnosis
In favour
TB
– Weight loss or failure to thrive
– Anorexia
– Night sweats
– Enlarged liver and spleen
– Chronic or intermittent fever
– History of exposure to infectious TB
– Abnormal chest X-ray
Asthma
– History of recurrent wheeze
– Hyperinfl ation of the chest
– Prolonged expiration
– Reduced air entry (in very severe airway obstruction)
– Good response to bronchodilators
Foreign body
– Sudden onset of choking or stridor
– Unilateral chest signs (e.g. wheezing or hyperinfl ation)
– Recurrent lobar consolidation
– Poor response to medical treatment
Pertussis
– Paroxysms of cough followed by whoop, vomiting,
cyanosis or apnoea
– Sub-conjunctival haemorrhages
– No history of DPT vaccination
– No fever
HIV
– Known or suspected maternal or sibling HIV infection
– Failure to thrive
– Oral or oesophageal thrush
– Chronic parotitis
– Skin infection with herpes zoster (past or present)
– Generalized lymphadenopathy
– Chronic fever
– Persistent diarrhoea
– Finger clubbing
Bronchiectasis
– History of severe pneumonia, TB or aspirated foreign
body
– Poor weight gain
– Purulent sputum, bad breath
– Finger clubbing
– Localized signs on X-ray
Lung abscess
– Reduced breath sounds over abscess
– Poor weight gain or chronically ill child
– Cystic or cavitating lesion on chest X-ray | 134 | 262 | 0 | WHO-0001 | 1 | who_corpus.pdf | 335 |
111
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Examination
■fever
■lymphadenopathy (generalized and localized, e.g. in the neck)
■wasting
■wheeze or prolonged expiration
■clubbing
■apnoeic episodes (with pertussis)
■subconjunctival haemorrhages
■signs associated with foreign body aspiration:
– unilateral wheeze
– area of decreased breath sounds that is either dull or hyper-resonant
on percussion
– deviation of the trachea or apex beat
■signs associated with HIV infection (see p.(?<=[.!?])\s+(?=[A-Z0-9])225).(?<=[.!?])\s+(?=[A-Z0-9])Treatment guidelines for the most common causes of chronic cough are
indicated below:
•
Asthma (p.(?<=[.!?])\s+(?=[A-Z0-9])96).
•
Pertussis (p.(?<=[.!?])\s+(?=[A-Z0-9])111).
•
TB (p.(?<=[.!?])\s+(?=[A-Z0-9])115).
•
Foreign body (p.(?<=[.!?])\s+(?=[A-Z0-9])119).
•
HIV (pp.(?<=[.!?])\s+(?=[A-Z0-9])84, 243). | 135 | 263 | 0 | WHO-0001 | 1 | who_corpus.pdf | 375 |
119).
•
HIV (pp.(?<=[.!?])\s+(?=[A-Z0-9])84, 243).(?<=[.!?])\s+(?=[A-Z0-9])4.7.1
Pertussis
Pertussis is most severe in young infants who have not yet been immunized.(?<=[.!?])\s+(?=[A-Z0-9])After an incubation period of 7–10 days, the child has fever, usually with a
cough and nasal discharge that are clinically indistinguishable from the com-
mon cough and cold.(?<=[.!?])\s+(?=[A-Z0-9])In the second week, there is paroxysmal coughing that
can be recognized as pertussis.(?<=[.!?])\s+(?=[A-Z0-9])The episodes of coughing can continue for
3 months or longer.(?<=[.!?])\s+(?=[A-Z0-9])The child is infectious for up to 3 weeks after the onset of
bouts of whooping cough.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Suspect pertussis if a child has had a severe cough for more than 2 weeks,
especially if the disease is known to be occurring locally.(?<=[.!?])\s+(?=[A-Z0-9])The most useful
diagnostic signs are:
PERTUSSIS | 135 | 264 | 1 | WHO-0001 | 1 | who_corpus.pdf | 354 |
112
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
■paroxysmal coughing followed by a
whoop when breathing in, often with
vomiting
■subconjunctival haemorrhages
■child not vaccinated against pertussis
■young infants may not whoop; in-
stead, the cough may be followed
by suspension of breathing (apnoea)
or cyanosis, or apnoea may occur
without coughing.(?<=[.!?])\s+(?=[A-Z0-9])Also examine the child for signs of
pneumonia, and ask about convulsions.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Treat mild cases in children aged ≥ 6 months at home with supportive care
(see below).(?<=[.!?])\s+(?=[A-Z0-9])Admit infants aged < 6 months to hospital; also admit any child
with pneumonia, convulsions, dehydration, severe malnutrition or prolonged
apnoea or cyanosis after coughing.(?<=[.!?])\s+(?=[A-Z0-9])Antibiotics
Give oral erythromycin (12.5 mg/kg four times a day) for 10 days. | 136 | 265 | 0 | WHO-0001 | 1 | who_corpus.pdf | 294 |
Antibiotics
Give oral erythromycin (12.5 mg/kg four times a day) for 10 days.(?<=[.!?])\s+(?=[A-Z0-9])This does
not shorten the illness but reduces the period of infectiousness.
Alternatively, if available, give azithromycin at 10 mg/kg (maximum, 500 mg)
on the fi rst day, then 5 mg/kg (maximum, 250 mg) once a day for 4 days.
