MSF Pediatric Guideline 2017 2017-06-21 06-19-42 622

PAEDIATRIC
GUIDELINES
Revision of first edition

February 2017
MSF OCP - MSF OCG, and MSF OCBA
Introduction
These guidelines are aimed at improving the care of the sick child in MSF programmes and are
designed for use in all programmes with paediatric care as a major component. They are written for
non-paediatric doctors and clinical officers with little expertise in the treatment of sick children, and
equally for experienced clinicians to help provide a more consistent approach to paediatric care in
our programmes. They focus on the most common paediatric disease presentations and their
management in a sub-Saharan context. They are evidence- based and take into consideration the
limitations of MSF field contexts in terms of laboratory and monitoring capacity, as well as availability
of drugs and equipment.
In some projects, there may be a need to adapt the recommendations to specific national protocols
or to emergency/specific situations. Please discuss this with your respective medical coordinator,
medical polyvalent/team leader and paediatric advisor prior to doing so. They are also meant to be
used in conjunction with other MSF guidelines. This book does not cover the care of neonates (≤ 28
days), who are covered in the Neonatal Guidelines (any exceptions to the 28-day cut-off are made
explicit in the relevant chapters); nor does it give detailed guidance on paediatric HIV, TB or
malnutrition management, as there are specific MSF guidelines dedicated to these topics.
As new evidence becomes available, these guidelines will require updating. The changes in content in
this edition reflect a desire to harmonise with WHO, as seen in the sections on triage, oxygen and
humidification of oxygen. This is particularly so in the extensive revisions in the sections on shock and
dehydration.
We have added a list of abbreviations. And, we have removed the section on laboratory values as the
availability of tests, and indeed the normal ranges, vary from site to site. We have also removed the
PEWS charts as these should be adapted on an ongoing basis to fit local requirements.
We hope these guidelines will be a useful tool. We have attempted to eliminate errors from the text,
and would be grateful for your feedback and suggestions for improvements. Please send feedback to
your respective paediatric medical advisor.
Acknowledgments
These Paediatric Guidelines are the product of the collaboration of many different contributors.
We want to particularly thank:
• Marianne Sutton, who wrote the first version of the guidelines
• David Green, who coordinated the revision of this edition
• Belen Caminoa, Marie Clarisse, Anthony Flynn, Magdalena Goyheneix, Kerstin Hanson,
Laurent Hiffler, Isabelle Lessard, Daniel Martinez, Marco Olla, Roberta Petrucci, Nicolas
Peyraud and Anne Pittet who all contributed substantially to the content by proofreading,
adding and correcting chapters
• Members of the MSF Paediatric Working Group
• Field workers (doctors, clinical officers and nurses) for their feedback
We also want to thank the countless supporters of this project, not named here.
To provide consistency the illustrations have been redrawn, by Anthony Calvert, from source
material primarily from WHO, Hospital Care for Children, MSF publications and from images provided
by David Watson. We thank WHO and David Watson for allowing us to use their material.
Photos were taken and used with consent of the respective patients/parents.
Myrto Schaefer and Marie-Claude Bottineau

Sydney and Geneva, February 2017
Editing of first edition: Heather Ehlers

Coordination: Susan Woodland
Abbreviations
ABCD Airway Breathing Circulation Disability LOC Level of consciousness
ACS Acute chest syndrome LP Lumbar puncture
ACT Artemisinin-based combination therapy MCD Minimal Change Disease
AED Anti-epileptic drug MDI Metered Dose Inhaler
AL Artemether-lumefantrine MRSA Methicillin-resistant Staphylococcus aureus
AOM Acute otitis media NaCl Normal (0.9%) saline
As-AQ Artesunate-amodiaquine NGT Nasogastric tube
AVPU Alert, Voice, Pain, Unresponsive (score) NPO Nil per os (nil by mouth)
BP Blood pressure NSAID Non-steroidal anti inflammatory drug
CO Cerebral oedema NTS Nontyphoid Salmonella
CQ Chloroquine ORS Oral rehydration solution
CRT Capillary refill time PEWS Paediatric Early Warning System
CSF Cerebrospinal fluid PIGN PostInfectious glomerulonephritis
CSOM Chronic suppurative otitis media PO Per os (by mouth)
CXR Chest X-ray PRBC Packed red blood cells
D Dextrose RBC Red blood cell
DKA Diabetic ketoacidosis RDT Rapid diagnostic test
DM Diabetes mellitus RL Ringer’s lactate
EG Ecthyma gangrenosum RR Respiratory rate
G6PD Glucose-6-phosphate dehydrogenase SAM Severe acute malnutrition
GCS Glasgow Coma Scale SBP Systolic blood pressure
GI Gastrointestinal SC Subcutaneous
Hb Haemoglobin SCD Sickle cell disease
HIV Human immunodeficiency virus SMA Severe malarial anaemia
HR Heart rate SpO2 Oxygen saturation
HU Hydroxyurea T Temperature
ICU Intensive care unit TB Tuberculosis
IM Intramuscular VOC Vaso-occlusive Crisis
IO Intraosseous WB Whole blood
IV Intravenous WHO World Health Organization
KCl Potassium chloride
Contents
Table of Contents
1. Clinical Exam and Vital Signs ............................................................................................................... 3
1.1. Paediatric Vital Signs ........................................................................................................................ 4
1.2. The Paediatric History and Clinical Exam ....................................................................................... 10
2. Triage and ABCDE .............................................................................................................................. 17

2.1. Triage Protocol including Assessment of Emergency Signs (ABCDE) and Priority Signs ................ 18
2.2. Management of the Seriously Ill Child ........................................................................................... 23
2.3. Paediatric Early Warning System (PEWS) ....................................................................................... 38
3. Management of Syndromes and Diseases ........................................................................................ 43

