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127
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Table 11.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with diarrhoea
Diagnosis
In favour
Acute (watery) diarrhoea
– More than three loose stools per day
– No blood in stools
Cholera
– Profuse watery diarrhoea with severe
dehydration during cholera ou... | 151 | 300 | 0 | WHO-0001 | 1 | who_corpus.pdf | 368 |
128
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Pinching the child’s
abdomen to test for
decreased skin turgor
Table 12.(?<=[.!?])\s+(?=[A-Z0-9])Classifi cation of the severity of dehydration in children with diarrhoea
Classifi cation
Signs or symptoms
Treatment
Severe
dehydration
Two or more of the
following signs:
■ letha... | 152 | 301 | 0 | WHO-0001 | 1 | who_corpus.pdf | 373 |
No
dehydration
Not enough signs to
classify as some or
severe dehydration
Give fl uid and food to treat
diarrhoea at home (see
diarrhoea treatment plan A,
p.(?<=[.!?])\s+(?=[A-Z0-9])138)
Advise mother on when to
return immediately (see p.(?<=[.!?])\s+(?=[A-Z0-9])133)
Follow up in 5 days if not
improving.(... | 152 | 302 | 1 | WHO-0001 | 1 | who_corpus.pdf | 134 |
129
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
5.2.1
Severe dehydration
Children with severe dehydration require rapid IV rehydration with close moni-
toring, followed by oral rehydration and zinc once the child starts to improve
suffi ciently.(?<=[.!?])\s+(?=[A-Z0-9])In areas where there is a cholera outbreak, give an anti... | 153 | 303 | 0 | WHO-0001 | 1 | who_corpus.pdf | 358 |
Do not use 5% glucose (dextrose) solution or 0.18% saline
with 5% dextrose solution, as they increase the risk for hyponatraemia, which
can cause cerebral oedema.
Give 100 ml/kg of the chosen solution, divided as shown in Table 13.(?<=[.!?])\s+(?=[A-Z0-9])Slow return of skin pinch
in severe dehydration
SEVERE D... | 153 | 304 | 1 | WHO-0001 | 1 | who_corpus.pdf | 91 |
130
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Table 13.(?<=[.!?])\s+(?=[A-Z0-9])Administration of intravenous fl uids to a severely dehydrated child
Age (months)
First, give 30 ml/kg in:
Then, give 70 ml/kg in:
< 12
1 ha
5 h
≥ 12
30 mina
2.5 h
a Repeat if the radial pulse is still very weak or not detectable.(?<=[.!?])\s+(?=... | 154 | 305 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
353).
Prescribe zinc supplementation as soon as vomiting stops (pp.(?<=[.!?])\s+(?=[A-Z0-9])133–4).(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
Reassess the child every 15–30 min until a strong radial pulse is present.(?<=[.!?])\s+(?=[A-Z0-9])Thereafter,
reassess the child by checking skin pinch, level of consciousness and... | 154 | 306 | 1 | WHO-0001 | 1 | who_corpus.pdf | 385 |
135).(?<=[.!?])\s+(?=[A-Z0-9])If the child is usually breastfed, encourage the mother to
continue breastfeeding frequently.
•
If there are no signs of dehydration, follow the guidelines in section 5.1.3
and treatment plan A, p.(?<=[.!?])\s+(?=[A-Z0-9])138.(?<=[.!?])\s+(?=[A-Z0-9])When appropriate, encourage the moth... | 154 | 307 | 2 | WHO-0001 | 1 | who_corpus.pdf | 169 |
131
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Chart 13.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan C:
Treat severe dehydration quickly
➞ Follow the arrows.(?<=[.!?])\s+(?=[A-Z0-9])If the answer is YES, go across.(?<=[.!?])\s+(?=[A-Z0-9])If NO, go down.(?<=[.!?])\s+(?=[A-Z0-9])CHART 13.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHO... | 155 | 308 | 0 | WHO-0001 | 1 | who_corpus.pdf | 362 |
If hydration
status is not improving, give the IV drip more rapidly.(?<=[.!?])\s+(?=[A-Z0-9])Also watch for over-hydration.
Also give ORS (about 5 ml/kg per h) as soon as the
child can drink: usually after 3–4 h (infants) and
1–2 h (children).
■Reassess an infant after 6 h and a child after 3 h.(?<=[.!?])\s+(?... | 155 | 309 | 1 | WHO-0001 | 1 | who_corpus.pdf | 350 |
Then, choose the appropriate plan (A, B or C)
to continue treatment.(?<=[.!?])\s+(?=[A-Z0-9])Note: If possible, observe the child for at least 6 h after
rehydration to be sure the mother can maintain hydration by
giving the child ORS solution by mouth.(?<=[.!?])\s+(?=[A-Z0-9])Refer urgently
to hospital
for IV or
... | 155 | 310 | 2 | WHO-0001 | 1 | who_corpus.pdf | 284 |
132
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
discharge, to confi rm that the mother is able to maintain the child’s hydra-
tion by giving ORS solution.(?<=[.!?])\s+(?=[A-Z0-9])All children should start to receive some ORS solution (about 5 ml/kg per h) by cup
when they can drink without diffi culty (usually within 3–4 h for... | 156 | 311 | 0 | WHO-0001 | 1 | who_corpus.pdf | 388 |
Note that if a child has only one of the above signs and one of the signs of
severe dehydration (e.g. restlessness or irritable and drinking poorly), then the
child also has some dehydration.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
In the fi rst 4 h, give the child ORS solution according to the child’s weight
(or age i... | 156 | 312 | 1 | WHO-0001 | 1 | who_corpus.pdf | 317 |
133
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Advise breastfeeding mothers to continue to breastfeed whenever the
child wants.
