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Diagnosis
•
The level of obstruction determines the clinical presentation.(?<=[.!?])\s+(?=[A-Z0-9])Proximal ob-
struction presents as vomiting with minimal distension and distal obstruction
as distension with vomiting occurring late.
•
Bile-stained (green) vomit in an infant is due to bowel obstruction until
prove... | 289 | 600 | 1 | WHO-0001 | 1 | who_corpus.pdf | 297 |
266
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Intravenous fl uid: use half-strength Darrow’s solution or normal saline plus
5% glucose (dextrose):
– Correct shock, if present, with 20 ml/kg bolus of normal saline or Ringer’s
lactate as a rapid IV bolus.
– If there is no shock but dehydration, give 10–20 ml/kg half-stre... | 290 | 601 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Treatment
Apply a sterile dressing, and cover with
a plastic bag or cling fi lm (to prevent fl uid loss).(?<=[.!?])\s+(?=[A-Z0-9])An exposed bowel can lead
to rapid fl uid loss and hypothermia.
Give nothing orally.(?<=[.!?])\s+(?=[A-Z0-9])Pass a nasogastric tube for free drainage.
Give IV fl uids: normal sal... | 290 | 602 | 1 | WHO-0001 | 1 | who_corpus.pdf | 334 |
267
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Urgent review by a surgeon experienced in paediatric surgery.(?<=[.!?])\s+(?=[A-Z0-9])9.2.4 Myelomeningocoele
Diagnosis
■Small sac that protrudes through a bony defect in the skull or vertebrae.(?<=[.!?])\s+(?=[A-Z0-9])The
commonest site is the lumbar region.
■May be associ... | 291 | 603 | 0 | WHO-0001 | 1 | who_corpus.pdf | 359 |
When the fl exed hip is abducted, a click can often be felt as
the dislocated femoral head enters the acetabulum (Ortolani’s sign).
■Diagnosis requires X-ray and/
or specialist ultrasound (See
paediatric textbook for details).(?<=[.!?])\s+(?=[A-Z0-9])Treatment
In milder cases, keep the hip in
fl exion and abduc... | 291 | 604 | 1 | WHO-0001 | 1 | who_corpus.pdf | 238 |
268
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
9.2.6 Talipes equinovarus (club foot)
Diagnosis
■The foot cannot be placed in the normal position.
■The commonest form includes three deformities: plantar fl exion of the foot,
inversion (inturning of the heel) and inturning of the forefoot.(?<=[.!?])\s+(?=[A-Z0-9])Treatment ... | 292 | 605 | 0 | WHO-0001 | 1 | who_corpus.pdf | 301 |
269
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
9.3
Injuries
Injuries are the commonest surgical problems of children.(?<=[.!?])\s+(?=[A-Z0-9])Proper treatment
can prevent death and lifelong disability.(?<=[.!?])\s+(?=[A-Z0-9])Whenever possible, try to prevent
childhood injuries.
•
See Chapter 1, section 1.10, p.(?<=[.!?])... | 293 | 606 | 0 | WHO-0001 | 1 | who_corpus.pdf | 373 |
Assessment
Burns may be partial or full thickness.(?<=[.!?])\s+(?=[A-Z0-9])A full-thickness burn involves destruc-
tion of the entire thickness of the skin, and the skin will not regenerate.(?<=[.!?])\s+(?=[A-Z0-9])Ask
two questions:
How deep is the burn?
•
Full thickness burns are black or white, usually dry, have... | 293 | 607 | 1 | WHO-0001 | 1 | who_corpus.pdf | 387 |
312), and ensure the airway are safe and remain safe by regular ob-
servation.(?<=[.!?])\s+(?=[A-Z0-9])Inform the anaesthetist if there is potential airway obstruction.(?<=[.!?])\s+(?=[A-Z0-9])INJURIES | 293 | 608 | 2 | WHO-0001 | 1 | who_corpus.pdf | 82 |
270
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
BURNS
Chart for estimating the percentage of body surface burnt
Estimate the total area burnt by adding the percentage of body surface
area affected as shown in the fi gure; refer to the table for areas A–F,
which change according to the age of the child.(?<=[.!?])\s+(?=[A-Z0-9])... | 294 | 609 | 0 | WHO-0001 | 1 | who_corpus.pdf | 161 |
271
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
– Severe facial burns and inhalation injuries may require early intubation
or tracheostomy to prevent or treat airway obstruction.
Fluid resuscitation is required for burns covering > 10% total body surface.(?<=[.!?])\s+(?=[A-Z0-9])Use Ringer’s lactate or normal saline with ... | 295 | 610 | 0 | WHO-0001 | 1 | who_corpus.pdf | 221 |
Example: 20 kg child with a 25% burn:
Total fl uid in fi rst 24 h = (60 ml/h x 24 h) + 4 ml x 20 kg x 25% burn
= 1440 ml + 2000 ml
= 3440 ml (1720 ml over fi rst 8 h)
– Second 24 h: give half to three quarters of fl uid required during the
fi rst day.
