REPUBLIC OF UGANDA

MINISTRY OF HEALTH

Basic Paediatric Protocols

March 2017

4th Edition
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Table of Contents

Topic Page Number

Abbreviations/ Principles 3–5

Clinical Audit and Hand hygiene 6–8
Essential Drugs
Basic Formulary 9
Emergency drugs – dose charts
 Diazepam and Glucose 11
 Phenobarbitone and Phenytoin 12
Intravenous antibiotics (age > 7 days) 13
Oral antibiotics 14
Maintenance Fluid / Feed Volumes – not malnourished 15
Triage 16
Paediatric Management guidelines
Infant / Child resuscitation 17
Emergency care – Signs of Life 18
Intra-osseous lines 19
Convulsions 20
Diarrhoea / dehydration 21
 Fluids for severe and some dehydration 22
Malaria 23
 Malaria drug doses 24
Malnutrition 31-39
 Emergency fluids & feed recipes
 Feeding
Meningitis 40-42
Respiratory disorders
 Pneumonia 42
 Pneumonia treatment failure 43
 Asthma 44
HIV – PITC and influence on acute treatment 45-47
Newborn Care Management Guidelines
 Newborn resuscitation 48
 Neonatal Sepsis / Prematurity / VLBW 50
 Neonatal Jaundice 51
 Newborn care notes – treatment, and early nutrition 52
 Newborn feeds / fluids (ages 1 – 7 days) 53
 Newborn drugs (ages 1 – 6 days) 54
Emergency estimation of child’s weight 46
Appendix 1 – Prescribing oxygen 47
Appendix 2 – Preparation of therapeutic feeds 48- 50
Weight for Length ( height) charts 51- 54
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Abbreviations

CTX = Cotrimoxazole prophylaxis treatment

OPD= Outpatient department
PITC= Provider initiated testing and counselling
RUTF = Ready to Use Therapeutic Foods
SDTM = Specially Diluted Therapeutic Milk

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Principles of good care:

1) Facilities must have basic equipment and drugs in stock at all times
2) Sick children coming to hospital must be immediately assessed
(triage) and if necessary provided with emergency treatment as soon
as possible.
3) Assessment of diagnosis and illness severity must be thorough and
treatment must be carefully planned. All stages should be
accurately documented.
4) The protocols provide a minimum, standard and safe approach to
most, but not all, common problems. Care needs to be taken to
identify and treat children with less common problems rather than just
applying the protocols without thinking.
5) All treatments should be clearly and carefully prescribed on patient
treatment sheets with doses checked by nurses before
administration. (Please write dose frequency as 6hrly, 8hrly, 12hrly
etc rather than qid, tid etc)
6) The parents / caretakers need to understand what the illness and its
treatment are. They can often then provide invaluable assistance
caring for the child. Being polite to parents considerably improves
communication.
7) The response to treatment needs to be assessed. For very severely ill
children this may mean regular review in the first 6 – 12 hours of
admission – such review needs to be planned between medical and
nursing staff.
8) Correct supportive care – particularly adequate feeding, use of
oxygen and fluids - is as important as disease specific care.
9) Laboratory tests should be used appropriately and use of
unnecessary drugs needs to be avoided.
10) An appropriate discharge and follow up plan needs to be made when
the child leaves hospital.
11) Good hand washing practices and good ward hygiene improve
outcomes for admitted newborns and children.

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Specific policies:

 All children admitted to hospital and all newborns requiring medical

treatment – even if born in hospital – should have their own inpatient
number and set of medical records. Admission should ideally be
recorded using a standardized paediatric or newborn admission record
 Medical records are a legal document and entries should be clear,
accurate and signed with a date and time of the entry recorded
 All paediatric admissions should be offered HIV testing using PITC
 All newborn admissions aged < 14 days should receive Vitamin K unless
it has already been given.
 Routine immunization status should be checked and missed vaccines
given before discharge.
 All admissions aged >6m should receive Vitamin A unless they have
received a dose within the last 1 month. (Malnourished children with eye
signs receive repeated doses).

Admission and Assessment:

 All admitted children must have weight recorded and used for calculation
of fluids / feeds and drug doses.
 Length / Height should be measured with weight for height (WHZ) used
to establish nutritional status
 Respiratory rates must be counted for 1 minute.
 Conscious level should be assessed on all children admitted using the
AVPU scale where:
o A = Alert and responsive
o V = responds to Voice or Verbal instructions, eg turns head to
mother’s call. These children may still be lethargic or unable to
drink / breastfeed (prostrate).
o P = responds to Pain appropriately. In a child older than 9 months a
painful stimulus such as rubbing your knuckles on the child’s sternum
should result in the child pushing the hand causing the pain away. In
a child 9 months and younger they do not reliably locate a painful
stimulus, in these children if they bend the arms towards the pain and
make a vigorous, appropriate cry they respond to pain = ‘P’. Children
in this category must be lethargic or unable to sit up or drink /
breastfeed (prostrate).
o U = Unconscious, cannot push a hand causing pain away or fail to
make a response at all.
 Children with AVPU < A should have their blood glucose checked. If this
is not possible treatment for hypoglycaemia should be given.
 The sickest newborns / children on the ward should be near the nursing
station and prioritized for re-assessment / observations.

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Clinical audit and use of the protocols
1. Clinical audit is aimed at self improvement and is not about finding who
to blame.
2. The aims are for hospitals to diagnose key problems in providing care -
it is essential that identifying problems is linked to suggesting who
needs to act, how and by when to implement solutions. Then follow up
on whether progress is being achieved with new audits. Identify new
problems and plan new actions etc.

3. Hospitals should have an audit team comprising 4 to 8 members, led by

a senior clinician and including nurses, admin, lab, nutrition etc. 1-2
people, usually MO or CO interns and nurses should be selected on a
rotating basis to perform the audit and report back to the audit team and
department staff. Deaths and surviving cases can be audited.
Records of all deaths should be audited within 24 hours of death

4. Use an audit tool to compare care given with recommendations in these

protocols and other guidelines (eg for TB, HIV/AIDS) and the most up to
date textbooks for less common conditions.

5. Was care reasonable? Look for where improvements could be made in

the system of care before the child comes to hospital (referral), on arrival
in hospital (care in the OPD / MCH etc), on admission to a ward, or
follow up on the ward.

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6. Look at assessments, diagnoses, investigations, treatments and whether
what was planned was done and recorded. Check doses and whether
drugs / fluids / feeds are correct and actually given and if clinical review
and nursing observations were adequate – if it is not written down it
was not done!

7. Look at several cases for each meeting and summarize the findings
looking for the major things that are common and need improving.
Then record the summaries for reporting.

Hand Hygiene

 Good hand hygiene saves lives

 Gloves can easily become contaminated too – they do not protect
patients
 Alcohol hand-rubs are more effective than soap and water and are
recommended
o If hands are visibly dirty they must be cleaned first with soap and
water before drying and using alcohol hand-rub
o The alcohol hand-rub must be allowed to dry off to be effective
o If alcohol hand-rub is not available then hands should be washed
with simple soaps and water and air-dried or dried with disposable
paper towels
 Hand hygiene should be performed:
o After contact with any body fluids
o Before and after touching a patient and most importantly before
and after handling cannulae, giving drugs or performing a
procedure (eg. Suction)
o Before and after touching potentially contaminated surfaces (eg.
cot sides, dirty mattresses, stethoscopes)
 Patients and caregivers should wash hands carefully after visits to the
bathrooms or contact with body fluids

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Use of Alcohol Hand rub / gel/ soap. Wash hand when visibly soiled

WHO guidelines on hand hygiene in health care 2009

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Essential Drugs Doses
Adrenaline 1 in 10,000 Dilute 1; 9 (1 in 1000 adrenaline in water for
injection). Give 0.1ml/kg in resuscitation.
Adrenaline 1 in 1,000 Severe viral croup 2ml of 1:1000 nebulized
If effective repeat with careful monitoring

Albendazole Age < 2yrs, 200mg stat, Age ≥ 2yrs, 400mg stat

Amikacin 15mg/kg once daily. Slow IV over 3-5min

If serious gram –ve infection/resistance to
gentamicin higher doses may be used with
monitoring
Aminophylline- iv Newborn Loading dose 6mg/kg iv over 1 hour or
ONLY used in hospital rectal, Maintenance (or oral): Age 0-7 days -
inpatients! 2.5mg/kg 12hrly, Age 7-28 days 4mg/kg 12hrly.
Asthma: 6mg/kg iv first dose over 30 mins
Use 25mg/kg/dose for mild infections and 40-
45mg/kg for pneumonia and severe infections
Amoxicillin
Neonate: 50mg/kg/dose 12 hourly IV or IM if
aged <7 days and 8 hourly if aged 8- 28 days.
Ampicillin
Aged 1m and over: 50mg/kg/dose ( Max 500mg)
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Artemether- Lumefantrine Page 26
Page 26
Artemisinin-Piperaquine/
If < 20kg give 3.0mg/kg/dose and if >20kg give
Artesunate - iv
2.4mg/kg/dose
Azithromycin 10mg/kg max 500mg PO daily for 3 days
Beclomethasone Age < 2yrs 50-100 micrograms 12hrly, ≥ 2yrs
100-200 micrograms 12hrly
Budesonide MDI with a spacer 200 micrograms daily

Benzyl Penicillin (X-pen) Neonate Page 50, other Page 13

Calcium Symptomatic hypocalcemia (tetany/convulsions)

Iv bolus of 10% calcium gluconate 0.5 ml/kg (
0.11 mmol/kg) to a maximum of 20ml over 5-10

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 min then continuous IV infusion over 24h of 1.0
mmol/kg ( maximum 8.8 mmol).
Mild hypocalcemia
50mg/kg/day of elemental calcium PO in 4
divided doses
Cefotaxime Preferred to ceftriaxone in treatment of neonatal
meningitis if aged < 7 days
Pre-term: 50mg/kg 12 hrly
Term aged < 7 days : 50mg/kg 8 hrly
Age < 7 days or weight <1200g: 50mg/kg IM/IV
12 hrly
Ceftazidime Age > 7 days or weight > 1200g: 50mg/kg IM/IV
8 hrly
1 mo- 12yrs: 30-50mg/kg IM/IV 8 hrly (Max:
6g/day) (for pseudomonas infections)

Ceftriaxone Neonate Page 50, other Page 13

Chloramphenicol iv
Page 13

(4% Chlorhexidine) apply once daily until cord

7.1% Chlorhexidine
separates
Digluconate

Ciprofloxacin - oral Dysentery dosing: Page 14

Clotrimazole 1% Apply paint / cream daily
Dexamethasone For severe croup 0.6mg/kg stat
Flucloxacillin Neonate Page 45, other Page 13
Co-trimoxazole– 240mg/5ml syrup 480mg tabs
Weight
pneumonia dosing 12hrly 12hrly
(4mg/kg Trimethoprim & 2 - 3kg 2.5mls 1/4
20mg/kg 4 - 10kg 5mls 1/2
sulphamethoxazole) 11 - 15 kg 7.5ls 1/2
16 - 20 kg 10mls 1

Diazepam - iv 0.3mg/kg (=300 mcg/kg) & See separate chart

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Diazepam – rectal 0.5mg/kg (=500 mcg/kg) & See separate chart

