Hospital care for children

POCKET BOOK
OF
Hospital care
for children
GUIDELINES FOR THE MANAGEMENT
OF COMMON ILLNESSES WITH
LIMITED RESOURCES

© World Health Organization 2005
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Designed by minimum graphics
Printed in China, Hong Kong Special Administrative Region
WHO Library Cataloguing-in-Publication Data
Pocket book of hospital care for children: guidelines for the management of
common illnesses with limited resources.
1.Pediatrics 2.Child care 3.Hospitals 4.Child, Hospitalized 5.Developing
countries 6.Practice guidelines 7.Manuals I.World Health Organization.
ISBN 92 4 154670 0 (NLM classification: WS 29)

iii
Contents
Acknowledgements xv
Foreword xvii
Abbreviations xix
Chart 1. Stages in the management of the sick child admitted to
hospital: summary of key elements xx
CHAPTER 1. TRIAGE AND EMERGENCY CONDITIONS 1
1.1 Summary of steps in emergency triage assessment and treatment 2
Triage of all sick children 4
Manage the choking infant 6
Manage the airway in a choking child 8
How to give oxygen 10
Position the unconscious child 11
Give IV fluids rapidly for shock in a child without
severe malnutrition 12
Give IV fluids for shock in a child with severe malnutrition 13
Give diazepam or paraldehyde rectally 14
Give IV glucose 15
Treat severe dehydration in an emergency setting 16
1.2 Notes for the assessment of emergency and priority signs 17
1.3 Notes for giving emergency treatment to the child with severe
malnutrition 18
1.4 Diagnostic considerations of children presenting with
emergency conditions 19
1.4.1 Child presenting with an airway or severe breathing
problem 19
1.4.2 Child presenting with shock 21
1.4.3 Child presenting with lethargy, unconsciousness or
convulsions 22
1.5 Common poisonings 25
1.5.1 Principles for ingested poisons 25

iv
HOSPITAL CARE FOR CHILDREN
1.5.2 Principles for poisons in contact with skin or eyes 27
1.5.3 Principles of inhaled poisons 28
1.5.4 Specific poisons 28
Corrosive compounds 28
Petroleum compounds 28
Organo-phosphorus and carbamate compounds 28
Paracetamol 29
Aspirin 30
Iron 30
Carbon monoxide 31
1.6 Snake bite 31
1.7 Scorpion sting 34
1.8 Other sources of envenoming 35
CHAPTER 2. DIAGNOSTIC APPROACH TO THE SICK CHILD 37
2.1 Relationship to the IMCI approach 37
2.2 Taking the history 37
2.3 Approach to the sick child and clinical examination 38
2.4 Laboratory investigations 39
2.5 Differential diagnoses 39
CHAPTER 3. PROBLEMS OF THE NEONATE AND YOUNG INFANT 41
3.1 Routine care of the newborn at delivery 42
3.2 Neonatal resuscitation 42
3.3 Routine care for all newborn babies after delivery 46
3.4 Prevention of neonatal infections 46
3.5 Management of the child with perinatal asphyxia 47
3.6 Danger signs in newborns and young infants 47
3.7 Serious bacterial infection 48
3.8 Meningitis 49
3.9 Supportive care for the sick neonate 51
3.9.1 Thermal environment 51
3.9.2 Fluid management 51

v
3.9.3 Oxygen therapy 52
3.9.4 High fever 53
3.10 Babies with low birth weight 53
3.10.1 Babies with birth weight between 2.25 and 2.5 kg 53
3.10.2 Babies with birth weight between 1.75 and 2.25 kg 53
3.10.3 Babies with birth weight below 1.75 kg 54
3.11 Necrotizing enterocolitis 56
3.12 Other common neonatal problems 57
3.12.1 Jaundice 57
3.12.2 Conjunctivitis 59
3.12.3 Congenital malformations 60
3.13 Babies of mothers with infections 60
3.13.1 Congenital syphilis 60
3.13.2 Baby of a mother with tuberculosis 61
3.13.3 Baby of a mother with HIV 61
Drug doses of common drugs for neonates and LBW babies 62
CHAPTER 4. COUGH OR DIFFICULT BREATHING 69
4.1 Child presenting with cough 69
4.2 Pneumonia 72
4.2.1 Very severe pneumonia 73
4.2.2 Severe pneumonia 78
4.2.3 Pneumonia (non-severe) 80
4.2.4 Pleural effusion and empyema 81
4.3 Cough or cold 82
4.4 Conditions presenting with wheeze 83
4.4.1 Bronchiolitis 85
4.4.2 Asthma 87
4.4.3 Wheeze with cough or cold 91
4.5 Conditions presenting with stridor 91
4.5.1 Viral croup 92
4.5.2 Diphtheria 94
CONTENTS

vi
4.6 Conditions presenting with chronic cough 96
4.7 Pertussis 98
4.8 Tuberculosis 101
4.9 Foreign body inhalation 104
4.10 Heart failure 106
CHAPTER 5. DIARRHOEA 109
5.1 Child presenting with diarrhoea 110
5.2 Acute diarrhoea 111
5.2.1 Severe dehydration 112
5.2.2 Some dehydration 115
5.2.3 No dehydration 119
5.3 Persistent diarrhoea 122
5.3.1 Severe persistent diarrhoea 122
5.3.2 Persistent diarrhoea (non-severe) 126
5.4 Dysentery 127
CHAPTER 6. FEVER 133
6.1 Child presenting with fever 133
6.1.1 Fever lasting longer than 7 days 136
6.2 Malaria 139
6.2.1 Severe malaria 139
6.2.2 Malaria (non-severe) 145
6.3 Meningitis 148
6.4 Measles 154
6.4.1 Severe complicated measles 154
6.4.2 Measles (non-severe) 157
6.5 Septicaemia 158
6.6 Typhoid fever 159
6.7 Ear infections 161
6.7.1 Mastoiditis 161
6.7.2 Acute otitis media 162
6.7.3 Chronic otitis media 163

vii
6.8 Urinary tract infection 163
6.9 Septic arthritis or osteomyelitis 165
6.10 Dengue 166
6.10.1 Severe dengue 167
CHAPTER 7. SEVERE MALNUTRITION 173
7.1 Diagnosis 174
7.2 Initial assessment of the severely malnourished child 174
7.3 Organization of care 176
7.4 General treatment 176
7.4.1 Hypoglycaemia 177
7.4.2 Hypothermia 178
7.4.3 Dehydration 179
7.4.4 Electrolyte imbalance 181
7.4.5 Infection 182
7.4.6 Micronutrient deficiencies 183
7.4.7 Initial refeeding 184
7.4.8 Catch-up growth 188
7.4.9 Sensory stimulation 189
7.4.10 Malnutrition in infants <6 months 190
7.5 Treatment of associated conditions 190
7.5.1 Eye problems 190
7.5.2 Severe anaemia 191
7.5.3 Skin lesions in kwashiorkor 191
7.5.4 Continuing diarrhoea 192
7.5.5 Tuberculosis 192
7.6 Discharge and follow-up 192
7.7 Monitoring the quality of care 194
7.7.1 Mortality audit 194
7.7.2 Weight gain during rehabilitation phase 195
CONTENTS

viii
CHAPTER 8. CHILDREN WITH HIV/AIDS 199
8.1 Sick child with suspected or confirmed HIV infection 200
8.1.1 Clinical diagnosis 200
8.1.2 Counselling 201
8.1.3 Testing and diagnosis of HIV infection in children 203
8.1.4 Clinical staging 204
8.2 Antiretroviral therapy (ART) 207
8.2.1 Antiretroviral drugs 207
8.2.2 When to start antiretroviral therapy 209
8.2.3 Side-effects of antiretroviral therapy and monitoring 210
8.2.4 When to change treatment 213
8.3 Other treatment for the HIV-positive child 214
8.3.1 Immunization 214
8.3.2 Cotrimoxazole prophylaxis 214
8.3.3 Nutrition 216
8.4 Management of HIV-related conditions 216
8.4.1 Tuberculosis 216
8.4.2 Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) 217
8.4.3 Lymphoid interstitial pneumonitis (LIP) 217
8.4.4 Fungal infections 218
8.4.5 Kaposi sarcoma 219
8.5 Perinatal HIV transmission and breastfeeding 219
8.6 Follow-up 220
8.7 Palliative and end-of-life care 221
CHAPTER 9. COMMON SURGICAL PROBLEMS 227
9.1 Care before, during and after surgery 227
9.1.1 Preoperative care 228
9.1.2 Intraoperative care 229
9.1.3 Postoperative care 232
9.2 Newborn and neonatal problems 234
9.2.1 Cleft lip and palate 234

ix
9.2.2 Bowel obstruction in the newborn 235
9.2.3 Abdominal wall defects 236
9.2.4 Myelomeningocele 237
9.2.5 Congenital dislocation of the hip 237
9.2.6 Talipes equino-varus (club foot) 238
9.3 Injuries 239
9.3.1 Burns 239
9.3.2 Principles of wound care 243
9.3.3 Fractures 245
9.3.4 Head injuries 249
9.3.5 Chest and abdominal injuries 250
9.4 Abdominal problems 250
9.4.1 Abdominal pain 250
9.4.2 Appendicitis 251
9.4.3 Bowel obstruction beyond the newborn period 252
9.4.4 Intussusception 253
9.4.5 Umbilical hernia 254
9.4.6 Inguinal hernia 254
9.4.7 Incarcerated hernias 255
9.4.8 Rectal prolapse 255
9.5 Infections requiring surgery 256
9.5.1 Abscess 256
9.5.2 Osteomyelitis 256
9.5.3 Septic arthritis 258
9.5.4 Pyomyositis 258
CHAPTER 10. SUPPORTIVE CARE 261
10.1 Nutritional management 261
10.1.1 Supporting breastfeeding 262
10.1.2 Nutritional management of sick children 267
10.2 Fluid management 273
10.3 Management of fever 274
CONTENTS

x
10.4 Pain control 275
10.5 Management of anaemia 276
10.6 Blood transfusion 277
10.6.1 Storage of blood 277
10.6.2 Problems with blood transfusion 277
10.6.3 Indications for blood transfusion 277
10.6.4 Giving a blood transfusion 278
10.6.5 Transfusion reactions 279
10.7 Oxygen therapy 281
10.8 Toys and play therapy 285
CHAPTER 11. MONITORING THE CHILD’S PROGRESS 289
11.1 Monitoring procedures 289
11.2 Monitoring chart 290
11.3 Audit of paediatric care 290
CHAPTER 12. COUNSELLING AND DISCHARGE FROM HOSPITAL 293
12.1 Timing of discharge from hospital 293
12.2 Counselling 294
12.3 Nutrition counselling 295
12.4 Home treatment 296
12.5 Checking the mother’s own health 296
12.6 Checking immunization status 297
12.7 Communicating with the first-level health worker 298
12.8 Providing follow-up care 298
FURTHER READING 301
APPENDICES
Appendix 1. Practical procedures 303
A1.1 Giving injections 305
A1.1.1 Intramuscular 305
A1.1.2 Subcutaneous 306
A1.1.3 Intradermal 306

