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218
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
7.5.2
Severe anaemia
Blood transfusion should be given in the fi rst 24 h only if:
•
Hb is < 4 g/dl
•
Hb is 4–6 g/dl and the child has respiratory distress.(?<=[.!?])\s+(?=[A-Z0-9])In severe acute malnutrition, the transfusion must be slower and of smaller
volume than for... | 242 | 500 | 0 | WHO-0001 | 1 | who_corpus.pdf | 282 |
Children with severe acute
malnutrition with oedema may have redistribution of fl uid leading to apparent
low Hb, which does not require transfusion.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring
Monitor the pulse and breathing rates, listen to the lung fi elds, examine the
abdomen for liver size and check the jugular venous pre... | 242 | 501 | 1 | WHO-0001 | 1 | who_corpus.pdf | 387 |
219
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
7.5.4
Continuing diarrhoea
Treatment
Giardiasis
Where possible, examine the stools by microscopy.
If cysts or trophozoites of Giardia lamblia are found, give metronidazole (7.5
mg/kg every 8 h for 7 days).(?<=[.!?])\s+(?=[A-Z0-9])Treat with metronidazole if stool micr... | 243 | 502 | 0 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Osmotic diarrhoea
Osmotic diarrhoea may be suspected if the diarrhoea worsens substantially
with hyperosmolar F-75 and ceases when the sugar content and osmolarity
are reduced.(?<=[.!?])\s+(?=[A-Z0-9])In these cases:
Use cereal-based starter F-75 (see recipe, p.(?<=[.!?])\s+(?=[A-Z0-9])212) or, if necessary, a co... | 243 | 503 | 1 | WHO-0001 | 1 | who_corpus.pdf | 348 |
7.6
Discharge and follow-up
7.6.1
Transfer to outpatient care
Children admitted to hospital with complicated severe acute malnutrition can
be transferred to outpatient care during the rehabilitation phase.(?<=[.!?])\s+(?=[A-Z0-9])Social factors,
such as loss of earnings for the mother and care for other children, s... | 243 | 504 | 2 | WHO-0001 | 1 | who_corpus.pdf | 101 |
220
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
be managed as outpatients or in the community.(?<=[.!?])\s+(?=[A-Z0-9])Carefully assess the child and
the available community support.(?<=[.!?])\s+(?=[A-Z0-9])The child will require continuing care as an
outpatient to complete rehabilitation and prevent relapse.(?<=[.!?])\s... | 244 | 505 | 0 | WHO-0001 | 1 | who_corpus.pdf | 350 |
Ask the caregiver
to bring the child back for weekly therapeutic food, and make sure the child
receives vaccinations and routine vitamin A supplements, as appropriate.(?<=[.!?])\s+(?=[A-Z0-9])The mother or carer should:
•
be available for child care
•
have received specifi c counselling on appropriate child feeding ... | 244 | 506 | 1 | WHO-0001 | 1 | who_corpus.pdf | 340 |
Thus, if mid-upper arm circumference was used, then it should
be used to assess and confi rm nutritional recovery, and similarly for weight for
length/height.(?<=[.!?])\s+(?=[A-Z0-9])Children admitted with only bilateral pitting oedema, should be
discharged on the basis of either mid-upper arm circumference or weight... | 244 | 507 | 2 | WHO-0001 | 1 | who_corpus.pdf | 167 |
221
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
The child should be fed at least fi ve times a day with foods that contain ap-
proximately 100 kcal and 2–3 g protein per 100 g of food.(?<=[.!?])\s+(?=[A-Z0-9])It is essential to give
frequent meals with a high energy and protein content.(?<=[.!?])\s+(?=[A-Z0-9])The mother s... | 245 | 508 | 0 | WHO-0001 | 1 | who_corpus.pdf | 340 |
In general, the child should be weighed
weekly after discharge.(?<=[.!?])\s+(?=[A-Z0-9])If he or she fails to gain weight over a 2-week period or loses weight between
two measurements or develops loss of appetite or oedema, the child should be
referred back to hospital for further assessment.(?<=[.!?])\s+(?=[A-Z0-9]... | 245 | 509 | 1 | WHO-0001 | 1 | who_corpus.pdf | 394 |
Were potassium and antibiotics given?
•
over 72 h: consider nosocomial infection, re-feeding syndrome, heart failure
and HIV infection.(?<=[.!?])\s+(?=[A-Z0-9])MONITORING THE QUALITY OF CARE | 245 | 510 | 2 | WHO-0001 | 1 | who_corpus.pdf | 56 |
222
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
•
at night: consider hypothermia due to insuffi cient covering of the child or
no night feeds.