Digoxin 15 mics/kg loading dose then 5 mics/kg 12 hrly

Erythromycin 30-50mg/kg/day in 3 -4 divided doses: max

2g/day

Gentamicin 7.5mg/kg/24hr IM or slow IV

Ibuprofen 5 - 10 mg/kg 8 hourly

Iron tabs / syrup 200mg tabs Syrup 140mg/5mls
200mg Ferrous sulphate tabs
Weight
Twice daily Twice daily
140mg /5mls Ferrous 3-6 kg - 2.5 mls
fumarate syrup 7-9 kg 1/4 5 mls
10-14 kg 1/2 10 mls
15-20 kg 1/2 15 mls
Ketoconazole 3mg/kg daily
Mebendazole (age > 1yr) 100mg bd for 3 days or 500mg stat
Metronidazole - oral Neonate Page 45, other Page 13
Morphine <1 month, 150mcg/kg, 1-11 months 200mcg/kg,
1 - 5yrs 2.5 - 5 mg, 6 – 12 yrs 5 – 10 mg
Multivitamins <6 months 2.5mls daily, >6months 5mls 12 hrly
Nystatin (100,000 iu/ml) 1ml 6hrly (2 weeks in HIV positive children)
Paracetamol 10-15mg / kg 6 to 8 hrly
Pethidine, im 0.5 to 1mg / kg every 4- 6 hours
Phenobarbitone Page 12
Potassium Oral: 1 - 4 mmol/kg/day (same dose for i.v route)
Prednisolone - tabs Asthma 1mg / kg daily (usually for 3 days)
Quinine Page 25
Salbutamol IV in hospital only over 5 mins – <2yrs 5
IV therapy should only be microgram/kg, ≥ 2yrs up to 15 microgram/kg max
used on an HDU, ideally dose 250 micrograms
with a monitor, and MUST
Nebulised 2.5mg/dose as req’d (see ‘Page 34)
be given slowly as directed
Oral salbutamol should Inhaled (100 microgram per puff) 2 puffs via
ONLY be used if inhaled spacer repeated as req’d acutely – see page 34
therapy is not possible and for emergency use - or 2 puffs up to 4-6 hrly for
for a maximum duration of 1 short-term maintenance or outpatient treatment.
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week. Use inhaled steroid Oral 1mg/dose 6-8hrly aged 2-11 months,
for persistent asthma 2mg/dose 6-8hrly aged 1 - 4 yrs (1 week only)
Vitamin A Age
Once on admission, not to < 6 months 50,000 u stat
be repeated within 1 month.
For malnutrition with eye 6 – 12 months 100,000 u stat
disease repeat on day 2 and > 12 months 200,000 u stat
day 14
Vitamin D – Rickets < 6 months 3,000 u = 75 micrograms
Low dose regimens daily for > 6 months 6,000 u = 150 micrograms
8 – 12 wks or high dose
stat. Calcium 50mg/kg/day > 6 months stat 300,000 u = 7,500
for first week of treatment. regimen micrograms or 7.5 mg Stat
Vitamin D – Maintenance < 6 months 200 - 400 u (5 – 10 μg)
After treatment course > 6 months 400 - 800 u (10 – 20 μg)
Vitamin K Newborns: 1mg stat im (<1500g, 0.5mg im stat)
For liver disease: 0.3mg/kg stat, max 10mg
Zinc Sulphate > 6 mths 20mg, ≤ 6mths 10mg od, 14 days

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 Emergency drugs – Diazepam and Glucose (NB Diazepam is not used in neonates).

Diazepam Glucose,
(The whole syringe barrel of a 1ml or 2ml syringe should be inserted
gently so that pr DZ is given at a depth of approx. 4 - 5cm) 5mls/kg of 10% glucose over 5 - 10 minutes
Weight, iv iv pr pr iv
(kg) mls of
Dose, Dose, mls of 10mg/2ml Total Volume of 10%
10mg/2ml To make 10% glucose
0.3mg/kg 0.5mg/kg solution Glucose
solution
3.00 1.0 0.20 1.5 0.3 15 50% Glucose and water
4.00 1.2 0.25 2.0 0.4 20 for injection:
5.00 1.5 0.30 2.5 0.5 25
6.00 1.8 0.35 3.0 0.6 30 10 mls syringe:
 2 mls 50% Glucose
7.00 2.1 0.40 3.5 0.7 35
 8 mls Water
8.00 2.4 0.50 4.0 0.8 40
9.00 2.7 0.55 4.5 0.9 45 20 mls syringe:
10.00 3.0 0.60 5.0 1.0 50  4 mls 50% Glucose
11.00 3.3 0.65 5.5 1.1 55  16 mls Water
12.00 3.6 0.70 6.0 1.2 60 50% Glucose and 5%
13.00 3.9 0.80 6.5 1.3 65 Glucose:
14.00 4.2 0.85 7.0 1.4 70
15.00 4.5 0.90 7.5 1.5 75 10 mls syringe:
 1 mls 50% Glucose
16.00 4.8 0.95 8.0 1.6 80
 9 mls 5% Glucose
17.00 5.1 1.00 8.5 1.7 85
18.00 5.4 1.10 9.0 1.8 90 20 mls syringe:
19.00 5.7 1.15 9.5 1.9 95  2 mls 50% Glucose
20.00 6.0 1.20 10.0 2.0 100  18 mls 5% Glucose

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 Anticonvulsant drug doses and administration

Weight Phenobarb, Phenobarb, Phenobarb Phenytoin, Phenytoin,

(kg) Loading dose, maintenance, maintenance loading dose, maintenance
15mg/kg 5mg/kg daily 2.5mg/kg daily 15mg/kg 5mg/kg daily
(use 20mg/kg for (high dose – (starting dose – fits in
neonates) chronic therapy) acute febrile illness)
im / oral im – mg oral - tabs im / oral iv / oral / ng iv / oral / ng
2.0 30 10 5 Tablets may be crushed and put
-
2.5 37.5 12.5 6.25 down ngt if required.
-
3.0 45 15 7.5 45 15
4.0 60 20 ½ tab 10 60 20
5.0 75 25 12.5 75 25
6.0 90 30 15 ½ tab 90 30
7.0 105 35 1 tab 17.5 105 35
8.0 120 40 20 120 40
9.0 135 45 22.5 135 45
10.0 150 50 1½ tab 25 1 tab 150 50
11.0 165 55 27.5 165 55
12.0 180 60 30 180 60
13.0 195 65 2 tabs 32.5 195 65
14.0 210 70 35 210 70
15.0 225 75 37.5 225 75
1½ tab
16.0 240 80 2½ tab 40 240 80
17.0 255 85 42.5 255 85
18.0 270 90 45 270 90
19.0 285 95 3 tabs 47.5 285 95
2 tabs
20.0 300 100 50 300 100

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Intravenous / intramuscular antibiotic doses – AGES 7 DAYS AND OLDER (NN doses see Page 45).

Weight Penicillin* Ampicillin or Chloramphenicol Gentamicin Ceftriaxone iv/im Metronidazole

(kg) (50,000iu/kg) Flucloxacillin (25mg/kg) (7.5mg/kg) Max 50mg/kg 24hrly (7.5mg/kg)
(50mg/kg) im or iv over for neonates**
iv / im iv / im iv / im 3-5 mins Meningitis / V Sev Iv
Sepsis, 100mg/kg
over 30-60 min. OD 12 hrly < 1m,
6 hrly 8 hrly 6hrly - meningitis 24 hrly 50mg/kg ≥ 1m 8 hrly
3.0 150,000 150 75 20 150 20
4.0 200,000 200 100 30 200 30
5.0 250,000 250 125 35 250 35
6.0 300,000 300 150 45 300 45
7.0 350,000 350 175 50 350 50
8.0 400,000 400 200 60 400 60
9.0 450,000 450 225 65 450 65
10.0 500,000 500 250 75 500 75
11.0 550,000 550 275 80 550 80
12.0 600,000 600 300 90 600 90
13.0 650,000 650 325 95 650 95
14.0 700,000 700 350 105 700 105
15.0 750,000 750 375 110 750 110
16.0 800,000 800 400 120 800 120
17.0 850,000 850 425 125 850 125
18.0 900,000 900 450 135 900 135
19.0 950,000 950 475 140 950 140
20.0 1,000,000 1000 500 150 1000 150
*NB. Double Pen doses if treating Meningitis and age > 1 month ** Not recommended if jaundiced
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 Oral antibiotic doses - For neonatal doses see Page 45.

Cloxacillin / High dose Amoxicillin for Metronidazole

Amoxicillin, oral, Ciprofloxacin
Flucloxacillin pneumonia and severe 7.5mg/kg/dos
25mg/kg/dose 15mg/kg/dose
15mg/kg/dose infections 40-45mg/kg/dose e
250mg
mls susp 250mg mls susp mls susp 250mg
caps or 250mg tabs 200mg tabs
125mg/5ml caps 125mg/5ml 125mg/5ml tabs - disp
tabs
Weight 12 hrly 12 hrly
12 hrly 12 hrly 8 hrly 8 hrly 8 hrly
kg (for 3 days)
3.0 5 1/2* 2.5 1/4 5 1/2tab
4.0 5 1/2* 2.5 1/4 7.5 1/4
5.0 5 1/2* 5 1/4 10 1/4 ¼
6.0 5 1/2* 5 1/2 10 1/4 ¼
1 tab = 250
7.0 7.5 1/2* 5 1/2 15 1/2 ½
8.0 7.5 1/2* 5 1/2 15 1/2 ½
9.0 7.5 1 5 1/2 15 1/2 ½
10.0 10 1 5 1 20 1/2 ½
11.0 10 1 10 1 20 2 tabs = 1 ½
12.0 10 1 10 1 20 500 1 ½
13.0 10 1 10 1 25 1 ½
14.0 15 2 10 1 25 1 1
15.0 15 2 10 1 25 1 1
16.0 15 2 10 1 1 1
3 tabs =
17.0 15 2 10 1 1 1
750
18.0 15 2 10 1 1 1
19.0 20 2 10 1 1 1
20.0 20 2 10 1 1 1
*Amoxicillin syrup should be used and capsules divided ONLY if syrup is not available 16
Initial Maintenance Fluids / Feeds – Normal Renal Function

Note:
 Feeding should start as soon as safe and infants may rapidly increase to
150mls/kg/day of feeds as tolerated (50% more than in the chart).
 Add 50mls 50% dextrose to 450mls Ringer’s Lactate to make Ringer’s/5%
dextrose a useful maintenance fluid.
 Drip rates are in drops per minute
Drip rate - Drip rate - 3hrly bolus
Weight, Volume in Rate in
adult iv set, paediatric burette feed
kg 24hrs mls / hr
20 drops = 1ml 60 drops = 1ml volume
3 300 13 4 13 40
4 400 17 6 17 50
5 500 21 7 21 60
6 600 25 8 25 75
7 700 29 10 29 90
8 800 33 11 33 100
9 900 38 13 38 110
10 1000 42 14 42 125
11 1050 44 15 44 130
12 1100 46 15 46 140
13 1150 48 16 48 140
14 1200 50 17 50 150
15 1250 52 17 52 150
16 1300 54 18 54 160
17 1350 56 19 56 160
18 1400 58 19 58 175
19 1450 60 20 60 175
20 1500 63 21 63 185
21 1525 64 21 64 185
22 1550 65 22 65 185
23 1575 66 22 66 185
24 1600 67 22 67 200
25 1625 68 23 68 200

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Triage of sick children
Emergency Signs:
If history of trauma ensure cervical spine is protected.

