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Chapter
Nursing Care of a Family When a
52 Child Has an Unintentional Injury

K E Y T E R M S Jason, a 5-year-old

• allografting • homografting boy, is seen in the

• autografting • near drowning emergency depart-
• contrecoup injury • otorrhea
• débridement ment after an automo-
• plumbism
• drowning • rhinorrhea bile accident. He is crying and upset,
• escharotomy • stupor
although the only visible signs of
• heterografts
trauma are a reddened and edema-
O B J E C T I V E S tous area on the middle of his fore-
After mastering the contents of this chapter, you should be able to: head. Vital signs reveal the following:
1. Describe the causes and consequences of common accidents and temperature, 99.4° F (37.5° C); respi-
injuries in childhood and measures to prevent them.
rations, 18 breaths/minute; pulse,
2. Identify National Health Goals related to children who have
experienced trauma that nurses can help the nation achieve. 62 beats per minute; and blood pres-
3. Use critical thinking to analyze ways that care of children with sure, 110/62 mm Hg. His left pupil is
unintentional injuries can be more family centered.
4. Assess a child who is unintentionally injured from an accident. more dilated than his right and it re-
5. Formulate nursing diagnoses related to an unintentionally acts sluggishly to light. His Glasgow
injured child.
6. Establish expected outcomes for an unintentionally injured child. Coma Scale score is 10. His mother
7. Plan nursing care related to an unintentionally injured child. tells you, “I’m sure he’s not injured
8. Implement nursing care for a child with an unintentional injury, such
as providing pain relief. badly. He was wearing his seat belt.”
9. Evaluate expected outcomes for achievement and effectiveness of Previous chapters described the
care.
growth and development of well
10. Identify areas related to care of children with unintentional injuries
that could benefit from additional nursing research or application of children and care of children with
evidence-based practice.
disorders of specific body systems.
11. Integrate knowledge of unintentional injuries in childhood with nursing
process to achieve quality maternal and child health care. This chapter adds information about
the characteristic changes, both
physical and psychosocial, that occur
when children experience an
unintentional injury.

Suppose you are a triage nurse. Would

you rate Jason as a child to be seen
immediately, or could he be given
second priority?

1543
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1544 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Accidents, such as those involving motor vehicles, falls,
burns, and water immersions, cause more deaths in the 1- to
4-year age group than the next six most prevalent causes
combined. In the 15- to 24-year age group, they cause half of
the deaths of the age group (NCHS, 2009). If unintentional
injuries such as these could be prevented, therefore, a major
cause of childhood morbidity and mortality could be elimi-
nated. However, total accident elimination may not be pos-
sible. Children commonly believe that accidents will not
happen to them and, as a result, fail to take sensible precau-
tions against them. Some parents may predispose their chil-
dren to accidents by overestimating their development and
giving them responsibility beyond their capabilities.
The frequency of various types of accidents varies accord-
ing to age group (Table 52.1). Because the anatomy and
physiology of children are different from those of adults, they
are not only involved in different types of accidents than
adults, but accidents affect them differently.
Family stress plays a large role in childhood poisoning ac-
cidents because these types of accidents tend to occur when
parents are preoccupied. Many medicine poisoning inges-
tions occur on the same day that the medicine was pur-
chased, implying that the stress of family illness plays a major
role. Eliminating accidents in children, therefore, is not a
simple procedure, because it involves reducing family stress
as well. National Health Goals related to children and
trauma are shown in Box 52.1.
Nursing Process Overview
For Care of a Child With an Unintentional Injury
Assessment
When children are seen at health care facilities because of
unintentional injuries, neither they nor their parents may
be functioning at their optimal level because of the stress
of the situation. Both may be apprehensive and frightened
not only about what has happened, but also about what
could have happened. Children often feel guilty and fear
that they will be scolded or punished. Their parents may
feel equally guilty; they may feel that if they were really
TABLE 52.1 ✽ Most Common Accidents in
Children by Age Group
Age (yr) Type of Accident
0–1 Falls, inhalation of foreign objects,
poisoning, burns, drowning
2–4 Falls, drowning, motor vehicles,
poisoning, burns
5–9 Motor vehicles, bicycle accidents,
drowning, burns, firearms
10–14 Motor vehicles, drowning, burns,
firearms, falls, bicycle accidents
15–18 Motor vehicles, drowning, firearms
National Center for Health Statistics. (2009). Health Data
for All Ages. Hyattsville, MD: Author.
BOX 52.1 ✽ Focus on
National Health Goals
Because prevention of unintentional injuries could have
immediate and long-term effects on the nation’s health,
several National Health Goals are concerned with pre-
venting accidents and unintentional injuries in children:
• Reduce the number of drownings each year from
a baseline of 1.5 per 100,000 to 0.7 per 100,000
children.
• Reduce the rate of firearm-related deaths from a base-
line of 10.3 per 100,000 to 3.6 per 100,000 children.
• Reduce the number of nonfatal poisonings from
a baseline of 348 per 100,000 to 292 per 100,000
children.
• Reduce the number of deaths caused by suffocation
from a baseline of 4.2 per 100,000 to 3.3 per 100,000
children.
• Reduce the rate of deaths caused by unintentional
injury from a baseline of 35.3 per 100,000 to 17.1 per
100,000 children.
• Reduce the number of deaths caused by motor ve-
hicle crashes from a baseline of 14.7 per 100,000 to
8 per 100,000 children.
• Increase the use of child automobile safety restraints
from a baseline of 92% to 100%.
• Increase the proportion of bicyclists, 1 to 15 years of
age, who regularly wear a bicycle helmet from a
baseline of 69% to 76%.
• Reduce the number of residential fire deaths from a
baseline of 1.2 per 100,000 to 0.2 per 100,000 chil-
dren (http://www.nih.gov).
Nurses can help the nation achieve these goals by
providing counseling on safety precautions to parents
and children. Nursing research in these areas that
would be helpful is: What are effective ways to com-
municate safety information to parents at well-child
visits when time is at a premium? In what ways should
safety teaching given after an accident to prevent a
further accident be different from that given as primary
prevention? Is there an association between children
setting fires and their exposure to fire experiences
with fireplaces or candles?
“good” parents, they would have been watching more
closely. They may feel defensive because they are worried
about being criticized. People under stress do not hear
well and may not perceive the information given to them
correctly. Information they receive in the emergency de-
partment, therefore, may be grossly misinterpreted or not
heard at all.
Children are likely to be in pain. They are frightened
not just from the pain of the injury but also from the cir-
cumstance of the injury. Children count on their parents
to keep them safe, yet they have been hurt. The trust is
broken momentarily. How can they be safe here if their
parents are no longer protecting them?
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1545

Because the emergency department nurse is often the
first person who sees a child after an injury, be ready to
make a preliminary assessment of the extent of a child’s
injuries before a physician arrives. Remember that chil-
dren may be seriously hurt but not crying because they
are in shock. They may be hemorrhaging, but, if they are
bleeding internally, the blood may not be visibly evident.
Accidents become fatal when lung, heart, or brain func-
tion becomes inadequate. These three body systems,
therefore, must be evaluated first (Airway, Breathing,
Circulation and Disability, or an ABCD evaluation).
Table 52.2 lists signs and symptoms to assess when de-
termining the respiratory, cardiovascular, and neurologic
status of an injured child.
While conducting a preliminary assessment of a child’s
major body systems, take a brief history of the accident.
What happened? How long ago did it happen? Was the
child using protective equipment such as a helmet or a se-
cured seatbelt? What have the parents done? If the child
fell, how far was the fall? On what body part did the child
land? (A head injury is more likely to be serious than an
ankle injury, although a child may be in more pain and
may have more obvious symptoms with the lesser injury.)
Ask the parents what they think are their child’s major in-
juries. Children may report one body part hurts at first,
but then a small cut elsewhere begins to bleed, and they
focus on the minor bleeding as their major injury. If par-
ents say, “At first, he acted as if his stomach hurt,” this
may be the first suggestion that he has a serious abdomi-
nal injury such as splenic rupture.
TABLE 52.2 ✽ Important Assessments on Initial
Examination of an Injured Child
Evaluating children in an emergency department is dif-
ficult, because they may be too young to communicate or
unconscious or they are so frightened that they cannot
stop crying to report which body parts are painful or to
indicate which parts should be assessed first. Spend a few
minutes attempting to calm children and get them past
this initial fright, unless symptoms of major body system
disturbances require that you direct your immediate ef-
forts elsewhere. Parents need frequent explanations of care
given or planned, because as long as they are worried and
tense, children cannot be calmed easily.
A proportion of unintentional injuries in children re-
sult from child abuse. Conflicting histories or a parent
and child recounting different stories is a hallmark of
this. Always ask yourself if this could be a possibility (see
Chapter 55).
Nursing Diagnosis
The nursing diagnosis used most frequently with injured
children is Pain. Depending on the particular injury, several
other nursing diagnoses are relevant, as are those that relate
to the suffering that parents experience when their child is
injured. Examples of possible nursing diagnoses are:
• Pain related to fractured tibia from sports injury
• Ineffective airway clearance related to burned
esophageal tissue
• Impaired physical mobility related to severe burn
injury
• Disturbed body image related to change in physical
appearance from thermal injury
• Parental fear related to outcome after head injury
in child
• Interrupted family processes related to child’s uninten-
tional injury
• Anxiety related to apprehension and lack of knowl-
edge regarding medical treatment of child

Body System Assessment

Respiratory Quality of respirations
system Rate of respirations
Sound of obstruction (wheezing,
stridor, retractions, coughing?)
Color (cyanotic?)
Oxygen hunger (restlessness,
inability to lie flat?)
Cardiovascular Color (pallor from hemorrhage or
system cardiovascular collapse?)
Gross bleeding
Pulse rate (increases with
hemorrhage)
Blood pressure (decreases with
hemorrhage)
Feeling of apprehension from
altered vascular pressure
Nervous Level of consciousness (child
system answers questions coherently,
infant attunes to parent’s voice?)
Pupils (equal and reacting to light?)
Bumps or bruises on head or
spinal column
Loss of motion or sensory function
in a body part
Outcome Identification and Planning
Parents in an emergency department are rarely ready for
long-term planning. They often have great difficulty in
coming up with answers to the most straightforward im-
mediate questions. Therefore, long-term planning may
have to be delayed until the immediate concern of the in-
jury has passed.
On discharge from the emergency department, parents
need printed instructions about the child’s care at home
and the name and number of the person to call if they have
questions about care or progress. They also need an ap-
pointment (or the number to call for a return appointment)
for follow-up care. If a child is admitted to the hospital
from the emergency department, it is helpful if the nurse
who cared for the child in the emergency department can
accompany the child to the hospital unit. The first person
who cares for a child after an injury becomes very impor-
tant to the child and parents, because that person was the
first one to recognize their distress. Parents have difficulty
letting this person go and accepting a new caregiver. A tran-
sition period, a “passing on of care,” helps a parent accept
the child’s new caregivers as being as dependable and trust-
worthy as the emergency department staff.
A key component of nursing intervention in an emer-
gency department is to help parents understand why an
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1546 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
injury happened and plan ways to make their immedi-
ate or community environment safe for children. An
organization that might be appropriate for referral is
the American Association of Poison Control Centers
(http://www.aapcc.org).
Implementation
The extent of a child’s injury depends on the injuring
agent, the part of the body that was injured, and often the
immediate care, including both physical and psychologi-
cal management, that a child receives.
The diameter of the airway in children is smaller than
in adults, so an injury to this body area almost always re-
sults in a greater danger of airway closure than in adults.
This could happen from the child’s inhaling a substance,
such as water, that directly obstructs the airway or from
inhaling toxic fumes that cause inflammation along the
lining of the airway, resulting in obstruction. A blow to
the neck can result in edema of surrounding tissues, caus-
ing the airway to close.
Injuries may involve some blood loss. Fortunately, a
child’s circulatory system is capable of rapid compensa-
tion for blood loss by vasoconstriction. Because the total
volume of blood in a child is reduced, however, blood loss
in children is always potentially serious. Because of this,
many health care agencies have standing orders that allow
emergency care nurses to begin intravenous normal saline
boluses on children with obvious blood loss.
Often, in the emergency department, large portions
of the child’s body must be exposed to view so that care
can be given easily. This means that rapid cooling can
occur. Because of the large body surface area of children
in relation to weight, always be conscious of body tem-
perature and take active measures to decrease cooling by
keeping a child covered as much as possible during ex-
amination times.
Standard infection precautions must be maintained in
emergency situations, the same as at any other time.
Parental consent must be obtained for treatment proce-
dures even in an emergency, except for life-saving actions,
such as cardiopulmonary resuscitation. In these instances,
action can and should be taken to save a child’s life with
or without parental permission (it is assumed that parents
would consent to life-saving procedures). Delaying emer-
gency procedures until parents can be located may result
in permanent disability or death.
Outcome Evaluation
After an injury, children need follow-up care to be certain
that the immediate interventions were adequate and that
healing is taking place. Evaluation visits are also the time
to determine whether the child’s environment has been
changed and is safer now than at the time of the accident
(if applicable). At the time of the accident, parents may
have been too anxious to hear health supervision informa-
tion. Now, with the accident behind them, they are ready
for such information and prepared to make changes.
If an injury could not have been anticipated, parents
appreciate hearing one more time that such an accident
could not have been avoided and that they are good par-
ents. This helps them maintain adequate self-esteem to
continue to function well as parents.
Examples of expected outcomes suggesting achieve-
ment of goals are:
• Child swallows fluids without distress after esophageal
burns.
• Child states pain is at tolerable level within 30
minutes.
• Child demonstrates full range of motion in hand after
thermal injury.
• Child states he understands that wearing a seat belt is
an important safety measure.
• Child states she will wear helmet when riding bicycle
in the future. ❧
HEALTH PROMOTION AND
RISK MANAGEMENT
In every care setting, nurses have the unique opportunity
among health care professionals to provide child and family
teaching concerning the prevention of accidents. Even in the
acute care setting when an accident has already occurred,
nurses can provide valuable instruction to families about
safeguarding their children against future accidents. In a
community setting, nurses have a great opportunity for as-
sessment of the unique threats that are present in particular
environments such as lead-based paint or kerosene heaters in
older homes, risk of drowning in a home with an unfenced
swimming pool, or the danger for children riding in the back
of pickup trucks. To teach effective accident prevention,
nurses need to be knowledgeable about common measures
that prevent injury.
Poisoning is an important cause of serious injuries in chil-
dren younger than 6 years of age; more than 1 million
episodes occur every year (Dart & Rumack, 2008). Common
household agents are often the cause. Since passage of the
Poison Prevention Packaging Act of 1970, potentially haz-
ardous products must be sold in child-resistant containers.
Passage of this act initiated a decrease in the incidence of
childhood poisonings from common medicines.
The home environment may still contain products that
can be hazardous and poisonous to children if handled im-
properly. Plants, cosmetics, and cleaning products can be
dangerous to children if ingested or absorbed through the
skin. Teach parents to be aware of these dangers and of
strategies for maintaining a safe home environment, includ-
ing learning basic first aid procedures.
Measures for a safe home environment include actions
such as installing child-resistant locks on low cabinets where
household products are stored, moving plants to a higher sur-
face or removing them from the home until the child is older,
keeping matches in safe places, and teaching street safety. In
addition, parents should anticipate that, even in the safest en-
vironment, a child can be injured. Along with knowledge of
basic first aid, the telephone number of the local poison con-
trol center should be posted by the telephone.
HEAD TRAUMA
Children receive head injuries when they are involved in mul-
tiple-trauma accidents, such as automobile crashes. Falls from
swing sets, porches, and bunk beds also cause many head in-
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
juries. Other children are injured by being struck on the head
by an object, such as a baseball, rock, or hockey puck, or by
falling from a bicycle (Faries & Battan, 2008).
Head injuries are always potentially serious not only be-
cause they can cause an immediate threat to the life of the
child, but also because several complications may follow. With
a depressed skull fracture, for example, recurrent seizures can
occur. Many of these children show focal abnormalities on an
electroencephalogram (EEG) because of scar tissue formation.
Some children with seizure involvement have normal EEGs,
however, so, by itself, the EEG is of limited value in predict-
ing whether posttraumatic seizures will occur.
Some children experience memory deficits or minor per-
sonality changes after head injury (Fazio et al., 2007).
Symptoms such as headache, irritability, and postural ver-
tigo (sensation of feeling faint or the inability to maintain
normal balance—also known as posttrauma syndrome) also
may occur. Behavioral manifestations may include aggres-
siveness or poor school performance. It often is difficult to
determine whether these symptoms are organic or the result
of being treated differently than usual by anxious parents.
Immediate Assessment
All children with head trauma require a neurologic assess-
ment as soon as they are seen and again at frequent intervals
to detect signs and symptoms of increased intracranial pres-
sure (ICP). Increasing pressure puts stress on the respiratory,
cardiac, and temperature centers, causing dysfunction in
these areas. With increased pressure, the pupils become slow
or unable to react immediately. Level of consciousness and
motor ability decrease, pulse and respiratory rates decrease,
and temperature and pulse pressure increase.
Assess vital signs to detect these changes and observe chil-
dren’s pupils to be certain that they are equal and react to
light. Assess children’s level of consciousness and motor
function. Stabilize the neck with a brace until cervical trauma
has been ruled out.
Immediate Management
After a head injury, brain edema is likely because fluid rushes
into the inflamed and bruised area. Both central venous and
central arterial lines may be inserted. ICP monitoring may be
initiated (see Chapter 49). A computed tomography (CT)
scan or magnetic resonance imaging (MRI) will be ordered to
determine areas of edema or bleeding. An attempt may be
made to decrease brain edema by intravenous (IV) adminis-
tration of a hypertonic solution, such as mannitol. This will
increase intravascular pressure and shift the edema fluid back
into the blood vessels. Steroids such as dexamethasone may
be added to decrease inflammation and edema. Keeping the
head elevated is also effective in reducing ICP.
Nursing Diagnoses and Related
Interventions
✽ vous system is open to infection. Test the fluid discharge
Nursing Diagnosis: Risk for excess fluid volume related
to administration of hypertonic solution
Outcome Evaluation: The child’s respiratory rate remains
between 16 to 24 breaths/minute; specific gravity of
1547
urine is between 1.003 and 1.030; pulse remains be-
tween 60 to 100 beats per minute; blood pressure
remains consistent for age group; lungs are clear to
auscultation.
When hypertonic solutions are being infused intra-
venously into children, assess vital signs frequently to
be certain that the fluid load being pulled into the in-
travascular system does not overtax it. This fluid must
be excreted by the kidneys to keep the vascular sys-
tem from becoming overloaded. Keep accurate intake
and output records to ensure that the kidneys are
functioning, and test the specific gravity of urine to
detect the development of pituitary compression and
resultant overproduction or underproduction of antidi-
uretic hormone from the posterior pituitary.
Nursing Diagnosis: Risk for delayed growth and devel-
opment related to late sequelae of head injury
Outcome Evaluation: Child shows no evidence of any
alteration in thought processes, seizure activity, or
memory at follow-up visits. Cognitive and physical de-
velopment are appropriate for age.
Helping care for a child with a head injury can be dif-
ficult for parents because they are so worried. Offer
information on the child’s progress as it becomes
available to you. Urge parents to help care for the
child to increase their sense of control.
During the acute phase of illness, ensure that
parents are informed about the dangers of increased
ICP. If they ask about the possibility that personality
changes or seizures will develop later in life, their
questions should be answered truthfully. At the same
time, do not give unnecessary warnings about
observing the child carefully in the months to come.
Head injuries by themselves are worrisome enough
to parents and children without adding to their
burden.
Skull Fracture
A skull fracture is a crack in the bone of the skull (Aminoff,
2009). Recognizing skull fractures in children is important,
because associated cerebral injury often occurs under the
fracture. Many skull fractures are simple linear types, most
often involving the parietal bones. In some children, the
skull does not fracture, but the suture lines separate. This
occurs more commonly in the lambdoid suture line; a coro-
nal suture separation is rare and, if present, indicates severe
trauma (Fig. 52.1).
Assessment
If the base of the skull is fractured, a child usually exhibits or-
bital or postauricular ecchymosis. Rhinorrhea or otorrhea
(clear fluid draining from the nose or ear, respectively) may
be present. This is escaping cerebrospinal fluid (CSF)—a se-
rious finding, because it means that the child’s central ner-
with a glucose reagent strip if there is doubt about the source
of the drainage. CSF will test positive for glucose, whereas
the clear, watery drainage from an upper respiratory tract in-
fection will not.
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1548 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Frontal suture
Anterior fontanel
Frontal bone
Coronal suture
Sagittal suture
Parietal bone
Lambdoid suture
Posterior fontanel
Occipital
bone
FIGURE 52.1 Location of suture lines of the skull.
Take a careful history of the accident, so that the strength
of the blow to the head can be judged. Shock with hypoten-
sion rarely occurs with an isolated head injury. If a child is in
shock, investigate for bleeding points other than the head in-
jury. Skull fractures are confirmed by skull radiography.
If a skull fracture is linear with no underlying pathology,
no treatment except observation and prescription of an anal-
gesic is necessary. In about 3 weeks, a repeat radiograph will
be needed to confirm that healing has taken place. Parents
can be reassured that a second radiograph this soon is not
harmful but necessary.
If a fracture is depressed (a bone fragment is pressing in-
ward) or compounded (bone is broken into pieces), surgery
will be necessary to remove or repair broken fragments.
Cranial surgery of this type is discussed in Chapter 49.
Therapeutic Management
If CSF is draining from the nose, a child will be admitted to
the hospital for observation. Keep the child in a semi-
Fowler’s position so that fluid drains out, not inward, to re-
duce the possibility of introducing infection. Make certain
that children do not attempt to hold their nose or pack their
nostrils with something to halt the drainage. Because cough-
ing and sneezing may allow air to enter the meningeal space,
coughing may be suppressed by medication. If the drainage
is excoriating to the upper lip, coat the space with petrola-
tum. Children may be prescribed a prophylactic antibiotic to
reduce the risk for meningitis. If the drainage does not stop
within a few days, surgery will be necessary to repair the frac-
ture and reduce the danger of meningitis. Air that enters in-
tracranial spaces usually is absorbed rapidly. If radiographs at
72 hours still show air in the cerebral spaces, it implies that a
skull defect remains, and surgery may be indicated to close
the defect.
Potential Complications
A long-term complication of even a linear fracture may be a
leptomeningeal cyst. This results from projection of the arach-
noid membrane into the fracture site. With the interfering
tissue, bone cannot heal and actually erodes, so that the frac-
ture site becomes progressively larger, not smaller. This be-
comes evident on a follow-up radiograph. It may be sus-
pected if a child develops focal seizures or symptoms of
increased ICP. The defect may be palpated on the skull as an
underlying indentation. Surgical resection is necessary to re-
move the cyst.
Subdural Hematoma
Subdural hematoma is venous bleeding into the space be-
tween the dura and the arachnoid membrane (Fig. 52.2A). It
occurs when head trauma lacerates minute veins in this area
(Amirjamshidi et al., 2007). The collection of blood is usu-
ally bilateral.
Subdural hematomas tend to occur in infants more often
than in older children. Symptoms may occur within 3 days
or as late as 20 days after trauma. Infants usually have symp-
toms of increased ICP. Seizures, vomiting, hyperirritability,
and enlargement of the head may occur. Anemia caused by
the substantial blood loss is a prominent sign. Angiography
or ultrasound reveals the extent of the hematoma.
In infants, accumulated subdural blood may be removed
by a subdural puncture through the lateral aspect of a patent
anterior fontanelle. The procedure is similar to a lumbar
puncture. Infants receive conscious sedation or must be held
extremely still during the procedure so that they do not move
and cause the aspiration needle to be inserted incorrectly.
Without conscious sedation, half of the success of subdural
puncture depends on the ability to hold the child still.
Subdural punctures may need to be repeated daily to
empty the subdural space. Once the space is empty, expand-
ing brain tissue will naturally occlude it. If the space has not
been occluded after 2 weeks of daily punctures, active bleed-
ing is still present, and surgery usually is necessary to reduce
the space and halt bleeding.
In older children, surgery usually is necessary, because the
anterior fontanelle is closed and the space cannot be reached
by puncture.
Epidural Hematoma
Epidural hematoma is bleeding into the space between the
dura and the skull (Fig. 52.2B). This happens when head
trauma is severe. Subdural hemorrhage is usually venous bleed-
ing, but epidural hemorrhage is usually a result of rupture of
the middle meningeal artery and is, therefore, arterial bleeding.
It usually is intense and causes rapid brain compression.
At the time of the injury, children become momentarily
unconscious. They then regain consciousness and, to the un-
trained eye, appear to be well for minutes or hours. Then
signs of cortical compression—vomiting, loss of conscious-
ness, headache, seizures, or hemiparesis (paralysis on one
side)—are observed. On physical examination, unequal dila-
tion or constriction of the pupils may be present. Decorticate
posturing (see Chapter 49) may be seen, indicating extreme
pressure on upper cortical centers. If the pressure is allowed
to continue unchecked, cortical compression may be so great
that brainstem, respiratory, or cardiovascular function be-
comes impaired.
As a rule, the closer to the time of the injury that symp-
toms of compression occur, the more extreme is the
amount of blood loss. The treatment is surgical removal of
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1549

Subdural hematoma

Dura mater
Pia
arachnoid

Dura mater

Epidural
hematoma

A B
FIGURE 52.2 (A) Subdural hematoma. The red area in the upper left area of the drawing is the hematoma. Note
the shift of structures. (B) Epidural hematoma. The red area in the lower left area of the drawing is the hematoma.
Note the broken blood vessel and the shift of midline structures.

the accumulated blood and cauterization or ligation of
the torn artery. The earlier the process is recognized and
treated, the less the chance of residual damage from extreme
pressure or anoxia to the involved portion of the brain.
Concussion
Concussion is the temporary and immediate impairment of
neurologic function caused by a hard, jarring shock (Wilson
& Matthews, 2008). It may occur on the side of the skull
that was struck (a coup injury) or on the opposite side of the
brain (a contrecoup injury; Fig. 52.3). As the brain recoils
from the force of the blow and strikes the posterior surface of
the skull, this second injury occurs. Children have at least a
transient loss of consciousness at the time of the injury. They
may vomit and may show irritability after regaining con-
sciousness. They typically have no memory (amnesia) of the
events leading up to the injury or of the injury itself. For