•
when beginning F-100 or RUTF: consider too rapid a transition from starter
to catch-up feeds.(?<=[.!?])\s+(?=[A-Z0-9])7.7.2
Weight gain during rehabilitation
Standardize weig... | 246 | 511 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
General aspects to be checked if weight gain is poor are described below.(?<=[.!?])\s+(?=[A-Z0-9])Inadequate feeding
Check:
•
that night feeds are given
•
that target energy and protein intakes are achieved.(?<=[.!?])\s+(?=[A-Z0-9])Is the actual intake
(i.e. what was offered minus what was left over) correctly recor... | 246 | 512 | 1 | WHO-0001 | 1 | who_corpus.pdf | 376 |
223
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
•
if complementary foods are given, check that they contain electrolyte/
mineral solution.(?<=[.!?])\s+(?=[A-Z0-9])Untreated infection
If feeding is adequate and there is no malabsorption, suspect a hidden infec-
tion if there is recurrence of oedema, hypoglycaemia or hypoth... | 247 | 513 | 0 | WHO-0001 | 1 | who_corpus.pdf | 378 |
For other HIV-related conditions, see Chapter 8.(?<=[.!?])\s+(?=[A-Z0-9])Psychological problems
Check for abnormal behaviour, such as stereotyped movements (rocking),
rumination (i.e. self-stimulation through regurgitation) and attention-seeking.(?<=[.!?])\s+(?=[A-Z0-9])Treat by giving the child special love and atten... | 247 | 514 | 1 | WHO-0001 | 1 | who_corpus.pdf | 243 |
224
7.(?<=[.!?])\s+(?=[A-Z0-9])MALNUTRITION
Notes | 248 | 515 | 0 | WHO-0001 | 1 | who_corpus.pdf | 30 |
225
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
CHAPTER 8
Children with HIV/AIDS
8.1 Sick child with suspected or confi rmed HIV infection
226
8.1.1 Clinical diagnosis
226
8.1.2 HIV counselling
228
8.1.3 Testing and diagnosis of HIV infection
229
8.1.4 Clinical staging
230
8.2 Antiretroviral therapy
232
8.2.1 A... | 249 | 516 | 0 | WHO-0001 | 1 | who_corpus.pdf | 379 |
226
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
In general, the management of specifi c conditions in HIV-infected children is
similar to that in other children (see Chapters 3–7).(?<=[.!?])\s+(?=[A-Z0-9])Most infections in HIV-
positive children are caused by the same pathogens as in HIV-negative children,
although they may ... | 250 | 517 | 0 | WHO-0001 | 1 | who_corpus.pdf | 370 |
All infants and children should have their HIV status established at their fi rst
contact with the health system, ideally at birth or at the earliest opportunity
thereafter.(?<=[.!?])\s+(?=[A-Z0-9])To facilitate this, all areas of the hospital in which maternal, neonatal
and child services are delivered should offer ... | 250 | 518 | 1 | WHO-0001 | 1 | who_corpus.pdf | 294 |
Clinical experience indicates that children infected with HIV perinatally who are
not on antiretroviral therapy fi t into one of three categories:
•
those with rapid progression (25–30%), most of whom die before their fi rst
birthday; they are thought to have acquired the infection in utero or during
the early postna... | 250 | 519 | 2 | WHO-0001 | 1 | who_corpus.pdf | 170 |
227
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Suspect HIV if any of the following signs, which are not common in HIV-negative
children, are present:
Signs that may indicate possible HIV infection
•
recurrent infection: three or more severe episodes of a bacterial infection
(such as pneumonia, meningitis, sepsis, cellulit... | 251 | 520 | 0 | WHO-0001 | 1 | who_corpus.pdf | 340 |
Typical skin rashes include
extensive fungal infections of the skin, nails and scalp and extensive mol-
luscum contagiosum.
•
chronic suppurative lung disease
Signs or conditions specifi c to HIV-infected children
Strongly suspect HIV infection if the following are present:
•
Pneumocystis jiroveci (formerly carinii)... | 251 | 521 | 1 | WHO-0001 | 1 | who_corpus.pdf | 105 |
228
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Signs common in HIV-infected children but which also occur in ill
children with no HIV infection:
•
chronic otitis media: ear discharge lasting ≥ 14 days
•
persistent diarrhoea: diarrhoea lasting ≥ 14 days
•
moderate or severe acute malnutrition: weight loss or a gradual but ... | 252 | 522 | 0 | WHO-0001 | 1 | who_corpus.pdf | 367 |
Even
in countries with a high prevalence of HIV infection, it remains an extremely
stigmatizing condition, and the parents may feel reluctant to undergo testing.(?<=[.!?])\s+(?=[A-Z0-9])In HIV counselling, the child should be treated as part of the family by taking
into account the psychological implications of HIV ... | 252 | 523 | 1 | WHO-0001 | 1 | who_corpus.pdf | 340 |
Indications for HIV counselling and testing
All infants and children in countries with generalized HIV epidemics with un-
known HIV status should be offered counselling and testing.(?<=[.!?])\s+(?=[A-Z0-9])In most cases,
the HIV status of the child is established by asking about maternal HIV testing
during pregnancy,... | 252 | 524 | 2 | WHO-0001 | 1 | who_corpus.pdf | 183 |
229
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
•
all HIV-exposed infants at birth or at the earliest opportunity thereafter.
•
any infant or child presenting with signs, symptoms or medical conditions
that could indicate HIV infection.
