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173
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
solution IV or intraosseusly rapidly (see Chart 10, p.(?<=[.!?])\s+(?=[A-Z0-9])16).(?<=[.!?])\s+(?=[A-Z0-9])Recheck the
blood glucose after 30 min.(?<=[.!?])\s+(?=[A-Z0-9])If the level is low (< 2.5 mmol/litre or < 45 mg/
dl), repeat the glucose (5 ml/kg).(?<=[.!?])\s+(?=[A-Z0-9])I... | 197 | 400 | 0 | WHO-0001 | 1 | who_corpus.pdf | 353 |
304).(?<=[.!?])\s+(?=[A-Z0-9])If the child develops signs of fl uid overload, stop the infusion
and feed by nasogastric tube.
Unconscious child: In an unconscious child, ensure that the airway is open
at all times and that the patient is breathing adequately.
•
Maintain clear airway.
•
Nurse the child in the re... | 197 | 401 | 1 | WHO-0001 | 1 | who_corpus.pdf | 395 |
304).(?<=[.!?])\s+(?=[A-Z0-9])Avoid fl uid overload, ensure an accurate record of intake and
output, and examine frequently for signs of fl uid overload (eyelid oedema,
enlarged liver, crackles at lung bases or fullness of neck veins).(?<=[.!?])\s+(?=[A-Z0-9])Give due attention to acute nutritional support and rehabili... | 197 | 402 | 2 | WHO-0001 | 1 | who_corpus.pdf | 390 |
174
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Monitoring
A nurse should monitor the child’s state of consciousness and vital signs (res-
piratory rate, heart rate and pupil size) every 3 h during the fi rst 24 h (thereafter,
every 6 h), and a doctor should monitor the child at least twice a day.(?<=[.!?])\s+(?=[A-Z0-9])At the t... | 198 | 403 | 0 | WHO-0001 | 1 | who_corpus.pdf | 390 |
21), hyponatraemia
and subdural effusions, which may lead to persistent fever.
•
Long-term complications: Some children have sensory hearing loss, motor
or development problems and epilepsy.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Sensorineural deafness is common after meningitis.(?<=[.!?])\s+(?=[A-Z0-9])Arrange a hearin... | 198 | 404 | 1 | WHO-0001 | 1 | who_corpus.pdf | 373 |
175
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
■one of the following: cough, runny nose or red
eyes.(?<=[.!?])\s+(?=[A-Z0-9])In children with HIV infection, some of these signs
may not be present, and the diagnosis of measles
may be diffi cult.(?<=[.!?])\s+(?=[A-Z0-9])6.4.1
Severe complicated measles
Diagnosis
In a child w... | 199 | 405 | 0 | WHO-0001 | 1 | who_corpus.pdf | 346 |
SEVERE COMPLICATED MEASLES
Distribution of measles
rash.(?<=[.!?])\s+(?=[A-Z0-9])The left side of
the drawing shows the
early rash covering the
head and upper part of
the trunk; the right side
shows the later rash
covering the whole
body.(?<=[.!?])\s+(?=[A-Z0-9])Corneal clouding: sign of xerophthalamia in vitam... | 199 | 406 | 1 | WHO-0001 | 1 | who_corpus.pdf | 124 |
176
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Vitamin A therapy.(?<=[.!?])\s+(?=[A-Z0-9])Give oral vitamin A to all children with measles, unless
the child has already had adequate vitamin A treatment for this illness as an
outpatient.(?<=[.!?])\s+(?=[A-Z0-9])Give oral vitamin A at 50 000 IU (for a child aged < 6 months),... | 200 | 407 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Encourage continued breastfeed-
ing.(?<=[.!?])\s+(?=[A-Z0-9])Encourage the child to take frequent small meals.(?<=[.!?])\s+(?=[A-Z0-9])Check for mouth ulcers
and treat them, if present (see below).(?<=[.!?])\s+(?=[A-Z0-9])Follow the guidelines on nutritional
management given in Chapter 10 (p.(?<=[.!?])\s+(?=[A-Z0-9])... | 200 | 408 | 1 | WHO-0001 | 1 | who_corpus.pdf | 386 |
102): Give supportive care.(?<=[.!?])\s+(?=[A-Z0-9])Do not
give steroids.
Eye problems.(?<=[.!?])\s+(?=[A-Z0-9])Conjunctivitis and corneal and retinal damage may occur due
to infection, vitamin A defi ciency or harmful local remedies.(?<=[.!?])\s+(?=[A-Z0-9])In addition to
giving vitamin A (as above), treat any i... | 200 | 409 | 2 | WHO-0001 | 1 | who_corpus.pdf | 392 |
177
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Mouth ulcers.(?<=[.!?])\s+(?=[A-Z0-9])If the child can drink and eat, clean the mouth with clean, salted
water (a pinch of salt in a cup of water) at least four times a day.
– Apply 0.25% gentian violet to sores in the mouth after cleaning.
– If the mouth ulcers are severe ... | 201 | 410 | 0 | WHO-0001 | 1 | who_corpus.pdf | 388 |
15, for treatment of convulsions and care of an unconscious child.