Airway &  Obstructed breathing

Breathing  Central Cyanosis
 Severe respiratory distress Immediate transfer to
 Weak / absent breathing emergency area:
 Start Life support
Cold Hands with ANY of: procedures
Circulation  Capillary refill >  Give oxygen
3seconds  Weigh if possible
 Weak + fast pulse
 Slow (<60bpm) or absent
pulse

Disability: Coma / convulsing / confusion: AVPU = ‘P or U’ or Convulsions

Diarrhoea with sunken eyes → assessment / treatment for severe dehydration

Priority Signs
 Tiny - Sick infant aged < 2 months
 Temperature – very high > 38.50C, very
low < 35.5C
 Front of the Queue:
 Trauma – major trauma
clinical review as
 Pain – child in severe pain
 Poisoning – mother reports poisoning
soon as possible
 Pallor – severe palmar pallor  Weigh
 Restless / Irritable / Floppy  Baseline
 Respiratory distress observations
 Referral – has an urgent referral letter
 Malnutrition - Visible severe wasting
 Oedema of both feet
 Burns – severe burns
 Burns – severe burns
Non-urgent – Children with none of the above signs

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Infant / Child Basic Life Support – Cardio-respiratory collapse

Safe, Stimulate, Shout for Help! - Rapidly move child to emergency area

1) Assess and clear airway, 2) Position head / neck to open airway

Assess breathing – look, listen, feel for 5 seconds

No breathing Adequate breathing

Give 5 rescue breaths with bag and

mask – if chest doesn’t move check Support airway
airway open and mask fit and repeat. Continue oxygen

After at least 5 good breaths

Check large pulse for 5 -10 seconds

Pulse palpable
and >60bpm
No or weak, slow pulse (<60bpm)

Give 15 chest compressions then 1) Continue 20 -30 breaths/min

continue giving 15 chest compressions with oxygen,
for each 2 breaths for 1-2 minute(s). 2) Look for signs of dehydration
/ poor circulation and give
Improvement emergency fluids as
Re-assess ABC
necessary,
No change 3) Consider treating
hypoglycaemia
1) Continue 15 chest 4) Continue full examination to
compressions : 2 Improvement establish cause of illness and
breaths for 2 minutes, treat appropriately.
2) Reassess ABC

No change Improvement
1) Consider iv 0.1ml/kg 1 in 10,000 [ mix 1ml (1in 1,000) in 9mls of
sterile water] Adrenaline if 3 people in team,
2) Consider fluid bolus if shock likely and treatment of hypoglycaemia
3) Continue CPR in cycles of 2 - 3 minutes after any intervention
4) Reassess ABC every 2 – 3 minutes.
5) Consider advanced life support/care; ( +/- referral to next level) 19
Management of the infant / child without trauma WITH SIGNS OF LIFE –
Assessment prior to a full history and examination
Obs Safe Eye contact / movements
Stimulate – if not Alert Shout unless obviously alert
Shout for Help – if not Alert If not Alert place on resus couch
Setting for further evaluation If alert it may be most appropriate to
continue evaluation while child is with
parent
A Assess for obstruction by listening Position only if not alert and placed
for stridor / airway noises. on couch
Look in the mouth if not alert Suction (to where you can see) if
Position – if not Alert (appropriate indicated (not in alert child),
for age) Guedel airway only if minimal
response to stimulation
B Assess adequacy of breathing Decide:
 Cyanosis?  Is there a need for oxygen?
 Grunting?  Is there a need for immediate
 Head nodding or bobbing? bronchodilators?
 Rapid or very slow breathing?
 Indrawing?
 Deep / Acidotic breathing
If signs of respiratory distress
listen for wheeze
C Assess adequacy of circulation Decide:
 Large pulse – very fast or If shock (all 4 signs) AND Diarrhoea.
very slow? Give 20mls/kg Ringer’s over 15
 Coldness of hands and line of minutes and progress to Plan C fluids
demarcation? for diarrhea/dehydration
 Capillary refill? > 3 sec
 Peripheral pulse – weak or If severe pallor anaemia with deep
not palpable? breathing/resp. distress, transfuse
 (Note initial response to immediately
stimulation / alertness)
 Check for severe pallor If shock (all 4 signs) and No
If signs of very poor circulation diarrhoea or severe anaemia, give
 Check for signs of severe 20mls/kg Ringer’s over 1-2 hours
malnutrition (oedema/ visible
wasting) If No diarrhoea or anaemia & < 4
If not shock but significant signs shock, give maintenance fluids
circulatory compromise (NO BOLUS)
 Check for severe dehydration
D Assess AVPU Decide:
If AVPU = A, Re-assess ABC  Does this child need 10%
If AVPU < A give 10% Dextrose dextrose? (if AVPU< A)
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Use of intra-osseous lines
Use IO for all children in shock if no IV access to avoid delays in initiation of fluid
therapy
 Use IO or bone marrow needle 15-18G if
available or 16-21G hypodermic needle
 Clean after identifying landmarks then
use sterile gloves and sterilize site
 Sterility - Use antiseptic and sterile
gauze to clean site (alcohol 70% or iodine
or chlohexidine)
 Site – Middle of the antero-medial (flat)
surface of tibia at junction of upper and
middle thirds – bevel to toes and
introduce vertically (900)- advance slowly
with rotating movement
 Stop advancing when there is a ‘sudden
give’ – then aspirate with 5mls needle
 Slowly inject 3mls N/Saline looking for
any leakage under the skin – if OK attach
iv fluid giving set and apply dressings and
strap down
 Give fluids as needed – a 20mls / 50mls
syringe will be needed for boluses
 Watch for leg / calf muscle swelling
 Replace IO access with iv within 8 hours

21
Treatment of convulsions
Convulsions in the first 1 month of life should be treated with Phenobarbitone
20mg/kg stat, a further 5-10mg/kg can be given within 24 hours of the loading
dose with maintenance doses of 5mg/kg daily.

Age > 1 month

Child 1) Ensure safety and check ABC.

Y
convulsing for 2) Start oxygen.
more than 5 3) Treat both fit and hypoglycaemia:
minutes Give i.v diazepam 0.3mg/kg slowly over 1
minute, OR rectal diazepam 0.5mg/kg.
N
Check glucose / give 5mls/kg 10% Dextrose
Child having 3rd 4) Check ABC when fit stops.
convulsion lasting
<5mins in < 2 hours.*
N Convulsion stops
Y by 10 minutes?
Check ABC, observe and
investigate cause. N
Y
Treatment:
5) Give iv diazepam 0.3mg/kg slowly over 1
minute, OR rectal diazepam 0.5mg/kg.
6) Continue oxygen.
7) Check airway is clear when fit stopped.

Check ABC, observe and Y Convulsion stops

investigate cause. by 15 minutes?
N
Treatment:
8) Give im phenobarbitone 15mg/kg – DO NOT
* If children have give more than 2 doses of diazepam in 24
up to 2 fits hours once phenobarbitone used. (If given iv,
lasting <5 mins give over 20mins)
they do not 9) Maintenance therapy should be initially with
require
emergency drug
phenobarbitone 5mg/kg OD x 48 hrs.
treatment. 10) Continue oxygen during active seizure.
11) Check ABC when fit stops.
12) Investigate cause.

22
Diarrhoea / GE protocol (excluding severe malnutrition)
Antibiotics are NOT indicated unless there is dysentery or persistent diarrhoea and proven
amoebiasis or giardiasis. If dysentery but unable to do stool analysis, cover for shigella first as
is the commonest cause Diarrhoea > 14 days may be complicated by intolerance of ORS –
worsening diarrhoea – if seen (increase in stool volumes, new/worsening dehydration)change
to iv regimens. cases to receive Zinc

History of diarrhoea / vomiting, age > 2 months

Hypovolaemic SHOCK. Ringers 20mls/kg over 15 minutes, a

All four of Y second boluses may be given if required
 Cold hands + temp grad before proceeding to step 2 of plan C
 weak i) / absent pulse . Treat for hypoglycaemia
 Capillary refill > 3 secs . Start ORS 5 mls/kg/hr once able to
drink
 AVPU < A
NB if Hb<5g/dl transfuse urgently
iv Step 1 - 30mls/kg
N Ringer’s over 30 mins if
o age ≥ 12m, over 60 mins
SEVERE Dehydration. Y
if age < 12m.
(Plan C)
Unable to drink or AVPU OR
< A plus: iv Step 2 - 70mls/kg Ringer’s over 2.5
 Sunken eyes hrs age ≥ 12m, over 5 hrs age <12m.
 Slow skin pinch ≥2
secs
If no iv access/ iv fluids: ngt
rehydration – 100mls/kg ORS
N over 6 hours
Re-assess at least hourly, after 3 - 6 hours re-classify as severe,
some or no dehydration and treat accordingly.

SOME DEHYDRATION Y Plan B,

Able to drink adequately 1) ORS by mouth at 75mls/kg over 4
but 2 or more of: hours, plus,
 Sunken eyes 2) Continue breast feeding and
 slow skin pinch 1-2 secs encourage feeding if > 6 months
 Restlessness / irritability Reassess at 4 hours, treat according
to classification.
N
o
NO DEHYRATION Y Plan A
Diarrhoea/GE with fewer 10mls/kg ORS after each loose stool
than 2 of the above signs Continue breast feeding and
of dehydration encourage feeding if > 6 months 23
 Dehydration management – Child WITHOUT severe malnutrition/severe anaemia *
Plan C – Step 1 Plan C – Step 2 Plan B - 75mls/kg
Shock,
20mls/kg 30mls/kg Ringer’s 70mls/kg Ringer’s or ngt ORS Oral /ngt ORS
Ringer’s or Age <12m, Age ≥ 1yr,
Weight Saline Age <12m, 1 hour
over 5 hrs Volume over 2½ hrs Over 4 hours
kg Immediately Age ≥1yr, ½ hour
= drops/min** = drops/min**
2.00 40 50 10 150 ** Assumes 150
2.50 50 75 13 200 ‘adult’ iv 150
giving sets
3.00 60 100 13 200 where 200
4.00 80 100 20 300 20drops=1ml 300
5.00 100 150 27 400 55 350
6.00 120 150 27 400 55 450
7.00 140 200 33 500 66 500
8.00 160 250 33 500 66 600
9.00 180 250 40 600 80 650
10.00 200 300 50 700 100 750
11.00 220 300 55 800 110 800
12.00 240 350 55 800 110 900
13.00 260 400 60 900 120 950
14.00 280 400 66 1000 135 1000
15.00 300 450 66 1000 135 1100
16.00 320 500 75 1100 150 1200
17.00 340 500 80 1200 160 1300
18.00 360 550 80 1200 160 1300
19.00 380 550 90 1300 180 1400
20.00 400 600 95 1400 190 1500
*Consider Immediate blood transfusion if severe pallor or Hb <5g/dl on admission
24
 Persistent diarrhea, points to remember

Diarrhea with or without blood lasting 14 days or more.

Asses for signs of dehydration and give fluids as per treatment plans A, B, or C.
(remember to watch out for worsening of diarrhea with ORS).
Asses for infections such as pneumonia, sepsis, oral thrush, otitis media, asses
for severe malnutrition.

Obtain samples for CBC, electrolytes, HIV, blood slide, blood culture, stool
microscopy, urine microscopy.

Provide medical treatment and Antibiotic cover as appropriate

All children should receive daily supplementary multivitamins and minerals for
two weeks.

Monitor daily the body weight for gain, food taken, temperature and number of
diarrhea stools.

Feeding in persistent diarrhoea

Infants < 6 months

Encourage exclusive breastfeeding as much as possible

If not breastfeeding, give low lactose breast milk substitute such as yoghurt, or
lactose free milk

Encourage use of cup or spoons as opposed to feeding bottle.

Children 6 months and above

Give reduced lactose diet, as the first option, for at least 7 days.
If there is no improvement after 7 days, change to the second diet, which is
lactose free.

