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2013 EDITION\nGUIDELINES FOR THE MANAGEMENT OF \nCOMMON CHILDHOOD ILLNESSES\nSecond edition\nPOCKET BOOK\n OF\nHospital care\nfor children | 1 | 0 | 0 | WHO-0001 | 1 | who_corpus.pdf | 38 |
ANTIMICROBIAL DRUGS FOR COMMON CONDITIONS
Please fill the blanks with your country’s most recent updated treatment guidelines.(?<=[.!?])\s+(?=[A-Z0-9])Page numbers refer to where generic guidance is found in the Pocket Book.(?<=[.!?])\s+(?=[A-Z0-9])Condition
Drug
Dose
Dysentery (p.(?<=[.!?])\s+(?=[A-Z0-9])144)
HIV treatment (p.(?<=[.!?])\s+(?=[A-Z0-9])233)
drug 2
drug 3
Malaria, non severe (p.(?<=[.!?])\s+(?=[A-Z0-9])164–5)
drug 2
Malaria, severe (p.(?<=[.!?])\s+(?=[A-Z0-9])158)
Mastoiditis (p.(?<=[.!?])\s+(?=[A-Z0-9])182)
drug 2
Meningitis (p.(?<=[.!?])\s+(?=[A-Z0-9])169)
drug 2
Osteomyelitis (p.(?<=[.!?])\s+(?=[A-Z0-9])187)
drug 2
Otitis media, acute (p.(?<=[.!?])\s+(?=[A-Z0-9])183)
Pneumonia, non-severe (p. | 2 | 1 | 0 | WHO-0001 | 1 | who_corpus.pdf | 371 |
183)
Pneumonia, non-severe (p.(?<=[.!?])\s+(?=[A-Z0-9])86)
Pneumonia, severe (p.(?<=[.!?])\s+(?=[A-Z0-9])82)
drug 2
Sepsis, neonatal (p.(?<=[.!?])\s+(?=[A-Z0-9])55)
drug 2
Sepsis, older child (p.(?<=[.!?])\s+(?=[A-Z0-9])180)
drug 2
Severe acute malnutrition,
uncomplicated (p.(?<=[.!?])\s+(?=[A-Z0-9])207)
complicated (p.(?<=[.!?])\s+(?=[A-Z0-9])207)
drug 2
drug 3
Tuberculosis (p.116-7)
drug 2
drug 3
drug 4
Typhoid fever (p.(?<=[.!?])\s+(?=[A-Z0-9])181)
drug 2
Urinary tract infection (p.(?<=[.!?])\s+(?=[A-Z0-9])185)
drug 2 | 2 | 2 | 1 | WHO-0001 | 1 | who_corpus.pdf | 297 |
POCKET BOOK\n OF\nHospital care\nfor children\nGUIDELINES FOR THE MANAGEMENT OF \nCOMMON CHILDHOOD ILLNESSES\nSecond edition | 3 | 3 | 0 | WHO-0001 | 1 | who_corpus.pdf | 33 |
WHO Library Cataloguing-in-Publication Data :
Pocket book of hospital care for children: guidelines for the management of
common childhood illnesses – 2nd ed.(?<=[.!?])\s+(?=[A-Z0-9])1.Pediatrics.(?<=[.!?])\s+(?=[A-Z0-9])2.Child care.(?<=[.!?])\s+(?=[A-Z0-9])3.Child, Hospitalized.(?<=[.!?])\s+(?=[A-Z0-9])4.Child health services.(?<=[.!?])\s+(?=[A-Z0-9])5.Guideline.(?<=[.!?])\s+(?=[A-Z0-9])I.World Health Organization.(?<=[.!?])\s+(?=[A-Z0-9])ISBN 978 92 4 154837 3
(NLM classifi cation: WS 29)
© World Health Organization 2013
All rights reserved.(?<=[.!?])\s+(?=[A-Z0-9])Publications of the World Health Organization are available on the
WHO web site (www.who.int) or can be purchased from WHO Press, World Health
Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264;
fax: +41 22 791 4857; e-mail: bookorders@who.int). | 4 | 4 | 0 | WHO-0001 | 1 | who_corpus.pdf | 369 |
Requests for permission to
reproduce or translate WHO publications – whether for sale or for non-commercial
distribution – should be addressed to WHO Press through the WHO web site (www.
who.int/about/licensing/copyright_form/en/index.html).(?<=[.!?])\s+(?=[A-Z0-9])The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries.(?<=[.!?])\s+(?=[A-Z0-9])Dotted lines on maps represent approximate border lines for which there may not
yet be full agreement.(?<=[.!?])\s+(?=[A-Z0-9])The mention of specifi c companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization
in preference to others of a similar nature that are not mentioned.(?<=[.!?])\s+(?=[A-Z0-9])Errors and
omissions excepted, the names of proprietary products are distinguished by initial
capital letters.(?<=[.!?])\s+(?=[A-Z0-9])All reasonable precautions have been taken by the World Health Organization to
verify the information contained in this publication.(?<=[.!?])\s+(?=[A-Z0-9])However, the published material
is being distributed without warranty of any kind, either expressed or implied. | 4 | 5 | 1 | WHO-0001 | 1 | who_corpus.pdf | 383 |
However, the published material
is being distributed without warranty of any kind, either expressed or implied.(?<=[.!?])\s+(?=[A-Z0-9])The
responsibility for the interpretation and use of the material lies with the reader.(?<=[.!?])\s+(?=[A-Z0-9])In no
event shall the World Health Organization be liable for damages arising from its use.(?<=[.!?])\s+(?=[A-Z0-9])Designed by minimum graphics
Printed in (country name) | 4 | 6 | 2 | WHO-0001 | 1 | who_corpus.pdf | 138 |
iii
Co ntents
Preface
xv
Acknowledgements
xviii
Abbreviations
xxi
Chart 1: Stages in the management of a sick child admitted
to hospital: key elements
xxii
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE AND EMERGENCY CONDITIONS
1
1.1
Triage
2
1.2 Summary of steps in emergency triage assessment and treatment
3
1.3 Assessment of emergency and priority signs
4
Triage of all sick children
5
How to manage a choking infant or child
7
How to manage the airway in a child with obstructed breathing
9
How to give oxygen
11
How to position the unconscious child
12
Give IV fl uids for shock in a child without severe acute malnutrition 13
Give IV fl uids for shock in a child with severe acute malnutrition
14
Give diazepam rectally
15
Give IV glucose
16
Treat severe dehydration in an emergency setting
17
1.4 Emergency treatment for a child with severe malnutrition
19
1.5 Diagnostic considerations for children with emergency conditions
20
1.5.1
Child presenting with an airway or severe breathing problem 20
1.5.2 Child presenting with shock
21
1.5.3 Child presenting with lethargy, unconsciousness
or convulsions
23
1.6 Common poisoning
26
1.6.1
Principles for ingested poisons
27
1.6.2 Principles for poisons in contact with skin or eyes
29 | 5 | 7 | 0 | WHO-0001 | 1 | who_corpus.pdf | 281 |
iv
1.6.3 Principles for inhaled poisons
29
1.6.4 Specifi c poisons
29
Corrosive compounds
29
Petroleum compounds
30
Organophosphorus and carbamate compounds
30
Paracetamol
31
Aspirin and other salicylates
31
Iron
32
Morphine and other opiates
32
Carbon monoxide
33
1.6.5 Prevention of poisoning
33
1.7
Drowning
33
1.8 Electrocution
34
1.9 Common causes of envenoming
34
1.9.1
Snake bite
34
1.9.2 Scorpion sting
37
1.9.3 Other sources of envenoming
38
1.10 Trauma and injuries
38
1.10.1 Primary survey or initial assessment
38
1.10.2 Secondary survey
39
2.(?<=[.!?])\s+(?=[A-Z0-9])DIAGNOSTIC APPROACHES TO THE SICK CHILD
41
2.1
Relationship to the IMCI approach and stages of hospital care
41
2.2 Taking history
42
2.3 Approach to the sick child and clinical examination
43
2.4 Laboratory investigations
43
2.5 Differential diagnoses
44
3.(?<=[.!?])\s+(?=[A-Z0-9])PROBLEMS OF THE NEONATE AND YOUNG INFANT
45
3.1
Essential newborn care at delivery
46
3.2 Neonatal resuscitation
46
3.2.1 Post resuscitation care
50
3.2.2 Cessation of resuscitation
50
3.3 Routine care for all newborns after delivery
50
3.4 Prevention of neonatal infections
51
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v
3.5 Management of the infant with hypoxic ischaemic encephalopathy
51
3.6 Danger signs in newborns and young infants
52
3.7 Convulsions or fi ts
53
3.8 Serious bacterial infection
54
3.9 Meningitis
55
3.10 Supportive care for sick neonates
56
3.10.1 Thermal environment
56
3.10.2 Fluid management
57
3.10.3 Oxygen therapy
58
3.10.4 High fever
58
3.11 Preterm and low-birth-weight infants
58
3.11.1 Infants with a birth weight of 2.0–2.5 kg
(35–36 weeks’ gestation)
58
3.11.2 Infants with a birth weight < 2.0 kg
(< 35 weeks’ gestation)
59
3.11.3 Common problems of low-birth-weight infants
61
3.11.4 Discharge and follow-up of low-birth-weight infants
63
3.12 Other common neonatal problems
64
3.12.1 Jaundice
64
3.12.2 Conjunctivitis
66
3.12.3 Congential malformations
67
3.13 Infants of mothers with infectious diseases
67
3.13.1 Congenital syphilis
67
3.13.2 Infants of mothers with tuberculosis
68
3.13.3 Infants of mothers with HIV infection
68
3.14 Doses of common drugs for neonates and low-birth-weight
infants
69
4.(?<=[.!?])\s+(?=[A-Z0-9])COUGH OR DIFFICULTY IN BREATHING
75
4.1
Child presenting with cough
76
4.2 Pneumonia
80
4.2.1 Severe pneumonia
80
4.2.2 Pneumonia
86
4.3 Complications of pneumonia
88
4.3.1 Pleural effusion and empyema
88
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vi
4.3.2 Lung abscess
89
4.3.3 Pneumothorax
90
4.4 Cough or cold
90
4.5 Conditions presenting with wheeze
91
4.5.1 Bronchiolitis
94
4.5.2 Asthma
96
4.5.3 Wheeze with cough or cold
101
4.6 Conditions presenting with stridor
102
4.6.1 Viral croup
102
4.6.2 Diphtheria
105
4.6.3 Epiglottitis
107
4.6.4 Anaphylaxis
108
4.7 Conditions presenting with chronic cough
109
4.7.1
Pertussis
111
4.7.2
Tuberculosis
115
4.7.3
Foreign body inhalation
119
4.8 Heart failure
120
4.9 Rheumatic heart disease
122
5.(?<=[.!?])\s+(?=[A-Z0-9])DIARRHOEA
125
5.1
Child presenting with diarrhoea
126
5.2 Acute diarrhoea
127
5.2.1 Severe dehydration
129
5.2.2 Some dehydration
132
5.2.3 No dehydration
134
5.3 Persistent diarrhoea
137
5.3.1 Severe persistent diarrhoea
137
5.3.2 Persistent diarrhoea (non-severe)
142
5.4 Dysentery
143
6.(?<=[.!?])\s+(?=[A-Z0-9])FEVER
149
6.1
Child presenting with fever
150
6.1.1
Fever lasting 7 days or less
150
6.1.2
Fever lasting longer than 7 days
153
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vii
6.2 Malaria
156
6.2.1 Severe malaria
156
6.2.2 Uncomplicated malaria
163
6.3 Meningitis
167
6.3.1 Bacterial meningitis
167
6.3.2 Meningococcal epidemics
170
6.3.3 Tuberculous meningitis
171
6.3.4 Cryptococcal meningitis
172
6.4 Measles
174
6.4.1 Severe complicated measles
175
6.4.2 Non-severe measles
178
6.5 Septicaemia
179
6.6 Typhoid fever
180
6.7 Ear infections
182
6.7.1
Mastoiditis
182
6.7.2
Acute otitis media
183
6.7.3
Chronic otitis media
184
6.8 Urinary tract infection
184
6.9 Septic arthritis or osteomyelitis
186
6.10 Dengue
188
6.10.1 Severe dengue
188
6.11 Rheumatic fever
193
7.(?<=[.!?])\s+(?=[A-Z0-9])SEVERE ACUTE MALNUTRITION
197
7.1
Severe acute malnutrition
198
7.2
Initial assessment of a child with severe acute malnutrition
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
7.4.5
Infection
207
7.4.6
Micronutrient defi ciencies
208
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viii
7.4.7
Initial re-feeding
209
7.4.8
Catch-up growth feeding
210
7.4.9
Sensory stimulation
215
7.4.10 Severe acute malnutrition in infants aged < 6 months
216
7.5
Treatment of associated conditions
217
7.5.1
Eye problems
217
7.5.2 Severe anaemia
218
7.5.3 Skin lesions in kwashiorkor
218
7.5.4
Continuing diarrhoea
219
7.5.5 Tuberculosis
219
7.6
Discharge and follow-up
219
7.6.1
Discharge to outpatient care
219
7.6.2 Discharge from nutritional treatment
220
7.6.3
Follow up
221
7.7
Monitoring the quality of care
221
7.7.1
Mortality audit
221
7.7.2
Weight gain during rehabilitation
222
8.(?<=[.!?])\s+(?=[A-Z0-9])CHILDREN WITH HIV/AIDS
225
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 Antiretroviral drugs
233
8.2.2 When to start antiretroviral therapy
235
8.2.3 Side-effects and monitoring
235
8.2.4 When to change treatment
238
8.3 Supportive care for HIV-positive children
240
8.3.1 Vaccination
240
8.3.2 Co-trimoxazole prophylaxis
241
8.3.3 Nutrition
243
HOSPITAL CARE FOR CHILDREN | 10 | 12 | 0 | WHO-0001 | 1 | who_corpus.pdf | 331 |
ix
8.4 Management of HIV-related conditions
243
8.4.1 Tuberculosis
243
8.4.2 Pneumocystis jiroveci pneumonia
244
8.4.3 Lymphoid interstitial pneumonitis
245
8.4.4 Fungal infections
246
8.4.5 Kaposi sarcoma
246
8.5 Prevention of mother-to-child HIV transmission, and infant feeding 247
8.5.1 Prevention of mother-to-child HIV transmission
247
8.5.2 Infant feeding in the context of HIV infection
248
8.6 Follow-up
249
8.6.1 Discharge from hospital
249
8.6.2 Referral
249
8.6.3 Clinical follow-up
250
8.7 Palliative and end-of-life care
250
8.7.1
Pain control
250
8.7.2
Management of anorexia, nausea and vomiting
252
8.7.3
Prevention and treatment of pressure sores
252
8.7.4
Care of the mouth
252
8.7.5
Airway management
252