Severe acute malnutrition: See guidelines in Chapter 7, p.(?<=[.!?])\s+(?=[A-Z0-9])197.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
Take the child’s temperature twice a day, and check for the presence of the
above complications daily.(?<=[.!?])\s+(?=[A-Z0-9... | 201 | 411 | 1 | WHO-0001 | 1 | who_corpus.pdf | 396 |
If infants aged 6–9 months
receive measles vaccine, it is essential that the second dose be given as soon
as possible after 9 months of age.(?<=[.!?])\s+(?=[A-Z0-9])Check the vaccination status of hospital staff and vaccinate, if necessary.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE COMPLICATED MEASLES | 201 | 412 | 2 | WHO-0001 | 1 | who_corpus.pdf | 97 |
178
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.4.2 Non-severe measles
Diagnosis
Diagnose non-severe measles in a child whose mother clearly reports that the
child has had a measles rash, or if the child has:
■fever and
■a generalized rash and
■one of the following: cough, runny nose or red eyes, but
■none of the fea... | 202 | 413 | 0 | WHO-0001 | 1 | who_corpus.pdf | 360 |
369.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
Fever.(?<=[.!?])\s+(?=[A-Z0-9])If the child’s temperature is ≥ 39 °C (≥ 102.2 °F) and is causing distress
or discomfort, give paracetamol.
Nutritional support.(?<=[.!?])\s+(?=[A-Z0-9])Assess the nutritional status by measuring the mid upper
arm circumference (MUAC... | 202 | 414 | 1 | WHO-0001 | 1 | who_corpus.pdf | 380 |
Never use steroid ointment.
Mouth care.(?<=[.!?])\s+(?=[A-Z0-9])If the child has a sore mouth, ask the mother to wash the mouth
with clean, salted water (a pinch of salt in a cup of water) at least four times a
day.(?<=[.!?])\s+(?=[A-Z0-9])Advise the mother to avoid giving salty, spicy or hot foods to the child.(... | 202 | 415 | 2 | WHO-0001 | 1 | who_corpus.pdf | 214 |
179
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.5
Septicaemia
Septicaemia should be considered in a child with acute fever who is severely ill,
when no other cause is found.(?<=[.!?])\s+(?=[A-Z0-9])Septicaemia can also occur as a complication of
meningitis, pneumonia, urinary tract infection or any other bacterial infection.... | 203 | 416 | 0 | WHO-0001 | 1 | who_corpus.pdf | 354 |
Always fully
undress the child and examine carefully for signs of local infection before
deciding that there is no other cause.(?<=[.!?])\s+(?=[A-Z0-9])On examination, look for:
■fever with no obvious focus of infection
■negative blood fi lm for malaria
■no stiff neck or other specifi c sign of meningitis, or ne... | 203 | 417 | 1 | WHO-0001 | 1 | who_corpus.pdf | 299 |
180
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Treatment
Start the child immediately on antibiotics.
Give IV ampicillin at 50 mg/kg every 6 h plus IV gentamicin 7.5 mg/kg once
a day for 7–10 days; alternatively, give ceftriaxone at 80–100 mg/kg IV once
daily over 30–60 min for 7–10 days.
When staphylococcal infection ... | 204 | 418 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
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])Check for the presence of new complications, such
as shock, cyanosis, reduced urine output, signs of bleeding (petaechiae,
purpura, bleeding from venepuncture sites) or skin ulcerati... | 204 | 419 | 1 | WHO-0001 | 1 | who_corpus.pdf | 315 |
181
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
■no stiff neck or other specifi c sign of meningitis, or negative lumbar puncture
for meningitis (Note: children with typhoid can occasionally have a stiff neck)
■signs of systemic upset, e.g. inability to drink or breastfeed, convulsions,
lethargy, disorientation or confusion,... | 205 | 420 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Supportive care
If the child has high fever (≥ 39 °C or ≥ 102.2 °F) that is causing distress or
discomfort, give paracetamol.(?<=[.!?])\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])Complications
Complications of ty... | 205 | 421 | 1 | WHO-0001 | 1 | who_corpus.pdf | 296 |
182
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Mastoiditis: a tender swelling behind
the ear which pushes the ear forward
If there are signs of gastrointestinal perforation, pass an IV line and nasogastric
tube, start appropriate fl uids, and obtain urgent surgical attention.(?<=[.!?])\s+(?=[A-Z0-9])6.7
Ear infections
6.7.1
... | 206 | 422 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
169), and, if possible, refer to a specialist
hospital immediately.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
If the child has a high fever (≥ 39 °C or ≥ 102.2 °F) that is causing distress
or discomfort, give paracetamol.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
The child should be checked by a nurse at least every 6 h a... | 206 | 423 | 1 | WHO-0001 | 1 | who_corpus.pdf | 238 |
183
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.7.2
Acute otitis media
Diagnosis
This is based on a history of ear pain or pus draining from the ear (for < 2 weeks).(?<=[.!?])\s+(?=[A-Z0-9])On examination, confi rm acute otitis media by otoscopy.(?<=[.!?])\s+(?=[A-Z0-9])The ear-drum will be
red, infl amed, bulging and opaque, ... | 207 | 424 | 0 | WHO-0001 | 1 | who_corpus.pdf | 372 |
Advise the
mother to wick the ear three
times daily until there is no
more pus.
Tell the mother not to place
anything in the ear between
wicking treatments.(?<=[.!?])\s+(?=[A-Z0-9])Do not
allow the child to go swimming
or get water in the ear.