Head
strikes
object

A B

COUP INJURY CONTRECOUP INJURY

Anterior of brain strikes Brain recoils and strikes
skull and is injured posterior skull, so is FIGURE 52.3 Etiology of (A) coup and (B) con-
injured twice trecoup injuries.
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1550 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
some children, this makes being asked questions about the
accident extremely upsetting because they do not remember
anything that happened and feel a frightening loss of control.
The child requires a skull radiograph to rule out skull frac-
ture and observation for 24 hours to rule out severe brain
trauma, edema, or laceration. A child usually can be observed
at home by the parents, who are instructed to check the
child’s level of consciousness every 1 to 2 hours while the
child is awake. Parents usually are instructed not to keep
waking children during the night, because multiple wakings
are disorienting and can be confused with unconsciousness.
Parents should wake the child at least once during the night,
however, and assess that the pulse rate is greater than 60 beats
per minute.
To be certain that children are alert, parents can ask them
to name a familiar object, such as a favorite toy, or to name
the color of some object shown to them. Telling parents their
name or where they live is equally revealing.
Give parents the telephone number to call if they have
any questions about their child’s care. Advise them to call if
their child’s behavior changes in any way that seems worri-
some. Many parents need to set an alarm clock to wake
themselves during the night to assess their child’s status.
There is an old belief that, if children fall asleep after a head
injury, they will die in their sleep; this belief causes some
parents to keep shaking children awake or making them
walk continually. Be certain they understand that it is all
right for children to sleep, but they must wake them at least
once to assess their status (see Focus on Nursing Care
Planning Box 52.2).
Contusion
A brain contusion occurs when there is tearing or laceration
of brain tissue (Fig. 52.4). The symptoms are the same type
as for concussion but more severe. In addition, there are spe-
cific symptoms related to the lacerated brain area such as a
focal seizure, eye deviation, or loss of speech. Surgery may be
necessary to halt bleeding. The child’s prognosis depends on
the extent of the injury and effectiveness of therapy.
What if... In the emergency department, Jason’s par-
ents state that since his head injury he has been vom-
iting? Is it more likely that the vomiting is a result of the
head injury, or that he has contracted a gastrointesti-
nal infection?
Coma
Coma (unconsciousness from which a child cannot be
roused) or stupor (grogginess from which a child can be
roused) may be present in children after severe head trauma.
Coma and stupor are both symptoms of underlying disor-
ders; a history of the injury must be obtained so that treat-
ment can be directed specifically toward the cause.
Assessment
Obtain a history to determine the circumstances immediately
before the time the child became comatose. Assess children
in coma carefully and completely, so that the cause of the de-
creased consciousness can quickly be determined.
Undress the child completely so that all body parts can be
inspected. Although head injury is most likely to be the un-
derlying cause of coma or seizure, metabolic disturbances
such as diabetes mellitus, dehydration, severe hemorrhage, or
drug ingestion, also must be considered as possible causes.
Count respirations and pulse and measure blood pressure to
establish baseline values, because changes in these values
often provide good clues regarding the cause of coma. A child
with increased ICP, for example, will show decreased pulse
and respiratory rates and increased blood pressure. Diabetes,
in contrast, leads to increased respirations. Hemorrhage leads
to an increased pulse rate and decreased blood pressure. Drug
ingestion may lead to either increased or decreased measure-
ments, depending on the drug ingested.
If bulbar (brainstem) compression is present, a child can-
not swallow effectively or safely. If this is suspected, turn the
child on the side to prevent aspiration. Observe the eyes for
signs of increased ICP. If both pupils are dilated, irreversible
brainstem damage is suggested, although such a finding may
also be present with poisoning from an atropine-like drug.
Pinpoint pupils suggest barbiturate or opiate intoxication.
One pupil dilated more than the other suggests third cranial
nerve compression. An eye may be deviated downward and
laterally as well. This also may be caused by a tentorial tear
(laceration of the membrane between the cerebellum and
cerebrum) and herniation of the temporal lobe into the torn
membrane. This situation requires immediate surgery to cor-
rect temporal compression.
The retina of the eye should be examined for papilledema,
which will be present if increased pressure is long-standing
(more than 24 to 48 hours). Lack of a doll’s eye reflex sug-
gests that compression of the oculomotor nerves (third,
fourth, or sixth) or of the brainstem is involved. Observe for
posturing, such as decerebrate posturing, which suggests
cerebral compression and dysfunction.
Many laboratory studies are helpful in determining the
cause of coma. Blood glucose, blood electrolytes, blood urea
Intracerebral
hemorrhage
FIGURE 52.4 Intracerebral hemorrhage. The central large
dark area represents the hemorrhage. Note the midline shift.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1551

BOX 52.2 ✽ Focus on Nursing Care Planning

A Multidisciplinary Care Map for a Child With a Concussion

Jason, a 5-year-old boy, is seen in the emergency de- edematous area on the middle of his forehead. His twin
partment after an automobile accident. His family is sister, in a car seat beside him, was not injured. His
here on vacation. Child is crying and upset, although mother tells you, “I’m sure he’s not injured badly. He
the only visible signs of trauma are a reddened and was wearing his seat belt.”

Family Assessment ✽ Child is staying with twin sister
and two parents in motel room while on 10-day vacation.
Father normally works as a salesman. Mother clerks in
department store. Father describes finances as “good.”
Father concerned because rented car was totally de-
stroyed in accident and his insurance may not cover this.
Client Assessment ✽ A 5-year-old boy visibly upset
and crying. Height and weight at 75th percentile for age.
Child unable to report or recall anything about the inci-
dent. Mother reports he was restrained by a seat belt
but not a car seat. Head hit side window when a car
struck their vehicle.
Vital signs: temperature, 99.4° F (37.5° C); respira-
tions, 18 breaths/minute; pulse, 62 bpm; and blood pres-
sure, 110/62 mm Hg. Left pupil is more dilated than his
right; it reacts sluggishly to light. Glasgow Coma score is
10. Alert enough to name toy racing car brought in with
him. Pupils equal, round, reactive to light and accommo-
dation bilaterally. 1.5-cm raised area noted on forehead.
Skin intact without evidence of bleeding. Child cries
when area is touched. Negative otorrhea or rhinorrhea.
Small 2-cm abrasion noted on right knee; 3-cm abrasion
noted on right hand. No other injuries noted. Able to
move all extremities through range of motion.
A diagnosis of mild contrecoup concussion is made,
and child is to be discharged to motel in parents’ care.
Nursing Diagnosis ✽ Risk for injury related to effects of
concussion
Outcome Criteria ✽ Child remains alert and oriented;
easily arousable. Pupils equal, round, react to light and
accommodation; vital signs within age-acceptable para-
meters; exhibits no signs or symptoms of neurologic
dysfunction.

Team Member
Responsible Assessment Intervention Rationale Expected Outcome

Activities of Daily Living

Nurse Take history of acci- Assess child’s vital
dent, speed car was signs, level of con-
traveling, and posi- sciousness, and
tion of child in neurologic function
vehicle. initially, and then
every 30 min until
discharge.
Changes in vital signs, Parent describes acci-
level of conscious- dent and reactions of
ness, or neurologic child since accident.
function indicate a
worsening of the
child’s condition and
possibly increasing
intracranial pressure.

Consultations

N/A N/A N/A N/A N/A

Procedures/Medications

Physician/nurse Assess whether child’s Institute measures to
demeanor (crying) is calm the child.
from fright or pain. Encourage the par-
ents to hold and
reassure him.
Physician/nurse Assess whether child Schedule a skull radi-
has had experi- ograph or other
ence with x-ray diagnostic tests as
examination. ordered, such as CT
scan or MRI.
Crying increases Parents are able to
intracranial pressure. calm child to allow
Involving the parents for better evaluation
provides them with a of condition.
concrete activity,
helping to provide
some sense of
control over the
situation.
Skull radiograph rules out Child cooperates with
a possible skull frac- diagnostic proce-
ture secondary to the dures; results are
trauma. CT scan or available for physi-
MRI helps determine cian review.
any areas of bleeding
or edema if present.
(continued)
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1552 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

BOX 52.2 ✽ Focus on Nursing Care Planning (continued)

Nutrition

Nurse Assess whether If not NPO, feed small Vomiting is a symptom of Child eats some food
child has vom- amount of a favorite increased intracranial without vomiting.
ited since head food to be certain pressure.
injury. child does not have
vomiting.

Patient/Family Education

Nurse Assess what par- Teach parents how A contrecoup injury Parents state they un-
ents understand contrecoup injuries causes injury or edema derstand why their
about concus- occur and symp- to the posterior brain. child has posterior
sion in children. toms they cause. (eye control) cranial
symptoms, such as
unequal pupils.

Psychosocial/Spiritual/Emotional Needs

Nurse Assess whether Orient the child to his Children often have no Parents and child state
child or parents surroundings. Offer memory of events with they understand
have any ques- explanations about concussion. Parents procedures being
tions about care. any treatments or are in strange commu- carried out. Voice
procedures that are nity. Orientation and confidence in new
to come. explanation help to situation.
minimize a child’s fear
of the unknown and of
his situation.
Nurse Attempt to identify Encourage parents to Identification of the mean- Parents state they were
the meaning and express their feel- ing and effect of the not responsible for
effect of the ings about them- child’s accident assists accident, or at least
child’s accident selves as parents in determining the did everything possi-
for the parents and their role in the degree to which the ble to avoid their
(e.g., father child’s accident. situation is affecting child’s injury.
upset over rent- the parents.
a-car liability).

Discharge Planning

Nurse/physician Assess whether Instruct parents to rouse Frequent waking can be Parents state they will
parents will be the child approximately disorienting to a child remain in motel for
staying in city or every 2 hours during and can be confused 24 hours, rather
traveling back daytime hours and at with altered levels of than fly home imme-
home during least once during the consciousness, but diately, so they can
next 24 hours. night, asking the child occasional waking is a observe child.
to name a familiar good way to assess
object or color. whether complications
are occurring.
Nurse Assess whether par- Schedule a return ap- A follow-up visit is neces- Parents state they un-
ents will be able pointment to clinic sary to be certain child derstand importance
to keep a follow- for 24-hour follow- can travel safely. of follow-up visit and
up appointment up visit. Supply will keep appoint-
for additional clinic telephone ment with child.
care. number if needed
before then.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1553

nitrogen (BUN), liver function tests, blood gas studies, lum-
bar puncture, and toxicology tests may be ordered to rule out
possible causes such as bacterial meningitis or hemorrhage.
Computed tomography (CT) or MRI will be done if a head
injury is the most likely cause (Claret-Teruel et al., 2007).
Coma is usually graded according to a standard scale so
that changes in the level of consciousness can be evaluated ac-
curately. Figure 52.5 shows the Glasgow Coma Scale, a com-
monly used evaluation system (Morris, 2008). Because this
system was devised as an adult assessment scale, it must be
modified for use with children or infants. Such a modifica-
tion is shown in Box 52.3.
A score of 3 to 8 on the scale suggests severe trauma (a
number less than 5 suggests a very severe prognosis); a score
of 9 to 12, moderate trauma; and 13 to 15, slight trauma.
Lumbar puncture has little value at first in predicting the
severity of a head injury, because any degree of cerebral con-
tusion usually leads to increased CSF pressure. Lumbar
puncture is contraindicated if increased ICP is present as re-
lease of fluid with the puncture can cause brainstem com-
pression into the cord. Obtain the child’s vital signs and as-
sess neurologic status, such as state of consciousness and the
ability of pupils to react to light, every 15 to 20 minutes or
as ordered. Accurately and carefully record this information
so that a picture of gradual change will become apparent.
A child’s prognosis after coma depends on the initial cause
of the coma. If the increased ICP can be relieved before any
permanent brain damage results, the effects of the coma will
be transient. Prognosis is always guarded, however, because
coma reflects a potential health problem for a child.

Therapeutic Management
If children are unconscious for longer than a transient period,
they usually are admitted to an observation unit for further
assessment. As a general rule, place a child who is comatose
on the side to reduce the risk of aspiration. Oral suctioning
to remove mucus from the mouth and pharynx may be nec-
essary. If a child has acute signs of respiratory difficulty, en-
dotracheal intubation may be necessary to ensure respiratory
function.
An IV route is established so that, when specific measures
such as blood replacement, electrolyte replacement, or fluid
replacement are needed, a route for immediate administra-
tion will be available. Blood will be drawn for a complete
blood count, electrolyte determination, toxicology tests, and
cross-matching. If the cause of the coma is unknown, a lum-
bar puncture and EEG may be done. Skull radiography, CT
scan, or MRI may be done.
Nursing Diagnoses and Related
Interventions
✽
Care of the child in coma is directed toward maintain-
ing body function in an optimal state until the child
reawakens.
Nursing Diagnosis: Risk for ineffective airway clear-
ance related to brainstem pressure
Outcome Evaluation: Child’s respiratory rate remains
between 16 and 20 breaths/minute; there are no re-
tractions or signs of obstruction.
Some children who are comatose require endotra-
cheal intubation or tracheostomy to ensure an open
airway. Some are placed on mechanical ventilation.
Oxygen may be prescribed if arterial blood gases

Glasgow Coma Scale A.M. P.M. A.M.

Assessment Reaction Score 8 10 12 2 4 6 8 10 12 2 4 6 8
Eye Opening Spontaneously 4 X X X X X X
Response To speech 3 X X