xi
A1.2 Procedures for giving parenteral fluids 308
A1.2.1 Insertion of an indwelling IV cannula
in a peripheral vein 308
A1.2.2 Intraosseous infusion 310
A1.2.3 Central vein cannulation 312
A1.2.4 Venous cut-down 313
A1.2.5 Umbilical vein catheterization 314
A1.3 Insertion of a nasogastric tube 315
A1.4 Lumbar puncture 316
A1.5 Insertion of a chest drain 318
A1.6 Supra-pubic aspiration 320
A1.7 Measuring blood glucose 321
Appendix 2. Drug dosages/regimens 325
Appendix 3. Equipment size for children 355
Appendix 4. Intravenous fluids 357
Appendix 5. Assessing nutritional status 359
Appendix 6. Job aids and charts 369
INDEX 371
CHARTS
Chart 1. Stages in the management of the sick child admitted to
hospital: summary of key elements xx
Chart 2. Triage of all sick children 4
Chart 3. How to manage the choking infant 6
Chart 4. How to manage the airway in a child with obstructed
breathing (or who has just stopped breathing) where no
neck trauma is suspected 8
Chart 5. How to give oxygen 10
Chart 6. How to position the unconscious child 11
Chart 7. How to give IV fluids rapidly for shock in a child without
Chart 8. How to give IV fluids for shock in a child with severe
malnutrition 13
Chart 9. How to give diazepam (or paraldehyde) rectally 14
CONTENTS

xii
Chart 10. How to give IV glucose 15
Chart 11. How to treat severe dehydration in an emergency setting after
initial management of shock 16
Chart 12. Neonatal resuscitation 43
Chart 13. Diarrhoea Treatment Plan C: Treat severe dehydration quickly 114
Chart 14. Diarrhoea Treatment Plan B: Treat some dehydration with ORS 117
Chart 15. Diarrhoea Treatment Plan A: Treat diarrhoea at home 120
Chart 16. Feeding recommendations during sickness and health 271
TABLES
Table 1. Differential diagnosis of the child presenting with an airway
or severe breathing problem 20
Table 2. Differential diagnosis of the child presenting with shock 20
Table 3. Differential diagnosis of the child presenting with lethargy,
unconsciousness or convulsions 23
Table 4. Differential diagnosis of the young infant (less than 2 months)
presenting with lethargy, unconsciousness or convulsions 24
Table 5. Poisoning: Amount of activated charcoal per dose 26
Table 6. Differential diagnosis of the child presenting with cough
or difficult breathing 71
Table 7. Classification of the severity of pneumonia 72
Table 8. Differential diagnosis of the child presenting with wheeze 84
Table 9. Differential diagnosis of the child presenting with stridor 92
Table 10. Differential diagnosis of the child presenting with
chronic cough 97
Table 11. Differential diagnosis of the child presenting with diarrhoea 111
Table 12. Classification of the severity of dehydration in children
with diarrhoea 111
Table 13. Administration of IV fluid to a severely dehydrated child 113
Table 14. Diet for persistent diarrhoea, first diet: A starch-based,
reduced milk concentration (low lactose) diet 124
Table 15. Diet for persistent diarrhoea, second diet: A no-milk
(lactose-free) diet with reduced cereal (starch) 125
Table 16. Differential diagnosis of fever without localizing signs 134

xiii
CONTENTS
Table 17. Differential diagnosis of fever with localized signs 135
Table 18. Differential diagnosis of fever with rash 136
Table 19. Additional differential diagnosis of fever lasting longer
than 7 days 138
Table 20. Time frame for the management of the child with
Table 21. Volumes of F-75 per feed for feeding malnourished children 185
Table 22. The WHO paediatric clinical staging system for HIV 205
Table 23. Classes of antiretroviral drugs recommend for use in
children in resource poor settings 208
Table 24. Possible first-line treatment regimens for children with HIV 208
Table 25. Summary of indications for initiating ART in children,
based on clinical staging 211
Table 26. Common side-effects of antiretroviral drugs 212
Table 27. Clinical and CD4 definition of ARV treatment failure in
children (after 6 months or more of ARV) 213
Table 28. Endotracheal tube size, by age 230
Table 29. Blood volume of children by age 232
Table 30. Normal pulse rate and blood pressure in children 232
Table 31. Examples of local adaptations of feeding recommendations
in the mother’s card from Bolivia, Indonesia, Nepal,
South Africa and Tanzania 272
Table 32. Maintenance fluid requirements 273
Table 33. Immunization schedule for infants recommended by the
Expanded Programme on Immunization 297
Table 34. Weight-for-age chart for children 359
Table 35. WHO/NCHS normalized reference weight-for-length
(49–84 cm) and weight-for-height (85–110 cm), by sex 365

Acknowledgements
This pocket book is the result of an international effort coordinated by the
World Health Organization’s Department of Child and Adolescent Health and
Development.
A special debt of gratitude is owed to Dr Harry Campbell, University of
Edinburgh, Scotland for the overall coordination of the preparation of the
chapters of the document and significant contributions to individual chapters.
WHO would like to thank the following for their preparation of and contributions
to the chapters:
Dr Ann Ashworth (UK); Dr. Stephen Bickler (USA); Dr Jacqueline Deen
(Philippines), Dr Trevor Duke (PNG/Australia); Dr Greg Hussey (South
Africa); Dr Michael English (Kenya); Dr Stephen Graham (Malawi);
Dr Elizabeth Molyneux (Malawi); Dr Nathaniel Pierce (USA); Dr Haroon
Saloojee (South Africa); Dr Barbara Stoll (USA); Dr Giorgio Tamburlini
(Italy); Dr Bridget Wills (Vietnam); and Fabienne Jäger (Switzerland) for
assistance in the review and revision process.
WHO is grateful to the following for reviewing the manuscript at different stages:
L. Adonis-Koffy, Côte d’Ivoire; E. Agyei-Yobo, Ghana; M. Agyemang, Ghana;
R. Ahmed, Maldives; E. Akrofi-Mantey, Ghana; H., Almaraz Monzon; A.
Amanor, Ghana; E. Aranda, Bolivia; W. , Asamoah, Ghana; C. Assamoi Bodjo,
Côte d’Ivoire; A. Bartos, Bolivia; Z. Bhutta, Pakistan; U. Bodhankar, India;
L. Bramante, Italy; L. Bravo, Philippines; D. Brewster, Vanuatu; J. Bunn,
UK; K. Bylsma, Ghana; C. Casanovas, Bolivia; N. Chintu, Zambia; B. Coulter,
UK; S. Cywes, South Africa; A. da Cunha, Brazil; S.-C. Daka, Cambodia;
A. Deorari, India; G.F. Ding, China; V. Doku, Ghana; P. Enarson, France;
J. Erskine, Gambia; F.A. Eshgh, Iran; A. Falade, Nigeria; J. Farrar, Vietnam,
C. Frago, Philippines; M. Funk, Ghana; S. C. Galina, Russia; E. Gallardo,
Philippines; R. Gie, South Africa; A. Grange, Nigeria; A. Hansmann,
Germany; H. Hartmann, Germany; S. Heinrich, Cambodia; E.M. Hubo,
Philippines; R. Ismail, Indonesia; P. Jeena, South Africa; A. Jhukral, India;
S. Junge, Switzerland; V. Kapoor, India; M. Kazemian, Iran; N. Kesaree,
India; E. Keshishian, Russia; H. T. Kim, Vietnam; E. Kissi Owusu, Ghana;
A. Klufio, Ghana; J. Kouawo, Côte d’Ivoire; M. Krawinkel, Germany;
B. Kretschmer, Germany; C. Krueger, Germany; A. Krug, South Africa;
M. Langaroodi; J. Lawn, UK; J. Lim, Philippines; W. Loening, South Africa;
M.P. Loscertales, Spain; C. Maclennan, Australia; A. Madkour, Egypt;
xv

xvi
I. Mahama, Ghana; D. Malchinkhuu, Mongolia; N. Manjavidze, Georgia;
P. Mazmanyan, Armenia; D. Mei, China; A. Mekasha, Ethiopia; C.A. Melean
Gumiel, Bolivia; C. Meng, Cambodia; W. Min, China; H. Mozafari, Iran;
K. Mulholland, Australia; A. Narang, India; S. Nariman, Iran; K.J. Nathoo,
Zimbabwe; K. Nel, South Africa; S. K. Newton, Ghana; K. Olness, USA;
K. Pagava, Georgia; V. Paul, India; I. Rahman, Sudan; M. Rakha, Egypt;
S.E. Razmikovna, Russia; R. Rios, Chile; H. Rode, South Africa; E. Rodgers,
Fiji; I. Ryumina, Russia; I. Sagoe-Moses, Ghana; G. Sall, Senegal;
L. C. Sambath, Cambodia; W. Sangu, Tanzania; J. Schmitz, France; F. Shann,
Australia; P. Sharma, Nepal; M. Shebbe, Kenya; L. Sher, South Africa;
N. Singhal, Canada; D. Southall, UK; J.-W. Sun, China; G. Swingler, South
Africa; T.T. Tam, Vietnam; E. Tanoh; M. Taylor, Ghana; E. Teye Adjase, Ghana;
I. Thawe, Malawi; M. Timite-Konan, Côte d’Ivoire; P. Torzillo, Australia;
R. Turki, Tunisia; F. Uxa, Italy; D.-H. Wang, China; D. Woods, South Africa;
B.J. Wudil, Nigeria; A.J. Yao, Côte d’Ivoire.
Valuable inputs were provided by the WHO Clusters of Communicable Diseases
and of Non Communicable Diseases, and WHO Departments of Disability/Injury
Prevention and Rehabilitation, Essential Drugs and Medicines Policy, Essential
Health Technology, HIV/AIDS, Nutrition for Health and Development, Protection
of the Human Environment, Reproductive Health and Research, Roll Back
Malaria, Stop Tuberculosis, and Vaccines and Biologicals and by WHO Regional
Offices.
WHO wishes to thank the following organizations who contributed to the
production of the pocket book:
Australian Agency for International Development (AusAID); Institute for
Child Health IRCCS “Burlo Garofolo”, Trieste, Italy; and the International
Paediatric Association.

xvii
Foreword
This pocket book is for use by doctors, senior nurses and other senior health
workers who are responsible for the care of young children at the first referral
level in developing countries. It presents up-to-date clinical guidelines which
are based on a review of the available published evidence by subject experts,
for both inpatient and outpatient care in small hospitals where basic laboratory
facilities and essential drugs and inexpensive medicines are available. In some
settings, these guidelines can be used in the larger health centres where a
small number of sick children can be admitted for inpatient care.
The guidelines require the hospital to have (1) the capacity to carry out certain
essential investigations—such as blood smear examinations for malaria
parasites, estimations of haemoglobin or packed cell volume, blood glucose,
blood grouping and cross-matching, basic microscopy of CSF and urine,
bilirubin determination for neonates, chest radiography and pulse oximetry—
and (2) essential drugs available for the care of seriously ill children. Expensive
treatment options, such as new antibiotics or mechanical ventilation, are not
described.
These guidelines focus on the inpatient management of the major causes of
childhood mortality, such as pneumonia, diarrhoea, severe malnutrition,
malaria, meningitis, measles, and related conditions. They contain guidance
on the management of children with HIV infection, neonates with problems,
and of the surgical management of children. Details of the principles underlying
the guidelines can be found in technical review papers published by WHO. A
companion background book has also been published by WHO which gives
details of burden of disease, pathophysiology and technical basis underlying
the guidelines for use by medical/nursing students or as part of inservice
training of health workers. The evidence-base underlying these recommen-
dations is published on the WHO website as well. (See Further Reading, page
301.)
This pocket book is part of a series of documents and tools that support the
Integrated Management of Childhood Illness (IMCI) and is consistent with the
IMCI guidelines for outpatient management of sick children. It is presented in
a format that could be carried by doctors, nurses and other health workers
during their daily work and so be available to help guide the management of
sick children. Standard textbooks of paediatrics should be consulted for rarer
conditions not covered in the pocketbook. These guidelines are applicable in

xviii
most areas of the world and may be adapted by countries to suit their specific
circumstances. Blank pages have been left at the end of each chapter to allow
individual readers to include their own notes—for example, on locally important
conditions not covered in this pocket book.
WHO believes that their widespread adoption would improve the care of children
in hospital and lead to lower case fatality rates.