•
all pregnant women and their partners in generalized HIV epidemics.(?<=[.!?])\s+(?=[... | 253 | 525 | 0 | WHO-0001 | 1 | who_corpus.pdf | 367 |
However, HIV virological testing should be done at the earliest
opportunity to confi rm infection.(?<=[.!?])\s+(?=[A-Z0-9])All diagnostic HIV testing of children must be confi dential, be accompanied
by counselling and conducted only with informed consent, so that it is both
informed and voluntary.(?<=[.!?])\s+(?=[A-Z... | 253 | 526 | 1 | WHO-0001 | 1 | who_corpus.pdf | 393 |
Virological tests
Virological testing for HIV-specifi c RNA or DNA is the most reliable method
for diagnosing HIV infection in children < 18 months of age.(?<=[.!?])\s+(?=[A-Z0-9])This may require
sending a blood sample to a specialized laboratory that can perform this
test, although virological testing is becoming ... | 253 | 527 | 2 | WHO-0001 | 1 | who_corpus.pdf | 129 |
230
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
on dried blood spots.(?<=[.!?])\s+(?=[A-Z0-9])The following assays (and respective specimen types)
may be available:
•
HIV DNA on whole blood specimen or dried blood spots
•
HIV RNA on plasma or dried blood spots
•
ultrasensitive p24 antigen detection in plasma or dried blood... | 254 | 528 | 0 | WHO-0001 | 1 | who_corpus.pdf | 365 |
Diagnosing HIV infection in breastfeeding infants
A breastfeeding infant is at risk of acquiring HIV infection from an infected
mother throughout the period of breastfeeding.(?<=[.!?])\s+(?=[A-Z0-9])Breastfeeding should not be
stopped in order to perform diagnostic HIV viral testing.(?<=[.!?])\s+(?=[A-Z0-9])Positive ... | 254 | 529 | 1 | WHO-0001 | 1 | who_corpus.pdf | 397 |
231
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
CLINICAL STAGING
Table 23.(?<=[.!?])\s+(?=[A-Z0-9])WHO paediatric clinical staging system for HIV infection
For use in children aged < 13 years with confi rmed laboratory evidence of HIV
infection (HIV antibodies for children > 18 months, virological testing for those
aged < 18 ... | 255 | 530 | 0 | WHO-0001 | 1 | who_corpus.pdf | 395 |
232
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
– Chronic orolabial or cutaneous herpes simplex infection (lasting > 1 month)
– Disseminated or extrapulmonary TB
– Kaposi sarcoma
– Oesophageal candidiasis
– Symptomatic HIV seropositive infant < 18 months with two or more of the
following: oral thrush, severe pneumonia,... | 256 | 531 | 0 | WHO-0001 | 1 | who_corpus.pdf | 378 |
Although antiretroviral drugs cannot cure HIV infection, they dramati-
cally reduce mortality and morbidity and improve the children’s quality of life.(?<=[.!?])\s+(?=[A-Z0-9])The current standard fi rst-line treatment for HIV infection is use of three
antiretroviral medications (triple drug therapy) to suppress viral ... | 256 | 532 | 1 | WHO-0001 | 1 | who_corpus.pdf | 335 |
233
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
•
the taste and palatability, and hence compliance, for young children.(?<=[.!?])\s+(?=[A-Z0-9])It is also important to ensure that HIV-infected parents access treatment; and
ART should ideally be ensured for other family members.(?<=[.!?])\s+(?=[A-Z0-9])8.2.1
Antiretroviral d... | 257 | 533 | 0 | WHO-0001 | 1 | who_corpus.pdf | 354 |
When viral load monitoring is available,
consideration can be given to substituting LPV/r with an NNRTI after virological
suppression is sustained.(?<=[.!?])\s+(?=[A-Z0-9])For children ≥ 3 years efavirenz (EFV) is the preferred NNRTI for fi rst-line
treatment particularly once daily therapy, although NVP may be used ... | 257 | 534 | 1 | WHO-0001 | 1 | who_corpus.pdf | 359 |
Drug dosages are given on pp.(?<=[.!?])\s+(?=[A-Z0-9])370–4, per kilogram of body weight for some
drugs and per surface area of the child for others.(?<=[.!?])\s+(?=[A-Z0-9])A table listing the equivalent
weights of various surface area values is given in Annex 2 (p.(?<=[.!?])\s+(?=[A-Z0-9])354) to help in
calculati... | 257 | 535 | 2 | WHO-0001 | 1 | who_corpus.pdf | 299 |
234
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
ANTIRETROVIRAL DRUGS
Table 24.(?<=[.!?])\s+(?=[A-Z0-9])Classes of antiretroviral drugs recommended for use in children
Nucleoside analogue reverse transcriptase inhibitors
Zidovudine
ZDV (AZT)
Lamivudine
3TC
Abacavir
ABC
Emtricitabine
FTC
Tenofovir
TDF
Non-nucleoside analogue rev... | 258 | 536 | 0 | WHO-0001 | 1 | who_corpus.pdf | 396 |
235
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
8.2.2 When to start antiretroviral therapy
All HIV-infected infants and children < 60 months of age should begin ART,
regardless of clinical or immunological status.(?<=[.!?])\s+(?=[A-Z0-9])Infants and children < 60 months
