POCKET BOOK OF Hospital Care For Children
POCKET BOOKOFHospital carefor childrenGUIDELINES FOR THE MANAGEMENTOF COMMON ILLNESSES WITHLIMITED RESOURCES
WHO Library Cataloguing-in-Publication DataPocket book of hospital care for children: guidelines for the management ofcommon illnesses with limited resources.1.Pediatrics 2.Child care 3.Hospitals 4.Child, Hospitalized 5.Developingcountries 6.Practice guidelines 7.Manuals I.World Health Organization.ISBN 92 4 154670 0(NLM classification: WS 29) World Health Organization 2005All rights reserved. Publications of the World Health Organization can be obtainedfrom WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,Switzerland (tel: 41 22 791 2476; fax: 41 22 791 4857; email: bookorders@who.int.Requests for permission to reproduce or translate WHO publications – whether forsale or for noncommercial distribution – should be addressed to WHO Press, at theabove address (fax: 41 22 791 4806; email: permissions@who.int).The designations employed and the presentation of the material in this publicationdo not imply the expression of any opinion whatsoever on the part of the WorldHealth Organization concerning the legal status of any country, territory, city orarea or of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may notyet be full agreement.The mention of specific companies or of certain manufacturers’ products does notimply that they are endorsed or recommended by the World Health Organization inpreference to others of a similar nature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization toverify the information contained in this publication. However, the published materialis being distributed without warranty of any kind, either express or implied. Theresponsibility for the interpretation and use of the material lies with the reader. Inno event shall the World Health Organization be liable for damages arising from itsuse.Designed by minimum graphicsPrinted in China, Hong Kong Special Administrative Region
sxixChart 1. Stages in the management of the sick child admitted tohospital: summary of key elementsxxCHAPTER 1. TRIAGE AND EMERGENCY CONDITIONS1.1 Summary of steps in emergency triage assessment and treatmentTriage of all sick children124Manage the choking infant6Manage the airway in a choking child8How to give oxygen10Position the unconscious child11Give IV fluids rapidly for shock in a child withoutsevere malnutrition12Give IV fluids for shock in a child with severe malnutrition13Give diazepam or paraldehyde rectally14Give IV glucose15Treat severe dehydration in an emergency setting161.2 Notes for the assessment of emergency and priority signs171.3 Notes for giving emergency treatment to the child with severemalnutrition181.4 Diagnostic considerations of children presenting withemergency conditions191.4.1 Child presenting with an airway or severe breathingproblem191.4.2 Child presenting with shock211.4.3 Child presenting with lethargy, unconsciousness orconvulsions1.5 Common poisonings1.5.1 Principles for ingested poisons222525iii
HOSPITAL CARE FOR CHILDREN1.5.2 Principles for poisons in contact with skin or eyes271.5.3 Principles of inhaled poisons281.5.4 Specific poisons28Corrosive compounds28Petroleum compounds28Organo-phosphorus and carbamate compounds28Paracetamol29Aspirin30Iron30Carbon monoxide311.6 Snake bite311.7 Scorpion sting341.8 Other sources of envenoming35CHAPTER 2. DIAGNOSTIC APPROACH TO THE SICK CHILD372.1 Relationship to the IMCI approach372.2 Taking the history372.3 Approach to the sick child and clinical examination382.4 Laboratory investigations392.5 Differential diagnoses39CHAPTER 3. PROBLEMS OF THE NEONATE AND YOUNG INFANT413.1 Routine care of the newborn at delivery423.2 Neonatal resuscitation423.3 Routine care for all newborn babies after delivery463.4 Prevention of neonatal infections463.5 Management of the child with perinatal asphyxia473.6 Danger signs in newborns and young infants473.7 Serious bacterial infection483.8 Meningitis493.9 Supportive care for the sick neonateiv513.9.1 Thermal environment513.9.2 Fluid management51