xix
Abbreviations
AIDS acquired
immunodeficiency
syndrome
AVPU simple consciousness
scale (alert, responding
to voice, responding to
pain, unconscious)
BP blood pressure
CMV cytomegalovirus
CSF cerebrospinal fluid
DHF dengue haemorrhagic
fever
DPT diphtheria, pertussis,
tetanus
DSS dengue shock syndrome
EPI expanded programme of
immunization
FG French gauge
G6PD glucose 6-phosphate
dehydrogenase
HIV human
immunodeficiency virus
HUS haemolytic uraemic
syndrome
IM intramuscular injection
IMCI Integrated Management
of Childhood Illness
IV intravenous injection
JVP jugular venous pressure
LIP lymphoid interstitial
pneumonitis
LP lumbar puncture
NG nasogastric
OPV oral polio vaccine
ORS oral rehydration salts
ORT oral rehydration therapy
PCP Pneumocystis carinii
pneumonia
PCV packed cell volume
PPD purified protein derivative
(used in a test for
tuberculosis)
ReSoMal rehydration solution for
malnutrition
RDA recommended daily
allowance
SD standard deviation
SP sulfadoxine-
pyrimethamine
STI sexually transmitted
infection
TB tuberculosis
TMP trimethoprim
TPHA treponema pallidum
haemogglutination
SMX sulfamethoxazole
UTI urinary tract infection
VDRL veneral disease research
laboratories
WBC white blood cell count
WHO World Health
Organization
°C degrees Celsius
°F degrees Fahrenheit
■ diagnostic sign or symptom
➤ treatment recommendation

➝
➝
➝➝➝
➝
➝
CHART 1. Stages in the management of the sick child
admitted to hospital: summary of key elements
TRIAGE
● Check for emergency signs give EMERGENCY TREATMENT
until stable
(absent)
● Check for priority signs or conditions
HISTORY AND EXAMINATION
(including assessment of immunization status, nutritional status and feeding)
● Check children with emergency and priority conditions first
LABORATORY AND OTHER INVESTIGATIONS, if required
List and consider DIFFERENTIAL DIAGNOSES
Select MAIN DIAGNOSIS (and secondary diagnoses)
Plan and begin INPATIENT TREATMENT Plan and begin
(including supportive care) OUTPATIENT TREATMENT
MONITOR for signs of Arrange FOLLOW-UP,
— improvement if required
— complications
— failure of treatment
(not improving or new problem) (improving)
REASSESS Continue treatment
for causes of failure of treatment PLAN DISCHARGE
RECONSIDER DIAGNOSIS
DISCHARGE HOME
REVISE Arrange continuing care or
TREATMENT FOLLOW-UP at hospital or
in community
➞
(present)
➞
➝
➝
➝
➝
➝
xx

1
1.ETAT
CHAPTER 1
Triage and emergency
conditions
1.1 Summary of steps in
emergency triage assess-
ment and treatment 2
Triage of all sick children 4
Manage the choking infant 6
Manage the airway in a
choking child 8
How to give oxygen 10
Position the unconscious
child 11
Give IV fluids rapidly for
shock in a child without
Give IV fluids for shock
in a child with severe
malnutrition 13
Give diazepam or
paraldehyde rectally 14
Give IV glucose 15
Treat severe dehydration
in an emergency setting 16
1.2 Notes for the assessment
of emergency and priority
signs 17
1.3 Notes for giving emergency
treatment to the child with
1.4 Diagnostic considerations
of children presenting with
emergency conditions 19
1.4.1 Child presenting with
an airway or severe
breathing problem 19
shock 21
lethargy, unconscious-
ness or convulsions 22
1.5 Common poisoning 25
1.5.1 Principles for
ingested poisons 25
1.5.2 Principles for poisons
in contact with skin
or eyes 27
1.5.3 Principles of inhaled
poisons 28
1.5.4 Specific poisons 28
Corrosive
compounds 28
Petroleum
compounds 28
Organo-phosphorus
and carbamate
compounds 28
Paracetamol 29
Aspirin 30
Iron 30
Carbon monoxide 31
1.6 Snake bite 31
1.7 Scorpion sting 34
1.8 Other sources of
envenoming 35

2
1.ETAT
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 while waiting in
the queue so that they can be assessed and treated without delay;
— non-urgent cases, who have neither emergency nor priority signs.
Emergency signs include:
■ obstructed breathing
■ severe respiratory distress
■ central cyanosis
■ signs of shock (cold hands; capillary refill longer than 3 seconds; weak,
fast pulse)
■ coma
■ convulsions
■ signs of severe dehydration in a child with diarrhoea (lethargy, sunken eyes,
very slow return after pinching the skin—any two of these).
Children with emergency signs require immediate treatment to avert death.
The priority signs (see below, page 5) identify children who are at higher risk
of dying. These children should be assessed without unnecessary delay.
1.1 Summary of steps in emergency triage
assessment and treatment
The process of emergency triage assessment and treatment is summarized in
the Charts on pages 4–16.
First, check for emergency signs.
Check for emergency signs in two steps:
• Step 1. If there is any airway or breathing problem, start immediate treatment
to restore breathing.
• Step 2. Quickly determine if the child is in shock or unconscious or
convulsing, or has diarrhoea with severe dehydration.
If emergency signs are found:
• Call an experienced health professional to help if available, but do not delay
starting the treatment. Stay calm and work with other health workers who
SUMMARY OF STEPS IN EMERGENCY TRIAGE ASSESSMENT AND TREATMENT

3
1.ETAT
may be required to give the treatment, because a very sick child may need
several treatments at once. The most experienced health professional should
continue assessing the child (see Chapter 2, page 37), to identify all
underlying problems and develop a treatment plan.
• Carry out emergency investigations (blood glucose, blood smear, haemo-
globin). Send blood for typing and cross-matching if the child is in shock,
or appears to be severely anaemic, or is bleeding significantly.
• After giving emergency treatment, proceed immediately to assessing,
diagnosing and treating the underlying problem.
Tables of common differential diagnoses for emergency signs are provided
from page 20 onwards.
If no emergency signs are found, check for priority signs:
■ Tiny baby: any sick child aged under 2 months
■ Temperature: child is very hot
■ Trauma or other urgent surgical condition
■ Pallor (severe)
■ Poisoning
■ Pain (severe)
■ Respiratory distress
■ Restless, continuously irritable, or lethargic
■ Referral (urgent)
■ Malnutrition: visible severe wasting
■ Oedema of both feet
■ Burns (major)
The above can be remembered with the help of “3TPR MOB”.
These children need prompt assessment (no waiting in the queue) to determine
what further treatment is needed. Move the child with any priority sign to the
front of the queue to be assessed next. If a child has trauma or other surgical
problems, get surgical help where available.
SUMMARY OF STEPS IN EMERGENCY TRIAGE ASSESSMENT AND TREATMENT

4
1.ETAT
CHART 2. Triage of all sick children
EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for
emergency laboratory investigations (glucose, malaria smear, Hb)
ASSESS TREAT
Do not move neck if cervical
spine injury possible
If foreign body aspiration
➤ Manage airway in choking
child (Chart 3)
If no foreign body aspiration
➤ Manage airway (Chart 4)
➤ Give oxygen (Chart 5)
➤ Make sure child is warm
➤ Stop any bleeding
➤ Give oxygen (Chart 5)
➤ Make sure child is warm
If no severe malnutrition:
➤ Insert IV and begin giving
fluids rapidly (Chart 7)
If not able to insert
peripheral IV, insert an
intraosseous or external
jugular line
(see pages 310, 312)
If severe malnutrition:
If lethargic or unconscious:
➤ Give IV glucose (Chart 10)
➤ Insert IV line and give
fluids (Chart 8)
If not lethargic or
unconscious:
➤ Give glucose orally or by
NG tube
➤ Proceed immediately to full
assessment and treatment
ANY SIGN
POSITIVE
ANY SIGN
POSITIVE
Check for
severe
malnutrition
Airway and
breathing
■ Obstructed breathing,
or
■ Central cyanosis,
or
■ Severe respiratory distress
Circulation
Cold hands with:
■ Capillary refill
longer than
3 seconds,
and
■ Weak and fast pulse

5
1.ETAT
CHART 2. Triage of all sick children (continued)
TREAT
Do not move neck if cervical
spine injury possible
➤ Manage airway (Chart 3)
➤ If convulsing, give diazepam or
paraldehyde rectally (Chart 9)
➤ Position the unconscious child (if
head or neck trauma is suspected,
stabilize the neck first) (Chart 6)
➤ Give IV glucose (Chart 10)
➤ Make sure child is warm.
If no severe malnutrition:
➤ Insert IV line and begin giving fluids
rapidly following Chart 11 and
Diarrhoea Treatment Plan C in
hospital (Chart 13, page 114)
If severe malnutrition:
➤ Do not insert IV
➤ Proceed immediately to full
assessment and treatment (see
section 1.3, page 18)
PRIORITY SIGNS
These children need prompt assessment and treatment
EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for
emergency laboratory investigations (glucose, malaria smear, Hb)
ASSESS
Coma/convulsing
■ Coma
or
■ Convulsing (now)
Severe
dehydration
(only in child
with diarrhoea)
Diarrhoea plus
any two of these:
■ Lethargy
■ Sunken eyes
■ Very slow skin
pinch
IF COMA OR
CONVULSING
DIARRHOEA
plus
TWO SIGNS
POSITIVE
Check for
severe
malnutrition
NON-URGENT
Proceed with assessment and further treatment according to
the child’s priority
■ Tiny baby (<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
■ Burns (major)
Note: If a child has trauma or other
surgical problems, get surgical help
or follow surgical guidelines

6
1.ETAT
CHART 3. How to manage the choking infant
➤ Lay the infant on
your arm or thigh in
a head down
position
➤ Give 5 blows to the
infant’s back with
heel of hand
➤ If obstruction
persists, turn infant
over and give
5 chest thrusts with
2 fingers, one finger
breadth below nipple
level in midline
(see diagram)
➤ If obstruction
persists, check
infant’s mouth for
any obstruction
which can be
removed
➤ If necessary, repeat
sequence with back
slaps again
Back slaps
Chest thrusts

7
1.ETAT
➤ Give 5 blows to the child’s back
with heel of hand with child sitting,
kneeling or lying
➤ If the obstruction persists, go
behind the child and pass your
arms around the child’s body;
form a fist with one hand
immediately below the child’s
sternum; place the other hand over
the fist and pull upwards into the
abdomen (see diagram); repeat
this Heimlich manoeuvre 5 times
➤ If the obstruction persists, check
the child’s mouth for any
obstruction which can be removed
➤ If necessary, repeat this sequence
with back slaps again
CHART 3. How to manage the choking child
(over 1 year of age)
Heimlich manoeuvre in
a choking older child
Slapping the back to clear airway
obstruction in a choking child