25
1st diet -Starch based, low lactose diet for persistent diarrhea*.
Item Amount Local approximate measures
Powder milk, 27.5g 3 tablespoon fulls
or whole milk
170 ml
Raw rice 30g 3 tablespoon fulls

Vegetable oil 8.75g 1 tablespoon full

Cane sugar 7.5g 1 tablespoon full
Water 500 ml cup

*Adapted from WHO guidelines 2013, quantities modified to aid measurement

Give 130 ml/kg /day

2nd diet – lactose free with reduced cereal*

Item Amount Approximate measures
Whole egg 160g 2 eggs

Raw rice 7.5g 1 tablespoon full

Vegetable oil 10g 1 tablespoon full

Sugar 7.5g 1 tablespoon full
Water To make 500ml 500 ml

* Adapted from WHO guidelines 2013, quantities modified to aid measurement

Give 145ml/kg/ day.

26
 Treatment of malaria
If a high quality blood slide is negative with signs of Severe malaria, do RDT to
confirm absence of malaria infection. Investigate for other causes of fever

Treat with i.v/i.m artesunate (or quinine if

Severe = Fever + any not available):
of: 1. Artesunate: 2.4mg/kg for >20kg or
1. AVPU = ‘V, P, U’, or,
3.0mg/kg for <20kg (at 0,12 & 24 hrs)
2. Unable to drink, or,
2. Treat hypoglycaemia.
3. Respiratory distress Yes 3. Maintenance fluids / feeds.
with severe anaemia or 4. DO NOT give bolus iv fluid unless
acidotic breathing, or, diarrhoea with signs of SEVERE
4. Hypoglycaemia Dehydration
(glucose ≤ 2.2mmols/l)
5. If Respiratory distress & Hb < 5 g/dl
5. 3 or more convulsions
transfuse 20 mls/kg whole blood
No urgently, give over 4 hrs.

Severe anaemia, Hb<5g/dl,

Give AL (or oral second line if
alert (AVPU= ‘A’), able to drink
not available) and iron, if Hb <
and breathing comfortable. Yes 4g/dL, transfuse 20 mls/kg whole
blood (or 10mk/kg packed cells)
No over 4hrs urgently

Fever, none of the severe signs Antimalarial not

above, able to drink / feed, AVPU = Test required, look for
‘A’ then follow reliable malaria test Negative another cause of
result (BS or RDT): illness. Repeat test if
concern remains.
Test Positive
If Hb < 9g/dl treat with oral
st
Treat with recommended 1 line oral iron for 14 days initially. If
antimalarial, or 2nd line if 1st line respiratory distress develops
treatment has failed/not available. and Hb < 5g/dl transfuse
urgently.

Treatment failure:
1) Consider other causes of illness / co-morbidity
2) A child on oral antimalarials who develops signs of severe malaria
(Unable to sit or drink, AVPU=U or P and / or respiratory distress) at
any stage should be changed to i.v artesunate.
3) If a child on oral antimalarials has fever and a positive blood slide
after 3 days (72 hours) then check compliance with therapy and if
treatment failure proceed to second line treatment
27
 Anti-malarial drug doses

Artesunate
Artesunate typically comes as a powder together with a 1ml vial of 5%
bicarbonate that then needs to be further diluted with either normal saline or 5%
dextrose- the amount depends on whether the drug is to be given iv or im (see
table below)
 Do not use water for injection to prepare artesunate for injection
 Do not give artesunate if the solution in the syringe is cloudy
 Do not give artesunate as a slow iv drip (infusion)
 You must use artesunate within 1 hour after it is prepared for injection

Preparing iv/ im Artesunate IV IM

Artesunate powder (mg) 60mg 60mg
Sodium Bicarbonate (mls, 5%) 1ml 1ml
Normal Saline or 5% Dextrose (mls) 5mls 2mls
Artesunate concentration (mg/ml) 10mg/ml 20mg/ml

Quinine

For iv infusion typically 5% or 10% dextrose is used

 Use at least 1 ml fluid for each 1mg of quinine to be given
 Do not infuse quinine at a rate of more than 5mg/kg/hour
o Use 5% dextrose or N/saline for infusion with 0.5-1ml of
fluid for each 1mg of quinine
o 10mg/kg dose takes 4 hours
For i.m quinine
 Take 1ml of the 2mls in a 600mg quinine sulphate iv vial and
add 5mls water for injection – this makes a 50mg/ml solution
 If you need to give more than 3mls in a child, divide the doses
and give into two i.m sites

28
 Malaria treatment doses
 Artesunate is given iv/im for a maximum of 24 hours
 As soon as the child can eat drink (after 24 hours for artesunate)
then change to a full course of artemisinin combination therapy
(ACT) typically the 1st line oral anti-malarial Artemether
Lumenfantrine
 Weight <20kg- 3mg/kg and .20kg – 2.4mg/kg of artesunate
Artesunate, 2.4mg/kg
Quinine,
At 0,12 and 24h then Quinine, tabs,
10mg/kg
daily for max 7 days 10mg/kg
iv mls Dose im mls iv infusion / im 300mg QN
fo in mg of sulphate
Weight 60mg 60mg 8 hrly 8 hourly
kg in 6mls in 3mls
3.0 0.75 7.5 0.35 30 1/4
4.0 1 10 0.5 40 1/4
5.0 1.2 12 0.6 50 1/4
6.0 1.5 14 0.7 60 1/4
7.0 1.7 17 0.8 70 1/4
8.0 1.9 19 1.0 80 1/4
9.0 2.1 22 1.1 90 1/4
10.0 2.4 24 1.2 100 1/2
11.0 2.6 26 1.3 110 1/2
12.0 2.9 29 1.5 120 1/2
13.0 3.1 31 1.6 130 1/2
14.0 3.4 34 1.7 140 1/2
15.0 3.6 36 1.8 150 1/2
16.0 3.8 38 1.9 160 1/2
17.0 4.1 41 2.0 170 1/2
18.0 4.3 43 2.2 180 1/2
19.0 4.6 46 2.3 190 1/2
20.0 4.8 48 2.4 200 1

AL (Artemether + Lumefantrine)
Dihydroartemisinin-piperaquine,
(20:120mg) - Give with food or Milk
OD for 3 days
Stat, +8hrs, BD on Day 2 and Day 3
Weight Age Dose Age Dose
<5kg - 1/2 tablet 3 – 35mth 1 paed tab
5 – 14 kg 3 – 35mth 1 tablet 3 - 5 yrs 2 paed tabs
15 – 24 kg 3 - 7 yrs 2 tablets
6 - 11 yrs 1 adult tab
25 – 34 kg 9 - 11 yrs 3 tablets
> 34kg > 12 yrs 4 tablets
29
 Assessment of nutritional status
Assessment of nutrition status involves history taking, physical
examination for signs of malnutrition and anthropometry.
Anthropometry is the measurement of body parameters in comparison to
reference standards to indicate nutrition status. These include:
 Mid-upper-arm circumference (MUAC)
 Body Weight
 Length (for children below 2years or less than 87cm) or height
(for children above 2years, or > 87.0 cm, adolescents and adults)

Weight and height measurements can be useful to detect wasting

and stunting and individual monitoring over time (growth velocity).
Determine the child’s age from child health card or recall from the
caregiver.
Mid-upper arm circumference
MUAC is used to measure wasting using a tape around the left
upper arm. It is quick and simple to perform in sick patients. It is
essential to use the age limit of 6 months for arm circumference
because there are no standard measurements for infants below
six months of age.

30
 Weight, Height and age
Weight for height (W/H): = measure of wasting, and indicates acute
malnutrition.
Height for age (H/A): measure of stunting and indicates chronic malnutrition
Weight for age (W/A): indicative of both acute and chronic
malnutrition. W/A is thus not used for diagnosis of acute
malnutrition but plotted over time in the diagnosis of acute
malnutrition, we use W/H expressed as Z scores obtained from
WHO growth reference standards and MUAC
Visible severe wasting tends to identify only severe cases of SAM.
It is better to use MUAC.

Bilateral Pitting oedema

Oedema is swelling from excess fluid in the tissues. Oedema is
usually seen in the feet and lower legs and arms. In severe cases
it may also be seen in the upper limbs and face.

Observation Classification
No oedema (0)
Bilateral oedema in both feet (below the + / (Grade 1) mild
ankles)
Bilateral oedema in both feet and legs, ++ / (Grade 2)
(below the knees) hands or lower arms moderate
Bilateral oedema observed on both feet, legs, +++ / (Grade 3)
arms, face severe

31
Classification of acute malnutrition
Age Nutritional Moderate Acute Severe Acute
category indicator Malnutrition (MAM) Malnutrition (SAM)
Infants less Weight for Greater or equal to -3 Less than -3 z-score
than six length z-score and less than - (<-3SD)
months (WFL) 2 z-score (≥ -3 SD & <
-2 SD)
Bilateral No bilateral pitting Presence of bilateral
pitting oedema pitting oedema
oedema
Children Weight for Greater or equal to -3 Less than -3 z-score
from 6 to height z-score and less than - (<-3SD)
59 months (WFH) 2 z-score (≥ -3 SD & <
-2 SD)
MUAC cut Greater or equal to Less than 11.5cm
off 11.5cm and less than (<11.5cm)
12.5cm (≥ 11.5cm & <
12.5cm)
Bilateral No bilateral pitting Presence of bilateral
pitting oedema pitting oedema
oedema
Children BMI for age 5-19 years Less than -3 z-score
5to19 Greater or equal to -3 (<-3SD)
years z-score and less than -
2 z-score (≥ -3 SD & <
-2 SD)
MUAC cut 5 to <10 years Less than 13.5cm
off* Greater or equal to (<13.5cm)
13.5cm and less than
14.5cm (≥ 13.5cm & <
14.5cm)
10 to <15 years Less than 16.0cm
Greater or equal to (<16.0cm)
16.0cm and less than
18.5cm (≥ 16.0cm & <
18.5cm)
15 to <18 years Less than 18.5cm
32
 Greater or equal to (<18.5cm)
18.5cm and less than
21.0cm (≥ 18.5cm & <
21.0cm)
Bilateral No bilateral pitting Presence of bilateral
pitting oedema pitting oedema
oedema

26

33
Complicated Severe Acute Malnutrition
Admit to inpatient therapeutic care centre/hospital if there is:
 WHZ < - 3 or MUAC below cut off for age
 Oedema grade 3 ( +++)
 Medical complications or IMCI dange signs
 Failed appetite test

Treat/prevent hypoglycemia: check blood glucose and treat if

<3mmol/l(5mls/kg 10% dextrose). If glucose test unavailable
Step 1
treat for hypoglycaemia if signs present. Oral/NGT glucose
immediately and therapeutic feeds should be given within
30mins

Treat/prevent hypothermia: check for hypothermia, axillary

Step 2 temperature < 35°C. If present, warm with blankets, kangaroo.
Start therapeutic feeds within 30 mins. Maintain room
temperature at 36°C.

Treat/prevent dehydration: Check for dehydration- use IMAM

Step 3 guidelines to classify then USE fluid plan for severe
malnutrition. If dehydrated, give 5ml/kg of resomal every 30
mins for first 2 hrs then 5-10mls/kg of resomal every 1 hr for up
to 10hrs

Step 4 Electroplye imbalance. Use F75. If not available milk with

mineral mix or 4mmol/kg/day of oral potassium. ( see appendix
3 for preparation of feeds for sevely malnourished children.)

Treat/prevent infection. All ill children with severe acute

Step 5 malnutrition should get iv ampicillin and gentamicin. Add
nystatin/ketoconazole for oral thrush if present. TEO (+atropine
drops) for pus/ulceration in the eye.