Check blood glucose or electrolytes if possible in a child who is restless
or irritable and convulsing, in case hypoglycaemia or hypernatraemia is
present.(?<=[.!?])\s+(?=[A-Z0-9])Manage... | 157 | 313 | 0 | WHO-0001 | 1 | who_corpus.pdf | 274 |
294).
(iv) Return if the child develops any of the following signs:
– drinking poorly or unable to drink or breastfeed
– develops a general danger sign
– becomes sicker
– develops a fever
– has blood mixed with the stools or more than a few drops on the
outside of the stool
•
If the child still has some dehydration, ... | 157 | 314 | 1 | WHO-0001 | 1 | who_corpus.pdf | 348 |
134
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Give zinc and advise the mother how much to give:
≤ 6 months: half tablet (10 mg) per day for 10–14 days
≥ 6 months: one tablet (20 mg) per day for 10–14 days
Feeding
Continuation of nutritious feeding is an important element in the management
of diarrhoea.
In the init... | 158 | 315 | 0 | WHO-0001 | 1 | who_corpus.pdf | 383 |
If the child is ≥ 6 months or already taking solid food,
give freshly prepared foods – cooked, mashed or ground.(?<=[.!?])\s+(?=[A-Z0-9])The following are
recommended:
•
cereal or another starchy food mixed with pulses, vegetables and meat or
fi sh, if possible, with 1–2 teaspoons of vegetable oil added to each serv... | 158 | 316 | 1 | WHO-0001 | 1 | who_corpus.pdf | 393 |
128).(?<=[.!?])\s+(?=[A-Z0-9])NO DEHYDRATION | 158 | 317 | 2 | WHO-0001 | 1 | who_corpus.pdf | 30 |
135
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Chart 14.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan B: Treat some
dehydration with oral rehydration salts
GIVE THE RECOMMENDED AMOUNT OF ORS IN THE CLINIC OVER 4 H
Determine amount of ORS to give during fi rst 4 h:
Agea
≤ 4 months
4 to ≤ 12 months
12 months
to ≤ 2 ye... | 159 | 318 | 0 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Also give her
two packets as recommended in plan A.
– Explain the four rules of home treatment:
1.(?<=[.!?])\s+(?=[A-Z0-9])Give extra fl uid.(?<=[.!?])\s+(?=[A-Z0-9])2.(?<=[.!?])\s+(?=[A-Z0-9])Give zinc supplements.(?<=[.!?])\s+(?=[A-Z0-9])3.(?<=[.!?])\s+(?=[A-Z0-9])Continue feeding.(?<=[.!?])\s+(?=[A-Z0-9])4.(?<=... | 159 | 319 | 1 | WHO-0001 | 1 | who_corpus.pdf | 352 |
136
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Treatment
Treat the child as an outpatient.
Counsel the mother on the four rules of home treatment:
– Give extra fl uid.
– Give zinc supplements.
– Continue feeding.
– Know when to return to the clinic.(?<=[.!?])\s+(?=[A-Z0-9])See treatment plan A (Chart 15 on p.(?<=... | 160 | 320 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
Tell the mother to give small sips from a cup.(?<=[.!?])\s+(?=[A-Z0-9])If the child vomits, wait 10 min,
and then give more slowly.(?<=[.!?])\s+(?=[A-Z0-9])She should continue giving extra fl uid until the
diarrhoea stops.(?<=[.!?])\s+(?=[A-Z0-9])Teach the mother how to mix and give ORS solution, and give her two pack... | 160 | 321 | 1 | WHO-0001 | 1 | who_corpus.pdf | 241 |
137
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
•
Older children can chew the tablet or drink it dissolved.
– Remind the mother to give the zinc supplement for the full 10–14 days.
Continue feeding: see nutrition counselling in Chapters 10 (p.(?<=[.!?])\s+(?=[A-Z0-9])293) and 12
(p.(?<=[.!?])\s+(?=[A-Z0-9])323).
Ad... | 161 | 322 | 0 | WHO-0001 | 1 | who_corpus.pdf | 369 |
See treatment plan A, (Chart 15, p.(?<=[.!?])\s+(?=[A-Z0-9])138).(?<=[.!?])\s+(?=[A-Z0-9])5.3
Persistent diarrhoea
Persistent diarrhoea is diarrhoea, with or without blood, that begins acutely
and lasts for ≥ 14 days.(?<=[.!?])\s+(?=[A-Z0-9])When there is some or severe dehydration, persistent
diarrhoea is classifi ... | 161 | 323 | 1 | WHO-0001 | 1 | who_corpus.pdf | 395 |
Perform stool microscopy
for parasites such as Isospora and Cryptosporidium.(?<=[.!?])\s+(?=[A-Z0-9])5.3.1
Severe persistent diarrhoea
Diagnosis
■Infants or children with diarrhoea lasting ≥ 14 days with signs of dehydra-
tion (see Table 12, p.(?<=[.!?])\s+(?=[A-Z0-9])128) have severe persistent diarrhoea and requ... | 161 | 324 | 2 | WHO-0001 | 1 | who_corpus.pdf | 195 |
138
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Chart 15.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan A:
Treat diarrhoea at home
COUNSEL THE MOTHER ON THE FOUR RULES OF HOME TREATMENT:
GIVE EXTRA FLUID.(?<=[.!?])\s+(?=[A-Z0-9])GIVE ZINC SUPPLEMENTS.(?<=[.!?])\s+(?=[A-Z0-9])CONTINUE FEEDING.(?<=[.!?])\s+(?=[A-Z0-9])KNOW... | 162 | 325 | 0 | WHO-0001 | 1 | who_corpus.pdf | 392 |
Give the mother two packets
of ORS to use at home.