8.7.6
Psychosocial support
253
9.(?<=[.!?])\s+(?=[A-Z0-9])COMMON SURGICAL PROBLEMS
255
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 Myelomeningocoele
267
9.2.5 Congenital dislocation of the hip
267
9.2.6 Talipes equinovarus (club foot)
268
CO NTENTS | 11 | 13 | 0 | WHO-0001 | 1 | who_corpus.pdf | 349 |
x
9.3 Injuries
269
9.3.1 Burns
269
9.3.2 Head injuries
272
9.3.3 Chest injuries
273
9.3.4 Abdominal injuries
275
9.3.5 Fractures
275
9.3.6 Principles of wound care
279
9.4 Abdominal problems
281
9.4.1 Abdominal pain
281
9.4.2 Appendicitis
282
9.4.3 Bowel obstruction after the neonatal period
283
9.4.4 Intussusception
284
9.4.5 Umbilical hernia
285
9.4.6 Inguinal hernia
285
9.4.7 Incarcerated hernia
286
9.4.8 Testicular torsion
286
9.4.9 Rectal prolapse
287
9.5 Infections requiring surgery
287
9.5.1 Abscess
287
9.5.2 Osteomyelitis
288
9.5.3 Septic arthritis
289
9.5.4 Pyomyositis
291
10.(?<=[.!?])\s+(?=[A-Z0-9])SUPPORTIVE CARE
293
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
10.6.1 Storage of blood
308
10.6.2 Problems in blood transfusion
308
HOSPITAL CARE FOR CHILDREN | 12 | 14 | 0 | WHO-0001 | 1 | who_corpus.pdf | 286 |
xi
10.6.3 Indications for blood transfusion
309
10.6.4 Giving a blood transfusion
309
10.6.5 Transfusion reactions
310
10.7 Oxygen therapy
312
10.8 Toys and play therapy
315
11.(?<=[.!?])\s+(?=[A-Z0-9])MONITORING THE CHILD’S PROGRESS
319
11.1 Monitoring procedures
319
11.2 Monitoring chart
320
11.3 Audit of paediatric care
320
12.(?<=[.!?])\s+(?=[A-Z0-9])COUNSELLING AND DISCHARGE FROM HOSPITAL
321
12.1 Timing of discharge from hospital
321
12.2 Counselling
322
12.3 Nutrition counselling
323
12.4 Home treatment
324
12.5 Checking the mother’s health
324
12.6 Checking immunization status
325
12.7 Communicating with the fi rst-level health worker
325
12.8 Providing follow-up care
327
BIBLIOGRAPHY
329
ANNEXES
Annex 1.(?<=[.!?])\s+(?=[A-Z0-9])Practical procedures
333
A1.1 Giving injections
335
A1.1.1
Intramuscular
336
A1.1.2 Subcutaneous
336
A1.1.3 Intradermal
336
A1.2 Giving parenteral fl uids
338
A1.2.1 Insertion of an indwelling intravenous
cannula in a peripheral vein
338
A1.2.2 Intraosseous infusion
340
A1.2.3 Central vein cannulation
342
A1.2.4 Venous cut-down
343
A1.2.5 Umbilical vein catheterization
344
A1.3 Insertion of a nasogastric tube
345
A1.4 Lumbar puncture
346
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xii
A1.5 Insertion of a chest drain
348
A1.6 Supra-pubic aspiration
350
A1.7 Measuring blood glucose
350
Annex 2.(?<=[.!?])\s+(?=[A-Z0-9])Drug dosages and regimens
353
Annex 3.(?<=[.!?])\s+(?=[A-Z0-9])Equipment sizes
375
Annex 4.(?<=[.!?])\s+(?=[A-Z0-9])Intravenous fl uids
377
A4.1 Choice of intravenous fl uids
378
Annex 5.(?<=[.!?])\s+(?=[A-Z0-9])Assessing nutritional status
379
A5.1 Calculating a child’s weight-for-age
379
A5.2 Calculating a child’s weight-for-length or height
386
Annex 6.(?<=[.!?])\s+(?=[A-Z0-9])Job aids and charts
403
INDEX
405
CHARTS
Chart 1.(?<=[.!?])\s+(?=[A-Z0-9])Stages in the management of a sick child admitted to
hospital: key elements
xxii
Chart 2.(?<=[.!?])\s+(?=[A-Z0-9])Triage of all sick children
5
Chart 3.(?<=[.!?])\s+(?=[A-Z0-9])How to manage a choking infant or child
7
Chart 4. | 14 | 16 | 0 | WHO-0001 | 1 | who_corpus.pdf | 356 |
How to manage a choking infant or child
7
Chart 4.(?<=[.!?])\s+(?=[A-Z0-9])How to manage the airways in a child with obstructed
breathing (or who has just stopped breathing)
9
Chart 5.(?<=[.!?])\s+(?=[A-Z0-9])How to give oxygen
11
Chart 6.(?<=[.!?])\s+(?=[A-Z0-9])How to position an unconscious child
12
Chart 7.(?<=[.!?])\s+(?=[A-Z0-9])How to give intravenous fl uids rapidly to a child in shock
without severe malnutrition
13
Chart 8.(?<=[.!?])\s+(?=[A-Z0-9])How to give intravenous fl uids to a child in shock with
severe malnutrition
14
Chart 9.(?<=[.!?])\s+(?=[A-Z0-9])How to give diazepam rectally
15
Chart 10.(?<=[.!?])\s+(?=[A-Z0-9])How to give glucose intravenously
16
Chart 11.(?<=[.!?])\s+(?=[A-Z0-9])How to treat severe dehydration in an emergency after
initial management of shock
17
Chart 12.(?<=[.!?])\s+(?=[A-Z0-9])Neonatal resuscitation
47
Chart 13.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan C: Treat severe dehydration quickly 130
Chart 14. | 14 | 17 | 1 | WHO-0001 | 1 | who_corpus.pdf | 399 |
Diarrhoea treatment plan C: Treat severe dehydration quickly 130
Chart 14.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan B: Treat some dehydration with
oral rehydration salts
135
Chart 15.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea treatment plan A: Treat diarrhoea at home
138
Chart 16.(?<=[.!?])\s+(?=[A-Z0-9])Feeding recommendations during sickness and health
302
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xiii
TABLES
Table 1.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with
an airways or severe breathing problem
21
Table 2.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with shock
22
Table 3.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with lethargy,
unconsciousness or convulsions
24
Table 4.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a young infant (< 2 months)
presenting with lethargy, unconsciousness or convulsions 25
Table 5.(?<=[.!?])\s+(?=[A-Z0-9])Poisoning: amount of activated charcoal per dose
28
Table 6.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with cough or
diffi culty in breathing
77
Table 7.(?<=[.!?])\s+(?=[A-Z0-9])Classifi cation of the severity of pneumonia
81
Table 8.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with wheeze
93
Table 9.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with stridor
103
Table 10. | 15 | 19 | 0 | WHO-0001 | 1 | who_corpus.pdf | 377 |
Differential diagnosis in a child presenting with stridor
103
Table 10.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with
chronic cough
110
Table 11.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with diarrhoea 127
Table 12.(?<=[.!?])\s+(?=[A-Z0-9])Classifi cation of the severity of dehydration in children
with diarrhoea
128
Table 13.(?<=[.!?])\s+(?=[A-Z0-9])Administration of intravenous fl uids to a severely
dehydrated child
130
Table 14.(?<=[.!?])\s+(?=[A-Z0-9])First diet for persistent diarrhoea: a starch-based,
reduced-milk (low-lactose) diet
141
Table 15.(?<=[.!?])\s+(?=[A-Z0-9])Second diet for persistent diarrhoea: a reduced-starch
(cereal) no-milk (lactose-free) diet
141
Table 16.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis of fever without localizing signs
151
Table 17.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis of fever with localized signs
152
Table 18.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis of fever with rash
153
Table 19. | 15 | 20 | 1 | WHO-0001 | 1 | who_corpus.pdf | 378 |
Differential diagnosis of fever with rash
153
Table 19.(?<=[.!?])\s+(?=[A-Z0-9])Additional differential diagnosis of fever lasting longer
than 7 days
155
Table 20
WHO criteria for the diagnosis of rheumatic fever
(based on the revised Jones criteria)
194
Table 21.(?<=[.!?])\s+(?=[A-Z0-9])Time frame for the management of a child with
severe acute malnutrition
201
Table 22.(?<=[.!?])\s+(?=[A-Z0-9])Volumes of F-75 per feed for malnourished children
(approximately 130 ml/kg per day)
211
Table 23.(?<=[.!?])\s+(?=[A-Z0-9])WHO paediatric clinical staging system for HIV infection
231
Table 24.(?<=[.!?])\s+(?=[A-Z0-9])Classes of antiretroviral drugs recommended for use
in children
234
CO NTENTS | 15 | 21 | 2 | WHO-0001 | 1 | who_corpus.pdf | 234 |
xiv
Table 25.(?<=[.!?])\s+(?=[A-Z0-9])First-line treatment regimens for children
234
Table 26.(?<=[.!?])\s+(?=[A-Z0-9])Common side-effects of antiretroviral drugs
236
Table 27.(?<=[.!?])\s+(?=[A-Z0-9])Recommended second-line treatment regimens
for children
240
Table 28.(?<=[.!?])\s+(?=[A-Z0-9])Endotracheal tube size by age
259
Table 29.(?<=[.!?])\s+(?=[A-Z0-9])Blood volume of children by age
260
Table 30.(?<=[.!?])\s+(?=[A-Z0-9])Normal pulse rate and blood pressure in children
261
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
303
Table 32.(?<=[.!?])\s+(?=[A-Z0-9])Maintenance fl uid requirements
304
Table 33. | 16 | 22 | 0 | WHO-0001 | 1 | who_corpus.pdf | 313 |
Maintenance fl uid requirements
304
Table 33.(?<=[.!?])\s+(?=[A-Z0-9])Primary vaccination schedule for infants recommended
in the Expanded Programme on Immunization
326
Table A2.1
Drug dosage by surface area (m2) of the child
354
Table A5.1.1 Weight-for-age from birth to 5 years: Boys
379
Table A5.1.2 Weight-for-age from birth to 5 years: Girls
381
Table A5.2.1 Weight-for-length from birth to 2 years: Boys
386
Table A5.2.2 Weight-for-length from birth to 2 years: Girls
391
Table A5.2.3 Weight-for-height from 2 to 5 years: Boys
395
Table A5.2.4 Weight-for-height from 2 to 5 years: Girls
399
HOSPITAL CARE FOR CHILDREN | 16 | 23 | 1 | WHO-0001 | 1 | who_corpus.pdf | 181 |
xv
Preface
This is the second edition of the World Health Organization (WHO) Pocket book
of hospital care for children, which was fi rst published in 2005.(?<=[.!?])\s+(?=[A-Z0-9])It is a compila-
tion of the updated WHO guidelines for the management of common childhood
illnesses at the fi rst-referral level in low-resource countries.(?<=[.!?])\s+(?=[A-Z0-9])It presents relevant,
up-to-date, evidence-based clinical guidelines that can be used by clinicians
in their daily work in hospitals with basic laboratory facilities and inexpensive
medicines.(?<=[.!?])\s+(?=[A-Z0-9])The guidelines focus on inpatient management of children who are
severely ill with conditions that are major causes of childhood mortality, such
as neonatal illness, pneumonia, diarrhoea, fever (mainly malaria, meningitis
and septicaemia), severe acute malnutrition and HIV/AIDS.(?<=[.!?])\s+(?=[A-Z0-9])It also includes
guidance on common surgical problems, appropriate supportive care and
monitoring of patients on the ward.(?<=[.!?])\s+(?=[A-Z0-9])The Pocket book is part of a series of tools for improving the quality of care
for severely ill children and is consistent with the Integrated Management of
Childhood Illness (IMCI) guidelines for outpatient management of sick chil-
dren. | 17 | 24 | 0 | WHO-0001 | 1 | who_corpus.pdf | 344 |
It is for use by doctors, senior nurses and other senior health workers
who are responsible for the care of young children at the fi rst referral level in
developing countries.(?<=[.!?])\s+(?=[A-Z0-9])The fi rst edition of the Pocket book was reviewed by a WHO guidelines steering
committee, which identifi ed those chapters that required updating, comprising:
•
revisions to align the Pocket book with recently published, WHO-approved
guidelines; and
•
priorities for which new information had become available, which was col-
lated, analysed and synthesized before updating.(?<=[.!?])\s+(?=[A-Z0-9])In the fi rst category, recommendations approved by the WHO Guidelines Re-
view Committee were incorporated.(?<=[.!?])\s+(?=[A-Z0-9])The second category required synthesis
of evidence and updates consistent with new recommendations.(?<=[.!?])\s+(?=[A-Z0-9])The changes
made are therefore based on published WHO guidelines and recommendations
as of 2012, which are listed in the bibliography on p.(?<=[.!?])\s+(?=[A-Z0-9])329; in addition, certain
subsections were added or removed, others reorganized and some editorial
changes made on the basis of feedback from Pocket book users.(?<=[.!?])\s+(?=[A-Z0-9])In response to
users’ feedback and the popularity of the fi rst edition, the presentation is similar. | 17 | 25 | 1 | WHO-0001 | 1 | who_corpus.pdf | 367 |
xvi
All the changes were reviewed by external clinical experts and were approved
by the WHO Guidelines Review Committee.(?<=[.!?])\s+(?=[A-Z0-9])A web version of the Pocket book