•
All children < 60 months of age with confi rmed HIV ... | 259 | 537 | 0 | WHO-0001 | 1 | who_corpus.pdf | 379 |
Occasionally
immediate initiation of ART treatment may be deferred until the child is stabilized
during treatment of acute infections.(?<=[.!?])\s+(?=[A-Z0-9])In the case of confi rmed or presumptive TB, initiating TB treatment is the prior-
ity.(?<=[.!?])\s+(?=[A-Z0-9])Any child with active TB should begin TB treatme... | 259 | 538 | 1 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Common side effects are summarized in
Table 26, p.(?<=[.!?])\s+(?=[A-Z0-9])236.(?<=[.!?])\s+(?=[A-Z0-9])WHEN TO START ANTIRETROVIRAL THERAPY | 259 | 539 | 2 | WHO-0001 | 1 | who_corpus.pdf | 68 |
236
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
SIDE-EFFECTS AND MONITORING
Table 26.(?<=[.!?])\s+(?=[A-Z0-9])Common side-effects of antiretroviral drugs
Drug
Abbreviation
Side-effectsa
Comments
Nucleoside reverse transcriptase inhibitors (NRTIs)
Lamivudine
3TC
Headache, abdominal
pain, pancreatitis
Well tolerated
Stavudineb
... | 260 | 540 | 0 | WHO-0001 | 1 | who_corpus.pdf | 341 |
May
cause hepatotoxicity or
lactic acidosis.(?<=[.!?])\s+(?=[A-Z0-9])Tenofovir
TDF
Renal insuffi ciency,
decrease in bone
mineral density
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz
EFV
Strange dreams,
sleepiness, rash
Take at night; avoid
taking with fatty food
Nevirapine
NVP
Rash, liver to... | 260 | 541 | 1 | WHO-0001 | 1 | who_corpus.pdf | 197 |
237
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Immune reconstitution infl ammatory syndrome
Immune reconstitution infl ammatory syndrome (IRIS) is a spectrum of clini-
cal signs and symptoms associated with immune recovery brought about by
a response to antiretroviral treatment.(?<=[.!?])\s+(?=[A-Z0-9])Although most HIV-infect... | 261 | 542 | 0 | WHO-0001 | 1 | who_corpus.pdf | 368 |
Where BCG immunization of infants and children is routine, BCG-associated
IRIS (localized and systemic) is frequently observed.(?<=[.!?])\s+(?=[A-Z0-9])Most cases of paradoxical IRIS resolve spontaneously, or can be managed
with non-steroidal anti-infl ammatory drugs, although some episodes can be
severe and even lea... | 261 | 543 | 1 | WHO-0001 | 1 | who_corpus.pdf | 398 |
238
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
•
any time there is a problem of concern to the caregiver or intercurrent illness.(?<=[.!?])\s+(?=[A-Z0-9])Important signs of infants’ and children’s responses to ART include:
•
improvement in the growth in children who have been failing to grow
•
improvement in neurological s... | 262 | 544 | 0 | WHO-0001 | 1 | who_corpus.pdf | 398 |
As few antiretroviral drugs are available, drug substitutions
should be limited to:
•
severe or life-threatening toxicity, such as:
– Stevens Johnson syndrome
WHEN TO CHANGE TREATMENT | 262 | 545 | 1 | WHO-0001 | 1 | who_corpus.pdf | 34 |
239
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
WHEN TO CHANGE TREATMENT
– severe liver toxicity
– severe haematological effects
•
drug interaction (e.g.(?<=[.!?])\s+(?=[A-Z0-9])TB treatment with rifampicin interfering with nevirapine
or protease inhibitor).
•
potential lack of adherence by the patient if he or she cannot... | 263 | 546 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
240
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Second-line treatment regimens
In the event of treatment failure, the entire regimen should be changed from a
fi rst-line to a second-line combination.(?<=[.!?])\s+(?=[A-Z0-9])The second-line regimen should include
at least three new drugs, one or more of them in a new class.(?<... | 264 | 547 | 0 | WHO-0001 | 1 | who_corpus.pdf | 323 |
Table 27.(?<=[.!?])\s+(?=[A-Z0-9])Recommended second-line treatment regimens for children
First-line treatment
Recommended second-line treatment
Children
< 3 years
Children ≥ 3 years
up to 12 years
LPV/r-based
fi rst line
ABC + 3TC + LPV/r
No changea
ZDV + 3TC + EFV
ZDV + 3TC + LPV/r
No changea
ABC or TDF + 3TC
+ EF... | 264 | 548 | 1 | WHO-0001 | 1 | who_corpus.pdf | 376 |
241
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
6 months of age and a second dose as soon as possible after 9 months of
age, unless they are severely immunocompromised at that time.
•
Pneumococcal vaccine: Pneumococcal conjugate vaccine should be given
to all children, but vaccination may be delayed if the child is severely... | 265 | 549 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
Co-trimoxazole
also protects against common bacterial infections, toxoplasmosis and malaria.(?<=[.!?])\s+(?=[A-Z0-9])Who should receive co-trimoxazole?