To pain 2 X X X

No response 1

Motor Response Obeys verbal command 6 X X X X X X

Localizes pain 5 X X

Flexion withdrawal 4 X X

Flexion 3 X

Extension 2
No response 1

Verbal Response Oriented x3 5 X X X X X X

Conversation confused 4 X X
Inappropriate speech 3 X

Incomprehensible sounds 2 X X

No response 1

FIGURE 52.5 Glasgow Coma Scale scoring for a child. A score of 3 to 8 denotes severe
trauma; 9 to 12, moderate trauma; 13 to 15, slight trauma. Notice the gradual improvement
from coma in this example.
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1554 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
BOX 52.3 ✽ Scoring for Glasgow Coma Scale
Eye Opening
4. Child opens eyes spontaneously when you
approach.
3. Child opens eyes in response to speech (spo-
ken or shouted).
2. Child opens eyes only in response to painful
stimuli, such as pressure on a nail bed.
1. Child does not open eyes in response to
painful stimuli.
Motor Response
6. Child can obey a simple command such as
“hand me a toy” (infant smiles or attunes).
5. Child moves an extremity to locate a painful
stimulus applied to the head or trunk and at-
tempts to remove the source.
4. Child attempts to withdraw from the source of
pain.
3. Child flexes arms at the elbows and wrists in
response to painful stimuli to the nail beds
(decorticate rigidity).
2. Child extends arms (straightens the elbows) in
response to painful stimuli (cerebrate rigidity).
1. Child has no motor response to pain on any
extremity.
Verbal Response
5. Child is oriented to time, place, and person
(child >4 years old knows name, date, and
where he or she is; infant appears to recog-
nize parent).
4. Child is able to converse, although not ori-
ented to time, place, or person (does not know
who or where he or she is; infant says words
but does not appear to differentiate parents
from others).
3. Child speaks only in words or phrases that
make little or no sense (“I want frazzle no”; in-
fant’s vocabulary is less than it is normally).
2. Child responds with incomprehensible sounds,
such as groans.
1. Child does not respond verbally at all.
Modified from Teasdale, G., & Bennett, B. (1974).
Assessment of coma and impaired consciousness: A prac-
tical scale. Lancet, 2 (7872), 81–84.
reveal poor oxygenation of body cells (oxygen ten-
sion [PO2] lower than 80 mm Hg). Endotracheal
tubes are replaced with a tracheostomy after 3 to
7 days to prevent necrosis of the pharynx from pres-
sure of the endotracheal tube.
Nursing Diagnosis: Risk for impaired skin integrity re-
lated to lack of mobility
Outcome Evaluation: Child exhibits no areas of broken
or irritated skin.
Bathe children who are comatose daily to stimulate skin
circulation. Include the hair as part of the bath about
every 3 days. Change their position at least every 2
hours to prevent pressure ulcer formation and develop-
ment of hydrostatic pneumonia from pooled secretions.
When turning, assess skin for reddened points. Keep
linen dry and free from wrinkles. Perform thorough pas-
sive range-of-motion exercises to maintain muscle tone
and prevent contractures. Use of a sheepskin, an egg-
carton foam, or an alternating pressure or water mat-
tress also can be important in decreasing pressure to
the skin.
Nursing Diagnosis: Risk for imbalanced nutrition, less
than body requirements, related to inability to take in
oral food or fluid
Outcome Evaluation: Child’s skin turgor is normal; weight
remains within acceptable percentile; hourly urine out-
put remains greater than 1 mL/kg.
Children who are unconscious cannot be fed orally or
they might aspirate. Therefore, nutrition is maintained
by nasogastric (NG) or gastrostomy tube feedings, IV
fluid administration, or total parenteral nutrition. IV
fluid is only a short-term answer, because adequate
protein and fat cannot be supplied solely by this route.
NG or gastrostomy feedings can supply total nutrient
needs. Always aspirate NG or gastrostomy tubes for
stomach contents before giving a feeding to check
tube placement and assess gastric residual amounts.
Return any amount of stomach residue aspirated, be-
cause if this is discarded each time, a child will lose a
large amount of stomach acid, possibly leading to al-
kalosis. Check whether the amount of the feeding
should be reduced by the amount of fluid remaining in
the stomach before feeding the full amount of pre-
scribed formula.
Give mouth care at least twice daily with clear
water and a padded tongue blade. Coat lips with
petrolatum to prevent drying and cracking. If a
child’s eyes tend to be dry, close them to prevent
corneal ulceration. Artificial tears (methylcellulose)
may be prescribed to keep eyes from drying until the
child regains consciousness.
Choking Games
Adolescents, seeking an inexpensive way to experience a
“rush” or euphoria, induce a partial or complete loss of con-
sciousness in themselves by intentionally depriving their
brain of oxygen for a short period of time by strangulation or
hanging or reducing the oxygen able to reach their nose by
some technique such as pulling a plastic bag over their head.
Extreme hyperventilation to induce hypocapnia is yet an-
other technique.
The practice may be seen as a rite of passage or ini-
tiation into a gang or club. The practice is also known as
erotic asphyxiation as it also induces a sexual response.
Unfortunately, the game results in injury and death. At
least 82 adolescents between the age of 6 and 19 have died
in the United States as a result of the game. Of these
86.6% were male; the mean age was 13.3. The majority of
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
the deaths occurred while the adolescent was alone; over
90% of the parents of the child were unaware of the game
(CDC, 2008a).
Injuries such as concussion, bone fractures, and tongue
biting may occur from falling. Teach parents that the game
exists and to be aware of signs that their child might be in-
terested or participating in the game. Common signs are
discussion of the game, bloodshot eyes, ligature marks on
the neck, severe headaches, disorientation, and the presence
of choke collars, ropes, scarves, or belts tied to bedroom
furniture.
ABDOMINAL TRAUMA
When children are brought to a health care facility after suf-
fering a multiple-injury trauma, several medical specialists
may be required: a neurosurgeon for consultation about a
head injury; an orthopedic physician for consultation about
a fractured extremity; and a thoracic surgeon to intubate or
investigate lung trauma. A nurse may serve the important
function of being the person who is best able to observe a
total child and recognize the subtle signs of abdominal
trauma.
Assessment
Abdominal trauma results from an object striking the ab-
domen, such as a baseball bat or a seat belt drawn tight in a
motor vehicle crash (Humphries, 2008). Assess vital signs
frequently until they are stable. Hypotension (less than
80 mm Hg systolic pressure in an older child; less than 60
mm Hg in an infant) usually suggests hemorrhage, which
may be hidden abdominal bleeding. In addition, children
may have increasing pallor and rapid respirations. If internal
bleeding is present, blood pressure will show little improve-
ment when IV fluid is administered.
If abdominal trauma is suspected, an NG tube is passed
and stomach contents are aspirated to be checked visually for
blood and to test for occult blood. Attach the tube to low in-
termittent suction if the presence of blood is established. An
indwelling urinary (Foley) catheter is also inserted to evalu-
ate urine for blood and urine output. Evidence of blood in
the urine or decreased output may indicate accompanying
kidney or bladder trauma. If the urine contains blood, an
emergency IV pyelogram or ultrasound may be ordered. Be
aware that having NG tubes or catheters passed is always
frightening for a child (unsure of their anatomy, children
have no clear idea where the tubes are going). After an acci-
dent, when they are already frightened, they and their par-
ents need a great deal of support to accept these procedures
(Box 52.4).
An abdominal radiograph or ultrasound may be ordered
to rule out a fractured pelvis, a condition that could con-
tribute to blood loss. Air under the diaphragm on the radi-
ograph suggests gastric or intestinal rupture with escape of
air from these organs into the peritoneal cavity. Free fluid
in the abdomen, shown on the radiograph when the child
is turned on the side, suggests leakage of bowel fluid or
splenic rupture and pooling of blood. Parents often find it
difficult to appreciate the seriousness of abdominal trauma,
because the signs are not as dramatic or obvious as those of
1555
BOX 52.4 ✽ Focus on Communication
Jason, a 5-year-old boy, is brought to the emergency
room after an automobile accident. He is being as-
sessed for multiple trauma.
Less Effective Communication
Mr. Varton: Why are you looking at his belly? He didn’t
hurt that.
Nurse: We need to assess his entire body just to make
sure that there aren’t any problems. He’s had major
trauma. You need to sign a consent form so he can
have a central intravenous line and indwelling uri-
nary catheter inserted and a CT scan to rule out
any problems.
Mr. Varton: I don’t want to put him through any more.
What if something else goes wrong?
Nurse: If you don’t consent to these tests and treat-
ments, we cannot take care of your child.
Mr. Varton: OK. Do what you have to. But I’m still
not sure.
Nurse: Good. Sign this consent for me.
More Effective Communication
Mr. Varton: Why are you looking at his belly? He didn’t
hurt that.
Nurse: We need to assess his entire body just to make
sure that there aren’t any problems. He’s had major
trauma. You need to sign a consent form so he can
have a central intravenous line and indwelling uri-
nary catheter inserted and a CT scan to rule out
any problems.
Mr. Varton: I don’t want to put him through any more.
What if something else goes wrong?
Nurse: I know it’s difficult for you to see your child in
such pain. Are you worried about anything specific?
Mr. Varton: Is he going to die?
Nurse: The things we’re doing are aimed to prevent
that very thing. Let me explain a little more about
what we’re doing and why these things are neces-
sary. I want you to feel comfortable signing the
consent form.
In the first scenario, the nurse focuses on obtaining
the parent’s consent but fails to recognize the fear and
apprehension in the parent. In the second scenario,
the nurse recognizes and attends to the fears of the
parent. By doing so, she helps to establish a sense of
support and trust in addition to obtaining consent for
procedures.
fractured extremities or lacerations. Some parents may not
bring their child to an emergency department immediately
after abdominal trauma, because they are unaware that se-
rious injury can result to this part of the body. Without
frightening them, explain that an injury need not be obvi-
ous at first glance to be serious and need care. They may ask
why a radiograph is necessary. When their child is asked to
turn on the radiograph table so that an abdominal fluid
level can be revealed, they may perceive this as unnecessary
manipulation of an injured child.
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1556 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Nursing Diagnoses and Related
Interventions
✽ shoulder elevated, so that the diaphragm is raised on the left
Nursing Diagnosis: Pain related to abdominal injury
Outcome Evaluation: Child states that level of pain is
tolerable; child does not grimace when body parts are
touched.
Routinely, analgesics are not administered to most
children after abdominal trauma unless their pain is
severe, to avoid masking the pain, as the location of
the pain can help identify which organs may be in-
jured. If parents did not recognize that the child was
injured, guilt and fear on their part may compound the
problem. Goal setting is usually concerned with the
immediate diagnostic procedures or anticipated
surgery. Interventions differ according to the specific
injury present.
Splenic Rupture
In children, the spleen is the most frequently injured organ
in abdominal trauma, because it is usually palpable under the
lower left ribs (Huether & McCance, 2007). It is frequently
injured by inappropriately applied seat belts in automobiles
and by handlebar injuries in bicycle accidents. It is increas-
ingly caused by snowboard injuries (Box 52.5). Children
BOX 52.5 ✽ Focus on Evidence-
Based Practice
Do snowboards cause as many injuries as skis in
children?
Snowboarding is a relatively new sport. To compare the
risk of unintentional injury as a result of skiing to the risk
of injury by snowboarding, researchers analyzed the
history of children seen in a pediatric trauma center over
a seven-year period. During the study period, there
were 57 snowboarders and 22 skiers seen for care. The
site of the injuries differed as all skiing injuries occurred
at recreational facilities whereas 12% of snowboard in-
juries occurred at home, another residence, or a public
park. Forty-one (72%) of snowboarders and 16 (73%) of
skiers required surgery for their injuries; 32 (56% of
snowboarders and 9 (41%) of skiers sustained frac-
tures; and 14 (25%) of snowboarders and 6 (27%) of
skiers sustained abdominal injuries. Serious splenic in-
juries were more common in snowboarders (14% vs 4%)
but the difference was not statistically significant.
Based on the above study, would it be important to ask
if a child was skiing or snowboarding when brought into
the hospital by the ski patrol?
Source: Hayes, J. R., & Groner, J. I. (2008). The increasing in-
cidence of snowboard-related trauma. Journal of Pediatric
Surgery, 43(5), 928–930.
with splenic injury have tenderness in the left upper quad-
rant, especially on deep inspiration, when the diaphragm
moves down and touches the spleen. They may hold their left
side, to keep this from happening. Occasionally, a child no-
tices radiated left shoulder pain while lying in a supine posi-
tion (Kehr’s sign). A radiograph will show little about the
spleen itself but may reveal a broken rib over the spleen, sug-
gesting the extent of the trauma to that area.
An IV line is begun immediately for fluid replacement,
and an IV pyelogram or MRI will be done to rule out dam-
age to the left kidney, which, because of its location just be-
hind the spleen, may also have suffered trauma. A complete
blood count is done to estimate the extent of the blood loss.
Blood is typed and cross-matched, so that blood for replace-
ment can be readied if necessary. The child will be admitted
to an observation unit if the blood loss from rupture appears
to be mild. If bleeding is severe, immediate surgery, such as
a partial or total splenectomy, may be necessary to halt bleed-
ing and save the child’s life.
After a splenectomy, children are very susceptible to in-
fection, particularly pneumococcal infections. Therefore, a
large percentage of children are managed expectantly to see if
the bleeding will halt without spleen removal (Dobremez et
al., 2007). Children who have their spleen removed are of-
fered the pneumococcal vaccine to protect them against
pneumococcal infections.
Liver Rupture
Livers are also more prone to rupture in children than in
adults, because the liver, like the spleen, is not completely
sheltered by the rib cage in children (Tataria et al., 2007).
Children with liver rupture or laceration usually have severe
abdominal pain that is most marked on inspiration, when the
diaphragm descends and touches the liver. They show symp-
toms of blood loss, including tachycardia, hypotension, anx-
iety, and pallor. The hematocrit will be low or falling. Such
children need to be prepared for immediate surgery, because
the liver is a highly vascular organ, and blood loss from it is
acute and possibly life-threatening.
Occasionally, a communication between an artery and the
bile duct occurs at the time of trauma. In this situation, symp-
toms are not immediate, but gastrointestinal (GI) bleeding,
such as hematemesis or melena, may occur in a few days. The
child may have colicky upper abdominal pain that is relieved
by emesis. Liver studies, such as a liver arteriogram, are neces-
sary to reveal the extent of the problem.
After either liver or spleen surgery, children need careful
observation for return of bowel function, assessment for the
possibility that peritonitis may develop, and careful reintro-
duction of oral nutrition.
DENTAL TRAUMA
Injuries to teeth occur most often from falls in which a child
strikes the upper front incisors or from blows to the face by ob-
jects such as baseball bats or hockey sticks. Such accidents are
always potentially serious, because they can lead to aspiration
of the injured teeth or malalignment of future teeth. If perma-
nent teeth that have been knocked out recently can be washed
with saline in the emergency department and replaced, there is
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
a good chance that they will reimplant successfully. If a tooth
is knocked out, parents should rinse the tooth in water, drop
it in a salt solution or milk, and bring it to the emergency de-
partment with them (Andersson, 2007).
Some dentists advocate immersing the tooth in an antisep-
tic and then in an antibiotic solution before replacing it. If a
tooth is replaced, it usually is wired into place to hold it in good
alignment. The child receives a course of oral antibiotics, such
as penicillin, to prevent infection. Only soft food must be eaten
until the tooth has firmly adhered (approximately 2 weeks).
If a blow to a child’s teeth was extensive, a radiograph may
be taken to rule out a mandibular or maxillary fracture. If a
portion of a tooth cannot be located, the possibility of aspi-
ration must be considered and confirmed or ruled out by a
chest radiography. In young children, often a tooth is not
knocked out but is pushed back up into the gum. These teeth
gradually regrow, and, although they may darken in color,
they usually are healthy. If the affected tooth is a deciduous
tooth, the permanent tooth is rarely injured even though it is
already formed in the gum. At the appropriate time, the per-
manent tooth will erupt normally.
NEAR DROWNING
Drowning is death caused by suffocation from submersion
in liquid. Inhaled water fills the lungs and therefore blocks
the exchange of oxygen in the alveoli. More than 3500 chil-
dren die from drowning annually, making it the second most
common cause of death by unintentional injury among chil-
dren. The term near drowning is used to describe the child
with a submersion injury who requires emergency treatment
and who survives the first 24 hours after injury (Lee, Mao, &
Thompson, 2007).
Most infant drownings occur in bathtubs; 1- to 4-year-old
children most frequently drown in artificial pools; older chil-
dren most frequently drown in bodies of fresh water. The
majority of drowning accidents that take place outside the
home occur in the summer months, when more children are
swimming and boating. Particularly at risk are male adoles-
cents, because they may take dares to swim farther than their
ability allows or may swim under the influence of alcohol,
which impairs their decision-making ability and their physi-
cal coordination.
Pathophysiology of Drowning
When children’s heads are submerged and they first inhale
water, they cough violently from the irritation of the water in
their nose and throat. If they cannot get their head out of
water at this point, water will enter the larynx. This causes the
larynx to spasm, preventing any further water but also air
from entering the trachea, so asphyxia results. If a child is ven-
tilated at this point, treatment usually is very effective because
there is little water in the lungs. The condition more closely
simulates asphyxia that occurs with croup or when a foreign
body, such as a nut, lodges in the trachea and stops air flow.
If treatment is not given at this point, the larynx relaxes
from the asphyxia and water enters the lungs. Oxygen can no
longer be exchanged, because the alveoli fill with water.
Hypoxia deepens, and cardiac arrest occurs.
Additional changes that occur when water enters the lungs
depend on whether the water is fresh or salt. Salt water is
1557
hypertonic, causing fluid to osmose from the bloodstream
and enter the alveoli, increasing the amount of fluid in the
lung tissue and increasing hypoxia. Tachycardia and de-
creased blood pressure from hypovolemia result. Blood vis-
cosity increases as shown by an increased hematocrit level.
Fresh water is hypotonic, so fluid in the lungs shifts into
the bloodstream because of osmotic pressure. This can lead
to hemolysis of red blood cells, a dilution of plasma, and pos-
sibly hypervolemia with tachycardia and increased blood
pressure. If the release of potassium from destroyed red blood
cells is great enough with fresh-water drowning, cardiac ar-
rhythmias may occur. In both instances, loss of surfactant
from lung alveoli, caused by introduction of water (adult res-
piratory distress syndrome), can lead to alveolar collapse on
expiration (Bowers & Anderson, 2008).
Parents should advocate for neighborhood pools to be
fenced and advise against hyperventilating before swimming.
When children blow off carbon dioxide with hyperventilation
this way, and then swim underwater for an extended period of
time, carbon dioxide levels will rise, but not adequately
enough to cause them to experience distress. Oxygen levels
decrease causing drowsiness and listlessness (children drown
without struggling or realizing their danger).
Very young children display a mammalian diving reflex
when they plunge under cold water that helps them survive
drowning. Immediately after plunging into cold water, a life-
saving bradycardia and shunting of blood away from the pe-
riphery of the body to the brain and heart occur. This reflex
is triggered when water is 70° F (21° C) or less and the face
is submerged first. This explains why very young children can
survive better than older children after being submerged in
water that is very cold.
Emergency Management
When a child is pulled from the water after near drowning,
mouth-to-mouth resuscitation should be started at once. If
cardiac arrest has occurred from hypoxia, simultaneous mea-
sures to initiate cardiac action must be taken. The technique
of cardiopulmonary resuscitation for infants and children is
discussed in Chapter 41.
Assuming that cardiopulmonary resuscitation is effective,
the child needs follow-up care at a health care facility, be-
cause the child is certain to be acidotic from accumulated
carbon dioxide and hypoxia (resulting from lack of oxygen
because of the water in the alveoli) and is at risk for respira-
tory infection from contaminants in the water.
Follow-up care aims to increase the child’s oxygen and car-
bon dioxide exchange capacity, using the lung areas that are
not filled with water. Typically, a child is intubated with a
cuffed intratracheal tube; mechanical ventilation with positive
end-expiratory pressure may be necessary to force air into the
alveoli. Because water has been swallowed, vomiting usually
occurs as the child is revived. The cuff of the intratracheal
tube prevents vomitus from being aspirated. The child is
given 100% oxygen so that as much space as possible in the
available lung alveoli can be used. An NG tube is inserted to
decompress the stomach, prevent vomiting, and free up
breathing space. Usually, albuterol is administered by aerosol
to prevent bronchospasm and, again, to allow the child to
make maximum use of the oxygen administered. If the child
aspirated salt water, plasma may be administered to replace
protein being lost into the lungs and prevent hypovolemia.
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1558 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
If the child’s body temperature is very low, gradual warm-
ing (not using a warming blanket) is advised so that the
metabolic requirement does not rise sharply before alveolar
space is ready to accommodate this need. Extracorporeal
membrane oxygenation may be used.
Unfortunately, neurologic damage occurs in as many as
21% of near-drowning incidents. If the child is awake or
only lethargic at the scene of the accident and immediately
afterward in the hospital, the prognosis is greatly improved
over that of the child who is comatose.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Risk for infection related to foreign
substance in respiratory tract
Outcome Evaluation: Child’s temperature remains within
normal parameters orally; rales are absent on lung
auscultation; respiratory rate is within age-acceptable
parameters.
Following near drowning, a child may be prescribed
prophylactic antibiotic therapy to prevent pneumonia
and additional airway interference. Assess vital signs
and auscultate lung sounds for adventitious sounds,
such as rales or fine rhonchi. Turning the child every
2 hours if on bedrest and encouraging deep breath-
ing and incentive spirometry every hour help to aerate
the lungs fully and prevent the accumulation of fluid,
which promotes infection.
Nursing Diagnosis: Fear related to near-drowning
experience
Outcome Evaluation: Child discusses fears; child
states that she understands that, although frightening,
the experience is over, and she is now safe.
Children may be admitted to an observation unit for
monitoring of blood gases until water from the alveoli
is absorbed and they once again can ventilate effec-
tively on their own. Such children may wake at night
from a nightmare that they are drowning. They need
their parents to reassure them that they are now safe
and definitely out of the water. Near drowning is a
thoroughly frightening experience. Encourage chil-
dren to verbalize this fright. They may need support
from parents before they try swimming again after
such a frightening experience.
POISONING
Poisoning occurs most commonly in children between the
ages of 2 and 3 years. It occurs in all socioeconomic groups.
Common agents include soaps, cosmetics, detergents or
cleaners, and plants. Poisoning can occur from over-the-
counter drugs, such as vitamins, iron compounds, aspirin, or
acetaminophen, or from prescription drugs, such as antide-
pressants. Unlike other unintentional injuries, poisoning is
entirely preventable. Parents need education about the high
risk for poisoning and strategies for maintaining a home en-
vironment that is safe for children of all ages. Be aware that
when poisoning occurs in an older child, it may not be poi-
soning but a suicide attempt.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Risk for injury related to matura-
tional age of child and presence of poisons
Outcome Evaluation: Parents identify poisonous and
toxic items in the home and describe how they are
stored safely; parents state local poison control cen-
ter number; parents describe measures to seek help
immediately if poisoning occurs.
Emergency Management of Poisoning at Home
If poisoning occurs, parents should telephone their local poi-
son control center to ask for advice. Information parents need
to provide includes:
• Child’s name, telephone number, address, weight, and
age and what the child swallowed
• How long ago the poisoning occurred
• The route of poisoning (oral, inhaled, sprayed on skin)
• How much of the poison the child took (the bottle should
say how many pills or liquid it originally held).
• If the poison was in pill form, whether there are pills scat-
tered under a chair or if they are all missing and presumed
swallowed
• What was swallowed; if the name of a medicine is not
known, what it was prescribed for and a description of it
(color, size, shape of pills)
• The child’s present condition (sleepy? hyperactive? comatose?)
If one child has swallowed a poison, parents should inves-
tigate whether other children have also poisoned themselves
as a preschooler often shares “candy” with a younger sibling.
Emergency Management of Poisoning at the
Health Care Facility
In the emergency department, the best method to deactivate
a swallowed poison is the administration of activated char-
coal, either orally or by way of an NG tube.
Activated charcoal is supplied as a fine black powder that
is mixed with water for administration. A sweet syrup may be
added to the mixture to make it more palatable. Caution par-
ents that, as the charcoal is excreted through the bowel over
the next 3 days, stools will appear black (Box 52.6).
Always follow emergency measures to neutralize a poison
with an education program for the family to prevent poison-
ing from happening again. Specific measures for each age
group are discussed in previous chapters, along with prob-
lems and concerns of that age group.
Acetaminophen Poisoning
Acetaminophen (Tylenol) is the drug most frequently involved
in childhood poisoning today, because parents use
acetaminophen to treat childhood fevers. Told that aceta-
minophen is safer than aspirin, parents may not be as careful
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
BOX 52.6 ✽ Focus on
Pharmacology
Activated Charcoal
Classification: Activated charcoal is an antidote for
poisoning.
Action: Absorbs toxic substances that have been swal-
lowed to prevent them from being absorbed by the
stomach (Karch, 2009).
Pregnancy Risk Category: C
Dosage: Provided as a powder that must be mixed with
water and administered orally or by way of nasogas-
tric (NG) tube.
Possible Adverse Effects: Vomiting, diarrhea, black
stools
Nursing Implications
• Administer orally to conscious victims only.
• Give the drug as soon as possible after poisoning.
• Store the drug in a closed container, because it ab-
sorbs gases from the air and is inactivated.
• Know that the solution feels gritty and tastes disagree-
able, so young children have difficulty swallowing the
drug. May have to be administered by NG tube.
• Caution child or parent that stools will be black for
several days after administration.
about putting this drug away as they were with aspirin. If their
child swallows acetaminophen, they may delay bringing the
child for help, thinking it is a harmless drug. Acetaminophen
in large doses, however, is not an innocent drug; it can cause
extreme liver destruction (Morgan & Borys, 2008).
Immediately after ingestion, the child will experience
anorexia, nausea, and vomiting. Soon, serum aspartate
transaminase (AST [SGOT]) and serum alanine transami-
nase (ALT [SGPT]), liver enzymes, become elevated. The
liver may feel tender as liver toxicity occurs.
Parents should call their local poison control center. In
the emergency department, activated charcoal or acetylcys-
teine, the specific antidote for acetaminophen poisoning, will
be administered. Acetylcysteine prevents hepatotoxicity by
binding with the breakdown product of acetaminophen so
that it will not bind to liver cells. Unfortunately, acetylcys-
teine has an offensive odor and taste. Administer it in a
carbonated beverage to help the child swallow it. For small
children, it is administered directly into an NG tube to avoid
this difficulty. If the child is admitted to an observation unit,
continue to observe for jaundice and tenderness over the
liver; assess ALT and AST levels as ordered.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Situational low self-esteem related
to child’s poisoning
Outcome Evaluation: Parents state guidelines for con-
tinued assessment of child at home; parents state
ways they can improve “childproofing.”
1559
After the child is stabilized, take some time to talk with
the parents about how they feel about this event.
Remember that poisoning tends to happen in homes
where there is stress. If stress was already present,
how has this poisoning added to it?
Before the child is discharged from a health care
facility, be certain the parents are comfortable with
any further assessment measures they will need to
continue at home, such as temperature taking and
urging a high fluid intake. Talk with the parents about
the necessity for childproofing their home.
✔Checkpoint Question 52.1
You see Jason’s sister in the emergency department after ac-
etaminophen poisoning. Which of the following would be an
appropriate action to take?
a. Advise the parents that their child must never receive ac-
etaminophen again.
b. Counsel the parents about not taking medications in front of
children.
c. Question an order to give activated charcoal to neutralize
the drug.
d. Sympathize with parents, but reassure them this poisoning
is not serious.
Caustic Poisoning
Ingestion of a strong alkali, such as lye, which is often con-
tained in toilet bowl cleaners or hair care products, may cause
burns and tissue necrosis in the mouth, esophagus, and stom-
ach. It is important that the parents do not try to make a child
vomit after ingestion of these substances, because they can
cause additional burning as they are vomited (ATSDR, 2008).
Assessment
After a caustic ingestion, the child has immediate pain in the
mouth and throat and drools saliva because of oral edema and
an inability to swallow. The mouth turns white immediately
from the burn. Later, the mouth turns brown as edema and ul-
ceration occur. There may be such marked edema of the lips
and mouth that it is difficult to examine them. The child may
immediately vomit blood, mucus, and necrotic tissue. The loss
of blood from the denuded, burned surface may lead to sys-
temic signs of tachycardia, tachypnea, pallor, and hypotension.
A chest radiograph may be ordered to determine whether
pulmonary involvement has occurred from any aspirated poi-
son or whether an esophageal perforation has allowed poison
to seep into the mediastinum. An esophagoscopy under con-
scious sedation may be done to assess the esophagus, although
this test may be omitted because of the possibility that an
esophagoscope might perforate the burned esophagus. After
2 weeks, a barium swallow or esophagoscopy may be per-
formed to reveal the final extent of the esophageal burns.
Therapeutic Management
When parents whose child has ingested a caustic substance
call a poison control center to ask for advice on how to pro-
ceed, they will be advised to immediately take the child to a
health care facility for treatment. There is a high possibility
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1560 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
that pharyngeal edema will be severe enough to obstruct the
child’s airway by even 20 minutes after the burn.
To detect respiratory interference, assess vital signs closely,
especially the respiratory rate. In infants, increasing restlessness
is an important accompanying sign of oxygen want. In the
emergency department, intubation may be necessary to pro-
vide a patent airway. Assess the child also for the degree of pain
involved. A strong analgesic, such as morphine, may need to
be ordered and administered to achieve pain relief.
Nursing Diagnoses and Related
Interventions
✽ jury also can result. Shock resulting from an increase in pe-
Nursing Diagnosis: Risk for ineffective airway clear-
ance related to burns of esophagus and mouth
Outcome Evaluation: Child’s respiration rate remains
within 16 to 20 breaths/minute.
Starting therapy immediately after a caustic burn with a
steroid such as dexamethasone (Decadron) and con-
tinuing it for about 4 weeks helps to reduce the chance
of permanent esophageal scarring. In addition, chil-
dren may be prescribed a prophylactic antibiotic to
reduce the possibility of infection and additional inflam-
mation in the denuded mouth and esophageal area.
Children who respond well to steroid therapy usu-
ally recover with no important sequelae. Children who
do not receive steroid therapy for some reason may
be left with scarring of the esophagus, resulting in
complete obstruction. To correct complete obstruc-
tion, a gastrostomy for feeding and repeated surgical
procedures are necessary. Sometimes transplanta-
tion of intestinal tissue or a synthetic graft is required
to replace stenosed esophageal tissue.
Nursing Diagnosis: Risk for imbalanced nutrition, less
than body requirements, related to esophageal stric-
ture from burn scarring
Outcome Evaluation: Child’s diet meets recommended
daily allowance requirements for age.
Oral intake commonly will be a problem for the first
week following a caustic injury because of soreness in
the child’s mouth. Liquid food is introduced first.
Liquid passing through the burned and scarring
esophagus tends to maintain esophageal patency, so
it is therapeutic for the burn as well as nutritious for the
child. Observe children carefully the first time they at-
tempt to drink something for coughing, choking, or
cyanosis, signs that are indicative of esophageal
stenosis or perforation. IV fluid may be needed as a
supplement for such children. If a child is totally un-
able to swallow, gastrostomy feedings or total par-
enteral nutrition will be necessary.
Hydrocarbon Ingestion
Hydrocarbons are substances contained in products such
as kerosene and furniture polish. Because these substances
are volatile, fumes rise from them, and their major effect is
respiratory, not gastric, irritation (see Chapter 40).
Iron Poisoning
Iron is frequently swallowed by small children because it is an
ingredient in vitamin preparations, particularly pregnancy vi-
tamins. When it is ingested, it is corrosive to the gastric mu-
cosa and leads to signs and symptoms of gastric irritation
(Aldridge, 2007). The immediate effects include nausea and
vomiting, diarrhea, and abdominal pain. After 6 hours, these
symptoms fade, and the child’s condition appears to im-
prove. By this time, however, hemorrhagic necrosis of the
lining of the GI tract has occurred. By 12 hours, melena
(blood in stool) and hematemesis (blood in emesis) are pres-
ent. Lethargy and coma, cyanosis, and vasomotor collapse
may occur. Coagulation defects may occur, and hepatic in-
ripheral vascular resistance and decreased cardiac output can
occur. Long-term effects can include gastric scarring from fi-
brotic tissue formation.
Assessment
It is difficult to estimate the amount of iron a child has swal-
lowed, because parents can only guess at the number of pills
in the bottle. In addition, the amount of elemental iron in
compounds varies. The child’s serum iron level should be
measured to establish a baseline.
Therapeutic Management
Parents should contact their poison control center immediately
after the ingestion. In the emergency department, stomach
lavage will be done to remove any pills not yet absorbed. A
cathartic may be given to help the child pass enteric-coated iron
pills. Activated charcoal is not given, because it is not effective
at neutralizing iron. A soothing compound such as Maalox or
Mylanta (aluminum hydroxide and magnesium hydroxide)
may be given to help decrease gastric irritation and pain.
A child who has ingested a potentially toxic dose will be
given a chelating agent, such as IV or intramuscular (IM) de-
feroxamine. Chelating agents combine with metals and allow
them to be excreted from the body. Caution parents that de-
feroxamine causes urine to turn orange as iron is excreted.
An exchange transfusion is another way that excess iron
can be removed from the body. An upper GI x-ray series and
liver studies may be ordered 1 week after the ingestion to
screen for long-term effects. The hope is that the iron load
was removed from the stomach in time so that not all of it
was absorbed.
Assist with emergency measures, such as gastric lavage, and
administer chelating agents as ordered. Parents may be asked to
test any stool passed for the next 3 days for occult blood, to as-
sess for stomach irritation and subsequent GI bleeding. Be cer-
tain that parents understand how to do this accurately.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Deficient parental knowledge re-
lated to the danger of iron as a poison
Outcome Evaluation: Parents state ways they have
safeguarded their child from future iron exposure.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
Iron poisoning occurs frequently because parents do
not think of iron pills or vitamins containing iron as
real medicine. Additionally, because many children’s
vitamins are manufactured in the shapes of familiar
television or cartoon characters, children often think
of vitamins as candy.
When you instruct parents to use an iron supple-
ment for themselves or their children, stress that over-
doses can be fatal to small children. Teach them to
think of iron as they would any other medicine and
keep it out of the reach of small children.
Lead Poisoning
When lead enters the body, it interferes with red blood cell
function by blocking the incorporation of iron into the pro-
toporphyrin compound that makes up the heme portion of
hemoglobin in red blood cells (Morgan & Borys, 2008). This
leads to a hypochromic, microcytic anemia. Kidney destruc-
tion may occur in addition, causing excess excretion of
amino acids, glucose, and phosphates in the urine. The most
serious effect, however, is lead encephalitis: inflammation of
brain cells because of the toxic lead content. Lead poisoning
(plumbism), like all forms of poisoning in children, tends to
occur most often in the toddler or preschool child. (See
Chapter 30 for measures to prevent lead poisoning.)
Assessment
Lead poisoning is said to be present when the child has two
successive blood lead levels greater than 10 ␮g/dL. A classifi-
cation of levels of lead poisoning is shown in Table 52.3. The
usual sources of ingested lead are paint chips or paint dust,
home-glazed pottery, or fumes from burning or swallowed
batteries (Olson, 2009). Paint tastes sweet, and a child will
repeatedly pick chips up off the floor or off the walls. If a crib
rail is painted with lead paint, a child will ingest it as the
child teethes on the rail. Chewing on windowsills is also
common. In fishing communities, swallowing lead sinkers
can be a common source. Restoring an older home saturates
the air with lead dust. In such homes, lead plumbing also
may contaminate the drinking water.
TABLE 52.3 ✽ Classification of Lead Poisoning Risk
Class Lead Blood Level
Concentration (␮g/dL)
Class I (low risk) ⬍9
Class IIa (rescreen) 10–14
Class IIb (moderate risk) 15–19
Class III (high risk) 20–44
Class IV (urgent risk) 45–69
Class V (urgent risk) ⬎ 70
Centers for Disease Control and Prevention. (2008). Preventing lead poisoning in young children. Washington, DC: U.S.
Department of Health and Human Services, Public Health Service.
1561
Many children with fairly high blood lead levels are
asymptomatic. Others show insidious symptoms of anorexia
and abdominal pain caused by the presence of lead in the
stomach. Children with encephalopathy usually have begin-
ning symptoms of lethargy, impulsiveness, and learning
difficulties. As the child’s blood level of lead increases, severe
encephalopathy with seizures and permanent neurologic
damage will result.
The most widely used method of screening for lead
levels is the blood lead determination (serum ferritin).
Unfortunately, this test requires the use of atomic absorp-
tion spectrophotometry, which is a costly procedure. The
free erythrocyte protoporphyrin test is a simple screening
procedure that involves only a fingerstick. Because proto-
porphyrin is blocked from entering heme by the lead, it will
be elevated in a child with lead poisoning.
Basophilic stippling (an odd striation of basophils) may
be apparent on a blood smear. A radiograph of the abdomen
may reveal paint chips in the intestinal tract (Fig. 52.6A).
“Lead lines” (areas of increased density) may be present near
the epiphyseal line of long bones (see Fig. 52.6B). The thick-
ness of the line shows the length of time lead ingestion has
been occurring (Kosnett, 2007).
Damage to the kidney nephrons from the presence of lead
leads to proteinuria, ketonuria, and glycosuria. Urine analy-
sis reveals this. The CSF may have an increased protein level.
Therapeutic Management
A child with a blood lead level between 10 and 14 ␮g/dL
needs to be rescreened to confirm the level. If the lead level
is 15 ␮g/dL or higher, a child needs active interventions to
prevent further lead exposure. These interventions may in-
clude removal of the child from the environment containing
the lead source or removal of the source of lead from the
child’s environment. Removal of the lead source can be dif-
ficult. If the family lives in a rented apartment, the landlord
may be legally obligated to remove the lead. Simple repaint-
ing or wallpapering does not remove a source of peeling paint
adequately. After some months, the new paint will begin to
peel because of the defective paint underneath. The walls
must therefore be covered by paneling or Masonite.
Recommended Action
Retest at 24 months for children age 6–35 months who
are considered low risk; retest every 6 months for ages
6–35 months who are considered high risk
Retest yearly; continue retesting yearly for children ⬎36
months until age 6 years
Retest every 3–4 months for children age 6–35 months
Retest every 3–4 months; begin home abatement program
Initiate chelating therapy and environmental remediation
Immediately treat with a chelating agent
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1562 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
A full 19-day course for optimal effectiveness.
B BAL has the advantage of removing lead from red blood
FIGURE 52.6 (A) Ingested paint chips (white crescents) in the
intestinal tract. (B) A radiograph of the long bones of a child
with chronic lead ingestion showing the characteristic “lead line”
or white marking at the epiphyseal line. (Radiographs courtesy
of Dr. Jerald P. Kuhn, Children’s Hospital, Buffalo, NY.)
All children with lead levels greater than 20 ␮g/100 mL
may be prescribed an oral chelating agent such as succimer
(Box 52.7). Children with blood lead levels of greater than
45 ␮g/100 mL may be admitted to the hospital for chelation
therapy with agents such as dimercaprol (BAL) or edetate cal-
cium disodium (CaEDTA) (Karch, 2009).
Chelating agents remove the lead from soft tissue and bone
(although not from red blood cells), allowing it to be elimi-
nated in the urine. Injections of EDTA, which must be given
IM into a large muscle mass, are painful and may be combined
with 0.5 mL of procaine. EDTA also removes calcium from
the body; therefore, serum calcium must be measured period-
ically to determine whether it is at a safe level. Measure intake
and output to ensure that kidney function is adequate to han-
dle the lead being excreted. BUN, serum creatinine, and
protein in urine may also be assessed to ensure that kidney
function is adequate. If kidney function is not adequate,
EDTA may lead to nephrotoxicity or kidney damage.
BOX 52.7 ✽ Focus on
Pharmacology
Succimer (Chemet)
Classification: Succimer is a chelating agent.
Action: Forms water-soluble chelates with lead, leading
to increased urinary excretion of lead (Karch, 2009)
Pregnancy Risk Category: C
Dosage: Orally, starting with 10 mg/kg or 350 mg/m2
every 8 hours orally for 5 days, then reducing dosage
to 10 mg/kg or 350 mg/m2 every 12 hours for 2 weeks.
The drug is taken for a total of 19 days.
Possible Adverse Effects: Nausea; vomiting; loss of
appetite; back, stomach, flank, head, or rib pain;
chills; flulike symptoms
Nursing Implications
• Obtain serum lead levels before beginning therapy
and again at the close of therapy.
• Instruct parents and child about the need to take the
• If the child has difficulty swallowing capsules, encour-
age parents to open capsules and mix capsule con-
tents with a small amount of soft food or administer
capsule contents on a spoon followed by a fruit drink.
• Urge the child to drink increased amount of fluid to
provide enough urine for removing the chelated lead
from the body.
• Ensure that a lead abatement program is instituted
concurrently to reduce the amount of lead to which
the child is exposed.
cells, but, because of severe toxicity, it is used only for children
who have severe forms of lead intoxication. Penicillamine
(Cuprimine) is yet another drug used for lead poisoning. It is
given orally after BAL or EDTA. Weekly complete blood cell
counts and renal and liver function tests accompany the
administration of penicillamine. It may be given for as long as
3 to 6 months.
Nursing Diagnoses and Related
Interventions
✽
Care planning can be difficult when a child is diag-
nosed with lead poisoning because parents are upset
at learning their child has been exposed to lead. They
may experience a loss of self-esteem and a sense of
powerlessness when realizing that their financial cir-
cumstances or lifestyle has hurt their child.
Nursing Diagnosis: Deficient knowledge related to the
dangers of lead ingestion
Outcome Evaluation: Parents state ways they have
safeguarded their child against further lead inges-
tion; parents identify measures to reduce lead in the
environment.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
Parental education about the risk of lead poisoning is
crucial. Teach parents to keep toddlers away from win-
dowsills and other common sources of lead paint.
Placing the television or an overstuffed chair against
the windowsill may be effective as a temporary mea-
sure. As a rule, children’s cribs should be placed about
3 feet away from walls in older homes to reduce the risk
of children’s picking at loose wallpaper when they first
wake in the morning or before they fall asleep at night
(plaster, which contains lead, clings to the wallpaper).
All children with elevated lead levels need careful fol-
low-up care to determine the seriousness of their con-
dition and to ensure that they are kept from a lead
source. Because children who recover from sympto-
matic lead poisoning have a high incidence of perma-
nent neurologic damage, all children with elevated
blood lead levels need appropriate follow-up care to
evaluate development and intelligence (CDC, 2008b).
Pesticide Poisoning
Pesticide poisoning can occur by accidental ingestion or
through skin or respiratory tract contact when children play in
an area that has recently been sprayed. Long-term exposure may
result from exposure to a parent’s clothing if the parent comes
home covered with pesticide spray. Although pesticide poison-
ing was once thought to be only a rural problem, the increase
in the use of lawn sprays by commercial lawn care companies
now makes this a suburban problem as well (Olson, 2009).
Many pesticides have an organophosphate base that causes
acetylcholine to accumulate at neuromuscular junctions; this
accumulation leads to muscle paralysis. Within a few minutes
to 2 hours after exposure, children develop nausea and vomit-
ing, diarrhea, excessive salivation, weakness of respiratory mus-
cles, confusion, depressed reflexes, and possibly seizures.
In the emergency department, activated charcoal may be
administered if the pesticide was swallowed. If clothing is
contaminated, remove it and wash the child’s skin and hair.
To prevent coming in contact with the pesticide yourself,
wear gloves while bathing the child.
Intravenous atropine and a cholinesterase reactivator,
pralidoxime (Protopam Chloride) are effective antidotes to
reverse symptoms. If parents apply a pesticide to children to
help avoid mosquito bites to reduce exposure to West Nile
virus infection or tick bites to reduce exposure to Lyme dis-
ease, diethyltoluamide (DEET)-based pesticides appear to be
safe if used sparingly, not applied to a child’s face, and
washed off when the child returns indoors (AAP, 2008).
Plant Poisoning
Plant poisoning (ingestion of a growing plant) occurs because
parents commonly do not think of plants as being poisonous
(Froberg, Ibrahim, & Furbee, 2007). Common plants to
which children may be exposed and the effects of ingestion
are shown in Box 52.8. Parents should phone their poison
control center for specific emergency steps.
Poisoning by Drugs of Abuse
Adolescents and even grade-school children are brought to
health care facilities by parents or friends because of a drug
1563
BOX 52.8 ✽ Focus on
Family Teaching
Identifying Poisonous Plants
Q. Jason’s father says to you, “We never realized plants
could be poisonous to our children. Which ones
should we be aware of?”
A. Several common plants can lead to poisoning in chil-
dren. Here are some and the symptoms they produce:
English ivy: Nausea, vomiting, excess salivation, diar-
rhea, abdominal pain
Holly (berries): Vomiting, diarrhea, abdominal pain
Hydrangea: Nausea, vomiting, muscular weakness,
seizures, dyspnea
Lily of the valley: Vomiting, abdominal pain, diarrhea,
cardiac disturbances
Mistletoe: Vomiting, diarrhea, bradycardia
Morning glory (seeds): Nausea, diarrhea, hallucinations
Philodendron: Swelling of the tongue, lips, irritation
of mouth
Poinsettia: Nausea, vomiting
Rhododendron: Nausea, vomiting, abdominal pain,
seizures, limb paralysis
Rhubarb (leaves): Irritant action on gastrointestinal tract
overdose or a “bad trip” caused by an unusual reaction or the
effect of an unfortunate combination of drugs. Typical drugs
involved include codeine and antidepressant drugs.
Frequently, the drugs taken were prescription drugs removed
from the family medicine cabinet (Schiesser, 2007).
Children are often extremely disoriented after this form of
ingestion. They may be having hallucinations. Obtaining a
history may be difficult because children may have no idea
what they took except that it was a red or a yellow capsule.
They may know but may be reluctant to name a drug if it
was obtained illegally.
Assessment
Although a child may not appear to hear well or may not
seem coherent, try to elicit a history. Avoid shouting or ag-
gravating, because children who are having a paranoid reac-
tion will be unable to cope rationally with this approach. If
friends accompany an ill child, point out that your role is not
that of a law enforcer. Your role is to help the child, and you
cannot do that effectively unless the drug is identified.
Approaching a child’s friends in this way is more likely to re-
sult in their naming the drug. If a child is brought in by par-
ents who have no idea what drug could possibly have been
taken, ask them to have someone at home check the child’s
bedroom for drugs or what could be missing from the medi-
cine cabinet (provided the child became ill while at home).
Expect to obtain blood specimens for electrolyte levels and
a toxicology screen. If the child is vomiting, save any vomitus
for analysis. Try to determine whether the ingestion was an ac-
cident (perhaps the child was unaware that two drugs would
react this way or took a wrong dose) or whether the child was
actually attempting suicide. All poisonings or drug ingestions
in children older than 7 years of age should be considered po-
tential suicides until established otherwise. If the ingestion was
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1564 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
an accident, the child will need counseling to avoid drug use
or about which drugs do not mix. If the incident was an at-
tempted suicide, the child will need observation and counsel-
ing toward more effective coping mechanisms in self-care.
Therapeutic Management
Children need supportive measures for their specific symp-
toms, including oxygen administration, electrolyte replace-
ment (particularly if there is accompanying nausea and vom-
iting), and perhaps IV fluid administration in an attempt to
dilute the drug.
Children who have swallowed a drug of abuse need im-
mediate treatment followed by investigation into the events
leading to the poisoning. This potentially lethal ingestion
may act as a turning point in the child’s life, possibly alerting
the child and family to a drug problem and the need for help.
Factors such as reduction of fear and anxiety, increased cop-
ing mechanisms, knowledge of the effects of drug use, and
availability of referral sources for a drug problem are impor-
tant areas to address. (See Chapter 33 for more information
related to adolescents and drug use.)
✔Checkpoint Question 52.2
Suppose Jason’s older brother had lead poisoning. What is
the most common source of lead poisoning in young children?
a. Smelling lead fumes from cooking utensils.
b. Chewing on batteries that fall out of toys.
c. Drinking lead-contaminated drinking water.
d. Chewing on chips of lead-based outdoor paint.
FOREIGN BODY OBSTRUCTION
Foreign bodies can become lodged in children’s esophagus,
ear canals, or noses, causing stasis of secretions and infection.
Direct obstruction or laceration of the mucous membrane
may also result, leading to serious consequences.
Whether a foreign substance is inhaled or embedded else-
where, nursing interventions should focus first on comfort-
ing the child and aiding in removal of the substance, and
then on teaching the child and parents ways to avoid such oc-
currences in the future.
Foreign Bodies in the Ear
Any child with a history of draining exudate from the ear
canal needs an otoscopic examination to establish the reason
for the drainage. In toddlers and preschoolers, the drainage
often is the result of a foreign body in the ear canal. The ob-
ject might be a small piece of a toy, a piece of paper, a small
battery, or food, such as a peanut (Singh et al., 2007).
Removal of a foreign body from the ear is difficult because
children are afraid that the instrument used will hurt them,
so they have difficulty lying still for the procedure. If there is
reason to think that the tympanic membrane is intact, irri-
gating the object from the ear canal with a syringe and nor-
mal saline may be possible. This should not be done if the
object is a substance that will swell when wet, such as a
peanut. If it is possible that the tympanic membrane is rup-
tured, the ear canal must not be irrigated or fluid will be
forced into the middle ear, possibly introducing infection
(otitis media).
Often, it is better to wait for an otolaryngologist to care
for the child, because trauma to the ear canal during an at-
tempt to remove a foreign body will increase the edema and
make removal even more difficult.
Foreign Bodies in the Nose
Foreign objects stuffed into the nose eventually cause in-
flammation and purulent discharge from the nares. The odor
accompanying such impaction is often the first sign noticed
by a parent. Objects pushed into the nose usually can be re-
moved with forceps. A local antibiotic might be necessary
after removal if ulceration resulted from the local irritation.
Foreign Bodies in the Esophagus or Stomach
Children tend not to chew food well or to swallow portions
that are too big to pass safely through the esophagus. Pieces
of candy, such as Lifesavers, are common objects caught in
the esophagus in young children; coins may be swallowed by
adolescents playing drinking games. Orthodontic appliances
may become dislodged and swallowed. Intense pain at the
site where the object is lodged will result. If it is an object
that will dissolve, such as a Lifesaver or a piece of digestible
meat, offer the child fluid to drink to help flush the object
into the stomach. Even after the object dissolves or passes
into the stomach, the child will feel transient pain at the orig-
inal site of the obstruction.
Magnets, particularly those in watches or hearing aids, are
also frequently swallowed by young children. These need to
be removed by endoscopy as soon as possible as they can lead
to bowel perforation or volvulus (Schierling et al., (2008).
Objects, such as a part of a toy or a chicken bone, that will
not dissolve and should not be passed, are also removed by
endoscopy (Weissberg & Refaely, 2007).
Small coins, such as pennies and dimes, usually pass by
themselves without difficulty. Parents (or children them-
selves if adolescents) should observe stools over the next sev-
eral days to determine that the coin does pass through the GI
tract (about 48 hours after ingestion). Without frightening
them, caution parents to observe for signs of bowel perfora-
tion or obstruction, such as vomiting or abdominal pain,
until the object has passed. If there is any doubt, a radiograph
taken 3 to 7 days after ingestion will establish whether the
object has been evacuated from the body.
Subcutaneous Objects
Children receive many wood splinters in the hands and feet.
These usually are removed easily by a probing needle and
tweezers after cleaning with an antiseptic solution. If the pen-
etrating object is metal, such as a sewing needle or nail, its
presence can be detected by radiography. If the object is one
that would have been in contact with soil, such as a rusty
nail, the child will need tetanus prophylaxis after extraction
of the object if tetanus immunization is not current.
What if... You received a call from your neighbor stating
that her 2-year-old son has swallowed a penny? What in-
terventions would you expect to be necessary? What
signs and symptoms would suggest GI obstruction?
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
BITES
Children receive bites from snakes and animals such as dogs
or raccoons; they occasionally receive bites from other chil-
dren. The source of a bite needs to be documented as human
bites can also result from sexual abuse.
Mammalian Bites
Dog bites account for approximately 90% of all bites in-
flicted on humans, and children and adolescents are involved
in one third to one half of reported incidents. The dog is usu-
ally one owned by the child’s family. Cat bites, wild animal
bites, and human bites also constitute a threat, although they
are less common in children. All of these bites can cause abra-
sions, puncture wounds, lacerations, and crushing injuries re-
lated to the size of the animal and the location of the bite
(Jacobs, Guglielmo, & Chin-Hong, 2009). The biggest con-
cerns associated with animal bites are the possibility of long-
term scarring and disfigurement and the possibility of infec-
tion, especially rabies, from the presence of microorganisms
in the animal’s mouth. This latter subject is discussed in
Chapter 43.
Snakebite
In the United States, snakebites tend to occur during the
warm months of the year, from April to October. Most fatal
snakebites (envenomations) in the United States are copper-
head or rattlesnake bites. Copperheads are found in eastern
and southern states, and rattlesnakes in almost every state. A
few bites occur from cottonmouth moccasins or coral snakes
(both found in southeastern states). The effect of the bite of
a rattlesnake, copperhead, or cottonmouth moccasin (all pit
vipers) is a failure of the blood coagulation system (Clark,
2007). Coral snakes are known for the small coral, yellow,
and black rings encircling their body. Fortunately, they are
shy and seldom bite. However, the venom injected through
the bite of these snakes leads to neuromuscular paralysis.
Assessment
Reaction to a pit viper bite is almost immediate. A white
wheal forms at the site, showing the puncture marks, accom-
panied by excruciating pain at the site. Purplish erythema
and edema begin to extend rapidly from the site.
By the time a child is seen at a health care facility, san-
guineous fluid may be oozing from the bite. Systemic symp-
toms, such as dizziness, vomiting, perspiration, and weak-
ness, may be present. Because snake venom interferes with
blood coagulation, the child may have hematemesis or bleed-
ing from the nose, intestines, or bladder because of subcuta-
neous or internal hemorrhage. The pupils may be dilated,
showing the potent effect on cerebral centers. If the enveno-
mation is not treated, seizures, coma, and death may result.
Emergency Management at the Scene
At the scene of a snakebite, apply a cold compress to the bite,
in the hope of slowing the spread of the venom and to reduce
edema formation. Urge the child to lie quietly, to slow cir-
culation. Keep the bitten extremity dependent, again to slow
venous circulation. Commercial snakebite kits have rubber
suction cups in them for suctioning out venom. If these are
1565
available, they should be used at the site where the bite oc-
curred. Excising the bite with a knife and sucking out the
venom orally (often shown in old western movies) is of ques-
tionable value and contradicts rules of standard infection pre-
cautions. If the person administering the treatment has open
mouth lesions, such as carious teeth, the procedure could be
dangerous to that person (venom is not dangerous when
swallowed, only when absorbed through open lesions).
Excising the bite also may lead to secondary infection and, if
done too vigorously, may injure tendon or muscle. No time
should be wasted before the child is transported to a health
care facility for treatment.
Emergency Management at the Health Facility
In the emergency facility, ask the child or a person who was
with the child to describe the snake. In areas where snakebites
are frequent, keep available photographs of the venomous
snakes commonly found. Even a preschooler may be able to
identify the snake by pointing to a photograph. Specific an-
tivenin is then administered. Because rattlesnakes, copper-
heads, and cottonmouth moccasins are all one type of snake
(pit vipers), one form of antivenin acts against all of these
bites. Specific antivenin is prepared for coral snake or cobra
bites and is kept at most zoos. If the child receives antivenin
promptly after a bite, the prognosis for full recovery is good.
Tetanus prophylaxis is instituted if the child’s immunization
status is unknown or if it has been more than 10 years since a
tetanus immunization was given.
Antivenin may contain a horse-serum base. Therefore,
before the serum is injected IM or IV, a skin test may need
to be performed to prevent a possible anaphylactic reaction
to the horse serum. If the serum is given IM, do not inject
it into an edematous body part, because medication ab-
sorption will be poor. Giving antivenin in the limb oppo-
site the bitten limb is just as effective as administering it
into the bitten limb.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Fear related to seriousness of
child’s condition
Outcome Evaluation: Parents and child state that they
are able to cope with the degree of fear present.
Children with snakebites are extremely frightened.
Their parents who have seen old western movies
showing the agony of snakebite also are thoroughly
frightened. Children need a great deal of support from
health care personnel, because their parents may be
too frightened to offer adequate support.
As a final care measure, teach children safety rules
for avoiding snakebites:
• Look for snakes before stepping into underbrush.
• Do not lift up rocks without looking at what could be
under them.
• Listen for the telltale sound of a rattlesnake.
• Be aware that snakes sun on warm rocks.
• Know the markings of poisonous snakes.
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1566 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
THERMAL INJURIES
Thermal injuries include those caused by either cold (frost-
bite) or by excessive heat (burns).
Frostbite
Frostbite is tissue injury caused by freezing cold (Stallard,
2008). Cold exposure leads to peripheral vasoconstriction,
cutting off the oxygen supply to surrounding cells. In chil-
dren, the body parts involved usually are the nose, fingers, or
toes. Cells at the site can be so injured that they die.
Assessment
The affected body part appears white or erythematous;
edema is present and it feels numb. Degrees of frostbite are
summarized in Table 52.4. Explore the cause of frostbite by
careful history taking. It occurs most frequently in children
who have been skiing, snowmobiling, or snowboarding for
long periods. If parents failed to provide adequate clothing
because they underestimated the degree of cold outside, the
possibility of neglect or child abuse must be ruled out as a
cause. Frostbite also can occur from sucking on popsicles and
from inhalant abuse.
Therapeutic Management
Always warm frostbitten areas gradually. Sudden warming in-
creases the metabolic rate of cells; without adequate blood flow
to the area because of still-present vasoconstriction, additional
damage can occur. Administration of a vasodilator and use of
hyperbaric oxygen may help reduce the effect on body cells.
Nursing Diagnoses and Related
Interventions
✽ and what is its extent and depth?” Burns are classified ac-
Nursing Diagnosis: Pain related to frostbite damage
to cells
Outcome Evaluation: Child states that pain is con-
trolled at a tolerable level.
As soon as warming begins, the frostbitten area be-
comes extremely painful because the cells that are
TABLE 52.4 ✽ Degrees of Frostbite
Degree Description
First Mild freezing of epidermis; appears
erythematous with edema
Second Partial- or full-thickness injury; appears
erythematous with blisters and pain
occurring after rewarming
Third Full-thickness injury (epidermis, dermis,
and subcutaneous tissue); appears
white
Fourth Complete necrosis with gangrene and
possible ultimate loss of body part
injured register their anoxic state. Children need an
analgesic for pain, such as IV morphine. Morphine
administered epidurally can be used for pain relief in
lower body areas.
During the next few days after severe frostbite,
necrosis of destroyed tissue occurs, and the affected
tissue sloughs away. Apply dressings as necessary to
avoid secondary bacterial contamination of a necrotic
injury site. Assess body temperature conscientiously
to detect early symptoms of infection at the site.
Burns
Burns are injuries to body tissue caused by excessive heat (heat
greater than 104° F [40° C]). Such injuries commonly occur
in children of all ages after infancy. They are the second great-
est cause of unintentional injury in children 1 to 4 years of age
and the third greatest cause in children age 5 to 14 years.
Toddlers are often burned by pulling pans of scalding water or
grease off the stove and onto themselves or from bath water
that is too hot (Leahy et al., 2007). They can bite into electri-
cal cords. Older children are more apt to suffer burns from
flames when they move too close to a campfire, heater, or fire-
place; touch a hot curling iron; or play with matches or lighted
candles. Eye burns can occur from splashed chemicals in sci-
ence classes (Pavan-Langston & Hamrah, 2008). Some burns
(particularly scalding) can be caused by child abuse (Hicks &
Stolfi, 2007). Burn injuries tend to be more serious in children
than in adults, because the same size burn covers a larger sur-
face of a child’s body. As many as 50% of burns could be pre-
vented with improved parent and child education.
Assessment
When children are brought to a health care facility with a
burn injury, the first questions must be, “Where is the burn
cording to the criteria of the American Burn Association as
major, moderate, or minor (Huether & McCance, 2007).
These classifications are shown in Table 52.5. Along with the
TABLE 52.5 ✽ Classification of Burns
Classification Description
Minor First-degree burn or second-
degree burn ⬍10% of body
surface or third-degree burn
⬍2% of body surface; no area
of the face, feet, hands, or
genitalia burned
Moderate Second-degree burn between
10% to 20% or on the face,
hands, feet, or genitalia or
third-degree burn ⬍10% of
body surface or if smoke
inhalation has occurred
Severe Second-degree burn ⬎20% of
body surface or third-degree
burn ⬎10% of body surface
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1567