will be updated regularly as new evidence with clinical implications emerges.(?<=[.!?])\s+(?=[A-Z0-9])Printed editions will be published every 5 years if there are substantial new
changes.(?<=[.!?])\s+(?=[A-Z0-9])Users are therefore advised to check the WHO web site regularly for
Pocket book updates (http://www.who.int/maternal_child_adolescent/en/).(?<=[.!?])\s+(?=[A-Z0-9])The main changes in the second edition are listed below.(?<=[.!?])\s+(?=[A-Z0-9])Chapters unchanged from the fi rst edition of the Pocket book (2005):
Chapters with only editorial changes or reorganization but with no major update
of previous information:
•
Chapter 1.(?<=[.!?])\s+(?=[A-Z0-9])Triage and emergency conditions
•
Chapter 2.(?<=[.!?])\s+(?=[A-Z0-9])Diagnostic approaches to the sick child
•
Chapter 5.(?<=[.!?])\s+(?=[A-Z0-9])Diarrhoea
•
Chapter 9.(?<=[.!?])\s+(?=[A-Z0-9])Common surgical problems
•
Chapter 11. | 18 | 26 | 0 | WHO-0001 | 1 | who_corpus.pdf | 396 |
Diarrhoea
•
Chapter 9.(?<=[.!?])\s+(?=[A-Z0-9])Common surgical problems
•
Chapter 11.(?<=[.!?])\s+(?=[A-Z0-9])Monitoring the child’s progress
•
Chapter 12.(?<=[.!?])\s+(?=[A-Z0-9])Counselling and discharge from hospital
•
Annexes 1, 3 and 6
Chapters substantially changed from the fi rst edition of the
Pocket book (2005):
Chapters with substantial changes to clinical guidance or which have been
restructured are:
•
Chapter 3.(?<=[.!?])\s+(?=[A-Z0-9])Problems of the neonate and young infant
•
Chapter 4.(?<=[.!?])\s+(?=[A-Z0-9])Cough or diffi culty in breathing
•
Chapter 6.(?<=[.!?])\s+(?=[A-Z0-9])Fever
•
Chapter 7.(?<=[.!?])\s+(?=[A-Z0-9])Severe acute malnutrition
•
Chapter 8.(?<=[.!?])\s+(?=[A-Z0-9])Children with HIV/AIDS
•
Chapter 10.(?<=[.!?])\s+(?=[A-Z0-9])Supportive care
•
Annexes 2, 4 and 5 | 18 | 27 | 1 | WHO-0001 | 1 | who_corpus.pdf | 355 |
xvii
Additional sections or subsections in this second edition
Several sections of some chapters were added or substantially expanded in
response to demand from users:
•
Chapter 1, section 1.10.(?<=[.!?])\s+(?=[A-Z0-9])Trauma and injuries
•
Chapter 3, section 3.7.(?<=[.!?])\s+(?=[A-Z0-9])Convulsions or fi ts
•
Chapter 3, section 3.11.3.(?<=[.!?])\s+(?=[A-Z0-9])Respiratory distress syndrome
•
Chapter 4, section 4.6.3.(?<=[.!?])\s+(?=[A-Z0-9])Epiglottitis
•
Chapter 4, section 4.6.4.(?<=[.!?])\s+(?=[A-Z0-9])Anaphylaxis
•
Chapter 4, section 4.9.(?<=[.!?])\s+(?=[A-Z0-9])Rheumatic heart disease
•
Chapter 6, section 6.11.(?<=[.!?])\s+(?=[A-Z0-9])Rheumatic fever
•
Chapter 8, section 8.5.(?<=[.!?])\s+(?=[A-Z0-9])Prevention of mother to child HIV transmission,
and infant feeding
The Pocket book is presented in a format that could be carried by doctors, nurses
and other health workers during their daily work and be available to help guide
the management of sick children. | 19 | 28 | 0 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Although some new topics have been added,
standard textbooks of paediatrics should be consulted for rarer conditions not
covered in the Pocket book.(?<=[.!?])\s+(?=[A-Z0-9])These guidelines are applicable in most areas of
the world and may be adapted by countries to suit their specifi c circumstances.(?<=[.!?])\s+(?=[A-Z0-9])WHO recommends that countries should locally adapt the Pocket book to include
important conditions not covered and believes its widespread adoption would
improve the care of children in hospital and lead to lower case fatality rates. | 19 | 29 | 1 | WHO-0001 | 1 | who_corpus.pdf | 143 |
xviii
Acknowledgements
WHO expresses its gratitude to the following members of the group that up-
dated the guidelines, people who made original contributions, and reviewers,
institutions and consultants for their contributions to updating the Pocket book
of hospital care for children.(?<=[.!?])\s+(?=[A-Z0-9])Guideline development group
WHO thanks the members of the guideline development group who reviewed
most of the evidence and made recommendations for updating the Pocket book
and also those who reviewed the chapters: Dr Fizan Abdullah, Johns Hopkins
University School of Medicine, USA; Shinjini Bhatnagar, All India Institute of
Medical Sciences, India; Bridget Wills, Clinical Research Unit, University of
Oxford Centre for Tropical Diseases, Viet Nam; Harry Campbell, University
of Edinburgh Medical School, United Kingdom; Leonila Dans, University of
Philippines, Philippines; Trevor Duke, Centre for International Child Health,
University of Melbourne, Australia; Michael English, University of Nairobi and
Kenya Medical Research Institute, Kenya; Andy Gray, University of KwaZulu-
Natal, South Africa; Sandra Grisi, São Paulo University, Brazil; Stuart Macleod,
University of British Columbia, Canada; Hilda Mujuru, University of Zimbabwe,
Zimbabwe; Susan Niermeyer, University of Colorado, USA; Jesca Nsungwa,
Ministry of Health, Uganda; Vinod Paul, All India Institute of Medical Sci-
ences, India; Haroon Saloojee, Witwatersrand University, South Africa; Mathu
Santosham, Johns Hopkins School of Public Health, USA; Giorgio Tamburlini,
Institute of Child Health, Italy; and Anita Zaidi, Aga Khan University, Pakistan. | 20 | 30 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
Special gratitude is owed to Rhona MacDonald, Maternal Child Health Advo-
cacy International, who incorporated the changes and prepared the fi rst draft.(?<=[.!?])\s+(?=[A-Z0-9])Original contributors and external reviewers
WHO coordinated the international contributions for the 2005 edition of the
Pocket book and thanks the original contributors to chapters: Dr Ann Ashworth
(United Kingdom), Dr Stephen Bickler (USA), Dr Jacqueline Deen (Philippines),
Dr Trevor Duke (Papaua New Guinea and Australia), Dr Greg Hussey (South
Africa), Dr Michael English (Kenya), Dr Stephen Graham (Malawi), Dr Eliza-
beth Molyneux (Malawi), Dr Nathaniel Pierce (USA), Dr Barbara Stoll (USA), | 20 | 31 | 1 | WHO-0001 | 1 | who_corpus.pdf | 188 |
xix
Dr Giorgio Tamburlini (Italy), Dr Bridget Wills (Viet Nam) and Fabienne Jäger
(Switzerland).(?<=[.!?])\s+(?=[A-Z0-9])WHO wishes to acknowledge the following for comments and contributions
made at various stages of the Pocket book updating: Sabrina Bakeere-Kitaka,
Makerere Medical School, Uganda; Zulfi qar Bhutta, Aga Khan University,
Pakistan; Stephen W.(?<=[.!?])\s+(?=[A-Z0-9])Bickler, University of California-San Diego, USA; Uday
Bodhankar, Commonwealth Association for Health and Disability, United
Kingdom; Adegoke Falade, College of Medicine, University of Ibadan, Nigeria;
Jeremy Farrar, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam;
Julian Kelly, Royal Children’s Hospital, Centre for International Child Health,
Melbourne, Australia; Carolyn Maclennan, Flinders University, Australia; Rhona
MacDonald, David Southall and Barbara Phillips, Maternal Child Health Advo-
cacy International; Amha Mekasha, Addis Ababa University, Ethiopia; Elizabeth
Molyneux, College of Medicine, Malawi; Maria Asuncion Silvestre, University
of the Philippines, Manila, Philippines, Joan Skinner, Victoria University of
Wellington, New Zealand and Andrew Steer, Royal Children’s Hospital, Centre
for International Child Health, Melbourne, Australia. | 21 | 32 | 0 | WHO-0001 | 1 | who_corpus.pdf | 355 |
Valuable input was provided by several WHO clusters and the departments of
Family, Women’s and Children’s Health, Health Systems and Services, HIV/AIDS,
Tuberculosis, Neglected Tropical Diseases, Noncommunicable Diseases, and
Mental Health.(?<=[.!?])\s+(?=[A-Z0-9])We particularly acknowledge the WHO staff who participated
as members of the Guidelines Steering Committee or who contributed to and
reviewed various draft chapters: Desta Teshome, WHO Regional Offi ce for
Africa; Meena Cherian, Essential Health Technologies; Tarun Dua, Mental Health
and Substance Abuse; Lisa Nelson, Martina Penazzato, and Sandra Gove, HIV/
AIDS; Malgorzata Grzemska, Stop TB; Emmalita Manalac, WHO Regional Of-
fi ce for the Western Pacifi c; Peter Olumese, Global Malaria Programme; Ma
del Carmen Casanovas, Zita Weise Prinzo and Chantal Gegout, Nutrition for
Health and Development; Susan Hill and Clive Ondari, Essential Medicines and
Pharmaceutical Policies; Raman Velayudhan, Neglected Tropical Diseases; and
Martin Weber, WHO Country Offi ce, Indonesia.(?<=[.!?])\s+(?=[A-Z0-9])Special thanks to Rami Subhi at the Centre for International Child Health
in Australia, who helped in collating the evidence for recommendations for
updating the Pocket book. | 21 | 33 | 1 | WHO-0001 | 1 | who_corpus.pdf | 319 |
Special thanks to Rami Subhi at the Centre for International Child Health
in Australia, who helped in collating the evidence for recommendations for
updating the Pocket book.(?<=[.!?])\s+(?=[A-Z0-9])The updating of the Pocket book was coordinated by Wilson Were, supported
by Rajiv Bahl, Lulu Muhe, Olivier Fontaine, Severin Ritter Von Xylander, Nigel
Rollins and Shamim Qazi of the Department of Maternal, Newborn, Child and
Adolescent Health. | 21 | 34 | 2 | WHO-0001 | 1 | who_corpus.pdf | 117 |
xx
Institutions
We are grateful to the following institutions for providing input and support
during the review of the Pocket book: Centre for International Child Health,
University of Melbourne, Australia; University of Edinburgh, Scotland; Kenya
Medical Research Institute, Kenya; Asociación Colaboración Cochrane Iber-
oamericana, Spain; Aga Khan University, Pakistan; Institute of Child Health
Burlo Garofolo, Italy; University of Malawi, Malawi; Capital Institute of Pae-
diatrics, China; University of Western Australia, Australia; and Instituto de
Medicina Integral Professor Fernando Figueira, Brazil.(?<=[.!?])\s+(?=[A-Z0-9])WHO acknowledges the fi nancial support for this second edition of the Pocket
book provided by the Bill and Melinda Gates Foundation through the medicines
for children project, and the Russian Federation through the quality of care
improvement initiative. | 22 | 35 | 0 | WHO-0001 | 1 | who_corpus.pdf | 197 |
xxi\nAbbreviations\nAIDS \nacquired immunodefi ciency syndrome\nART \nantiretroviral therapy\nAVPU \nalert, responding to voice, responding to pain, unconscious \n(simple consciousness scale) \nBCG \nbacille Calmette-Guérin\nCSF \ncerebrospinal fl uid\nDPT \ndiphtheria, pertussis, tetanus\nEVF \nerythrocyte volume fraction (haematocrit)\nHb \nhaemoglobin\nHIV \nhuman immunodefi ciency virus\nIM \nintramuscular (injection), intramuscularly\nIMCI \nIntegrated Management of Childhood Illness\nIV \nintravenous (injection), intravenously\nMDR \nmultidrug-resistant\nNNRTI \nnon-nucleoside reverse transcriptase inhibitor\nNRTI \nnucleoside reverse transcriptase inhibitor\nNSAID \nnon-steroidal anti-infl ammatory drug\nORS \noral rehydration salt(s)\nPCP \nPneumocystis carinii pneumonia\nReSoMal rehydration solution for malnutrition\nSD \nstandard deviation\nTB \ntuberculosis\nWHO \nWorld Health Organization\nSymbols\n \n■diagnostic sign or symptom\n \n treatment recommendation | 23 | 36 | 0 | WHO-0001 | 1 | who_corpus.pdf | 287 |
xxii
Chart 1.(?<=[.!?])\s+(?=[A-Z0-9])Stages in the management of a sick child
admitted to hospital: key elements
TRIAGE
(present)
• Check for emergency signs
(absent)
• Check for priority signs or conditions
Give emergency
treatment until stable
HISTORY AND EXAMINATION
(including assessment of vaccination status, nutritional status and feeding)
• Check children with emergency and priority conditions fi rst.(?<=[.!?])\s+(?=[A-Z0-9])Laboratory and other investigations, if required
List and consider differential diagnoses
Select main diagnoses (and secondary diagnoses)
Plan and begin inpatient treatment
(including supportive care)
Monitor for signs of
— improvement
— complications
— failure of treatment.(?<=[.!?])\s+(?=[A-Z0-9])Plan and begin outpatient
treatment.(?<=[.!?])\s+(?=[A-Z0-9])Arrange follow-up, if
required.