3.1. Respiratory Problems and Otitis..................................................................................................... 44
3.2. Shock and Circulatory Impairment ................................................................................................. 73
3.3. Gastrointestinal Disorders .............................................................................................................. 83
3.4. Renal Disorders............................................................................................................................... 93
3.5. Metabolic Disorders ..................................................................................................................... 104
3.6. Fever and Sepsis ........................................................................................................................... 107
3.7. Blood Disorders ............................................................................................................................ 114
3.8. Neurological Disorders ................................................................................................................. 129
3.9. Bone and Joint Problems .............................................................................................................. 147
3.10. Skin Problems ............................................................................................................................. 155
3.11. Malaria........................................................................................................................................ 164
3.12. Meningitis ................................................................................................................................... 181
3.13. Tetanus ....................................................................................................................................... 187
3.14. Typhoid Fever ............................................................................................................................. 193
4. Pain Management ........................................................................................................................... 197
5. Termination of Resuscitation and Palliative Care............................................................................ 209

5.1. Termination of Resuscitation ....................................................................................................... 210
5.2. Palliative and Comfort Care .......................................................................................................... 211
6. Enteral Nutrition for Non-SAM Children (non-surgical cases) ........................................................ 215
7. Drugs, Fluid and Electrolyte Administration.................................................................................... 219

7.1. Maintenance Fluids ...................................................................................................................... 220
7.2. Potassium in Intravenous Fluids ................................................................................................... 224
7.3. How to Switch from Parenteral to Oral Antibiotics ...................................................................... 226
7.4. Amoxicillin and Clavulanic Acid .................................................................................................... 227
7.5 Antimalarials .................................................................................................................................. 230
7.6. How to give Epinephrine infusion ................................................................................................ 239
7.7. Thiamine Protocol ........................................................................................................................ 241
7.8. Midazolam and Diazepam for Sedation ....................................................................................... 242
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Contents
7.9. Phenobarbital and Phenytoin ....................................................................................................... 244

7.10. Ketamine..................................................................................................................................... 247
7.11. Oxygen Therapy .......................................................................................................................... 251
8. Procedures ....................................................................................................................................... 257

8.1. Blood Transfusions ....................................................................................................................... 258
8.2. IV Lines.......................................................................................................................................... 265
8.3. Intraosseous Access...................................................................................................................... 270
8.4. Finger Prick for Capillary Blood .................................................................................................... 277
8.5. Chest Tube Placement .................................................................................................................. 278
8.6. Decompression of Tension Pneumothorax .................................................................................. 282
8.7. Pleural Puncture ........................................................................................................................... 284
8.8. Lumbar Puncture .......................................................................................................................... 286
8.9. Paracentesis.................................................................................................................................. 290
8.10. Urine Collection .......................................................................................................................... 292
8.11. Paediatric Perfusor Use .............................................................................................................. 296
9. Appendix .......................................................................................................................................... 297

9.1. Definitions .................................................................................................................................... 298
9.2. WHO Growth Charts ..................................................................................................................... 306
9.3. Developmental Milestones .......................................................................................................... 310
2
1. Clinical Exam and Vital Signs
1.1. Paediatric Vital Signs ........................................................................................................................ 4

1.2. The Paediatric History and Clinical Exam ....................................................................................... 10
3
1.1. Paediatric Vital Signs
Initial Assessment
All vital signs must be taken and appropriately documented during the initial assessment.
Standard monitoring
Vital signs to be collected for all patients
• Heart rate (HR)
• Respiratory rate (RR)
• Oxygen saturation (SpO2)
• Capillary refill time (CRT)
• Temperature (T)
• Level of consciousness (AVPU)
Selected vital signs, depending on the child’s condition, must be regularly and frequently reassessed
and documented for as long as the child remains in the emergency department (e.g. repeated
assessment of temperature in cases of fever).
Situation-specific monitoring
The following vital signs only require assessment under specific circumstances:
• Blantyre Consciousness/Coma Scale or Glasgow Coma Scale (for a child with an altered state
of consciousness who requires additional monitoring)
• pain score (for a child who is hospitalised and/or has a painful condition [burns, other
trauma, etc.])
• systolic blood pressure (for a child in shock, with severe dehydration, etc.).
Frequency of monitoring
How often vital signs must be re-assessed depends on the severity of the case. Timing of repeated
assessments must be prescribed by a doctor. Additional specific monitoring must also be ordered by
the doctor.
If the nurse evaluating the child feels that measurement of specific vital signs is indicated, the nurse
should always perform the assessment. Nurses caring for children should know the age-appropriate
normal values for all vital signs and must alert the doctor when a vital sign is not in the normal range.
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Standard Monitoring
The following vital signs are to be taken for all children presenting to the emergency room.
Heart rate (HR)

Heart rate is obtained by feeling the wrist (radial), arm (brachial) or groin (femoral) pulse or listening
to the chest with a stethoscope. When palpating the pulse, also note the quality (strong, weak) of
distal pulses (radial, brachial or pedal [feet]) as compared to central pulses (carotid [neck] or
femoral).
Bradycardia (slow heart rate) can be a sign of hypoxemia (low oxygen), sepsis, heart disease, acidosis,
an acute intracranial hypertensive event or late stage shock. Tachycardia (rapid heart rate) can be a
sign of pain, fever, sepsis, dehydration, anaemia, shock, sepsis, medication toxicities, hypoglycaemia
or endocrine problems. See Table 1.1.1, Normal heart and respiratory rates by age, for a list of the
normal heart rates based on age.
Respiratory rate (RR)

Respiratory rate (number of breaths/minute) is obtained by counting how many times the chest or
abdomen rises in one minute. Bradypnoea (slow breathing) can be a sign of ingestion of toxins or
impending respiratory arrest. Tachypnoea (rapid breathing) can be a sign of fever, sepsis, pneumonia,
dehydration, shock or pain. Kussmaul breathing (deep and laboured breathing) can be a sign of
acidosis. See Table 1.1.1, Normal heart and respiratory rates by age, for a list of the normal
respiratory rates based on age.
Table 1.1.1 Normal heart and respiratory rates by age