size and depth, be certain to assess and document the loca- and is misleading in the very young child. Data for deter-
tion of the burn. Face and throat burns are particularly haz- mining the extent of burns in children are shown in Figure
ardous because there may be accompanying but unseen 52.7. Computer analysis is now available to rapidly assess the
burns in the respiratory tract. Resulting edema could lead to extent of burns.
respiratory tract obstruction. Hand burns are also hazardous
because, if the fingers and thumb are not positioned properly Depth of Burn. When estimating the depth of a burn, use
during healing, adhesions will inhibit full range of motion in the appearance of the burn and the sensitivity of the area to
the future. Burns of the feet and genitalia carry a high risk for pain as criteria. Descriptions of tissue at various burn depths
secondary infection. Genital burns are also hazardous be- are shown in Table 52.6 and are illustrated in Figure 52.8.
cause edema of the urinary meatus may prevent a child from Partial-thickness burns include first- and second-degree
voiding. burns. A first-degree burn involves only the superficial epi-
With adults, the “rule of nines” is a quick method of esti- dermis. The area appears erythematous. It is painful to touch
mating the extent of a burn. For example, each upper ex- and blanches on pressure (Fig. 52.9A). Scalds and sunburn
tremity represents 9% of the total body surface; each lower are examples of first-degree burns. Such burns heal by simple
extremity represents two 9s, or 18%, and the head and neck regeneration and take only 1 to 10 days to heal.
represent 9%. Because the body proportions of children are A second-degree burn involves the entire epidermis. Sweat
different from those of adults, this rule does not always apply glands and hair follicles are left intact. The area appears very

Infant
Anterior A A Posterior

1 1.25
1.25 1

1.5 1.5
2 2 2
2 1.5
13 1.25 13
1.5

1.25
B B
1 2.5 2.5
B
C B
C
C C
1.75 1.75
1.75 1.75

AREA BIRTH AGE 1 YR AGE 5 YR

A = 1/2 of head 9 1/2 8 1/2 6 1/2
B = 1/2 of one thigh 2 3/4 3 1/4 4
C = 1/2 of one leg 2 1/2 2 1/2 2 3/4

A 5-9 year-old A

1 1

2 13 2
2 13 2

1.5 1.5
1.5 1.5
1 2.5 2.5 1.25
1.25 1.25 1.25

B B
B B

C C C C

1.75 1.75 1.75 1.75

AREA AGE 10 YR AGE 15 YR ADULT

A = 1/2 of head 5 1/2 4 1/2 3 1/2
B = 1/2 of one thigh 4 1/2 4 1/2 4 3/4
C = 1/2 of one leg 3 3 1/4 3 1/2
FIGURE 52.7 Determination of extent of
burns in children.
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1568 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

TABLE 52.6 ✽ Characteristics of Burns

Severity Depth of Tissue Involved Appearance Example

First degree Epidermis Erythematous, dry, painful Sunburn
(partial thickness)
Second degree Epidermis Blistered, erythematous to white Scalds
(partial thickness) Portion of dermis
Third degree Entire skin, including nerves Leathery; black or white; not sensitive Flame
(full thickness) and blood vessels in skin to pain (nerve endings destroyed)

Depths of burns Skin grafts

Epidermis
Superficial
(1st degree)
Split
Partial thickness
thickness
(2nd degree)
Full
thickness

Full
thickness
(3rd degree)
Dermis

Subcutaneous
tissue

FIGURE 52.8 Depths of burns.