8
1.ETAT
CHART 4. How to manage the airway in a child
with obstructed breathing (or who has just stopped
breathing) where no neck trauma is suspected
Child conscious
1. Inspect mouth and
remove foreign
body, if present
2. Clear secretions
from throat
3. Let child assume
position of maximal
comfort
Child unconscious
1. Tilt the head as
shown
2. Inspect mouth and
remove foreign
body, if present
3. Clear secretions
from throat
4. Check the airway by
looking for chest
movements,
listening for breath
sounds and feeling
for breath
■ OLDER CHILD
■ INFANT
Neutral position to open the airway
in an infant
Look, listen and feel for breathing
Sniffing position to open the airway
in an older child

9
1.ETAT
CHART 4. How to manage the airway in a child
with obstructed breathing (or who has just stopped
breathing) where neck trauma or possible cervical
spine injury is suspected
1. Stabilize the neck, as shown in Chart 6
2. Inspect mouth and remove foreign body, if present
3. Clear secretions from throat
4. Check the airway by looking for chest movements, listening for breath
sounds, and feeling for breath
Use jaw thrust without head tilt. Place the 4th and 5th finger 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
If the child is still not breathing after
carrying out the above, ventilate with
bag and mask

10
1.ETAT
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 FG size tube
➤ Measure the distance from
the side of the nostril to
the inner eyebrow margin
with the catheter
➤ Insert the catheter to
this depth
➤ Secure with tape
Start oxygen flow at
1–2 litres/minute
(see pages 281–284)
CHART 5. How to give oxygen

11
1.ETAT
CHART 6. How to position the unconscious child
■ 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
■ 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 firm board
to secure this position
➤ Prevent the neck from
moving by supporting the
child’s head (e.g. using
litre bags of IV fluid on
each side)
➤ If vomiting, turn on
the side, keeping
the head in line
with the body.

12
1.ETAT
CHART 7. How to give IV fluids rapidly for shock in a child
without severe malnutrition
➤ If the child is severely malnourished the fluid volume and rate are
different, so check that the child is not severely malnourished
Shock in child without severe malnutrition—Chart 7
Shock in child with severe malnutrition—Chart 8 (and section 1.3,
page 18)
➤ Insert an intravenous 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.
Volume of Ringer's lactate
or normal saline solution
Age/weight (20 ml/kg)
2 months (<4 kg) 75 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 child after appropriate volume has run in
Reassess after first infusion: If no improvement, repeat 20 ml/kg as
rapidly as possible.
Reassess after second infusion: If no improvement, repeat 20 ml/kg as
rapidly as possible.
Reassess after third infusion: If no improvement, give blood 20 ml/kg
over 30 minutes (if shock is not caused
by profuse diarrhoea, in this case repeat
Ringer’s lactate or normal saline).
Reassess after fourth infusion: If no improvement, see disease-specific
treatment guidelines. You should have
established a provisional diagnosis by
now.
After improvement at any stage (pulse slows, faster capillary refill), go to
Chart 11, page 16.

13
1.ETAT
CHART 8. How to give IV fluids for shock in a child
with severe malnutrition
Give this treatment only if the child has signs of shock and is lethargic or has lost
consciousness:
➤ Insert an IV line (and draw blood for emergency laboratory investigations)
➤ Weigh the child (or estimate the weight) to calculate the volume of fluid to be
given
➤ Give IV fluid 15 ml/kg over 1 hour. Use one of the following solutions (in order of
preference), according to availability:
— Ringer's lactate with 5% glucose (dextrose); or
— half-normal saline with 5% glucose (dextrose); or
— half-strength Darrow’s solution with 5% glucose (dextrose); or, if these are
unavailable,
— Ringer's lactate.
Weight Volume IV fluid Weight Volume IV fluid
Give over 1 hour (15 ml/kg) Give over 1 hour (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 and breathing rate at the start and every 5–10 minutes.
If there are signs of improvement (pulse and respiratory rates fall):
— give repeat IV 15 ml/kg over 1 hour; then
— switch to oral or nasogastric rehydration with ReSoMal (see page 179),
10 ml/kg/h up to 10 hours;
— initiate refeeding with starter F-75 (see page 184).
If the child fails to improve after the first 15ml/kg IV, assume the child has septic
shock:
— give maintenance IV fluid (4 ml/kg/h) while waiting for blood;
— when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over
3 hours (use packed cells if in cardiac failure); then
— initiate refeeding with starter F-75 (see page 184);
— start antibiotic treatment (see page 182).
If the child deteriorates during the IV rehydration (breathing increases by
5 breaths/min or pulse by 15 beats/min), stop the infusion because IV fluid can
worsen the child’s condition.

14
1.ETAT
CHART 9. How to give diazepam (or paraldehyde) rectally
■ Give diazepam rectally:
➤ Draw up the dose from an ampoule of diazepam into a tuberculin (1
ml) syringe. Base the dose on the weight of the child, where possible.
Then remove the needle.
➤ Insert the syringe into the rectum 4 to 5 cm and inject the diazepam
solution.
➤ Hold buttocks together for a few minutes.
Diazepam given rectally Paraldehyde given
10 mg/2ml solution rectally
Age/weight Dose 0.1ml/kg Dose 0.3–0.4 ml/kg
2 weeks to 2 months (<4 kg)* 0.3 ml (1.5 mg) 1.0 ml
2–<4 months (4–<6 kg) 0.5 ml (2.5 mg) 1.6 ml
4–<12 months (6–<10 kg) 1.0 ml (5 mg) 2.4 ml
1–<3 years (10–<14 kg) 1.25 ml (6.25 mg) 4 ml
3–<5 years (14–19 kg) 1.5 ml (7.5 mg) 5 ml
If convulsion continues after 10 minutes, give a second dose of
diazepam rectally (or give diazepam intravenously (0.05 ml/kg =
0.25 mg/kg) if IV infusion is running).
If convulsion continues after another 10 minutes, give a third dose of
diazepam or give paraldehyde rectally (or phenobarbital IV or IM
15 mg/kg).
■ If high fever:
➤ Sponge the child with room-temperature water to reduce the fever.
➤ Do not give oral medication until the convulsion has been controlled
(danger of aspiration).
* Use phenobarbital (200 mg/ml solution) in 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 minute
Weight 3 kg—initial dose: 0.3 ml, repeat 0.15 ml after 30 minute
if
convulsions
continue}

15
1.ETAT
CHART 10. How to give IV glucose
➤ Insert IV line and draw blood for emergency laboratory investigations
➤ Check blood glucose. If low (<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 dextrostix is not available:
➤ Give 5 ml/kg of 10% glucose solution rapidly by IV injection
Volume of 10% glucose solution
Age/weight to give as bolus (5 ml/kg)
Less than 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 minutes. If it is still low, repeat
5 ml/kg of 10% glucose solution.
➤ Feed the child as soon as conscious.
If not able to feed without danger of aspiration, give:
— milk or sugar solution via nasogastric tube (to make sugar solution,
dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of
clean water), or
— IV fluids containing 5–10% glucose (dextrose) (see App. 4, p. 357)
Note: 50% glucose solution is the same as 50% dextrose solution or D50.
If only 50% glucose solution is available: dilute 1 part 50% glucose solution to
4 parts sterile water, or dilute 1 part 50% glucose solution to 9 parts 5% glucose
solution.
Note: For the use of dextrostix, refer to instruction on box. Generally, the strip must
be stored in its box, at 2–3 °C, avoiding sunlight or high humidity. A drop of blood
should be placed on the strip (it is necessary to cover all the reagent area). After 60
seconds, 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 will vary with different strips.)

16
1.ETAT
For children with severe dehydration but without shock, refer to diarrhoea
treatment plan C, p.114.
If the child is in shock, first follow the instructions in Charts 7 and 8
(pages 12 and 13). Switch to the present chart when the child’s pulse
becomes slower or the capillary refill is faster.
➤ Give 70 ml/kg of Ringer's lactate solution (or, if not available, normal
saline) over 5 hours in infants (aged <12 months) and over 21
/2 hours
in children (aged 12 months to 5 years).
Total volume IV fluid (volume per hour)
Age <12 months Age 12 months to 5 years
Weight Give over 5 hours Give over 21
/2 hours
<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 hours. If the hydration status is not
improving, give the IV drip more rapidly
Also give ORS solution (about 5 ml/kg/hour) as soon as the child can
drink; this is usually after 3–4 hours (in infants) or 1–2 hours (in children).
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 hours (infants) and after 3 hours (children). Classify
dehydration. Then choose the appropriate plan (A, B, or C, pages 120,
117, 114) to continue treatment.
If possible, observe the child for at least 6 hours after rehydration to be
sure that the mother can maintain hydration by giving the child ORS
solution by mouth.
CHART 11. How to treat severe dehydration in an
emergency setting after initial management of shock

17
1.ETAT
1.2 Notes for the assessment of emergency
and priority signs
■ Assess the airway and breathing (A, B)
Does the child’s breathing appear obstructed? Look and listen to determine if
there is poor air movement during breathing.
Is there severe respiratory distress? The breathing is very laboured, the child
uses auxiliary muscles for breathing (shows head nodding), is breathing very
fast, and the child appears to tire easily. Child is not able to feed because of
respiratory distress.
Is there central cyanosis? There is a bluish/purplish discoloration of the tongue
and the inside of the mouth.
■ Assess circulation (for shock) (C)
Check if the child’s hand is cold? If so
Check if the capillary refill time is longer than 3 seconds. Apply pressure to
whiten the nail of the thumb or the big toe for 3 seconds. Determine the time
from the moment of release until total recovery of the pink colour.
If capillary refill takes longer than 3 seconds, check the pulse. Is it weak and
fast? If the radial pulse is strong and not obviously fast, the child is not in
shock. If you cannot feel a radial pulse of an infant (less than 1 year old), feel
the brachial pulse or, if the infant is lying down, the femoral pulse. If you
cannot feel the radial pulse of a child, feel the carotid. If the room is very cold,
rely on the pulse to determine whether the child may be in shock.
■ Assess for coma or convulsions or other abnormal mental status (C)
Is the child in coma? Check the level of consciousness on the AVPU scale:
A alert,
V responds to voice,
P responds to pain,
U unconscious.
If the child is not awake and alert, try to rouse the child by talking or shaking
the arm. If the child is not alert, but responds to voice, he is lethargic. If there
is no response, ask the mother if the child has been abnormally sleepy or
difficult to wake. Look if the child responds to pain, or if he is unresponsive to
a painful stimulus. If this is the case, the child is in coma (unconscious) and
needs emergency treatment.
Is the child convulsing? Are there spasmodic repeated movements in an
unresponsive child?
ASSESSMENT OF EMERGENCY AND PRIORITY SIGNS

18
1.ETAT EMERGENCY TREATMENT FOR THE CHILD WITH SEVERE MALNUTRITION
■ Assess for severe dehydration if the child has diarrhoea (D)
Does the child have sunken eyes? Ask the mother if the child’s eyes are more
sunken than usual.
Does a skin pinch go back very slowly (longer than 2 seconds)? Pinch the skin
of the abdomen halfway between the umbilicus and the side for 1 second, then
release and observe.
■ Assess for priority signs
While assessing for emergency signs, you will have noted several possible
priority signs:
Is there any respiratory distress (not severe)?
Is the child lethargic or continuously irritable or restless?
This was noted when you assessed for coma.
Note the other priority signs (see page 5).
1.3 Notes for giving emergency treatment to the child
with severe malnutrition
During the triage process, all children with severe malnutrition will be identified
as having priority signs, which means that they require prompt assessment
and treatment.
A few children with severe malnutrition will be found during triage assess-
ment to have emergency signs.
• Those with emergency signs for “airway and breathing” and “coma or
convulsions” should receive emergency treatment accordingly (see charts
on pages 4–16).
• Those with signs of severe dehydration but not shock should not be
rehydrated with IV fluids. This is because the diagnosis of severe dehydration
is difficult in severe malnutrition and is often misdiagnosed. Giving IV fluids
puts these children at risk of overhydration and death from heart failure.
Therefore, these children should be rehydrated orally using the special
rehydration solution for severe malnutrition (ReSoMal). See Chapter 7 (page
179).
• Those with signs of shock are assessed for further signs (lethargic or
unconscious). This is because in severe malnutrition the usual emergency
signs for shock may be present even when there is no shock.
— If the child is lethargic or unconscious, keep warm and give 10% glucose
5 ml/kg IV (see Chart 10, page 15), and then IV fluids (see Chart 8, page
13, and the Note given below).