(not improving or new problem)
(improving)
Reassess
for causes of failure of
treatment.(?<=[.!?])\s+(?=[A-Z0-9])Revise treatment.(?<=[.!?])\s+(?=[A-Z0-9])Continue treatment.(?<=[.!?])\s+(?=[A-Z0-9])Plan discharge.(?<=[.!?])\s+(?=[A-Z0-9])Discharge home.(?<=[.!?])\s+(?=[A-Z0-9])Arrange continuing care or
follow-up at hospital or in
the community. | 24 | 37 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
1
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHAPTER 1
T riage and emergency
conditions
1.1
Triage
2
1.2 Summary of steps in emergency triage assessment and treatment
3
1.3 Assessment of emergency and priority signs
4
Triage of all sick children
5
How to manage a choking infant or child
7
How to manage the airway in a child with obstructed breathing
9
How to give oxygen
11
How to position the unconscious child
12
Give IV fl uids for shock in a child without severe acute malnutrition 13
Give IV fl uids for shock in a child with severe acute malnutrition
14
Give diazepam rectally
15
Give IV glucose
16
Treat severe dehydration in an emergency setting
17
1.4 Emergency treatment for a child with severe malnutrition
19
1.5 Diagnostic considerations for children with emergency conditions 20
1.5.1
Child presenting with an airway or severe breathing
problem
20
1.5.2 Child presenting with shock
21
1.5.3 Child presenting with lethargy, unconsciousness
or convulsions
23
1.6 Common poisoning
26
1.6.1
Principles for ingested poisons
27
1.6.2 Principles for poisons in contact with skin or eyes
29
1.6.3 Principles for inhaled poisons
29
1.6.4 Specifi c poisons
29
Corrosive compounds
29
Petroleum compounds
30
Organophosphorus and carbamate compounds
30
Paracetamol
31
Aspirin and other salicylates
31
Iron
32
Morphine and other opiates
32
Carbon monoxide
33
1.6.5 Prevention of poisoning
33 | 25 | 38 | 0 | WHO-0001 | 1 | who_corpus.pdf | 320 |
2
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
1.1
Triage
Triage is the process of rapidly screening sick children soon after their arrival
in hospital, in order to identify:
– those with emergency signs, who require immediate emergency treatment;
– those with priority signs, who should be given priority in the queue so that
they can be assessed and treated without delay; and
– non-urgent cases, who have neither emergency nor priority signs.(?<=[.!?])\s+(?=[A-Z0-9])Emergency signs include:
■obstructed or absent breathing
■severe respiratory distress
■central cyanosis
■signs of shock (cold hands, capillary refi ll time longer than 3 s, high heart
rate with weak pulse, and low or unmeasurable blood pressure)
■coma (or seriously reduced level of consciousness)
■convulsions
■signs of severe dehydration in a child with diarrhoea (lethargy, sunken eyes,
very slow return after pinching the skin or any two of these).(?<=[.!?])\s+(?=[A-Z0-9])Children with these signs require immediate emergency treatment to avert
death.(?<=[.!?])\s+(?=[A-Z0-9])The priority signs (see p.(?<=[.!?])\s+(?=[A-Z0-9])6) identify children who are at higher risk of dying.(?<=[.!?])\s+(?=[A-Z0-9])These children should be assessed without unnecessary delay. | 26 | 39 | 0 | WHO-0001 | 1 | who_corpus.pdf | 380 |
These children should be assessed without unnecessary delay.(?<=[.!?])\s+(?=[A-Z0-9])If a child has
one or more emergency signs, don’t spend time looking for priority signs.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
1.7 Drowning
33
1.8 Electrocution
34
1.9 Common causes of envenoming
34
1.9.1
Snake bite
34
1.9.2 Scorpion sting
37
1.9.3 Other sources of envenoming
38
1.10 Trauma and injuries
38
1.10.1 Primary survey or initial assessment
38
1.10.2 Secondary survey
39 | 26 | 40 | 1 | WHO-0001 | 1 | who_corpus.pdf | 158 |
3
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
1.2
Summary of steps in emergency triage assessment
and treatment
Steps in emergency triage assessment and treatment are summarized in the
charts on pp.(?<=[.!?])\s+(?=[A-Z0-9])5–17.(?<=[.!?])\s+(?=[A-Z0-9])First check for emergency signs in three steps:
•
Step 1.(?<=[.!?])\s+(?=[A-Z0-9])Check whether there is any airway or breathing problem; start im-
mediate treatment to restore breathing.(?<=[.!?])\s+(?=[A-Z0-9])Manage the airway and give oxygen.
•
Step 2.(?<=[.!?])\s+(?=[A-Z0-9])Quickly check whether the child is in shock or has diarrhoea with
severe dehydration.(?<=[.!?])\s+(?=[A-Z0-9])Give oxygen and start IV fl uid resuscitation.(?<=[.!?])\s+(?=[A-Z0-9])In trauma,
if there is external bleeding, compress the wound to stop further blood loss.
•
Step 3.(?<=[.!?])\s+(?=[A-Z0-9])Quickly determine whether the child is unconscious or convulsing. | 27 | 41 | 0 | WHO-0001 | 1 | who_corpus.pdf | 362 |
Quickly determine whether the child is unconscious or convulsing.(?<=[.!?])\s+(?=[A-Z0-9])Give IV glucose for hypoglycaemia and/or an anti-convulsant for convulsing.(?<=[.!?])\s+(?=[A-Z0-9])If emergency signs are found:
•
Call for help from an experienced health professional if available, but do
not delay starting treatment.(?<=[.!?])\s+(?=[A-Z0-9])Stay calm and work with other health workers
who may be required to give the treatment, because a very sick child may
need several treatments at once.(?<=[.!?])\s+(?=[A-Z0-9])The most experienced health professional
should continue assessing the child (see Chapter 2, p.(?<=[.!?])\s+(?=[A-Z0-9])41), to identify all
underlying problems and prepare a treatment plan.
•
Carry out emergency investigations (blood glucose, blood smear, haemoglo-
bin [Hb]).(?<=[.!?])\s+(?=[A-Z0-9])Send blood for typing and cross-matching if the child is in shock,
appears to be severely anaemic or is bleeding signifi cantly.
•
After giving emergency treatment, proceed immediately to assessing,
diagnosing and treating the underlying problem.(?<=[.!?])\s+(?=[A-Z0-9])Tables of common differential diagnoses for emergency signs are provided
from p. | 27 | 42 | 1 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Tables of common differential diagnoses for emergency signs are provided
from p.(?<=[.!?])\s+(?=[A-Z0-9])21 onwards.(?<=[.!?])\s+(?=[A-Z0-9])If no emergency signs are found, check for priority signs:
■Tiny infant: any sick child aged < 2 months
■Temperature: child is very hot
■Trauma or other urgent surgical condition
■Pallor (severe)
■Poisoning (history of)
■Pain (severe)
■Respiratory distress
■Restless, continuously irritable or lethargic
SUMMARY OF STEPS IN EMERGENCY TRIAGE ASSESSMENT AND TREATMENT | 27 | 43 | 2 | WHO-0001 | 1 | who_corpus.pdf | 153 |
4
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
■Referral (urgent)
■Malnutrition: visible severe wasting
■Oedema of both feet
■Burns (major)
The above can be remembered from the mnemonic 3TPR MOB.(?<=[.!?])\s+(?=[A-Z0-9])These children need prompt assessment (no waiting in the queue) to determine
what further treatment is needed.(?<=[.!?])\s+(?=[A-Z0-9])Move a child with any priority sign to the
front of the queue to be assessed next.(?<=[.!?])\s+(?=[A-Z0-9])If a child has trauma or other surgical
problems, get surgical help where available.(?<=[.!?])\s+(?=[A-Z0-9])1.3
Assessment of emergency and priority signs
■Assess the airway and breathing (A, B)
Does the child’s breathing appear to be obstructed?(?<=[.!?])\s+(?=[A-Z0-9])Look at the chest wall
movement, and listen to breath sounds to determine whether there is poor air
movement during breathing.(?<=[.!?])\s+(?=[A-Z0-9])Stridor indicates obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Is there central cyanosis? | 28 | 44 | 0 | WHO-0001 | 1 | who_corpus.pdf | 370 |
Stridor indicates obstruction.(?<=[.!?])\s+(?=[A-Z0-9])Is there central cyanosis?(?<=[.!?])\s+(?=[A-Z0-9])Determine whether there is bluish or purplish dis-
coloration of the tongue and the inside of the mouth.(?<=[.!?])\s+(?=[A-Z0-9])Is the child breathing?(?<=[.!?])\s+(?=[A-Z0-9])Look and listen to determine whether the child is
breathing.(?<=[.!?])\s+(?=[A-Z0-9])Is there severe respiratory distress?(?<=[.!?])\s+(?=[A-Z0-9])The breathing is very laboured, fast or
gasping, with chest indrawing, nasal fl aring, grunting or the use of auxiliary
muscles for breathing (head nodding).(?<=[.!?])\s+(?=[A-Z0-9])Child is unable to feed because of
respiratory distress and tires easily.
■Assess circulation (for shock) (C)
Children in shock who require bolus fl uid resuscitation are lethargic and have
cold skin, prolonged capillary refi ll, fast weak pulse and hypotension.(?<=[.!?])\s+(?=[A-Z0-9])Check whether the child’s hand is cold.(?<=[.!?])\s+(?=[A-Z0-9])If so, determine whether the child is
in shock. | 28 | 45 | 1 | WHO-0001 | 1 | who_corpus.pdf | 399 |
If so, determine whether the child is
in shock.(?<=[.!?])\s+(?=[A-Z0-9])Check whether the capillary refi ll time is longer than 3 s.(?<=[.!?])\s+(?=[A-Z0-9])Apply pressure to
whiten the nail of the thumb or the big toe for 5 s.(?<=[.!?])\s+(?=[A-Z0-9])Determine the time from the
moment of release until total recovery of the pink colour.(?<=[.!?])\s+(?=[A-Z0-9])If capillary refi ll is longer than 3 s, check the pulse.(?<=[.!?])\s+(?=[A-Z0-9])Is it weak and fast?(?<=[.!?])\s+(?=[A-Z0-9])If the
radial pulse is strong and not obviously fast, the child is not in shock.(?<=[.!?])\s+(?=[A-Z0-9])If you
cannot feel the radial pulse of an infant (< 1 year old), feel the brachial pulse
or, if the infant is lying down, the femoral pulse.(?<=[.!?])\s+(?=[A-Z0-9])If you cannot feel the radial
pulse of a child, feel the carotid.(?<=[.!?])\s+(?=[A-Z0-9])ASSESSMENT OF EMERGENCY AND PRIORITY SIGNS | 28 | 46 | 2 | WHO-0001 | 1 | who_corpus.pdf | 378 |
5
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 2.(?<=[.!?])\s+(?=[A-Z0-9])Triage of all sick children
Emergency signs:
If any sign is positive, call for help, assess and resuscitate, give
treatment(s), draw blood for emergency laboratory investigations
(glucose, malaria smear, Hb)
CHART 2.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE OF ALL SICK CHILDREN
TREAT
Do not move neck if a cervical spine
injury is possible, but open the airway.(?<=[.!?])\s+(?=[A-Z0-9])ASSESS
Check for
severe
malnutrition
ANY SIGN
POSITIVE
SIGNS
POSITIVE
Airway and breathing
■ Obstructed or
absent breathing
or
■ Central cyanosis
or
■ Severe respiratory
distress
Circulation
Cold skin with:
■ Capillary refi ll
longer than 3 s
and
■ Weak and fast
pulse
If foreign body aspirated
Manage airway in choking
child (Chart 3)
If no foreign body aspirated
Manage airway (Chart 4)
Give oxygen (Chart 5)
Make sure the child is warm
Stop any bleeding
Give oxygen (Chart 5)
Make sure the child is warm.(?<=[.!?])\s+(?=[A-Z0-9])If no severe malnutrition
Insert an IV line and begin
giving fl uids rapidly (Chart 7).(?<=[.!?])\s+(?=[A-Z0-9])If peripheral IV cannot be
inserted, insert an intraosseous
or external jugular line
(see pp.(?<=[.!?])\s+(?=[A-Z0-9])340, 342). | 29 | 47 | 0 | WHO-0001 | 1 | who_corpus.pdf | 398 |
340, 342).(?<=[.!?])\s+(?=[A-Z0-9])If severe malnutrition:
If lethargic or unconscious:
Give IV glucose (Chart 10).
Insert IV line and give fl uids
(Chart 8).(?<=[.!?])\s+(?=[A-Z0-9])If not lethargic or unconscious:
Give glucose orally or by
nasogastric tube.
Proceed immediately to full
assessment and treatment. | 29 | 48 | 1 | WHO-0001 | 1 | who_corpus.pdf | 112 |
6
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHART 2.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE OF ALL SICK CHILDREN
Chart 2.(?<=[.!?])\s+(?=[A-Z0-9])Triage of all sick children
Emergency signs:
If any sign is positive: call for help, assess and resuscitate, give
treatment(s), draw blood for emergency laboratory investigations
(glucose, malaria smear, Hb)
PRIORITY SIGNS
These children need prompt assessment and treatment
ASSESS
TREAT
Do not move neck if you suspect cervical
spine injury, but open the airway.(?<=[.!?])\s+(?=[A-Z0-9])Coma/
convulsing
■ Coma
or
■ Convulsing
(now)
Manage the airway (Chart 4)
If convulsing, give diazepam rectally
(Chart 9)
Position the unconscious child (if
head or neck trauma is suspected,
stabilize the neck fi rst) (Chart 6).
Give IV glucose (Chart 10).