– Monitor the child closely while giving emergency fl uids (pulse, re... | 295 | 611 | 1 | WHO-0001 | 1 | who_corpus.pdf | 380 |
272
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
cloxacillin (25 mg/kg orally four times a day).(?<=[.!?])\s+(?=[A-Z0-9])If septicaemia is suspected,
use gentamicin (7.5 mg/kg IM or IV once a day) plus cloxacillin (25–50
mg/kg IM or IV four times a day).(?<=[.!?])\s+(?=[A-Z0-9])If infection is suspected beneath an
eschar, rem... | 296 | 612 | 0 | WHO-0001 | 1 | who_corpus.pdf | 341 |
This hap-
pens even with the best treatment (and nearly always happens with poor
treatment).
– Prevent contractures by passive mobilization of the involved areas and
by splinting fl exor surfaces to keep them extended.(?<=[.!?])\s+(?=[A-Z0-9])Splints can be made
of plaster of Paris.(?<=[.!?])\s+(?=[A-Z0-9])Splints ... | 296 | 613 | 1 | WHO-0001 | 1 | who_corpus.pdf | 325 |
273
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
•
Concussion: the mildest injury, with temporary loss of brain function
•
Contusion: the brain is bruised, and function may be affected for hours to
days or even weeks.
•
Compression: may result from swelling or a growing blood clot (epidural
or subdural haematoma).(?<=[.!?]... | 297 | 614 | 0 | WHO-0001 | 1 | who_corpus.pdf | 351 |
The best way of retaining brain
function after a head injury is to ensure that the airway remains open and
breathing is adequate, correct shock and prevent hypotension.(?<=[.!?])\s+(?=[A-Z0-9])If the child does
not respond to pain or is unconscious (P or U on the AVPU scale), seek urgent
help from an anaesthetist, ... | 297 | 615 | 1 | WHO-0001 | 1 | who_corpus.pdf | 391 |
They may result from blunt or penetrating
injuries.(?<=[.!?])\s+(?=[A-Z0-9])Because the rib-cage of children is more pliable than that of adults,
there may be extensive chest injuries without rib fractures.(?<=[.!?])\s+(?=[A-Z0-9])Chest injuries
CHEST INJURIES | 297 | 616 | 2 | WHO-0001 | 1 | who_corpus.pdf | 89 |
274
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
include rib fractures, pulmonary contusions, pneumothorax and haemothorax.(?<=[.!?])\s+(?=[A-Z0-9])All suspected chest injuries require urgent review by a surgeon experienced
in paediatric surgery.(?<=[.!?])\s+(?=[A-Z0-9])Pneumothorax
Tension pneumothorax develops when air enters... | 298 | 617 | 0 | WHO-0001 | 1 | who_corpus.pdf | 368 |
If the haemorrhage is
severe, hypovolaemic shock will occur, as well as respiratory distress due to
compression of the lung on the involved side.(?<=[.!?])\s+(?=[A-Z0-9])The child may be in respiratory
distress with cyanosis, decreased chest movement and air entry on the affected
side but with dullness on percussio... | 298 | 618 | 1 | WHO-0001 | 1 | who_corpus.pdf | 395 |
275
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Rib fractures
Fractured ribs may occur at the point of impact, and damage to the underlying
lung may produce lung bruising or puncture.(?<=[.!?])\s+(?=[A-Z0-9])The ribs usually become fairly
stable within 10 days to 2 weeks, and fi rm healing with callus formation is seen
after ... | 299 | 619 | 0 | WHO-0001 | 1 | who_corpus.pdf | 353 |
Any penetration of the bowel wall will lead to peritonitis in a day or
two, and surgical intervention is essential.
■Be especially cautious with injuries around the anus, as penetrating rectal
injuries can be easily missed.
■Look for signs of bruising and penetrating trauma, listen for bowel sounds,
check rena... | 299 | 620 | 1 | WHO-0001 | 1 | who_corpus.pdf | 373 |
276
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Treatment
•
Ask two questions:
– Is there a fracture?
– Which bone is broken (either by clinical examination or X-ray)?
•
Consider referral for review by a surgeon experienced in paediatric surgery
for complicated fractures such as those that are displaced, involve growth
p... | 300 | 621 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
The
posterior splint is held in place with
an elastic bandage.(?<=[.!?])\s+(?=[A-Z0-9])Monitor capillary
refi ll and temperature of the fi ngers
to ensure that the splint has not been
placed too tightly.(?<=[.!?])\s+(?=[A-Z0-9])FRACTURES
Posterior
splint
Sling to support
an injured arm | 300 | 622 | 1 | WHO-0001 | 1 | who_corpus.pdf | 100 |
277
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
FRACTURES
Gallows traction
A: Lower extremity
skin traction
B: Prevention of
rotational deformity
can be achieved
by adding a piece
of wood to a foot
plaster.(?<=[.!?])\s+(?=[A-Z0-9])A
B | 301 | 623 | 0 | WHO-0001 | 1 | who_corpus.pdf | 87 |
278
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
FRACTURES
Treatment of a supracondylar fracture
A.(?<=[.!?])\s+(?=[A-Z0-9])X-ray of displaced supracondylar fracture
B.(?<=[.!?])\s+(?=[A-Z0-9])Pull as shown to reduce the fracture displacement.(?<=[.!?])\s+(?=[A-Z0-9])C.(?<=[.!?])\s+(?=[A-Z0-9])Carefully bend the elbow, maintain... | 302 | 624 | 0 | WHO-0001 | 1 | who_corpus.pdf | 393 |
279
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Treatment of a supra-condylar fracture is shown on the previous page.(?<=[.!?])\s+(?=[A-Z0-9])An
important complication of this fracture is constriction of the artery at the elbow,
where it can become entrapped.(?<=[.!?])\s+(?=[A-Z0-9])Assess the blood fl ow to the hand.(?<=[.!?]... | 303 | 625 | 0 | WHO-0001 | 1 | who_corpus.pdf | 398 |
Treatment of a mid-shaft femoral fracture in an older child is skin traction
(see fi gure A on p.(?<=[.!?])\s+(?=[A-Z0-9])277).(?<=[.!?])\s+(?=[A-Z0-9])This is a simple, effective method for treating femur
fractures in children aged 3–15 years.(?<=[.!?])\s+(?=[A-Z0-9])If the child can raise his or her leg off the
bed... | 303 | 626 | 1 | WHO-0001 | 1 | who_corpus.pdf | 386 |
Never
use a tourniquet in a child with sickle-cell anaemia.