If the child has ear pain or high
fever (≥ 39 °C or ≥ 102.2 ... | 207 | 425 | 1 | WHO-0001 | 1 | who_corpus.pdf | 141 |
184
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
URINARY TRACT INFECTION
Follow-up
Ask the mother to return after 5 days.
•
If ear pain or discharge persists, treat for 5 more days with the same antibiotic
and continue wicking the ear.(?<=[.!?])\s+(?=[A-Z0-9])Follow up in 5 days.(?<=[.!?])\s+(?=[A-Z0-9])6.7.3
Chronic otitis me... | 208 | 426 | 0 | WHO-0001 | 1 | who_corpus.pdf | 364 |
Drops containing quinolones are more effective than other antibiotic drops.(?<=[.!?])\s+(?=[A-Z0-9])Topical antiseptics are not effective in the treatment of chronic otitis media
in children.(?<=[.!?])\s+(?=[A-Z0-9])Follow-up
Ask the mother to return after 5 days.(?<=[.!?])\s+(?=[A-Z0-9])If the ear discharge persists:... | 208 | 427 | 1 | WHO-0001 | 1 | who_corpus.pdf | 371 |
185
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Diagnosis
In young children, urinary tract infection often presents as nonspecifi c signs.(?<=[.!?])\s+(?=[A-Z0-9])Consider a diagnosis of urinary tract infection in all infants and children with:
■fever of ≥ 38 °C for at least 24 h without obvious cause
■vomiting or poor feeding... | 209 | 428 | 0 | WHO-0001 | 1 | who_corpus.pdf | 361 |
If microscopy shows no bacteriuria and no pyuria or the dipstick tests are
negative, rule out urinary tract infection.
■If possible, obtain a ‘clean’ urine sample for culture.(?<=[.!?])\s+(?=[A-Z0-9])In sick infants, a speci-
men taken with an in–out urinary catheter or supra-pubic bladder aspiration
may be require... | 209 | 429 | 1 | WHO-0001 | 1 | who_corpus.pdf | 329 |
Alternatives include ampicillin, amoxicillin
and cefalexin, depending on local sensitivity patterns of E. coli and other
Gram-negative bacilli that cause urinary tract infection and on the availability
of antibiotics (see p.(?<=[.!?])\s+(?=[A-Z0-9])353 for details of dosage regimens).
If there is a poor response... | 209 | 430 | 2 | WHO-0001 | 1 | who_corpus.pdf | 137 |
186
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
cephalosporin (see p.(?<=[.!?])\s+(?=[A-Z0-9])358).(?<=[.!?])\s+(?=[A-Z0-9])Consider complications such as pyelonephritis
(tenderness in the costo-vertebral angle and high fever) or septicaemia.
Treat young infants aged < 2 months with gentamicin at 7.5 mg/kg IM or IV
once dai... | 210 | 431 | 0 | WHO-0001 | 1 | who_corpus.pdf | 393 |
6.9
Septic arthritis or osteomyelitis
Acute infection of the bone or joint is usually caused by spread of bacteria
through the blood.(?<=[.!?])\s+(?=[A-Z0-9])However, some bone or joint infections result from an
adjacent focus of infection or from a penetrating injury.(?<=[.!?])\s+(?=[A-Z0-9])Occasionally, several ... | 210 | 432 | 1 | WHO-0001 | 1 | who_corpus.pdf | 393 |
Laboratory investigations
X-rays are not helpful in diagnosis in the early stages of the disease.(?<=[.!?])\s+(?=[A-Z0-9])If septic
arthritis is strongly suspected, introduce a sterile needle under strictly aseptic
SEPTIC ARTHRITIS OR OSTEOMYELITIS | 210 | 433 | 2 | WHO-0001 | 1 | who_corpus.pdf | 61 |
187
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
conditions into the affected joint and aspirate it.(?<=[.!?])\s+(?=[A-Z0-9])The fl uid may be cloudy.(?<=[.!?])\s+(?=[A-Z0-9])If
there is pus in the joint, use a wide-bore needle (after local anaesthesia with 1%
lignocaine) to obtain a sample and remove as much pus as possible.(?<=... | 211 | 434 | 0 | WHO-0001 | 1 | who_corpus.pdf | 365 |
Treatment
The choice of antibiotic is based on the organism involved, modifi ed by the
results of Gram staining and culture.(?<=[.!?])\s+(?=[A-Z0-9])If culture is possible, treat according to
the causative organism and the results of antibiotic sensitivity tests.(?<=[.!?])\s+(?=[A-Z0-9])Otherwise:
Treat with IM or... | 211 | 435 | 1 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Treat according to national TB control programme guidelines.(?<=[.!?])\s+(?=[A-Z0-9])Surgical
treatment is almost never needed because the abscesses will subside with
anti-TB treatment.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
The affected limb or joint should be rested.(?<=[.!?])\s+(?=[A-Z0-9])If it is the leg, the c... | 211 | 436 | 2 | WHO-0001 | 1 | who_corpus.pdf | 208 |
188
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
6.10
Dengue
Dengue is caused by an arbovirus transmitted by Aedes mosquitoes.(?<=[.!?])\s+(?=[A-Z0-9])It is
highly seasonal in many countries in Asia and South America and increasingly
in Africa.(?<=[.!?])\s+(?=[A-Z0-9])The illness usually starts with acute onset of fever, retro... | 212 | 437 | 0 | WHO-0001 | 1 | who_corpus.pdf | 338 |
It can be
diffi cult to distinguish dengue from other common childhood infections.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Most children can be managed at home, provided the parents have good ac-
cess to a hospital.