Step 6 Correct micronutrient deficiencies. Give high dose Vitamin A on

admission and days 2 and 15 if eye signs. Delay vitamin A until
oedema subsides. Multivits and Folic acid if no F75/F100 or
RUTF
Step 7 Start cautious feeding with F75. See feeding chart. Prescribe the
feeds. ( Feed 2 hourly for first 24hrs, then 3 hrly thereafter)

Steps 8,9,10: Ensure appetite and weight are monitored. Start catch-up feeding with F-100 or
RUTF. Provide a caring and stimulating environment for the child and start educating the
family on nutritional needs of the child. Discharge on RUTF
 Emergency Fluid management in Severe acute Malnutrition

Shock: AVPU < A, plus Cold hands with temperature gradient plus
absent or weak pulse plus capillary refill >3secs
 Give oxygen , Give 10% dextrose, 5ml/kg by IV
 Give IV fluids: 15ml/kg in 1 hour Half Strength Darrow’s
(HSD) in 5% dextrose or Ringers lactate. If HSD in 5%
Dextrose not available it can be made by adding 50mls
50% dextrose to 450mls HSD.
If severe anaemia start urgent blood transfusion not Ringers
If improves:
Give 15ml/kg for another 1 hour of half strength Darrow’s in 5% dextrose
or ringers lactate
then switch to oral ReSomal at 5-10ml/kg every hour alternating with F-
75 therapeutic feeds for up to 10 hours.
If does not improve
 Give maintenance iv fluid at 4mls/kg/hr
 when blood is available, stop all oral and IV fluids, Transfuse
10mls/kg whole blood over 3 hours.
 Introduce F75 after transfusion complete.
Oral / ngt Emergency
Shock
Resomal Maintenance
15mls/kg 10mls/kg/hr 4mls/kg/hr
Half-Strength Darrows in 5% D Resomal HSD in 5% D
iv Oral / ngt Iv
Drops/min if
Weight Shock 10mls/kg/hr for Hourly until
20drops/ml
kg = over 1 hour giving set up to 10 hours transfusion
4.00 60 20 40 15
5.00 75 25 50 20
6.00 90 30 60 25
7.00 105 35 70 30
8.00 120 40 80 30
9.00 135 45 90 35
10.00 150 50 100 40
11.00 165 55 110 44
12.00 180 60 120 46
13.00 200 65 130 48
14.00 220 70 140 50
15.00 240 80 150 52
*See appendix 3 for procedures in preparation of F-75
 Dry Skimmed Milk Vegetable Oil Sugar Water
F 75* 25g 27g 100g Make up to 1000mls
F 100* 80g 60g 50g Make up to 1000mls
* Ideally add electrolyte / mineral solution and at least add potassium
28
Feeding children with severe acute malnutrition –
1. Feeding must be started cautiously, in frequent, small amounts. F-75 s the starter feed.
2. When the child is stabilized (usually after 2-7 days), the “catch-up” formula F-100 or Ready-to-Use-Therapeutic-
Food (RUTF) is used to rebuild wasted tissues.
1) If respiratory distress or oedema get worse or the jugular veins are engorged reduce feed volumes.

F75 – acute feeding F100 RUTF if

No or grade + or ++ Severe oedema, even face no F100
F100 @ 150mls/kg/day
oedema (100mls/kg/day)
(130mls/kg/day)
Weight Total Feeds 3 hourly feed Total Feeds 3 hourly feed Total Feeds 3 hourly 20mg/Kg
(kg) / 24 hrs volume / 24 hrs volume / 24 hrs feed volume
4.0 520 65 400 50 600 75 -
4.5 585 75 450 60 675 85 -
5.0 650 80 500 65 750 95 100
5.5 715 90 550 70 825 105 110
6.0 780 100 600 75 900 115 120
6.5 845 105 650 85 975 125 130
7.0 910 115 700 90 1050 135
7.5 975 120 750 95 1125 140
8.0 1040 130 800 100 1200 150
8.5 1105 140 850 110 1275 160 170
9.0 1170 145 900 115 1350 170 180
9.5 1235 155 950 120 1425 180 190
10.0 1300 160 1000 125 1500 190 200
10.5 1365 170 1050 135 1575 200 210
11.0 1430 180 1100 140 1650 210 220
11.5 1495 185 1150 145 1725 215 230
12.0 1560 195 1200 150 1800 225 240

29
13.0 1690 211 1300 162 1950 243 260
13.5 1755 219 1350 168 2025 253 270
14.0 1820 228 1400 175 2100 262 280
14.5 1885 236 1450 181 2175 271 290
15.0 1950 244 1500 187 2250 281 300
15.5 2015 252 1550 193 2325 290 310
16.0 2080 260 1600 200 2400 300 320
16.5 2145 268 1650 206 2475 309 330
17.0 2210 276 1700 212 2550 318 340
17.5 2275 284 1750 218 2625 328 350
18.0 2340 293 1800 225 2700 337 360
18.5 2405 301 1850 231 2775 346 370
19.0 2470 309 1900 237 2850 356 380
19.5 2535 317 1950 243 2925 365 390
20.0 2600 325 2000 250 3000 375 400
20.5 2665 333 2050 256 3075 384 410

38
 Meningitis – investigation and treatment.
Age ≥ 60 days and history of fever
Immediate LP to view by
eye and laboratory
LP must be done if there’s one of: examination even if malaria
 One of: Coma, inability to drink slide positive unless:
/ feed, AVPU = ‘P or U’. Yes  Child has severe resp.
 Stiff neck, distress
 Bulging fontanelle,  Pupils respond poorly to
 Fits if age <6 months or > 6 light, unequal pupils
 Skin infection at LP site
years,
 GCS < 7/15
 Any seizures
No
Do an LP unless completely
 Agitation / irritability, Yes normal mental state after
febrile convulsion. Review
within 8 hours and LP if
No doubt persists.

Meningitis unlikely, investigate other causes of fever.

Interpretation of LP and treatment definitions:

Either Bedside examination:
 Looks cloudy in bottle (turbid) and not a blood stained tap,
And / or Laboratory examination with one or more of (if possible):
 White cell count > 10 x 106/L
 Gram positive diplococci or Gram negative cocco-bacilli,

Yes to one Classify as definite meningitis:

No to all
1) Ceftriazone, OR
2) Chloramphenicol + Penicillin –
One of:
double dose if age >1mo
 Coma,
Minimum 10 days of treatment i.v/i.m
 Stiff neck,
Steroids are not indicated.
 Bulging fontanelle,
Classify probable meningitis:
+ LP looks clear Yes
1) Chloramphenicol + Penicillin –
double dose if age > 1 mo.
None of these signs Minimum 10 days of treatment i.v / im
Steroids are not indicated.
CSF Wbc + Gram stain result 2)
If meningitis considered
Tests not done
All normal possible –i.v /im
Chloramphenicol & Penicllin
No meningitis
and senior review. 39
40
Pneumonia protocol for children aged 2 - 59 months without severe
acute malnutrition

For HIV exposed / infected children see page 36

History of cough or difficulty

breathing, age > 60 days.

One of the danger signs Y *Severe Pneumonia

Oxygen sat. <90%  Oxygen,
Wheeze

Cyanosis,
 Ampicillin or penicillin
Inability to drink / breast
AND Gentamycin
feed
AVPU = ‘V, P or U’, or
Grunting

Lower chest wall in Y *Pneumonia –

drawing, and/or fast  Oral Amoxicillin, high
breathing dose 40-45mg/kg
Wheeze

No pneumonia,
probable URTI.

Possible Asthma – Treat according to separate protocol p31 and

REVISE classification after initial treatment with bronchodilators

 Revised WHO classification for the management and

treatment of childhood pneumonia February 2014
41
Pneumonia treatment failure definitions
HIV infection may underlie treatment failure – testing helps the child.

See HIV page for indications for PCP treatment.

Definition Action required

Any time.
Progression of pneumonia to very
severe pneumonia (development of Change treatment from Penicillin
cyanosis or inability to drink in a alone to chloramphenicol AND
child with pneumonia without these Gentamycin.
signs on admission)
Obvious cavitations on CXR Treat with oral Cloxacillin* and
gentamicin iv for Staph. Aureus or
Gram negative pneumonia.
48 hours
Severe pneumonia child getting Switch to Ceftriaxone unless
worse, re-assess thoroughly, get suspect Staphylococcal pneumonia
chest X ray if not already done then use oral cloxacillin* and
(looking for empyema / effusion, gentamicin.
cavitations etc). Do CBC and blood
culture. Suspect PCP especially if <12m,
an HIV test must be done - treat
for Pneumocystis if HIV positive/
sero-exposed
Severe pneumonia without
improvement in at least one of:
 Respiratory rate, Change treatment from penicillin to
 Severity of indrawing, chloramphenicol
 Fever >37.5C,
 Eating / drinking.
Day 5.
At least 3 of: a) If only on penicillin change to
0
 Fever, temp >37.5 C chloramphenicol.
 Respiratory rate >60 bpm b) If on chloramphenicol change to
 Still cyanosed or saturation ceftriaxone.
<90% , consider cardiac c) Suspect PCP, do HIV test
disease (must) - treat for PCP if HIV
 Chest indrawing persistent positive or sero-exposed.
 Worsening CXR, d) Consult cardiologist if? cardiac
 Persistent fever and Consider TB, perform mantoux and
respiratory distress. check TB treatment guidelines.
* iv cloxacillin can cause phlebitis, oral route recommended

42
Possible asthma – admission management of the wheezy child

Wheeze + history of cough or difficult breathing – likelihood of asthma

much higher if age > 12m and recurrent wheeze

Y
Immediate Management
Severe:  Oxygen – measure saturation
Wheeze, AVPU < A, Y  Nebulize 2.5mg salbutamol every
Cyanosis, Inability to 20 minutes for 3 doses if needed
drink / breast feed or or inhaler + spacer + mask
inability to talk repeated up to 6 to 10 puffs in
Oxygen sats. <90% 30min (see box below)*.
Pulse rate >200 bpm ( 0-  Consider ipratropium bromide
3 yrs) >180 bpm (4-5 250mcg if poor response
yrs)  Start oral (prednisolone) or iv
steroids if cannot drink
N

Y  Salbutamol 2 puffs of inhaler ( or

Mild or Moderate
2.5mg nebulized) evry 20 mins up
Wheeze and fast
to 3 doses if needed
breathing or lower
 Oxygen
chest wall indrawing
Age 2 – 11 months:
Respiratory rate ≥ 50,
Age ≥12 months:
Respiratory rate ≥ 40 Monitor closely for 1-2 hours

If mild symptoms
If lack of response refer to
allow home on MDI
immediate management above

 Salbutamol by inhaler, spacer + mask

 Reassess respiratory rate after 20-30 minutes, if persistently
elevated give antibiotics for pneumonia and give maintenance fluids
 Give education on use of inhaler, spacer + mask and danger signs
and discharge on salbutamol 4-6 hrly for no more than 5 days plus if
recurrent asthma consider inhaled corticosteroid prophylaxis Look
out for co-morbidities. Prednisolone administered for 3- 5 days.

* If a nebulizer is not available then 1 puff of salbutamol into a spacer

repeated every 3 or so minutes up to 10 times in 30 minutes according
to need (shake inhaler every 2 puffs) 43
HIV – Provider Initiated Testing and Counseling (PITC), Treatment
and Feeding

It is government policy that ALL SICK CHILDREN presenting to facilities with

unknown status should be offered HIV testing using PITC

PITC is best done on admission when other investigations are ordered. All
clinicians should be able to perform PITC and discuss a positive / negative result
Below is quick guide to PITC:
 As much as possible find a quiet place to discuss the child’s admission
diagnosis, tests and treatment plans
 After careful history / examination plan all investigations and then inform
caretaker what tests are needed and that HIV is common in Uganda
 Explain MoH guidance that ALL sick children with unknown status should
have an HIV test – so their child is not being ‘picked out’
 That in this situation it is normal to do an HIV test on a child because:
o You came to hospital wanting to know what the problem was and find
the best treatment for it,
o Knowing the HIV test result gives doctors the best understanding of the
illness and how to treat it
o The treatment that is given to the child will change if the child has HIV
o If the child has HIV s/he will need additional treatment for a long time
and the earlier this is started the better
 That the HIV test will be done with their approval and not secretly
 That the result will be given to them and that telling other family / friends is
their decision
 That the result will be known only by doctors / nurses caring for the child as
they need this knowledge to provide the most appropriate care.
 Give the parent / guardian the opportunity to ask questions.
The person doing PITC should record HIV testing results in the medical
record and indicate whether the caretakers has been informed of the result.