Prevent infection
– Cleaning the wound is the most important way of preventing wound
infection.(?<=[.!?])\s+(?=[A-Z0-9])Most wounds are contaminated when fi rst seen.(?<=[.!?])\s+(?=[A-Z0-9])They may
contain blood clots, dirt, dead or dying tissue and ... | 303 | 627 | 2 | WHO-0001 | 1 | who_corpus.pdf | 307 |
280
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
– Antibiotics are usually not necessary when wounds are carefully cleaned;
however, some wounds should be treated with antibiotics:
•
wounds older than 12 h (likely to be already infected)
•
wounds penetrating deep into tissue (e.g. a dirty stick, knife wound
or animal bite)
... | 304 | 628 | 0 | WHO-0001 | 1 | who_corpus.pdf | 212 |
281
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
– The wound should not be closed if it is > 24 h old, it contained a lot of dirt
and foreign material or it was caused by an animal bite.
– Wounds not treated with primary closure should be packed lightly with
damp sterile gauze.(?<=[.!?])\s+(?=[A-Z0-9])If the wound is clean ... | 305 | 629 | 0 | WHO-0001 | 1 | who_corpus.pdf | 377 |
9.4
Abdominal problems
9.4.1
Abdominal pain
Not all abdominal pain is caused by gastrointestinal infections.(?<=[.!?])\s+(?=[A-Z0-9])Abdominal
pain lasting > 4 h should be regarded as a potential abdominal emergency.(?<=[.!?])\s+(?=[A-Z0-9])Assessment
■Ask three questions:
– Are there associated symptoms?(?<=[.!?... | 305 | 630 | 1 | WHO-0001 | 1 | who_corpus.pdf | 354 |
282
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
■Signs of peritonitis include tenderness during palpation, pain in the abdo-
men, especially on movement, and involuntary guarding (spasm of the
abdominal musculature on palpation).(?<=[.!?])\s+(?=[A-Z0-9])A rigid abdomen that does not move
with respiration is another sign of ... | 306 | 631 | 0 | WHO-0001 | 1 | who_corpus.pdf | 335 |
If shock persists,
repeat the IV bolus of 20 ml/kg, but watch carefully for circulatory fl uid
overload.(?<=[.!?])\s+(?=[A-Z0-9])If there is no shock but the child is dehydrated, give 10–20 ml/kg
half-strength Darrow solution or normal saline plus 5% glucose over 20 min,
and give 150% maintenance fl uid requirements ... | 306 | 632 | 1 | WHO-0001 | 1 | who_corpus.pdf | 378 |
Faecoliths,
lymphoid hyperplasia and gastrointestinal parasites can cause obstruction.(?<=[.!?])\s+(?=[A-Z0-9])If appendicitis is not recognized, the appendix ruptures, leading to peritonitis
and abscess formation.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
This is very diffi cult, especially in young children.
■fever, anore... | 306 | 633 | 2 | WHO-0001 | 1 | who_corpus.pdf | 158 |
283
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
A raised white blood cell count can be helpful.(?<=[.!?])\s+(?=[A-Z0-9])Ultrasound examination by a
skilled observer can be very helpful.(?<=[.!?])\s+(?=[A-Z0-9])Treatment
Give the child nothing orally.
Give IV fl uids.
– Correct shock, if present, with 20 ml/kg normal... | 307 | 634 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Appendectomy should be done as soon as possible to prevent perforation,
peritonitis and abscess formation.(?<=[.!?])\s+(?=[A-Z0-9])It is better to operate and be wrong about
the diagnosis than to delay and have peritonitis occur.(?<=[.!?])\s+(?=[A-Z0-9])9.4.3 Bowel obstruction after the neonatal period
Bowel obstruct... | 307 | 635 | 1 | WHO-0001 | 1 | who_corpus.pdf | 341 |
Treatment
Give the child nothing orally.
Give fl uid resuscitation.(?<=[.!?])\s+(?=[A-Z0-9])Most children presenting with bowel obstruction
have been vomiting and are dehydrated.
Correct shock, if present, with 20 ml/kg normal saline or Hartmann’s solu-
tion as a rapid IV bolus (see p.(?<=[.!?])\s+(?=[A-... | 307 | 636 | 2 | WHO-0001 | 1 | who_corpus.pdf | 151 |
284
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
20 ml/kg, but watch carefully for circulatory fl uid overload.(?<=[.!?])\s+(?=[A-Z0-9])If the child is not
in shock but is dehydrated, give 10–20 ml/kg half-strength Darrow solution
or normal saline plus 5% glucose over 20 min.