19
1.ETAT
CHILDREN PRESENTING WITH EMERGENCY CONDITIONS
— If the child is alert, keep warm and give 10% glucose (10 ml/kg) by
mouth or nasogastric tube, and proceed to immediate full assessment
and treatment. See Chapter 7 (page 173) for details.
Note: When giving IV fluids, treatment for shock differs from that for a well-
nourished child. This is because shock from dehydration and sepsis are likely
to coexist and these are difficult to differentiate on clinical grounds alone.
Children with dehydration respond to IV fluids (breathing and pulse rates fall,
faster capillary refill). Those with septic shock and no dehydration will not
respond. The amount of fluid given should be guided by the child’s response.
Avoid overhydration. Monitor the pulse and breathing at the start and every
5–10 minutes to check if improving or not. Note that the type of IV fluid also
differs in severe malnutrition, and the infusion rate is slower.
All severely malnourished children require prompt assessment and treatment
to deal with serious problems such as hypoglycaemia, hypothermia, severe
infection, severe anaemia and potentially blinding eye problems. 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.
1.4 Diagnostic considerations of children presenting with
emergency conditions
The following text provides guidance for the approach to the diagnosis and the
differential diagnosis of presenting conditions for which emergency treatment
has been provided. After you have stabilized the child and provided emergency
treatment, determine the underlying cause of the problem, to be able to provide
specific curative treatment. The following lists and tables provide some guidance
which help with the differential diagnosis, and are complemented by the tables
in the symptom-specific chapters.
1.4.1 Child presenting with an airway or severe breathing problem
History
• Onset of symptoms: slowly developing or sudden onset
• Previous similar episodes
• Upper respiratory tract infection
• Cough
— duration in days
• History of choking
• Present since birth, or acquired
• Immunization history
— DTP, measles (continued on page 21)

20
1.ETAT CHILD PRESENTING WITH AN AIRWAY OR SEVERE BREATHING PROBLEM
Table 1. Differential diagnosis of the child presenting with an airway
or severe breathing problem
Diagnosis or underlying cause In favour
Pneumonia — Cough with fast breathing and fever
— Development over days, getting worse
— Crepitations on auscultation
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
Diphtheria — Bull neck appearance of neck due to enlarged lymph
nodes
— Red throat
— Grey pharyngeal membrane
— No DTP vaccination
Table 2. Differential diagnosis of the child presenting with shock
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
— Enlarged neck veins and liver
Septic shock — History of febrile illness
— Very ill child
— Known outbreak of meningococcal infection
Shock associated with severe — History of profuse diarrhoea
dehydration — Known cholera outbreak

21
1.ETAT
CHILD PRESENTING WITH SHOCK
• Known HIV infection
• Family history of asthma
Examination
• Cough
— quality of cough
• Cyanosis
• Respiratory distress
• Grunting
• Stridor, abnormal breath sounds
• Nasal flaring
• Swelling of the neck
• Crepitations
• Wheezing
— generalized
— focal
• Reduced air entry
— generalized
— focal
1.4.2 Child presenting with shock
History
• Acute or sudden onset
• Trauma
• Bleeding
• History of congenital or rheumatic heart disease
• History of diarrhoea
• Any febrile illness
• Known dengue outbreak
• Known meningitis outbreak
• Fever
• Able to feed
Examination
• Consciousness
• Any bleeding sites
• Neck veins
• Liver size
• Petechiae
• Purpura

22
1.ETAT
1.4.3 Child presenting with lethargy, unconsciousness or
convulsions
History
Determine if there is a history of:
• fever
• head injury
• drug overdose or toxin ingestion
• convulsions: How long do they last? Have there been previous febrile
convulsions? Epilepsy?
In the case of an infant less than 1 week old, consider:
• birth asphyxia
• birth injury.
Examination
General
• jaundice
• severe palmar pallor
• peripheral oedema
• level of consciousness
• petechial rash.
Head/neck
• stiff neck
• signs of head trauma, or other injuries
• pupil size and reactions to light
• tense or bulging fontanelle
• abnormal posture.
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.
In a malarious area, prepare a blood smear.
If the child is unconscious, check the blood glucose. Check the blood pressure
(if a suitable paediatric cuff is available) and carry out urine microscopy if
possible .
It is important to determine the length of time a child has been unconscious
and his/her AVPU score (see page 17). This coma scale score should be
CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS

23
1.ETAT
Table 3. Differential diagnosis of the child presenting with lethargy,
unconsciousness or convulsions
Meningitis a,b — Very irritable
— Stiff neck or bulging fontanelle
— Petechial rash (meningococcal meningitis only)
Cerebral malaria (only in — Blood smear positive for malaria parasites
children exposed to — Jaundice
P. falciparum transmission; — Anaemia
often seasonal) — Convulsions
— Hypoglycaemia
Febrile convulsions (not likely — Prior episodes of short convulsions when febrile
to be the cause of — Associated with fever
unconsciousness) — Age 6 months to 5 years
— Blood smear normal
Hypoglycaemia (always seek — Blood glucose low; responds to glucose treatment c
the cause, e.g. severe malaria,
and treat the cause to prevent
a recurrence)
Head injury — Signs or history of head trauma
Poisoning — History of poison ingestion or drug overdose
Shock (can cause lethargy or — Poor perfusion
unconsciousness, but is — Rapid, weak pulse
unlikely to cause convulsions)
Acute glomerulonephritis with — Raised blood pressure
encephalopathy — Peripheral or facial oedema
— Blood 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 tuberculous
meningitis. If these are common in your area, 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 pages 149,
316). A positive lumbar puncture is one where there is cloudy CSF on direct visual inspection. CSF
examination shows an abnormal number of white cells (>100 polymorphonuclear cells per ml). A cell
count should be carried out, if possible. However, if this is not possible, then a cloudy CSF on direct
visual inspection could be considered positive. Confirmation is given by a low CSF glucose
(<1.5 mmol/litre), high CSF protein (>0.4 g/litre), organisms identified by Gram stain or a positive
culture, where these are available.
c Low blood glucose is <2.5 mmol/litre (<45 mg/dl), or <3.0 mmol/litre (<54 mg/dl) in a severely
malnourished child.

24
1.ETAT
monitored regularly. In young infants (less than 1 week old), note the time
between birth and the onset of unconsciousness.
Other causes of lethargy, unconsciousness or convulsions in some regions of
the world include Japanese encephalitis, dengue haemorrhagic fever, typhoid,
and relapsing fever.
Table 4. Differential diagnosis of the young infant (less than 2 months)
presenting with lethargy, unconsciousness or convulsions
Birth asphyxia — Onset in first 3 days of life
Hypoxic ischaemic encephalopathy — History of difficult delivery
Birth trauma
Intracranial haemorrhage — Onset in first 3 days of life in a low-birth-weight
or preterm Infant
Haemolytic disease of the — Onset in first 3 days of life
newborn, kernicterus — Jaundice
— Pallor
— Serious bacterial infection
Neonatal tetanus — Onset at age 3–14 days
— Irritability
— Difficulty in breastfeeding
— Trismus
— Muscle spasms
— Convulsions
Meningitis — Lethargy
— Apnoeic episodes
— Convulsions
— High-pitched cry
— Tense/bulging fontanelle
Sepsis — Fever or hypothermia
— Shock
— Seriously ill with no apparent cause

25
1.ETAT
1.5 Common poisonings
Suspect poisoning in any unexplained illness in a previously healthy child.
Consult standard textbook of paediatrics for management of exposure to
specific poisons and/or any local sources of expertise in the management of
poisoning, for example a poison centre. The principles of the management of
ingestion of a few of the more common poisons only is given here. Note that
traditional medicines can be a source of poisoning.
Diagnosis
This is made from the history by the child or carer, from clinical examination,
and the results of investigations, where appropriate.
■ Find out full details of the poisoning agent, the amount ingested and the
time of ingestion.
Attempt to identify the exact agent involved requesting to see the container,
where relevant. Check that no other children were involved. 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 (laryngeal
damage) suggesting ingestion of corrosives.
➤ Admit all children who have ingested iron, pesticides, paracetamol or aspirin,
narcotics, antidepressant drugs; children who have ingested deliberately
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 6 hours. Corrosives can cause
oesophageal burns which may not be immediately apparent and petroleum
products, if aspirated, can cause pulmonary oedema which may take some
hours to develop.
1.5.1 Principles for ingested poisons
Gastric decontamination (removal of poison from stomach) is most effective
within one hour of ingestion, and after this time there is usually little benefit,
except with agents that delay gastric emptying or in patients who are deeply
unconscious. The decision on whether to attempt this has to consider each
case separately and must weigh the likely benefits against the risks with each
method. Gastric decontamination will not guarantee that all of the substance
has been removed, so the child may still be in danger.
COMMON POISONINGS

26
1.ETAT
Contraindications to gastric decontamination are:
— an unprotected airway in an unconscious child
— ingestion of corrosives or petroleum products unless there is the risk of
serious toxicity.
➤ Check the child for emergency signs (see page 2) and check for hypo-
glycaemia (page 177).
➤ Identify the specific agent and remove or adsorb it as soon as possible.
Treatment is most effective if given as quickly as possible after the poisoning
event, ideally within 1 hour.
• If the child has 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 burned (for example with bleach, toilet cleaner or
battery acid), then do not make the child vomit but give water orally.
➤ Never use salt as an emetic as this can be fatal.
➤ If the child has swallowed other poisons
➤ Give activated charcoal, if available, and do not induce vomiting; give
by mouth or NG tube according to table below. If giving by NG tube, be
particularly careful that the tube is in the stomach.
Table 5. Amount of activated charcoal per dose
Children up to one year of age: 1 g/kg
Children 1 to 12 years of age: 25 to 50 g
Adolescents and adults: 25 to 100 g
• Mix the charcoal in 8–10 times the amount of water, e.g. 5 g in 40 ml of water.
• If possible, give the whole amount at once; if the child has difficulty in tolerating it, the
charcoal dose can be divided.
➤ If charcoal is not available, then induce vomiting but only if the child is
conscious by rubbing the back of the child’s throat with a spatula or
spoon handle; if this does not work, give an emetic such as paediatric
ipecacuanha (10 ml for 6 months to 2 year-olds or 15 ml for over 2
years); if this does not work, then try rubbing the back of the child’s
throat again. Note: ipecacuanha can cause repeated vomiting, drowsiness
and lethargy which can confuse the diagnosis of poisoning.
Gastric lavage
Only do it in health care facilities if staff has experience in the procedure, and
if the ingestion was only a few hours ago and is life threatening, and there has
PRINCIPLES FOR INGESTED POISONS