If there is fever, if erythromycin or azithromycin is not available, or if there
are signs of pneumonia, treat with amoxicillin as possible secondary pneu-
monia.(?<=[.!?])\s+(?=[A-Z0-9])Follow the other guidelines for severe pneumonia (see 4.2.1, p.(?<=[.!?])\s+(?=[A-Z0-9])80).(?<=[.!?])\s+(?=[A-Z0-9])Oxygen
Give oxygen to children who have spells of apnoea or cyanosis, severe
paroxysms of coughing or low oxygen saturation ≤ 90% on a pulse oximeter.(?<=[.!?])\s+(?=[A-Z0-9])Use nasal prongs, not a nasopharyngeal catheter or nasal catheter, which
can provoke coughing.(?<=[.!?])\s+(?=[A-Z0-9])Place the prongs just inside the nostrils and secure
with a piece of tape just above the upper lip. | 136 | 266 | 1 | WHO-0001 | 1 | who_corpus.pdf | 359 |
Place the prongs just inside the nostrils and secure
with a piece of tape just above the upper lip.(?<=[.!?])\s+(?=[A-Z0-9])Care should be taken to keep the
nostrils clear of mucus, as this blocks the fl ow of oxygen.(?<=[.!?])\s+(?=[A-Z0-9])Set a fl ow rate of
1–2 litres/min (0.5 litre/min for young infants).(?<=[.!?])\s+(?=[A-Z0-9])Humidifi cation is not required
with nasal prongs.(?<=[.!?])\s+(?=[A-Z0-9])PERTUSSIS
Subconjunctival haemorrhages
prominent on the white sclera | 136 | 267 | 2 | WHO-0001 | 1 | who_corpus.pdf | 198 |
113
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Continue oxygen therapy until the above signs are no longer present, after
which there is no value in continuing oxygen.
A nurse should check, every 3 h, that the prongs or catheter are in the cor-
rect place and not blocked with mucus and that all connections are secure.(?<=[.!?])\s+(?=[A-Z0-9])See p.(?<=[.!?])\s+(?=[A-Z0-9])314 for further details.(?<=[.!?])\s+(?=[A-Z0-9])Airway management
During paroxysms of coughing, place the child in the recovery position to
prevent inhalation of vomitus and to aid expectoration of secretions.
– If the child has cyanotic episodes, clear secretions from the nose and
throat with brief, gentle suction.
– If apnoea occurs, clear the airways immediately with gentle suction under
direct vision, breathe for the infant using a bag-valve mask ideally with
a reservoir bag and connected to high-fl ow oxygen
Supportive care
•
Avoid, as far as possible, any procedure that could trigger coughing, such
as application of suction, throat examination or use of a nasogastric tube
(unless the child cannot drink).
•
Do not give cough suppressants, sedatives, mucolytic agents or antihis-
tamines.
If the child has fever (≥ 39 °C, ≥ 102.2 °F) that appears to be causing dis-
tress, give paracetamol.
Encourage breastfeeding or oral fl uids. | 137 | 268 | 0 | WHO-0001 | 1 | who_corpus.pdf | 361 |
If the child cannot drink, pass a
nasogastric tube and give small, frequent amounts of fl uid (ideally expressed
breast milk) to meet the child’s maintenance needs (see p.(?<=[.!?])\s+(?=[A-Z0-9])304).(?<=[.!?])\s+(?=[A-Z0-9])If there is
severe respiratory distress and maintenance fl uids cannot be given through
a nasogastric tube because of persistent vomiting, give IV fl uids to avoid
the risk of aspiration and avoid triggering coughing.(?<=[.!?])\s+(?=[A-Z0-9])Ensure adequate nutrition by giving small, frequent feeds.(?<=[.!?])\s+(?=[A-Z0-9])If there is continued
weight loss despite these measures, feed the child by nasogastric tube.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
The child should be assessed by a nurse every 3 h and by a doctor once a day.(?<=[.!?])\s+(?=[A-Z0-9])To facilitate early detection and treatment of apnoeic or cyanotic spells or severe
episodes of coughing, the child should occupy a bed in a place close to the nurs-
ing station, where oxygen and assisted ventilation are available.(?<=[.!?])\s+(?=[A-Z0-9])Also, teach the
child’s mother to recognize apnoeic spells and to alert the nurse if these occur. | 137 | 269 | 1 | WHO-0001 | 1 | who_corpus.pdf | 381 |
Also, teach the
child’s mother to recognize apnoeic spells and to alert the nurse if these occur.(?<=[.!?])\s+(?=[A-Z0-9])PERTUSSIS | 137 | 270 | 2 | WHO-0001 | 1 | who_corpus.pdf | 52 |
114
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Complications
Pneumonia: This is the commonest complication of pertussis and is caused by
secondary bacterial infection or inhalation of vomit.
■Signs suggesting pneumonia include fast breathing between coughing
episodes, fever and the rapid onset of respiratory distress.
Treat pneumonia in children with pertussis as follows:
– Give parenteral ampicillin (or benzylpenicillin) and gentamicin for 5 days,
or alternatively give azithromycin for 5 days.
– Give oxygen as described for the treatment of severe pneumonia (see
sections 4.2.1 and 10.7, pp.(?<=[.!?])\s+(?=[A-Z0-9])80 and 312).(?<=[.!?])\s+(?=[A-Z0-9])Convulsions.(?<=[.!?])\s+(?=[A-Z0-9])These may result from anoxia associated with an apnoeic or
cyanotic episode or toxin-mediated encephalopathy.