Pass a nasogastric tube to relieve nausea and vo... | 308 | 637 | 0 | WHO-0001 | 1 | who_corpus.pdf | 385 |
Treatment
Arrange urgent review by a surgeon experienced in paediatric surgery.(?<=[.!?])\s+(?=[A-Z0-9])Proceed to an operation if air or a barium enema is unable to reduce the
intussusception.(?<=[.!?])\s+(?=[A-Z0-9])If the bowel is ischaemic or dead, bowel resection will
be required.(?<=[.!?])\s+(?=[A-Z0-9])Tra... | 308 | 638 | 1 | WHO-0001 | 1 | who_corpus.pdf | 388 |
The
pressure of the column of barium slowly reduces the intussusception; the
reduction is complete only when several loops of small bowel are seen to fi ll
with barium.(?<=[.!?])\s+(?=[A-Z0-9])INTUSSUSCEPTION | 308 | 639 | 2 | WHO-0001 | 1 | who_corpus.pdf | 63 |
285
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Pass a nasogastric tube.
Give fl uid resuscitation.(?<=[.!?])\s+(?=[A-Z0-9])Correct shock, if present, with 20 ml/kg normal
saline or Hartmann’s solution as a rapid IV bolus (see p.(?<=[.!?])\s+(?=[A-Z0-9])13).(?<=[.!?])\s+(?=[A-Z0-9])If shock per-
sists, repeat the IV bol... | 309 | 640 | 0 | WHO-0001 | 1 | who_corpus.pdf | 321 |
The
duration of post-operative antibiotics depends on the severity of disease:
in an uncomplicated intussusception reduced with an air enema, give for
24–48 h postoperatively; in a child with a perforated bowel with resection,
continue antibiotics for 7–14 days, depending on response.(?<=[.!?])\s+(?=[A-Z0-9])9.4.5 ... | 309 | 641 | 1 | WHO-0001 | 1 | who_corpus.pdf | 287 |
286
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Treatment
•
Uncomplicated inguinal hernia: elective surgical repair to prevent incar-
ceration
•
Hydrocoele: repair if not resolved by the age of 1 year.(?<=[.!?])\s+(?=[A-Z0-9])Unrepaired hydro-
coeles can become inguinal hernias.(?<=[.!?])\s+(?=[A-Z0-9])9.4.7 Incarcerated hern... | 310 | 642 | 0 | WHO-0001 | 1 | who_corpus.pdf | 287 |
Treatment
Urgent review by a surgeon experienced in paediatric surgery is required.
Attempt to reduce the hernia by steady constant pressure, provided that
there are no signs of strangulation or perforation.(?<=[.!?])\s+(?=[A-Z0-9])If the hernia does not
reduce easily, an operation will be required.
Give... | 310 | 643 | 1 | WHO-0001 | 1 | who_corpus.pdf | 386 |
287
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
9.4.9 Rectal prolapse
Rectal prolapse is caused by straining during a bowel motion and is associated
with chronic diarrhoea and poor nutrition.(?<=[.!?])\s+(?=[A-Z0-9])Causative factors include gastroin-
testinal parasites (such as Trichuris) and cystic fi brosis.(?<=[.!?])\s+(?=... | 311 | 644 | 0 | WHO-0001 | 1 | who_corpus.pdf | 377 |
9.5
Infections requiring surgery
9.5.1
Abscess
Infection can cause a collection of pus in almost any area of the body.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
■Fever, swelling, tenderness and a fl uctuant mass.
■Determine the cause of the abscess (e.g. injection, foreign body or under-
lying bone infection).(?<=[.!?])\... | 311 | 645 | 1 | WHO-0001 | 1 | who_corpus.pdf | 281 |
288
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
abscess), give ampicillin (25–50 mg/kg IM or IV four times a day), gen-
tamicin (7.5 mg/kg IM or IV once a day) plus metronidazole (10 mg/kg
three times a day).(?<=[.!?])\s+(?=[A-Z0-9])9.5.2 Osteomyelitis
Infection of a bone usually results from blood spread (see p.(?<=[.!?])\s+(... | 312 | 646 | 0 | WHO-0001 | 1 | who_corpus.pdf | 348 |
289
9. SURGERY
Diagnosis
•
Acute osteomyelitis:
– pain and tenderness of the involved bone
– usually, intermittent fever
– refusal to move the affected limb
– refusal to bear weight if in the leg
In early osteomyelitis, the X-ray may be normal; it usually takes 12–14 days
for X-ray changes to appear.