CONTENTS3.9.3 Oxygen therapy523.9.4 High fever533.10 Babies with low birth weight3.10.1 Babies with birth weight between 2.25 and 2.5 kg53533.10.2 Babies with birth weight between 1.75 and 2.25 kg533.10.3 Babies with birth weight below 1.75 kg543.11 Necrotizing enterocolitis563.12 Other common neonatal problems573.12.1 Jaundice573.12.2 Conjunctivitis593.12.3 Congenital malformations603.13 Babies of mothers with infections603.13.1 Congenital syphilis603.13.2 Baby of a mother with tuberculosis613.13.3 Baby of a mother with HIVDrug doses of common drugs for neonates and LBW babiesCHAPTER 4. COUGH OR DIFFICULT BREATHING6162694.1 Child presenting with cough694.2 Pneumonia724.2.1 Very severe pneumonia734.2.2 Severe pneumonia784.2.3 Pneumonia (non-severe)804.2.4 Pleural effusion and empyema814.3 Cough or cold4.4 Conditions presenting with wheeze82834.4.1 Bronchiolitis854.4.2 Asthma874.4.3 Wheeze with cough or cold914.5 Conditions presenting with stridor914.5.1 Viral croup924.5.2 Diphtheria94v
HOSPITAL CARE FOR CHILDREN4.6 Conditions presenting with chronic cough4.7 Pertussis96984.8 Tuberculosis1014.9 Foreign body inhalation1044.10 Heart failure106CHAPTER 5. DIARRHOEA5.1 Child presenting with diarrhoea5.2 Acute diarrhoea1091101115.2.1 Severe dehydration1125.2.2 Some dehydration1155.2.3 No dehydration1195.3 Persistent diarrhoea1225.3.1 Severe persistent diarrhoea1225.3.2 Persistent diarrhoea (non-severe)1265.4 DysenteryCHAPTER 6. FEVER6.1 Child presenting with fever6.1.1 Fever lasting longer than 7 days6.2 Malaria1271331331361396.2.1 Severe malaria1396.2.2 Malaria (non-severe)1456.3 Meningitis1486.4 Measles1546.4.1 Severe complicated measles6.4.2 Measles (non-severe)1541576.5 Septicaemia1586.6 Typhoid fever1596.7 Ear infections161vi6.7.1 Mastoiditis1616.7.2 Acute otitis media1626.7.3 Chronic otitis media163
CONTENTS6.8 Urinary tract infection1636.9 Septic arthritis or osteomyelitis1656.10 Dengue1666.10.1 Severe dengueCHAPTER 7. SEVERE MALNUTRITION1671737.1 Diagnosis1747.2 Initial assessment of the severely malnourished child1747.3 Organization of care1767.4 General treatment7.4.1 Hypoglycaemia1761777.4.2 Hypothermia1787.4.3 Dehydration1797.4.4 Electrolyte imbalance1817.4.5 Infection1827.4.6 Micronutrient deficiencies1837.4.7 Initial refeeding1847.4.8 Catch-up growth1887.4.9 Sensory stimulation1897.4.10 Malnutrition in infants 6 months1907.5 Treatment of associated conditions1907.5.1 Eye problems1907.5.2 Severe anaemia1917.5.3 Skin lesions in kwashiorkor1917.5.4 Continuing diarrhoea1927.5.5 Tuberculosis1927.6 Discharge and follow-up1927.7 Monitoring the quality of care1947.7.1 Mortality audit1947.7.2 Weight gain during rehabilitation phase195vii
HOSPITAL CARE FOR CHILDRENCHAPTER 8. CHILDREN WITH HIV/AIDS8.1 Sick child with suspected or confirmed HIV infection1992008.1.1 Clinical diagnosis2008.1.2 Counselling2018.1.3 Testing and diagnosis of HIV infection in children2038.1.4 Clinical staging2048.2 Antiretroviral therapy (ART)2078.2.1 Antiretroviral drugs2078.2.2 When to start antiretroviral therapy2098.2.3 Side-effects of antiretroviral therapy and monitoring2108.2.4 When to change treatment2138.3 Other treatment for the HIV-positive child2148.3.1 Immunization2148.3.2 Cotrimoxazole prophylaxis2148.3.3 Nutrition2168.4 Management of HIV-related conditions8.4.1 Tuberculosis2162168.4.2 Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) 2178.4.3 Lymphoid interstitial pneumonitis (LIP)2178.4.4 Fungal infections2188.4.5 Kaposi sarcoma2198.5 Perinatal HIV transmission and breastfeeding2198.6 Follow-up2208.7 Palliative and end-of-life care221CHAPTER 9. COMMON SURGICAL PROBLEMS9.1 Care before, during and after surgery2272279.1.1 Preoperative care2289.1.2 Intraoperative care2299.1.3 Postoperative care2329.2 Newborn and neonatal problems2349.2.1 Cleft lip and palate234viii
CONTENTS9.2.2 Bowel obstruction in the newborn2359.2.3 Abdominal wall defects2369.2.4 Myelomeningocele2379.2.5 Congenital dislocation of the hip2379.2.6 Talipes equino-varus (club foot)2389.3 Injuries2399.3.1 Burns2399.3.2 Principles of wound care2439.3.3 Fractures2459.3.4 Head injuries2499.3.5 Chest and abdominal injuries2509.4 Abdominal problems2509.4.1 Abdominal pain2509.4.2 Appendicitis2519.4.3 Bowel obstruction beyond the newborn period2529.4.4 Intussusception2539.4.5 Umbilical hernia2549.4.6 Inguinal hernia2549.4.7 Incarcerated hernias2559.4.8 Rectal prolapse2559.5 Infections requiring surgery9.5.1 Abscess2562569.5.2 Osteomyelitis2569.5.3 Septic arthritis2589.5.4 Pyomyositis258CHAPTER 10. SUPPORTIVE CARE10.1 Nutritional management26126110.1.1 Supporting breastfeeding26210.1.2 Nutritional management of sick children26710.2 Fluid management27310.3 Management of fever274ix