Show the mother how much fl uid to give in addition to the usual fl uid intake:
≤ 2 years: 50–100 ml after each loose stool
≥ 2 years: 100–200 ml after each loose stool
Tell the mother to:
– Give frequent small sips from a cup.
– If the child vomits, wait 10 min.... | 162 | 326 | 1 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Continue feeding.(?<=[.!?])\s+(?=[A-Z0-9])4.(?<=[.!?])\s+(?=[A-Z0-9])Know when to return to the clinic.(?<=[.!?])\s+(?=[A-Z0-9])CHART 15.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA TREATMENT PLAN A:
See mother’s card (p.(?<=[.!?])\s+(?=[A-Z0-9])322) | 162 | 327 | 2 | WHO-0001 | 1 | who_corpus.pdf | 156 |
139
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
ORS solution is effective for most children with persistent diarrhoea.(?<=[.!?])\s+(?=[A-Z0-9])A few
children, however, may have impaired glucose absorption, and ORS solution
may not be as effective.(?<=[.!?])\s+(?=[A-Z0-9])When these children are given ORS, their stool volume... | 163 | 328 | 0 | WHO-0001 | 1 | who_corpus.pdf | 381 |
141.
Treat persistent diarrhoea with blood in the stools with an oral antibiotic
effective for Shigella, as described in section 5.4, p.(?<=[.!?])\s+(?=[A-Z0-9])143.
Give oral metronidazole at 10 mg/kg three times a day for 5 days only if:
– microscopic examination of fresh faeces reveals trophozoites of Enta... | 163 | 329 | 1 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Infants aged < 6 months
•
Encourage exclusive breastfeeding.(?<=[.!?])\s+(?=[A-Z0-9])Help mothers who are not breastfeeding
exclusively to do so.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE PERSISTENT DIARRHOEA | 163 | 330 | 2 | WHO-0001 | 1 | who_corpus.pdf | 74 |
140
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
•
If the child is not breastfeeding, give a breast milk substitute that is low in
lactose, such as yoghurt, or is lactose-free.(?<=[.!?])\s+(?=[A-Z0-9])Use a spoon or cup; do not use
a feeding bottle.(?<=[.!?])\s+(?=[A-Z0-9])Once the child improves, help the mother to re-esta... | 164 | 331 | 0 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Two recommended diets
Tables 14 and 15 show two diets recommended for children and infants aged
> 6 months with severe persistent diarrhoea.(?<=[.!?])\s+(?=[A-Z0-9])If there are signs of dietary failure
(see below) or if the child is not improving after 7 days of treatment, the fi rst
diet should be stopped and the ... | 164 | 332 | 1 | WHO-0001 | 1 | who_corpus.pdf | 369 |
Children may then return home but must be followed up
regularly to ensure continued weight gain and compliance with feeding advice.(?<=[.!?])\s+(?=[A-Z0-9])Dietary failure is indicated by:
■an increase in stool frequency (usually to > 10 watery stools a day), often with
a return of signs of dehydration (usually sh... | 164 | 333 | 2 | WHO-0001 | 1 | who_corpus.pdf | 133 |
141
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Table 14.(?<=[.!?])\s+(?=[A-Z0-9])First diet for persistent diarrhoea: a starch-based, reduced-milk
(low-lactose) diet
The diet should contain at least 70 calories/100 g, provide milk or yoghurt as a
source of animal protein, but no more than 3.7 g lactose/kg per day and shoul... | 165 | 334 | 0 | WHO-0001 | 1 | who_corpus.pdf | 299 |
The following example provides 75
calories/100 g:
■ whole egg
64 g
■ rice
3 g
■ vegetable oil
4 g
■ glucose
3 g
■ water to make up
200 ml
Finely ground, cooked chicken (12 g) can be used in place of egg to give a diet
providing 70 calories/100 g
Supplementary multivitamins and minerals
Give all children with per... | 165 | 335 | 1 | WHO-0001 | 1 | who_corpus.pdf | 220 |
142
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Monitoring
Nurses should check the following daily:
•
body weight
•
temperature
•
food taken
•
number of diarrhoeal stools.(?<=[.!?])\s+(?=[A-Z0-9])5.3.2 Persistent diarrhoea (non-severe)
Children with non-severe persistent diarrhoea do not require hospital treatment
but ne... | 166 | 336 | 0 | WHO-0001 | 1 | who_corpus.pdf | 382 |
These children require admission to hospital for IV rehydration until ORS
solution can be taken without aggravating the diarrhoea.(?<=[.!?])\s+(?=[A-Z0-9])Identify and treat specifi c infections
Do not routinely treat with antibiotics, as they are not effective; however,
give antibiotic treatment to children with ... | 166 | 337 | 1 | WHO-0001 | 1 | who_corpus.pdf | 306 |
143
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Feeding
Careful attention to feeding is essential for all children with persistent diar-
rhoea.(?<=[.!?])\s+(?=[A-Z0-9])These children may have diffi culty in digesting animal milk other than
breast milk.