•
Chroni... | 313 | 647 | 0 | WHO-0001 | 1 | who_corpus.pdf | 313 |
290
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
SEPTIC ARTHRITIS
Techniques for aspirating hip (A,B), knee (C,D) and elbow (E) joints
A
B
C
D
E
Treatment
Aspiration of the joint to confi rm the diagnosis (see fi gure, above).(?<=[.!?])\s+(?=[A-Z0-9])The
commonest organism is S. aureus.(?<=[.!?])\s+(?=[A-Z0-9])Aspiration sho... | 314 | 648 | 0 | WHO-0001 | 1 | who_corpus.pdf | 195 |
291
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
PYOMYOSITIS
Give chloramphenicol (25 mg/kg three times a day) to children aged
< 3 years and those with sickle cell disease; or give cloxacillin (50 mg/kg
IM or IV four times a day) to children aged > 3 years for at least 3 weeks.(?<=[.!?])\s+(?=[A-Z0-9])Give parenteral anti... | 315 | 649 | 0 | WHO-0001 | 1 | who_corpus.pdf | 335 |
292
9.(?<=[.!?])\s+(?=[A-Z0-9])SURGERY
Notes | 316 | 650 | 0 | WHO-0001 | 1 | who_corpus.pdf | 30 |
293
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
10.1 Nutritional management
294
10.1.1 Supporting breastfeeding
294
10.1.2 Nutritional management of sick children
299
10.2 Fluid management
304
10.3 Management of fever
305
10.4 Pain control
306
10.5 Management of anaemia
307
10.6 Blood transfusion
308
10.6... | 317 | 651 | 0 | WHO-0001 | 1 | who_corpus.pdf | 279 |
294
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
10.1
Nutritional management
Health workers should follow the advice on counselling in sections 12.3 and
12.4 (pp.(?<=[.!?])\s+(?=[A-Z0-9])322–4).(?<=[.!?])\s+(?=[A-Z0-9])A mother’s card with pictures of the advice can be helpful
for the mother to take home as a remind... | 318 | 652 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
Observe the mother while breastfeeding to decide whether she needs
help.(?<=[.!?])\s+(?=[A-Z0-9])Observe:
•
how the infant is attached to the breast (see next page).(?<=[.!?])\s+(?=[A-Z0-9])Signs of good
attachment are:
– areola visible above infant’s mouth
– mouth wide open
– lower lip turned out
– infant’s chi... | 318 | 653 | 1 | WHO-0001 | 1 | who_corpus.pdf | 231 |
295
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Good (left) and poor (right) positioning of infant for breastfeeding
Good (left) and poor (right) attachment of infant to the mother’s breast
Good (left) and poor (right) attachment: cross-sectional view of breast and infant
SUPPORTING BREASTFEEDING | 319 | 654 | 0 | WHO-0001 | 1 | who_corpus.pdf | 83 |
296
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
•
poor weight gain (< 500 g/month or < 125 g/week or infant weighing less
than the birth weight after 2 weeks)
•
passing a small amount of concentrated urine (less than six times a day,
yellow and strong-smelling)
Common reasons why an infant may not be getting enough... | 320 | 655 | 0 | WHO-0001 | 1 | who_corpus.pdf | 323 |
A mother whose breast milk supply is reduced will have to increase it, while a
mother who has stopped breastfeeding may need to relactate.(?<=[.!?])\s+(?=[A-Z0-9])Help a mother to breastfeed again by:
•
keeping the infant close to her and not giving him or her to other carers
•
ensuring plenty of skin-to-skin contac... | 320 | 656 | 1 | WHO-0001 | 1 | who_corpus.pdf | 382 |
Do not
use bottles or pacifi ers.(?<=[.!?])\s+(?=[A-Z0-9])Reduce the other milk by 30–60 ml per day as the
mother’s breast milk starts to increase.(?<=[.!?])\s+(?=[A-Z0-9])Monitor the infant’s weight gain.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTING BREASTFEEDING | 320 | 657 | 2 | WHO-0001 | 1 | who_corpus.pdf | 117 |
297
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
3.(?<=[.!?])\s+(?=[A-Z0-9])Refusal or reluctance to breastfeed
The main reasons why an infant might refuse to breastfeed are:
•
The infant is ill, in pain or sedated.
– If the infant is able to suckle, encourage the mother to breastfeed more
often.(?<=[.!?])\s+(?=[A-Z... | 321 | 658 | 0 | WHO-0001 | 1 | who_corpus.pdf | 394 |
If this is not available,
apply 1% gentian violet solution.(?<=[.!?])\s+(?=[A-Z0-9])Encourage the mother of a teething infant
to be patient and keep offering the breast.
– If the mother is on regular sedation, reduce the dose or try a less sedat-
ing alternative.
•
There is diffi culty with the breastfeeding techniq... | 321 | 659 | 1 | WHO-0001 | 1 | who_corpus.pdf | 338 |
Oversupply may also occur if a mother tries to make her infant feed from
both breasts at each feed, when this is not necessary.
•
A change has upset the infant.(?<=[.!?])\s+(?=[A-Z0-9])Changes such as separation from the mother, a new carer, illness of the
mother, a change in the family routine or the mother’s smel... | 321 | 660 | 2 | WHO-0001 | 1 | who_corpus.pdf | 149 |
298
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Low-birth-weight and sick infants
Infants with a birth weight < 2.5 kg need breast milk even more than larger
infants; often, however, they cannot breastfeed immediately after birth, espe-
cially if they are very small.(?<=[.!?])\s+(?=[A-Z0-9])For the fi rst few days, an ... | 322 | 661 | 0 | WHO-0001 | 1 | who_corpus.pdf | 358 |
This may stimulate the infant’s digestive tract and help weight gain.(?<=[.!?])\s+(?=[A-Z0-9])Low-birth-weight infants at ≥ 32 weeks’ gestational age can start suckling on
the breast.(?<=[.!?])\s+(?=[A-Z0-9])Let the mother put her infant to the breast as soon as the infant is
well enough.(?<=[.!?])\s+(?=[A-Z0-9])Cont... | 322 | 662 | 1 | WHO-0001 | 1 | who_corpus.pdf | 366 |
Dilute
cow’s milk by adding 50 ml of
water to 100 ml of milk, then
add 10 g of sugar, with an
approved micronutrient sup-
plement.(?<=[.!?])\s+(?=[A-Z0-9])If possible, do not use
for premature infants. | 322 | 663 | 2 | WHO-0001 | 1 | who_corpus.pdf | 69 |
299
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Expressed breast milk is the best choice, in the following amounts:
– Infants ≥ 2.0 kg: Give 150 ml/kg daily, divided into eight feeds at 3-h
intervals.