If a convulsion does not stop within 2 min, give diazepam, following the
guidelines in Chapter 1 (Chart 9, p.(?<=[.!?])\s+(?=[A-Z0-9])15).(?<=[.!?])\s+(?=[A-Z0-9])Malnutrition.(?<=[.!?])\s+(?=[A-Z0-9])Children with pertussis may become malnourished as a result of
reduced food intake and frequent vomiting.
Prevent malnutrition by ensuring adequate feeding, as described above,
under ‘Supportive care’. | 138 | 271 | 0 | WHO-0001 | 1 | who_corpus.pdf | 383 |
Children with pertussis may become malnourished as a result of
reduced food intake and frequent vomiting.
Prevent malnutrition by ensuring adequate feeding, as described above,
under ‘Supportive care’.(?<=[.!?])\s+(?=[A-Z0-9])Haemorrhage and hernias
■Subconjunctival haemorrhage and epistaxis are common during pertussis.
No specifi c treatment is needed.
■Umbilical or inguinal hernias may be caused by violent coughing.
Do not treat them unless there are signs of bowel obstruction, but refer the
child for surgical evaluation after the acute phase.(?<=[.!?])\s+(?=[A-Z0-9])Public health measures
Give DPT vaccine to any child in the family who is not fully immunized and
to the child with pertussis.
Give a DPT booster to previously vaccinated children.
Give erythromycin estolate (12.5 mg/kg four times a day) for 10 days to any
infant in the family who is < 6 months old and has fever or other signs of a
respiratory infection.(?<=[.!?])\s+(?=[A-Z0-9])PERTUSSIS | 138 | 272 | 1 | WHO-0001 | 1 | who_corpus.pdf | 258 |
115
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
4.7.2
Tuberculosis
Most children infected with M. tuberculosis do not develop TB.(?<=[.!?])\s+(?=[A-Z0-9])The only
evidence of infection may be a positive skin test.(?<=[.!?])\s+(?=[A-Z0-9])The development of TB
depends on the competence of the immune system to resist multiplication of
the M. tuberculosis infection.(?<=[.!?])\s+(?=[A-Z0-9])This competence varies with age, being least in
the very young.(?<=[.!?])\s+(?=[A-Z0-9])HIV infection and malnutrition lower the body’s defenses, and
measles and whooping cough temporarily impair the strength of the immune
system.(?<=[.!?])\s+(?=[A-Z0-9])In the presence of any of these conditions, TB can develop more easily.(?<=[.!?])\s+(?=[A-Z0-9])TB is most often severe when it is located in the lungs, meninges or kidney.(?<=[.!?])\s+(?=[A-Z0-9])Cervical lymph nodes, bones, joints, abdomen, ears, eyes and skin may also
be affected.(?<=[.!?])\s+(?=[A-Z0-9])Many children present only with failure to grow normally, weight
loss or prolonged fever. | 139 | 273 | 0 | WHO-0001 | 1 | who_corpus.pdf | 390 |
Many children present only with failure to grow normally, weight
loss or prolonged fever.(?<=[.!?])\s+(?=[A-Z0-9])Cough for > 14 days can also be a presenting sign; in
children, however, sputum-positive pulmonary TB is rarely diagnosed.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
The risk for TB is increased when there is an active case (infectious, smear-pos-
itive pulmonary TB) in the same house or when the child is malnourished, has
HIV/AIDS or had measles in the past few months.(?<=[.!?])\s+(?=[A-Z0-9])Consider TB in any child with:
A history of:
■unexplained weight loss or failure to grow normally
■unexplained fever, especially when it continues for longer than 2 weeks
■chronic cough (i.e. cough for > 14 days, with or without a wheeze)
■exposure to an adult with probable or defi nite infectious pulmonary TB. | 139 | 274 | 1 | WHO-0001 | 1 | who_corpus.pdf | 246 |
On examination:
■fl uid on one side of the chest (reduced air entry, stony dullness to percussion)
■enlarged non-tender lymph nodes or a lymph node abscess, especially in
the neck
■signs of meningitis, especially when these develop over several days and the
spinal fl uid contains mostly lymphocytes and elevated protein
■abdominal swelling, with or without palpable lumps
■progressive swelling or deformity in the bone or a joint, including the spine
Investigations
■Try to obtain specimens for microscopic examination of acid-fast bacilli
(Ziehl-Neelsen stain) and for culture of tubercle bacilli.(?<=[.!?])\s+(?=[A-Z0-9])Possible specimens
include three consecutive early-morning, fasting gastric aspirates, CSF (if
clinically indicated) and pleural fl uid and ascites fl uid (if present).(?<=[.!?])\s+(?=[A-Z0-9])As the
TUBERCULOSIS | 139 | 275 | 2 | WHO-0001 | 1 | who_corpus.pdf | 220 |
116
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
detection rates with these methods are low, a positive result confi rms TB,
but a negative result does not exclude the disease.
■New rapid diagnostic tests are more accurate and may be more widely
available in future.
■Obtain a chest X-ray.(?<=[.!?])\s+(?=[A-Z0-9])A diagnosis of TB is supported when a chest X-ray
shows a miliary pattern of infi ltrates or a persistent area of infi ltrate or
consolidation, often with pleural effusion, or a primary complex.