A B
FIGURE 52.9 Partial-thickness burns. (A) An infant with a first-degree burn on the arm and chest caused by scalding with hot
water. (B) A toddler with a second-degree burn caused by scalding. The area appears severely reddened and moist with some
blistering. (A, © Dr. P. Marazzi/SPL/Science Source/Photo Researchers. B, © NMSB/Custom Medical Stock Photograph.)
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
FIGURE 52.10 Full-thickness (third-degree) burn of the foot.
Both layers of skin are involved with this type of burn. (© Dr.
Michael English/Custom Medical Stock Photograph.)
erythematous, blistered, and moist from exudate. It is ex-
tremely painful. Scalds can cause second-degree burns (see
Fig. 52.9B). Such burns heal by regeneration of tissue but
take 2 to 6 weeks to heal.
A third-degree burn is a full-thickness burn involving
both skin layers, epidermis and dermis. It may also involve
adipose tissue, fascia, muscle, and bone. The burn area ap-
pears either white or black (Fig. 52.10). Flames are a com-
mon cause of third-degree burns. Because the nerves, sweat
glands, and hair follicles have been burned, third-degree
burns are not painful. Such burns cannot heal by regenera-
tion because the underlying layers of skin have been de-
stroyed. Skin grafting is usually necessary, and healing takes
months. Scar tissue will cover the final healed site. Many
burns are compound, involving first-, second-, and third-
degree burns. There may be a central white area that is in-
sensitive to pain (third degree), surrounded by an area of
erythematous blisters (second degree), surrounded by an-
other area that is erythematous only (first degree).
Undress children with burns completely so the entire
body can be inspected. A first-degree burn is painful, whereas
a third-degree burn is not. Therefore, a child may be crying
from a superficial burn that is obvious on the arm, although
the condition needing the most immediate attention is a
third-degree burn on the chest, which is covered by a jacket.
Be certain to ask what caused the burn, because different
materials cause different degrees of burn. Hot water, for ex-
ample, causes scalding, a generally lesser degree of burn than
one caused by flaming clothing. Ask where the fire happened.
Fires in closed spaces are apt to cause more respiratory in-
volvement than fires in open areas.
Ask whether the child has any secondary health problem.
In their anxiety over the present burn, parents may forget to
report important facts, such as the child has diabetes or is al-
lergic to a common drug. After a fire, parents may pick up a
burned child and bring the child to a health care facility,
leaving other children unprotected at home. Ask about other
children and where they are. Parents may have burned hands
from putting out the fire on the child’s clothes and need
equal care, but in their anxiety about the child’s condition,
they do not mention this. Ask who put out the fire. Were any
other family members or animals hurt? Does anyone else
need care?
1569
Emergency Management of Burns
All burns need immediate care because of the pain involved
(Rieman, Gordon, & Marvin, 2007).
Minor Burns. Although minor burns (typically first-degree
partial-thickness burns) are the simplest type of burn, they
involve pain and death of skin cells, so they must be treated
seriously. Immediately apply ice to cool the skin and prevent
further burning. Application of an analgesic–antibiotic oint-
ment and a gauze bandage to prevent infection is usually the
only additional treatment required. The child should have a
follow-up visit in 2 days to have the area inspected for a
secondary infection and to have the dressing changed.
Caution parents to keep the dressing dry (no swimming or
getting the area wet while bathing for 1 week). A first-degree
burn heals in about that time.
Moderate Burns. Moderate or second-degree burns may
have blisters. Do not rupture them, because doing so invites
infection. The burn will be covered with a topical antibiotic
such as silver sulfadiazine and a bulky dressing to prevent
damage to the denuded skin. The child usually is asked to re-
turn in 24 hours to assess that pain control is adequate and
there are no signs and symptoms of infection. Broken blisters
may be débrided (cut away) to remove possible necrotic tis-
sue as the burn heals.
Severe Burns. The child with a severe burn is critically in-
jured and needs swift, sure care, including fluid therapy, sys-
temic antibiotic therapy, pain management, and physical
therapy, to survive the injury without a disability caused by
scarring, infection, or contracture.
Electrical Burns of the Mouth. If a child puts the prongs of
a plugged-in extension cord into the mouth or chews on an
electric cord, the mouth will be burned severely (Kidd et
al., 2007). Electrical current from the plug is conducted for
a distance through the skin and underlying tissue, so a tis-
sue area much larger than where the prongs or cord actually
touched is involved, leaving an angry-looking ulcer. If
blood vessels were burned, active bleeding will be present.
The immediate treatment for electrical burns of the mouth
is to unplug the electric cord and control bleeding. Pressure
applied to the site with gauze is usually effective. Most chil-
dren are admitted to a hospital for at least 24 hours in an
observation unit because edema in the mouth can lead to
airway obstruction.
Supply adequate pain relief as long as necessary. Clean the
wound about four times a day with an antiseptic solution, such
as half-strength hydrogen peroxide, or as otherwise ordered to
reduce the possibility of infection (a real danger in this area,
because bacteria are always present in the mouth).
Eating will be a problem for the child because the mouth
is so sore. The child may be able to drink fluids from a cup
best. Bland fluids, such as artificial fruit drinks or flat ginger
ale, are best.
Electrical burns of the mouth turn black as local tissue
necrosis begins. They heal with white, fibrous scar tissue,
possibly causing a deformity of the lip and cheeks with heal-
ing. This can be minimized by the use of a mouth appliance,
which helps maintain lip contour. Some children have diffi-
culty with speech sounds because of resulting lip scarring.
They need follow-up care by a plastic surgeon to restore their
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1570 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
lip contour. Obviously, you need to review with parents the
importance of not leaving “live” electrical cords where young
children can reach them.
Nursing Diagnoses and Related
Interventions
✽ over burn dressings to maintain the joints in extension.
Nursing Diagnosis: Pain related to trauma to body cells
Outcome Evaluation: Child states that pain is at a tol-
erable level.
Morphine sulfate is commonly the agent of choice. It
can be administered IM, but, because circulation is
impaired in children with shock, IV or epidural admin-
istration is most effective. Use of patient-controlled
analgesia before performing any burn care such as
débridement (the removal of necrotic tissue from a
burned area) is also effective. Be sure to assess after
administration that pain relief was adequate.
In addition to the pain from the burn, children may
be required to remain in awkward positions to keep
joints overextended for most of every day. Doing so
helps to prevent formation of contractures from scar
A of burn injury and hypovolemia can lead to a marked
FIGURE 52.11 (A) An adoles-
cent’s hand scarred from third-
degree burns. Note the proper
extension and alignment of the
hand and fingers, which were
maintained by the use of splints
(B) during healing. (A, © Dr. P.
Marazzi/SPL/Science
B Source/Photo Researchers.)
tissue (Fig. 52.11). If the anterior throat is burned, for
example, the head will be hyperextended to keep scar
tissue that forms on the anterior neck from pulling the
chin down against the chest in a contracture. It is diffi-
cult for children to watch television in this position or
even to view activities on the unit so they need to be
encouraged to maintain this position. If they have
burns at extremity joints, they may have splints applied
Again, this makes activities very difficult and adds to
their stress if they do not have adequate pain relief.
Children who experience smoke inhalation may be
unconscious from brain anoxia immediately after a
burn. Most children, however, are awake and very
aware of the pain and treatments involved. Therefore,
a priority need is immediate pain relief. After the first
week following a major burn, some children develop
symptoms of delirium, seizures, and coma that result
from toxic breakdown of damaged cells, sensory de-
privation, isolation, and lack of sleep. Nursing care
aimed at reducing unnecessary stimuli and providing
adequate pain relief helps to prevent these late symp-
toms from occurring.
Nursing Diagnosis: Deficient fluid volume related to
fluid shifts from severe burn
Outcome Evaluation: Skin turgor remains good; hourly
urine output is greater than 1 mL/kg, with specific
gravity between 1.003 and 1.030; vital signs are within
acceptable parameters.
Immediately after a severe burn, the child’s circulatory
system becomes hypovolemic, because of a loss of
plasma, which oozes from blood vessels into the burn
site and then sequesters in edematous tissue sur-
rounding the site. This outpouring of plasma is caused
by an increased permeability of capillaries (or dam-
age to capillaries). It is most marked during the first
6 hours after a burn. It continues to some extent for the
first 24 hours.
A primary response of the myocardium to the shock
reduction in cardiac output and decreased blood pres-
sure. Therefore, even with relatively minor burns, moni-
tor vital signs closely to allow early detection of this
event. A child may be severely anemic because of in-
jury to red blood cells caused by heat and loss of blood
at the wound site. The large amount of sodium lost with
the edematous burn fluid and the release of potassium
from damaged cells can lead to an immediate hypona-
tremia and hyperkalemia (Table 52.7).
Lactated Ringer’s solution is the commercially
available solution most compatible with extracellular
fluid. Usually, it is one of the first fluids begun for fluid
replacement, although normal saline may be used. A
child may also need plasma replacement and addi-
tional fluid, such as 5% dextrose in water. Do not
administer potassium immediately after a burn until
kidney function is evaluated, to be certain that extra
potassium can be eliminated. IV fluid is usually ad-
ministered by the most convenient venous access, so
that morphine sulfate can be administered to relieve
pain. A more stable fluid line may then be inserted.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
TABLE 52.7 ✽ Fluid Shifts After Burn Injury
Fluid Shifts in Remobilization of Fluid
First 24 Hours After 48 Hours
Burn Edematous tissue surround-
ing burn area
↓ ↓
Increased capillary Intravascular compartment
permeability
↓ ↓
Hypoproteinemia
Hyponatremia Hypervolemia
Hyperkalemia Hypernatremia
Hypovolemia Hypokalemia
The amount of fluid necessary is calculated carefully,
based on predicted insensible fluid loss and loss be-
cause of the burn. The Parkland formula is commonly
used to calculate the amount of fluid needed for the
first 24 hours: 4 mL/kg body weight for each 1% of
body surface area burned.
This fluid is administered rapidly for the first 8 hours
(half of the 24-hour load), then more slowly for the next
16 hours (the second half). It is important that admin-
istration be continued beyond the time of increased
capillary permeability (at least the first 24 hours). The
administration site, therefore, must be protected to
prevent infiltration. A central venous pressure or pul-
monary artery catheter may be inserted to determine
hemodynamic and fluid volume status and evaluate
that the child is receiving adequate fluid.
About 48 hours after the burn, as inflammation de-
creases, the extracellular fluid at the burn site begins
to be reabsorbed into the bloodstream. Edema begins
to subside; the child has diuresis and loses weight.
The heart rate increases because of temporary hyper-
volemia. The hematocrit level is low because red
blood cells are diluted. The child needs frequent eval-
uation of electrolyte levels to determine fluid balance
during this period. Potassium supplements may be
necessary to maintain normal heart function, because,
although potassium was released into the serum from
destroyed cells, it is rapidly excreted by the kidneys.
If the child needs continued electrolyte replacement
at this time, carefully monitor the rate of flow so the
blood volume does not exceed the child’s tolerance. If
many red blood cells were destroyed at the burn site,
the child may need packed red blood cells to maintain
an adequate hemoglobin level.
Nursing Diagnosis: Risk for ineffective tissue perfusion
related to cardiovascular adjustments after burn injury
Outcome Evaluation: Child’s vital signs stay within nor-
mal limits; hourly urine output remains greater than
1 mL/kg.
Take height, weight, and vital signs on admission, and
continue to take vital signs every 15 minutes until they
are stable. Once vital signs are stabilized, record
1571
pulse, blood pressure, and central venous pressure
hourly until the child passes the immediate danger of
shock (at least 24 hours). Another important period
occurs at 48 hours after the injury, when fluid is re-
turning to the bloodstream. Remember that gradual
but persistent changes in blood pressure may be as
informative as sudden changes.
A complete blood cell count, blood typing and
cross-matching, electrolyte and BUN determinations,
and blood gas studies to ascertain blood levels of
oxygen and carbon dioxide are important to obtain.
Nursing Diagnosis: Risk for ineffective breathing pat-
terns related to respiratory edema from burn injury
Outcome Evaluation: Child’s respiratory rate remains
within 16 to 20 breaths/minute; lung auscultation re-
veals no rales.
If a child inhaled smoke from a fire, the injury from the
smoke inhalation can be more serious than the skin
surface burns. Smoke coming from a fire is at the tem-
perature of the fire. Inhaling smoke, therefore, is the
same as exposing the upper respiratory tract to open
flame. In addition, toxic substances and soot given off
by the fire cause even more irritation to the respiratory
tract. If carbon monoxide is inhaled with the smoke, it
enters red blood cells in place of oxygen, shutting off
the oxygen supply to body cells. If this is extensive, it
can lead to loss of consciousness because of cere-
bral anoxia. If the trachea is burned, edema fluid will
pass into the injured bronchioles and trachea, caus-
ing pulmonary edema or obstruction limiting air inflow.
This can lead to dyspnea and stridor. About 1 week
after the smoke inhalation, the child is at risk for the
development of pneumonia because of denuded tra-
cheal and bronchial tract areas. The fact that inhala-
tion of smoke or flame from a fire can be more serious
than the skin burns the child suffers may be difficult
for parents to understand. They are relieved if they
learn that the child has suffered only smoke inhalation.
They may need an explanation of the physiologic con-
sequences that can result from pulmonary injury.
To help rule out smoke inhalation, obtain a history
to assess whether the fire occurred in a closed
space, such as a garage. Assess for burns of the
face, neck, or chest, which would indicate that the fire
was near the nose and respiratory tract. Assess the
quality of the child’s voice (it will be hoarse if the
throat is irritated from smoke). Carefully monitor the
respiratory rate of all burned children, because respi-
ratory rate increases with respiratory obstruction.
A child also may become restless and thrash about
because of lack of oxygen. Measurement of blood
gases will demonstrate the degree of hypoxia present
from carbon monoxide intoxication. Administration of
100% oxygen is the best therapy for displacing car-
bon monoxide and providing adequate oxygenation
to body cells. The child may need endotracheal intu-
bation or a tracheostomy with assisted ventilation to
ensure adequate oxygenation. Intubation is best, be-
cause tracheostomies can lead to infection, and this
child is at a much higher risk for pneumonia than the
average child.
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1572 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Symptoms of smoke inhalation may not occur im-
mediately but only 8 to 24 hours after the burn. A chest
radiograph taken at this time will reveal collecting ede-
matous fluid and decreased aeration. Continue to as-
sess the child’s temperature every 4 hours for the first
week after the injury, to assess that lung infection is not
developing. Bronchodilators and antibiotics may be
prescribed. High-frequency ventilation may be helpful
to keep alveoli functioning. Some children need extra-
corporeal membrane oxygenation (ECMO) support
because smoke inhalation has compromised their lung
function to such a great extent.
Nursing Diagnosis: Risk for impaired urinary elimina-
tion related to burn injury
Outcome Evaluation: Child’s urine output is greater
than 1 mL/kg of body weight per hour.
Because the child’s blood volume decreases immedi-
ately after a burn, renal function is threatened by kidney
ischemia just when it is needed to rid the body of break-
down products from burned cells. If the child is burned
over more than 10% of body surface, urinary output
may decrease immediately. Blood volume must be
maintained by IV fluid administration to establish good
urinary output once more. Urine output should be
1 mL/kg of body weight per hour. The specific gravity
of urine also should be monitored to determine whether
the kidneys can concentrate urine to conserve body
fluid (failing kidneys lose this ability rapidly). In the days
after the burn, because products of necrotic tissue and
toxic substances must be evacuated by the kidneys
and antidiuretic hormone and aldosterone levels are in-
creased in response to low blood pressure, kidney
function may fail again. If free hemoglobin from de-
stroyed red blood cells plugs kidney tubules (acute
tubular necrosis), urine color will be red to black be-
cause of the hemoglobin present.
An indwelling urinary (Foley) catheter should be in-
serted in the emergency department, and an immedi-
ate urine specimen should be obtained for analysis. A
diuretic, such as mannitol, may be administered to
flush hemoglobin from the kidneys. If this is effective,
the urine returns to its usual straw color. Throughout
the child’s hospital stay, observing urinary output is a
major nursing responsibility.
Nursing Diagnosis: Risk for imbalanced nutrition, less
than body requirements, related to burn injury
Outcome Evaluation: Child’s weight remains within
normal age-appropriate growth percentiles; skin tur-
gor remains normal; urine specific gravity remains be-
tween 1.003 and 1.030.
After burns, the metabolic rate increases in children
as the body begins to pool its resources to adjust to
the insult. If children do not receive enough calories in
IV fluid, their body will begin to break down protein.
This is particularly dangerous because a child needs
protein for burn healing. Additionally, breakdown of
protein can lead to acidosis.
After a severe burn, some children are nauseated
from the systemic shock. An NG tube may be inserted
and attached to low, intermittent suction as prophylac-
tic therapy to prevent aspiration of vomitus. The tube
must remain in place until bowel sounds are detected.
This usually occurs within 24 hours but may take as
long as 72 hours in severely burned children. Fluid suc-
tioned from an NG tube may be blood-tinged (coffee-
ground fluid) because of bleeding caused by stomach
vessel congestion. Closely observe this drainage for a
change to fresh bleeding, which can be caused by a
stress ulcer (Curling’s ulcer). This type of ulcer can be
prevented by administering a histamine-2 receptor an-
tagonist, such as cimetidine (Tagamet) or a proton
pump inhibitor such as omeprazole (Prilosec) in an at-
tempt to reduce gastric acidity and ulcer formation.
If a bleeding ulcer occurs, gastric lavage with iced
saline may be necessary. Blood for transfusion should
be readily available, because the blood loss from a GI
ulcer can be rapid and severe.
If a child has burns over more than 30% of the body
surface, paralytic ileus may occur. Symptoms of in-
testinal obstruction, such as vomiting, abdominal dis-
tention, and colicky pain, will appear within hours of
the burn.
Children with severe burns usually are allowed
nothing by mouth for 24 hours because of the danger
of vomiting or paralytic ileus. After this, most children
are able to eat, so oral feedings are begun as soon as
possible. To supply adequate calories for increased
metabolic needs and spare protein for repair of cells,
the diet is high in calories and protein (25 kcal/kg
body weight plus 40 kcal for each percent of burn sur-
face per 24 hours). Children may also need supple-
mental vitamins (particularly B and C) and iron sup-
plements (Moelleken, 2009). High-protein drinks may
be necessary between meals to ensure an adequate
protein intake (Faries & Battan, 2008).
Because adequate nutrition is important, it may be
necessary to supplement the child’s diet with IV or
parenteral nutrition solutions or NG tube feeding. As
additional methods of stimulating interest in eating,
encourage school-age children to help add intake
and output columns, help the dietitian add a calorie-
count list, or keep track of their own daily weight
(taken at the same time each day in the same cloth-
ing). It may be helpful to make contracts with older
children for a good nutritional intake.
Nursing Diagnosis: Risk for injury related to effects of
burn, denuded skin surfaces, and lowered resistance
to infection with burn injury
Outcome Evaluation: Child’s temperature remains at
98.6° F (37° C); skin areas surrounding burned areas
show no signs of erythema or warmth.
There appears to be some defect in the ability of neu-
trophils to phagocytize bacteria after burn injury. The
formation of immunoglobulin G antibodies also ap-
parently fails. For these reasons, a child has reduced
protection against infection. Staphylococcus aureus
and group A ␤-hemolytic streptococci are the gram-
positive organisms, and Pseudomonas aeruginosa is
the gram-negative organism, that commonly invade
burn tissue. Children are usually prescribed par-
enteral penicillin to prevent group A ␤-hemolytic
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1573

streptococcal infection and tetanus toxoid to prevent
tetanus. In addition to bacteria, fungi also may invade
burns. Candida species are the most frequently seen
(Madoff, 2008).
Nose, throat, and wound cultures may be done im-
mediately and then daily to detect offending organ-
isms. Bacteria and fungi can penetrate the burn es-
char readily, so this tissue offers little protection from
infection. Fortunately, granulation tissue, which forms
under the eschar 3 to 4 weeks after the burn, is resis-
tant to microbial invasion.
Systemic antibiotics are not very effective in con-
trolling burn-wound infection, probably because the
burned and constricted capillaries around the burn
site cannot carry the antibiotic to the area. For this rea-
son, any equipment used with the child must be ster-
ile, to avoid introducing infection. Children are placed
on a sterile sheet on the examining table. Personnel
caring for the severely burned child should wear caps,
masks, gowns, and gloves, even for emergency care.
Although their burns may be covered by gauze
dressings, children usually are cared for in private
rooms to help reduce the possibility of infection.
Helping children maintain their self-esteem and keep-
ing them from withdrawing from social contacts can be
difficult when infection control precautions are required.
Therapy for Burns
Second- and third-degree burns may receive open treatment,
leaving the burned area exposed to the air, or a closed treat-
ment, in which the burned area is covered with an antibacter-
ial cream and many layers of gauze. These two methods are
compared in Table 52.8. A synthetic skin covering (Biobrane),
artificial skin (Integra), or amniotic membrane from placentas
can be used to help decrease infection and protect granulation
tissue. As a rule, burn dressings are applied loosely for the first
24 hours to prevent interference with circulation as edema
forms. Be certain not to allow two burned body surfaces, such
as the sides of fingers or the back of the ears and the scalp, to
touch, because, as healing takes place, a webbing will form
between these surfaces. Do not use adhesive tape to anchor
dressings to the skin; it is painful to remove and can leave ex-
coriated areas, which provide additional entry for infection.
Netting is useful to hold dressings in place, because it expands
easily and needs no additional tape.
Topical Therapy. Silver sulfadiazine (Silvadene) is the drug
of choice for burn therapy to limit infection at the burn site
for children. It is applied as a paste to the burn, and the area
is then covered with a few layers of mesh gauze. Silver sulfa-
diazine is an effective agent against both gram-negative and
gram-positive organisms and even against secondary infec-
tious agents, such as Candida. It is soothing when applied
and tends to keep the burn eschar soft, making débridement
easier. It does not penetrate the eschar well, which is its one
drawback.
Antiseptic solutions, such as povidone-iodine (Betadine),
may also be used to inhibit bacterial and fungal growth.
Unfortunately, iodine stings as it is applied and stains skin and
clothing brown. Dressings must be kept continually wet to
keep them from clinging to and disrupting the healing tissue.
If Pseudomonas is detected in cultures, nitrofurazone
(Furacin) cream may be applied. If a topical cream is not ef-
fective against invading organisms in the deeper tissue under
the eschar, daily injections of specific antibiotics into the
deeper layers of the burned area may be necessary.
If a burned area, such as the female genitalia, cannot be
readily dressed, the area can be left exposed. The danger of
this method is the potential invasion of pathogens.
Escharotomy. An eschar is the tough, leathery scab that
forms over moderately or severely burned areas. Fluid accu-
mulates rapidly under eschars, putting pressure on underly-
ing blood vessels and nerves. If an extremity or the trunk has
been burned so that both anterior and posterior surfaces have
eschar formation, a tight band may form around the extrem-
ity or trunk, cutting off circulation to distal body portions.
Distal parts feel cool to the touch and appear pale. The child
notices tingling or numbness. Pulses are difficult to palpate,
and capillary refill is slow (longer than 5 seconds). To allevi-
ate this problem, an escharotomy (cut into the eschar) is per-
formed (Moelleken, 2009). Some bleeding will occur after
escharotomy. Packing the wound and applying pressure usu-
ally relieves this.
Débridement. Débridement is the removal of necrotic tissue
from a burned area. Débridement reduces the possibility
of infection, because it reduces the amount of dead tissue

TABLE 52.8 ✽ Comparing Open and Closed Burn Therapy

Method Description Advantages Disadvantages

Open Burn is exposed to air; used
for superficial burns or
body parts that are prone
to infection, such as
perineum
Closed Burn is covered with non-
adherent gauze; used for
moderate and severe burns
Allows frequent inspection of
site; allows child to follow
healing process
Provides better protection from
injury; is easier to turn and
position child; allows child
more freedom to play
Requires strict isolation to
prevent infection; area may
scrape and bleed easily and
impede healing
Requires dressing changes that
are painful; possibility of
infection may increase
because of dark, moist
environment
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1574 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

present on which microorganisms could thrive. Children

usually have 20 minutes of hydrotherapy before débridement
to soften and loosen eschar, which then can be gently re-
moved with forceps and scissors. Débridement is painful,
and some bleeding occurs with it. Premedicate the child with
a prescribed analgesic, and help the child use a distraction
technique during the procedure to reduce the level of pain.
Transcutaneous electrical nerve stimulation (TENS) therapy
or patient-controlled analgesia may also be helpful. Praise
any degree of cooperation. Plan an enjoyable activity after-
ward to aid in pain relief and also to help re-establish some
sense of control over the situation.
Children need to have a “helping” person with them, to
hold their hand, to stroke their head, and to offer some ver-
bal comfort during débridement: “It’s all right to cry; we
know that hurts. We don’t like to do this, but it’s one of the
things that makes burns heal” (Fig. 52.12). Nursing person-
nel need a great deal of talk time to voice their feelings about
assisting with or doing débridement procedures. Be careful
when serving as the “helping” person that you do not project
yourself as the healer and comforter and a fellow nurse as the
hurter or “bad guy.” It helps if people alternate this chore so
that, on alternate days, each serves as the protector or the
comforter.
If eschar tissue is débrided in this manner day after day, FIGURE 52.13 Mesh grafting is necessary to cover large
granulation tissue forms underneath. When a full bed of areas of the body such as in this young child with third-degree
granulation tissue is present (about 2 weeks after the injury), burns. (© CC Studio/SPL/Photo Researchers Inc.)
the area is ready for skin grafting. In some burn centers, this
waiting period is avoided by immediate surgical excision of
eschar and placement of skin grafts. Another trend in
débridement is the use of collagenase (Santyl), an enzyme porcine (pig) skin, may be used. Autografting is a process in
that dissolves devitalized tissue. which a layer of skin of both epidermis and a part of the der-
mis (called a split-thickness graft) is removed from a distal, un-
Grafting. Homografting (also called allografting) is the burned portion of the child’s body and placed at the prepared
placement of skin (sterilized and frozen) from cadavers or a burn site, where it will grow and replace the burned skin
donor on the cleaned burn site. These grafts do not grow but (Robinson, 2008). Cultured epithelium is derived from a full-
provide a protective covering for the area. In small children, thickness skin biopsy. This can be grown into a coherent sheet
heterografts (also called xenografts) from other sources, such as and supply an unlimited source for autografts. Larger areas
may require mesh grafts (a strip of partial-thickness skin that is
slit at intervals so that it can be stretched to cover a larger area;
Fig. 52.13). The advantage of grafting is that it reduces fluid
and electrolyte loss, pain, and the chance of infection.
After the grafting procedure, the area is covered by a bulky
dressing. So that the growth of the newly adhering cells will
not be disrupted, this should not be removed or changed. The
donor site on the child’s body (often the anterior thigh or but-
tocks) is also covered by a gauze dressing. Both donor and
graft dressings should be observed for fluid drainage and odor.
Observe the child to determine whether there is pain at either
site, which might indicate infection. Monitor the child’s tem-
perature every 4 hours. A rise in systemic temperature may be
the first indication that there is infection at the graft or donor
site. Autograft sites can be reused every 7 to 10 days, so any
one site can provide a great deal of skin for grafting.