– Infants < 2.0 kg: See p.(?<=[.!?])\s+(?=[A-Z0-9])60 for detailed guidance for low-birth-weight
infants.
– If the... | 323 | 664 | 0 | WHO-0001 | 1 | who_corpus.pdf | 356 |
The food provided should be:
•
palatable (to the child)
•
easily eaten (soft or liquid consistency)
•
easily digested
•
nutritious: rich in energy and nutrients.(?<=[.!?])\s+(?=[A-Z0-9])The basic principle of nutritional management is to provide a diet with suffi cient
energy-producing foods and high-quality protei... | 323 | 665 | 1 | WHO-0001 | 1 | who_corpus.pdf | 389 |
Put drops
of saline into the nose with a moistened wick to help soften the mucus.(?<=[.!?])\s+(?=[A-Z0-9])A minority of children who are unable to eat for a number of days (due, e.g.
to impaired consciousness in meningitis or respiratory distress in severe
NUTRITIONAL MANAGEMENT OF SICK CHILDREN | 323 | 666 | 2 | WHO-0001 | 1 | who_corpus.pdf | 81 |
300
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
NUTRITIONAL MANAGEMENT OF SICK CHILDREN
Catch-up meals
The recipes provide 100 kcal and 3 g protein/100 ml.(?<=[.!?])\s+(?=[A-Z0-9])The individual
servings contain approximately 200 kcal and 6 g protein.(?<=[.!?])\s+(?=[A-Z0-9])A child should
eat seven meals in 24 h.(?... | 324 | 667 | 0 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Make up to 1 litre.(?<=[.!?])\s+(?=[A-Z0-9])For rice pudding, replace cereal fl our with the same amount of rice.(?<=[.!?])\s+(?=[A-Z0-9])These recipes may have to be supplemented with vitamins and
minerals. | 324 | 668 | 1 | WHO-0001 | 1 | who_corpus.pdf | 87 |
301
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
NUTRITIONAL MANAGEMENT OF SICK CHILDREN
Recipe 3 (rice-based meal)
Ingredient
To make 600 g
For one serving
Rice
75 g
25
Lentils (dhal)
50 g
20 g
Pumpkin
75 g
25 g
Green leaves
75 g
25 g
Oil or margarine
25 g
10 g
Water
800 ml
Put rice, lentils, pumpkin, oil, spices and ... | 325 | 669 | 0 | WHO-0001 | 1 | who_corpus.pdf | 384 |
Cook for a few
minutes.(?<=[.!?])\s+(?=[A-Z0-9])Fry onion and tomato for fl avour and add leaves.(?<=[.!?])\s+(?=[A-Z0-9])Stir into por-
ridge or serve separately.
a Big = 10 ml spoon, rounded
b Teaspoon = 5 ml | 325 | 670 | 1 | WHO-0001 | 1 | who_corpus.pdf | 95 |
302
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
NUTRITIONAL MANAGEMENT OF SICK CHILDREN
Chart 16.(?<=[.!?])\s+(?=[A-Z0-9])Feeding recommendations during
sickness and healtha
Up to 6 months of age
Breastfeed as often as the child wants, day and
night, at least eight times in 24 h.(?<=[.!?])\s+(?=[A-Z0-9])Frequent ... | 326 | 671 | 0 | WHO-0001 | 1 | who_corpus.pdf | 243 |
6–12 months
Breastfeed as often as the child wants day and night, at least eight times
in 24 h.