■Perform a purifi ed protein derivative skin test (PPD or mantoux test).(?<=[.!?])\s+(?=[A-Z0-9])The
test is usually positive in children with pulmonary TB (reactions of > 10 mm
suggest TB; < 10 mm in a child previously vaccinated with BCG is equivo-
cal).(?<=[.!?])\s+(?=[A-Z0-9])The purifi ed protein derivative test may be negative in children with TB
who have HIV/AIDS, miliary disease, severe malnutrition or recent measles.
■Xpert MTB/RIF should be used as the initial diagnostic test in children
suspected of having multidrug-resistant TB (MDR-TB) or HIV-associated TB.
■Routine HIV testing should be offered to all children suspected of TB. | 140 | 276 | 0 | WHO-0001 | 1 | who_corpus.pdf | 338 |
Treatment
Give a full course of treatment to all confi rmed or strongly suspected cases.
When in doubt, e.g. in a child with strongly suspected TB or who fails to
respond to treatment for other probable diagnoses, give treatment for TB.(?<=[.!?])\s+(?=[A-Z0-9])Treatment failures for other diagnoses include antibiotic treatment for apparent
bacterial pneumonia (when the child has pulmonary symptoms), for possible
meningitis (when the child has neurological symptoms) or for intestinal worms
or giardiasis (when the child fails to thrive or has diarrhoea or abdominal
symptoms).
Suspected or confi rmed childhood TB should be treated with a combination
of anti-TB drugs, depending on the severity of disease, HIV status and level
of isoniazid resistance.
Follow the national TB programme guidelines for recommended treatment.
To reduce the risk for drug-induced hepatotoxicity in children, follow the
recommended dosages:
– Isoniazid (H): 10 mg/kg (range, 10–15 mg/kg); maximum dose, 300 mg/day
– Rifampicin (R): 15 mg/kg (range, 10–20 mg/kg); maximum dose, 600 mg/
kg per day
– Pyrazinamide (Z): 35 mg/kg (range, 30–40 mg/kg)
– Ethambutol (E): 20 mg/kg (range, 15–25 mg/kg).(?<=[.!?])\s+(?=[A-Z0-9])TUBERCULOSIS | 140 | 277 | 1 | WHO-0001 | 1 | who_corpus.pdf | 323 |
117
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Treatment regimens
If national recommendations are not available, follow the WHO guidelines
according to the regimens given below:
Four-drug regimen: HRZE for 2 months, followed by a two-drug (HR) regimen
for 4 months for all children with suspected or confi rmed pulmonary TB or
peripheral lymphadenitis living in an area of high HIV prevalence or where
resistance to H is high or children with extensive pulmonary disease living
in areas of low HIV prevalence or low H resistance;
Three-drug regimen: HRZ for 2 months, followed by a two-drug (HR) regimen
for 4 months for children with suspected or confi rmed pulmonary TB or
tuberculous peripheral lymphadenitis living in areas of low HIV prevalence
or low H resistance or HIV-negative;
In cases of suspected or confi rmed tuberculous meningitis, spinal TB with
neurological signs or osteo-articular TB, treat for 12 months with a four-
drug regimen (HRZE) for 2 months, followed by a two-drug (HR) regimen
for 10 months;
In infants (aged 0–3 months) with suspected or confi rmed pulmonary TB
or tuberculous peripheral lymphadenitis, treat promptly with the standard
regimens described above, with adjustment of doses to reconcile the effect
of age and possible toxicity in young infants.(?<=[.!?])\s+(?=[A-Z0-9])Intermittent regimens: In areas with well-established directly observed therapy,
thrice-weekly regimens can be considered for children known to be HIV-nega-
tive. | 141 | 278 | 0 | WHO-0001 | 1 | who_corpus.pdf | 347 |
Intermittent regimens: In areas with well-established directly observed therapy,
thrice-weekly regimens can be considered for children known to be HIV-nega-
tive.(?<=[.!?])\s+(?=[A-Z0-9])They should not be used in areas with a high HIV prevalence, because there
is a high risk of treatment failure and development of multidrug-resistant TB.(?<=[.!?])\s+(?=[A-Z0-9])Precautions: Streptomycin should not be used as part of fi rst-line treatment
regimens for children with pulmonary TB or tuberculous peripheral lymphad-
enitis.(?<=[.!?])\s+(?=[A-Z0-9])It should be reserved for the treatment of multidrug-resistant TB in
children with known susceptibility to this medicine.(?<=[.!?])\s+(?=[A-Z0-9])Multidrug-resistant TB
In cases of MDR TB, treat children with proven or suspected pulmonary TB
or tuberculous meningitis with a fl uoroquinolone or other second-line TB
drug.(?<=[.!?])\s+(?=[A-Z0-9])An appropriate MDR TB treatment regimen in the context of a well-
functioning MDR TB control programme should be used.(?<=[.!?])\s+(?=[A-Z0-9])The decision to
treat should be taken by a clinician experienced in managing paediatric TB.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
Confi rm that the medication is being taken as instructed, by direct observation
of each dose. | 141 | 279 | 1 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Monitoring
Confi rm that the medication is being taken as instructed, by direct observation
of each dose.(?<=[.!?])\s+(?=[A-Z0-9])Monitor the child’s weight gain daily and temperature twice a
TUBERCULOSIS | 141 | 280 | 2 | WHO-0001 | 1 | who_corpus.pdf | 58 |
118
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
day in order to check for resolution of fever.(?<=[.!?])\s+(?=[A-Z0-9])These are signs of response to
therapy.(?<=[.!?])\s+(?=[A-Z0-9])When treatment is given for suspected TB, improvement should be
seen within 1 month.(?<=[.!?])\s+(?=[A-Z0-9])If this does not occur, review the patient, check compli-
ance, re-investigate and reconsider the diagnosis.(?<=[.!?])\s+(?=[A-Z0-9])Public health measures
Notify the case to the responsible district health authorities.(?<=[.!?])\s+(?=[A-Z0-9])Ensure that
treatment is monitored as recommended by the national TB programme.(?<=[.!?])\s+(?=[A-Z0-9])Check all household members of the child (and, if necessary, school contacts)
for undetected cases of TB, and arrange treatment for any that are found.