Any child < 18 months with a positive rapid test is HIV exposed and is treated as
though infected until definitive testing rules out HIV infection.

Ongoing Treatment / Feeding.

1) If breastfed encourage exclusive breastfeeding until 6 months then introduce
complementary feed, breastfeed until 12 months of age.
2) Do not abruptly stop breast feeding at 6months, just add complementary feeds.
3) Refer child and caregiver to an HIV support clinic – HAART should be started in
all HIV infected children as soon as the diagnosis is confirmed.
4) All HIV exposed / infected infants should start cotrimoxazole (CTX) prophylaxis
from 6 weeks of age.

44
Managing the HIV exposed / infected infant – Please check for
updates – ARV doses change fast!

PMTCT Nevirapine Prophylaxis:

 If formula fed from birth give nevirapine (NVP) for first 6 weeks only
 If breastfeeding – give NVP from birth until 6weeks of age. For high risk
infants, give NVP from birth until 12weeks of age. High risk infants are
those whose mothers either: have received ART for 4weeks or less before
delivery; or have a viral load (VL) > 1000copies/ml in 4weeks before
delivery; or are diagnosed with HIV during the 3rd trimester or post natal
period.

Age Nevirapine Dosing (10mg/ml formulation)
1 ml (10 mg) once daily (Birth weight <2,500 grams)
0 - 6 weeks
1.5 ml (15 mg) once daily (Birth weight >2,500 grams)
6 w to 6 months 2 ml (20 mg) once daily
6 – 9 months 3 ml (30 mg) once daily
9 – 12 months 4 ml (40 mg) once daily

Pneumonia - All HIV exposed / infected children admitted with signs of severe
pneumonia are treated with:
1. Ampicillin + Gentamicin as first line therapy, Ceftriaxone being reserved for
second line therapy
2. Empiric high dose co-trimoxazole for suspected Pneumocystis jirovecii
pneumonia (see table below) is recommended as additional treatment for HIV-
infected and HIV exposed infants aged 2months – 1year with severe
pneumonia.
Treat and prevent Pneumocystis jirovecii pneumonia (PCP) with Co-
trimoxazole (CTX)

Weight CTX syrup CTX Tabs CTX Tabs Frequency

240mg/5mls 120mg/tab 480mg/tab
1-4 kg 2.5 mls 1 tab 1/4 24hrly for
5-8 kg 5 mls 2 tabs 1/2 prophylaxis,
9-16 kg 10 mls - 1 6 hrly for 3wks for
17-50 kg - 2 PCP treatment

Diarrhoea - All HIV exposed / infected children admitted with acute diarrhoea are
treated in the same way as HIV uninfected children with fluids and zinc. For
persistent diarrhea (≥14days) low-lactose or lactose free milks are recommended if
the child is ≥ 6 months of age
45
Meningitis – Request CSF examination for cryptococcus as well as traditional
microscopy and culture for bacteria.

HAART – See national guidelines for the latest regimens

TB – See national guidelines for TB treatment in an HIV exposed / infected child

46
 Newborn Resuscitation – for trained Health Workers – Be Prepared!
Prepare Before delivery – Equipment, Warmth, Getting Help

If the baby has not taken a breath at all think-

Is there MECONIUM
Breathing should be started within 60 secs

NO Yes

Use warm cloth: dry and stimulate, Before first breath and before
observe activity, colour and drying/ stimulating- Suck oro-
breathing, wrap in dry warm cloth pharynx under direct vision. Do not
with chest exposed do deep, blind suction

Baby now active and Yes Skin to skin with mother to keep
taking breaths? warm: observe and initiate breast
feeding
No

Check airway if clear – if secretions/meconium

visible use suction to clear
A
Put head in neutral position

Keep warm, count rate of

breathing and heart rate –
B Is the baby breathing well? Yes
give oxgen if continued
respiratory distress

Poor or No Breathing / Gasping – Call for Help!

ABC OK

B Person 1 – Start ventilation Give 5

slow breaths – the chest must rise –
continue at 30 – 50 breaths / min Continue with ventilation until 30 – 50
Person 2 – Check chest rise, check breaths / min, Reassess ABC every 1-2
heart rate at 45 – 60sec mins, stop using bag when breathing is
30-50 breaths/min and heart rate is
Yes >100bpm

Give 1 EFFECTIVE breath for every 3 chest

compressions for 1 min, Reassess ABC every
Is the heart rate 1-2 mins, stop compressions when HR >60
C
> 60bpm? No bpm and support breathing until 30-50
breaths/min

47
Neonatal Sepsis / Jaundice – see Page 45 for NN Antibiotic Doses

Age < 60 days

Yes
One or more of:
 Change in level of activity Do LP unless severe respiratory
 Bulging fontanelle distress
 History of convulsions
 Feeding difficulty
 Temperature ≥37.50C or 1) Check for hypoglycaemia, treat
<35.50C if unable to measure glucose.
 Fast breathing / respiratory 2) Start gentamicin and penicillin
rate ≥ 60 bpm Yes (see chart),
 Severe chest in drawing 3) Give oxygen if cyanosed / RR >
 Grunting 60 bpm.
 Cyanosis 4) Give Vitamin K if born at home
or not given on maternity.
Also check 5) Keep warm.
6) Maintain feeding by mouth or
 Jaundice (see page 37 & 38) ngt, use iv fluids only if
 Capillary refill respiratory distress or severe
 Severe Pallor abdominal distension (see
 PROM >18hrs if aged < Yes
7d chart).
 Weight loss >10% of birth wt
Use information to decide -
does baby need fluids, feeds
(Page 40/41) or blood?
No signs of serious illness
Where appropriate:
Is there: 1) Treat for neonatal ophthalmia
 Pus from eye 2) Treat with oral antibiotic –
 Pus from ear cloxacillin, if large, pus-filled
 Pus from umbilicus and Yes septic spots (suspect S.aureus)
redness of abdominal skin 3) Give mother advice and
 Pus-filled blisters / septic arrange review
spots.

None of the above NB. A Newborn with weight <2kg &

premature delivery or small size for
No sign of severe illness, gestational age with reduced ability
review if situation changes. to suck as the only problem may only
require warmth, feeding support and
a clean environment.
48
Neonatal Jaundice

 Assess for jaundice in bright, natural light if possible, check the eyes, blanched
skin on nose and the sole of the foot
 Always measure serum bilirubin if age < 24 hours and if clinically moderate or
severe - Any jaundice if aged <24hrs needs further investigation and treatment
 Refer early if jaundice in those aged <24hrs and facility cannot provide
phototherapy and exchange transfusion
 See next page for guidance on bilirubin levels
 If bilirubin measure unavailable start phototherapy:
o In a well baby with jaundice easily visible on the sole of the foot
o In a preterm baby with ANY visible jaundice
o In a baby with easily visible jaundice and inability to feed or other signs of
neurological impairment and consider immediate exchange transfusion

Stop phototherapy – when bilirubin 50 micromol/L lower than phototherapy

threshold (see next page) for the baby’s age on day of testing

Phototherapy and Supportive Care - Checklist

1. Shield the eyes with eye patches. - Remove periodically such as
during feeds
2. Keep the baby naked
3. Place the baby close to the light source – 45 cm distance is often
recommended but the more light power the baby receives the better the
effect so closer distances are OK if the baby is not overheating
especially if need rapid effect. May use white cloth to reflect light back
onto the baby making sure these do not cause overheating.
4. Do not place anything on the phototherapy devices – lights and
baby need to keep cool so do not block air vents / flow or light. Also
keep device clean – dust can carry bacteria and reduce light
5. Promote frequent breastfeeding. Unless dehydrated, supplements
or intravenous fluids are unnecessary. Phototherapy use can be
interrupted for feeds; allow maternal bonding.
6. Periodically change position supine to prone - Expose the maximum
surface area of baby to phototherapy; may reposition after each feed.
7. Monitor temperature every 4 hrs and weight every 24 hrs
8. Periodic (12 to 24 hrs) plasma/serum bilirubin test. Visual testing for
jaundice or transcutaneous bilirubin is unreliable.
9. Make sure that each light source is working and emitting light.
Fluorescent tube lights should be replaced if:
a. More than 6 months in use (or usage time >2000 hrs)
b. Tube ends have blackened
c. Lights flicker.
49
Treatment of Jaundice if Gestational Age < 37 wks

 Initiate phototherapy earlier than for full term neonates – ideally consult a
gestational age specific chart
 Exchange transfusion if baby has gestational age < 37 wks AND age is
72 hours or more if:
Bilirubin in micromol/litre ≥ gestational age × 10

Treatment if 37 weeks or more gestational age

Bilirubin measurement in micromol/L

Age Repeat Consider Initiate Perform an

(in hours - measurement phototherapy phototherapy exchange
round age in 6 hours - especially if risk transfusion
up to factors - and unless the bilirubin
nearest repeat in 6 level falls below
threshold hours threshold while the
given) treatment is being
prepared
0 - - >100 >100
6 > 100 > 112 > 125 > 150
12 > 100 > 125 > 150 > 200
18 > 100 > 137 > 175 > 250
24 > 100 > 150 > 200 > 300
30 > 112 > 162 > 212 > 350
36 > 125 > 175 > 225 > 400
42 > 137 > 187 > 237 > 450
48 > 150 > 200 > 250 > 450
54 > 162 > 212 > 262 > 450
60 > 175 > 225 > 275 > 450
66 > 187 > 237 > 287 > 450
72 > 200 > 250 > 300 > 450
78 - > 262 > 312 > 450
84 - > 275 > 325 > 450
90 - > 287 > 337 > 450
96+ - > 300 > 350 > 450

50
Duration of Treatment for Neonatal / Young Infant Sepsis
Problem Days of treatment
Signs of Young  Antibiotics could be stopped after 48 hours if all the signs
Infant Infection in a of possible sepsis have resolved and the child is feeding
baby breast feeding well and LP, if done, is normal. Blood culture negative.
well.  Give oral treatment to complete 5 days in total. Advise
the mother to return with the child if problems recur.
Skin infection with  IV / IM antibiotics could be stopped after 72 hours if the
signs of generalised child is feeding well without fever and has no other
illness such as poor problem and LP, if done, is normal. Blood culture
feeding negative.
 Oral antibiotics should be continued for a further 5 days.
Clinical or  IV / IM antibiotics should be continued for a minimum of 5
radiological days or until completely well for 24 hrs.
pneumonia.  For positive LP see below. For positive blood culture see
sensitivity report.
Severe Neonatal  The child should have had an LP and a blood culture
Sepsis  IV / IM antibiotics should be continued for a minimum of 7
days or until completely well if the LP is clear
Neonatal meningitis  IV / IM antibiotics should be continued for a minimum of
or severe sepsis and 14 days.
no LP performed  If Gram negative meningitis is suspected treatment
should be iv for 3 weeks.
NB: IM antibiotics for pre-referral treatment

Newborn Care

**Refer to the National Essential Newborn care package

Fluids, Growth, Vitamins and Minerals in the Newborn:

Babies should gain about 10g / kg of body weight every day after the first 7 days of
life. If they are not check that the right amount of feed is being given.
Vitamin K: All infants aged < 14 days should receive Vitamin K on admission if not
already given.
 All babies born in hospital should receive Vitamin K soon after birth
 If born at home and admitted aged <14d give Vitamin K unless already given
 1mg Vitamin K im if term neonate , 0.5mg im if preterm neonate

51
All premature infants (< 36 weeks or < 2kg) should receive:
 2.5 mls of multivitamin syrup daily once they are on full milk feeding at the age
of about 2 wks plus folate 2.5mg weekly
 2.5mls of ferrous fumarate suspension daily starting at 4-6 weeks of age for
12 wks.