Give adequate servings of locally appropriate nutrient-dense foods, well
mashed or fi nely chopped, increasing gradually (see Table 31 for examples):
– three times per day if breastfed
– fi ve times per day if not... | 326 | 672 | 1 | WHO-0001 | 1 | who_corpus.pdf | 256 |
303
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
NUTRITIONAL MANAGEMENT OF SICK CHILDREN
Table 31.(?<=[.!?])\s+(?=[A-Z0-9])Examples of local adaptations of feeding recommendations on the mother’s card in Bolivia, Indonesia, Nepal,
South Africa and the United Republic of Tanzania
Country
6–12 months
1–2 years
≥ 2 years
... | 327 | 673 | 0 | WHO-0001 | 1 | who_corpus.pdf | 283 |
Also twice a day, nutritious foods
between meals, such as green beans,
porridge, banana, biscuit, nagasari
Nepal
Adequate servings of (mashed) foods such as rice, lentils (dhal), mashed bread (roti), biscuits, milk,
yoghurt, seasonal fruits (such as banana, guava, mango), vegetables (such as potatoes, carrots, green... | 327 | 674 | 1 | WHO-0001 | 1 | who_corpus.pdf | 398 |
304
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
pneumonia) may have to be fed through a nasogastric tube.(?<=[.!?])\s+(?=[A-Z0-9])The risk for aspi-
ration can be reduced if small volumes are given frequently and by ensuring
before each feed that the tube is in the stomach.(?<=[.!?])\s+(?=[A-Z0-9])To supplement the ch... | 328 | 675 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Table 32.(?<=[.!?])\s+(?=[A-Z0-9])Maintenance fl uid requirements
Body weight of child (kg)
Fluid (ml/day)
2
200
4
400
6
600
8
800
10
1000
12
1100
14
1200
16
1300
18
1400
20
1500
22
1550
24
1600
26
1650
Give the sick child more than the above amounts if he or she has fever (increase
by 10% for every 1 °C o... | 328 | 676 | 1 | WHO-0001 | 1 | who_corpus.pdf | 287 |
305
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
If it is impossible to monitor the IV fl uid infusion closely, the IV route should be
used only for the management of severe dehydration, septic shock, delivering
IV antibiotics and for children for whom oral fl uids are contraindicated (such as
those with perforation of... | 329 | 677 | 0 | WHO-0001 | 1 | who_corpus.pdf | 375 |
Fever is not an indication for antibiotic treatment and may help the immune
defence against infection.(?<=[.!?])\s+(?=[A-Z0-9])High fever (> 39 °C or > 102.2 °F) can have harmful
effects, such as:
•
reducing the appetite
•
making the child irritable
•
precipitating convulsions in some children aged 6 months to 5 ... | 329 | 678 | 1 | WHO-0001 | 1 | who_corpus.pdf | 394 |
306
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Other agents
Aspirin is not recommended as a fi rst-line antipyretic because it has been
linked with Reye syndrome, a rare but serious condition affecting the liver
and brain.(?<=[.!?])\s+(?=[A-Z0-9])Avoid giving aspirin to children with chickenpox, dengue fever and
oth... | 330 | 679 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
Use the following drugs for effective pain control:
Mild pain: such as headaches, post-traumatic pain and pain due to spasticity
Give paracetamol or ibuprofen to children > 3 months who can take oral
medication.(?<=[.!?])\s+(?=[A-Z0-9])For infants < 3 months of age, use only paracetamol.
– paracetamol at 10–15 mg... | 330 | 680 | 1 | WHO-0001 | 1 | who_corpus.pdf | 146 |
307
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
■If morphine does not adequately relieve pain, then switch to alternative
opioids, such as fentanyl or hydromorphone.(?<=[.!?])\s+(?=[A-Z0-9])Note: Monitor carefully for respiratory depression.(?<=[.!?])\s+(?=[A-Z0-9])If tolerance develops, the
dose should be increase... | 331 | 681 | 0 | WHO-0001 | 1 | who_corpus.pdf | 259 |
Commonly used drugs
include diazepam for muscle spasm, carbamazepine for neuralgic pain and
corticosteroids (such as dexamethasone) for pain due to an infl ammatory
swelling pressing on a nerve.(?<=[.!?])\s+(?=[A-Z0-9])Pain control for procedures:
Local anaesthetics: for painful lesions in the skin or mucosa or durin... | 331 | 682 | 1 | WHO-0001 | 1 | who_corpus.pdf | 309 |
218.
Give (home) treatment with iron (daily iron–folate tablet or dose of iron
syrup) for 14 days.
•
Ask the parent to return with the child in 14 days.(?<=[.!?])\s+(?=[A-Z0-9])Treat for 3 months when
possible, as it takes 2–4 weeks to correct anaemia and 1–3 months to build
up iron stores.
If the child is... | 331 | 683 | 2 | WHO-0001 | 1 | who_corpus.pdf | 172 |
308
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Severe anaemia
Give a blood transfusion as soon as possible (see below) to:
■all children with an EVF of ≤ 12% or Hb of ≤ 4 g/dl
■less severely anaemic children (EVF, 13–18%; Hb, 4–6 g/dl) with any of the
following clinical features:
– clinically detectable deh... | 332 | 684 | 0 | WHO-0001 | 1 | who_corpus.pdf | 371 |
Give packed cells when available or whole blood at
10 ml/kg (rather than 20 ml/kg), and do not repeat transfusion based on the
Hb level, or within 4 days of transfusion(see p.(?<=[.!?])\s+(?=[A-Z0-9])218).(?<=[.!?])\s+(?=[A-Z0-9])10.6 Blood transfusion
10.6.1 Storage of blood
Use blood that has been screened and foun... | 332 | 685 | 1 | WHO-0001 | 1 | who_corpus.pdf | 394 |
309
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
10.6.3 Indications for blood transfusion
There are fi ve general indications for blood transfusion:
•
acute blood loss, when 20–30% of the total blood volume has been lost,
and bleeding is continuing
•
severe anaemia
•
septic shock (if IV fl uids are insuffi cient to ma... | 333 | 686 | 0 | WHO-0001 | 1 | who_corpus.pdf | 382 |
Do not inject into the blood pack.(?<=[.!?])\s+(?=[A-Z0-9])Make baseline recordings of the child’s temperature, respiratory rate and
pulse rate.(?<=[.!?])\s+(?=[A-Z0-9])The volume of whole blood transfused should initially be 20 ml/kg, given
over 3–4 h.(?<=[.!?])\s+(?=[A-Z0-9])During transfusion:
•
If available, use... | 333 | 687 | 1 | WHO-0001 | 1 | who_corpus.pdf | 224 |
310
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
•
Record the times the transfusion was started and ended, the volume of blood
transfused and any reactions.(?<=[.!?])\s+(?=[A-Z0-9])After transfusion:
•
Reassess the child.(?<=[.!?])\s+(?=[A-Z0-9])If more blood is needed, a similar quantity should be
transfused and th... | 334 | 688 | 0 | WHO-0001 | 1 | who_corpus.pdf | 313 |
311
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Mild reaction (due to mild hypersensitivity)
Signs and symptoms:
■itchy rash
Management
Slow the transfusion.