HOSPITAL CARE FOR CHILDREN10.4 Pain control27510.5 Management of anaemia27610.6 Blood transfusion27710.6.1 Storage of blood27710.6.2 Problems with blood transfusion27710.6.3 Indications for blood transfusion27710.6.4 Giving a blood transfusion27810.6.5 Transfusion reactions27910.7 Oxygen therapy28110.8 Toys and play therapy285CHAPTER 11. MONITORING THE CHILD’S PROGRESS11.1 Monitoring procedures28928911.2 Monitoring chart29011.3 Audit of paediatric care290CHAPTER 12. COUNSELLING AND DISCHARGE FROM HOSPITAL12.1 Timing of discharge from hospital29329312.2 Counselling29412.3 Nutrition counselling29512.4 Home treatment29612.5 Checking the mother’s own health29612.6 Checking immunization status29712.7 Communicating with the first-level health worker29812.8 Providing follow-up care298FURTHER READING301APPENDICESAppendix 1. Practical proceduresA1.1 Giving injectionsx303305A1.1.1 Intramuscular305A1.1.2 Subcutaneous306A1.1.3 Intradermal306
CONTENTSA1.2 Procedures for giving parenteral fluids308A1.2.1 Insertion of an indwelling IV cannulain a peripheral vein308A1.2.2 Intraosseous infusion310A1.2.3 Central vein cannulation312A1.2.4 Venous cut-down313A1.2.5 Umbilical vein catheterization314A1.3 Insertion of a nasogastric tube315A1.4 Lumbar puncture316A1.5 Insertion of a chest drain318A1.6 Supra-pubic aspiration320A1.7 Measuring blood glucose321Appendix 2. Drug dosages/regimens325Appendix 3. Equipment size for children355Appendix 4. Intravenous fluids357Appendix 5. Assessing nutritional status359Appendix 6. Job aids and charts369INDEX371CHARTSChart 1. Stages in the management of the sick child admitted tohospital: summary of key elementsxxChart 2. Triage of all sick children4Chart 3. How to manage the choking infant6Chart 4. How to manage the airway in a child with obstructedbreathing (or who has just stopped breathing) where noneck trauma is suspected8Chart 5. How to give oxygen10Chart 6. How to position the unconscious child11Chart 7. How to give IV fluids rapidly for shock in a child withoutsevere malnutrition12Chart 8. How to give IV fluids for shock in a child with severemalnutrition13Chart 9. How to give diazepam (or paraldehyde) rectally14xi
HOSPITAL CARE FOR CHILDRENChart 10. How to give IV glucose15Chart 11. How to treat severe dehydration in an emergency setting afterinitial management of shock16Chart 12. Neonatal resuscitationChart 13. Diarrhoea Treatment Plan C: Treat severe dehydration quickly43114Chart 14. Diarrhoea Treatment Plan B: Treat some dehydration with ORS 117Chart 15. Diarrhoea Treatment Plan A: Treat diarrhoea at home120Chart 16. Feeding recommendations during sickness and health271TABLESTable 1.Differential diagnosis of the child presenting with an airwayor severe breathing problem20Table 2.Differential diagnosis of the child presenting with shock20Table 3.Differential diagnosis of the child presenting with lethargy,unconsciousness or convulsions23Table 4.Differential diagnosis of the young infant (less than 2 months)presenting with lethargy, unconsciousness or convulsions24Table 5.Poisoning: Amount of activated charcoal per dose26Table 6.Differential diagnosis of the child presenting with coughor difficult breathing71Table 7.Classification of the severity of pneumonia72Table 8.Differential diagnosis of the child presenting with wheeze84Table 9.Differential diagnosis of the child presenting with stridor92Table 10. Differential diagnosis of the child presenting withchronic cough97Table 11. Differential diagnosis of the child presenting with diarrhoea111Table 12. Classification of the severity of dehydration in childrenwith diarrhoea111Table 13. Administration of IV fluid to a severely dehydrated child113Table 14. Diet for persistent diarrhoea, first diet: A starch-based,reduced milk concentration (low lactose) diet124Table 15. Diet for persistent diarrhoea, second diet: A no-milk(lactose-free) diet with reduced cereal (starch)125Table 16. Differential diagnosis of fever without localizing signs134xii