■Advise the mother to reduce the amount of animal milk in the child’s d... | 167 | 338 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
Supplementary micronutrients, including zinc
See box, p.(?<=[.!?])\s+(?=[A-Z0-9])141.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Ask the mother to bring the child back for reassessment after 5 days, or
earlier if the diarrhoea worsens or other problems develop.
Fully reassess children who have not gained weight or who... | 167 | 339 | 1 | WHO-0001 | 1 | who_corpus.pdf | 356 |
144
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Diagnosis
The diagnostic signs of dysentery are frequent loose stools mixed with visible
red blood.(?<=[.!?])\s+(?=[A-Z0-9])Other fi ndings on examination may include:
■abdominal pain
■fever
■convulsions
■lethargy
■dehydration (see section 5.2, p.(?<=[.!?])\s+(?=[A-Z0-... | 168 | 340 | 0 | WHO-0001 | 1 | who_corpus.pdf | 341 |
Note: There is widespread Shigella resistance to ampicillin, co-trimoxazole,
chloramphenicol, nalidixic acid, tetracycline, gentamicin and fi rst- and second-
generation cephalosporin, which are no longer effective.(?<=[.!?])\s+(?=[A-Z0-9])There is also already
reported resistance to ciprofl oxacin in some countries.(?... | 168 | 341 | 1 | WHO-0001 | 1 | who_corpus.pdf | 170 |
145
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
•
If there is no improvement after 2 full days of treatment:
check for other conditions (see Chapter 2),
stop the fi rst antibiotic, and give a second-line antibiotic or a known ef-
fective against Shigella in the area (see Annex 2 for dosages).
•
If the two antibiotic... | 169 | 342 | 0 | WHO-0001 | 1 | who_corpus.pdf | 319 |
Dysentery is
unusual in neonates and young infants; therefore, consider life-threatening
bacterial sepsis
For suspected sepsis give IM or IV ceftriaxone at 100 mg/kg once daily
for 5 days.(?<=[.!?])\s+(?=[A-Z0-9])Severely malnourished children
See Chapter 7 for the general management of severely malnourished ch... | 169 | 343 | 1 | WHO-0001 | 1 | who_corpus.pdf | 364 |
Never give drugs for symptomatic relief of abdominal or rectal pain or to reduce
the frequency of stools, as these drugs can increase the severity of the illness.(?<=[.!?])\s+(?=[A-Z0-9])Treatment of dehydration
Assess the child for signs of dehydration and give fl uids according to treat-
ment plan A, B or C (pp.(... | 169 | 344 | 2 | WHO-0001 | 1 | who_corpus.pdf | 148 |
146
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Nutritional management
Ensuring a good diet is important, as dysentery has a marked adverse effect on
nutritional status.(?<=[.!?])\s+(?=[A-Z0-9])Feeding is often diffi cult because of lack of appetite; return
of appetite is an important sign of improvement.
Breastfeeding s... | 170 | 345 | 0 | WHO-0001 | 1 | who_corpus.pdf | 373 |
Potassium depletion can be prevented by giving ORS
solution (when indicated) or potassium-rich foods such as bananas, coconut
water or dark-green leafy vegetables.
•
High fever.(?<=[.!?])\s+(?=[A-Z0-9])If the child has high fever (≥ 39 °C or ≥ 102.2 °F) that appears to
be causing distress, give paracetamol and cons... | 170 | 346 | 1 | WHO-0001 | 1 | who_corpus.pdf | 373 |
Always check for hypoglycaemia.
•
Haemolytic uraemic syndrome.(?<=[.!?])\s+(?=[A-Z0-9])Where laboratory tests are not possible,
suspect haemolytic uraemic syndrome in patients with easy bruising, pallor,
altered consciousness and low or no urine output.