HR RR
Age (Beats/min) (Breaths/min)
Tachycardia Bradycardia Bradypnoea Tachypnoea
<2 months >160 <100 <30 >60
2 to 12 months >160 <90 <30 >50
>12 months to 5 years >140 <80 <25 >40
>5 to 12 years >120 <70 <20 >30
>12 years >100 <60 <14 >20
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Oxygen saturation (SpO2)

Pulse oximetry is a non-invasive monitoring technique used to estimate the percentage of
haemoglobin that is saturated with oxygen at the time of the measurement. Hypoxemia (SpO2 <94%)
can be a sign of lung or heart disease, sepsis or shock.
If the oximeter sensor fails to detect a pulse, there are several possible causes.
• The peripheral pulse is not palpable: try another limb or the earlobe
• The extremity is cold: warm the hand or foot, then reapply the sensor
• Excessive environmental light is interfering with the light sensor: reapply the sensor or shield
it with a towel or blanket
• Movement artefact
Capillary refill time (CRT)

Capillary refill time is the time taken for blood to refill empty capillaries. Assessment of CRT is best
performed in a room-temperature environment; a cool environment can cause peripheral
vasoconstriction and alter the results.
Capillary refill times are the same in both children and adults. A CRT taken at the finger of ≥2 seconds
is considered delayed. Delayed CRT can be a sign of hypothermia, impaired circulation or shock.
To measure CRT:
1. Lift the finger to be tested to a level slightly above the heart.
2. Apply pressure to the finger by compressing gently until the skin blanches (5 seconds).
3. Release pressure from the finger and count the number of seconds until the skin colour
returns to normal. The amount of time it takes for the skin to return to normal is the CRT.
Temperature (T)
Temperature should be taken under the arm (axillary) or in the ear (auricular). The correct
thermometer should be used for the site chosen. Regardless of how the temperature is taken, record
it as taken, i.e.do not make a correction based on the thermometer/location used.
A fever (temperature greater than 37.5 degrees Celsius) may be a sign of malaria; a bacterial or viral
infection, including sepsis; or a toxic ingestion. Hypothermia (temperature less than 35 degrees
Celsius) occurs frequently in neonates and can be a sign of sepsis.
Level of consciousness
Depressed consciousness in a child can be a sign of shock, increased intracranial pressure, toxic
ingestion, severe dehydration, postictal state or sepsis. A child’s level of consciousness can be
evaluated with the following three scores: AVPU (quickest), the Blantyre Coma Scale and the Glasgow
Coma Scale.
The AVPU (Alert, Voice, Pain, Unresponsive) score is quick and easy to administer and should be used
for triage and emergencies.
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To administer the AVPU test, determine how responsive the patient is.
• A: The patient is fully awake and spontaneously responsive.
• V: The patient responds when spoken to.
• P: The patient responds when a pain stimulus is applied.
• U: The patient is unresponsive to either voice or pain stimulus.
A patient rated as A or V is considered to be in good condition. A patient rated as P or U is considered

to have altered consciousness (P) or be in a coma (U). Scores of P or U are roughly equivalent to a
Glasgow Coma Score of <8.
Situation-Specific Monitoring
Blantyre Coma Score

The Blantyre Coma Score should only be used for follow-up or inpatient monitoring.
Table 1.1.2 Blantyre Coma Score

Eye movement
1 - Watches or follows
0 - Fails to watch or follow
Best motor response
2 - Localises painful stimulus
1 - Withdraws limb from painful stimulus
0 - No response or inappropriate response
Best verbal response
2 - Cries appropriately with pain, or, if verbal, speaks
1 - Moan or abnormal cry with pain
0 - No vocal response to pain
The Blantyre Coma Score is based on 3 response components: eye movement, motor response and
verbal response. The scores for each component are added, to give a range of 0 (worst) to 5 (best).
Eye movement can only be assessed in children who are alert enough to open their eyes. Shine a
bright light into the eyes or use a visual threat to determine whether or not the child can see. If they
are able to close their eyes to avoid a bright light or to blink in response to a threat, provide a moving
visual target (e.g., the face of the examiner) to see if the child is able to follow it. Children who can
track a moving object receive a score of 1; those who cannot are scored as 0.
The first step in evaluating the motor response is to apply firm pressure to a fingernail bed and
observe the response. If there is no response or if the child extends his or her arm, the score for the
motor response is 0. If the child withdraws, pressure is then applied to the sternum or the
supraorbital ridge. If the child can localise with purposeful movement, the score is 2; if her or she can
only withdraw, the score for the motor element is 1.
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It is important to listen to the verbal response while applying painful stimuli. No response at all is
scored as 0. A moan or an abnormal cry receives a score of 1 and a normal cry or appropriate speech
(in children who are old enough to talk) is scored as 2.
Table 1.1.3 Interpretation of Blantyre Coma Scale

Score 5 = normal consciousness
Score < 3 = coma
Score 0 = deep coma
Paediatric and adult Glasgow Coma Scale (GCS)