Make sure the child is warm.(?<=[.!?])\s+(?=[A-Z0-9])If no severe malnutrition:
Insert an IV line and begin giving
fl uids rapidly following Chart 11 and
diarrhoea treatment plan C in hospital
(Chart 13, p.(?<=[.!?])\s+(?=[A-Z0-9])131).(?<=[.!?])\s+(?=[A-Z0-9])If severe malnutrition:
Do not insert an IV line.
Proceed immediately to full
assessment and treatment (see
section 1.4, p. | 30 | 49 | 0 | WHO-0001 | 1 | who_corpus.pdf | 397 |
If severe malnutrition:
Do not insert an IV line.
Proceed immediately to full
assessment and treatment (see
section 1.4, p.(?<=[.!?])\s+(?=[A-Z0-9])19).(?<=[.!?])\s+(?=[A-Z0-9])IF COMA OR
CONVULSION
DIARRHOEA
PLUS
two signs
positive
Check for
severe
malnutrition
Severe
dehydration
(only in a child
with diarrhoea)
Diarrhoea plus
any two of these
signs:
■ Lethargy
■ Sunken eyes
■ Very slow skin pinch
■ Unable to drink or drinks
poorly
■ Tiny infant (< 2 months)
■ Temperature very high
■ Trauma or other urgent surgical
condition
■ Pallor (severe)
■ Poisoning (history of)
■ Pain (severe)
■ Respiratory distress
■ Restless, continuously irritable, or lethargic
■ Referral (urgent)
■ Malnutrition: visible severe wasting
■ Oedema of both feet or face
■ Burns (major)
Note: If a child has trauma or other surgical problems,
get surgical help or follow surgical guidelines.(?<=[.!?])\s+(?=[A-Z0-9])NON-URGENT
Proceed with assessment and further treatment according to the child’s priority. | 30 | 50 | 1 | WHO-0001 | 1 | who_corpus.pdf | 269 |
7
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHART 3.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO MANAGE A CHOKING INFANT
Chart 3.(?<=[.!?])\s+(?=[A-Z0-9])How to manage a choking infant
Chest thrusts
Lay the infant on your arm
or thigh in a head-down
position.
Give fi ve blows to the
middle of the infant’s back
with the heel of the hand.
If obstruction persists, turn
the infant over and give
fi ve chest thrusts with two
fi ngers on the lower half of
the sternum.
If obstruction persists,
check infant’s mouth for
any obstruction that can be
removed.
If necessary, repeat
sequence with back slaps.(?<=[.!?])\s+(?=[A-Z0-9])Back slaps | 31 | 51 | 0 | WHO-0001 | 1 | who_corpus.pdf | 224 |
8
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHART 3.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO MANAGE A CHOKING CHILD
Chart 3.(?<=[.!?])\s+(?=[A-Z0-9])How to manage a choking child (> 1 year of age)
Heimlich manoeuvre for
a choking older child
Administer back blows to clear airway
obstruction in a choking child.
Give fi ve blows to the middle of the
child’s back with the heel of the hand,
with the child sitting, kneeling or
lying.
If the obstruction persists, go behind
the child and pass your arms around
the child’s body; form a fi st with one
hand immediately below the child’s
sternum; place the other hand over
the fi st and pull upwards into the
abdomen (see diagram); repeat this
Heimlich manoeuvre fi ve times.
If the obstruction persists, check the
child’s mouth for any obstruction that
can be removed.
If necessary, repeat this sequence
with back blows.(?<=[.!?])\s+(?=[A-Z0-9])Back blows to clear airway
obstruction in a choking child | 32 | 52 | 0 | WHO-0001 | 1 | who_corpus.pdf | 300 |
9
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHART 4.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO MANAGE THE AIRWAY IN A CHILD
Chart 4.(?<=[.!?])\s+(?=[A-Z0-9])How to manage the airway in a child with
obstructed breathing (or who has just stopped
breathing)
A: When no neck trauma is suspected
■ OLDER CHILD
Look, listen and feel for breathing
Child conscious
1.(?<=[.!?])\s+(?=[A-Z0-9])Inspect mouth and
remove foreign body,
if present.(?<=[.!?])\s+(?=[A-Z0-9])2.(?<=[.!?])\s+(?=[A-Z0-9])Clear secretions from
the throat.(?<=[.!?])\s+(?=[A-Z0-9])3.(?<=[.!?])\s+(?=[A-Z0-9])Let child assume
position of maximal
comfort.(?<=[.!?])\s+(?=[A-Z0-9])Child unconscious
1.(?<=[.!?])\s+(?=[A-Z0-9])Tilt the head as shown,
keep it tilted and lift
chin to open airway.(?<=[.!?])\s+(?=[A-Z0-9])2. | 33 | 53 | 0 | WHO-0001 | 1 | who_corpus.pdf | 387 |
2.(?<=[.!?])\s+(?=[A-Z0-9])Inspect mouth and
remove foreign body
if present and easily
visible.(?<=[.!?])\s+(?=[A-Z0-9])3.(?<=[.!?])\s+(?=[A-Z0-9])Clear secretions from
the throat.(?<=[.!?])\s+(?=[A-Z0-9])4.(?<=[.!?])\s+(?=[A-Z0-9])Check the airway
by looking for chest
movements, listening
for breath sounds and
feeling for breath (see
diagram).
■ INFANT
Neutral position to open the airway in an
infant
Tilting position to
open the airway in
an older child | 33 | 54 | 1 | WHO-0001 | 1 | who_corpus.pdf | 194 |
10
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHART 4.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO MANAGE THE AIRWAY IN A CHILD
Chart 4.(?<=[.!?])\s+(?=[A-Z0-9])How to manage the airway in a child with
obstructed breathing (or who has just stopped
breathing)
B: When neck trauma or cervical spine injury is suspected: jaw thrust
Use jaw thrust if airway are still not open.(?<=[.!?])\s+(?=[A-Z0-9])Place the fourth and fi fth fi ngers
behind the angle of the jaw and move it upwards so that the bottom of the
jaw is thrust forwards, at 90° to the body
1.(?<=[.!?])\s+(?=[A-Z0-9])Stabilize the neck as shown in Chart 6, and open the airway.(?<=[.!?])\s+(?=[A-Z0-9])2.(?<=[.!?])\s+(?=[A-Z0-9])Inspect mouth and remove foreign body, if present.(?<=[.!?])\s+(?=[A-Z0-9])3.(?<=[.!?])\s+(?=[A-Z0-9])Clear secretions from throat under direct vision.(?<=[.!?])\s+(?=[A-Z0-9])4. | 34 | 55 | 0 | WHO-0001 | 1 | who_corpus.pdf | 394 |
Clear secretions from throat under direct vision.(?<=[.!?])\s+(?=[A-Z0-9])4.(?<=[.!?])\s+(?=[A-Z0-9])Check the airway by looking for chest movements, listening for breath
sounds and feeling for breath.(?<=[.!?])\s+(?=[A-Z0-9])If the child is still not breathing
after the above, ventilate with bag
and mask, ideally with a reservoir
bag and oxygen | 34 | 56 | 1 | WHO-0001 | 1 | who_corpus.pdf | 128 |
11
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 5.(?<=[.!?])\s+(?=[A-Z0-9])How to give oxygen
CHART 5.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO GIVE OXYGEN
Give oxygen through nasal
prongs or a nasal catheter.
■ NASAL PRONGS
Place the prongs just inside
the nostrils and secure with
tape.
■ NASAL CATHETER
Use an 8 French gauge size
tube
Measure the distance from
the side of the nostril to the
inner eyebrow margin with
the catheter.
Insert the catheter as shown
in the diagram.
Secure with tape.(?<=[.!?])\s+(?=[A-Z0-9])Start oxygen fl ow at
1–2 litres/min to aim for an
oxygen saturation > 90%
(see section 10.7, p.(?<=[.!?])\s+(?=[A-Z0-9])312). | 35 | 57 | 0 | WHO-0001 | 1 | who_corpus.pdf | 251 |
12
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 6.(?<=[.!?])\s+(?=[A-Z0-9])How to position an unconscious child
CHART 6.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO POSITION AN UNCONSCIOUS CHILD
■ If neck trauma is suspected:
Stabilize the child’s neck and keep the child lying on the back.
Tape the child’s forehead and chin
to the sides of a fi rm board to
secure this position.
Prevent the neck from moving
by supporting the child’s head
(e.g. using litre bags of IV
fl uid on each side).
If the child is vomiting,
turn on the side, keeping
the head in line with
the body.
■ If neck trauma is not suspected:
Turn the child on the side to reduce risk of aspiration.
Keep the neck slightly extended, and stabilize by placing cheek on one
hand.
Bend one leg to stabilize the body position. | 36 | 58 | 0 | WHO-0001 | 1 | who_corpus.pdf | 237 |
13
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 7.(?<=[.!?])\s+(?=[A-Z0-9])How to give intravenous fl uids to a child in
shock without severe malnutrition
Check that the child is not severely malnourished, as the fl uid volume
and rate are different. (Shock with severe malnutrition, see Chart 8.)
Insert an IV line (and draw blood for emergency laboratory
investigations).
Attach Ringer’s lactate or normal saline; make sure the infusion is
running well.
Infuse 20 ml/kg as rapidly as possible.(?<=[.!?])\s+(?=[A-Z0-9])Age (weight)
Volume of Ringer’s lactate or normal saline
solution (20 ml/kg)
2 months (< 4 kg)
50 ml
2–< 4 months (4–< 6 kg)
100 ml
4–< 12 months (6–< 10 kg)
150 ml
1–< 3 years (10–< 14 kg)
250 ml
3–< 5 years (14–19 kg)
350 ml
Reassess the child after the appropriate volume has run in.(?<=[.!?])\s+(?=[A-Z0-9])Reassess
after fi rst
infusion:
• If no improvement, repeat 10–20 ml/kg as rapidly as
possible.
• If bleeding, give blood at 20 ml/kg over 30 min, and
observe closely. | 37 | 59 | 0 | WHO-0001 | 1 | who_corpus.pdf | 337 |
Reassess
after
second
infusion:
• If no improvement with signs of dehydration (as in profuse
diarrhoea or cholera), repeat 20 ml/kg of Ringer’s lactate
or normal saline.
• If no improvement, with suspected septic shock, repeat
20 ml/kg and consider adrenaline or dopamine if available
(see Annex 2, p.(?<=[.!?])\s+(?=[A-Z0-9])353).
• If no improvement, see disease-specifi c treatment
guidelines.(?<=[.!?])\s+(?=[A-Z0-9])You should have established a provisional
diagnosis by now.(?<=[.!?])\s+(?=[A-Z0-9])After improvement at any stage (pulse volume increases, heart rate slows,
blood pressure increases by 10% or normalizes, faster capillary refi ll < 2 s),
go to Chart 11, p.(?<=[.!?])\s+(?=[A-Z0-9])17.(?<=[.!?])\s+(?=[A-Z0-9])Note: In children with suspected malaria or anaemia with shock, rapid fl uid
infusion must be administered cautiously, or blood transfusion should be
given in severe anaemia instead.(?<=[.!?])\s+(?=[A-Z0-9])CHART 7.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO GIVE INTRAVENOUS FLUIDS RAPIDLY TO A CHILD IN SHOCK | 37 | 60 | 1 | WHO-0001 | 1 | who_corpus.pdf | 365 |
14
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 8.(?<=[.!?])\s+(?=[A-Z0-9])How to give intravenous fl uids to a child in
shock with severe malnutrition
Give this treatment only if the child has signs of shock (usually there will also be a
reduced level of consciousness, i.e. lethargy or loss of consciousness):
Insert an IV line (and draw blood for emergency laboratory investigations).
Weigh the child (or estimate the weight) to calculate the volume of fl uid to be given.
Give IV fl uid at 15 ml/kg over 1 h.(?<=[.!?])\s+(?=[A-Z0-9])Use one of the following solutions according to
availability:
– Ringer’s lactate with 5% glucose (dextrose);
– Half-strength Darrow’s solution with 5% glucose (dextrose);
– 0.45% NaCl plus 5% glucose (dextrose).(?<=[.!?])\s+(?=[A-Z0-9])Weight
Volume of IV fl uid
Give over 1 h (15 ml/kg)
Weight
Volume of IV fl uid
Give over 1 h (15 ml/kg)
4 kg
60 ml
12 kg
180 ml
6 kg
90 ml
14 kg
210 ml
8 kg
120 ml
16 kg
240 ml
10 kg
150 ml
18 kg
270 ml
Measure the pulse rate and volume and breathing rate at the start and every 5–10
min. | 38 | 61 | 0 | WHO-0001 | 1 | who_corpus.pdf | 346 |
If there are signs of improvement (pulse rate falls, pulse volume increases or
respiratory rate falls) and no evidence of pulmonary oedema
– repeat IV infusion at 15 ml/kg over 1 h; then
– switch to oral or nasogastric rehydration with ReSoMal at 10 ml/kg per h up to
10 h (see p.(?<=[.!?])\s+(?=[A-Z0-9])204);
– initiate re-feeding with starter F-75 (see p.(?<=[.!?])\s+(?=[A-Z0-9])209).(?<=[.!?])\s+(?=[A-Z0-9])If the child fails to improve after two IV boluses of 15 ml/kg,
– give maintenance IV fl uid (4 ml/kg per h) while waiting for blood;
– when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over 3 h
(use packed cells if the child is in cardiac failure); then
– initiate re-feeding with starter F-75 (see p.(?<=[.!?])\s+(?=[A-Z0-9])209);
– start IV antibiotic treatment (see p.(?<=[.!?])\s+(?=[A-Z0-9])207). | 38 | 62 | 1 | WHO-0001 | 1 | who_corpus.pdf | 313 |
209);
– start IV antibiotic treatment (see p.(?<=[.!?])\s+(?=[A-Z0-9])207).(?<=[.!?])\s+(?=[A-Z0-9])If the child deteriorates during IV rehydration (breathing rate increases by 5/min and
pulse rate increases by 15/min, liver enlarges, fi ne crackles throughout lung fi elds,
jugular venous pressure increases, galloping heart rhythm develops), stop the
infusion, because IV fl uid can worsen the child’s condition by inducing pulmonary
oedema.(?<=[.!?])\s+(?=[A-Z0-9])CHART 8.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO GIVE INTRAVENOUS FLUIDS TO A CHILD IN SHOCK | 38 | 63 | 2 | WHO-0001 | 1 | who_corpus.pdf | 202 |
15
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 9.(?<=[.!?])\s+(?=[A-Z0-9])How to give diazepam rectally
■ Give diazepam rectally:
Draw up the dose from an ampoule of diazepam into a tuberculin (1-ml)
syringe.(?<=[.!?])\s+(?=[A-Z0-9])Base the dose on the weight of the child, when possible.(?<=[.!?])\s+(?=[A-Z0-9])Then
remove the needle.