CONTENTSTable 17. Differential diagnosis of fever with localized signs135Table 18. Differential diagnosis of fever with rash136Table 19. Additional differential diagnosis of fever lasting longerthan 7 days138Table 20. Time frame for the management of the child withsevere malnutrition176Table 21. Volumes of F-75 per feed for feeding malnourished children185Table 22. The WHO paediatric clinical staging system for HIV205Table 23. Classes of antiretroviral drugs recommend for use inchildren in resource poor settings208Table 24. Possible first-line treatment regimens for children with HIV208Table 25. Summary of indications for initiating ART in children,based on clinical staging211Table 26. Common side-effects of antiretroviral drugs212Table 27. Clinical and CD4 definition of ARV treatment failure inchildren (after 6 months or more of ARV)213Table 28. Endotracheal tube size, by age230Table 29. Blood volume of children by age232Table 30. Normal pulse rate and blood pressure in children232Table 31. Examples of local adaptations of feeding recommendationsin the mother’s card from Bolivia, Indonesia, Nepal,South Africa and Tanzania272Table 32. Maintenance fluid requirements273Table 33. Immunization schedule for infants recommended by theExpanded Programme on Immunization297Table 34. Weight-for-age chart for children359Table 35. WHO/NCHS normalized reference weight-for-length(49–84 cm) and weight-for-height (85–110 cm), by sex365xiii
AcknowledgementsThis pocket book is the result of an international effort coordinated by theWorld Health Organization’s Department of Child and Adolescent Health andDevelopment.A special debt of gratitude is owed to Dr Harry Campbell, University ofEdinburgh, Scotland for the overall coordination of the preparation of thechapters of the document and significant contributions to individual chapters.WHO would like to thank the following for their preparation of and contributionsto the chapters:Dr Ann Ashworth (UK); Dr. Stephen Bickler (USA); Dr Jacqueline Deen(Philippines), Dr Trevor Duke (PNG/Australia); Dr Greg Hussey (SouthAfrica); Dr Michael English (Kenya); Dr Stephen Graham (Malawi);Dr Elizabeth Molyneux (Malawi); Dr Nathaniel Pierce (USA); Dr HaroonSaloojee (South Africa); Dr Barbara Stoll (USA); Dr Giorgio Tamburlini(Italy); Dr Bridget Wills (Vietnam); and Fabienne Jäger (Switzerland) forassistance 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
HOSPITAL CARE FOR CHILDRENI. Mahama, Ghana; D. Malchinkhuu, Mongolia; N. Manjavidze, Georgia;P. Mazmanyan, Armenia; D. Mei, China; A. Mekasha, Ethiopia; C.A. MeleanGumiel, 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, SouthAfrica; 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 Diseasesand of Non Communicable Diseases, and WHO Departments of Disability/InjuryPrevention and Rehabilitation, Essential Drugs and Medicines Policy, EssentialHealth Technology, HIV/AIDS, Nutrition for Health and Development, Protectionof the Human Environment, Reproductive Health and Research, Roll BackMalaria, Stop Tuberculosis, and Vaccines and Biologicals and by WHO RegionalOffices.WHO wishes to thank the following organizations who contributed to theproduction of the pocket book:Australian Agency for International Development (AusAID); Institute forChild Health IRCCS “Burlo Garofolo”, Trieste, Italy; and the InternationalPaediatric Association.xvi
ForewordThis pocket book is for use by doctors, senior nurses and other senior healthworkers who are responsible for the care of young children at the first referrallevel in developing countries. It presents up-to-date clinical guidelines whichare based on a review of the available published evidence by subject experts,for both inpatient and outpatient care in small hospitals where basic laboratoryfacilities and essential drugs and inexpensive medicines are available. In somesettings, these guidelines can be used in the larger health centres where asmall number of sick children can be admitted for inpatient care.The guidelines require the hospital to have (1) the capacity to carry out certainessential investigations—such as blood smear examinations for malariaparasites, 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. Expensivetreatment options, such as new antibiotics or mechanical ventilation, are notdescribed.These guidelines focus on the inpatient management of the maj
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.
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23 Eastman Dental Hospital 24 Royal National Throat, Nose & Ear Hospital 25 The Nuffield Hearing and Speech Centre 26 Moorfields Eye Hospital 27 St. Bartholomew's Hospital 28 London Bridge Hospital 29 Guy's Hospital 30 Churchill Clinic 31 St. Thomas' Hospital 32 Gordon Hospital 33 The Lister Hospital 34 Royal Hospital Chelsea 35 Charter .
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