•
All infants born to HIV-infected mothers should receive co-trimoxazole 4–6
weeks after birth or at their fi rst encounter with the health care system.(?<=[.!?])\s+(... | 265 | 550 | 1 | WHO-0001 | 1 | who_corpus.pdf | 322 |
242
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
see below).(?<=[.!?])\s+(?=[A-Z0-9])It is not known whether co-trimoxazole continues to provide
protection after the immune system is restored.
•
Children with a history of PCP: Continue indefi nitely.(?<=[.!?])\s+(?=[A-Z0-9])Under what circumstances should co-trimoxazole be di... | 266 | 551 | 0 | WHO-0001 | 1 | who_corpus.pdf | 284 |
What doses of co-trimoxazole should be used?
Recommended dosages of 6–8 mg/kg trimethoprim once daily should be
used.
– children aged < 6 months, give one paediatric tablet (or one quarter of an
adult tablet, 20 mg trimethoprim–100 mg sulfamethoxazole);
– children aged 6 months to 5 years, give two paediatri... | 266 | 552 | 1 | WHO-0001 | 1 | who_corpus.pdf | 323 |
243
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
8.3.3 Nutrition
The mothers of infants and young children known to be infected with HIV
are strongly encouraged to breastfeed them exclusively for 6 months and
to continue breastfeeding up to the age of 1 year.(?<=[.!?])\s+(?=[A-Z0-9])Older children should eat
varied, energy-r... | 267 | 553 | 0 | WHO-0001 | 1 | who_corpus.pdf | 363 |
8.4
Management of HIV-related conditions
The treatment of most infections (such as pneumonia, diarrhoea and meningitis)
in HIV-infected children is the same as in other children.(?<=[.!?])\s+(?=[A-Z0-9])In cases of treatment
failure, consider giving a second-line antibiotic.(?<=[.!?])\s+(?=[A-Z0-9])Treatment of rec... | 267 | 554 | 1 | WHO-0001 | 1 | who_corpus.pdf | 374 |
As HIV infection progresses and immu-
nity declines, dissemination of TB becomes more common, and tuberculous
meningitis, miliary TB and widespread tuberculous lymphadenopathy occur.(?<=[.!?])\s+(?=[A-Z0-9])HIV-infected infants and children with active TB should begin TB treatment
immediately.(?<=[.!?])\s+(?=[A-Z0-9]... | 267 | 555 | 2 | WHO-0001 | 1 | who_corpus.pdf | 250 |
244
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Isoniazid preventive therapy
All HIV-infected infants and children should be screened for TB infection, as
they are at special risk.(?<=[.!?])\s+(?=[A-Z0-9])If a child has cough, fever or weight loss, assess for
TB.(?<=[.!?])\s+(?=[A-Z0-9])If the child does not have TB, give is... | 268 | 556 | 0 | WHO-0001 | 1 | who_corpus.pdf | 376 |
8.4.2 Pneumocystis jiroveci pneumonia
PCP should be suspected in any HIV-positive infant with severe pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])If PCP is untreated, mortality from this condition is very high.(?<=[.!?])\s+(?=[A-Z0-9])It is therefore
imperative to provide treatment as early as possible.(?<=[.!?])\s+(?=[A-Z0-9])... | 268 | 557 | 1 | WHO-0001 | 1 | who_corpus.pdf | 336 |
245
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
pattern, with no hilar lymph nodes or effusion.(?<=[.!?])\s+(?=[A-Z0-9])PCP may also present with
pneumothorax.(?<=[.!?])\s+(?=[A-Z0-9])Induced sputum and nasopharyngeal aspiration are useful for obtaining sputum
for examination.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Promptly g... | 269 | 558 | 0 | WHO-0001 | 1 | who_corpus.pdf | 322 |
8.4.3 Lymphoid interstitial pneumonitis
Diagnosis
The child is often asymptomatic in the early stages but may later have:
■persistent cough, with or without diffi culty in breathing,
■bilateral parotid swelling,
■persistent generalized lymphadenopathy,
■hepatomegaly and other signs of heart failure, and
■... | 269 | 559 | 1 | WHO-0001 | 1 | who_corpus.pdf | 312 |
246
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Give oral prednisolone at 1–2 mg/kg per day for 2 weeks.(?<=[.!?])\s+(?=[A-Z0-9])Then decrease
the dose over 2–4 weeks, depending on the response to treatment.(?<=[.!?])\s+(?=[A-Z0-9])Beware
of reactivating TB.
Start ART if not already on treatment.(?<=[.!?])\s+(?=[A-Z0... | 270 | 560 | 0 | WHO-0001 | 1 | who_corpus.pdf | 370 |
Suspect oesophageal candidiasis if the child has diffi culty or pain while vomiting
or swallowing, is reluctant to take food, is salivating excessively or cries dur-
ing feeding.(?<=[.!?])\s+(?=[A-Z0-9])The condition may occur with or without evidence of oral thrush.(?<=[.!?])\s+(?=[A-Z0-9])If oral thrush is not found,... | 270 | 561 | 1 | WHO-0001 | 1 | who_corpus.pdf | 355 |
The presentation is often subacute, with chronic headache or only mental
status changes.(?<=[.!?])\s+(?=[A-Z0-9])An India ink stain of CSF confi rms the diagnosis.