Children < 5 years of age who are household or close contacts of people with
TB and who, after an appropriate clinical evaluation, are found not to have
active TB should be given 6 months of isoniazid preventive therapy (10 mg/
kg/day, range 7–15 mg/kg, maximum dose 300 mg/day). | 142 | 281 | 0 | WHO-0001 | 1 | who_corpus.pdf | 363 |
Follow-up
A programme of ‘active’ follow-up, in which a health worker visits the child
and his or her family at home, can reduce default from TB treatment.(?<=[.!?])\s+(?=[A-Z0-9])During
follow-up at home or in hospital, health workers can:
•
Check whether medications for TB are being taken regularly.
•
Remind the family and the treatment supporter about the importance of
taking medications regularly, even if the child is well, for the full duration
of treatment.
•
Screen family contacts, including other children in the family, by inquiring
about cough, and start these children on isoniazid preventive therapy.
•
Suggest how the family’s home environment might be made healthier for
children, such as eliminating smoking inside the house, good ventilation
and hand-washing.
•
Discuss with the parents the importance of nutrition in recovery from TB
and any problems in providing good nutrition for their children.
•
Check the child for growth, nutritional state and signs of TB and other treat-
able conditions.(?<=[.!?])\s+(?=[A-Z0-9])If problems are found, the health worker should recommend
how these can be treated or refer the family to a paediatrician.
•
Check the child’s health record, and tell the parents when and where they
should bring the child for doses of vaccine.
•
Ask the parents if they have any questions or concerns, and answer or
discuss these, or refer the family to a paediatrician.
•
Record their observations on the TB treatment card.(?<=[.!?])\s+(?=[A-Z0-9])TUBERCULOSIS | 142 | 282 | 1 | WHO-0001 | 1 | who_corpus.pdf | 357 |
119
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
4.7.3
Foreign body inhalation
Nuts, seeds or other small objects may be inhaled, most often by children < 4
years of age.(?<=[.!?])\s+(?=[A-Z0-9])The foreign body usually lodges in a bronchus (more often in the
right) and can cause collapse or consolidation of the portion of lung distal to
the site of blockage.(?<=[.!?])\s+(?=[A-Z0-9])Choking is a frequent initial symptom.(?<=[.!?])\s+(?=[A-Z0-9])This may be fol-
lowed by a symptom-free interval of days or weeks before the child presents
with persistent wheeze, chronic cough or pneumonia, which fails to respond
to treatment.(?<=[.!?])\s+(?=[A-Z0-9])Small sharp objects can lodge in the larynx, causing stridor or
wheeze.(?<=[.!?])\s+(?=[A-Z0-9])Rarely, a large object lodged in the larynx can cause sudden death from
asphyxia, unless it can be dislodged or an emergency tracheostomy be done.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Inhalation of a foreign body should be considered in a child with the following
signs:
■sudden onset of choking, coughing or wheezing; or
■segmental or lobar pneumonia that fails to respond to antibiotic therapy. | 143 | 283 | 0 | WHO-0001 | 1 | who_corpus.pdf | 389 |
Examine the child for:
■unilateral wheeze
■an area of decreased breath sounds that is either dull or hyper-resonant
on percussion
■deviation of the trachea or apex beat.(?<=[.!?])\s+(?=[A-Z0-9])Obtain a chest X-ray at full expiration to detect an area of hyperinfl ation or
collapse, mediastinal shift (away from the affected side) or a foreign body if
it is radio-opaque.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Emergency fi rst aid for the choking child (see p.(?<=[.!?])\s+(?=[A-Z0-9])7): Attempt to dislodge and
expel the foreign body.(?<=[.!?])\s+(?=[A-Z0-9])The management depends on the age of the child.(?<=[.!?])\s+(?=[A-Z0-9])For infants:
Lay the infant in a head-down position on one of your arms or on your thigh.
Strike the middle of the infant’s back fi ve times with the heel of your hand.
If the obstruction persists, turn the infant over and give fi ve fi rm chest thrusts
with two fi ngers on the lower half of the sternum.
If the obstruction persists, check the infant’s mouth for any obstruction
that can be removed.(?<=[.!?])\s+(?=[A-Z0-9])FOREIGN BODY INHALATION | 143 | 284 | 1 | WHO-0001 | 1 | who_corpus.pdf | 371 |
120
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
If necessary, repeat this sequence with back slaps.(?<=[.!?])\s+(?=[A-Z0-9])For older children:
While the child is sitting, kneeling or lying, strike the child’s back fi ve times
with the heel of the hand.