52
 Continuous Positive Airway Pressure

(For maximum benefit start as soon as symptoms are identified)

Newborn with severe Defer CPAP if any of the

respiratory distress with all of following
these Uncontrollable seizures,
Weight >1000gm, APGAR floppy infant or apnoeic or
score of >4 at 5 mins and gasping respiration
Respiratory distress defined as
a Silverman Anderson Score of
>4
Initiate CPAP

Monitor every three hours

 Vital signs- temp., heart rate, resp. rate
 Pulse oximetry
 Silverman Anderson Scoring
 Need of nasal clearing/suction

 Ensure the CPAP Continue CPAP and

seal and equipment Monitor until Silverman
is working well Anderson score of <4
 Senior review for
futher evaluation

Transition from CPAP to

oxygen by nasal prongs

Silverman Anderson Score

Feature Score 0 Score 1 Score 2
Chest movement Equal Respiratory lag Seesaw respiration
Intercostal retraction None Minimal Marked
Xiphoid retraction None Minimal Marked
Nasal flaring None Minimal Marked
Expiratory grunt None Audible with sthethoscope Audible
** Score of >6 initiate CPAP ( consider transfer for mechanical ventilation)

53
Newborn Feeding/Fluid requirements Age Total Daily Fluid / Milk Vol.
 Well baby - immediate milk feeding - Table A. For first feed give 7.5mls
and increase by this amount each feed until full daily volume reached
Day 1 60 mls/kg/day
 Day 1 - Sick baby or Weight <1.5kg start with 24hrs iv 10%D – Table B
 From Day 2 unless baby very unwell start NGT feeds - Begin with 5mls
Day 2 80 mls/kg/day
each 3hrly feed if <1.5kg; 7.5mls 3hrly if ≥1.5kg <2kg; and 10mls 3hrly if ≥
2kg. Increase feed by the same amount every day and reduce iv fluids to
Day 3 100 mls/kg/day
keep within the total daily volume until IVF stopped – Table C
 For IVF from Day 2 use 2 parts 10% dextrose to 1 part HS Darrow’s (eg.
Day 4 120 mls/kg/day
200mls 10% D + 100mls HSD) if not able to calculate or give added Na+
(2-3mmol/kg/day) and K+ (1-2mmol/kg/day) to glucose solution.
Day 5 140 mls/kg/day
 Please ensure sterility of iv fluids when mixing / adding
 Always use EBM for NGT feeds unless contra-indicated
Day 6 160 mls/kg/day
 If signs of poor perfusion or fluid overload please ask for senior opinion on
whether to give a bolus, step-up or step-down daily fluids.
Day 7 180 mls/kg/day

A. Nasogastric 3 hrly feed amounts for well babies on full volume feeds on Day 1 and afterwards
Weight 1.5 to 1.7 to 1.9 to 2.1 to 2.3 to 2.5 to 2.7 to 2.9 to 3.1 to 3.3 to 3.5 to 3.7 to 3.9 to
(kg) 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0
Day 1 12 14 15 17 18 20 21 23 24 26 27 29 30
Day 2 15 18 20 22 24 26 28 30 32 34 36 38 40
Day 3 19 23 25 28 30 33 35 38 40 43 45 48 50
Day 4 24 27 30 33 36 39 42 45 48 51 54 57 60
Day 5 28 32 35 39 42 46 49 53 56 60 63 67 70
Day 6 32 36 40 44 48 52 56 60 64 68 72 76 80
Day 7 36 41 45 50 54 59 63 68 72 77 81 86 90

48
B. IV fluid rates in mls / hr for sick newborns who cannot be fed orally/via ngt on FULL volume

Weight 1.0 - 1.2 - 1.4 - 1.6 - 1.8 - 2.0 - 2.2 - 2.4 - 2.6 - 2.8 - 3.0 - 3.2 - 3.4 - 3.6 - 3.8 -
(kg) 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7 2.9 3.1 3.3 3.5 3.7 3.9
Day 1 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10
Day 2 4 4 5 6 6 7 8 8 9 10 10 11 12 12 13
Day 3 5 5 6 7 8 9 10 10 11 12 13 14 15 15 16
Day 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Day 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23
Day 6 7 9 10 11 13 14 15 17 18 19 21 22 23 25 26
Day 7+ 8 10 11 13 14 16 17 19 20 22 23 25 26 28 29

C. Standard regimen for introducing NGT feeds in a VLBW or sick newborn after 24hrs IV fluids

Weight 1.0 - 1.1 1.2 - 1.3 1.4 - 1.5 1.6 - 1.7 1.8 - 1.9 2.0 - 2.1 2.2 - 2.3 2.4 - 2.5
(kg) IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT
mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly
per feed per feed per feed per feed per feed per feed per feed per feed
hr hr hr hr hr hr hr hr
Day 1 3 0 3 0 4 0 4 0 5 0 5 0 6 0 6 0
Day 2 2 5 3 5 3 5 3 8 4 8 4 10 4 10 5 10
Day 3 1 10 2 10 3 10 2 15 3 15 2 20 3 20 4 20
Day 4 1 15 2 15 3 15 1 22 2 22 0 30 2 30 3 30
Day 5 0 18 1 20 2 20 0 30 1 30 0 36 0 39 1 40
Day 6 0 21 0 25 2 25 0 34 0 38 0 42 0 45 0 50
Day 7+ 0 24 0 30 0 33 0 38 0 42 0 48 0 51 0 56

49
Intravenous / intramuscular antibiotics aged < 7 days Oral antibiotics aged < 7 days
Ampicillin / Gentamicin
Penicillin Ceftriaxone Metronidazole
(50,000iu/kg)
Cloxacillin (3mg/kg <2kg,
(50mg/kg) (7.5mg/kg) Ampicillin /
(50mg/kg) 5mg/kg ≥ 2kg) Amoxycillin,
Cloxacillin
iv / im iv / im iv / im iv / im iv
Weight 25mg/kg 25mg/kg
12 hrly 12 hrly 24 hrly 24 hrly 12 hrly
kg 125mg/5mls 125mg/5mls
1.00 50,000 50 3 50 7.5 Weight
kg 12 hrly 12 hrly
1.25 75,000 60 4 62.5 10
2.00 2 2
1.50 75,000 75 5 75 12.5
2.50 3 3
1.75 100,000 85 6 75 12.5
3.00 3 3
2.00 100,000 100 10 100 15 4.00 4 4
2.50 150,000 125 12.5 125 20
3.00 150,000 150 15 150 22.5
4.00 200,000 200 20 200 30

Ophthalmia Neonatorum: Warning:

Swollen red eyelids with pus  Gentamicin – Please check the dose is correct for weight and age in DAYS
should be treated with a  Gentamicin used OD should be given im or as a slow iv push – over 2-3 mins.
single dose of:  If a baby is not obviously passing urine after more than 24 hours consider
 Amikacin 7.5-10 stopping gentamicin.
mg/kg/dose bd or,  Penicillin dosing is twice daily in babies aged < 7 days
 Ceftriaxone 50mg/kg im  Chloramphenicol should not be used in babies aged < 7 days.
 Ceftriaxone is not recommended in obviously jaundiced newborns – Cefotaxime
is a safer cephalosporin in the first 7 days of life

50
POISONING/ENVENOMING

History: Obtain full details of the poisoning agent, amount and time of ingestion.
SAFETY: WEAR GLOVES (see below: organophosphates)
Examination: A, B, C, D approach
Airway – Check for burns in/around mouth and stridor (corrosives), consider anaesthetic airway support.
Breathing – If respiratory distress, give oxygen (NB: some poisons depress breathing: support with bag valve mask
ventilation). Corrosives and petroleum compounds may cause pulmonary oedema that may take some hours to develop.
Circulation – Assess and treat for shock
Disability – AVPU scale (some poisons cause coma). Check and treat for hypoglycaemia (5ml/kg 10% dextrose). If
eyes involved (conjunctival/ corneal damage) refer to ophthalmologist.

Caution: Method:
Activated - Unprotected airway in - Ideally use within 1hour of ingestion.
charcoal an unconscious child Don’t induce vomiting. May need NGT.
(unless intubated). - Mix charcoal in 8-10 volumes of water.
- Do NOT use with Eg: 5g in 40mls water
ingestion of corrosives or ≤ 1 year 1g/kg
petroleum products. 1-12 years 25-50 grams
> 12years 25-100 grams
Gastric - Do NOT use with - Use in life-threatening poisoning.
lavage ingestion of corrosives or - Ideally within 1hour of ingestion
petroleum products - Left lateral head down position. Insert
- Have suction available large bore NGT, check position, give
as child may vomit 10ml/kg N/saline, aspirate same volume,
repeat until aspirated solution is clear.
48
Organophosphates and carbamates (e.g Malathion, parathion, tetra ethyl pyrophosphate, mevinphos (Phosdrin),
carbamates)

 Wear gloves: can be absorbed through skin

 Wash contact surface e.g. eye or skin
 Give activated charcoal within 4hours if ingested (when unavailable carefully aspirated stomach via NGT)
 DO NOT induce vomiting.
 If parasympathetic activation (salivation, excess respiratory secretions, respiratory compromise, sweating, slow pulse,
small pupils, convulsions, muscle weakness, incontinence) give atropine: 20micrograms/kg (maximum dose 2000
micrograms) every 5-10mins until secretions reduce, pupils dilate and heart rate increases. May need repeated
dosing every 1-4 hours for at least 24hours. Give oxygen.
 With muscle weakness, consider IV pralidoxime 25-50mg/kg infusion over 30mins, may need repeated once/twice.

Petroleum compounds (e.g. Paraffin/kerosene, petrol, turpentine)

 DO NOT induce vomiting or give activated charcoal, may cause aspiration leading to pulmonary oedema or
pneumonitis. Give oxygen and treat wheeze.
 May cause encephalopathy: treat convulsions with diazepam + 10% dextrose.

Corrosive compounds (e.g Bleaches, acids, disinfectants, hydroxides)

 DO NOT induce vomiting or give activated charcoal, may cause further burns to mouth, throat, lungs, oesophagus.
 Give milk or water as soon as possible to dilute the corrosive
 Make child nil orally, get a surgical review to assess damage

49
Specific drugs with antidotes:
Paracetamol
- If within 4hrs give activated charcoal
- If ingested ≥ 150mg/kg: If not vomiting and conscious and within 8hrs:
PO methionine 4 hourly for 4 doses (<6yrs:1g; ≥6yrs:2.5g)

Otherwise use IV acetylcysteine, treatment duration 20hours:

Loading 150mg/kg in 3ml/kg 5% dextrose over 15mins
then 50mg/kg in 7ml/kg 5% dextrose over 4hrs
then 100mg/kg in 14ml/kg 5% dextrose over 16hrs
Over 20kg child volume of glucose can be increased
- Continue infusion beyond 20hrs if late presentation or evidence of liver toxicity
Aspirin and salicylates
- Treat symptomatic cases or if Ingested more than 125mg/kg
- Can cause vomiting, tinnitus, acidotic breathing, cardiac dysrhythmias, coma.
- May need several doses of activated charcoal (if unavailable use gastric lavage)
- If severe acidosis: IV sodium bicarbonate 1mmol/kg over 4hrs + PO potassium
2-5mmol/kg/day divided into 3 doses.
- Give IV maintenance fluids, monitor blood glucose. IM or IV Vit K 10mg STAT.
Iron
- Ingestions of ≥20mg/kg elemental iron is potentially toxic
- If asymptomatic after 6hrs; unlikely to need antidote
- Activated charcoal doesn’t work. Consider gastric lavage.
- Use deferoxamine only if clinical evidence of poisoning (vomiting, diarrhoea,
abdo pain, GI bleeding, drowsiness, convulsions, acidosis). Can give IV or IM.
- IV infusion: 15mg/kg/hr for 4hours, then reduce rate so total dose in 24hours is

50
not greater than 80mg/kg (Maximum dose: 6g/day)
- IM 50mg/kg every 6hours (Maximum dose: 6g/day)

Snake bite
 First aid: splint the limb, apply firm bandage, avoid tourniquet, clean wound
 If systemic or severe local signs draw up IM adrenaline (0.15ml 1:1000) before giving IV antivenom over 1hr (dilute in
2-3 volumes N/saline). Start slowly, monitor for anaphylaxis, if this occurs, stop antivenom and give adrenaline.
Consider salbutamol, hydrocortisone, chlorphenamine.
 When stable, restart antivenom slowly. Repeated doses maybe required.
 Ongoing treatment: hydration, surgical review, analgesia, antitetanus.