•
Toxic megacolon.(?<=[.!?])\s+(?=[A-Z0-9])Toxic megacolon us... | 170 | 347 | 2 | WHO-0001 | 1 | who_corpus.pdf | 237 |
147
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Notes | 171 | 348 | 0 | WHO-0001 | 1 | who_corpus.pdf | 30 |
148
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
Notes | 172 | 349 | 0 | WHO-0001 | 1 | who_corpus.pdf | 30 |
149
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
CHAPTER 6
F ever
This chapter gives treatment guidelines for the management of the most impor-
tant conditions for which children aged between 2 months and 5 years present
with fever.(?<=[.!?])\s+(?=[A-Z0-9])Management of febrile conditions in young infants (< 2 months) is
descri... | 173 | 350 | 0 | WHO-0001 | 1 | who_corpus.pdf | 357 |
150
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.1
Child presenting with fever
6.1.1
Fever lasting 7 days or less
Special attention should be paid to children presenting with fever.(?<=[.!?])\s+(?=[A-Z0-9])The main
aim is to differentiate serious, treatable infections from mild self-resolving
febrile illness.(?<=[.!?])\s+(?... | 174 | 351 | 0 | WHO-0001 | 1 | who_corpus.pdf | 383 |
151
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
FEVER LASTING 7 DAYS OR LESS
Laboratory investigations
•
oxygen saturation
•
blood smear
•
urine microscopy and culture
•
full blood count
•
lumbar puncture if signs suggest meningitis
•
blood culture
Differential diagnosis
The four major categories of fever in children are:
... | 175 | 352 | 0 | WHO-0001 | 1 | who_corpus.pdf | 379 |
152
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Table 17.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis of fever with localized signs
Diagnosis
In favour
Meningitis
– Multiple or complicated convulsions
– Altered level of consciousness
– Lumbar puncture positive
– Stiff neck
– Bulging fontanelle in infancy
– Meningococcal... | 176 | 353 | 0 | WHO-0001 | 1 | who_corpus.pdf | 365 |
153
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Table 18.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis of fever with rash
Diagnosis
In favour
Measles
– Typical rash (see p.(?<=[.!?])\s+(?=[A-Z0-9])174)
– Cough, runny nose, red eyes
– Mouth ulcers
– Corneal clouding
– Recent exposure to a measles case
– No documented measl... | 177 | 354 | 0 | WHO-0001 | 1 | who_corpus.pdf | 368 |
Some causes of fever are found only
in certain regions (e.g. malaria, dengue haemorrhagic fever, relapsing fever).(?<=[.!?])\s+(?=[A-Z0-9])Other fevers may be seasonal (e.g. malaria, meningococcal meningitis) or
occur in epidemics (measles, dengue, meningococcal meningitis, typhus).(?<=[.!?])\s+(?=[A-Z0-9])6.1.2
Fev... | 177 | 355 | 1 | WHO-0001 | 1 | who_corpus.pdf | 272 |
154
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
History
Take a history, as for fever (see p.(?<=[.!?])\s+(?=[A-Z0-9])150).(?<=[.!?])\s+(?=[A-Z0-9])In addition, consider the possibility of
HIV, TB or malignancy, which can cause persistent fever.(?<=[.!?])\s+(?=[A-Z0-9])Examination
Fully undress the child, and examine the whole bo... | 178 | 356 | 0 | WHO-0001 | 1 | who_corpus.pdf | 339 |
Laboratory investigations
When available, perform the following:
•
blood fi lms or rapid diagnostic test for malaria parasites (a positive test in
an endemic area does not exclude other, co-existing causes of fever)
•
full blood count, including platelet count, and examination of a thin fi lm for
cell morphology
•
... | 178 | 357 | 1 | WHO-0001 | 1 | who_corpus.pdf | 167 |
155
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Differential diagnosis
Review all the conditions listed in Tables 16–18 (pp.(?<=[.!?])\s+(?=[A-Z0-9])151–3).(?<=[.!?])\s+(?=[A-Z0-9])In addition, consider
the causes of fever lasting > 7 days in Table 19.(?<=[.!?])\s+(?=[A-Z0-9])Table 19.(?<=[.!?])\s+(?=[A-Z0-9])Additional differe... | 179 | 358 | 0 | WHO-0001 | 1 | who_corpus.pdf | 381 |
85)
Brucellosis (local
knowledge of
prevalence is
important)
– Chronic relapsing or persistent fever
– Malaise
– Musculoskeletal pain
– Lower backache or hip pain
– Enlarged spleen
– Anaemia
– History of drinking unboiled milk
FEVER LASTING LONGER THAN 7 DAYS | 179 | 359 | 1 | WHO-0001 | 1 | who_corpus.pdf | 52 |
156
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Table 19.(?<=[.!?])\s+(?=[A-Z0-9])Continued
Diagnosis
In favour
Borreliosis
(relapsing fever)
(local knowledge
of prevalence
important)
– Painful muscles and joints
– Red eyes
– Enlarged liver and spleen
– Jaundice
– Petaechial rash
– Decreased level of consciousness
– S... | 180 | 360 | 0 | WHO-0001 | 1 | who_corpus.pdf | 382 |
A change of behaviour, confusion, drowsiness, altered conscious-
ness and generalized weakness are usually indicative of ‘cerebral malaria’.(?<=[.!?])\s+(?=[A-Z0-9])Examination.(?<=[.!?])\s+(?=[A-Z0-9])Make a rapid clinical assessment, with special attention to level
of consciousness, blood pressure, rate and depth of... | 180 | 361 | 1 | WHO-0001 | 1 | who_corpus.pdf | 277 |
157
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
■circulatory collapse or shock with systolic blood pressure < 50 mm Hg
■haemoglobinuria (dark urine)
Laboratory fi ndings.(?<=[.!?])\s+(?=[A-Z0-9])Children with the following fi ndings on investigation
have severe malaria:
•
hypoglycaemia (blood glucose < 2.5 mmol/litre or < 45 ... | 181 | 362 | 0 | WHO-0001 | 1 | who_corpus.pdf | 392 |
A lumbar puncture should
be done if there are no contraindications (see p.(?<=[.!?])\s+(?=[A-Z0-9])346).(?<=[.!?])\s+(?=[A-Z0-9])If lumbar puncture is
delayed and bacterial meningitis cannot be excluded, give antibiotic treat-
ment in addition to antimalarial treatment (see p.(?<=[.!?])\s+(?=[A-Z0-9])169).(?<=[.!?])\... | 181 | 363 | 1 | WHO-0001 | 1 | who_corpus.pdf | 384 |
Keep the airway open, and place in recovery position.