The Glasgow Coma Scale can be used in both adult and paediatric patients. The GCS is scored using
the following equation: (Score for eye opening [1 to 4]) + (score for best non-verbal or verbal
response [1 to 5]) + (score for best motor response [1 to 6]), with a minimum score of 3 (worst
prognosis) and a maximum score of 15 (best prognosis). A score of 7 or higher indicates a good
chance of recovery, while a score of 3 to 5 is considered potentially fatal, especially if accompanied
by fixed pupils.
Table 1.1.4 Paediatric Glasgow Coma Scale (for children younger than 2 years)
1 2 3 4 5 6
Eyes Does not Opens eyes in Opens eyes in Opens eyes N/A N/A
open eyes response to response to spontaneously
painful stimuli speech
Verbal No verbal Inconsolable, Inconsolable, Cries but Smiles, orients N/A
response moans to pain cries to pain consolable; to sounds,
inappropriate follows
interactions objects,
interacts
Motor No motor Extension to Abnormal Infant Infant Infant moves
response pain flexion to pain withdraws withdraws spontaneously
(decerebrate for an infant from pain from touch or
response) (decorticate purposefully
response)
Table 1.1.5 Glasgow Coma Scale for adults and children older than 2 years
1 2 3 4 5 6
Eyes Does not Opens eyes in Opens eyes in Opens eyes N/A N/A
open eyes response to response to spontaneously
painful stimuli voice
Verbal Makes no Incomprehens Utters Confused, Oriented, N/A
sounds ible sounds inappropriate disoriented converses
words normally
Motor Makes no Extension to Abnormal Flexion/withdr Localises Obeys
movements painful stimuli flexion to awal to painful stimuli commands
(decerebrate painful stimuli painful stimuli
response) (decorticate
response)
8
Pain evaluation scales

There is no standardised pain evaluation scale that can be used in all ages or circumstances. The
EVENDOL pain scale is validated to measure acute and chronic pain in children from 3 months to 7
years. For children over 5 years, auto-evaluation is preferred if the child is able.
For a discussion of the different pain scales, assessment and treatment, refer to Chapter 4, Pain
Management.
Blood pressure (BP)

Blood pressure cuffs come in a range of sizes for adults, children and infants. Cuffs that are too small
may give falsely high readings, and cuffs that are too large may give falsely low readings. Correct cuff
size depends on arm size; the correct size is the largest cuff that will fit on the upper arm with room
underneath for the stethoscope head. Blood pressure should be measured in the right arm of a
relaxed child who is either sitting or lying.
Systolic blood pressure (SBP) can also be measured by palpation of the radial or brachial pulse. Low
systolic blood pressure, also known as hypotension, can be a sign of cardiac disease, shock,
dehydration or sepsis.
Table 1.1.6 Normal systolic blood pressure by age
Age SBP (mm Hg)*

1-2 months ≥50
>2 to 11 months ≥60
1 to 5 years ≥70
>5 to 12 years ≥80
>12 years >90
*Only the normal minimum value for systolic blood pressure as defined by age is given because
hypertension is not a common emergency problem among children.
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1.2. The Paediatric History and Clinical Exam

What follows are the principles and steps for carrying out a full paediatric history and clinical exam:
not everything will always be relevant.
Paediatric History
I. Chief Complaint
A brief statement of the primary problem, (including its duration), that caused the family to seek
medical attention.
II. History of Present Illness

Collect the age, sex and any other important identifying information about the patient, along with a
concise chronological account of the illness, including any previous treatment. In addition, note who
provides the information—the child (rarely)/mother/aunt/sister etc.
III. Past Medical History

Note any of the following:
• major illnesses (medical and surgical) and trauma: type(s) and approximate dates
• previous hospital admissions: reason for admission and approximate dates, if known
• current medications
• known allergies
• immunisation status: if vaccination card is available, document this information in the
patient’s chart.
If time allows and the information would be relevant, obtain a pregnancy and birth history
(prematurity, malaria, etc.), developmental history (see Chapter 9.4 for developmental milestone
chart) and feeding history (if breastfed and for how long; what child eats at home and how often).
IV. Review of Systems

Perform a quick review of the systems, looking for any unusual conditions or recent changes. This is
usually very abbreviated for infants and younger children.
• Weight: Any recent changes

• Skin and lymphatic system: Any new or worsening rashes, lumps, bruising and bleeding
• Head, eyes, ears, nose and throat: Any recent changes
• Cardiac: Is the patient having difficulty feeding, running or playing with other children?
• Respiratory: Is the patient having trouble breathing?
• Gastrointestinal: Any new or worsening vomiting, diarrhoea, jaundice, abdominal pain or
decrease in appetite
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• Genitourinary: Any trouble with or changes in urination

• Musculoskeletal: Any weakness or trouble walking
V. Family History
Is there any family history of illness that could be relevant to the current illness (e.g. tuberculosis or
chronic illnesses)? Are the patient’s parents and/or siblings alive? If not, what did they die of and at
what age?
VI. Social
Gather information regarding the child’s living situation and conditions.
• Are there safety issues or concerns about food security?
• How many siblings does the child have?
• Who is the primary caregiver?
• If relevant, what is the occupation of the parents?
General Approach to the Paediatric Clinical Exam

At first, simply stand back and get a general impression of the child’s overall attitude and behaviour.
Try to gather as much data as possible by observation, before touching the child. Note the position of
child (e.g. if he/she is on a parent’s lap vs. the exam table). Stay at the child’s level as much as
possible. It is crucial to understand the developmental stage’s impact on the child’s response (see
Chapter 9.4).
Order of Exam (From Least Distressing to Most Distressing)

Before beginning the exam, make sure your hands and your stethoscope are warm.
1. Observation and general impression
2. Place the stethoscope on the child’s leg and work your way up to listening to the chest
without disturbing the child (demonstrate on the parent first to show child that it does not
hurt).
3. Feel abdomen.
4. Observe extremities.
5. Examine ears and mouth (the is the most invasive and should be performed at the end).
6. If you want to observe gait, pick the child up and carry him or her a few metres from the
parent; the child will run/walk back towards the parent.
7. Examine any painful areas last. See if the child can move the area (e.g. a joint) herself first.
8. Be honest: If something is going to hurt, tell the child in a calm fashion.
Outline of a Paediatric Clinical Examination
I. Vital signs
See Chapter 1.1, Vital Signs, for detailed information.
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II. General
How does the child look overall? Is he or she alert? Breathing well? Appears well nourished? Sitting in
a caregiver’s lap and smiling, or lying on the bed without movement?
Obtain an accurate weight, height and temperature.
How “generally sick” does the child look? The specifics of the examination should be tailored to how
sick the child is. In emergency situations, perform ABCD (Chapter 2.2) first. After the child has been
stabilised, perform a full examination. This is especially important in sick children as they may have
more than one pathology.
III. Skin and lymphatic system