Nursing Diagnoses and Related

Interventions
✽
FIGURE 52.12 A nurse provides comfort and support to a Nursing Diagnosis: Social isolation related to infection
child before débridement. (© Kathy Sloane/Science control precautions necessary to control spread of
Source/Photo Researchers.) microorganisms
15610_Ch52.qxd 7/6/09 7:18 AM Page 1575
CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
Outcome Evaluation: Child states that he understands
the reason for infection control precautions; child ac-
cepts it as a necessary part of therapy.
Infection control measures involved in the care of chil-
dren with major burns consist of more than just plac-
ing the child in a private room. Aseptic technique and
appropriate barriers are necessary to reduce the risk
of exposing the child to infection. In some agencies,
all the people who come into the room must wear
gowns, masks, caps, and sterile gloves. The child is
doubly isolated—by distance and by never being
touched directly.
It is easy for children with burns (who were told
measures such as not to play with matches or go too
close to the fireplace) to interpret confinement in a
room as punishment. Make every effort to make the
child’s environment as warm and comforting as possi-
ble, despite infection control procedures. Place chil-
dren’s beds so they can see as much unit activity as
possible. Decorate walls in front of them with cards
they receive or with a changing gallery of pictures
drawn by staff members of things in which the child
appears interested.
Provide time for children to discuss their feelings
about being kept in a room by themselves. A question
such as, “It’s hard to understand a lot of things about
a hospital; do you understand why your bed is in this
special room?” gives children a chance to express
their feelings.
Show parents how to put on gowns, gloves, and
masks (depending on agency policy), so they can
participate in the child’s care as much as possible.
Parents often do not ask to do these things sponta-
neously when their children are severely burned. They
are in a state of grief, so they do not react in a normal
manner. They may believe the bulky dressings will
make it impossible for them to hold the child. Actually,
the closed bulky dressings on the burned area make
it possible for the child to be held. If it is not possible
for the child to be held, help the parents to see that
stroking their child’s face or touching a hand (even
with gloves in place) gives the child a feeling of still
being loved.
Nursing Diagnosis: Interrupted family processes re-
lated to the effects of severe burns in family member
Outcome Evaluation: Family members state that they
are able to cope effectively with the degree of stress
to which they are subjected; family demonstrates pos-
itive coping mechanisms.
Children with severe burns always have a difficult hos-
pitalization because of the pain, restrictions, and (at
some point) awareness of the disfigurement that ac-
companies major burns.
Some parents grieve so deeply over the child’s con-
dition or are so concerned with other upsetting factors
in their lives (many burns happen because of situa-
tional crises in the family) that their interaction with the
child seems to falter or proves very difficult for them.
They may avoid visiting because the sound of the
child’s crying when they leave is more than they can
endure. At the same time, they may have lost their
1575
home and possessions to fire. They may need help in
establishing priorities. It may be important that they
wait at home one morning for an insurance inspector to
make an estimate on damage to their house or furni-
ture caused by the fire. Other tasks, such as shopping
or house cleaning, could possibly be done by relatives
or neighbors, leaving them time to visit their child.
Nursing Diagnosis: Deficient diversional activity re-
lated to restricted mobility after severe burn
Outcome Evaluation: Child expresses interest in obtain-
ing school homework; child communicates with friends
and relatives by way of telephone, letters, or e-mail.
Remember that, even if a child’s chest, abdomen, and
hands are burned, he does not stop thinking so chil-
dren who are burned need stimulation in their envi-
ronment. A television set is good for passing time but
should not be the child’s main communication with the
outside world. Listening to favorite tapes, having sto-
ries read to them, talking about what is going on at
home or what they normally do at school, and doing
schoolwork are also important.
It is important to make toys and play materials
available. Make certain to visit the child just to talk to
him or come to play a game at times other than pro-
cedure or treatment times. The child may be hospital-
ized for a long time. He needs to view the nursing staff
as friends and caregivers. Frequent visits convey that
he is not alone and that others are aware of important
needs.
Nursing Diagnosis: Disturbed body image related to
changes in physical appearance with burn injury
Outcome Evaluation: Child expresses fears about
physical appearance; demonstrates desire to resume
age-appropriate activities.
Children with burns are often forced to become ex-
tremely dependent on the nursing staff because of the
position in which they must lie and because the bulky
dressings that cover their arms or hands prevent them
from feeding themselves. They respond to this forced
dependence at first with gratitude. They are hurt, and
someone is taking care of them. After a period, how-
ever, their response may become less healthy. The
young school-age child or preschooler may revert to
bedwetting or baby talk. Older children respond by
becoming openly aggressive to counteract their feel-
ings of helplessness. They attempt to re-establish in-
dependence in the ways that they can, often by refus-
ing to eat or to lie in a position that is best for them.
Make certain to allow independent decision-making
whenever possible. Children must take their 10 o’clock
medicine, for example, but they can choose the fluid
they want to swallow after it. They must be fed meals
because of the bulky dressings over their hands, but
they can decide which food they will eat first. They
must have their dressings changed, but they can
choose the story you will read them afterward.
Be careful not to give choices when there really are
none to give. Inappropriate questions include, “Can I
change your dressing now?” “Do you want dinner
now?” “Will you swallow this pill?”
15610_Ch52.qxd 7/6/09 7:18 AM Page 1576

1576 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Immediately after a severe burn, children (if they
are old enough to understand), parents, and proba-
bly the hospital staff are most concerned with
whether the child will live. After body systems have
stabilized and it seems appropriate to reassure the
parents that their child will live, thoughts turn to the
child’s cosmetic appearance. At first, it is easy for
children and parents to ignore this problem, be-
cause the burned areas are covered by dressings.
Even when the dressings are removed for débride-
ment or whirlpool therapy, it is easy for children to
assume that the appearance of the burned area is
only temporary and that the area will eventually heal
and have a good appearance. They have probably
never seen anyone with a scar from a second- or
third-degree burn and have no reason to worry
about it (Fig. 52.14).
When children see others on the unit with burn
scars, they begin to realize what healing will look like.
Depending on the extent and the site of the burn, par-
ents and children have varying degrees of difficulty
accepting this reality. It can cause them to lose confi-
dence in health care personnel.
Parents and children need time to talk about their
feelings. A girl may be extremely concerned if her
chest is burned because she is worried that breast tis-
sue will not develop, a very real concern, depending
on the extent of the burn (Foley et al., 2008). Her par-
ents may be most concerned because they can see
that, although a blouse can cover her chest, her right
hand will not have full function. Do not assume that
your biggest concern is the same as the child’s or the
✔Checkpoint Question 52.3
parents’ biggest concern. A father who dreamed that
his son would be a great track star may be most con-
cerned about a leg scar; the child may be most con-
cerned about a facial burn.
Children watch you as you care for them to see if
you find them unattractive. As dressings are removed,
children may expose parts of their body seemingly in-
appropriately, to see if you are shocked or revolted by
them. It is easy to think that you will not react this way,
but, for everyone, the first sight of a severe burn is
a shock and it is difficult not to react accordingly.
Imagining how children feel, realizing that this muti-
lated skin is their skin, helps health care providers
maintain a professional attitude.
Returning to school can be difficult for children
who have been hospitalized or have been receiving
home care for a long time. Their old friends have
new friends, so they may feel cut out of school ac-
tivities. They look different if they have burn scars.
The appearance of scar formation can be improved
by the application of pressure dressings that the
child wears 24 hours a day. If the child has facial
burns, facing friends with a compression bandage
in place or returning for laser therapy to reduce burn
scarring may be difficult. They need a great deal of
support from health care personnel to be able to en-
dure this. Some children need referral for formal
counseling. Some parents need formal counseling
also, to help them accept their child’s changed
appearance.
If Jason spilled scalding hot water on his hand, which of the
following would be the best emergency action?
a. Apply an ice compress to his hand.
b. Pour vegetable oil over his hand.
c. Cover his hand with a gauze dressing.
d. Apply hand lotion to keep the area moist.

Key Points for Review

● Children need total body assessment after an uninten-
tional injury, because they may be unable to describe
other injuries besides the primary one they have suffered.
● Be aware that some trauma in children occurs as a result
of child abuse. Screen for this by history and physical
examination.
● Use aseptic technique when caring for trauma victims, so
that the child does not develop an additional unnecessary
infection.
● Head injuries are always potentially serious in children.
Skull fractures, subdural hematomas, epidural hematomas,
FIGURE 52.14 Extensive scarring on the chest of a 9-year-old
boy with third-degree burns. The child and his family will need concussions, and contusions can occur. Coma (uncon-
much support to help them deal with his appearance. (© Dr. sciousness from which a child cannot be roused) may be
P. Marazzi/SPL/Science Source/Photo Researchers.) present after severe head trauma.
15610_Ch52.qxd 7/6/09 7:18 AM Page 1577
CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury
● Abdominal trauma resulting in rupture of the spleen or
liver may occur in connection with multiple trauma.
● Near drowning can occur in salt or fresh water. The phys-
iologic basis for complications after drowning differs de-
pending on the type of water.
● Common substances children swallow that result in poi-
soning include acetaminophen (Tylenol), caustic sub-
stances, and hydrocarbons. Teach parents to keep the
number of the local poison control center next to their
telephone and always to call first before administering an
antidote for poisoning.
● Lead poisoning most frequently occurs from the ingestion
of paint chips in older housing units. Preventing this is a
major nursing responsibility.
● Burns are classified as mild, moderate, and severe and can be
divided into three types—first, second, and third degree—
depending on the depth of the burn. Burns produce sys-
temic body reactions and require long-term nursing care.
CRITICAL THINKING EXERCISES
1. Jason, a 5-year-old boy, is seen in the emergency depart-
ment after an automobile accident. He is crying and
upset, although the only visible signs of trauma are a red-
dened and edematous area on the middle of his forehead.
Vital signs reveal the following: temperature, 99.4° F
(37.5° C); respirations, 18 breaths per minute; pulse, 62
beats per minute; and blood pressure, 110/62 mm Hg.
His left pupil is more dilated than his right; it reacts slug-
gishly to light. His Glasgow Coma Scale score is 10. His
mother tells you, “I’m sure he’s not injured badly. He was
wearing his seat belt.” You are the triage nurse. Would
you rate Jason as a child to be seen immediately, or could
he be given second priority?
2. Jason’s twin sister was seen in the emergency depart-
ment for acetaminophen poisoning last month. Her
father tells you they normally lock all medicine away
carefully. His wife left acetaminophen on the counter
because she had a bad headache. Would you want to
discuss the necessity of poisoning prevention with these
parents, or should they have learned from this experi-
ence that their actions were not safe?
3. A 10-year-old girl has third-degree burns on her legs
from lighting a fire to burn leaves. She will probably
have a lengthy hospitalization and may need skin grafts
to improve healing. What precautions does this child
need to prevent infection until healing is complete?
What areas of care would you plan to address during the
hospitalization?
4. Examine the National Health Goals related to trauma
and children. Most government-sponsored funds for
nursing research are allotted based on these goals. What
would be a possible research topic to explore pertinent
to these goals that would be applicable to Jason’s family
and also advance evidence-based practice?
1577
CRITICAL THINKING SCENARIO
Open the accompanying CD-ROM or visit http://
thePoint.lww.com and read the Patient Scenario in-
cluded for this chapter, then answer the questions to
further sharpen your skills and grow more familiar
with NCLEX style questions related to unintentional
injuries in children. Confirm your answers are cor-
rect by reading the rationales.
REFERENCES
Agency for Toxic Substances and Disease Registry. (2008). Managing haz-
ardous material incidence. Washington, DC: Centers for Disease Control
and Prevention.
Aldridge, M. D. (2007). Acute iron poisoning: What every pediatric inten-
sive care unit nurse should know. DCCN: Dimensions of Critical Care
Nursing, 26(2), 43–48.
American Academy of Pediatrics (AAP). (2008). Prevention of Lyme disease.
Evanston, IL: Author.
Aminoff, M. J. (2009). Neurology. In S. J. McPhee & M. A. Papadakis (Eds.).
Current medical diagnosis and treatment. Columbus, OH: McGraw-Hill.
Amirjamshidi, A., et al. (2007). Outcomes and recurrence rates in chronic
subdural haematoma. British Journal of Neurosurgery, 21(3), 272–275.
Andersson, L. (2007). Tooth avulsion and replantation. Dental Traumatology,
23(3), 129–130.
Bowers, R. C., & Anderson, T. K. (2008). Disorders due to physical and
environmental agents. In C. K. Stone & R. L. Humphries (Eds.).
Current diagnosis and treatment: Emergency medicine (6th ed). Columbus,
OH: McGraw-Hill.
Centers for Disease Control and Prevention. (2008a). Unintentional stran-
gulation deaths from the “choking game” among youths aged 6–19
years—United States, 1995–2007. Morbidity and Mortality Weekly
Report, 57(06), 141–144.
Centers for Disease Control and Prevention. (2008b). Preventing lead poi-
soning in young children. Washington, DC: Author.
Claret-Teruel, G., et al. (2007). Severe head injury among children: Computed
tomography evaluation as a prognostic factor. Journal of Pediatric Surgery,
42(11), 1903–1906.
Clark, R. F. (2007). Snakebite. In Olson, K.R. (2007). Poisoning and drug
overdose (5th ed.). Columbus, OH: McGraw-Hill.
Dart, R. C., & Rumack, B. H. (2008). Poisoning. In W. W. Hay, et al.
(Eds.). Current pediatric diagnosis and treatment (18th ed.). Columbus,
OH: McGraw-Hill.
Dobremez, E., et al. (2007). Complications occurring during conservative
management of splenic trauma in children. European Journal of Pediatric
Surgery, 16(3), 166–170.
Faries, G., & Battan, F. K. (2008). Emergencies and injuries. In W. W.
Hay, et al. (Eds.). Current pediatric diagnosis and treatment (18th ed.).
Columbus, OH: McGraw-Hill.
Fazio, V. C., et al. (2007). The relation between post concussion symptoms
and neurocognitive performance in concussed athletes. Neurorehabilitation,
22(3), 207–216.
Foley, P., et al. (2008). Breast burns are not benign: Long-term outcomes
of burns to the breast in pre-pubertal girls. Burns, 34(3), 412–417.
Froberg, B., Ibrahim, D., & Furbee, R. B. (2007). Plant poisoning.
Emergency Medicine Clinics of North America, 25(2), 375–433.
Hayes, J. R., & Groner, J. I. (2008). The increasing incidence of snow-
board-related trauma. Journal of Pediatric Surgery, 43(5), 928–930.
Hicks, R. A., & Stolfi A. (2007). Skeletal surveys in children with burns
caused by child abuse. Pediatric Emergency Care, 23(5), 308–313.
Huether, S. E., & McCance, K. L., (2007). Understanding pathophysiology
(4th ed.). St. Louis: Mosby.
Integrated Management of Childhood Illness

Chart Booklet

March 2014
WHO Library Cataloguing-in-Publication Data:

Integrated Management of Childhood Illness: distance learning course.

15 booklets
Contents: - Introduction, self-study modules – Module 1: general danger signs for
the sick child – Module 2: The sick young infant – Module 3: Cough or difficult
breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and
anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of
the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide –
Implementation: introduction and roll out – Logbook – Chart book

1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education,
Distance. 7.Teaching Material. I.World Health Organization.

ISBN 978 92 4 150682 3 (NLM classification: WS 200)

© World Health Organization 2014

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Integrated Management of Childhood Illness
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD

ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE

Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS
on TREAT THE CHILD chart.
if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referal treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?

If yes, ask:
For how long?
If the child is:
2 months up to 12 months
12 Months up to 5 years
Look, listen, feel*: Any general danger sign Pink: Give first dose of an appropriate antibiotic
Count the or SEVERE Refer URGENTLY to hospital**
Classify
breaths in COUGH or Stridor in calm child. PNEUMONIA OR
one minute. DIFFICULT VERY SEVERE
Look for BREATHING DISEASE
chest
CHILD Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
indrawing.
MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
Look and
CALM acting bronchodilator) give an inhaled
listen for
bronchodilator for 5 days****
stridor.
If chest indrawing in HIV exposed/infected child,
Look and
give first dose of amoxicillin and refer.
listen for
Soothe the throat and relieve the cough with a
wheezing.
safe remedy
If wheezing with either If coughing for more than 14 days or recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for up Follow-up in 3 days
to three times 15-20 minutes
No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting
apart. Count the breaths and
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
look for chest indrawing
5 days****
again, and then classify.
Soothe the throat and relieve the cough with a
Fast breathing is: safe remedy
50 breaths per minute or more If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
40 breaths per minute or more assessment
Advise mother when to return immediately
Follow-up in 5 days if not improving

*If pulse oximeter is available, determine oxygen saturation and refer if < 90%.
** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze.
Does the child have diarrhoea?

If yes, ask: Look and feel:
For how long? Look at the child's general
Is there blood in the stool? condition. Is the child:
Lethargic or
unconscious?
Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the
child:
Not able to drink or
drinking poorly?
Drinking eagerly,
thirsty?
Pinch the skin of the
abdomen. Does it go back:
Very slowly (longer
than 2 seconds)?
Slowly?
Two of the following signs:
Lethargic or unconscious
for DEHYDRATION Sunken eyes
Not able to drink or drinking
poorly
Classify DIARRHOEA
Skin pinch goes back very
slowly.
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back
slowly.
Not enough signs to classify
as some or severe
dehydration.
Pink: If child has no other severe classification:
SEVERE Give fluid for severe dehydration (Plan C)
DEHYDRATION OR
If child also has another severe
classification:
Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue
breastfeeding
If child is 2 years or older and there is
cholera in your area, give antibiotic for
cholera
Yellow: Give fluid, zinc supplements, and food for some
SOME dehydration (Plan B)
DEHYDRATION If child also has a severe classification:
Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
Advise the mother to continue
breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Green: Give fluid, zinc supplements, and food to treat
NO DEHYDRATION diarrhoea at home (Plan A)
Advise mother when to return immediately
Follow-up in 5 days if not improving

Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhoea 14 SEVERE has another severe classification
days or more PERSISTENT Refer to hospital
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
DIARRHOEA Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days

Blood in the stool. Yellow: Give ciprofloxacin for 3 days

and if blood in stool
DYSENTERY Follow-up in 3 days
Does the child have fever?
If yes:
Decide Malaria Risk: high or low
Then ask:
For how long?
If more than 7 days, has fever been
present every day?
Has the child had measles within the
last 3 months?
Do a malaria test***: If NO severe classification
In all fever cases if High malaria risk.
In Low malaria risk if no obvious cause of fever present.
If the child has measles now or
within the last 3 months:
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
*** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables.
Look and feel:
Look or feel for stiff neck.
Look for runny nose.
Classify FEVER
Look for any bacterial cause of
fever**.
Look for signs of MEASLES.
Generalized rash and
One of these: cough, runny nose,
or red eyes.
Look for mouth ulcers.
Are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
Any general danger sign or Pink: Give first dose of artesunate or quinine for severe malaria
Stiff neck. VERY SEVERE FEBRILE Give first dose of an appropriate antibiotic
High or Low Malaria DISEASE Treat the child to prevent low blood sugar
Risk
or above)
Refer URGENTLY to hospital
Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
MALARIA
or above)
Give appropriate antibiotic treatment for an identified bacterial cause
of fever
Advise mother when to return immediately
Follow-up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment
Malaria test NEGATIVE Green:
Other cause of fever PRESENT. FEVER: or above)
NO MALARIA Give appropriate antibiotic treatment for an identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign Pink: Give first dose of an appropriate antibiotic.
No Malaria Risk and No
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
Travel to Malaria Risk
DISEASE
Area
or above).
Refer URGENTLY to hospital.
No general danger signs Green:
No stiff neck. FEVER or above)
Give appropriate antibiotic treatment for any identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 2 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign or Pink: Give Vitamin A treatment
Clouding of cornea or SEVERE COMPLICATED Give first dose of an appropriate antibiotic
If MEASLES now or within last 3 Deep or extensive mouth ulcers. MEASLES**** If clouding of the cornea or pus draining from the eye, apply
months, Classify tetracycline eye ointment
Refer URGENTLY to hospital
Pus draining from the eye or Yellow: Give Vitamin A treatment
Mouth ulcers. MEASLES WITH EYE OR If pus draining from the eye, treat eye infection with
MOUTH tetracycline eye ointment
COMPLICATIONS**** If mouth ulcers, treat with gentian violet
Follow-up in 3 days
Measles now or within the last 3 Green: Give Vitamin A treatment
months. MEASLES
Does the child have an ear problem?

If yes, ask: Look and feel:
Is there ear pain? Look for pus draining from
Is there ear discharge? the ear.
If yes, for how long? Feel for tender swelling
behind the ear.
Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
ear. MASTOIDITIS Give first dose of paracetamol for pain
Classify EAR PROBLEM Refer URGENTLY to hospital
Pus is seen draining from Yellow: Give an antibiotic for 5 days
the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR INFECTION
the ear.
THEN CHECK FOR ACUTE MALNUTRITION

CHECK FOR ACUTE MALNUTRITION Oedema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar
STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Look for oedema of both feet.
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
If WFH/L less than -3 z-scores or MUAC less than 115 complication present
mm, then: or
Check for any medical complication present: Not able to finish RUTF
Any general danger signs or
Any severe classification Breastfeeding
Pneumonia with chest indrawing problem.
If no medical complications present: WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
Child is 6 months or older, offer RUTF*** to scores UNCOMPLICATED Give ready-to-use therapeutic food for a child
eat. Is the child: OR SEVERE ACUTE aged 6 months or more
MUAC less than 115 mm MALNUTRITION Counsel the mother on how to feed the child.
Not able to finish RUTF portion? Assess for possible TB infection
AND
Able to finish RUTF portion? Advise mother when to return immediately
Able to finish RUTF.
Follow up in 7 days
Child is less than 6 months, assess
breastfeeding: WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
2 z-scores MODERATE ACUTE mother on the feeding recommendations
Does the child have a breastfeeding OR MALNUTRITION If feeding problem, follow up in 7 days
problem? Assess for possible TB infection.
MUAC 115 up to 125 mm.
Advise mother when to return immediately
Follow-up in 30 days
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
more NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
recommendations
MUAC 125 mm or more.
If feeding problem, follow-up in 7 days

*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.
THEN CHECK FOR ANAEMIA

Check for anaemia Severe palmar pallor Pink: Refer URGENTLY to hopsital
Look for palmar pallor. Is it: SEVERE ANAEMIA
Severe palmar pallor*? Classify
Some pallor Yellow: Give iron**
Some palmar pallor? ANAEMIA Classification
arrow ANAEMIA Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days

*Assess for sickle cell anaemia if common in your area.

**If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care.

Positive virological test in Yellow: Initiate ART treatment and HIV care
ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis*
Classify OR INFECTION
Has the mother or child had an HIV test? HIV counselling to the mother
status Positive serological test in a
IF YES: child 18 months or older Advise the mother on home care
Decide HIV status: Asess or refer for TB assessment and INH
Mother: POSITIVE or NEGATIVE preventive therapy
Child: Follow-up regularly as per national guidelines
Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status**
unknown, ASK: ago
Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother
the test? Mother HIV-positive, child Advise the mother on home care
Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines
If breastfeeding ASK: Is the mother and child on ARV OR
prophylaxis?
Positive serological test in a
IF NO, THEN TEST: child less than 18 months
Mother and child status unknown: TEST mother. old
Mother HIV positive and child status unknown: TEST child.
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
or child HIV INFECTION
UNLIKELY

* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE
Birth BCG* OPV-0 Hep B0 VITAMIN A
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1*** SUPPLEMENTATION
Give every child a
10 weeks DPT+HIB-2 OPV-2 Hep B2 RTV2 PCV2 dose of Vitamin A
every six months
from the age of 6
months. Record the
dose on the child's
chart.
14 weeks DPT+HIB-3 OPV-3 Hep B3 RTV3 PCV3 ROUTINE WORM
TREATMENT
Give every child
mebendazole every 6
9 months Measles **
months from the age
of one year. Record
the dose on the
18 months DPT child's card.
*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated.
**Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.

ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
blood sugar.
HIV TESTING AND INTERPRENTING RESULTS
HIV testing is RECOMMENDED for:

Types of HIV Tests

What does the test detect? How to interpret the test?
SEROLOGICAL These tests detect antibodies made by HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not
TESTS immune cells in response to HIV. disappear until the child is 18 months of age.
(Including rapid They do not detect the HIV virus itself. This means that a positive serological test in children less than 18 months in NOT a reliable way to check for infection of the child.
tests)
VIROLOGICAL These tests directly detect the presence of Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old.
TESTS the HIV virus or products of the virus in the If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected.
(Including DNA blood.
or RNA PCR)
For HIV exposed children 18 months or older, a positive HIV antibody test result means the child is infected.
For HIV exposed children less than 18 months of age:
If PCR or other virological test is available, test from 4 - 6 weeks of age.
A positive result means the child is infected.
A negative result means the child is not infected, but could become infected if they are still breast feeding.
If PCR or other virological test is not available, use HIV antibody test. A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected.

Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age
Breastfeeding status POSITIVE (+) test NEGATIVE (-) test
NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected
last 6 weeks Repeat test at 18 months.
BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been
could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks.
breastfeeding has been discontinued for more than 6 weeks.
WHO PAEDIATRIC STAGING FOR HIV INFECTION
Stage 1
Asymptomatic
- -
Symptoms/Signs No symptoms, or only:
Persistent generalized
lymphadenopathy (PGL)
*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.
Stage 2 Stage 3 Stage 4
Mild Disease Moderate Disease Severe Disease (AIDS)
Unexplained severe Severe unexplained wasting/stunting/severe acute
acute malnutrition not responding malnutrition not responding to standard therapy
to standard therapy
Enlarged liver and/or spleen Oral thrush (outside neonatal Oesophageal thrush
Enlarged parotid period). More than one month of herpes simplex ulcerations.
Skin conditions (prurigo, seborraic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacteria infections > 2
molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis
herpes zoster) to standard pneumonia (PCP)*
Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma.
gingival Erythema) Diarhoea for over 14 days Extrapulmonary tuberculosis.
Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess*
(sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis*
ortorrhea) 50,000/mm3 for 1month Acquired HIVassociated rectal
Neutropenia* (under fistula
500/mm3 for 1 month) HIV encephalopathy*
Anaemia for over 1 month
(haemoglobin under 8 gm)*
Recurrent severe bacterial
pneumonia
Pulmonary TB
Lymp node TB
Symptomatic lymphoid
interstitial pneumonitis (LIP)*
Acute necrotising ulcerative
gingivitis/periodontitis
Chronic HIV associated lung
diseses including
bronchiectasis*
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Give an Appropriate Oral Antibiotic
Also follow the instructions listed with each drug's dosage table. FOR PNEUMONIA, ACUTE EAR INFECTION:
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
Determine the appropriate drugs and dosage for the child's age or weight. AMOXICILLIN*
Tell the mother the reason for giving the drug to the child. Give two times daily for 5 days
AGE or WEIGHT
Demonstrate how to measure a dose. TABLET SYRUP
Watch the mother practise measuring a dose by herself. 250 mg 250mg/5 ml
Ask the mother to give the first dose to her child. 2 months up to 12 months (4 - <10 kg) 1 5 ml
Explain carefully how to give the drug, then label and package the drug. 12 months up to 3 years (10 - <14 kg) 2 10 ml
If more than one drug will be given, collect, count and package each drug 3 years up to 5 years (14-19 kg) 3 15 ml
separately. * Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy and
increasing high resistance to cotrimoxazole.
Explain that all the oral drug tablets or syrups must be used to finish the course of
FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:
treatment, even if the child gets better. ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
Check the mother's understanding before she leaves the clinic. COTRIMOXAZOLE
(trimethoprim + sulfamethoxazole)

AGE Give once a day starting at 4-6 weeks of age

Syrup Paediatric tablet Adult tablet
(40/200 mg/5ml) (Single strength 20/100 mg) (Single strength 80/400 mg)
Less than 6 months 2.5 ml 1 -
6 months up to 5 years 5 ml 2 1/2
FOR DYSENTERY give Ciprofloxacine
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
CIPROFLOXACINE
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet 500 mg tablet
Less than 6 months 1/2 1/4
6 months up to 5 years 1 1/2
FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
ERYTHROMYCIN TETRACYCLINE
Give four times daily for 3 days Give four times daily for 3 days
AGE or WEIGHT
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Give Oral Antimalarial for MALARIA
Also follow the instructions listed with each drug's dosage table. If Artemether-Lumefantrine (AL)
Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child
vomits within an hour repeat the dose.
Give second dose at home after 8 hours.
Give Inhaled Salbutamol for Wheezing Then twice daily for further two days as shown below.
USE OF A SPACER* Artemether-lumefantrine should be taken with food.
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years If Artesunate Amodiaquine (AS+AQ)
should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. Give first dose in the clinic and observe for an hour, if a child vomits within an hour repeat the
dose.
Then daily for two days as per table below using the fixed dose combination.
Repeat up to 3 times every 15 minutes before classifying pneumonia.

Spacers can be made in the following way: Artemether-Lumefantrine Artesunate plus Amodiaquine tablets
Use a 500ml drink bottle or similar. tablets Give Once a day for 3 days
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. (20 mg artemether and 120
This can be done using a sharp knife. mg lumefantrine)
WEIGHT (age) (25 mg AS/67.5 (50 mg AS/135 mg
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the Give two times daily for 3 mg AQ) AQ)
bottle. days
Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as Day Day
a mask. Day 1 Day 2 day 3 Day 2 Day 3 Day 2 Day 3
1 1
Flame the edge of the cut bottle with a candle or a lighter to soften it.
In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. 5 - <10 kg (2 months up
1 1 1 1 1 1 - - -
to 12 months)
Alternatively commercial spacers can be used if available.
10 - <14 kg (12 months
1 1 1 - - - 1 1 1
To use an inhaler with a spacer: up to 3 years)
Remove the inhaler cap. Shake the inhaler well. 14 - <19 kg (3 years up to
2 2 2 - - - 1 1 1
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. 5 years)
The child should put the opening of the bottle into his mouth and breath in and out through the mouth.
A carer then presses down the inhaler and sprays into the bottle while the child continues to breath
normally.
Wait for three to four breaths and repeat.
For younger children place the cup over the child's mouth and use as a spacer in the same way.
Give paracetamol every 6 hours until high fever or ear pain is gone.
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
PARACETAMOL
AGE or WEIGHT
TABLET (100 mg) TABLET (500 mg)
2 months up to 3 years (4 - <14 kg) 1 1/4
3 years up to 5 years (14 - <19 kg) 1 1/2 1/2
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.