Check for hypoglycaemia and correct, if present (see p.(?<=[.!?])\s+(?=[A-Z0-9])161).(?<=[.!?])\s+(?=[A-Z0-9])If blood glu-
cose cannot be measured and hypoglycaemia is suspected, give glucose.
Treat convulsions with rectal or IV diazepam (see Chart 9, p.(?... | 181 | 364 | 2 | WHO-0001 | 1 | who_corpus.pdf | 229 |
158
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Check for associated dehydration, and treat appropriately if present (see
fl uid balance disturbances, p.(?<=[.!?])\s+(?=[A-Z0-9])159).
Treat severe anaemia (see p.(?<=[.!?])\s+(?=[A-Z0-9])160).
Institute regular observation of vital and neurological signs.(?<=[.!?])\s+(... | 182 | 365 | 0 | WHO-0001 | 1 | who_corpus.pdf | 274 |
If it is not available, parenteral artemether or quinine should
be used.(?<=[.!?])\s+(?=[A-Z0-9])Give antimalarial agents by the parenteral route until the child can
take oral medication or for a minimum of 24 h even if the patient can tolerate
oral medication earlier.
Artesunate: Give artesunate at 2.4 mg/kg IV... | 182 | 366 | 1 | WHO-0001 | 1 | who_corpus.pdf | 380 |
If IV quinine infusion is not possible, quinine
dihydrochloride can be given as a diluted divided IM injection.(?<=[.!?])\s+(?=[A-Z0-9])Give the loading
dose split into two as 10 mg/kg of quinine salt into the anterior aspect of each
thigh.(?<=[.!?])\s+(?=[A-Z0-9])Then, continue with 10 mg/kg every 8 h until oral me... | 182 | 367 | 2 | WHO-0001 | 1 | who_corpus.pdf | 358 |
159
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
•
artesunate plus sulfadoxine–pyrimethamine,
•
dihydroartemisinin plus piperaquine.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
•
Ensure meticulous nursing care, especially for unconscious patients.
•
Ensure that they receive daily fl uid requirements, and monitor fl uid status
car... | 183 | 368 | 0 | WHO-0001 | 1 | who_corpus.pdf | 375 |
Eyelid oedema is a useful sign of fl uid overload.(?<=[.!?])\s+(?=[A-Z0-9])If, after careful rehydration, the urine output over 24 h is < 4 ml/kg, give IV
furosemide, initially at 2 mg/kg.(?<=[.!?])\s+(?=[A-Z0-9])If there is no response, double the dose at
hourly intervals to a maximum of 8 mg/kg (given over 15 min).(... | 183 | 369 | 1 | WHO-0001 | 1 | who_corpus.pdf | 379 |
In children with cerebral malaria:
•
Assess, monitor and record the level of consciousness according to the AVPU
or another locally used coma scale for children (see p.(?<=[.!?])\s+(?=[A-Z0-9])18).(?<=[.!?])\s+(?=[A-Z0-9])SEVERE MALARIA | 183 | 370 | 2 | WHO-0001 | 1 | who_corpus.pdf | 88 |
160
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
•
Exclude other treatable causes of coma (e.g. hypoglycaemia, bacterial menin-
gitis).(?<=[.!?])\s+(?=[A-Z0-9])Always exclude hypoglycaemia by checking blood glucose; if this is not
possible, treat for hypoglycaemia (see p.(?<=[.!?])\s+(?=[A-Z0-9])161).(?<=[.!?])\s+(?=[A-Z0-9])Per... | 184 | 371 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
15).
•
Check blood glucose to exclude hypoglycaemia, and correct with IV glucose
if present; if blood glucose cannot be measured, treat for hypoglycaemia
(see p.(?<=[.!?])\s+(?=[A-Z0-9])161).
If there are repeated convulsions, give phenobarbital (see Chart 9, p.(?<=[.!?])\s+(?=[A-Z0-9])15).
If temperature... | 184 | 372 | 1 | WHO-0001 | 1 | who_corpus.pdf | 344 |
Severe anaemia
Severe anaemia is indicated by severe palmar pallor, often with a fast pulse
rate, diffi cult breathing, confusion or restlessness.(?<=[.!?])\s+(?=[A-Z0-9])Signs of heart failure such
as gallop rhythm, enlarged liver and, rarely, pulmonary oedema (fast breathing,
fi ne basal crackles on auscultation) ma... | 184 | 373 | 2 | WHO-0001 | 1 | who_corpus.pdf | 93 |
161
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Give a blood transfusion as soon as possible (see p.(?<=[.!?])\s+(?=[A-Z0-9])308) to:
– all children with an EVF ≤ 12% or Hb ≤ 4 g/dl.