Check for the following:
• rashes, petechiae, jaundice or turgor
• lymph node enlargement, location, mobility and consistency
• any scars or injuries.
IV. Head
• Examine the hair, noting colour and quality (check for evidence of kwashiorkor).
• Check to see if the fontanel is bulging or sunken.
V. Eyes
• Examine the general appearance of the eyes for any potential issues (e.g., xerophthalmia).
• Do the eyes demonstrate appropriate movement (e.g., following objects)?
• Are the pupils round, reactive to light and equal in size?
• Examine the conjunctiva.
VI. Ears
Visualise the tympanic membranes with an otoscope.
VII. Nose
Check for any discharge, noting the colour, smell, etc. if relevant.
VIII. Mouth and throat

• Examine the lips, tongue and teeth for any injury or deformity.
• Look at the tonsils, noting the size, colour and any exudates.
• Check the posterior pharyngeal wall (back of throat) and note the colour.
IX. Neck
Note the general appearance, as well as the presence or absence of nuchal rigidity.
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X. Lungs/thorax
Inspection
• Note the pattern of breathing (is the child breathing comfortably, or does he or she appear
to be struggling to breath). Note that abdominal breathing and periodic breathing (pause <15
seconds) are normal in small infants.
• Record respiratory rate (see Chapter 1.1, Vital Signs).
• Note the use of accessory muscles or chest indrawing, including the degree and location of
retraction, and if nasal flaring is present.
Auscultation
When listening to the lungs, pay attention to the following:
• Are breath sounds equal in both lungs?
• Note the presence of rales, wheezes or rhonchi; upper airway noise; or transmitted voice
sounds.
Percussion
Percuss over the chest. Normally the sound should be resonant, like percussing a drum. Dullness
replaces resonance in consolidated lung from pneumonia, empyema or pleural effusion. To increase
the likelihood of detecting an empyema, have the child sit up and percuss the back.
XI. Cardiovascular
Pulses
Check the pulse in multiple locations, noting the quality (weak/strong) in both the upper and lower
extremities.
Auscultation
Listen to the heart and note the heart rhythm and any murmurs. Pay close attention to the quality of
heart sounds, as very quiet sounds may indicate pericardial effusion.
XII. Abdomen
• Start with a visual inspection, checking for wounds, infections, hernias or distension.
• Listen for bowel sounds.
• Palpate the abdomen, noting tenderness (avoid tender area until the end of the exam),
rebounding or guarding. Be sure to examine the liver, spleen and kidneys (tap over the flanks
if you suspect pyelonephritis).
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XIII. Musculoskeletal
A detailed musculoskeletal exam is only necessary if a related concern is discovered in the child’s
history. However, if possible, always have the child walk, as a very sick child will be unable to walk.
• Examine the back for kyphosis, lordosis or scoliosis.
• Examine the joints (range of motion, stability, any swelling or tenderness) and muscles.
• Check the extremities for the following:
- Deformity
- Symmetry
- Oedema
- Clubbing
• Observe the child’s gait and note any limping.
XIV. Neurologic
Perform a brief neurological exam on all children. Most of the exam can be accomplished through
observation alone: How does the child look? Alert? Happy? Interested in his or her surroundings?
Somnolent? Weak? Tired? Extremely fatigued? Gazing into space, too ill to interact?
Determining the child’s muscle tone and strength is the most important part of the exam. If the child
is lying on the bed, lift them gently by the arms and, if older than 6 months, attempt to have them sit.
Is there head lag? Is the child too weak to sit? Is the child stiff? Does he or she resist the examiner
because of pain? Is the child unable to hold up his or her head up because of illness or weakness?
Deep tendon reflexes should also be tested.
A full neurologic examination should be performed if there is a need to assess neurologic disability. If
possible, perform most of the examination while the child is seated in the parent's lap, deferring
uncomfortable and anxiety-provoking procedures until the end of the session.
Perform a developmental assessment.
Cranial nerve examination

I: Check that the child has a working sense of smell.
II: Test the child’s vision by placing an object in front of the child and see if he or she reaches for it.
For older children, ask the child to read.
I and III: Check if the pupils react to light by shining a bright light in the child’s eye; the pupil should
constrict. Perform a fundoscopic exam with an ophthalmoscope if trained in the procedure.
III, IV and VI: Have the child follow your finger with only his or her eyes (no head movement). If the
child’s eyes do not follow your finger, there may be paralysis of one of the cranial nerves.
V: Test if the child can feel you lightly touching his or her cheek with your finger. Ask the child to bite
down.
VII: Check facial symmetry. An asymmetric face indicates nerve dysfunction.
VIII: Test the child’s hearing by speaking softly into his or her ear. Poor head control, unsteadiness,
gait ataxia, nausea or vomiting may indicate dysfunction.
14
IX and X: Test swallowing and for a gag reflex.

XI: Have the child shrug his or her shoulders.
XII: Ask the child to stick out his or her tongue.
Motor system
Test strength by asking the child to push and pull against you with his or her arms and legs. Note any
trembling, weakness or asymmetry.
Sensation
Test if the child feels light sensation and hot or cold on all parts of his or her body (if old enough to
cooperate).
Reflexes
Test the child’s patellar reflex by tapping the patellar tendon with a reflex hammer. Ask the child to
walk, sit and stand on one leg. Note any abnormalities.
XV. Genitourinary tract

Visually examine the external genitalia. Note any hernias, hydroceles (accumulation of fluids inside
scrotum) or instances of cryptorchidism (absence of one or both testes from the scrotum).
Rectal and pelvic exams are not routinely performed, although special indications may exist.
15
16
2. Triage and ABCDE
2.1. Triage Protocol including Assessment of Emergency Signs (ABCDE) and Priority Signs ................ 18
2.2. Management of the Seriously Ill Child ........................................................................................... 23
2.3. Paediatric Early Warning System (PEWS) ....................................................................................... 38
17
2. Triage and ABCDE
2.1. Triage Protocol including Assessment of