Insert the syringe 4–5 cm into the rectum, and inject the diazepam
solution.
Hold the buttocks together for a few minutes. | 39 | 64 | 0 | WHO-0001 | 1 | who_corpus.pdf | 186 |
Then
remove the needle.
Insert the syringe 4–5 cm into the rectum, and inject the diazepam
solution.
Hold the buttocks together for a few minutes.(?<=[.!?])\s+(?=[A-Z0-9])Age (weight)
Diazepam given rectally
10 mg/2 ml solution
Dose 0.1 ml/kg
2 weeks to 2 months (< 4 kg)a
0.3 ml
2–< 4 months (4–< 6 kg)
0.5 ml
4–< 12 months (6–< 10 kg)
1.0 ml
1–< 3 years (10–< 14 kg)
1.25 ml
3–< 5 years (14–19 kg)
1.5 ml
a Use phenobarbital (200 mg/ml solution) at a dose of 20 mg/kg to control convulsions
in infants < 2 weeks of age:
Weight 2 kg – initial dose, 0.2 ml; repeat 0.1 ml after 30 min
If convulsions
Weight 3 kg – initial dose, 0.3 ml; repeat 0.15 ml after 30 min
continue
If convulsions continue after 10 min, give a second dose of diazepam
(or give diazepam IV at 0.05 ml/kg = 0.25 mg/kg if IV infusion is running).(?<=[.!?])\s+(?=[A-Z0-9])Do not give more than two doses of diazepam.(?<=[.!?])\s+(?=[A-Z0-9])If convulsions continue after another 10 min, suspect status epilepticus:
Give phenobarbital IM or IV at 15 mg/kg over 15 min;
or
Phenytoin at 15–18 mg/kg IV (through a different line from diazepam)
over 60 min. | 39 | 65 | 1 | WHO-0001 | 1 | who_corpus.pdf | 383 |
Ensure a very good IV line, as the drug is caustic and will
cause local damage if it extravasates.
■ If high fever:
Undress the child to reduce the fever.
Do not give any oral medication until the convulsion has been controlled
(danger of aspiration).
After convulsions stop and child is able to take orally, give paracetamol
or ibuprofen.(?<=[.!?])\s+(?=[A-Z0-9])Warning: Always have a working bag and mask of appropriate size available in
case the patient stops breathing, especially when diazepam is given.(?<=[.!?])\s+(?=[A-Z0-9])CHART 9.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO GIVE DIAZEPAM RECTALLY | 39 | 66 | 2 | WHO-0001 | 1 | who_corpus.pdf | 183 |
16
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 10.(?<=[.!?])\s+(?=[A-Z0-9])How to give glucose intravenously
Insert an IV line, and draw blood for emergency laboratory
investigations.
Check blood glucose with a glucose monitoring stick.(?<=[.!?])\s+(?=[A-Z0-9])If the level is
< 2.5 mmol/litre (45 mg/dl) in a well-nourished or < 3 mmol/litre
(54 mg/dl) in a severely malnourished child or if blood glucose cannot be
measured as no stick test is available, treat as for hypoglycaemia:
Give 5 ml/kg of 10% glucose solution rapidly by IV injection
Age (weight)
Volume of 10% glucose solution
as bolus (5 ml/kg)
< 2 months (< 4 kg)
15 ml
2–< 4 months (4–< 6 kg)
25 ml
4–< 12 months (6–< 10 kg)
40 ml
1–< 3 years (10–< 14 kg)
60 ml
3–< 5 years (14–< 19 kg)
80 ml
Recheck the blood glucose in 30 min.(?<=[.!?])\s+(?=[A-Z0-9])If it is still low, repeat 5 ml/kg of
10% glucose solution.
Feed the child as soon as he or she is conscious. | 40 | 67 | 0 | WHO-0001 | 1 | who_corpus.pdf | 335 |
If it is still low, repeat 5 ml/kg of
10% glucose solution.
Feed the child as soon as he or she is conscious.(?<=[.!?])\s+(?=[A-Z0-9])If the child is unable to feed without danger of aspiration, give:
– milk or sugar solution via a nasogastric tube (to make sugar solution,
dissolve four level teaspoons of sugar (20 g) in a 200-ml cup of clean
water), or
– IV fl uids containing 5–10% glucose (dextrose) (see Annex 4, p.(?<=[.!?])\s+(?=[A-Z0-9])377)
Note: 50% glucose solution is the same as 50% dextrose solution.(?<=[.!?])\s+(?=[A-Z0-9])If only 50% glucose solution is available: dilute one part 50% glucose solution in four
parts sterile water, or dilute one part 50% glucose solution in nine parts 5% glucose
solution.(?<=[.!?])\s+(?=[A-Z0-9])For example, 10 ml 50% solution with 90 ml 5% solution gives 100 ml of
approximately a 10% solution.(?<=[.!?])\s+(?=[A-Z0-9])Note: To use blood glucose stick tests, refer to instructions on box.(?<=[.!?])\s+(?=[A-Z0-9])Generally, the strip
must be stored in its box at 2–3 °C, avoiding sunlight or high humidity. | 40 | 68 | 1 | WHO-0001 | 1 | who_corpus.pdf | 371 |
Generally, the strip
must be stored in its box at 2–3 °C, avoiding sunlight or high humidity.(?<=[.!?])\s+(?=[A-Z0-9])A drop of blood
should be placed on the strip (it should cover all the reagent area).(?<=[.!?])\s+(?=[A-Z0-9])After 60 s, the blood
should be washed off gently with drops of cold water and the colour compared with
the key on the bottle or on the blood glucose reader. (The exact procedure varies for
different strips.) Note: Sublingual sugar may be used as an immediate ‘fi rst aid’ measure in managing
hypoglycaemia if IV access is impossible or delayed. Place one level teaspoonful of sugar
moistened with water under the tongue every 10–20 min.
CHART 10. HOW TO GIVE GLUCOSE INTRAVENOUSLY | 40 | 69 | 2 | WHO-0001 | 1 | who_corpus.pdf | 194 |
17
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Chart 11.(?<=[.!?])\s+(?=[A-Z0-9])How to treat severe dehydration in an
emergency after initial management of shock
For children with severe dehydration but without shock, refer to diarrhoea
treatment plan C, p.(?<=[.!?])\s+(?=[A-Z0-9])131.(?<=[.!?])\s+(?=[A-Z0-9])If the child is in shock, fi rst follow the instructions in Charts 7 and 8 (pp.(?<=[.!?])\s+(?=[A-Z0-9])13
and 14).(?<=[.!?])\s+(?=[A-Z0-9])Switch to the chart below when the child’s pulse becomes slower
or capillary refi ll is faster.
Give 70 ml/kg of Ringer’s lactate (Hartmann’s) solution (or, if not
available, normal saline) over 5 h to infants (aged < 12 months) and over
2.5 h to children (aged 12 months to 5 years). | 41 | 70 | 0 | WHO-0001 | 1 | who_corpus.pdf | 292 |
Total volume IV fl uid (volume per hour)
Weight
Age < 12 months
Give over 5 h
Age 12 months to 5 years
Give over 2.5 h
< 4 kg
200 ml (40 ml/h)
–
4–6 kg
350 ml (70 ml/h)
–
6–10 kg
550 ml (110 ml/h)
550 ml (220 ml/h)
10–14 kg
850 ml (170 ml/h)
850 ml (340 ml/h)
14–19 kg
–
1200 ml (480 ml/h)
Reassess the child every 1–2 h.(?<=[.!?])\s+(?=[A-Z0-9])If the hydration status is not improving,
give the IV drip more rapidly.(?<=[.!?])\s+(?=[A-Z0-9])Also give oral rehydration salt (ORS) solution (about 5 ml/kg per h) as soon
as the child can drink, usually after 3–4 h (in infants) or 1–2 h (in children).(?<=[.!?])\s+(?=[A-Z0-9])Weight
Volume of ORS solution per hour
< 4 kg
15 ml
4–6 kg
25 ml
6–10 kg
40 ml
10–14 kg
60 ml
14–19 kg
85 ml
Reassess after 6 h for infants and after 3 h for children.(?<=[.!?])\s+(?=[A-Z0-9])Classify
dehydration.(?<=[.!?])\s+(?=[A-Z0-9])Then choose the appropriate plan A, B or C (pp. | 41 | 71 | 1 | WHO-0001 | 1 | who_corpus.pdf | 374 |
Then choose the appropriate plan A, B or C (pp.(?<=[.!?])\s+(?=[A-Z0-9])138, 135, 131)
to continue treatment.(?<=[.!?])\s+(?=[A-Z0-9])If possible, observe the child for at least 6 h after rehydration to be sure
that the mother can maintain hydration by giving the child ORS solution by
mouth.(?<=[.!?])\s+(?=[A-Z0-9])CHART 11.(?<=[.!?])\s+(?=[A-Z0-9])HOW TO TREAT SEVERE DEHYDRATION IN AN EMERGENCY | 41 | 72 | 2 | WHO-0001 | 1 | who_corpus.pdf | 166 |
18
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
If the room is very cold, rely on the pulse to determine whether the child is
in shock.(?<=[.!?])\s+(?=[A-Z0-9])Check whether the systolic blood pressure is low for the child’s age (see Table
below).(?<=[.!?])\s+(?=[A-Z0-9])Shock may be present with normal blood pressure, but very low blood
pressure means the child is in shock.(?<=[.!?])\s+(?=[A-Z0-9])Normal blood pressure ranges in infants and children
Age
Systolic blood pressure
Premature
55–75
0–3 months
65–85
3–6 months
70–90
6–12 months
80–100
1–3 years
90–105
3–6 years
95–110
■Assess for coma or convulsions or other abnormal mental status (C)
Is the child in coma?(?<=[.!?])\s+(?=[A-Z0-9])Check the level of consciousness on the ‘AVPU’ scale:
A
alert,
V
responds to voice,
P
responds to pain,
U
unconscious.(?<=[.!?])\s+(?=[A-Z0-9])If the child is not awake and alert, try to rouse the child by talking or shaking
the arm.(?<=[.!?])\s+(?=[A-Z0-9])If the child is not alert but responds to voice, he or she is lethargic. | 42 | 73 | 0 | WHO-0001 | 1 | who_corpus.pdf | 383 |
If the child is not alert but responds to voice, he or she is lethargic.(?<=[.!?])\s+(?=[A-Z0-9])If
there is no response, ask the mother whether the child has been abnormally
sleepy or diffi cult to wake.(?<=[.!?])\s+(?=[A-Z0-9])Determine whether the child responds to pain or
is unresponsive to a painful stimulus.(?<=[.!?])\s+(?=[A-Z0-9])If this is the case, the child is in coma
(unconscious) and needs emergency treatment.(?<=[.!?])\s+(?=[A-Z0-9])Is the child convulsing?(?<=[.!?])\s+(?=[A-Z0-9])Are there spasmodic repeated movements in an
unresponsive child?
■Assess the child for severe dehydration if he or she has diarrhoea
Does the child have sunken eyes?(?<=[.!?])\s+(?=[A-Z0-9])Ask the mother if the child’s eyes are more
sunken than usual.(?<=[.!?])\s+(?=[A-Z0-9])Does a skin pinch go back very slowly (longer than 2 s)?(?<=[.!?])\s+(?=[A-Z0-9])Pinch the skin of the
abdomen halfway between the umbilicus and the side for 1 s, then release
and observe. | 42 | 74 | 1 | WHO-0001 | 1 | who_corpus.pdf | 375 |
Pinch the skin of the
abdomen halfway between the umbilicus and the side for 1 s, then release
and observe.(?<=[.!?])\s+(?=[A-Z0-9])ASSESSMENT OF EMERGENCY AND PRIORITY SIGNS | 42 | 75 | 2 | WHO-0001 | 1 | who_corpus.pdf | 57 |
19
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
■Assess for priority signs
While assessing the child for emergency signs, you will have noted several
possible priority signs:
Is there any respiratory distress (not severe)?(?<=[.!?])\s+(?=[A-Z0-9])Is the child lethargic or continuously irritable or restless?(?<=[.!?])\s+(?=[A-Z0-9])This was noted when you assessed for coma.(?<=[.!?])\s+(?=[A-Z0-9])Note the other priority signs (see p.(?<=[.!?])\s+(?=[A-Z0-9])6).(?<=[.!?])\s+(?=[A-Z0-9])1.4
Emergency treatment for a child with
severe malnutrition
During triage, all children with severe malnutrition will be identifi ed as having
priority signs, which means that they require prompt assessment and treatment.(?<=[.!?])\s+(?=[A-Z0-9])A few children with severe malnutrition will be found during triage assessment
to have emergency signs.(?<=[.!?])\s+(?=[A-Z0-9])Those with emergency signs for ‘airway and breathing’ or ‘coma or convulsions’
should receive emergency treatment accordingly (see charts on pp. | 43 | 76 | 0 | WHO-0001 | 1 | who_corpus.pdf | 356 |
Those with emergency signs for ‘airway and breathing’ or ‘coma or convulsions’
should receive emergency treatment accordingly (see charts on pp.(?<=[.!?])\s+(?=[A-Z0-9])5–17).