27
1.ETAT
been no ingestion of corrosives or petroleum derivatives. Make sure a suction
apparatus is available in case the child vomits. Place the child in the left lateral/
head down position. Measure the length of tube to be inserted. Pass a 24–28
French gauge tube through the mouth into the stomach, as a smaller size
nasogastric tube is not sufficient to let particles such as tablets pass. Ensure
the tube is in the stomach. Perform lavage with 10 ml/kg body weight of warm
normal saline (0.9%). The volume of lavage fluid returned should approximate
to the amount of fluid given. Lavage should be continued until the recovered
lavage solution is clear of particulate matter.
Note that tracheal intubation may be required to reduce risk of aspiration.
➤ Give specific antidote if this is indicated
➤ Give general care.
➤ Keep the child under observation for 4–24 hours depending on the poison
swallowed
➤ Keep unconscious children in recovery position.
➤ Consider transferring child to next level referral hospital, where appropriate
and where this can be done safely, if the child is unconscious or has
deteriorating conscious level, has burns to mouth and throat, is in severe
respiratory distress, is cyanosed or is in heart failure.
1.5.2 Principles for poisons in contact with skin or eyes
Skin contamination
➤ Remove all clothing and personal effects and thoroughly flush all exposed
areas with copious amounts of tepid water. Use soap and water for oily
substances. Attending staff should take care to protect themselves from
secondary contamination by wearing gloves and apron. Removed clothing
and personal effects should be stored safely in a see-through plastic bag
that can be sealed, for later cleansing or disposal.
Eye contamination
➤ Rinse the eye for 10–15 minutes with clean running water or saline, taking
care that the run-off does not enter the other eye. The use of anaesthetic
eye drops will assist irrigation. Evert the eyelids and ensure that all surfaces
are rinsed. In the case of an acid or alkali irrigate until the pH of the eye
returns to, and remains, normal (re-check pH 15–20 minutes after stopping
irrigation). Where possible, the eye should be thoroughly examined under
fluorescein staining for signs of corneal damage. If there is significant
conjunctival or corneal damage, the child should be seen urgently by an
ophthalmologist.
PRINCIPLES FOR POISONS IN CONTACT WITH SKIN OR EYES

28
1.ETAT
1.5.3 Principles of inhaled poisons
➤ Remove from the source of exposure.
➤ Administer supplemental oxygen if required.
Inhalation of irritant gases may cause swelling and upper airway obstruction,
bronchospasm and delayed pneumonitis. Intubation, bronchodilators and
ventilatory support may be required.
1.5.4 Specific poisons
Corrosive compounds
Examples—sodium hydroxide, potassium hydroxide, acids, bleaches or
disinfectants
➤ Do not induce vomiting or use activated charcoal when corrosives have
been ingested as this may cause further damage to the mouth, throat, airway,
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/rupture, if severe.
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. Ingestion can cause encephalopathy.
➤ Specific treatment includes oxygen therapy if respiratory distress (see page
281)
Organo-phosphorus and carbamate compounds
Examples: organophosphorus – malathion, parathion, TEPP, mevinphos
(Phosdrin); and carbamates – methiocarb, carbaryl
These can be absorbed through the skin, ingested or inhaled.
The child may complain of vomiting, diarrhoea, blurred vision or weakness.
Signs are those of excess parasympathetic activation: salivation, sweating,
lacrimation, slow pulse, small pupils, convulsions, muscle weakness/twitching,
then paralysis and loss of bladder control, pulmonary oedema, respiratory
depression.
PRINCIPLES OF INHALED POISONS

29
1.ETAT
Treatment involves:
➤ Remove poison by irrigating eye or washing skin (if in eye or on skin).
➤ Give activated charcoal if ingested and within 1 hour of the ingestion.
➤ Do not induce vomiting because most pesticides are in petrol-based solvents.
➤ In a serious ingestion where activated charcoal cannot be given, consider
careful aspiration of stomach contents by NG tube (the airway should be
protected).
➤ If the child has signs of excess parasympathetic activation (see above),
then give atropine 15–50 micrograms/kg IM (i.e. 0.015–0.05mg/kg) or by
intravenous infusion over 15 minutes. The main aim is to reduce bronchial
secretions whilst avoiding atropine toxicity. Auscultate the chest for signs
of respiratory secretions and monitor respiratory rate, heart rate and coma
score (if appropriate). Repeat atropine dose every 15 minutes until no chest
signs of secretions, and pulse and respiratory rate returns to normal.
➤ Check for hypoxaemia with pulse oximetry, if possible, if giving atropine as
it can cause heart irregularities (ventricular arrythmias) in hypoxic children.
Give oxygen if oxygen saturation is less that 90%.
➤ If muscle weakness, give pralidoxime (cholinesterase reactivator) 25–50mg/
kg diluted with 15 ml water by IV infusion over 30 minutes repeated once or
twice, or followed by an intravenous infusion of 10 to 20 mg/kg/hour, as
necessary.
Paracetamol
➤ If within 1 hour of ingestion give activated charcoal, if available, or induce
vomiting UNLESS an oral antidote may be required (see below).
➤ Decide if antidote is required to prevent liver damage: ingestions of 150 mg/
kg or more, or toxic 4 hour paracetamol level where this is available. Antidote
is more often required for older children who deliberately ingest paracetamol
or when parents overdose children by mistake.
➤ If within 8 hours of ingestion give oral methionine or IV acetylcysteine.
Methionine can be used if the child is conscious and not vomiting (<6 years:
1 gram every 4 hours for 4 doses; 6 years or older: 2.5 grams every 4 hours
for 4 doses).
➤ If more than 8 hours after ingestion, or the child cannot take oral treatment,
give IV acetylcysteine. Note that the fluid volumes used in the standard
regimen are too large for young children.
PARACETAMOL

30
1.ETAT
For children <20 kg give the loading dose of 150 mg/kg in 3 ml/kg of
5% glucose over 15 minutes, followed by 50 mg/kg in 7 ml/kg of 5% glucose
over 4 hours, then 100 mg/kg IV in 14 ml/kg of 5% glucose over 16 hours.
The volume of glucose can be scaled up for larger children.
Aspirin and other salicylates
This can be very serious in young children because they rapidly become acidotic
and are consequently more likely to suffer the severe CNS effects of toxicity.
Salicylate overdose can be complex to manage.
■ These cause acidotic-like breathing, vomiting and tinnitus.
➤ Give activated charcoal if available. Note that salicylate tablets tend to form
a concretion in the stomach leading to delayed absorption, so it is worthwhile
giving several doses of charcoal. If charcoal is not available and a severely
toxic dose has been given, then perform gastric lavage or induce vomiting,
as above.
➤ Give IV sodium bicarbonate 1 mmol/kg over 4 hours to correct acidosis and
to raise the pH of the urine to above 7.5 so that salicylate excretion is
increased. Give supplemental potassium too. Monitor urine pH hourly.
➤ Give IV fluids at maintenance requirements unless child shows signs of
dehydration in which case give adequate rehydration (see chapter 5).
➤ Monitor blood glucose every 6 hours and correct as necessary (see page
321).
➤ Give vitamin K 10mg IM or IV.
Iron
■ Check for clinical features of iron poisoning: nausea, vomiting, abdominal
pain and diarrhoea. The vomit and stools are often grey or black. In severe
poisoning there may be gastrointestinal haemorrhage, hypotension,
drowsiness, convulsions and metabolic acidosis. Gastrointestinal features
usually appear in the first 6 hours and a child who has remained
asymptomatic for this time probably does not require antidote treatment.
➤ Activated charcoal does not bind to iron salts, therefore consider giving a
gastric lavage if potentially toxic amounts of iron were taken.
➤ Decide whether to give antidote treatment. Since this can have side-effects
it should only be used if there is clinical evidence of poisoning (see above).
➤ If you decide to give antidote treatment, give deferoxamine (50 mg/kg IM
up to a maximum of 1 g) by deep IM injection repeated every 12 hours; if
ASPIRIN AND OTHER SALICYLATES

31
1.ETAT
very ill, give IV infusion 15 mg/kg/hour to a maximum of 80 mg/kg in 24
hours.
Carbon monoxide poisoning
➤ Give 100% oxygen to accelerate removal of carbon monoxide (note patient
can look pink but still be hypoxaemic) until signs of hypoxia disappear.
➤ Monitor with pulse oximeter but be aware that these can give falsely high
readings. If in doubt, be guided by presence or absence of clinical signs of
hypoxaemia.
Prevention
➤ Teach the parents to keep drugs and poisons in proper containers and out
of reach of children
➤ Advise parents on first aid if this happens again in the future
— Do not make child vomit if child has swallowed kerosene, petrol or petrol-
based products or if child’s mouth and throat have been burned, nor if
the child is drowsy.
— Try to make the child vomit if other drugs or poisons have been taken
by stimulating the back of the throat.
— Take the child to a health facility as soon as possible, together with
information about the substance concerned e.g. the container, label,
sample of tablets, berries etc.
1.6 Snake bite
■ Snake bite should be considered in any severe pain or swelling of a limb or
in any unexplained illness presenting with bleeding or abnormal neurological
signs. Some cobras spit venom into the eyes of victims causing pain and
inflammation.
Diagnosis of envenoming
■ General signs include shock, vomiting and headache. Examine bite for signs
such as local necrosis, bleeding or tender local lymph node enlargement.
■ Specific signs depend on the venom and its effects. These include:
— Shock
— Local swelling that may gradually extend up the bitten limb
— Bleeding: external from gums, wounds or sores; internal especially
intracranial
CARBON MONOXIDE POISONING

32
1.ETAT
— Signs of neurotoxicity: respiratory difficulty or paralysis, ptosis, bulbar
palsy (difficulty swallowing and talking), limb weakness
— Signs of muscle breakdown: muscle pains and black urine
■ Check haemoglobin (where possible, blood clotting should be assessed).
Treatment
First aid
➤ Splint the limb to reduce movement and absorption of venom. If the bite
was likely to have come from a snake with a neurotoxic venom, apply a firm
bandage to affected limb from fingers or toes to proximal of site of bite.
➤ Clean the wound.
➤ If any of the above signs, transport to hospital which has antivenom as
soon as possible. If snake has already been killed, take this with child to
hospital.
➤ Avoid cutting the wound or applying tourniquet.
Hospital care
Treatment of shock/respiratory arrest
➤ Treat shock, if present (see pages 3, 15 and 16).
➤ Paralysis of respiratory muscles can last for days and requires intubation
and mechanical ventilation or manual ventilation (with a mask or
endotracheal tube and bag) by relays of staff and/or relatives until respiratory
function returns. Attention to careful securing of endotracheal tube is
important. An alternative is to perform an elective tracheostomy.
Antivenom
■ If there are systemic signs or severe local signs (swelling of more than half
of the limb or severe necrosis), give antivenom, if available.
➤ Prepare IM epinephrine and IV chlorpheniramine and be ready if allergic
reaction occurs (see below).
➤ Give monovalent antivenom if the species of snake is known. Give polyvalent
antivenom if the species is not known. Follow the directions given on the
antivenom preparation. The dose for children is the same as for adults.
— Dilute the antivenom in 2–3 volumes of 0.9% saline and give intra-
venously over 1 hour. Give more slowly initially and monitor closely for
anaphylaxis or other serious adverse reactions.
SNAKE BITE

