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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)
■... | 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+(?=[... | 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 intr... | 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, giv... | 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 dri... | 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... | 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,... | 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 se... | 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 par... | 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+(... | 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... | 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 ... | 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... | 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 ... | 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 sho... | 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... | 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 o... | 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 inf... | 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, de... | 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 a... | 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.(?<=[.... | 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 ... | 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 th... | 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, particula... | 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 und... | 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 ... | 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 dos... | 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... | 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).
... | 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 overhydrati... | 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 w... | 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... | 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 ... | 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
... | 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-d... | 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 dif... | 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.(?<=... | 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 p... | 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-... | 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 ci... | 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... | 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 con... | 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 t... | 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 th... | 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... | 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... | 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 onl... | 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... | 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 ... | 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 improve... | 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]... | 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... | 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 anti... | 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, ... | 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
sho... | 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 managemen... | 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])Th... | 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 in... | 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
... | 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 subc... | 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 c... | 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 f... | 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... | 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 ind... | 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 ap... | 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 ... | 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).(?<=[.!?... | 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.(... | 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 na... | 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.
... | 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 ... | 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 multiplica... | 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 ... | 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 p... | 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 o... | 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 ant... | 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 o... | 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 m... | 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 pa... | 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... | 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 lun... | 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 fro... | 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 ar... | 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+(?=... | 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 ... | 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
... | 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+... | 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 disea... | 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 wor... | 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... | 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.
•
Ens... | 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
... | 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... | 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... | 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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