Emergency Signs (ABCDE) and Priority Signs
Triage is the process of rapidly screening each child immediately upon arrival and evaluating him or
her for any potentially serious illnesses or injuries. After evaluation, each child is assigned to one of
three clinical priorities and provided with a colour-coded card.
Table 2.1.1 Triage priority categories
Category Procedure
Red: Emergency signs of an • The child is immediately admitted to the medical care zone
immediately life-threatening to be stabilised and treated by the doctor.
situation are present.
• Child should be given priority in the queue so that he or

she can be admitted to the medical care zone after all red
Yellow: Priority, though not
cases have been resolved.
immediately life-threatening, signs
• The child can wait up to 1 hour to see the doctor.
are present.
• The child must be reassessed every 20 minutes to ensure
that they do not progress to the red category.
• The child is admitted to the medical care zone after all red
or yellow cases have been resolved.
Green: Neither emergency nor • The child can wait up to 4 hours to see the doctor.
priority signs are present. • The child must be reassessed every 60 minutes to ensure
that he or she does not progress to either the red or yellow
categories.
Assessment and Categorisation

The first step of triage is to evaluate the child and determine if he or she has any emergency or
urgent health issues that require immediate attention.
The initial assessment should be performed as quickly as possible and should involve taking vital
signs (temperature, HR, RR, CRT and SpO2) and creating a medical record sheet for the patient.
Depending on the situation, vital signs can be taken either in triage or in the yellow or red areas.
Gather a brief history of the present illness, including the chief complaint, symptoms and duration.
From the vital signs and history, determine if there are any emergency or priority signs.
18
2.1. Triage Protocol
Emergency Signs
Children presenting with emergency signs should be categorised as level red; they must be treated
immediately and reassessed at least every 10 minutes for any changes in their condition. During the
primary assessment, as soon as an emergency sign has been identified, stop the evaluation and
immediately treat the patient in a designated emergency area/room, according to Chapter 2.2. (Note
that although Chapter 2.2 follows this chapter, assessment and resuscitation take place
simultaneously). In addition, call for help so that you can continue with the evaluation while
simultaneously providing treatment.
Table 2.1.2 Emergency signs (ABCD)

Airway (A) Manage Airway
Complete or Partial Airway Obstruction Call for help
The following signs suggest that the upper airway is • Support or open airways
obstructed: • Consider an oropharyngeal airway if
• Increased inspiratory effort with retractions significant obstruction and impaired
• Abnormal inspiratory sounds (snoring or stridor) consciousness
• Episodes where no airway or breath sounds are • Suction as needed
present despite respiratory effort • Remove visualised foreign body
(See Chapter 2.2 for information regarding airway
management)
Breathing (B) Manage Breathing
Absent/laboured breathing • Administer O2
Cyanosis (blue lips, tongue and fingertips. NB. If the child is • Support ventilation as needed
anaemic, he or she may not be cyanosed even if hypoxic) • Give inhaled medication as needed
Severe respiratory distress - one of the following:
• Nasal flaring • If suspicion of tension pneumothorax,
• Abnormal positioning immediate decompression (see Chapter 8.6)
• Accessory muscle use (nodding)
• Severe indrawing
• Abdominal breathing
• Grunting
Circulation (C) Manage Circulation
Shock criteria are all 3 of: • Stop any bleeding
• Cold extremities • Administer O2
• Weak OR fast (or slow) pulse • Ensure vascular access (IV/IO)
• CRT > 3 seconds
Severe dehydration criteria (in context of fluid lose) are 2 or • Follow specific protocols for shock or severe
more of: dehydration
• Lethargy or unconsciousness
• Sunken eyes
• Unable to drink or drinks poorly
• Skin pinch goes back very slowly (≥ 2 s)
Disability (neurological status) (D) Manage coma and convulsion
Coma (AVPU) • Administer O2
Convulsion • Ensure vascular access (IV/IO)
• Check glucose and treat hypoglycaemia if
present
• Administer diazepam if convulsion is present
• Put patient in recovery position
• Check malaria and Hb as needed
Note: Our ABCD is different to WHO’s ABCD (WHO has Airway, Breathing, Circulation, then a 2nd “C”
for Coma, Convulsions, Confusion, then D for (severe) Dehydration).
19
2. Triage and ABCDE
An additional area of focus, Exposure (E), is sometimes included in the primary assessment (ABCDE).
Table 2.1.3 Completion of primary assessment
Exposure (E) • Treat hypothermia (survival blanket)

Hypothermia • Treat fever according protocol
Hyperthermia/Hyperpyrexia • Treat burns according protocol
Bleeding
Petechiae/purpura (signs of septic shock)
Trauma
Burns
Rashes
Consider patients who present with any of the following as category red cases:
• severe trauma (high-energy trauma or poly-trauma)
• severe burns
• contagious diseases (determine the presence of contagious diseases, such as measles; infectious
diarrhoea, such as cholera; or suspected viral haemorrhagic fever to isolate the child).
Once ABCDE has been performed and any emergency signs have been addressed, you can begin the
secondary assessment. (A second medical professional can also perform the secondary assessment
concurrently with any interventions.)
Priority Signs
If no emergency signs are found, continue the evaluation and check for any of the following priority
signs to identify children who are at higher risk of dying. These children should be classified as level
yellow, reassessed every 20 minutes and treated after all red cases have been resolved and without
unnecessary delay.
• Tiny baby: any sick infant younger than 2 months
• Temperature >39 degrees Celsius or <36 degrees Celsius
• Trauma or other urgent surgical/postoperative condition
• Poisoning (history of)
• Pain (severe)
• Pallor (severe) and signs of severe anaemia
• Respiratory distress (milder than red case; for example: rapid breathing, cough)
• Restless, continuously irritable or lethargic
• Referral from a different structure
• Malnutrition: visible severe wasting/oedema of both feet
• Burns (less severe than red category)
• Moderate dehydration (in context of fluid loss) ≥2 of the following signs:
- restlessness, irritability
- sunken eyes
- drinks eagerly, thirsty
- skin pinch goes back slowly
20
2.1. Triage Protocol
Non-urgent Signs
If neither emergency nor urgent/priority signs are present and the child appears stable, he or she
should be classified as level green. These patients can wait up to 4 hours to receive treatment and
should be re-assessed every 60 minutes.
Procedures and Organisation of Triage
Setting up the Triage Area