– less severely anaemic children (EVF > 12–15%; Hb 4–5 g/dl) with any
of the following:
•
shock or clinically detectable dehydration
•
im... | 185 | 374 | 0 | WHO-0001 | 1 | who_corpus.pdf | 343 |
Give whole blood (10 ml/kg rather than 20 ml/kg)
once only and do not repeat the transfusion.
Give a daily iron–folate tablet or iron syrup for 14 days (see p.(?<=[.!?])\s+(?=[A-Z0-9])364).(?<=[.!?])\s+(?=[A-Z0-9])Hypoglycaemia
Hypoglycaemia (blood glucose < 2.5 mmol/litre or < 45 mg/dl) is particularly
common i... | 185 | 375 | 1 | WHO-0001 | 1 | who_corpus.pdf | 350 |
340)
or give sublingual sugar solution.(?<=[.!?])\s+(?=[A-Z0-9])Recheck the blood glucose after 30 min,
and repeat the dextrose (5 ml/kg) if the level is low (< 3.0 mmol/l; < 54 mg/dl).(?<=[.!?])\s+(?=[A-Z0-9])Prevent further hypoglycaemia in an unconscious child by giving 10% dextrose
in normal saline or Ringer’s l... | 185 | 376 | 2 | WHO-0001 | 1 | who_corpus.pdf | 251 |
162
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Monitor blood glucose and signs of fl uid overload.(?<=[.!?])\s+(?=[A-Z0-9])If the child develops fl uid
overload and blood glucose is still low, stop the infusion; repeat 10% glucose
(5 ml/kg), and feed the child by nasogastric tube as appropriate.(?<=[.!?])\s+(?=[A-Z0-9])Once the ... | 186 | 377 | 0 | WHO-0001 | 1 | who_corpus.pdf | 345 |
Continue monitoring blood glucose, and
treat accordingly (as above) if it is < 2.5 mmol/litre or < 45 mg/dl.(?<=[.!?])\s+(?=[A-Z0-9])Respiratory distress (acidosis)
Respiratory distress presents as deep, laboured breathing, while the chest is
clear on auscultation, often accompanied by lower chest wall indrawing.(?<=... | 186 | 378 | 1 | WHO-0001 | 1 | who_corpus.pdf | 398 |
Check the respiratory rate and pulse
rate every 15 min.(?<=[.!?])\s+(?=[A-Z0-9])If either shows any rise, transfuse more slowly to avoid
precipitating pulmonary oedema (see guidelines on blood transfusion,
section 10.6, p.(?<=[.!?])\s+(?=[A-Z0-9])308).
Monitor response by continuous clinical observation (oxygen ... | 186 | 379 | 2 | WHO-0001 | 1 | who_corpus.pdf | 222 |
163
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
•
Give IV ampicillin and gentamicin for a total of 7 days.(?<=[.!?])\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.(?<=[.!?])\s+(?=[A-Z0-9])The IV infusion rate should be checked hourly.(?<=[.!?])\s+(?=[A-Z0... | 187 | 380 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Partially empty
the IV bottle or bag to reduce the amount before starting the infusion.(?<=[.!?])\s+(?=[A-Z0-9])If
the risk of over-infusion cannot be ruled out, it is safer to rehydrate or feed
through a nasogastric tube.
•
Keep a careful record of fl uid intake (including IV infusions) and output.(?<=[.!?])\s+(?=[... | 187 | 381 | 1 | WHO-0001 | 1 | who_corpus.pdf | 250 |
164
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Note: If a child in a malarious area has fever with no obvious cause and it is
not possible to confi rm malaria on a blood fi lm or with a rapid diagnostic test,
treat the child for malaria.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Treat with a fi rst-line antimalarial agent, as in the nati... | 188 | 382 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Separate tablets of 50 mg
artesunate and 500 mg sulfadoxine–25 mg pyrimethamine:
Dosage:
•
Aim for a target dose of 4 mg/kg per day artesunate once a day for 3 days
and 25 mg/kg sulfadoxine – 1.25 mg/kg pyrimethamine on day 1.(?<=[.!?])\s+(?=[A-Z0-9])Artesunate:
•
child weighing 3 – < 10 kg: half tablet once dail... | 188 | 383 | 1 | WHO-0001 | 1 | who_corpus.pdf | 167 |
165
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Artesunate plus mefl oquine.(?<=[.!?])\s+(?=[A-Z0-9])Separate tablets of 50 mg artesunate and
250 mg mefl oquine base:
Dosage:
Aim for a target dose of 4 mg/kg per day artesunate once a day for 3 days
and 25 mg/kg of mefl oquine divided into two or three doses.
Dihydroartemis... | 189 | 384 | 0 | WHO-0001 | 1 | who_corpus.pdf | 355 |
Patients on zidovudine or efavirenz should, however, avoid
amodiaquine-containing artemisinin-based combination therapy, and those
on co-trimoxazole (trimethoprim plus sulfamethoxazole) prophylaxis should
avoid sulfadoxine–pyrimethamine.(?<=[.!?])\s+(?=[A-Z0-9])Uncomplicated P. vivax, ovale and malariae malaria: Mal... | 189 | 385 | 1 | WHO-0001 | 1 | who_corpus.pdf | 347 |
166
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Palmar pallor:
sign of anaemia
Chloroquine-resistant vivax malaria should be treated with amodiaquine,
mefl oquine or dihydroartemisinin plus piperaquine as the drugs of choice.(?<=[.!?])\s+(?=[A-Z0-9])Complications
Anaemia
In any child with palmar pallor, determine the Hb or E... | 190 | 386 | 0 | WHO-0001 | 1 | who_corpus.pdf | 374 |
365).