33
1.ETAT
➤ If itching/urticarial rash, restlessness, fever, cough or difficult breathing
develop, then stop antivenom and give epinephrine 0.01 ml/kg of 1/1000 or
0.1 ml/kg of 1/10,000 solution subcutaneously and IM or IV/SC chlor-
pheniramine 250 micrograms/kg. When the child is stable, re-start antivenom
infusion slowly.
➤ More antivenom should be given after 6 hours if there is recurrence of blood
incoagulability, or after 1–2 hr if the patient is continuing to bleed briskly or
has deteriorating neurotoxic or cardiovascular signs.
Blood transfusion should not be required if antivenom is given. Clotting function
returns to normal only after clotting factors are produced by the liver. Response
of abnormal neurological signs to antivenom is more variable and depends on
type of venom.
➤ If there is no reponse to antivenom infusion this should be repeated.
➤ Anticholinesterases can reverse neurological signs in some species of snake
(see standard textbooks of paediatrics for further details).
Other treatment
Surgical opinion
Seek surgical opinion if there is severe swelling in a limb, it is pulseless or
painful or there is local necrosis.
Surgical care will include:
— Excision of dead tissue from wound
— Incision of fascial membranes to relieve pressure in limb compartments,
if necessary
— Skin grafting, if extensive necrosis
— Tracheostomy (or endotracheal intubation) if paralysis of muscles
involved in swallowing occurs
Supportive care
➤ Give fluids orally or by NG tube according to daily requirements (see page
273). Keep a close record of fluid intake and output.
➤ Provide adequate pain relief
➤ Elevate limb if swollen
➤ Give antitetanus prophylaxis
➤ Antibiotic treatment is not required unless there is tissue necrosis at wound
site
SNAKE BITE

34
1.ETAT
➤ Avoid intramuscular injections
➤ Monitor very closely immediately after admission, then hourly for at least
24 hours as envenoming can develop rapidly.
1.7 Scorpion sting
Scorpion stings can be very painful for days. Systemic effects of venom are
much more common in children than adults.
Diagnosis of envenoming
Signs of envenoming can develop within minutes and are due to autonomic
nervous system activation. They include:
■ shock
■ high or low BP
■ fast and/or irregular pulse
■ nausea, vomiting, abdominal pain
■ breathing difficulty (due to heart failure) or respiratory failure
■ muscle twitches and spasms.
➤ Check for low BP or raised BP and treat if signs of heart failure (see page
107).
Treatment
First aid
➤ Transport to hospital as soon as possible.
Hospital care
Antivenom
➤ If signs of severe envenoming give scorpion antivenom, if available (as
above for snake antivenom infusion).
Other treatment
➤ Treat heart failure, if present (see page 106)
➤ Consider use of prazosin if there is pulmonary oedema (see standard
textbooks of paediatrics)
SCORPION STING

35
1.ETAT
Supportive care
➤ Give oral paracetamol or oral or IM morphine according to severity. If very
severe, infiltrate site with 1% lignocaine, without epinephrine.
1.8 Other sources of envenoming
➤ Follow the same principles of treatment, as above. Give antivenom, where
available, if severe local or any systemic effects.
In general, venomous spider bites can be painful but rarely result in systemic
envenoming. Antivenom is available for some species such as widow and
banana spiders. Venomous fish can give very severe local pain but, again,
systemic envenoming is rare. Box jellyfish stings are occasionally rapidly life-
threatening. Apply vinegar on cotton wool to denature the protein in the skin.
Adherent tentacles should be carefully removed. Rubbing the sting may cause
further discharge of venom. Antivenom may be available. The dose of antivenom
to jellyfish and spiders should be determined by the amount of the venom
injected. Higher doses are required for multiple bites, severe symptoms or
delayed presentation.
OTHER SOURCES OF ENVENOMING

37
2.DIAGNOSIS
CHAPTER 2
Diagnostic approach
to the sick child
2.1 Relationship to the IMCI approach
The pocket book is symptom-based in its approach, with the symptoms
following the sequence of the IMCI guidelines: cough, diarrhoea, fever. The
diagnoses also closely match the IMCI classifications, except that the expertise
and investigative capabilities that are available in a hospital setting allow
classifications like “very severe disease” or “very severe febrile disease” to be
defined more precisely, making possible such diagnoses as very severe
pneumonia, severe malaria, and meningitis. Classifications for conditions such
as pneumonia and dehydration follow the same principles as the IMCI. Young
infants (up to 2 months) are considered separately (see Chapter 3), as in the
IMCI approach, but the guidelines cover conditions arising at birth such as
birth asphyxia. The severely malnourished child is also considered separately
(see Chapter 7), because these children require special attention and treatment
if the high mortality is to be reduced.
2.2 Taking the history
Taking the history generally should start with the presenting complaint:
Why did you bring the child?
Then it progresses to the history of the present illness. The symptom-specific
chapters give some guidance on specific questions which are important to ask
concerning these specific symptoms, and which help in the differential diagnosis
of the illness. This includes the personal history, family and social and
environmental history. The latter might link to important counselling messages
such as sleeping under a bednet for a child with malaria, breastfeeding or
sanitary practices in a child with diarrhoea, or reducing exposure to indoor air
pollution in a child with pneumonia.
2.1 Relationship to the IMCI
approach 37
2.2 Taking the history 37
2.3 Approach to the sick child 38
2.4 Laboratory investigations 39
2.5 Differential diagnoses 39

38
2.DIAGNOSIS APPROACH TO THE SICK CHILD
Especially for younger infants, the history of pregnancy and birth is very
important. In the infant and younger child, feeding history becomes essential.
The older the child, the more important is information of the milestones of
development and behaviour of the child. Whereas the history is obtained from
a parent or caretaker in the younger child, an older child will contribute important
information.
2.3 Approach to the sick child and clinical examination
All children must be examined fully so that no important sign will be missed.
However, in contrast to the systematic approach in adults, the examination of
the child needs to be organized in a way to upset the child as little as possible.
• Do not upset the child unnecessarily.
• Leave the child in the arms of the mother or carer.
• Observe as many signs as possible before touching the child. These include
— Is the child alert, interested and looking about?
— Does the child appear drowsy?
— Is the child irritable?
— Is the child vomiting?
— Is the child able to suck or breastfeed?
— Is the child cyanosed or pale?
— Are there signs of respiratory distress?
• Does the child use auxiliary muscles?
• Is there lower chest wall indrawing?
• Does the child appear to breath fast?
• Count the respiratory rate.
These and other signs should all be looked for and recorded before the child is
disturbed. You might ask the mother or caretaker to cautiously reveal part of
the chest to look for lower chest wall indrawing or to count the respiratory
rate. If a child is distressed or crying, it might need to be left for a brief time
with its mother in order to settle, or the mother could be ask to breastfeed,
before key signs such as respiratory rate can be measured.
Then proceed to signs which require touching the child but are little disturbing,
such as listening to the chest. You get little useful information if you listen to
the chest of a crying child. Therefore, signs that involve interfering with the
child, such as recording the temperature or testing for skin turgor, should be
done last.

39
2.DIAGNOSIS
2.4 Laboratory investigations
Laboratory investigations are targeted based on the history and examination,
and help narrow the differential diagnosis. The following basic laboratory
investigations should be available in all small hospitals which provide paediatric
care in developing countries:
• haemoglobin or packed cell volume (PCV)
• blood smear for malaria parasites
• blood glucose
• microscopy of CSF and urine
• blood grouping and cross-matching
• HIV testing.
In the care of sick newborns (under 1 week old), blood bilirubin is also an
essential investigation.
Indications for these tests are outlined in the appropriate sections of this pocket
book. Other investigations, such as pulse oximetry, chest X-ray, blood cultures
and stool microscopy, can help in complicated cases.
2.5 Differential diagnoses
After the assessment has been completed, consider the various conditions
that could cause the child’s illness and make a list of possible differential
diagnoses. This helps to ensure that wrong assumptions are not made, a wrong
diagnosis is not chosen, and rare problems are not missed. Remember that a
sick child might have more than one diagnosis or clinical problem requiring
treatment.
Section 1.4 and Tables 1–4 (pages 19–24) present the differential diagnoses
for emergency conditions encountered during triage. Further tables of
symptom-specific differential diagnoses for common problems are found at
the beginning of each chapter and give details of the symptoms, examination
findings and results of laboratory investigations, which can be used to determine
the main diagnosis and any secondary diagnoses.
After the main diagnosis and any secondary diagnoses or problems have been
determined, treatment should be planned and started. Once again, if there is
more than one diagnosis or problem, the treatment recommendations for all
of them may have to be taken together. It is necessary to review the list of
differential diagnoses again at a later stage after observing the response to
treatment, or in the light of new clinical findings. The diagnosis might be revised
at this stage, or additional diagnoses included in the considerations.
LABORATORY INVESTIGATIONS

41
3.YOUNGINFANTS
CHAPTER 3
Problems of the neonate
and young infant
3.1 Routine care of the
newborn at delivery 42
3.2 Neonatal resuscitation 42
3.3 Routine care for all
newborn babies after
delivery 46
3.4 Prevention of neonatal
infections 46
3.5 Management of the child
with perinatal asphyxia 47
3.6 Danger signs in
newborns and young
infants 47
3.7 Serious bacterial infection 48
3.8 Meningitis 49
3.9 Supportive care for the
sick neonate 51
3.9.1 Thermal
environment 51
3.9.2 Fluid management 51
3.9.3 Oxygen therapy 52
3.9.4 High fever 53
3.10 Babies with low birth
weight 53
3.10.1 Babies with birth
weight between
2.25 and 2.5 kg 53
weight between
1.75 and 2.25 kg 53
weight below
1.75 kg 54
3.11 Necrotizing enterocolitis 56
3.12 Other common neonatal
problems 57
3.12.1 Jaundice 57
3.12.2 Conjunctivitis 59
3.12.3 Congenital
malformations 60
3.13 Babies of mothers with
infections 60
3.13.1 Congenital syphilis 60
3.13.2 Baby of a mother
with tuberculosis 61
3.13.3 Baby of a mother
with HIV 61
Drug doses of common drugs
for neonates and LBW babies 62

42
3.YOUNGINFANTS
This chapter provides guidance for the management of problems in neonates
and young infants from birth to 2 months of age. This includes neonatal
resuscitation, the recognition and management of neonatal sepsis and other
bacterial infections, and the management of low and very low birth weight
(VLBW) infants. Drug tables for commonly used drugs in neonates and young
infants are included at the end of this chapter, also providing dosages for low
birth weight and premature babies.
3.1 Routine care of the newborn at delivery
Most babies require only simple supportive care at and after delivery.
➤ Dry the baby with a clean towel.
➤ Observe baby (see chart 12) while drying.
➤ Give the baby to the mother as soon as possible, place on chest/abdomen.
➤ Cover the baby to prevent heat loss.
➤ Encourage initiation of breastfeeding within the first hour.
Skin-to-skin contact and early breastfeeding are the best ways to keep a baby
warm and prevent hypoglycaemia.
3.2 Neonatal resuscitation
For some babies the need for resuscitation may be anticipated: those born to
mothers with chronic illness, where the mother had a previous fetal or neonatal
death, a mother with pre-eclampsia, in multiple pregnancies, in preterm delivery,
in abnormal presentation of the fetus, with a prolapsed cord, or where there is
prolonged labour or rupture of membranes, or meconium-stained liquor.
However, for many babies the need for resuscitation cannot be anticipated
before delivery. Therefore,
• be prepared for resuscitation at every delivery,
• follow the assessment steps of chart 12.
ROUTINE CARE OF THE NEWBORN AT DELIVERY