Give Iron*
Give one dose daily for 14 days.
IRON/FOLATE
IRON SYRUP
TABLET

AGE or WEIGHT Ferrous sulfate

Ferrous fumarate 100 mg per 5 ml (20 mg
Folate (60 mg elemental iron per ml)
elemental iron)
2 months up to 4 months (4 -
1.00 ml (< 1/4 tsp.)
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp.)
(6 - <10 kg)
12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp.)
(10 - <14 kg)
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
19 kg)
* Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
not be given Iron.
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
Treat for Mouth Ulcers with Gentian Violet (GV)
Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box. Treat for mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except for remedy for Wash hands.
cough or sore throat). Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
Tell her how often to do the treatment at home. Paint the mouth with half-strength gentian violet (0.25% dilution).
If needed for treatment at home, give mother the tube of tetracycline ointment or a Wash hands again.
small bottle of gentian violet. Continue using GV for 48 hours after the ulcers have been cured.
Give paracetamol for pain relief.
Check the mothers understanding before she leaves the clinic.

Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin
Safe remedies to recommend: Treat thrush four times daily for 7 days
Breast milk for a breastfed infant. Wash hands
_____________________________________________________________________________
Instill nystatin 1ml four times a day
_____________________________________________________________________________ Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
_____________________________________________________________________________ Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
_____________________________________________________________________________ Give paracetamol if needed for pain
_____________________________________________________________________________

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 4 times daily.
Wash hands.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.

Clear the Ear by Dry Wicking and Give Eardrops*

Dry the ear at least 3 times daily.
Roll clean absorbent cloth or soft, strong tissue paper into a wick.
Place the wick in the child's ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps until the ear is dry.
Instill quinolone eardrops after dry wicking three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.
GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC
Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately

Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHILDREN
Thereafter vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A within the past
month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
Always record the dose of Vitamin A given on the child's card.
AGE VITAMIN A DOSE
6 up to 12 months 100 000 IU
One year and older 200 000 IU

Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Give Artesunate Suppositories or Intramuscular Artesunate or
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Quinine for Severe Malaria
Use a sterile needle and sterile syringe when giving an injection. FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Measure the dose accurately. Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
Give the drug as an intramuscular injection. artesunate injection or quinine).
If child cannot be referred, follow the instructions provided. Artesunate suppository: Insert first dose of the suppository and refer child urgently
Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE:
Give Intramuscular Antibiotics For artesunate injection:
Give first dose of artesunate intramuscular injection
GIVE TO CHILDREN BEING REFERRED URGENTLY Repeat dose after 12 hrs and daily until the child can take orally
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
AMPICILLIN Give first dose of suppository
Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
Give full dose of oral antimalarial as soon as the child is able to take orally
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
For quinine:
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times. Give first dose of intramuscular quinine.
The child should remain lying down for one hour.
Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able
GENTAMICIN
to take an oral antimalarial. Do not continue quinine injections for more than 1 week.
7.5 mg/kg/day once daily
If low risk of malaria, do not give quinine to a child less than 4 months of age.
AMPICILLIN GENTAMICIN
AGE or WEIGHT
500 mg vial 2ml/40 mg/ml vial
RECTAL ARTESUNATE INTRAMUSCULAR INTRAMUSCULAR
2 up to 4 months (4 - <6 kg) 1m 0.5-1.0 ml SUPPOSITORY ARTESUNATE QUININE
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml AGE or WEIGHT 50 mg 200 mg
suppositories suppositories 60 mg 150 mg/ml* 300 mg/ml*
12 months up to 3 years (10 - <14 kg) 3 ml 1.9-2.7 ml vial (20mg/ml) 2.4 (in 2 ml (in 2 ml
Dosage 10 Dosage 10 mg/kg ampoules) ampoules)
3 years up to 5 years (14 - 19 kg) 5m 2.8-3.5 ml mg/kg mg/kg
2 months up to 4
1 1/2 ml 0.4 ml 0.2 ml
months (4 - <6 kg)
4 months up to 12
Give Diazepam to Stop Convulsions months (6 - <10 kg)
2 1 ml 0.6 ml 0.3 ml

Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. 12 months up to 2
2 - 1.5 ml 0.8 ml 0.4 ml
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a years (10 - <12 kg)
tuberculin syringe) or using a catheter.
2 years up to 3
Check for low blood sugar, then treat or prevent. 3 1 1.5 ml 1.0 ml 0.5 ml
years (12 - <14 kg)
Give oxygen and REFER
If convulsions have not stopped after 10 minutes repeat diazepam dose 3 years up to 5
3 1 2 ml 1.2 ml 0.6 ml
years (14 - 19 kg)
DIAZEPAM
AGE or WEIGHT
10mg/2mls * quinine salt
2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
12 months up to 3 years (10 - <14 kg) 1.5 ml
3 years up to 5 years (14-19 kg) 2.0 ml
GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:
Ask the mother to breastfeed the child.
If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
If neither of these is available, give sugar water*.
Give 30 - 50 ml of milk or sugar water* before departure.
If the child is not able to swallow:
Give 50 ml of milk or sugar water* by nasogastric tube.
If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
water.
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart)
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
PLAN A: TREAT DIARRHOEA AT HOME WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5
Counsel the mother on the 4 Rules of Home Treatment: months months years years
1. Give Extra Fluid In ml 200 - 450 450 - 800 800 - 960 960 - 1600
2. Give Zinc Supplements (age 2 months up to 5 years) * Use the child's age only when you do not know the weight. The approximate amount of ORS
3. Continue Feeding required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
4. When to Return. If the child wants more ORS than shown, give more.
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
1. GIVE EXTRA FLUID (as much as the child will take) period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
TELL THE MOTHER: SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Breastfeed frequently and for longer at each feed. Give frequent small sips from a cup.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. If the child vomits, wait 10 minutes. Then continue, but more slowly.
If the child is not exclusively breastfed, give one or more of the following: Continue breastfeeding whenever the child wants.
ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean AFTER 4 HOURS:
water. Reassess the child and classify the child for dehydration.
It is especially important to give ORS at home when: Select the appropriate plan to continue treatment.
the child has been treated with Plan B or Plan C during this visit. Begin feeding the child in clinic.
the child cannot return to a clinic if the diarrhoea gets worse. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF Show her how to prepare ORS solution at home.
ORS TO USE AT HOME. Show her how much ORS to give to finish 4-hour treatment at home.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
INTAKE: in Plan A.
Up to 2 years 50 to 100 ml after each loose stool Explain the 4 Rules of Home Treatment:
2 years or more 100 to 200 ml after each loose stool 1. GIVE EXTRA FLUID
Tell the mother to: 2. GIVE ZINC (age 2 months up to 5 years)
Give frequent small sips from a cup. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
If the child vomits, wait 10 minutes. Then continue, but more slowly. 4. WHEN TO RETURN
Continue giving extra fluid until the diarrhoea stops.
2. GIVE ZINC (age 2 months up to 5 years)
TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
2 months up to 6 months 1/2 tablet daily for 14 days
6 months or more 1 tablet daily for 14 days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
START HERE Start IV fluid immediately. If the child can drink, give ORS by
Can you give mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid Solution (or, if not available, normal saline), divided as follows
immediately? AGE First give Then give
NO 30 ml/kg in: 70 ml/kg in:
Infants (under 12 1 hour* 5 hours
months)
Children (12 months up 30 minutes* 2 1/2 hours
to 5 years)
* Repeat once if radial pulse is still very weak or not
detectable.
Reassess the child every 1-2 hours. If hydration status is
not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can
drink: usually after 3-4 hours (infants) or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B,
or C) to continue treatment.

Is IV treatment Refer URGENTLY to hospital for IV treatment.

available nearby (within If the child can drink, provide the mother with ORS solution and
30 minutes)? show her how to give frequent sips during the trip or give ORS
NO by naso-gastric tube.

Are you trained to use Start rehydration by tube (or mouth) with ORS solution:
a naso-gastric (NG) give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
tube for rehydration? Reassess the child every 1-2 hours while waiting for
NO transfer:
If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
Can the child drink?
If hydration status is not improving after 3 hours, send the
NO child for IV therapy.
After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.

Refer URGENTLY to NOTE:

hospital for IV or NG If the child is not referred to hospital, observe the child at least
treatment 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
GIVE READY-TO-USE THERAPEUTIC FOOD

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Wash hands before giving the ready-to-use therapeutic food (RUTF).
Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
Encourage the child to eat the RUTF without forced feeding.

If still breastfeeding, continue by offering breast milk first before every RUTF feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE MOTHER
chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.

Recommended Amounts of Ready-to-Use Therapeutic Food

Packets per day
CHILD'S WEIGHT (kg) Packets per Week Supply
(92 g Packets Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
TREAT THE HIV INFECTED CHILD

Steps when Initiating ART in Children

All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage.
Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
Child is under 18 months: If child is less than 3 kg or has TB, Refer for ART initiation.
HIV infection is confirmed if virological test (PCR) is positive If child weighs 3 kg or more and does not have TB, GO TO STEP 4
Child is over 18 months:
Two different serological tests are positive
Send any further confirmatory tests required
If results are discordant, refer
If HIV infection is confirmed, and child is in stable condition,
GO TO STEP 2

STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
Weight and height
to another adult who can assist with providing ART, or be part Pallor if present
of a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests
Caregiver not able: classify as CONFIRMED HIV INFECTION that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.

STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatement:
Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
Give co-trimoxazole prophylaxis
Give other routine treatments, including Vitamin A and immunizations
Follow-up regularly as per national guidelines
TREAT THE HIV INFECTED CHILD

Preferred and Alternative ARV Regimens

AGE Preferred Alternative Children with TB/HIV Infection

Birth up to 3 YEARS ABC or AZT + 3TC + LPV/r ABC or AZT + 3TC + NVP ABC or AZT + 3TC + NVP
AZT + 3TC + ABC

3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP ABC or AZT + 3TC + EFV
AZT + 3TC + ABC

Give Antiretroviral Drugs (Fixed Dose Combinations)

AZT/3TC AZT/3TC/NVP ABC/AZT/3TC ABC/3TC
WEIGHT (Kg) Twice daily Twice daily Twice daily Twice daily
60/30 mg tablet 300/150 mg tablet 60/30/50 mg tablet 300/150/200 mg tablet 60/60/30 mg tablet 300/300/150 mg tablet 60/30 mg tablet 600/300 mg tablet
3 - 5.9 1 - 1 - 1 - 1 -
6 - 9.9 1.5 - 1.5 - 1.5 - 1.5 -
10 - 13.9 2 - 2 - 2 - 2 -
14 - 19.9 2.5 - 2.5 - 2.5 - 2.5 -
20 - 24.9 3 - 3 - 3 - 3 -
25 - 34.9 - 1 1 1 - 0.5
TREAT THE HIV INFECTED CHILD

Give Antiretroviral Drugs

LOPINAVIR / RITONAVIR (LPV/r), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)

LOPINAVIR / RITONAVIR (LPV/r) NE VIR AP INE (NVP ) EFAVIRENZ (EFV)

WEIGHT (KG) T arget dos e 15 mg/Konc
g e da ily
80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet 200 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Once daily
3 - 5.9 1 ml - 5 ml 1 - -
6 - 9.9 1.5 ml - 8 ml 1.5 - -
10 - 13.9 2 ml 2 10 ml 2 - 1
14 - 19.9 2.5 ml 2 - 2.5 - 1.5
20 - 24.9 3 ml 2 - 3 - 1.5
25 - 34.9 - 3 - - 1 2
ABACAVIR (ABC), ZIDOVUDINE (AZT or ZDV) & LAMIVUDINE (3TC)

AB AC AVIR (AB C )
Z IDO VUDINE (AZ T or Z DV)
L AMIVUDINE (3T C )
WEIGHT (KG) T arget dos e: 8mg/K g/dos e twice daily
20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml liquid 30 mg tablet 150 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
TREAT THE HIV INFECTED CHILD

Side Effects ARV Drugs

Very common side-effets: Potentially serious side effects: Side effects occurring later during
treatment:
warn patients and suggest ways patients can warn patients and tell them to seek care discuss with patients
manage;
manage when patients seek care
Abacavir (ABC) Seek care urgently:
Fever, vomiting, rash - this may indicate hypersensitivity to
abacavir
Lamivudine (3TC) Nausea
Diarrhoea
Lopinavir/ritonavir Nausea Changes in fat distribution:
Vomiting Arms, legs, buttocks, cheeks become THIN
Breasts, tummy, back of neck become FAT
Diarrhoea
Elevated blood cholesterol and glucose
Nevirapine (NVP) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Severe skin rash
Fatigue AND shortness of breath
Fever
Zidovudine Nausea Seek care urgently:
(ZDV or AZT) Diarrhoea Pallor (anaemia)
Headache
Fatigue
Muscle pain
Efavirenz (EFV) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Strange dreams Psychosis or confusion
Difficulty sleeping Severe skin rash
Memory problems
Headache
Dizziness
TREAT THE HIV INFECTED CHILD

Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS APPROPRIATE CARE RESPONSE
Yellow eyes (jaundice) or Stop drugs and REFER URGENTLY
abdominal pain
Rash If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is associated with
fever or vomiting: stop drugs and REFER URGENTLY
Nausea Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer.
Vomiting Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being given.
If vomiting persists, the caregiver should bring the child to clinic for evaluation.
If vomiting everything, or vomiting associated with severe abdominal pain or difficulty breathing, REFER URGENTLY.
Diarrhoea Assess, classify, and treat using diarrhoea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If not
improved after two weeks, call for advice or refer.
Fever Assess, classify, and treat using feve chart.
Headache Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or refer.
Sleep disturbances, This may be due to efavirenz. Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for advice or
nightmares, anxiety refer.
Tingling, numb or painful feet If new or worse on treatment, call for advice or refer.
or legs
Changes in fat distribution Consider switching from stavudine to abacavir, consider to viral load. Refer if needed.
TREAT THE HIV INFECTED CHILD

Give Pain Relief to HIV Infected Child

Give paracetamol or ibuprofen every 6 hours if pain persists.
For severe pain, morphine syrup can be given.
PARACETAMOL ORAL MORPHINE
AGE or WEIGHT
TABLET (100 mg) SYRUP (120 mg/5ml) (0.5 mg/5 ml)

2 up to 4 months (4 - <6 kg) - 2 ml 0.5 ml

4 up to 12 months (6 - <10 kg) 1 2.5 ml 2 ml
12 months up to 2 years (10 - <12 kg) 1 1/2 5 ml 3 ml
2 up to 3 years (12 - <14 kg) 2 7.5 ml 4 ml
3 up to 5 years (14 -<19 kg) 2 10 ml 5 ml
Recommended dosages for ibuprofen
ibuprofen in children under the age of 3 months.

IMMUNIZE EVERY SICK CHILD AS NEEDED

FOLLOW-UP

GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

DYSENTERY
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications. After 3 days:
If the child has any new problem, assess, classify and treat the new problem as on Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart.
the ASSESS AND CLASSIFY chart.
Ask:
Are there fewer stools?
Is there less blood in the stool?
PNEUMONIA Is there less fever?
Is there less abdominal pain?
After 3 days: Is the child eating better?
Check the child for general danger signs.
Treatment:
Assess the child for cough or difficult breathing.
Ask: If the child is dehydrated, treat dehydration.
If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or
Is the child breathing slower? See ASSESS & CLASSIFY chart.
the same:
Is there a chest indrawing? Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days.
Is there less fever? Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to
Is the child eating better? hospital.
Exceptions - if the child: is less than 12 months old, or
Treatment: was dehydrated on the first visit, or REFER to hospital.
If any general danger sign or stridor, refer URGENTLY to hospital. if he had measles within the last 3 months
If chest indrawing and/or breathing rate, fever and eating are the same or worse, refer
URGENTLY to hospital. If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better,
If breathing slower, no chest indrawing, less fever, and eating better, complete the 5 days of continue giving ciprofloxacin until finished.
antibiotic.
Ensure that mother understands the oral rehydration method fully and that she also understands
the need for an extra meal each day for a week.

PERSISTENT DIARRHOEA
After 5 days: MALARIA
Ask:
Has the diarrhoea stopped? If fever persists after 3 days:
How many loose stools is the child having per day? Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full Treatment:
reassessment of the child. Treat for dehydration if present. Then refer to hospital.
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow
If the child has any othercause of fever other than malaria, provide appropriate treatment.
the usual feeding recommendations for the child's age.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the
child to a hospital.
If there is no other apparent cause of fever and you do not have a microscopy to check for
parasites, refer the child to a hospital.
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is , refer URGENTLY to
hospital.
Treatment: Acute ear infection:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking
to dry the ear. Follow-up in 5 days.
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
days if the fever persists.
finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the child has any other cause of fever other than malaria, provide treatment. Chronic ear infection:
If there is no other apparent cause of fever: Check that the mother is wicking the ear correctly and giving quinolone drops tree times a day.
If the fever has been present for 7 days, refer for assessment. Encourage her to continue.

MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR FEEDING PROBLEM

MOUTH ULCERS, OR THRUSH After 7 days:
Reassess feeding. > See questions in the COUNSEL THE MOTHER chart.
After 3 days: Ask about any feeding problems found on the initial visit.
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers or white patches in the mouth (thrush). Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make
Smell the mouth. significant changes in feeding, ask her to bring the child back again.
If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to return 30 days
Treatment for eye infection:
after the initial visit to measure the child's WFH/L, MUAC.
If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If
treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct
treatment.
If the pus is gone but redness remains, continue the treatment.
If no pus or redness, stop the treatment. ANAEMIA
After 14 days:
Treatment for mouth ulcers:
Give iron. Advise mother to return in 14 days for more iron.
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Continue giving iron every 14 days for 2 months.
If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5
If the child has palmar pallor after 2 months, refer for assessment.
days.

Treatment for thrush:

If thrush is worse check that treatment is being given correctly.
If the child has problems with swallowing, refer to hospital.
If thrush is the same or better, and the child is feeding well, continue nystatine for a total of 7 days.
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

After 14 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for oedema of both feet.
Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older.

Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes
appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask
mother to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell

scores or more, and/or MUAC is 125 mm or more.

If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).

MODERATE ACUTE MALNUTRITION

After 30 days:
Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit:
If WFH/L, weigh the child, measure height or length and determine if WFH/L.
If MUAC, measure using MUAC tape.
Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Treatment:
If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and
encourage her to continue.
If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any
feeding problem found. Ask the mother to return again in one month. Continue to see the child monthly
until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or
MUAC is 125 mm. or more.
Exception:
If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has
diminished, refer the child.
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
CONFIRMED HIV INFECTION NOT ON ART
Follow up regularly as per national guidelines.
HIV EXPOSED At each follow-up visit follow these instructions:
Follow up regularly as per national guidelines. Ask the mother: Does the child have any problems?
At each follow-up visit follow these instructions: Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
new problem
Ask the mother: Does the child have any problems?
Counsel and check if mother able or willing now to initiate ART for the child.
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
new problem
counselling
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
Continue cotrimoxazole prophylaxis if indicated.
counselling
Initiate or continue isoniazid preventive therapy if indicated.
Continue cotrimoxazole prophylaxis
If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children)
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How
Monitor CD4 count and percentage.
often, if ever, does the child/mother miss a dose?

Home care:
Plan for the next follow-up visit
Counsel the mother about any new or continuing problems
HIV testing:
If appropriate, put the family in touch with organizations or people who could provide support
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Advise the mother about hygiene in the home, in particular when preparing food
test result. Plan for the next follow-up visit

to the test result.

If child is confirmed HIV infected
Start on ART and enrol in chronic HIV care.
Continue follow-up as for CONFIRMED HIV INFECTION ON ART
If child is confirmed uninfected
Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks
of cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about her own health
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD

CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF

FOLLOW-UP CARE
Follow up regularly as per national guidelines.
STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART
ASK: Does the child have any IF ANY OF FOLLOWING PRESENT, REFER
problems? NON-URGENTLY:
Has the child received care at another If any of these
health facility since the last visit? present, refer
CHECK: for general danger signs - If NON-
present, complete assessment, give URGENTLY:
pre-referral treatment, REFER Record the Child's weight Not gaining
URGENTLY. and height weight for 3
ASSESS, CLASSIFY, TREAT and Assess adherence months
COUNSEL any sick child as Ask about adherence: how Loss of
appropriate. often, if ever, does the milestones
CHECK for ART severe side effects child miss a dose? Record Poor
your assessment. adherence
Severe Assess and record clinical Stage
skin rash stage worse than
Assess clinical stage. before
Difficulty
breathing CD4 count
and stage at previous visits. lower than
If present, give before
severe Monitor laboratory results
any pre- LDL higher
abdominal Record results of tests
referral than 3.5
pain that have been sent.
treatment, mmol/L
Yellow
REFER TG higher
eyes
URGENTLY than 5.6
Fever,
vomiting, mmol/L
rash (only Manage side effects
if on Send tests that are due
Abacavir)
Check for other ART side effects
STEP 3: PROVIDE ART, STEP 4: COUNSEL THE MOTHER OR CAREGIVER
COTRIMOXAZOLE AND ROUTINE
TREATMENTS Use every visit to educate and provide support to
If child is stable: continue with the the mother or caregiver
ART regimen and cotrimoxazole doses.
Key issues to discuss include:
Check for appropriate doses:
remember these will need to increase How the child is progressing, feeding, adherence,
as the child grows side-effects and correct management, disclosure
Give routine care: Vitamin A (to others and the child), support for the caregiver
supplementation, deworming, and
immunization as needed Remember to check that the mother and other
family members are receiving the care that
they need
Set a follow-up visit: if well, follow-up as per
nastional guidelines. If problems, follow-up as
indicated.
COUNSEL THE MOTHER

FEEDING COUNSELLING

Assess Child's Appetite

All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (oedema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical
complication should be assessed for appetite.
Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed to eating the
RUTF. Usually the child eats the RUTF portion in 30 minutes.
Explain to the mother:
The purpose of assessing the child's appetite.
What is ready-to-use-therapeutic food (RUTF).
How to give RUTF:
Wash hands before giving the RUTF.
Sit with the child on the lap and gently offer the child RUTF to eat.
Encourage the child to eat the RUTF without feeding by force.
Offer plenty of clean water to drink from a cup when the child is eating the RUTF.
Offer appropriate amount of RUTF to the child to eat:
After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide:
Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
FEEDING COUNSELLING

Assess Child's Feeding

Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED. Ask questions about the child's usual
feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age.
ASK - How are you feeding your child?
If the child is receiving any breast milk, ASK:
How many times during the day?
Do you also breastfeed during the night?

Does the child take any other food or fluids?

What food or fluids?
How many times per day?
What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What foods are available in the home?
During this illness, has the child's feeding changed?
If yes, how?

In addition, for HIV EXPOSED child:

If mother and child are on ARV treatment or prophylaxis and child breastfeeding, ASK:
Do you take ARV drugs? Do you take all doses, miss doses, do not take medication?
Does the child take ARV drugs (If the policy is to take ARV prophylaxis until 1 week after breastfeeding has stopped)? Does he or she take all doses, missed doses,
does not take medication?
If child not breastfeeding, ASK:
What milk are you giving?
How many times during the day and night?
How much is given at each feed?
How are you preparing the milk?
Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant.
Are you giving any breast milk at all?
Are you able to get new supplies of milk before you run out?
How is the milk being given? Cup or bottle?
How are you cleaning the feeding utensils?
FEEDING COUNSELLING

Feeding Recommendations
Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis
Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months

Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING

Feeding Recommendations for HIV EXPOSED Child on Infant Formula

These feeding recommendations are for HIV EXPOSED children in setting where the national authorities recommend to avoid all breastfeeding or when the mother has chosen
formula feeding.
PMTCT: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.
Up to 6 months 6 up to 12 monts 12 months up to 2 years Safe preparation of replacement feeding

Infant formula
Always use a marked cup or glass and
spoon to measure water and the
scoop to measure the formula
powder.
Wash your hands before preparing a
feed.
Bring the water to boil and then let it
cool. Keep it covered while it cools.
FORMULA FEED exclusively. Do not give Give 1-2 cups (250 - 500 ml) of infant Give 1-2 cups (250 - 500 ml) of boiled,
Measure the formula powder into a
any breast milk. Other foods or fluids formula or boiled, then cooled, full then cooled, full cream milk or infant
marked cup or glass. Make the scoops
are not necessary. cream milk. Give milk with a cup, not a formula.
level. Put in one scoop for every 25 ml
Prepare correct strength and amount bottle. Give milk with a cup, not a bottle.
of water.
just before use. Use milk within two Give: Give: Add a small amount of the cooled
boiled water and stir. Fill the cup or
can store formula for 24 hours.
glass to the mark with the water. Stir
Cup feeding is safer than bottle
well.
feeding. Clean the cup and utensils * * Feed the infant using a cup.
with hot soapy water.
Start by giving 2-3 tablespoons of food 2 or family foods 3 or 4 times per day. Give Wash the utensils.
Give the following amounts of formula 8 - 3 times a day. Gradually increase to 1/2 3/4 cup (1 cup = 250 ml) at each meal.
to 6 times per day: cup (1 cup = 250 ml) at each meal and to
Offer 1-2 snacks between meals.
Age in months Approx. amount and times giving meals 3-4 times a day.
Continue to feed your child slowly, Cow' s or other animal milks are not
per day Offer 1-2 snacks each day when the
patiently. suitable for infants below 6 months of
0 up to 1 60 ml x 8 child seems hungry.
Encourage - but do not force - your child age (even modified).
1 up to 2 90 ml x 7 For snacks give small chewable items
to eat. For a child between 6 and 12 month of
2 up to 4 120 ml x 6 that the child can hold. Let your child try to
4 up to 6 150 ml x 6 age: boil the milk and let it cool (even if
eat the snack, but provide help if needed.
pasteurized).
Feed the baby using a cup.

* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING

Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup

Learn how to prepare a store milk safely at home

2. HELP MOTHER MAKE TRANSITION:

Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2 months)
Clean all utensils with soap and water

3. STOP BREASTFEEDING COMPLETELY:

Express and discard enough breast milk to keep comfortable until lactation stops

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer breastfeeds, day and night.
If taking other milk:
replace with increased breastfeeding OR
replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food.
For other foods, follow feeding recommendations for the child's age.
EXTRA FLUIDS AND MOTHER'S HEALTH

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given.
Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counselling on STD and AIDS prevention.