When designing a triage area, be sure to consider the following:
• The waiting room should have ample seating for patients and families. Ideally, children and
their parents should wait in an area separate from the adult waiting area.
• Toilets must be available.
• Ensure the spatial organisation of the site allows for regular patient flow.
• Separate areas must be set up for red, yellow and green patients.
• Depending on the setting, the triage nurse may give red, yellow or green cards depending on
the priority level assigned.
• In very busy settings, two people may be needed for triage: a “meet and greet nurse” for
initial evaluation and immediate triage and a second clinician for vital signs, height and weight.
• An examining table is needed to weigh, measure and assess the child
• The nurse must have easy access to and a clear view of patients arriving and in the waiting room.
The following personnel are the minimum required to staff a triage zone:
• one nurse or doctor for triage, whose decisions are final (he or she assigns the
red/yellow/green cards to the patients)
• one secretary for registering the patients
• one nurse to provide first aid
• one maintenance/hygiene person.
Table 2.1.4 Necessary equipment for triage areas
Hand-washing facility and gloves

Registration/log book and writing paper
Tally sheet
Coloured cards (red, yellow, green)
Drinking water or 5% to 10% sugary drinking water and cups
Oral rehydration solution
Phone for basic communication to treatment areas or physician
Scale
Table for measuring length
IV/IO equipment and IV fluids
MSF protocol books
Equipment for taking vital signs (thermometer, stethoscope, pulse oximeter, etc.)
Point of care tests (haemoglobin, malaria, glucose, etc.)
IV poles
Emergency medications for the treatment room or emergency treatment area
21
2. Triage and ABCDE
Important note
Triage is a dynamic process. Patients need to be re-evaluated regularly, irrespective of their

initial classification.
A patient who was initially classified as green will receive priority treatment after four hours of
waiting, even if his or her condition remains at green after several evaluations during this
waiting period.
22
2.2. Management of the Seriously Ill Child

The initial impression serves to quickly identify life-threatening conditions and immediately begin life
support interventions. It is performed within the first few seconds of assessment, before you even
touch the child.
Assess:
• Consciousness (responsive or unresponsive)
• Breathing (not breathing, breathing with or without respiratory distress)
• Colour (cyanotic, pallor, pink, bleeding)
Is the child unresponsive with no breathing or only gasping?
• Yes: Start CPR (see Figure 2.2.1, CPR algorithm)
• No: Follow Evaluate – Identify – Intervene sequence
Figure 2.2.1 CPR algorithm
Unresponsive
Not breathing or only gasping
Shout for help • Give 1 breath every 3 seconds

• Give oxygen
• Add compressions if pulse
Open airway ± give 2 breaths remains < 60 beats/min with
poor perfusion despite adequate
Check pulse (take ≤ 10 seconds) Definite oxygenation and ventilations
pulse • Recheck pulse every 2 minutes
No pulse
One rescuer: Begin cycles of 30 compressions and 2 breaths
Two rescuers: Begin cycles of 15 compressions and 2 breaths
CPR 2 minutes High Quality CPR

Adrenaline IV/IO every 3-5 minutes • Rate at least 100 compressions/min
0.1mL/kg (1:10000) • Compression depth to at least 1/3
Treat reversible causes* anterior-posterior diameter of chest,
about 4cm in infants and 5cm in
children
• Allow complete chest recoil after each
• Stop CPR if the child recovers
compression
• Stop CPR after 10 minutes if no pulse
• Minimise interruptions in chest
• Stop CPR after 30 minutes if pulse is
compressions
present but no breathing
• Avoid excessive ventilation
*Reversible causes: Hypovolaemia, hypoxia, hypoglycaemia, hypothermia, hypo- or hyperkalemia, acidosis,

tension pneumothorax, cardiac tamponade, toxins, thromboembolism
23
2. Triage and ABCDE
Evaluate – Identify – Intervene Sequence

If the child is responsive, begin this sequence. During the evaluation portion, you will be able to
identify the type and severity of the problem(s) and intervene appropriately. This is an ongoing
process. Remember that several steps are often performed at the same time (for example, the
evaluation of airways and breathing).
Primary Assessment
Primary assessment is based on the ABCDE (see Chapter 2.1), a rapid approach to evaluate
respiratory, circulatory and neurologic function. This step includes assessment of vital signs and pulse
oximetry. The aim is to support the vital functions (respiratory, circulatory and neurologic) and
stabilise the patient.
Evaluation of Airway (A)

Assess the airway to determine whether it is open and clear or obstructed.
• Look for movement of the chest or abdomen.
• Listen for bilateral breath sounds and air movement.
• Feel for movement of air at the nose and mouth.
A clear airway is one that is open and unobstructed for normal breathing. If there is some airway
obstruction, decide if the airway is maintainable or not maintainable.
• Maintainable: Airway is obstructed but can be opened (maintained) by simple measures (in
cases of coma, partial upper airway obstruction, etc.)
• Not maintainable: Airway is obstructed and cannot be maintained without advanced
interventions (for example, complete upper airway obstruction)
If you think that the airway is obstructed, decide where the obstruction is located. Signs that suggest
the upper airway is obstructed include the following:
• Increased inspiratory effort with retractions
• Abnormal inspiratory sounds (snoring or stridor)
• Decreased air movement despite increased respiratory effort
Management of airway (A)