•
Those with signs of severe dehydration but not in shock should not be rehy-
drated with IV fl uids, because severe dehydration is diffi cult to diagnose in
severe malnutrition and is often misdiagnosed.(?<=[.!?])\s+(?=[A-Z0-9])Giving IV fl uids puts these
children at risk of over-hydration and death from heart failure.(?<=[.!?])\s+(?=[A-Z0-9])Therefore,
these children should be rehydrated orally with the special rehydration solu-
tion for severe malnutrition (ReSoMal).(?<=[.!?])\s+(?=[A-Z0-9])See Chapter 7 (p.(?<=[.!?])\s+(?=[A-Z0-9])204).
•
In severe malnutrition, individual emergency signs of shock may be pre-
sent even when there is no shock. | 43 | 77 | 1 | WHO-0001 | 1 | who_corpus.pdf | 279 |
204).
•
In severe malnutrition, individual emergency signs of shock may be pre-
sent even when there is no shock.(?<=[.!?])\s+(?=[A-Z0-9])Malnourished children with many signs
of shock: lethargy, reduced level of consciousness, cold skin, prolonged
capillary refi ll and fast weak pulse, should receive additional fl uids for
shock as above.
•
Treatment of a malnourished child for shock differs from that for a well-
nourished child, because shock from dehydration and sepsis are likely to
coexist, and these are diffi cult to differentiate on clinical grounds alone, and
because children with severe malnutrition may not cope with large amounts
of water and salt.(?<=[.!?])\s+(?=[A-Z0-9])The amount of fl uid given should be guided by the child’s
response.(?<=[.!?])\s+(?=[A-Z0-9])Avoid over-hydration.(?<=[.!?])\s+(?=[A-Z0-9])Monitor the pulse and breathing at the start
and every 5–10 min to check whether they are improving.(?<=[.!?])\s+(?=[A-Z0-9])Note that the type
of IV fl uid differs for severe malnutrition, and the infusion rate is slower.(?<=[.!?])\s+(?=[A-Z0-9])All severely malnourished children require prompt assessment and treatment
to deal with serious problems such as hypoglycaemia, hypothermia, severe
EMERGENCY TREATMENT FOR A CHILD WITH SEVERE MALNUTRITION | 43 | 78 | 2 | WHO-0001 | 1 | who_corpus.pdf | 377 |
20
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
infection, severe anaemia and potentially blinding eye problems.(?<=[.!?])\s+(?=[A-Z0-9])It is equally
important to take prompt action to prevent some of these problems, if they were
not present at the time of admission to hospital.(?<=[.!?])\s+(?=[A-Z0-9])1.5
Diagnostic considerations for children with
emergency conditions
The following text provides guidance for approaches to the diagnosis and dif-
ferential diagnosis of presenting conditions for which emergency treatment
has been given.(?<=[.!?])\s+(?=[A-Z0-9])After you have stabilized the child and provided emergency
treatment, determine the underlying cause of the problem, in order to provide
specifi c curative treatment.(?<=[.!?])\s+(?=[A-Z0-9])The following lists and tables are complemented
by the tables in the disease-specifi c chapters. | 44 | 79 | 0 | WHO-0001 | 1 | who_corpus.pdf | 255 |
The following lists and tables are complemented
by the tables in the disease-specifi c chapters.(?<=[.!?])\s+(?=[A-Z0-9])1.5.1
Child presenting with an airway or severe breathing problem
History
•
Onset of symptoms: slow or sudden
•
Previous similar episodes
•
Upper respiratory tract infection
•
Cough and duration in days
•
History of choking
•
Present since birth or acquired
•
Vaccination history: diphtheria, pertussis, tetanus (DPT), measles
•
Known HIV infection
•
Family history of asthma
Examination
•
Cough and quality of cough
•
Cyanosis
•
Respiratory distress
•
Grunting
•
Stridor, abnormal breath sounds
•
Nasal fl aring
•
Swelling of the neck
•
Crepitations
•
Wheezing
– generalized
– focal
•
Reduced air entry
– generalized
– focal
DIAGNOSTIC CONSIDERATIONS FOR CHILDREN WITH EMERGENCY CONDITIONS | 44 | 80 | 1 | WHO-0001 | 1 | who_corpus.pdf | 180 |
21
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Table 1.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with an airway or severe
breathing problem
Diagnosis or underlying cause
In favour
Pneumonia
– Cough with fast breathing and fever
– Grunting or diffi culty in breathing
– Development over days, getting worse
– Crepitations on auscultation
– Signs of consolidation or effusion
Asthma
– History of recurrent wheezing
– Prolonged expiration
– Wheezing or reduced air entry
– Response to bronchodilators
Foreign body aspiration
– History of sudden choking
– Sudden onset of stridor or respiratory
distress
– Focal reduced air entry or wheeze
Retropharyngeal abscess
– Slow development over days, getting worse
– Inability to swallow
– High fever
Croup
– Barking cough
– Hoarse voice
– Associated with upper respiratory tract
infection
– Stridor on inspiration
– Signs of respiratory distress
Diphtheria
– ‘Bull neck’ appearance due to enlarged lymph
nodes
– Signs of airway obstruction with stridor and
recession
– Grey pharyngeal membrane
– No DPT vaccination
1.5.2
Child presenting with shock
History
•
Acute or sudden onset
•
Trauma
•
Bleeding
•
History of congenital or rheumatic heart disease
•
History of diarrhoea
•
Any febrile illness
CHILD PRESENTING WITH SHOCK | 45 | 81 | 0 | WHO-0001 | 1 | who_corpus.pdf | 288 |
22
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
•
Known dengue outbreak
•
Known meningitis outbreak
•
Fever
•
Able to feed
Examination
•
Consciousness level
•
Any bleeding sites
•
Cold or warm extremities
•
Neck veins (elevated jugular venous pressure)
•
Pulse volume and rate
•
Blood pressure
•
Liver size increased
•
Petaechiae
•
Purpura
CHILD PRESENTING WITH SHOCK
Table 2.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with shock
Children with shock are lethargic, have fast breathing, cold skin, prolonged
capillary refi ll, fast weak pulse and may have low blood pressure as a late sign.(?<=[.!?])\s+(?=[A-Z0-9])To help make a specifi c diagnosis of the cause of shock, look for the signs below.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis or underlying cause
In favour
Bleeding shock
– History of trauma
– Bleeding site
Dengue shock syndrome
– Known dengue outbreak or season
– History of high fever
– Purpura
Cardiac shock
– History of heart disease or heart murmur
– Enlarged neck veins and liver
– Crepitations in both lung fi elds
Septic shock
– History of febrile illness
– Very ill child
– Skin may be warm but blood pressure low,
or skin may be cold
– Purpura may be present or history of
meningococcal outbreak
Shock associated with severe
dehydration
– History of profuse diarrhoea
– Known cholera outbreak | 46 | 82 | 0 | WHO-0001 | 1 | who_corpus.pdf | 345 |
23
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
1.5.3
Child presenting with lethargy, unconsciousness
or convulsions
History
•
Fever
•
Head injury
•
Drug overdose or toxin ingestion
•
Convulsions: How long do they last?(?<=[.!?])\s+(?=[A-Z0-9])Have there been previous febrile
convulsions?(?<=[.!?])\s+(?=[A-Z0-9])Epilepsy?(?<=[.!?])\s+(?=[A-Z0-9])In the case of an infant < 1 week old, consider history of:
•
birth asphyxia
•
birth injury to the brain
Examination
General
•
Jaundice
•
Severe palmar pallor
•
Peripheral or facial oedema (suggesting renal failure)
•
Level of consciousness
•
Petaechial rash
•
Blood pressure
•
Determine AVPU score (see p.(?<=[.!?])\s+(?=[A-Z0-9])18).(?<=[.!?])\s+(?=[A-Z0-9])Head and neck
•
Stiff neck
•
Signs of head trauma or other injuries
•
Pupil size and reactions to light
•
Tense or bulging fontanelle
•
Abnormal posture, especially opisthotonus (arched back).(?<=[.!?])\s+(?=[A-Z0-9])The coma scale score should be monitored regularly.(?<=[.!?])\s+(?=[A-Z0-9])In young infants < 1
week old, note the time between birth and the onset of unconsciousness. | 47 | 83 | 0 | WHO-0001 | 1 | who_corpus.pdf | 398 |
In young infants < 1
week old, note the time between birth and the onset of unconsciousness.(?<=[.!?])\s+(?=[A-Z0-9])Other causes of lethargy, unconsciousness or convulsions in some regions of
the world include malaria, Japanese encephalitis, dengue haemorrhagic fever,
measles encephalitis, typhoid and relapsing fever.(?<=[.!?])\s+(?=[A-Z0-9])Laboratory investigations
•
If meningitis is suspected and the child has no signs of raised intracranial
pressure (unequal pupils, rigid posture, paralysis of limbs or trunk, irregular
breathing), perform a lumbar puncture.(?<=[.!?])\s+(?=[A-Z0-9])CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS | 47 | 84 | 1 | WHO-0001 | 1 | who_corpus.pdf | 184 |
24
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS
Table 3.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a child presenting with lethargy,
unconsciousness or convulsions
Diagnosis or underlying cause
In favour
Meningitisa,b
– Very irritable
– Stiff neck or bulging fontanelle
– Petaechial rash (meningococcal
meningitis only)
– Opisthotonous
Cerebral malaria (only in children
exposed to P. falciparum; often
seasonal)
– Blood smear or rapid diagnostic test
positive for malaria parasites
– Jaundice
– Anaemia
– Convulsions
– Hypoglycaemia
Febrile convulsions (not likely to be
the cause of unconsciousness)
– Prior episodes of short convulsions
when febrile
– Associated with fever
– Age 6 months to 5 years
– Blood smear normal
Hypoglycaemia (always seek
the cause, e.g. severe malaria,
and treat the cause to prevent a
recurrence)
– Blood glucose low (< 2.5 mmol/litre
(< 45 mg/dl) or < 3.0 mmol/litre
(< 54 mg/dl) in a severely
malnourished child); responds to
glucose treatment
Head injury
– Signs or history of head trauma
Poisoning
– History of poison ingestion or drug
overdose
Shock (can cause lethargy or
unconsciousness, but is unlikely to
cause convulsions)
– Poor perfusion
– Rapid, weak pulse
•
In a malarious area, perform a rapid malaria diagnostic test and prepare
a blood smear.
•
If the child is unconscious, check the blood glucose.(?<=[.!?])\s+(?=[A-Z0-9])If not possible, then
treat as hypoglycaemia; if the level of consciousness improves, presume
hypoglycaemia.
•
Carry out urine microscopy if possible. | 48 | 85 | 0 | WHO-0001 | 1 | who_corpus.pdf | 400 |
25
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS
Table 3.(?<=[.!?])\s+(?=[A-Z0-9])Continued
Diagnosis or underlying cause
In favour
Acute glomerulonephritis with
encephalopathy
– Raised blood pressure
– Peripheral or facial oedema
– Blood and/or protein in urine
– Decreased or no urine
Diabetic ketoacidosis
– High blood sugar
– History of polydipsia and polyuria
– Acidotic (deep, laboured) breathing
a The differential diagnosis of meningitis may include encephalitis, cerebral abscess or tuber-
culous meningitis.(?<=[.!?])\s+(?=[A-Z0-9])Consult a standard textbook of paediatrics for further guidance.
b A lumbar puncture should not be done if there are signs of raised intracranial pressure (see
section 6.3, p.(?<=[.!?])\s+(?=[A-Z0-9])167 and A1.4, p.(?<=[.!?])\s+(?=[A-Z0-9])346).(?<=[.!?])\s+(?=[A-Z0-9])A positive lumbar puncture may show cloudy cerebrospinal
fl uid (CSF) on direct visual inspection, or CSF examination shows an abnormal number of white
cells (usually > 100 polymorphonuclear cells per ml in bacterial meningitis). | 49 | 86 | 0 | WHO-0001 | 1 | who_corpus.pdf | 339 |
Confi rmation is
given by a low CSF glucose (< 1.5 mmol/litre), high CSF protein (> 0.4 g/litre), organisms
identifi ed by Gram staining or a positive culture.(?<=[.!?])\s+(?=[A-Z0-9])Table 4.(?<=[.!?])\s+(?=[A-Z0-9])Differential diagnosis in a young infant (< 2 months) presenting with
lethargy, unconsciousness or convulsions
Diagnosis or underlying cause
In favour
Birth asphyxia
Hypoxic ischaemic encephalopathy
Birth trauma
– Onset in fi rst 3 days of life
– History of diffi cult delivery
Intracranial haemorrhage
– Onset in fi rst 3 days of life in a low-
birth-weight or preterm infant
Haemolytic disease of the
newborn, kernicterus
– Onset in fi rst 3 days of life
– Jaundice
– Pallor
– Serious bacterial infection
– No vitamin K given
Neonatal tetanus
– Onset at age 3–14 days
– Irritability
– Diffi culty in breastfeeding
– Trismus
– Muscle spasms
– Convulsions | 49 | 87 | 1 | WHO-0001 | 1 | who_corpus.pdf | 240 |
26
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
COMMON POISONING
Table 4.(?<=[.!?])\s+(?=[A-Z0-9])Continued
Diagnosis or underlying cause
In favour
Meningitis
– Lethargy
– Apnoeic episodes
– Convulsions
– High-pitched cry
– Tense or bulging fontanelle
Sepsis
– Fever or hypothermia
– Shock (lethargy, fast breathing, cold
skin, prolonged capillary refi ll, fast
weak pulse, and sometimes low blood
pressure)
– Seriously ill with no apparent cause
For poisoning and envenomation see below and p.(?<=[.!?])\s+(?=[A-Z0-9])34.(?<=[.!?])\s+(?=[A-Z0-9])1.6
Common poisoning
Suspect poisoning in any unexplained illness in a previously healthy child.(?<=[.!?])\s+(?=[A-Z0-9])Consult standard textbook of paediatrics for management of exposure to
specifi c poisons and/or any local sources of expertise in the management of
poisoning, for example a poison centre.(?<=[.!?])\s+(?=[A-Z0-9])Only the principles for managing inges-
tion of few common poisons are given here.(?<=[.!?])\s+(?=[A-Z0-9])Note that traditional medicines
can be a source of poisoning. | 50 | 88 | 0 | WHO-0001 | 1 | who_corpus.pdf | 359 |
Note that traditional medicines
can be a source of poisoning.(?<=[.!?])\s+(?=[A-Z0-9])Diagnosis
A diagnosis is based on a history from the child or carer, a clinical examination
and the results of investigations, where appropriate.