If the obstruction persists, go behind the child and pass your arms around
the child’s body; form a fi st with one hand immediately below the sternum;
place the other hand over the fi st, and thrust sharply upwards into the abdo-
men.(?<=[.!?])\s+(?=[A-Z0-9])Repeat this up to fi ve times.
Then check the child’s mouth for any obstruction that can be removed.
If necessary, repeat the sequence with back slaps.(?<=[.!?])\s+(?=[A-Z0-9])Once this has been done, it is important to check the patency of the airway by:
■looking for chest movements
■listening for breath sounds and
■feeling for breath.(?<=[.!?])\s+(?=[A-Z0-9])If further management of the airways is required after the obstruction is re-
moved, Chart 4, pp.(?<=[.!?])\s+(?=[A-Z0-9])9–10 describes actions that will keep the child’s airways
open and prevent the tongue from falling back to obstruct the pharynx while
the child recovers.
Later treatment of suspected foreign body aspiration. | 144 | 285 | 0 | WHO-0001 | 1 | who_corpus.pdf | 386 |
If a foreign body is
suspected, refer the child to a hospital where diagnosis is possible and the
object can be removed after bronchoscopy.(?<=[.!?])\s+(?=[A-Z0-9])If there is evidence of pneumonia,
begin treatment with ampicillin (or benzylpenicillin) and gentamicin, as for
severe pneumonia (see p.(?<=[.!?])\s+(?=[A-Z0-9])82), before attempting to remove the foreign body.(?<=[.!?])\s+(?=[A-Z0-9])4.8
Heart failure
Heart failure causes fast breathing and respiratory distress.(?<=[.!?])\s+(?=[A-Z0-9])The underlying
causes include congenital heart disease (usually in the fi rst months of life),
acute rheumatic fever, cardiac arrhythmia, myocarditis, suppurative peri-
carditis with constriction, infective endocarditis, acute glomerulonephritis,
severe anaemia, severe pneumonia and severe malnutrition.(?<=[.!?])\s+(?=[A-Z0-9])Heart failure
can be precipitated or worsened by fl uid overload, especially when large
volumes of IV fl uids are given.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
The commonest signs of heart failure, on examination, are:
HEART FAILURE | 144 | 286 | 1 | WHO-0001 | 1 | who_corpus.pdf | 322 |
121
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
HEART FAILURE
■tachycardia (heart rate
> 160/min in a child < 12
months; > 120/min in a
child aged 12 months to
5 years)
■gallop rhythm with basal
crackles on auscultation
■enlarged, tender liver
■in infants, fast breathing
(or sweating), especially
when feeding (see section
4.1, p.(?<=[.!?])\s+(?=[A-Z0-9])76, for defi nition of
fast breathing); in older
children, oedema of the
feet, hands or face or dis-
tended neck veins (raised
jugular venous pressure)
Severe palmar pallor may be present if severe anaemia is the cause of the
heart failure.(?<=[.!?])\s+(?=[A-Z0-9])Heart murmur may be present in rheumatic heart disease, congenital heart
disease or endocarditis.(?<=[.!?])\s+(?=[A-Z0-9])If the diagnosis is in doubt, a chest X-ray can be taken and may show an enlarged
heart or abnormal shape.(?<=[.!?])\s+(?=[A-Z0-9])Measure blood pressure if possible.(?<=[.!?])\s+(?=[A-Z0-9])If it is raised, consider acute glomerulo-
nephritis (See standard paediatric textbook for treatment). | 145 | 287 | 0 | WHO-0001 | 1 | who_corpus.pdf | 359 |
If it is raised, consider acute glomerulo-
nephritis (See standard paediatric textbook for treatment).(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Treatment depends on the underlying heart disease (Consult international or
national paediatric guidelines).(?<=[.!?])\s+(?=[A-Z0-9])The main measures for treating heart failure in
children who are not severely malnourished are:
Oxygen.(?<=[.!?])\s+(?=[A-Z0-9])Give oxygen if the child has a respiratory rate of ≥ 70/min, shows
signs of respiratory distress, or has central cyanosis or low oxygen satura-
tion.(?<=[.!?])\s+(?=[A-Z0-9])Aim to keep oxygen saturation > 90%.(?<=[.!?])\s+(?=[A-Z0-9])See p.(?<=[.!?])\s+(?=[A-Z0-9])314.
Diuretics.(?<=[.!?])\s+(?=[A-Z0-9])Give furosemide: A dose of 1 mg/kg should increase urine fl ow
within 2 h.(?<=[.!?])\s+(?=[A-Z0-9])For faster action, give the drug IV.(?<=[.!?])\s+(?=[A-Z0-9])If the initial dose is not effec-
tive, give 2 mg/kg and repeat in 12 h, if necessary. | 145 | 288 | 1 | WHO-0001 | 1 | who_corpus.pdf | 388 |
If the initial dose is not effec-
tive, give 2 mg/kg and repeat in 12 h, if necessary.(?<=[.!?])\s+(?=[A-Z0-9])Thereafter, a single daily
dose of 1–2 mg/kg orally is usually suffi cient.(?<=[.!?])\s+(?=[A-Z0-9])Raised jugular venous pressure –
a sign of heart failure | 145 | 289 | 2 | WHO-0001 | 1 | who_corpus.pdf | 108 |
122
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Digoxin.(?<=[.!?])\s+(?=[A-Z0-9])Consider giving digoxin (see Annex 2, p.(?<=[.!?])\s+(?=[A-Z0-9])362).