Counsel the parents to bring the child back for daily follow-up and to return
immediately if any of the... | 212 | 438 | 1 | WHO-0001 | 1 | who_corpus.pdf | 392 |
189
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Plasma leakage, sometimes suffi cient to cause shock, is the most important
complication of dengue infection in children.(?<=[.!?])\s+(?=[A-Z0-9])The patient is considered to
have shock if the pulse pressure (i.e. the difference between the systolic and
diastolic pressures) is ≤ 2... | 213 | 439 | 0 | WHO-0001 | 1 | who_corpus.pdf | 357 |
Most deaths occur in children in profound
shock, particularly if the situation is complicated by fl uid overload (see below).(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
Suspect severe dengue in an area of risk for dengue if the child has fever lasting
> 2 days, and any of the following features:
■evidence of plasma leakage
... | 213 | 440 | 1 | WHO-0001 | 1 | who_corpus.pdf | 222 |
190
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Treatment
Admit all patients with severe dengue to a hospital with facilities for urgent
IV fl uid treatment and blood pressure and EVF monitoring.(?<=[.!?])\s+(?=[A-Z0-9])Fluid management: patients without shock (pulse pressure > 20 mm Hg)
Give IV fl uids for repeated vomiti... | 214 | 441 | 0 | WHO-0001 | 1 | who_corpus.pdf | 310 |
Fluid management: patients in shock (pulse pressure ≤ 20 mm Hg)
Treat as an emergency.(?<=[.!?])\s+(?=[A-Z0-9])Give 10–20 ml/kg of an isotonic crystalloid solution
such as Ringer’s lactate (Hartmann’s solution) or normal saline over 1 h.
– If the child responds (capillary refi ll and peripheral perfusion start to ... | 214 | 442 | 1 | WHO-0001 | 1 | who_corpus.pdf | 340 |
Changes in the EVF
can be a useful guide to treatment but must be interpreted with the clinical
response.(?<=[.!?])\s+(?=[A-Z0-9])For example, a rising EVF with unstable vital signs (particularly
narrowing of the pulse pressure) indicates the need for a further bolus of
fl uid, but extra fl uid is not needed if the v... | 214 | 443 | 2 | WHO-0001 | 1 | who_corpus.pdf | 279 |
191
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Treatment of haemorrhagic complications
■Mucosal bleeding may occur in any patient with dengue but is usually minor.(?<=[.!?])\s+(?=[A-Z0-9])It is due mainly to the low platelet count, and this usually improves rapidly
during the second week of illness.
■If major bleeding occur... | 215 | 444 | 0 | WHO-0001 | 1 | who_corpus.pdf | 364 |
When indicated, it should be given with
extreme care because of the problem of fl uid overload.(?<=[.!?])\s+(?=[A-Z0-9])If major bleeding
is suspected, give 5–10 ml/kg fresh whole blood or 10 ml/kg packed cells
slowly over 2–4 h, and observe the clinical response.(?<=[.!?])\s+(?=[A-Z0-9])Consider repeating
if there ... | 215 | 445 | 1 | WHO-0001 | 1 | who_corpus.pdf | 343 |
192
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
■Late signs:
– pulmonary oedema
– cyanosis
– irreversible shock (often a combination of ongoing hypovolaemia and
cardiac failure)
The management of fl uid overload varies depending on whether the child is
in or out of shock:
•
Children who remain in shock and show signs of se... | 216 | 446 | 0 | WHO-0001 | 1 | who_corpus.pdf | 371 |
Supportive care
Treat high fever with paracetamol if the child is uncomfortable.(?<=[.!?])\s+(?=[A-Z0-9])Do not give
aspirin or NSAIDs such as ibuprofen, as they aggravate the bleeding.
Do not give steroids.
Convulsions are not common in children with severe dengue.(?<=[.!?])\s+(?=[A-Z0-9])If they occur,
... | 216 | 447 | 1 | WHO-0001 | 1 | who_corpus.pdf | 342 |
193
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Monitoring
For children in shock, monitor the vital signs hourly (particularly the pulse
pressure, if possible) until the patient is stable, and check the EVF three or
four times a day.(?<=[.!?])\s+(?=[A-Z0-9])A doctor should review the patient at least four times a day
and p... | 217 | 448 | 0 | WHO-0001 | 1 | who_corpus.pdf | 373 |
Children with mild disease may have only a heart murmur.(?<=[.!?])\s+(?=[A-Z0-9])Severe disease can
present with fever, fast or diffi cult breathing and lethargy.(?<=[.!?])\s+(?=[A-Z0-9])The child may have
chest pain or fainting.(?<=[.!?])\s+(?=[A-Z0-9])Affected children are usually > 5 years of age.(?<=[.!?])\s+(?=[A... | 217 | 449 | 1 | WHO-0001 | 1 | who_corpus.pdf | 313 |
The diagnosis is based on two major or
one major and two minor manifestations plus evidence of a previous group A
streptococcal infection.(?<=[.!?])\s+(?=[A-Z0-9])Investigations
Diagnosis of rheumatic fever requires evidence of a prior streptococcal infec-
tion.