Give chlorphenamine at 0.1 mg/kg IM, if available.
Continue the transfusion at the normal rate if there is no progression of
symptoms after 30 mi... | 335 | 689 | 0 | WHO-0001 | 1 | who_corpus.pdf | 399 |
312
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Life-threatening reaction (due to haemolysis, bacterial contamination and
septic shock, fl uid overload or anaphylaxis)
Signs and symptoms
■fever > 38 °C (> 100.4 °F) (Note: Fever may have been present before the
transfusion.)
■rigor
■restlessness
■raised heart ... | 336 | 690 | 0 | WHO-0001 | 1 | who_corpus.pdf | 341 |
13).
Give 200 mg hydrocortisone IV or chlorphenamine 0.1 mg/kg IM, if available.
Give a bronchodilator, if there is wheezing (see pp.(?<=[.!?])\s+(?=[A-Z0-9])98–9).
Report to the doctor in charge and to the blood laboratory as soon as
possible.
Maintain renal blood fl ow with IV furosemide at 1 mg/kg.
... | 336 | 691 | 1 | WHO-0001 | 1 | who_corpus.pdf | 291 |
313
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
although they are less reliable.(?<=[.!?])\s+(?=[A-Z0-9])Oxygen should be given to children with very
severe pneumonia, bronchiolitis or asthma who have:
■central cyanosis
■inability to drink (when this is due to respiratory distress)
■severe lower chest wall indra... | 337 | 692 | 0 | WHO-0001 | 1 | who_corpus.pdf | 370 |
Oxygen delivery
Nasal prongs are the preferred
method of delivery in most
circumstances, as they are
safe, non-invasive, reliable
and do not obstruct the nasal
airway.(?<=[.!?])\s+(?=[A-Z0-9])Nasal or nasopharyn-
geal catheters may be used as
an alternative only when nasal
prongs are not available.(?<=[.!?])\s+(... | 337 | 693 | 1 | WHO-0001 | 1 | who_corpus.pdf | 283 |
314
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
tape on the cheeks near the nose (see fi gure).(?<=[.!?])\s+(?=[A-Z0-9])Care should be taken to keep the
nostrils clear of mucus, which could block the fl ow of oxygen.
Set a fl ow rate of 1–2 litres/min (0.5 litre/min for young infants) to deliver an
inspired oxygen c... | 338 | 694 | 0 | WHO-0001 | 1 | who_corpus.pdf | 389 |
A 6 or 8
French gauge catheter is passed to
the pharynx just below the level of
the uvula.(?<=[.!?])\s+(?=[A-Z0-9])Insert the catheter at a
distance equal to that from the side
of the nostril to the front of the ear
(see fi gure).(?<=[.!?])\s+(?=[A-Z0-9])If it is placed too far
down, gagging and vomiting and,
ra... | 338 | 695 | 1 | WHO-0001 | 1 | who_corpus.pdf | 352 |
315
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Pulse oximetry
Normal oxygen saturation at sea level in a child is 95–100%; in children with
severe pneumonia, this usually decreases.(?<=[.!?])\s+(?=[A-Z0-9])Oxygen should be given if satura-
tion drops to < 90% (measured at room air).(?<=[.!?])\s+(?=[A-Z0-9])Different ... | 339 | 696 | 0 | WHO-0001 | 1 | who_corpus.pdf | 360 |
When the child is stable and improving,
take the child off oxygen for a few minutes.(?<=[.!?])\s+(?=[A-Z0-9])If the oxygen saturation remains
> 90%, discontinue oxygen, but check again half an hour later and every 3 h
thereafter on the fi rst day off oxygen to ensure that the child is stable.(?<=[.!?])\s+(?=[A-Z0-9])... | 339 | 697 | 1 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Activities with toys
Ring on a string (from 6 months)
Thread cotton reels and other small
objects (e.g. cut from the neck of
plastic bottles) onto a string.(?<=[.!?])\s+(?=[A-Z0-9])Tie
the string in a ring, leaving a long
piece of string hanging.(?<=[.!?])\s+(?=[A-Z0-9])Blocks
(from 9 months)
Smooth the surfaces o... | 339 | 698 | 2 | WHO-0001 | 1 | who_corpus.pdf | 162 |
316
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
Nesting toys (from 9 months)
Cut off the bottoms of two bottles of identical shape
but different size, and place the smaller bottle inside the
larger bottle.(?<=[.!?])\s+(?=[A-Z0-9])In-and-out toy
(from 9 months)
Any plastic or cardboard
container and small objects
(... | 340 | 699 | 0 | WHO-0001 | 1 | who_corpus.pdf | 391 |
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