Supplemental potassium.(?<=[.!?])\s+(?=[A-Z0-9])Supplemental potassium is not required when
furosemide is given alone for treatment lasting only a few days.(?<=[.!?])\s+(?=[A-Z0-9])When digoxin
and furosemide are given, or if furosemide is given for more than 5 days,
give oral potassium at 3–5 mmol/kg per day.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
•
Avoid giving IV fl uids, if possible.
•
Support the child in a semi-seated position with head and shoulders elevated
and lower limbs dependent.
•
Relieve any fever with paracetamol to reduce the cardiac workload.
•
Consider transfusion if severe anaemia is present.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
The child should be checked by a nurse every 6 h (every 3 h while on oxygen
therapy) and by a doctor once a day.(?<=[.!?])\s+(?=[A-Z0-9])Monitor both respiratory and pulse rates,
liver size and body weight to assess the response to treatment. | 146 | 290 | 0 | WHO-0001 | 1 | who_corpus.pdf | 375 |
Monitor both respiratory and pulse rates,
liver size and body weight to assess the response to treatment.(?<=[.!?])\s+(?=[A-Z0-9])Continue
treatment until the respiratory and pulse rates are normal and the liver is no
longer enlarged.(?<=[.!?])\s+(?=[A-Z0-9])4.9
Rheumatic heart disease
Chronic rheumatic heart disease is a complication of acute rheumatic fever,
which leaves permanent damage to the heart valves (see p.(?<=[.!?])\s+(?=[A-Z0-9])193).(?<=[.!?])\s+(?=[A-Z0-9])In some chil-
dren, antibodies produced in response to group A β-haemolytic streptococci
lead to varying degrees of pancarditis, with associated valve insuffi ciency in
the acute phase.(?<=[.!?])\s+(?=[A-Z0-9])The risk for rheumatic heart disease is higher with repeated episodes of acute
rheumatic fever.(?<=[.!?])\s+(?=[A-Z0-9])It leads to valve stenosis, with varying degrees of regurgitation,
atrial dilatation, arrhythmia and ventricular dysfunction.(?<=[.!?])\s+(?=[A-Z0-9])Chronic rheumatic
heart disease is a major cause of mitral valve stenosis in children.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Rheumatic heart disease should be suspected in any child with a previous
history of rheumatic fever who presents with heart failure or is found to have
a heart murmur. | 146 | 291 | 1 | WHO-0001 | 1 | who_corpus.pdf | 396 |
Diagnosis
Rheumatic heart disease should be suspected in any child with a previous
history of rheumatic fever who presents with heart failure or is found to have
a heart murmur.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis is important because penicillin prophylaxis can
prevent further episodes of rheumatic fever and avoid worse damage to the
heart valves.(?<=[.!?])\s+(?=[A-Z0-9])The presentation depends on the severity.(?<=[.!?])\s+(?=[A-Z0-9])Mild disease may cause few
symptoms except for a heart murmur in an otherwise well child and is rarely
RHEUMATIC HEART DISEASE | 146 | 292 | 2 | WHO-0001 | 1 | who_corpus.pdf | 161 |
123
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
diagnosed.(?<=[.!?])\s+(?=[A-Z0-9])Severe disease may present with symptoms that depend on the
extent of heart damage or the presence of infective endocarditis.(?<=[.!?])\s+(?=[A-Z0-9])History
•
chest pain
•
heart palpitations
•
symptoms of heart failure (including orthopnoea, paroxysmal nocturnal
dyspnoea and oedema)
•
fever or stroke usually associated with infection of damaged heart valves
•
breathlessness on exertion or exercise
•
fainting (syncope)
Examination
•
signs of heart failure
•
cardiomegaly with a heart murmur
•
signs of infective endocarditis (e.g. conjunctival or retinal haemorrhages,
hemiparesis, Osler nodes, Roth spots and splenomegaly)
Investigations
•
chest X-ray: cardiomegaly with congested lungs
•
an echocardiogram, if available, is useful for confi rming rheumatic heart
disease, the extent of valve damage and evidence of infective endocarditis.
•
full blood count
•
blood culture
Management
•
Admit the child if in heart failure or has suspected bacterial endocarditis.
•
Treatment depends on the type and extent of valvular damage.
•
Manage heart failure if present (see p.(?<=[.!?])\s+(?=[A-Z0-9])121).
Give diuretics to relieve symptoms of pulmonary congestion and vasodila-
tors when necessary.
Give penicillin or ampicillin or ceftriaxone plus gentamicin IV or IM for 4–6
weeks for infective endocarditis.
Refer for echocardiographic evaluation and decision on long-term man-
agement. | 147 | 293 | 0 | WHO-0001 | 1 | who_corpus.pdf | 366 |
May require surgical management in severe valvular stenosis or
regurgitation.(?<=[.!?])\s+(?=[A-Z0-9])RHEUMATIC HEART DISEASE | 147 | 294 | 1 | WHO-0001 | 1 | who_corpus.pdf | 39 |
124
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH
Follow-up care
•
All children with rheumatic heart disease should receive routine antibiotic
prophylaxis.