•
Streptococcal serum antibody tests (antistreptolys... | 217 | 450 | 2 | WHO-0001 | 1 | who_corpus.pdf | 115 |
194
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Table 20.(?<=[.!?])\s+(?=[A-Z0-9])WHO criteria for the diagnosis of rheumatic fever (based on the
revised Jones criteria)
Diagnostic category
Criteria
Primary episode of rheumatic fever
or
Recurrent attack of rheumatic fever in
a patient without established rheumatic
heart dise... | 218 | 451 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
195
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
oxygen
furosemide at 1 mg/kg every 6 h
prednisolone at 1 mg/kg per day orally for 1 week for severe heart failure
blood transfusion if Hb < 8 mg/dl
antibiotics to eradicate pharyngeal streptococcal infection
Follow-up care
All children will require antibiotic ... | 219 | 452 | 0 | WHO-0001 | 1 | who_corpus.pdf | 156 |
196
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
Notes | 220 | 453 | 0 | WHO-0001 | 1 | who_corpus.pdf | 30 |
197
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
CHAPTER 7
S evere acute malnutrition
7.1
Severe acute malnutrition
198
7.2 Initial assessment
198
7.3 Organization of care
200
7.4 General management
200
7.4.1 Hypoglycaemia
201
7.4.2 Hypothermia
202
7.4.3 Dehydration
203
7.4.4 Electrolyte imbalance
206
7... | 221 | 454 | 0 | WHO-0001 | 1 | who_corpus.pdf | 271 |
198
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
7.1
Severe acute malnutrition
Severe acute malnutrition is defi ned in these guidelines as the presence of
oedema of both feet or severe wasting (weight-for-height/length <-3SD or mid-
upper arm circumference < 115 mm).(?<=[.!?])\s+(?=[A-Z0-9])No distinction is made between... | 222 | 455 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Children with severe acute malnutri-
tion should fi rst be assessed with a
full clinical examination to confi rm
whether they have any general danger
sign, medical complications and an
appetite.(?<=[.!?])\s+(?=[A-Z0-9])Children with severe acute malnutri-
tion with loss of appetite or any medi-
cal complication have ... | 222 | 456 | 1 | WHO-0001 | 1 | who_corpus.pdf | 210 |
199
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
■breastfeeding
■duration and frequency of
diarrhoea and vomiting
■type of diarrhoea (watery/
bloody)
■loss of appetite
■family circumstances
■cough > 2 weeks
■contact with TB
■recent contact with measles
■known or suspected HIV
infection/exposure.(?<=[.... | 223 | 457 | 0 | WHO-0001 | 1 | who_corpus.pdf | 356 |
225)
INITIAL ASSESSMENT
Child with severe acute
malnutrition oedema
Pitting oedema on dorsum of foot.(?<=[.!?])\s+(?=[A-Z0-9])When
pressure is applied for a few seconds, a pit
remains after the fi nger is removed. | 223 | 458 | 1 | WHO-0001 | 1 | who_corpus.pdf | 64 |
200
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
■fever (temperature ≥ 37.5 °C or ≥ 99.5 °F) or hypothermia (rectal temperature
< 35.5 °C or < 95.9 °F)
■mouth ulcers
■skin changes of kwashiorkor:
– hypo- or hyperpigmentation
– desquamation
– ulceration (spreading over limbs, thighs, genitalia, groin and behind
th... | 224 | 459 | 0 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Facilities and suffi cient staff should be available to ensure correct preparation
of appropriate therapeutic foods and to feed the child regularly, day and night.(?<=[.!?])\s+(?=[A-Z0-9])Accurate weighing machines or MUAC tapes are needed, and records of the
feeds given and the child’s weight or anthropometric measur... | 224 | 460 | 1 | WHO-0001 | 1 | who_corpus.pdf | 225 |
201
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
the eye, cover with a saline-soaked eye pad, and bandage (see section 7.5.1,
p.(?<=[.!?])\s+(?=[A-Z0-9])217).(?<=[.!?])\s+(?=[A-Z0-9])Severe anaemia, if present, will require urgent treatment (see section
7.5.2, p.(?<=[.!?])\s+(?=[A-Z0-9])218).(?<=[.!?])\s+(?=[A-Z0-9])Gener... | 225 | 461 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Dehydration
4.(?<=[.!?])\s+(?=[A-Z0-9])Electrolytes
5.(?<=[.!?])\s+(?=[A-Z0-9])Infection
6.(?<=[.!?])\s+(?=[A-Z0-9])Micronutrients
no iron
with iron
7.(?<=[.!?])\s+(?=[A-Z0-9])Initiate feeding
8.(?<=[.!?])\s+(?=[A-Z0-9])Catch-up feeding
9.(?<=[.!?])\s+(?=[A-Z0-9])Sensory stimulation
10.(?<=[.!?])\s+(?=[A-Z0-9])Prepare ... | 225 | 462 | 1 | WHO-0001 | 1 | who_corpus.pdf | 392 |
Hypoglycaemia is present when the blood glucose is < 3 mmol/litre (< 54 mg/
dl).(?<=[.!?])\s+(?=[A-Z0-9])If blood glucose cannot be measured, it should be assumed that all children
with severe acute malnutrition are hypoglycaemic and given treatment.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Give 50 ml of 10% glucose or s... | 225 | 463 | 2 | WHO-0001 | 1 | who_corpus.pdf | 143 |
202
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Give the fi rst feed of F-75 therapeutic milk, if it is quickly available, and
then continue with feeds every 2 h for 24 h; then continue feeds every 2 or
3 h, day and night.