Treat with amphotericin at 0.5–1.5 mg/kg per day for 14 days, then with
fl uconazole 6–12 mg/kg (maximum 800 mg) for 8 weeks.
Start fl uconazole 6 ... | 270 | 562 | 2 | WHO-0001 | 1 | who_corpus.pdf | 256 |
247
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
persistent diarrhoea, weight loss, intestinal obstruction, abdominal pain or
large pleural effusion.(?<=[.!?])\s+(?=[A-Z0-9])Consider referral to a larger hospital for management.(?<=[.!?])\s+(?=[A-Z0-9])8.5
Prevention of mother-to-child HIV transmission,
and infant feeding
8... | 271 | 563 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
In order to eliminate paediatric HIV there are two main options, which should
start early in pregnancy, at 14 weeks or as soon as possible thereafter.(?<=[.!?])\s+(?=[A-Z0-9])These
options signifi cantly reduce mother-to-child transmission:
Option B: A three-drug prophylactic regimen for the mother taken during
p... | 271 | 564 | 1 | WHO-0001 | 1 | who_corpus.pdf | 179 |
248
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Option B+: A Triple ARV treatment regimen for the mother beginning in
pregnancy and continued for life, as well as infant prophylaxis for 6 weeks
after birth, whether or not the infant is breastfeeding.(?<=[.!?])\s+(?=[A-Z0-9])Option B+ is now preferred.(?<=[.!?])\s+(?=[A-Z... | 272 | 565 | 0 | WHO-0001 | 1 | who_corpus.pdf | 346 |
ART greatly reduces the risk for HIV transmission, while simultaneously ensur-
ing that the mother receives appropriate care to improve her own health.(?<=[.!?])\s+(?=[A-Z0-9])If an
HIV-positive mother breastfeeds her infant while taking ART and gives ART
to her infant each day, the risk for transmission is reduced t... | 272 | 566 | 1 | WHO-0001 | 1 | who_corpus.pdf | 360 |
249
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
When a decision has been taken to continue breastfeeding because the
child is already infected, ART treatment and infant feeding options should
be discussed for future pregnancies.
If the mother is known to be HIV-positive and the child’s HIV status is
unknown, the mot... | 273 | 567 | 0 | WHO-0001 | 1 | who_corpus.pdf | 372 |
If the mother is using breast-milk substitutes, counsel her
about their correct use and demonstrate safe preparation.(?<=[.!?])\s+(?=[A-Z0-9])8.6
Follow-up
8.6.1
Discharge from hospital
HIV-infected children may respond slowly or incompletely to the usual treat-
ment.(?<=[.!?])\s+(?=[A-Z0-9])They may have persisten... | 273 | 568 | 1 | WHO-0001 | 1 | who_corpus.pdf | 378 |
250
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
8.6.3 Clinical follow-up
Children who are known to be HIV-infected should, when not ill, attend well-
infant clinics like other children.(?<=[.!?])\s+(?=[A-Z0-9])In addition, they need regular clinical follow-up
at fi rst-level facilities to monitor their:
– clinical condition
... | 274 | 569 | 0 | WHO-0001 | 1 | who_corpus.pdf | 349 |
Some treatments for pain control and relief of
distressing conditions (such as oesophageal candidiasis or convulsions) can
signifi cantly improve the quality of the child’s remaining life.(?<=[.!?])\s+(?=[A-Z0-9])Give end-of-life (terminal) care if:
– the child has progressively worsening illness
– everything possib... | 274 | 570 | 1 | WHO-0001 | 1 | who_corpus.pdf | 354 |
251
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
•
Give analgesics regularly (‘by the clock’), so that the child does not have
to experience recurrence of severe pain in order to obtain another dose of
analgesic.