Give benzathine benzylpenicillin at 600 000 U IM every 3–4 weeks
•
Ensure antibiotic prophylaxis for endocarditis before dental and invasive
surgical procedures.
•
Ensure that vaccinations are up to date.
•
Review every 3–6 months, depending on severity of valvular damage.(?<=[.!?])\s+(?=[A-Z0-9])Complications
Infective endocarditis is more common.(?<=[.!?])\s+(?=[A-Z0-9])It presents with fever and heart mur-
mur in a very unwell child.(?<=[.!?])\s+(?=[A-Z0-9])Treat with ampicillin and gentamicin for 6 weeks.(?<=[.!?])\s+(?=[A-Z0-9])Atrial fi brillation or thromboembolism may occur, especially in the presence
of mitral stenosis.(?<=[.!?])\s+(?=[A-Z0-9])Notes
RHEUMATIC HEART DISEASE | 148 | 295 | 0 | WHO-0001 | 1 | who_corpus.pdf | 279 |
125
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
CHAPTER 5
Diarrhoea
This chapter gives treatment guidelines on the management of acute diarrhoea
(with severe, some or no dehydration), persistent diarrhoea and dysentery in
children aged 1 week to 5 years.(?<=[.!?])\s+(?=[A-Z0-9])Assessment of severely malnourished children
is described in sections 7.2 and 7.4.3 (pp.(?<=[.!?])\s+(?=[A-Z0-9])198 and 203).(?<=[.!?])\s+(?=[A-Z0-9])The three essential ele-
ments in the management of all children with diarrhoea are rehydration therapy,
zinc supplementation and counselling for continued feeding and prevention.(?<=[.!?])\s+(?=[A-Z0-9])In diarrhoea, there is excess loss of water, electrolytes (sodium, potassium, and
bicarbonate) and zinc in liquid stools.(?<=[.!?])\s+(?=[A-Z0-9])Dehydration occurs when these losses
are not adequately replaced and there are defi cits of water and electrolytes.(?<=[.!?])\s+(?=[A-Z0-9])The degree of dehydration is graded according to symptoms and signs that
refl ect the amount of fl uid lost; see sections 2.3 (p.(?<=[.!?])\s+(?=[A-Z0-9])43) and 5.2 (p. | 149 | 296 | 0 | WHO-0001 | 1 | who_corpus.pdf | 388 |
43) and 5.2 (p.(?<=[.!?])\s+(?=[A-Z0-9])127).(?<=[.!?])\s+(?=[A-Z0-9])The
rehydration regimen is selected according to the degree of dehydration.(?<=[.!?])\s+(?=[A-Z0-9])All
children with diarrhoea should receive zinc supplements.(?<=[.!?])\s+(?=[A-Z0-9])During diarrhoea, decreased food intake and nutrient absorption and increased
nutrient requirements often combine to cause weight loss and failure to grow.(?<=[.!?])\s+(?=[A-Z0-9])Malnutrition can make diarrhoea more severe, more prolonged and more
frequent than in well-nourished children.(?<=[.!?])\s+(?=[A-Z0-9])This vicious circle can be broken by
giving nutrient-rich foods during and continuing after the diarrhoea episode,
when the child is well.(?<=[.!?])\s+(?=[A-Z0-9])5.1 Child presenting with diarrhoea
126
5.2 Acute diarrhoea
127
5.2.1 Severe dehydration
129
5.2.2 Some dehydration
132
5.2.3 No dehydration
134
5.3 Persistent diarrhoea
137
5.3.1 Severe persistent diarrhoea
137
5.3.2 Persistent diarrhoea (non-severe)
142
5.4 Dysentery
143 | 149 | 297 | 1 | WHO-0001 | 1 | who_corpus.pdf | 355 |
126
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Antibiotics should not be used except for children with bloody diarrhoea
(probable shigellosis), suspected cholera with severe dehydration and other
serious non-intestinal infections such as pneumonia and urinary tract infection.(?<=[.!?])\s+(?=[A-Z0-9])Antiprotozoal drugs are rarely indicated. ‘Antidiarrhoeal’ drugs and anti-emetics
should not be given to young children with acute or persistent diarrhoea or
dysentery: they do not prevent dehydration or improve nutritional status, and
some have dangerous, sometimes fatal, side-effects.(?<=[.!?])\s+(?=[A-Z0-9])5.1
Child presenting with diarrhoea
History
A careful feeding history is essential in the management of a child with diar-
rhoea.(?<=[.!?])\s+(?=[A-Z0-9])Inquiries should also be made about:
■frequency of stools
■number of days of diarrhoea
■blood in stools
■report of a cholera outbreak in the area
■recent antibiotic or other drug treatment
■attacks of crying with pallor in an infant.(?<=[.!?])\s+(?=[A-Z0-9])Examination
Look for:
■signs of some dehydration or severe dehydration:
– restlessness or irritability
– lethargy or reduced level of consciousness
– sunken eyes
– skin pinch returns slowly or very slowly
– thirsty or drinks eagerly, or drinking poorly or not able to drink
■blood in stools
■signs of severe malnutrition
■abdominal mass
■abdominal distension. | 150 | 298 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
There is no need for routine stool microscopy or culture in children with non-
bloody diarrhoea.(?<=[.!?])\s+(?=[A-Z0-9])CHILD PRESENTING WITH DIARRHOEA | 150 | 299 | 1 | WHO-0001 | 1 | who_corpus.pdf | 48 |
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