43
3.YOUNGINFANTS
▼▼▼
Compress
the chest
(see figure
on page 44)
CHART 12. Neonatal resuscitation
➤Dry the baby with clean cloth and
place where the baby will be warm.
Look for ■ Breathing or crying
■ Good muscle tone
■ Colour pink
➤Position the head of the baby in the neu-
tral position to open the airway,
➤Clear airway, if necessary
➤Stimulate, reposition
➤Give oxygen, as necessary
➤Use a correctly fitting mask and give the
baby 5 slow ventilations with bag.
■ Check position and mask fit
➤Adjust position, if necessary
➤Provide ventilation with bag and mask.
■ If chest not moving well
➤Suction airway
■ Check the heart rate (HR) (cord pulsa-
tion or by listening with stethoscope)
➤Continue to bag at a rate of about 40
breaths per minute.
■ Make sure the chest is moving
adequately.
➤Use oxygen if available.
■ Every 1–2 minutes stop and see if the
pulse or breathing has improved.
➤Stop compressions once the HR
>100/min.
➤Stop bagging when respiratory rate
>30/min.
➤Continue oxygen until pink and active.
▼
If HR
<60/min
CALL FOR HELP!
Routine care
(see 6.1)
Routine care
and observe
closely
YES
Breathing
and pink
Not breathing, cyanosed
▼
NO
A
B
C
▼
30SECONDS
▼
▼
30SECONDS
▼
Observe
closely
▼
Breathing▼
If not breathing
If HR >60/min

44
3.YOUNGINFANTS
Correct head position to open up
airways and for bag ventilation.
Do not hyperextend the neck
There is no need to slap the baby, drying is enough for stimulation.
A. Airway
➤ Suction airway—if there is meconium stained fluid AND baby is NOT
crying and moving limbs:
— Suck the mouth, nose and oropharynx, do not suck right down the
throat as this can cause apneoa/bradycardia.
B. Breathing
➤ Choosing mask size: Size 1 for normal weight baby, size 0 for small (less
than 2.5 kg) baby
➤ Ventilation with bag and mask at 40–60 breaths/minute
■ Make sure the chest moves up with each press on the bag and in a very
small baby make sure the chest does not move too much.
C. Circulation
➤ 90 compressions coordinated with 30 breaths/min (3 compressions:
1 breath every 2 seconds).
➤ Place thumbs just below the line connecting the nipples on the sternum
(see below).
➤ Compress 1/3 the A-P diameter of the chest.
Correct position of hands for
cardiac massage in a neonate.
The thumbs are used for
compression over the sternum

45
3.YOUNGINFANTS
Inadequate seal
If you hear air escaping
from the mask, form a
better seal. The most
common leak is between
the nose and the cheeks.
Ventilating a neonate
with bag and mask
Pull the jaw forward
towards the mask with
the third finger of the
hand holding the mask
Do not hyperextend
the neck
Fitting mask over face:
right size
and position mask held mask too mask too
of mask too low small large
right wrong wrong wrong
Neonatal self-inflating
resuscitation bag with
round mask

46
3.YOUNGINFANTS
3.2.1 Cessation of resuscitation
If after 20 minutes of resuscitation the baby is:
• Not breathing and pulse is absent: cease efforts.
• Explain to the mother that the baby has died, and give it to her to hold if she
wishes.
3.3 Routine care for all newborn babies after delivery
(and for neonates born outside and brought to
the hospital)
➤ Keep dry in a warm room away from drafts, well covered
➤ Keep the baby with the mother, rooming in
➤ Initiate breastfeeding within the first hour
➤ Let the baby breastfeed on demand if able to suck
➤ Give vitamin K (phytomenadione), according to national guidelines
1 ampoule (1 mg/0.5ml or 1 mg/ml) IM once
(Do NOT use 10 mg/ml ampoule)
➤ Keep umbilical cord clean and dry
➤ Apply antiseptic ointment or antibiotic eye drops/ointment (e.g. tetracycline
eye ointment) to both eyes once, according to national guidelines
➤ Give oral polio, hepatitis B and BCG vaccines, depending on national
guidelines
3.4 Prevention of neonatal infections
Many early neonatal infections can be prevented by:
• Good basic hygiene and cleanliness during delivery of the baby
• Special attention to cord care
• Eye care
Many late neonatal infections are acquired in hospitals. These can be prevented
by:
• Exclusive breastfeeding
• Strict procedures for hand washing for all staff and for families before and
after handling babies
• Not using water for humidification in incubators (where Pseudomonas will
easily colonize) or by avoiding incubators (using kangaroo mother care
instead).
ROUTINE CARE FOR ALL NEWBORN BABIES AFTER DELIVERY

47
3.YOUNGINFANTS
• Strict sterility for all procedures
• Clean injection practices
• Removing intravenous drips when they are no longer necessary
• Avoiding unnecessary blood transfusion
3.5 Management of the child with perinatal asphyxia
May be the result of a lack of oxygen supply to organs before, during or
immediately after birth. Initial treatment is effective resuscitation (see above).
Problems in the days after birth:
➤ Convulsions: treat with phenobarbital (see page 49), check glucose.
➤ Apnoea: common after severe birth asphyxia. Sometimes associated with
convulsions. Manage with oxygen by nasal catheter and resuscitation with
bag and mask.
➤ Inability to suck: feed with milk via a nasogastric tube. Beware of delayed
emptying of the stomach which may lead to regurgitation of feeds.
➤ Poor motor tone. May be floppy or have limb stiffening (spasticity).
Prognosis: can be predicted by recovery of motor function and sucking ability.
A baby who is normally active will usually do well. A baby who, a week after
birth, is still floppy or spastic, unresponsive and cannot suck has a severe
brain injury and will do poorly. The prognosis is less grim for babies who have
recovered some motor function and are beginning to suck. The situation should
be sensitively discussed with parents throughout the time the baby is in hospital.
3.6 Danger signs in newborns and young infants
Neonates and young infants often present with non-specific symptoms and
signs which indicate severe illness. These signs might be present at or after
delivery, or in a newborn presenting to hospital, or develop during hospital
admission. Initial management of the neonate presenting with these signs is
aimed at stabilizing the child and preventing deterioration. Signs include:
■ Unable to breastfeed
■ Convulsions
■ Drowsy or unconscious
■ Respiratory rate less than 20/min or apnoea (cessation of breathing for
>15 secs)
■ Respiratory rate greater than 60/min
PERINATAL ASPHYXIA

48
3.YOUNGINFANTS
■ Grunting
■ Severe chest indrawing
■ Central cyanosis
EMERGENCY MANAGEMENT of danger signs:
➤ Give oxygen by nasal prongs or nasal catheter if the young infant is cyanosed
or in severe respiratory distress.
➤ Give bag and mask ventilation (page 45), with oxygen (or room air if oxygen
is not available) if respiratory rate too slow (<20).
➤ Give ampicillin (or penicillin) and gentamicin (see below).
➤ If drowsy, unconscious or convulsing, check blood glucose.
If glucose <1.1 mmol/l (<20 mg/100 ml), give glucose IV.
If glucose 1.1–2.2 mmol/l (20–40 mg/100 ml), feed immediately and increase
feeding frequency.
If you cannot check blood glucose quickly, assume hypoglycaemia and give
glucose IV. If you cannot insert an IV drip, give expressed breast milk or
glucose through a nasogastric tube.
➤ Give phenobarbital if convulsing (see page 49).
➤ Admit, or refer urgently if treatment is not available at your hospital
➤ Give vitamin K (if not given before).
➤ Monitor the baby frequently (see below).
3.7 Serious bacterial infection
Risk factors for serious bacterial infections are:
■ Maternal fever (temperature >37.9 °C before delivery or during labour)
■ Membranes ruptured more than 24 hours before delivery
■ Foul smelling amniotic fluid
All of the DANGER SIGNS are signs of serious bacterial infection, but there are
others:
■ Deep jaundice
■ Severe abdominal distension
Localizing signs of infection are:
■ Painful joints, joint swelling, reduced movement, and irritability if these
parts are handled
SERIOUS BACTERIAL INFECTION

49
3.YOUNGINFANTS
■ Many or severe skin pustules
■ Umbilical redness
extending to the peri-
umbilical skin or
umbilicus draining pus.
■ Bulging fontanelle
(see below)
Treatment
Antibiotic therapy
➤ Admit to hospital
➤ Where blood cultures are available, obtain blood cultures before starting
antibiotics
➤ For any of these signs, give ampicillin (or penicillin) and gentamicin (for
dosages see pages 62–66)
➤ Give cloxacillin (if available) instead of penicillin if extensive skin pustules
or abscesses as these might be signs of Staphylococcus infecton
➤ Most serious bacterial infections in neonates should be treated with
antibiotics for at least 10 days
➤ If not improving in 2–3 days the antibiotic treatment may need to be changed,
or the baby referred
Other treatment
➤ Give all sick infants aged <2 weeks 1 mg of vitamin K (IM)
➤ Treat convulsions with IM phenobarbital (1 dose of 15 mg/kg). If needed,
continue with phenobarbital 5 mg/kg once daily
➤ For management of pus draining from eyes, see page 59
➤ If child is from malarious area and has fever, take blood film to check for
malaria also. Neonatal malaria is very rare. If confirmed, treat with quinine
(see page 140)
➤ For supportive care, see page 51
3.8 Meningitis
Clinical signs
Suspect if signs of serious bacterial infection are present, or any one of the
following signs of meningitis.
MENINGITIS
Peri-umbilical flare in umbilical sepsis.
The inflammation extends beyond the
umbilicus to the abdominal wall.

50
3.YOUNGINFANTS
General signs
■ Drowsy, lethargic or unconscious
■ Reduced feeding
■ Irritable
■ High pitched cry
■ Apnoeic episodes
More specific signs
■ Convulsion
■ Bulging fontanelle
Do a lumbar puncture (LP) if you suspect meningitis, unless the baby is having
apnoea or there is no motor response to stimuli.
Treatment
Antibiotics
➤ Give ampicillin and gentamicin or a third generation cephalosporin, such as
ceftriaxone (50 mg/kg every 12 hours (might cause biliary sludge leading
to jaundice)) or cefotaxime (50 mg/kg every 6 hours) for 3 weeks.
➤ Alternative antibiotics are penicillin and gentamicin (see pages 65–66).
Chloramphenicol is an alternative but should not be used in premature/low
weight neonates (see page 64).
➤ If there are signs of hypoxaemia, give oxygen (see page 52).
Convulsions/fits
➤ Treat convulsions with phenobarbital (loading dose of 15 mg/kg). If
convulsion persists, give further doses of 10 mg/kg phenobarbital up to a
MENINGITIS
Bulging
fontanelle –
sign of
meningitis in
young infants
with an open
fontanelle
Normal fontanelle Bulging fontanelle
➞
➞

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