•
Administer by the most appropriate, simplest, most effective and least painful
route, by mouth when possible ... | 275 | 571 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
If tolerance develops, the
dose should be increased to maintain the same degree of pain relief.(?<=[.!?])\s+(?=[A-Z0-9])Adjuvant medicines: There is no suffi cient evidence that adjuvant therapy
relieves persistent pain or specifi c types such as neuropathic pain, bone pain
and pain associated with muscle spasm in chi... | 275 | 572 | 1 | WHO-0001 | 1 | who_corpus.pdf | 269 |
252
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
8.7.2
Management of anorexia, nausea and vomiting
Loss of appetite during a terminal illness is diffi cult to treat.(?<=[.!?])\s+(?=[A-Z0-9])Encourage carers
to continue providing meals and to try:
•
giving small feeds more frequently, particularly in the morning when the
chi... | 276 | 573 | 0 | WHO-0001 | 1 | who_corpus.pdf | 393 |
If mouth ulcers develop,
clean the mouth at least four times a day with clean water or salt solution and
a clean cloth rolled into a wick.(?<=[.!?])\s+(?=[A-Z0-9])Apply 0.25% or 0.5% gentian violet to any
sores.(?<=[.!?])\s+(?=[A-Z0-9])If the child has a high fever or is irritable or in pain, give paracetamol.(?<=[.... | 276 | 574 | 1 | WHO-0001 | 1 | who_corpus.pdf | 384 |
If there is pus due to a secondary bacterial infection, apply tetracycline or
chloramphenicol ointment.(?<=[.!?])\s+(?=[A-Z0-9])If there is a foul smell in the mouth, give IM
benzylpenicillin (50 000 U/kg every 6 h), plus oral metronidazole suspension
(7.5 mg/kg every 8 h) for 7 days.(?<=[.!?])\s+(?=[A-Z0-9])8.7.5
... | 276 | 575 | 2 | WHO-0001 | 1 | who_corpus.pdf | 168 |
253
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
8.7.6
Psychosocial support
Helping parents and siblings through their emotional reaction towards the dying
child is one of the most important aspects of care in the terminal stage of HIV
disease.(?<=[.!?])\s+(?=[A-Z0-9])How this is done depends on whether care is being given a... | 277 | 576 | 0 | WHO-0001 | 1 | who_corpus.pdf | 314 |
254
8.(?<=[.!?])\s+(?=[A-Z0-9])HIV/AIDS
Notes | 278 | 577 | 0 | WHO-0001 | 1 | who_corpus.pdf | 32 |
255
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
9.1 Care before, during and after surgery
256
9.1.1 Preoperative care
256
9.1.2 Intraoperative care
258
9.1.3 Postoperative care
260
9.2 Congenital anomalies
264
9.2.1 Cleft lip and palate
264
9.2.2 Bowel obstruction
265
9.2.3 Abdominal wall defects
266
9.2.4... | 279 | 578 | 0 | WHO-0001 | 1 | who_corpus.pdf | 315 |
256
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Infants and children have distinct surgical diseases and special perioperative
needs.(?<=[.!?])\s+(?=[A-Z0-9])This chapter provides guidelines for the supportive care of children with
surgical problems and briefl y describes the management of the commonest
surgical conditions.(?... | 280 | 579 | 0 | WHO-0001 | 1 | who_corpus.pdf | 368 |
Restoration of urine output implies adequate volume resus-
citation.
– Correct anaemia.(?<=[.!?])\s+(?=[A-Z0-9])Severe anaemia interferes with oxygen transport.(?<=[.!?])\s+(?=[A-Z0-9])As
a consequence, the heart must pump more blood.(?<=[.!?])\s+(?=[A-Z0-9])Surgery may cause
blood loss, and the anaesthetic may aff... | 280 | 580 | 1 | WHO-0001 | 1 | who_corpus.pdf | 370 |
Surgical care at the district hospital.(?<=[.!?])\s+(?=[A-Z0-9])Geneva, 2003.
http://www.who.int/surgery/publications/en/. | 280 | 581 | 2 | WHO-0001 | 1 | who_corpus.pdf | 54 |
257
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
– Check that the child is in the best nutritional state possible. | 281 | 582 | 0 | WHO-0001 | 1 | who_corpus.pdf | 42 |
Good nutrition
is needed to heal wounds.
•
Check that the child has an empty stomach before a general anaesthetic.
– Infants < 12 months: the child should be given no solids orally for 8 h, no
formula for 6 h, no clear liquids for 4 h or no breast milk for 4 h before
the operation.
– If prolonged periods of fa... | 281 | 583 | 1 | WHO-0001 | 1 | who_corpus.pdf | 386 |
258
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
9.1.2
Intraoperative care
Successful procedures require teamwork and careful planning.(?<=[.!?])\s+(?=[A-Z0-9])The operating
room staff should function as a team, including surgeons, anaesthesia staff,
nurses, scrub technicians and others.(?<=[.!?])\s+(?=[A-Z0-9])Ensure that e... | 282 | 584 | 0 | WHO-0001 | 1 | who_corpus.pdf | 361 |
Ketamine is an excellent anaesthetic when muscle relaxation is not required.
– Insert an intravenous cannula.(?<=[.!?])\s+(?=[A-Z0-9])It may be more convenient to delay this
until after ketamine has been given IM.
•
Induction and maintenance of anaesthesia (short procedures) and analgesia
for short painful procedu... | 282 | 585 | 1 | WHO-0001 | 1 | who_corpus.pdf | 352 |
259
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Special considerations
Airway
•
The smaller-diameter airway of children makes them especially susceptible
to airway obstruction, so they often need intubation to protect their airway
during surgical procedures.
•
Small children also have diffi culty in moving heavy columns of ... | 283 | 586 | 0 | WHO-0001 | 1 | who_corpus.pdf | 398 |
Listen to the lungs with a stethoscope
after intubation to ensure that the breath sounds are equal on the two sides.(?<=[.!?])\s+(?=[A-Z0-9])Hypothermia
Small children lose heat more rapidly than adults because they have a greater
relative surface area and are poorly insulated.(?<=[.!?])\s+(?=[A-Z0-9])This is import... | 283 | 587 | 1 | WHO-0001 | 1 | who_corpus.pdf | 140 |
260
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
•
Prevent hypothermia in the operating room by maintaining a temperature
> 28 °C when operating on an infant or small child, and cover the exposed
parts of the child.