51
 Emergency estimation of child’s weight from their age

All babies and children

admitted to hospital Child looks well
should be weighed and nourished, average
the weight recorded in size for age Child looks obviously
underweight – find age
the medial record and in Estimated
but step back 2 age
the Maternal Child Health Age Weight (kg)
/weight categories and
Booklet. 1 – 3 weeks 3.0 use the weight
4 - 7 weeks 4.0 appropriate for this
Estimate the weight younger age-group.
from the age only if 2 - 3 months 5.0
immediate life support Eg. Child thin and age
4 - 6 months 7.0
is required or the 10 months, use the
7 to 9 months 9.0 weight for a 4-6 month
patient is in shock –
well nourished child.
then check weight as 10 to 12 months 10.0
soon as stabilised. 1 to 2 yrs 11.0 If there is severe
malnutrition this chart
All other children 2 to 3 yrs 13.0 will be inaccurate.
should have weight 3 to 4 yrs 15.0
measured.
4 to 5 yrs 17.0

48
Appendix 1: Prescribing Oxygen

Oxygen Administration Flow rate and inspired O2 concentration

Device
Nasal prong or short nasal Neonate – 0.5 L/min
catheter Infant / Child – 1 – 2 L/min
O2 concentration – approx 30-35%

Naso-pharyngeal (long) Neonate – not recommended

catheter Infant / Child – 1 – 2 L/min
O2 concentration – approx 45%

Plain, good fitting oxygen face Neonate / Infant / Child – 5 - 6 L/min

mask (check instructions for mask)
O2 concentration – approx 40 - 60%

Oxygen face mask with Neonate / Infant / Child – 10 - 15 L/min

reservoir bag O2 concentration – approx 80 - 90%

49
 Appendix 2: summary of Antibiotics for Severely Malnourished Children

IF: Give:
NO COMPLICATIONS Amoxicillin oral: 25 mg/kg every 12 hours for 5 days
COMPLlCATIONS Gentamicin1 IV or IM (5 mg/kg), once daily for 7 days, plus:
(shock, hypoglycaemia, hypothermia, severe Ampicillin IV or IM (50 Followed by: Amoxicillin2 Oral:25 mg/kg,
dermatosis, infections, IMCI danger signs, severe mg/kg), every 12 hours for 5 days
anaemia, cardiac failure, and corneal ulceration) every 6 hours for 2
days
If resistance to amoxicillin and ampicillin, and See details of drug use below the drug kit (support material):
presence of medical complications: In the case of sepsis or septic shock: IM ceftriaxone or cefotaxime
(For children / infants beyond one month: 50 mg / kg every 8 to 12
hours) + oral ciprofloxacin (5 to 15 mg / kg 2 times per day).
If suspected staphylococcal infections: Add: cloxacillin (12, 5 to 50
mg /kg / dose four times a day, depending on the severity of the
infection).
If a specific infection requires an additional Specific antibiotic are directed on the drug kit (see support
antibiotic, ALSO GIVE: materials). Refer to the drug kit for severe acute malnutrition with
medical complications.
1
If the child is not passing urine, gentamicin may accumulate in the body and cause deafness. Do not give the second
dose until the child is passing urine.
2
If amoxicillin is not available, give ampicillin, 50 mg/kg orally every 6 hours for 5 days.

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Appendix 3: Preparation of therapeutic feeds for severely malnourished children
1. Dietary management of infants < 6 months with acute malnutrition
All infants with acute malnutrition that are less than six month with or without prospect of breastfeeding should be
managed on diluted F100 (also known as specially diluted therapeutic milk – SDTM) during hospital care. After
discharge from hospital, infants without prospect of breastfeeding are fed on replacement feeds .
Preparation of diluted F100 (SDTM)
Mix one sachet of F100 (410g) in 2.8L of water to make 3.2 L of SDTM. OR
Add 350 ml of water to 1 l of prepared F 100 to make 1.335 L of SDTM
Note: SDTM can be used as an alternative to F75 in case of shortage of F75

2. Dietary management of infants > 6 months and children with acute malnutrition
Preparation of therapeutic feeds F75 and F100
F75 and F100 contain all the elements (milk, fat, sugar, minerals and vitamins) needed for the treatment of acute
severe malnutrition. The milk must be diluted in warm chlorinated or boiled water. Make sure that the temperature is
not above 40°C to avoid damaging the vitamins.
PREPARATION
Add one sachet of powder (410g) to 2L of water to make 2.4L of milk. Sachets should not be spilt. If you have
few patients and you have to prepare small quantity of milk, follow the instructions below.Smaller volumes can
be mixed using the red scoop (4.1g) included with the F75 package (add 20 ml water/ red scoop (4.1g) of F75)

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3. Preparation of local therapeutic feeds
Recipes for F-75 and F-100

Use one of the following recipes for F-75 (Note that

cooking facilities are needed):
Alternatives Ingredient Amount for F-
75
If you have Dried whole milk 35 g
dried whole milk Sugar 70 g
Cereal flour 35 g
Vegetable oil 20 g
Combined Mineral ½ leveled
and Vitamin mix* scoop
Water to make 1000 1000 ml**
ml
If you have Milk 300 ml
fresh cow’s Sugar 70 g
milk, or
Cereal flour 35 g
full-cream
(whole) long life Vegetable oil 20 g
milk Combined Mineral ½ levelled
and Vitamin mix* scoop
Water to make 1000 1000 ml**
ml
Use one of the following recipes for F-100:
If you have Fresh cow’s milk, or 880 ml
fresh cow’s full- cream (whole)
milk, or long life milk
full-cream Sugar 75 g
(whole) long life Vegetable oil 20 g
milk
Combined Mineral ½ leveled scoop
and Vitamin mix*
Water to make 1000 1000 ml**
ml
If you have Dried whole 110 g
dried whole milk milk
 Sugar 50 g
Vegetable oil 30 g
Combined Mineral ½ leveled
and Vitamin mix* scoop
Water to make 1000 1000 ml**
ml
* Where CMV is not available, a mineral mix should be used (20 ml for one
liter of preparation). Contents of mineral mix are given in Annex 3 of the
Introduction Module *

**Important note about adding water: Add just the amount of water
needed to make 1000 ml of formula. (This amount will vary from recipe to
recipe, depending on the other ingredients.) Do not simply add 1000 ml of
water, as this will make the formula too dilute. A mark for 1000 ml should be
made on the mixing container for the formula, so that water can be added to
the other ingredients up to this mark.

Directions for making cooked F-75 with cereal flour (top recipes)
You will need a 1-litre electric blender or a hand whisk (rotary whisk or
balloon whisk), a 1-litre measuring jug, a cooking pot, and a stove or hot
plate. Amounts of ingredients are listed on the previous page. Cereal flour
may be maize meal, rice flour, or whatever is the staple cereal in the area.

It is important to use cooled, boiled water even for recipes that involve
cooking. The cooking is only 4 minutes of gentle boiling, and this may not be
enough to kill all pathogens in the water. The water should be cooled
because adding boiling water to the powdered ingredients may create
lumps.

If using a hand whisk:

1. Mix the flour, milk or milk powder, sugar and oil in a1-litre measuring jug.
(If using milk powder, this will be a paste.)
2. Slowly add boiled, cooled water up to 1000 ml mark.
3. Transfer to cooking pot and whisk the mixture vigorously.
4. Boil gently for 4 minutes while stirring continuously.
5. Some water will evaporate while cooking, so transfer the mixture back to
the measuring jug after cooking and add enough boiled cooled water to
make 1000 ml. Add the CMV and whisk again

Directions for making non-cooked F-100 recipes

If using an electric blender:
1. Put about 200 ml of the boiled, cooled water into the blender. (If using
liquid milk instead of milk powder, omit this step.)
2. Add the required amounts of milk or milk powder, sugar, oil, and CMV.
3. Add boiled cooled water to the 1000 ml mark and then blend at high
speed.*

If using a hand whisk:

1. Mix the required amounts of milk powder and sugar in a 1-litre
measuring jug; then add the oil and stir well to make a paste (If you
use liquid milk, mix the sugar and oil, and then add the milk.)
2. Add CMV, and slowly add boiled, cooled water up to 1000 ml mark,
while stirring all the time1.*
3. Whisk vigorously.

1
Whether using a blender or a whisk, it is important to measure up to the 1000 ml mark before
blending/whisking. Otherwise, the mixture becomes too frothy to judge where the liquid line is.
 RUTF reference card.
Quantities of RUTF in Transition.

Child's weight Daily weight of RUTF (g) Number of RUTF

sachets per day (if
one sachet = 92g).
3 83 1
3.2 88 1
3.4 94 1
3.6 99 1.2
3.8 105 1.2
4.0 110 1.5
4.2 116 1.5
4.4 121 1.5
4.6 127 1.5
4.8 132 1.5
5 138 1.5
5.2 144 1.5
5.4 149 1.75
5.6 155 1.75
5.8 160 1.75
6 166 1.75
6.2 171 2
6.4 177 2
6.6 182 2
6.8 188 2
7 193 2.2
7.2 199 2.2
7.4 204 2.2
7.6 210 2.5
7.8 215 2.5
8 221 2.5
8.2 226 2.5
8.4 232 2.5
8.6 237 2.75
8.8 243 2.75
9 248 2.75
9.2 254 2.75
9.4 259 3
9.6 265 3
9.8 270 3
10 276 3
4. Preparation of kitoobero
Kitoobero is a multi-mix food prepared from a carbohydrate and two protein sources (plant and animal origin). It
is fed to children six months and above.
How to prepare kitoobero using beans, meat and matooke mixture.
Ingredients: 1 palm of dry beans or peas ( 90g), 1 fist of meat ( 60g), 3 fingers of matooke (300-500g), 1 pinch of
salt, ½ mug of water ( 250ml).
1. Measure the dry beans and soak overnight for about 6 hours. Remove the skins and wash them. The skinned
beans will now become 2 palmful (180g).
2. Scrape the meat, mix it with water which had been boiled and cooled, in a container and try to separate the
particles of the meat
3. Peel the matooke, cut into small pieces and wash them.
4. Mix all the ingredients in a clean saucepan. Cover and steam for 3 hours.
5. When the food is ready, mash and divide it into two equal halves, one for lunch and the other for supper.
Any tuber (irish potatoes, sweet potatoes, cassava, yams) can be prepared in a similar way. Dry peas can
be prepared the way as dry beans.

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Adapted from the Uganda IMAM guidelines for the management of
dehydration in malnutrition 2016

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