■Obtain full details of the poisoning agent, the amount ingested and the time
of ingestion.(?<=[.!?])\s+(?=[A-Z0-9])Attempt to identify the exact agent involved and ask to see
the container, when relevant.(?<=[.!?])\s+(?=[A-Z0-9])Check that no other children were involved.(?<=[.!?])\s+(?=[A-Z0-9])The symptoms and signs depend on the agent ingested and therefore vary
widely – see below.
■Check for signs of burns in or around the mouth or of stridor (upper airway
or laryngeal damage), which suggest ingestion of corrosives.
Admit all children who have deliberately ingested iron, pesticides, par-
acetamol or aspirin, narcotics or antidepressant drugs; and those who may
have been given the drug or poison intentionally by another child or adult.
Children who have ingested corrosives or petroleum products should not
be sent home without observation for at least 6 h.(?<=[.!?])\s+(?=[A-Z0-9])Corrosives can cause | 50 | 89 | 1 | WHO-0001 | 1 | who_corpus.pdf | 331 |
27
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
PRINCIPLES FOR INGESTED POISONS
oesophageal burns, which may not be immediately apparent, and petroleum
products, if aspirated, can cause pulmonary oedema, which may take some
hours to develop.(?<=[.!?])\s+(?=[A-Z0-9])1.6.1
Principles for ingested poisons
All children who present as poisoning cases should quickly be assessed for
emergency signs (airway, breathing, circulation and level of consciousness),
as some poisons depress breathing, cause shock or induce coma.(?<=[.!?])\s+(?=[A-Z0-9])Ingested
poisons must be removed from the stomach.(?<=[.!?])\s+(?=[A-Z0-9])Gastric decontamination is most effective within 1 h of ingestion.(?<=[.!?])\s+(?=[A-Z0-9])After this
time, there is usually little benefi t, except for agents that delay gastric empty-
ing or in patients who are deeply unconscious.(?<=[.!?])\s+(?=[A-Z0-9])A decision to undertake gastric
decontamination must weigh the likely benefi ts against the risks associated
with each method.(?<=[.!?])\s+(?=[A-Z0-9])Gastric decontamination does not guarantee that all the
substance has been removed, so the child may still be in danger. | 51 | 90 | 0 | WHO-0001 | 1 | who_corpus.pdf | 362 |
Gastric decontamination does not guarantee that all the
substance has been removed, so the child may still be in danger.(?<=[.!?])\s+(?=[A-Z0-9])Contraindications to gastric decontamination are:
– an unprotected airway in an unconscious child, except when the airway
has been protected by intubation with an infl ated tube by the anaesthetist
– ingestion of corrosives or petroleum products
Check the child for emergency signs (see p.(?<=[.!?])\s+(?=[A-Z0-9])2) and for hypoglycaemia; if blood
glucose is not available and the child has a reduced level of consciousness,
treat as if hypoglycaemia (p.(?<=[.!?])\s+(?=[A-Z0-9])16).
Identify the specifi c agent and remove or adsorb it as soon as possible.(?<=[.!?])\s+(?=[A-Z0-9])Treatment is most effective if given as quickly as possible after the poison-
ing event, ideally within 1 h.
•
If the child swallowed kerosene, petrol or petrol-based products (note that
most pesticides are in petrol-based solvents) or if the child’s mouth and
throat have been burnt (for example with bleach, toilet cleaner or battery
acid), do not make the child vomit but give water or, if available, milk, orally. | 51 | 91 | 1 | WHO-0001 | 1 | who_corpus.pdf | 332 |
Call an anaesthetist to assess the airway.
•
If the child has swallowed other poisons, never use salt as an emetic, as
this can be fatal.
Give activated charcoal, if available, and do not induce vomiting; give by
mouth or nasogastric tube at the doses shown in Table 5.(?<=[.!?])\s+(?=[A-Z0-9])If a nasogastric
tube is used, be particularly careful that the tube is in the stomach and not
in the airway or lungs. | 51 | 92 | 2 | WHO-0001 | 1 | who_corpus.pdf | 114 |
28
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Table 5.(?<=[.!?])\s+(?=[A-Z0-9])Poisoning: Amount of activated charcoal per dose
Children ≤ 1 year of age
1 g/kg
Children 1–12 years of age
25–50 g
Adolescents and adults
25–100 g
•
Mix the charcoal in 8–10 volumes of water, e.g.(?<=[.!?])\s+(?=[A-Z0-9])5 g in 40 ml of water.
•
If possible, give the whole amount at once; if the child has diffi culty in
tolerating it, the charcoal dose can be divided.
If charcoal is not available, then induce vomiting, but only if the child is
conscious, and give an emetic such as paediatric ipecacuanha (10 ml for
children aged 6 months to 2 years and 15 ml for those > 2 years).(?<=[.!?])\s+(?=[A-Z0-9])Note:
Ipecacuanha can cause repeated vomiting, drowsiness and lethargy, which
can confuse a diagnosis of poisoning.(?<=[.!?])\s+(?=[A-Z0-9])Never induce vomiting if a corrosive
or petroleum-based poison has been ingested.(?<=[.!?])\s+(?=[A-Z0-9])Gastric lavage
Undertake gastric lavage only if staff have experience in the procedure, if inges-
tion was less than 1 h previously and is life-threatening and if the child did not
ingest corrosives or petroleum derivatives. | 52 | 93 | 0 | WHO-0001 | 1 | who_corpus.pdf | 391 |
Make sure a suction apparatus is
available in case the child vomits.(?<=[.!?])\s+(?=[A-Z0-9])Place the child in the left lateral head-down
position.(?<=[.!?])\s+(?=[A-Z0-9])Measure the length of tube to be inserted.(?<=[.!?])\s+(?=[A-Z0-9])Pass a 24–28 French gauge
tube through the mouth into the stomach, as a smaller nasogastric tube is not
suffi cient to let particles such as tablets pass.(?<=[.!?])\s+(?=[A-Z0-9])Ensure the tube is in the stomach.(?<=[.!?])\s+(?=[A-Z0-9])Perform lavage with 10 ml/kg of normal saline (0.9%).(?<=[.!?])\s+(?=[A-Z0-9])The volume of lavage
fl uid returned should approximate the amount of fl uid given.(?<=[.!?])\s+(?=[A-Z0-9])Lavage should
be continued until the recovered lavage solution is clear of particulate matter. | 52 | 94 | 1 | WHO-0001 | 1 | who_corpus.pdf | 304 |
Lavage should
be continued until the recovered lavage solution is clear of particulate matter.(?<=[.!?])\s+(?=[A-Z0-9])Note that tracheal intubation by an anaesthetist may be required to reduce
the risk of aspiration.
Give a specifi c antidote if this is indicated.
Give general care.
Keep the child under observation for 4–24 h, depending on the poison
swallowed.
Keep unconscious children in the recovery position.
Consider transferring the child to next level referral hospital only when
appropriate and when this can be done safely, if the child is unconscious
or has a deteriorating level of consciousness, has burns to the mouth and
throat, is in severe respiratory distress, is cyanosed or is in heart failure.(?<=[.!?])\s+(?=[A-Z0-9])PRINCIPLES FOR INGESTED POISONS | 52 | 95 | 2 | WHO-0001 | 1 | who_corpus.pdf | 190 |
29
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
1.6.2
Principles for poisons in contact with skin or eyes
Skin contamination
Remove all clothing and personal effects, and thoroughly clean all exposed
areas with copious amounts of tepid water.(?<=[.!?])\s+(?=[A-Z0-9])Use soap and water for oily
substances.(?<=[.!?])\s+(?=[A-Z0-9])Attending staff should take care to protect themselves from
secondary contamination by wearing gloves and aprons.(?<=[.!?])\s+(?=[A-Z0-9])Removed clothing
and personal effects should be stored safely in a see-through plastic bag
that can be sealed, for later cleansing or disposal.(?<=[.!?])\s+(?=[A-Z0-9])Eye contamination
Rinse the eye for 10–15 min with clean running water or normal saline, tak-
ing care that the run-off does not enter the other eye if the child is lying on
the side, when it can run into the inner canthus and out the outer canthus.(?<=[.!?])\s+(?=[A-Z0-9])The use of anaesthetic eye drops will assist irrigation.(?<=[.!?])\s+(?=[A-Z0-9])Evert the eyelids
and ensure that all surfaces are rinsed. | 53 | 96 | 0 | WHO-0001 | 1 | who_corpus.pdf | 359 |
Evert the eyelids
and ensure that all surfaces are rinsed.(?<=[.!?])\s+(?=[A-Z0-9])When possible, the eye should be
thoroughly examined under fl uorescein staining for signs of corneal damage.(?<=[.!?])\s+(?=[A-Z0-9])If there is signifi cant conjunctival or corneal damage, the child should be
seen urgently by an ophthalmologist.(?<=[.!?])\s+(?=[A-Z0-9])1.6.3
Principles for inhaled poisons
Remove the child from the source of exposure.
Urgently call for help.
Administer supplementary oxygen if the child has respiratory distress, is
cyanosed or has oxygen saturation ≤ 90%.
Inhalation of irritant gases may cause swelling and upper airway obstruction,
bronchospasm and delayed pneumonitis.(?<=[.!?])\s+(?=[A-Z0-9])Intubation, bronchodilators and
ventilatory support may be required.(?<=[.!?])\s+(?=[A-Z0-9])1.6.4
Specifi c poisons
Corrosive compounds
Examples: sodium hydroxide, potassium hydroxide, acids, bleaches or disin-
fectants
Do not induce vomiting or use activated charcoal when corrosives have been
ingested, as this may cause further damage to the mouth, throat, airway,
lungs, oesophagus and stomach.
Give milk or water as soon as possible to dilute the corrosive agent.
Then give the child nothing by mouth and arrange for surgical review to
check for oesophageal damage or rupture, if severe. PRINCIPLES FOR POISONS IN CONTACT WITH SKIN OR EYES | 53 | 97 | 1 | WHO-0001 | 1 | who_corpus.pdf | 379 |
30
1.(?<=[.!?])\s+(?=[A-Z0-9])TRIAGE
Petroleum compounds
Examples: kerosene, turpentine substitutes, petrol
Do not induce vomiting or give activated charcoal, as inhalation can cause
respiratory distress with hypoxaemia due to pulmonary oedema and lipoid
pneumonia.(?<=[.!?])\s+(?=[A-Z0-9])Ingestion can cause encephalopathy.
Specifi c treatment includes oxygen therapy if there is respiratory distress
(see p.(?<=[.!?])\s+(?=[A-Z0-9])312).(?<=[.!?])\s+(?=[A-Z0-9])Organophosphorus and carbamate compounds
Examples: organophosphorus compounds (malathion, parathion, tetra ethyl
pyrophosphate, mevinphos (Phosdrin)); carbamates (methiocarb, carbaryl)
These compounds can be absorbed through the skin, ingested or inhaled.(?<=[.!?])\s+(?=[A-Z0-9])The child may complain of vomiting, diarrhoea, blurred vision or weakness.(?<=[.!?])\s+(?=[A-Z0-9])The signs are those of excess parasympathetic activation: excessive bronchial
secretion, salivation, sweating, lachrymation, slow pulse, small pupils, convul-
sions, muscle weakness or twitching, then paralysis and loss of bladder control,
pulmonary oedema and respiratory depression. | 54 | 98 | 0 | WHO-0001 | 1 | who_corpus.pdf | 353 |
Treatment
Remove the poison by irrigating eye if in eye or washing skin if on skin.
Give activated charcoal within 4 h of ingestion if ingested.
Do not induce vomiting because most pesticides are in petrol-based solvents.
In a serious case of ingestion, when activated charcoal cannot be given,
consider careful aspiration of stomach contents by nasogastric tube (the
airway should be protected).
If the child has signs of excess parasympathetic activation (see above), one
of the main risks is excessive bronchial secretion.(?<=[.!?])\s+(?=[A-Z0-9])Give atropine at 20 µg/
kg (maximum dose, 2000 µg or 2 mg) IM or IV every 5–10 min, depending
on the severity of the poisoning, until there is no sign of secretions in the
chest, the skin becomes fl ushed and dry, the pupils dilate and tachycardia
develops.(?<=[.!?])\s+(?=[A-Z0-9])Doses may be repeated every 1–4 h for at least 24 h to maintain
atropine effects.(?<=[.!?])\s+(?=[A-Z0-9])The main aim is to reduce bronchial secretions while avoid-
ing atropine toxicity.(?<=[.!?])\s+(?=[A-Z0-9])Auscultate the chest for signs of respiratory secretions,
and monitor respiratory rate, heart rate and coma score (if appropriate).
Check for hypoxaemia by pulse oximetry if atropine is given, as it can cause
heart irregularities (ventricular arrhythmia) in hypoxic children.(?<=[.!?])\s+(?=[A-Z0-9])Give oxygen
if the oxygen saturation is ≤ 90%
SPECIFIC POISONS | 54 | 99 | 1 | WHO-0001 | 1 | who_corpus.pdf | 389 |
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