If the child is unconscious, treat with IV 10% glucose at 5 ml/kg or, if IV
access cannot b... | 226 | 464 | 0 | WHO-0001 | 1 | who_corpus.pdf | 332 |
207).(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
If the initial blood glucose was low, repeat the measurement (using fi nger or
heel prick blood and measure with the Dextrostix®, when available) after 30 min.
•
If blood glucose falls to < 3 mmol/litre (< 54 mg/dl), repeat the 10% glucose
or oral sugar solution.
•
If the re... | 226 | 465 | 1 | WHO-0001 | 1 | who_corpus.pdf | 366 |
Diagnosis
■If the axillary temperature is < 35 °C (< 95°F) or does not register on a nor-
mal thermometer, assume hypothermia.(?<=[.!?])\s+(?=[A-Z0-9])When a low-reading thermometer
is available, take the rectal temperature (< 35.5 °C or < 95.9 °F) to confi rm
hypothermia.(?<=[.!?])\s+(?=[A-Z0-9])HYPOTHERMIA | 226 | 466 | 2 | WHO-0001 | 1 | who_corpus.pdf | 118 |
203
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Treatment
All children with hypothermia should be treated routinely for hypoglycaemia
and infection.
Feed the child immediately and then every 2 h unless they have abdominal
distension; if dehydrated, rehydrate fi rst.
Re-warm the child: Make sure the child is cloth... | 227 | 467 | 0 | WHO-0001 | 1 | who_corpus.pdf | 342 |
Keep the head
covered, preferably with a warm bonnet, to reduce heat loss.
•
Check for hypoglycaemia whenever hypothermia is found.(?<=[.!?])\s+(?=[A-Z0-9])Prevention
Feed immediately and then every 2–3 h, day and night.
Place the bed in a warm, draught-free part of the ward, and keep the child
covered.
... | 227 | 468 | 1 | WHO-0001 | 1 | who_corpus.pdf | 312 |
204
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
dehydration accurately from clinical signs alone.(?<=[.!?])\s+(?=[A-Z0-9])Assume that all children with
watery diarrhoea or reduced urine output have some dehydration.(?<=[.!?])\s+(?=[A-Z0-9])It is important
to note that poor circulatory volume or perfusion can co-exist wit... | 228 | 469 | 0 | WHO-0001 | 1 | who_corpus.pdf | 311 |
The standard WHO ORS solution for general use has a high sodium
and low potassium content, which is not suitable for severely malnourished
children.(?<=[.!?])\s+(?=[A-Z0-9])Instead, give special rehydration solution for malnutrition, ReSoMal.
Give the ReSoMal rehydration fl uid orally or by nasogastric tube, more ... | 228 | 470 | 1 | WHO-0001 | 1 | who_corpus.pdf | 385 |
If neither is
available, 0.45% saline with 5% dextrose should be used (see Chart 8, p.(?<=[.!?])\s+(?=[A-Z0-9])14)
Monitoring
During rehydration, respiration and pulse rate should fall and urine start to be
passed.(?<=[.!?])\s+(?=[A-Z0-9])The return of tears, a moist mouth, less sunken eyes and fontanelle,
and impro... | 228 | 471 | 2 | WHO-0001 | 1 | who_corpus.pdf | 335 |
205
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
DEHYDRATION
Recipe for ReSoMal using standard WHO ORS
Ingredient
Amount
Water
2 litres
WHO ORS
One 1-litre packeta
Sucrose
50 g
Electrolyte/mineral solutionb
40 ml
a 2.6 g sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium chloride, 13.5 g
glucose
b See bel... | 229 | 472 | 0 | WHO-0001 | 1 | who_corpus.pdf | 336 |
Electrolyte and mineral powders are produced by some manufacturers.(?<=[.!?])\s+(?=[A-Z0-9])If
these are not available or affordable, prepare the solution (2500 ml) using the following
ingredients:
Ingredient
g
mol/20 ml
Potassium chloride (KCl)
224
24 mmol
Tripotassium citrate
81
2 mmol
Magnesium chloride (MgCl2.6H2... | 229 | 473 | 1 | WHO-0001 | 1 | who_corpus.pdf | 389 |
Make a 10% stock
solution of potassium chloride (100 g in 1 litre of water) and a 1.5% solution of zinc
acetate (15 g in 1 litre of water).(?<=[.!?])\s+(?=[A-Z0-9])For the oral rehydration solution ReSoMal, use 45 ml of the stock potassium chloride
solution instead of 40 ml electrolyte/mineral solution
For milk feed... | 229 | 474 | 2 | WHO-0001 | 1 | who_corpus.pdf | 220 |
206
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
•
increase in respiratory rate
•
increase in pulse rate
•
urine frequency (Has the child urinated since last checked?)