Give additional counselling if the mother is HIV-positive

Emphasize good hygiene, and early treatment of illnesses

WHEN TO RETURN

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the child's
problems.
If the child has: Return for
follow-up in:
PNEUMONIA 3 days
DYSENTERY
MALARIA, if fever persists
FEVER: NO MALARIA, if fever persists
WHEN TO RETURN IMMEDIATELY
MEASLES WITH EYE OR MOUTH
COMPLICATIONS Advise mother to return immediately if the child has any of these signs:
MOUTH OR GUM ULCERS OR THRUSH Any sick child Not able to drink or breastfeed
5 days Becomes sicker
PERSISTENT DIARRHOEA
Develops a fever
ACUTE EAR INFECTION
CHRONIC EAR INFECTION If child has COUGH OR COLD, also return if: Fast breathing
COUGH OR COLD, if not improving Difficult breathing
UNCOMPLICATED SEVERE ACUTE If child has diarrhoea, also return if: Blood in stool
14 days
MALNUTRITION Drinking poorly
FEEDING PROBLEM
ANAEMIA 14 days
MODERATE ACUTE MALNUTRITION 30 days
CONFIRMED HIV INFECTION According to national
HIV EXPOSED recommendations

NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
SICK YOUNG INFANT AGE UP TO 2 MONTHS

ASSESS AND CLASSIFY THE SICK YOUNG INFANT

ASSESS CLASSIFY IDENTIFY TREATMENT
DO A RAPID APRAISAL OF ALL WAITING INFANTS
ASK THE MOTHER WHAT THE YOUNG INFANT'S
PROBLEMS ARE USE ALL BOXES THAT MATCH THE
INFANT'S SYMPTOMS AND
Determine if this is an initial or follow-up visit for this PROBLEMS TO CLASSIFY THE
problem.
ILLNESS
if follow-up visit, use the follow-up instructions.
if initial visit, assess the child as follows:
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
ASK:
Is the infant having
difficulty in feeding?
Has the infant had
convulsions (fits)?
** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
LOOK, LISTEN, FEEL: Any one of the following Pink: Give first dose of intramuscular antibiotics
Count the signs VERY SEVERE Treat to prevent low blood sugar
Classify ALL YOUNG
breaths in one DISEASE Refer URGENTLY to hospital **
YOUNG INFANTS Not feeding well or
minute. Repeat Advise mother how to keep the infant warm
INFANT Convulsions or
the count if more on the way to the hospital
MUST Fast breathing (60 breaths
than 60 breaths
BE per minute or more) or
per minute.
CALM Severe chest indrawing or
Look for severe
or
chest indrawing.
Low body temperature (less
Measure axillary or
temperature. Movement only when
Look at the umbilicus. Is it stimulated or no movement
red or draining pus? at all.
Look for skin pustules.
Umbilicus red or draining pus Yellow: Give an appropriate oral antibiotic
Look at the young infant's
Skin pustules LOCAL Teach the mother to treat local infections at home
movements.
If infant is sleeping, ask
BACTERIAL Advise mother to give home care for the young
the mother to wake
INFECTION infant
him/her. Follow up in 2 days
Does the infant move None of the signs of very Green: Advise mother to give home care.
on his/her own? severe disease or local SEVERE DISEASE
If the young infant is not bacterial infection OR LOCAL
moving, gently stimulate INFECTION
him/her. UNLIKELY
Does the infant not
move at all?
CHECK FOR JAUNDICE

If jaundice present, ASK: LOOK AND FEEL:
When did the jaundice Look for jaundice (yellow
appear first? eyes or skin)
Look at the young infant's
palms and soles. Are they
yellow?
Any jaundice if age less
than 24 hours or
CLASSIFY Yellow palms and soles at
JAUNDICE any age
Jaundice appearing after 24 Yellow:
hours of age and
Palms and soles not yellow
No jaundice
Pink: Treat to prevent low blood sugar
SEVERE JAUNDICE Refer URGENTLY to hospital
Advise mother how to keep the infant warm
on the way to the hospital
Advise the mother to give home care for the
JAUNDICE young infant
Advise mother to return immediately if palms and
soles appear yellow.
If the young infant is older than 14 days, refer to a
hospital for assessment
Follow-up in 1 day
Green: Advise the mother to give home care for the
NO JAUNDICE young infant

THEN ASK: Does the young infant have diarrhoea*?

IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification:
Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C)
Infant's movements Classify stimulated or no movement DEHYDRATION OR
Does the infant move on his/her own? DIARRHOEA for at all If infant also has another severe
Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification:
then stops? Skin pinch goes back very Refer URGENTLY to hospital with
Does the infant not move at all? slowly. mother giving frequent sips of ORS on
Is the infant restless and irritable? the way
Advise the mother to continue
Look for sunken eyes.
breastfeeding
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Two of the following signs: Yellow: Give fluid and breast milk for some dehydration
or slowly? Restless and irritable SOME (Plan B)
Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with
slowly. mother giving frequent sips of ORS on
the way
Advise the mother to continue
breastfeeding
Advise mother when to return immediately
Follow-up in 2 days if not improving
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO DEHYDRATION continue breastfeeding (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 2 days if not improving

* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
THEN CHECK FOR HIV INFECTION

Positive virological test in Yellow: Give cotrimoxazole prophylaxis from age 4-6
ASK young infant CONFIRMED HIV weeks
Classify INFECTION Give HIV ART and care
Has the mother and/or young infant had an HIV test? HIV Advise the mother on home care
status
Follow-up regularly as per national guidelines
IF YES: Mother HIV positive AND Yellow: Give cotrimoxazole prophylaxis from age 4-6
What is the mother's HIV status?: negative virological test HIV EXPOSED weeks
Serological test POSITIVE or NEGATIVE in young Start or continue PMTCT ARV prophylaxis as per
What is the young infant's HIV status?: infant breastfeeding or if national recommendations**
Virological test POSITIVE or NEGATIVE only stopped less than 6 Do virological test at age 4-6 weeks or repeat 6
Serological test POSITIVE or NEGATIVE weeks ago. weeks after the child stops breastfeeding
OR Advise the mother on home care
If mother is HIV positive and NO positive virological test Mother HIV positive, young Follow-up regularly as per national guidelines
in child ASK: infant not yet tested
Is the young infant breastfeeding now? OR
Was the young infant breastfeeding at the time of test Positive serological test in
or before it? young infant
Is the mother and young infant on PMTCT ARV
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
prophylaxis?*
or young infant HIV INFECTION
UNLIKELY

IF NO test: Mother and young infant status unknown

Perform HIV test for the mother; if positive, perform
virological test for the young infant

* Prevention of Maternal-To-Child-Transmission (PMTCT) ART prophylaxis.

**Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis from birth for 6 weeks if breastfeeding or 4-6 weeks if on replacement
feeding.
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING
PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS"
If an infant has no indications to refer urgently to hospital:

Ask: LOOK, LISTEN, FEEL:
Is the infant breastfed? If
yes, how many times in 24
hours?
Does the infant usually
receive any other foods or
drinks? If yes, how often?
If yes, what do you use to
feed the infant?
Determine weight for age.
Look for ulcers or white
patches in the mouth
(thrush).
Not well attached to breast
or
Classify FEEDING Not suckling effectively or
Less than 8 breastfeeds in
24 hours or
Receives other foods or
drinks or
Low weight for age or
Thrush (ulcers or white
patches in mouth).
Not low weight for age and
no other signs of inadequate
feeding.
Yellow: If not well attached or not suckling effectively,
FEEDING PROBLEM teach correct positioning and attachment
OR If not able to attach well immediately, teach the
LOW WEIGHT mother to express breast milk and feed by a cup
If breastfeeding less than 8 times in 24 hours,
advise to increase frequency of feeding. Advise
the mother to breastfeed as often and as long as
the infant wants, day and night
If receiving other foods or drinks, counsel the
mother about breastfeeding more, reducing other
foods or drinks, and using a cup
If not breastfeeding at all*:
Refer for breastfeeding counselling and
possible relactation*
Advise about correctly preparing breast-milk
substitutes and using a cup
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise mother to give home care for the young
infant
Follow-up any feeding problem or thrush in 2 days
Follow-up low weight for age in 14 days
Green: Advise mother to give home care for the young
NO FEEDING infant
PROBLEM Praise the mother for feeding the infant well

ASSESS BREASTFEEDING:
Has the infant breastfed in the previous hour?
If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)
Is the infant well attached?
not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.

* Unless not breastfeeding because the mother is HIV positive.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS
Use this chart for HIV EXPOSED infants not breastfeeding AND the infant has no indications to refer urgently to hospital:

Ask: LOOK, LISTEN, FEEL: Milk incorrectly or Yellow: Counsel about feeding
What milk are you giving? Determine weight for age. unhygienically prepared or FEEDING PROBLEM Explain the guidelines for safe replacement feeding
How many times during the Look for ulcers or white Classify FEEDING
Giving inappropriate OR Identify concerns of mother and family about
day and night? patches in the mouth replacement feeds or LOW WEIGHT feeding.
How much is given at each (thrush). If mother is using a bottle, teach cup feeding
Giving insufficient
feed? Advise the mother how to feed and keep the low
replacement feeds or
How are you preparing the weight infant warm at home
milk? An HIV positive mother
If thrush, teach the mother to treat thrush at home
mixing breast and other
Let mother demonstrate or Advise mother to give home care for the young
feeds before 6 months or
explain how a feed is infant
prepared, and how it is Using a feeding bottle or
Follow-up any feeding problem or thrush in 2 days
given to the infant. Low weight for age or Follow-up low weight for age in 14 days
Are you giving any breast Thrush (ulcers or white
milk at all? patches in mouth).
What foods and fluids in Not low weight for age and Green: Advise mother to give home care for the young
addition to replacement no other signs of inadequate NO FEEDING infant
feeds is given? feeding. PROBLEM Praise the mother for feeding the infant well
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:

IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN

A
Birth BCG OPV-0 Hep B0 200 000
IU to the
mother
within 6
weeks of
delivery
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1

Give all missed doses on this visit.

Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.

ASSESS OTHER PROBLEMS

Nutritional status and anaemia, contraception. Check hygienic practices.

TREAT AND COUNSEL

TREAT THE YOUNG INFANT

GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

Give first dose of both ampicillin and gentamicin intramuscularly.
AMPICILLIN
Dose: 50 mg per kg GENTAMICIN
To a vial of 250 mg
WEIGHT Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 ml sterile water to 2 ml vial containing 80
mg* = 8 ml at 10 mg/ml
Add 1.3 ml sterile water = 250 mg/1.5ml
AGE <7 days AGE >= 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
1.5-<2 kg 0.5 ml 0.9 ml* 1.3 ml*
2-<2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
2.5-<3 kg 0.8 ml 1.4 ml* 2.0 ml*
3-<3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
3.5-<4 kg 1.1 ml 1.9 ml* 2.8 ml*
4-<4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
* Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times
daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.

TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10 ml/kg) sugar water (To make sugar water: Dissolve 4 level
teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.
TREAT THE YOUNG INFANT

TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM ON THE WAY TO THE HOSPITAL
Provide skin to skin contact
OR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with
a blanket.

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL BACTERIAL INFECTION

First-line antibiotic: ___________________________________________________________________________________________
Second-line antibiotic:_________________________________________________________________________________________
AMOXICILLIN
Give 2 times daily for 5 days
AGE or WEIGHT
Tablet Syrup
250 mg 125 mg in 5 ml
Birth up to 1 month (<4 kg) 1/4 2.5 ml
1 month up to 2 months (4-<6 kg) 1/2 5 ml
.

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain how the treatment is given.
Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.

To Treat Skin Pustules or Umbilical Infection
The mother should do the treatment twice daily for 5 days:
Wash hands
Gently wash off pus and crusts with soap and water
Dry the area
Paint the skin or umbilicus/cord with full strength gentian violet (0.5%)
Wash hands
To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment four times daily for 7 days:
Wash hands
Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger
Wash hands

To Treat Diarrhoea, See TREAT THE CHILD Chart.

TREAT THE YOUNG INFANT

Immunize Every Sick Young Infant, as Needed

GIVE ARV FOR PMTCT PROPHYLAXIS

Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis*:
Nevirapine or zidovudine are provided to young infant classified as HIV EXPOSED to minimize the risk of mother-to-child HIV transmission (PMTCT).
If breast feeding: Give NVP for 6 weeks beginning at birth or when HIV exposure is recognized.
If not breast feeding: Give NVP or ZDV for 4-6 weeks beginning at birth or when HIV exposure is recognized.
NEVIRAPINE ZIDOVUDINE (AZT)
AGE
Give once daily. Give once daily
Birth up to 6 weeks:
Birth weight 2000 - 2499 g 10 mg 10 mg
Birth weight > 2500 g 15 mg 15 mg
Over 6 weeks: 20 mg -

* PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART PROPHYLAXIS:

OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR AZT FOR 4-6 WEEKS IF ON
REPLACEMENT FEEDING.
OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NVP OR
AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.
COUNSEL THE MOTHER
TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT
WARM AT HOME
TEACH CORRECT POSITIONING AND ATTACHMENT FOR
Keep the young infant in the same bed with the mother.
BREASTFEEDING
of cold air.
Show the mother how to hold her infant.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm
with the infant's head and body in line. water, dry immediately and thoroughly after bathing and clothe the young infant immediately.
with the infant approaching breast with nose opposite to the nipple. Change clothes (e.g. nappies) whenever they are wet.
with the infant held close to the mother's body. Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
with the infant's whole body supported, not just neck and shoulders. Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's
Show her how to help the infant to attach. She should: head turned to one side.
touch her infant's lips with her nipple Cover the infant with mother's clothes (and an additional warm blanket in cold weather).
wait until her infant's mouth is opening wide When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all
move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple. times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young
infant in a soft dry cloth and cover with a blanket.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
again. Breastfeed the infant frequently (or give expressed breast milk by cup).

TEACH THE MOTHER HOW TO EXPRESS BREAST MILK

Ask the mother to:
Wash her hands thoroughly.
Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they
are opposite each other (at least 4 cm from the tip of the nipple).
Compress and release the breast tissue between her finger and thumb a few times.
If the milk does not appear she should re-position her thumb and finger closer to the nipple and
compress and release the breast as before.
Compress and release all the way around the breast, keeping her fingers the same distance from
the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on
the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.

TEACH THE MOTHER HOW TO FEED BY A CUP

Put a cloth on the infant's front to protect his clothes as some milk can spill.
Hold the infant semi-upright on the lap.
Put a measured amount of milk in the cup.
Hold the cup so that it rests lightly on the infant's lower lip.
Tip the cup so that the milk just reaches the infant's lips.
Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
COUNSEL THE MOTHER

ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG

INFANT
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT
Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the
infant wants.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
Follow up visit
If the infant has: Return for first follow-up in:
JAUNDICE 1 day
LOCAL BACTERIAL INFECTION 2 days
FEEDING PROBLEM
THRUSH
DIARRHOEA
LOW WEIGHT FOR AGE 14 days
CONFIRMED HIV INFECTION According to national recommendations
HIV EXPOSED

WHEN TO RETURN IMMEDIATELY:

Advise the mother to return immediately if the young infant has any of these
signs:
Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow
FOLLOW-UP

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT

LOCAL BACTERIAL INFECTION

After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.

Treatment:
If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped?

Treatment
If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?"
If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?

Treatment:
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant
changes in feeding, ask her to bring the young infant back again.
If the young infant is low weight for age, ask the mother to return 14 days of this follow up visit. Continue follow-up until the infant is gaining weight well.

Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

LOW WEIGHT FOR AGE

After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within 14 days or when she returns for immunization, whichever is the
earlier.
If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she returns for
immunization, if this is within 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly and is no longer low weight for age.

Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
If thrush is worse check that treatment is being given correctly.
If the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.

CONFIRMED HIV INFECTION OR HIV EXPOSED

A young infant classified as CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits regularly as per national guidelines.
Follow the instructions for follow-up care for child aged 2 months up to 5 years.
Annex:

Skin Problems

IDENTIFY SKIN PROBLEM

IDENTIFY SKIN PROBLEM
IF SKIN IS ITCHING
SIGNS
Itching rash with small papules
and scratch marks. Dark spots
with pale centres
An itchy circular lesion with a
raised edge and fine scaly area
in the centre with loss of hair.
May also be found on body or
web on feet
Rash and excoriations on torso;
burrows in web space and
wrists. face spared
CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
PAPULAR Treat itching: Is a clinical stage 2 defining case
ITCHING Calamine lotion
RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV
RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
WORM patches existing nail infection which has to be treated
(TINEA) adequately to prevent recurrence of tinea
If extensive refer, if not give:
infections of skin.
Ketoconazole
Fungal nail infection is a clinical stage 2
for 2 up to 12 months(6-10 kg) 40mg per day
defining disease
for 12 months up to 5 years give 60 mg per day
or give griseofulvin 10mg/kg/day
if in hair shave hair treat itching as above
SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals scabies may
25% topical Benzyl Benzoate at night, repeat for 3 manifest as crust scabies.
days after washing and or 1% lindane cream or
Crusted scabies presents as extensive areas
lotion once wash off after 12 hours
of crusting mainly on the scalp, face back and
feet. Patients may not complain of itching. The
scales will teeming with mites
IDENTIFY SKIN PROBLEM

IF SKIN HAS BLISTERS/SORES/PUSTULES

SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV
Vesicles over body. CHIKEN POX Treat itching as above Presentation atypical only if
Vesicles appear Refer URGENTLY if pneumonia or child is immunocompromised
progressively over jaundice appear Duration of disease longer
days and Complications more frequent
form scabs after they Chronic infection with
rupture continued
appearance of new lesions
for >1 month; typical vesicles
evolve into nonhealing ulcers
that become necrotic, crusted,
and hyperkeratotic.

Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease longer
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Haemorrhagic vesicles,
body with intense pain Give pain relief necrotic
or scars Follow-up in 7 days ulceration
plus shooting pain. Rarely recurrent, disseminated
Herpes zoster is or multi-dermatomal
uncommon in
children except where
Is a Clinical stage 2 defining
they are
disease
immuno-compromised,
for example
if infected with HIV

Red, tender, warm IMPETIGO OR Clean sores with antiseptic

crusts or small lesions FOLLICULITIS Drain pus if fluctuant
Start cloxacillin if size >4cm or red streaks or tender nodes or multiple
abscesses for 5 days ( 25-50 mg/kg every 6 hours)
Refer URGENTLY if child has fever and /
or if infection extends to the muscle.
IDENTIFY SKIN PROBLEM

NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules with MOLLUSCUM Can be treated by various Incidence is higher
a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm in
commonly seen on the face and trunk in Leave them alone unless size), or coalescent
children. superinfected Pouble or triple lesions
Use of phenol: Pricking each lesion may be seen
with a needle or sharpened More than 100 lesions
orange stick and dabbing the lesion may be seen.
with phenol Lesions often chronic and
Electrodesiccation difficult to eradicate
Liquid nitrogen application (using Extensive molluscum
orange stick) contagiosum is a Clinical
stage 2 defining disease
Curettage
The common wart appears as papules WARTS Treatment: Lesions more numerous
or nodules with a rough (verrucous) Topical salicylic acid preparations ( and recalcitrant to
surface eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is a
Electrocautery Clinical stage 2 defining
disease

Greasy scales and redness on central SEBBHORREA Ketoconazole shampoo Seborrheic dermatitis may
face, body folds If severe, refer or provide tropical be severe in HIV
steroids infection.
For seborrheic dermatitis: 1%
Secondary infection may
hydrocortisone cream X 2 daily
be common
If severe, refer
CLINICAL REACTION TO DRUGS

DRUG AND ALLERGIC REACTIONS

SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Generalized red, wide spread with small bumps or blisters; or FIXED DRUG Stop medications give oral Could be a sign of reactions to
REACTIONS antihistamines, if pealing ARVs
one or more dark skin areas (fixed drug reactions)
rash refer

Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching

Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Height/Length (cm):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGN General danger sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing?
Look for chest indrawing
Look and listen for stridor
Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child:
Is there blood in the stool? Lethargic or unconscious? Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer then 2 seconds)? Slowly?
Yes __ No __
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
For how long? ___ Days Look for runny nose
If more than 7 days, has fever been present every day? Look for signs of MEASLES:
Has child had measles within the last 3 months? Generalized rash and
One of these: cough, runny nose, or red eyes
Do a malaria test, if NO general danger sign in all cases in
Look for any other cause of fever.
high malaria risk or NO obvious cause of fever in low
malaria risk:
Test POSITIVE? P. falciparum P. vivax NEGATIVE?
If the child has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
last 3 months: Look for pus draining from the eye.
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
AND ANAEMIA Determine WFH/L z-score:
Less than -3? Between -3 and -2? -2 or more ?
Child 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or Is there any medical complication: General danger sign?
WFH/L less than -3 Z scores: Any severe classification? Pneumonia with chest indrawing?
Child 6 months or older: Offer RUTF to eat. Is the child:
Not able to finish? Able to finish?
Child less than 6 months: Is there a breastfeeding problem?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on:
________________
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole
(Date)
Hep B0 Hep B1 Hep B2 Hep B3
RTV-1 RTV-2 RTV-3
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, FEEDING
ANAEMIA, or is HIV exposed or infected PROBLEMS
Do you breastfeed your child? Yes ___ No ___
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___
Does the child take any other foods or fluids? Yes ___ No ___
If Yes, what food or fluids?
How many times per day? ___ times. What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child's feeding changed? Yes ___ No ___
If Yes, how?
ASSESS OTHER PROBLEMS: Ask about mother's own health
 TREAT
Remember to refer any child who has a danger sign and no other severe classification

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positive Send tests that are required ____
Check that child has not breastfed for at least 6 weeks Send confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____ NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5
Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS
Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other
2. ____________________________________________________________
recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ___________________________________________________ ACTIONS
ASK: has the child received care at another health YES ____ NO ____ TAKEN:
facility since the last visit?
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING If general danger signs or ART severe side effects, provide pre-referral treatment
CONVULSIONS and REFER URGENTLY
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Difficulty breathing and severe abdominal pain Refer if necessary.
Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms:
Cough or difficulty breathing
Diarrhoea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
TAKEN:
Takes all doses - Frequently misses doses - Not gaining weight for 3 months
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER MEDICATION
ABC+3TC+LPV/r RECORD ART DOSAGES:
ABC+3TC+EFV 1. ____________________________________________________________
Cotrimaoxazole 2. ____________________________________________________________
Vitamin A 3. ____________________________________________________________
Other Medication COTRIMOXAZOLE DOSAGE:_______________________________________
VITAMIN A DOSAGE: _____________________________________________
OTHER MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Side-
effects and correct management
RECORD ACTIONS TAKEN:
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Age: Weight (kg):
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
Is the infant having difficulty in feeding? Count the breaths in one minute. ___ breaths per minute
Has the infant had convulsions? Repeat if elevated: ___ Fast breathing?
Look for severe chest indrawing.
Look and listen for grunting.
Look at the umbiculus. Is it red or draining pus?

Look for skin pustules. Are there many or severe pustules?

Movement only when stimulated or no movement even when
stimulated?
THEN CHECK FOR JAUNDICE
When did the jaundice appear first? Look for jaundice (yellow eyes or skin)
Look at the young infant's palms and soles. Are they yellow?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___
DIARRHOEA? move only when stimulated?
not move even when stimulated?
Is the infant restless and irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
If the infant has no indication to refer urgently to hospital Determine weight for age. Low ___ Not low ___
Is there any difficulty feeding? Yes ___ No ___ Look for ulcers or white patches in the mouth (thrush).
Is the infant breastfed? Yes ___ No ___
If yes, how many times in 24 hours? ___ times
Does the infant usually receive any other foods or
drinks? Yes ___ No ___
If yes, how often?
What do you use to feed the child?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status:
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV positive and and NO positive virological test in young infant:
Is the infant breastfeeding now?
Was the infant breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and infant on ARV prophylaxis?
ASSESS BREASTFEEDING
Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
Is the infant able to attach? To check attachment, look for:
Chin touching breast: Yes ___ No ___
Mouth wide open: Yes ___ No ___
Lower lip turned outward: Yes ___ No ___
More areola above than below the mouth: Yes ___ No ___
not well attached good attachment
Is the infant sucking effectively (that is, slow deep sucks, sometimes
pausing)?
not sucking sucking effectively
effectively
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U immunization on:
OPV-0 OPV-1 OPV-2 vitamin A to ________________
mother (Date)
ASSESS OTHER PROBLEMS: Ask about mother's own health
 TREAT

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
Weight-for-age GIRLS
Birth to 6 month s (z-sco res)

WHO Child Growth Standards

Weight-for-age BOYS
Birth t o 6 month s (z-scores)

WHO Child Growth Standards

Weight-for-Iength GIRLS
Birth to 2 years (z-scores)

WHO Child Growth Standards

Weight-for-Iength BOYS i i
Birth to 2 yea rs (z-scores)

W HO Child Growth Standards

Weight-for-Height GIRLS Work! Health
Organization
2 to 5 years (z-scores)

WHO Chi ld Growth Standards

Weight-for-height BOYS
2 to 5 yea rs (z-scores)

WHO Child Growth Standards

 GIVE GOOD H OME CARE FOR YOUR CHILD

._-
FOA ANY SICK Ctll.O .
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IMCI clinical guidelines are based on the following
principles:
o Examining all sick children aged up to five
years of age fo r general danger signs and all
young infants for signs of very severe disease .
These signs indicate sever e illness and the need
for immediate referral or admission to hospital.
f) The children and infants are then assessed for
main symptoms:
• In older children the main symptoms include:
•
•
Cough o r difficulty breathing,
Diarrhoea.
• Fever, and
• Ear infection.
• In young infants, the main symptoms include:
• Local bacterial infection,
• Diarrhoea, and
• Jaundice,
€) The n in addition , all sick children are routinely
checked for:
• Nutritional and immunization status,
• HIV statu s in high HIV settings, and
• Other pote ntial pl'Oblems.
o Only a limited number of clinical signs are
used. selected on the basis of theil' sensitivity and
specificity to detect disease through
classification .
A combination of individual signs leads to a child's
classification within one or m ore symptom groups
rather than a diagnosis. The classification of illness
is based on a colou r -coded triage system :
• "PINK" indicates urgent hospital referral 01'
admission,
• indicates in iti ation of s pecific
o utpatient treatment.
• "GREEN " indicates supportive home care,
o IMCI management procedUl'es use a limited
number of essential drugs and encourage
a ctive parti ci pation of caregivers in the
treatment of their children.
at An essential component of IMCI is the
counselling of caregivers regarding h o me care:
• Appropr iate feeding and fluids ,
• When to retu rn to the clinic immediat ely, a nd
• When to retu rn for follow -up