•
Use warmed fl uids (but not too hot).
•
Avoid long procedures (> 1 h) unless the child can be kept warm.
... | 284 | 588 | 0 | WHO-0001 | 1 | who_corpus.pdf | 394 |
Table 29.(?<=[.!?])\s+(?=[A-Z0-9])Blood volume of children by age
ml/kg body weight
Neonate
85–90
Children
80
Adults
70
9.1.3
Postoperative care
Communicate to the family the outcome of the operation, any problems
encountered during the procedure and the expected postoperative course.(?<=[.!?])\s+(?=[A-Z0-9])POSTOPER... | 284 | 589 | 1 | WHO-0001 | 1 | who_corpus.pdf | 103 |
261
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Immediately after surgery
Ensure that the child recovers safely from the anaesthesia.(?<=[.!?])\s+(?=[A-Z0-9])The patient should
be kept on the ward or recovery area where she or he can be adequately moni-
tored, with clear orders to:
•
monitor the airway, breathing and circula... | 285 | 590 | 0 | WHO-0001 | 1 | who_corpus.pdf | 355 |
In infants and
children, the presence or absence of a strong central pulse is often a more use-
ful guide to the presence or absence of shock than a blood pressure reading.(?<=[.!?])\s+(?=[A-Z0-9])Fluid management
Postoperatively, children commonly require more than maintenance fl uid.(?<=[.!?])\s+(?=[A-Z0-9])Children ... | 285 | 591 | 1 | WHO-0001 | 1 | who_corpus.pdf | 370 |
Monitor fl uid status closely.
•
Record inputs and outputs (IV fl uids, nasogastric drainage, vomit, urine
drain outputs) every 4–6 h.(?<=[.!?])\s+(?=[A-Z0-9])Urine output is the most sensitive indicator of fl uid status in a child:
•
Normal urine output: infants, 1–2 ml/kg per h; children, 1 ml/kg per h
POSTOPERATIV... | 285 | 592 | 2 | WHO-0001 | 1 | who_corpus.pdf | 102 |
262
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
If urinary retention is suspected, pass a urinary catheter.(?<=[.!?])\s+(?=[A-Z0-9])This also allows
hourly measurements of urine output, which can be valuable for severely ill
children.(?<=[.!?])\s+(?=[A-Z0-9])Suspect urinary retention if the bladder is palpable or the child is... | 286 | 593 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
Prevention of complications
•
Encourage early mobilization:
– deep breathing and coughing
– active daily exercise
•
Move joints passively
– muscular strengthening
– provide walking aids, such as canes, crutches and walkers, with instruc-
tions for their use
•
Prevent skin breakdown and pressure sores:
– Turn th... | 286 | 594 | 1 | WHO-0001 | 1 | who_corpus.pdf | 101 |
263
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Common postoperative problems
•
Tachycardia (raised pulse rate, see Table 30, p.(?<=[.!?])\s+(?=[A-Z0-9])261) may be caused by pain,
hypovolaemia, anaemia, fever, hypoglycaemia or infection.
– Examine the child.
– Review the child’s pre-operative and intra-operative care.
–... | 287 | 595 | 0 | WHO-0001 | 1 | who_corpus.pdf | 233 |
279 for information on the diagnosis and treatment
of wound infections.
•
Low urine output may be due to hypovolaemia, urinary retention or renal
failure; usually due to inadequate fl uid resuscitation.
– Examine the child.
– Review the child’s fl uid record.
– If hypovolaemia is suspected, give normal saline (10... | 287 | 596 | 1 | WHO-0001 | 1 | who_corpus.pdf | 356 |
264
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
– If the infection is deep, involves muscles and is causing necrosis (necrotiz-
ing fasciitis), give antibiotics until necrotic tissue has been removed and
the patient is fever-free for 48 h.
– Give ampicillin (25–50 mg/kg IM or IV four times a day) plus gentamicin
(7.5 mg/kg ... | 288 | 597 | 0 | WHO-0001 | 1 | who_corpus.pdf | 346 |
Reassure the parents
that the problem can be dealt with, as there may be concern about the unat-
tractive appearance.(?<=[.!?])\s+(?=[A-Z0-9])CONGENITAL ANOMALIES
Unilateral
Bilateral
With cleft palate
Cleft lip and palate
Treatment
Infants with isolated cleft lip can feed normally, whereas cleft palate is associ-... | 288 | 598 | 1 | WHO-0001 | 1 | who_corpus.pdf | 200 |
265
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Feed with expressed breast milk from a cup and spoon or bottles, if avail-
able and adequate sterility can be ensured; a special teat may be used.(?<=[.!?])\s+(?=[A-Z0-9])The
technique of feeding is to deliver a bolus of milk over the back of the tongue
into the pharynx with... | 289 | 599 | 0 | WHO-0001 | 1 | who_corpus.pdf | 389 |
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