Advise the mother about good feeding practice.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
If the child is treated as an outpatient, ask the mother to return if the fever
persists after 3 days’ treatment, or sooner if the child’s condition gets worse.(?<=[.!?])\s+(?=[A-Z0-9])If the child returns, check if the child ac... | 190 | 387 | 1 | WHO-0001 | 1 | who_corpus.pdf | 365 |
167
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.3
Meningitis
Early diagnosis is essential for effective treatment.(?<=[.!?])\s+(?=[A-Z0-9])This section refers to
children and infants > 2 months.(?<=[.!?])\s+(?=[A-Z0-9])For diagnosis and treatment of meningitis in
young infants, see section 3.9, p.(?<=[.!?])\s+(?=[A-Z0-9])55... | 191 | 388 | 0 | WHO-0001 | 1 | who_corpus.pdf | 310 |
The possibility of viral encephalitis or tuberculous meningitis
must be considered as differential diagnoses in children with meningeal signs.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Look for a history of:
■convulsions
■vomiting
■inability to drink or breastfeed
■a headache or pain in back of neck
■irritability
... | 191 | 389 | 1 | WHO-0001 | 1 | who_corpus.pdf | 213 |
168
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Unequal pupil size: sign of
raised intracranial pressure
Opisthotonus and rigid posture:
sign of meningeal irritation and
raised intracranial pressure
■rigid posture or posturing
■focal paralysis in any of the limbs
■irregular breathing
Laboratory investigations
■Confi rm... | 192 | 390 | 0 | WHO-0001 | 1 | who_corpus.pdf | 288 |
169
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Precaution: If there are signs of increased intracranial pressure, the potential
value of the information from a lumbar puncture should be carefully weighed
against the risk of the procedure.(?<=[.!?])\s+(?=[A-Z0-9])If in doubt, it might be better to start treatment
for suspected... | 193 | 391 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
Cefotaxime: 50 mg/kg per dose IM or IV every 6 h for 7–10 days.
or
3.(?<=[.!?])\s+(?=[A-Z0-9])When there is no known signifi cant resistance to chloramphenicol and
β-lactam antibiotics among bacteria that cause meningitis, follow national
guidelines or choose either of the following two regimens:
•
Chloramphenicol: ... | 193 | 392 | 1 | WHO-0001 | 1 | who_corpus.pdf | 337 |
170
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
– Consider the presence of common complications, such as subdural effu-
sions (persistent fever plus focal neurological signs or reduced level of
consciousness) or a cerebral abscess.(?<=[.!?])\s+(?=[A-Z0-9])If these are suspected, refer the
child to a hospital with specialized f... | 194 | 393 | 0 | WHO-0001 | 1 | who_corpus.pdf | 378 |
Steroids should be given within
10–20 min before or during administration of antibiotics.(?<=[.!?])\s+(?=[A-Z0-9])There is insuffi cient
evidence to recommend routine use of steroids in all children with bacterial
meningitis in developing countries, except in tuberculous meningitis.(?<=[.!?])\s+(?=[A-Z0-9])Do not use... | 194 | 394 | 1 | WHO-0001 | 1 | who_corpus.pdf | 339 |
171
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
•
For children aged ≥ 2–5 years, Neisseria meningitidis is the most likely
pathogen and presumptive treatment is justifi ed.
Give ceftriaxone at 100 mg/kg/day IM or IV once daily for 5 days to children
aged 2 months to 5 years or for at least 7 days to children aged 0–2 months... | 195 | 395 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
It may present
with cranial nerve defi cits, or it may have a more indolent course involving
headache, meningismus and altered mental status.(?<=[.!?])\s+(?=[A-Z0-9])The initial symptoms are
usually nonspecifi c, including headache, vomiting, photophobia and fever.(?<=[.!?])\s+(?=[A-Z0-9])Consult up-to-date internatio... | 195 | 396 | 1 | WHO-0001 | 1 | who_corpus.pdf | 363 |
Consult national TB
programme guidelines.(?<=[.!?])\s+(?=[A-Z0-9])Treatment: The optimal treatment regimen comprises:
Four-drug regimen (HRZE) for 2 months, followed by a two-drug regimen
(HR) for 10 months, the total duration of treatment being 12 months.(?<=[.!?])\s+(?=[A-Z0-9])TUBERCULOUS MENINGITIS | 195 | 397 | 2 | WHO-0001 | 1 | who_corpus.pdf | 102 |
172
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
– 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)
Dexamethasone (0.6 mg... | 196 | 398 | 0 | WHO-0001 | 1 | who_corpus.pdf | 399 |
Children will present with meningitis
with altered mental status.
•
Perform a lumbar puncture.(?<=[.!?])\s+(?=[A-Z0-9])The opening pressure may be elevated, but CSF
cell count, glucose and protein may be virtually normal.
•
Analyse CSF with India ink preparation, or, if available, do a rapid CSF cryp-
tococcal ant... | 196 | 399 | 1 | WHO-0001 | 1 | who_corpus.pdf | 391 |
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