•
enlarging liver size on palpation
•
frequency of stools and vomit.(?<=[.!?])\s+(?=[A-Z0-9])If you fi nd signs of overhydration (early signs are respir... | 230 | 475 | 0 | WHO-0001 | 1 | who_corpus.pdf | 364 |
7.4.4
Electrolyte imbalance
All severely malnourished children have defi ciencies of potassium and mag-
nesium, which may take about 2 weeks to correct.(?<=[.!?])\s+(?=[A-Z0-9])Oedema is partly a result
of potassium defi ciency and sodium retention.(?<=[.!?])\s+(?=[A-Z0-9])Do not treat oedema with a
diuretic.(?<=[.!?... | 230 | 476 | 1 | WHO-0001 | 1 | who_corpus.pdf | 395 |
Add 20 ml of this solution to 1 litre of feed to supply the extra
potassium and magnesium required.(?<=[.!?])\s+(?=[A-Z0-9])Alternatively, use commercially available
pre-mixed sachets (specially formulated for malnourished children).
When rehydrating, give low sodium rehydration fl uid (ReSoMal) (see
recipe, p.(?... | 230 | 477 | 2 | WHO-0001 | 1 | who_corpus.pdf | 151 |
207
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
7.4.5
Infection
In severe acute malnutrition, the usual signs of bacterial infection, such as
fever, are often absent, yet multiple infections are common.(?<=[.!?])\s+(?=[A-Z0-9])Therefore, assume
that all children with severe acute malnutrition have an infection on their... | 231 | 478 | 0 | WHO-0001 | 1 | who_corpus.pdf | 295 |
Choice of broad-spectrum antibiotics
If the child has uncomplicated severe acute malnutrition, give oral amoxicillin
(for dosage, see p.(?<=[.!?])\s+(?=[A-Z0-9])356) for 5 days.
If there are complications (hypoglycaemia, hypothermia or the child looks
lethargic or sickly) or any other medical complication, ... | 231 | 479 | 1 | WHO-0001 | 1 | who_corpus.pdf | 388 |
208
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
– TB is common, but anti-TB treatment should be given only if TB is diag-
nosed or strongly suspected (see section 7.5.5, p.(?<=[.!?])\s+(?=[A-Z0-9])219).
– For HIV-exposed children, see Chapter 8.(?<=[.!?])\s+(?=[A-Z0-9])Treatment for parasitic worms
If there is evidence ... | 232 | 480 | 0 | WHO-0001 | 1 | who_corpus.pdf | 350 |
If the
child is infected with HIV, start ART as soon as possible after stabilization of
metabolic complications and sepsis.(?<=[.!?])\s+(?=[A-Z0-9])They should be monitored closely (inpa-
tient and outpatient) in the fi rst 6–8 weeks following initiation of ART to identify
early metabolic complications and opportunis... | 232 | 481 | 1 | WHO-0001 | 1 | who_corpus.pdf | 390 |
When pre-
mixed packets are used, there is no need for additional doses.(?<=[.!?])\s+(?=[A-Z0-9])In addition, if there are no eye signs or history of measles, then do not give
a high dose of vitamin A because the amounts already present in therapeutic
foods are enough.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Give vitam... | 232 | 482 | 2 | WHO-0001 | 1 | who_corpus.pdf | 204 |
209
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
– < 6 months, 50 000 U
– 6–12 months, 100 000 U
– > 12 months, 200 000 U
Start iron at 3 mg/kg per day after 2 days on F-100 catch-up formula.(?<=[.!?])\s+(?=[A-Z0-9])Do
not give iron in the stabilization phase, and do not give iron if the child is
receiving ready-... | 233 | 483 | 0 | WHO-0001 | 1 | who_corpus.pdf | 241 |
Treatment
The essential features of initial feeding are:
•
frequent (every 2–3 h) oral small feeds of low osmolality and low lactose
•
nasogastric feeding if the child is eating ≤ 80% of the amount offered at
two consecutive feeds
•
calories at 100 kcal/kg per day
•
protein at 1–1.5 g/kg per day
•
liquid at 130... | 233 | 484 | 1 | WHO-0001 | 1 | who_corpus.pdf | 265 |
210
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
for recipes).(?<=[.!?])\s+(?=[A-Z0-9])As cereal-based F-75 partially replaces sugar with cereal fl our, it
has the advantage of lower osmolarity, which may benefi t some children with
persistent diarrhoea, but it has to be cooked.(?<=[.!?])\s+(?=[A-Z0-9])Feed from a cup or a ... | 234 | 485 | 0 | WHO-0001 | 1 | who_corpus.pdf | 396 |
Ask moth-
ers and other carers to help with feeding.(?<=[.!?])\s+(?=[A-Z0-9])Show them what to do, and supervise
them.(?<=[.!?])\s+(?=[A-Z0-9])Night feeds are essential, and staff rosters may have to be adjusted.(?<=[.!?])\s+(?=[A-Z0-9])If,
despite all efforts, not all the night feeds can be given, the feeds should b... | 234 | 486 | 1 | WHO-0001 | 1 | who_corpus.pdf | 390 |
Signs that a child has reached rehabilitation phase for catch-up growth are:
•
return of appetite
•
no episodes of hypoglycaemia (metabolically stable)
•
reduced or disappearance of all oedema
CATCH-UP GROWTH FEEDING | 234 | 487 | 2 | WHO-0001 | 1 | who_corpus.pdf | 40 |
211
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Table 22.(?<=[.!?])\s+(?=[A-Z0-9])Volumes of F-75 per feed for malnourished children (approximately
130 ml/kg per day)
Child’s weight (kg)
2-hourly (ml/feed)
3-hourly (ml/feed)
4-hourly (ml/feed)
2.0
20
30
45
2.2
25
35
50
2.4
25
40
55
2.6
30
45
55
2.8
30
45
60
3.0
35
50
65
3... | 235 | 488 | 0 | WHO-0001 | 1 | who_corpus.pdf | 360 |
212
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
CATCH-UP GROWTH FEEDING
Recipes for re-feeding formulas F-75 and F-100
F-75a
(starter: cereal-based)
F-100b
(catch-up)
Dried skimmed milk (g)
25
80
Sugar (g)
70
50
Cereal fl our (g)
35
—
Vegetable oil (g)
27
60
Electrolyte/mineral solution (ml)
20
20
Water: make up to (ml)
100... | 236 | 489 | 0 | WHO-0001 | 1 | who_corpus.pdf | 370 |
213
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Treatment
Make a gradual transition from starter F-75 to catch-up formula F-100 or ready-
to-use therapeutic food over 2–3 days, as tolerated.
Replace starter F-75 with an equal amount of catch-up F-100 for 2 days.(?<=[.!?])\s+(?=[A-Z0-9])Give a milk-based formula, such a... | 237 | 490 | 0 | WHO-0001 | 1 | who_corpus.pdf | 369 |
If the child
CATCH-UP GROWTH FEEDING
Recipes for re-feeding formulas F-75 and F-100
Alternative for F-75 if milk is unavailable
Use precooked corn–soya or wheat–soya blend
Corn–soya or wheat–soya blend, 50 g
Sugar, 85 g
Oil, 25 g
Electrolyte/mineral mix, 20 ml
Make up to 1000 ml with boiled water
Alternat... | 237 | 491 | 1 | WHO-0001 | 1 | who_corpus.pdf | 143 |
214
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
cannot eat the whole amount of RUTF per meal in the transition phase,
top up with F-75 to complete the feed, until is able to eat a full RUTF meal.
– If the child cannot take at least half of recommended amount of RUTF in
12 h, stop RUTF and give F-75.(?<=[.!?])\s+(?=[A-Z0... | 238 | 492 | 0 | WHO-0001 | 1 | who_corpus.pdf | 176 |
Recommended amounts per day of ready-to-use therapeutic food
containing 500 kcal
Transition Phase
150 kcal/kg/day
Rehabilitation Phase
200 kcal/kg/day
Child’s weight (kg)
Packets per day (92 g Packets
Containing 500 kcal)
Packets per day (92 g Packets
Containing 500 kcal)
4.0–4.9
1.5
2.0
5.0–6.9
2.1
2.5
7.0–8.4
2.... | 238 | 493 | 1 | WHO-0001 | 1 | who_corpus.pdf | 383 |
215
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
•
Then, gradually increase as follows:
– 115 ml/kg per day for next 24 h
– 130 ml/kg per day for the following 48 h
•
Thereafter, increase each feed by 10 ml as described earlier.(?<=[.!?])\s+(?=[A-Z0-9])Assess progress.(?<=[.!?])\s+(?=[A-Z0-9])After the transition, moni... | 239 | 494 | 0 | WHO-0001 | 1 | who_corpus.pdf | 323 |
Calculate average daily weight gain: 300 g ÷ 3 days = 100 g/day
Step 3.(?<=[.!?])\s+(?=[A-Z0-9])Divide by child’s average weight in kg: 100 g/day ÷ 6.15 kg = 16.3 g/kg
per day
If the weight gain is:
•
poor (< 5 g/kg per day), the child requires a full re-assessment
•
moderate (5–10 g/kg per day), check whether the ... | 239 | 495 | 1 | WHO-0001 | 1 | who_corpus.pdf | 325 |
216
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
7.4.10 Severe acute malnutrition in infants aged < 6 months
Severe acute malnutrition is less common in infants < 6 months than in older
children.(?<=[.!?])\s+(?=[A-Z0-9])An organic cause for the malnutrition or failure to thrive should be
considered, and, when appropriate,... | 240 | 496 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
212 up to 1.5 litres instead
of 1 litre) to supplement breastfeeding.
For infants with severe acute malnutrition with no oedema, give expressed
breast milk; and when not possible, commercial infant formula or F-75 or
diluted F-100, in this order of preference.(?<=[.!?])\s+(?=[A-Z0-9])During nutritional rehabilit... | 240 | 497 | 1 | WHO-0001 | 1 | who_corpus.pdf | 186 |
217
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Assessment of the physical and mental health of mothers or caretakers should
be promoted and relevant treatment or support provided.(?<=[.!?])\s+(?=[A-Z0-9])Discharge
Infants less than 6 months of age admitted to inpatient care can be transferred
to outpatient care if:
•
a... | 241 | 498 | 0 | WHO-0001 | 1 | who_corpus.pdf | 365 |
386).(?<=[.!?])\s+(?=[A-Z0-9])7.5
Treatment of associated conditions
7.5.1
Eye problems
If the child has any eye signs of vitamin A defi ciency (see p.(?<=[.!?])\s+(?=[A-Z0-9])199):
Give vitamin A orally on days 1, 2 and 14 (age < 6 months, 50 000 IU; age
6–12 months, 100 000 IU; older children, 200 000 IU).(?<... | 241 | 499 | 1 | WHO-0001 | 1 | who_corpus.pdf | 310 |
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