Depending on the results of your evaluation, the following actions could be taken:
• Support airways: Allow the child to assume a position of comfort or elevate the head of the
bed
• Simple manoeuvres
- Head tilt–chin lift
- Jaw thrust (if suspected cervical spinal injury)
- Suctioning
- Airway adjuncts (oral airway)
• Advanced intervention (note: intubation is not always possible in MSF settings)
24
How to position the child

Neutral position in infants (younger than 1 year) and slight head extension (sniffing position) in older
children (older than 1 year) is recommended.
Place the child on his or her back. Flex the child’s neck forward at the level of the shoulders while
simultaneously tilting the head and lifting the chin. Position the opening of the external ear canal at
the level of, or in front of, the anterior aspect of the shoulder while the head is extended. Avoid
hyperextending the neck because this may obstruct the airway
Sniffing position (> 1 year old) Neutral position (< I year)
Head tilt-chin lift

To relieve upper airway obstruction, the clinician uses two hands to extend the patient's neck. While
one hand applies downward pressure to the patient's forehead, the tips of the index and middle
fingers of the second hand lift the mandible at the chin, which lifts the tongue from the posterior
pharynx. The head tilt–chin lift may be used in any patient in whom cervical spine injury is not a
concern.
Head tilt–chin lift into sniffing position

(>1 year)
25
2. Triage and ABCDE
Jaw thrust (if suspected cervical spinal injury)

The rescuer uses two or three fingers of each hand to lift the jaw upward and outward so that the
lower central incisors are anterior to the upper central incisors. In children with traumatic injuries,
the cervical spine must be maintained in a neutral position during this manoeuvre.
Suctioning
Suctioning should be performed with caution and only if necessary. Suctioning can cause laryngospasm
and apnoea in children.
Suction the nose and oropharynx (if secretions are present) and remove a visualised foreign body (if
it is easy to remove). Never perform a deep suction.
Airway adjuncts
An oral airway can be used in an unconscious child to lift the tongue and pharyngeal soft tissues off
of the posterior pharynx to maintain a patent airway.
26
To choose the correctly sized oral airway, hold

it along the side of the child's face with the
flange at the corner of the mouth. The tip of
the airway should reach the angle of the
mandible. It should be inserted using a tongue
depressor to push the tongue to the floor of
the mouth to avoid pushing the device into the
base of the tongue.
Evaluation of breathing (B)

Assess breathing by evaluating the following:
• Respiratory rate and pattern (see Chapter 1.1, Vital Signs)
- Tachypnoea (fast breathing)
- Bradypnoea (slow breathing)
- Irregular breathing (Kussmaul, etc.)
• Respiratory effort
- Nasal flaring
- Retractions (subcostal, substernal, intercostal, etc.)
- Head bobbing and seesaw respiration
• Chest expansion (symmetrical/asymmetrical)
• Air movement in the lungs (present/absent)
• Lung and airway sounds (stridor, snoring, hoarseness, grunting, wheezing, crackles)
• Oxygen saturation by pulse oximetry (normal SpO2 >94%)
27
2. Triage and ABCDE
After your assessment, try to identify the type and severity of the respiratory problem.
Types of respiratory problems

• Upper airway obstruction (croup, foreign body)
• Lower airway obstruction (asthma, bronchiolitis)
• Lung tissue disease (pneumonia)
• Disordered control of breathing (poisoning, trauma)
Signs of moderate respiratory distress may vary in severity, but include the following:
• increased respiratory rate
• increased respiratory effort (indrawing)
• abnormal airway and lung sounds (stridor, wheezing)
• tachycardia
The patient is in severe respiratory distress if he or she demonstrates one or more of the following:
• cyanosis
• low oxygen saturation (<90%) despite high-flow oxygen
• very laboured breathing
• gasping
• very severe indrawing
• nasal flaring
• grunting
• head nodding
• bradycardia (ominous)
• decreased level of consciousness.
Management of breathing (B)

The primary goal for initial management of a child in respiratory distress is to support or restore
adequate oxygenation and ventilation. Depending on the results of your evaluation, the following
actions could be taken:
• manage the airways (see previous)
• assist ventilation with bag-mask device as needed
• provide oxygen as needed (see Chapter 7.10)
• administer medication (salbutamol, adrenaline, etc.) as needed
• monitor SpO2
• ensure vascular access (IV/IO) and support the circulatory system as needed
• look for the cause(s) of the distress and treat accordingly (foreign body, croup, asthma,
pneumonia, etc.)
28
Bag-and-Mask Ventilation (with self-Inflating bag)

A bag-mask device consists of a ventilation bag and a
facemask. Bag-and-mask ventilation is used for
resuscitation or anaesthesia only. It can be used with
or without an oxygen source.
The mask should be used with a filter reservoir bag

and the oxygen supply attached to the back of the
bag. Masks and valves should be cleaned and
decontaminated or sterilised between each patient
(please refer to MSF procedures manual).
For ventilation to be effective with a bag-mask device, you must know how to select the facemask,
prepare the ventilation bag and provide supplementary oxygen if needed.
First, select a facemask that extends from the bridge of the child’s nose to the cleft of the chin,
covering the nose and mouth but not compressing the eyes.
Second, select the correct self-inflating bag with reservoir.
Use a self-inflating bag with a volume of at least 450 to 500 mL for infants and young children.
Smaller bags may not deliver an adequate volume of oxygen. In older children or adolescents, you
may need to use an adult self-inflating bag (1000 mL or larger) to provide effective ventilation.
Remember to check it before use to ensure proper function.
29
2. Triage and ABCDE
How to perform single-person bag-mask ventilation

1. Open the airway and make a seal between the mask and the face; in the absence of suspected
cervical spine injury, tilt the head back.
Head tilt–chin lift into sniffing position (>1 year)
For children < 1 year perform head tilt-chin lift neutral position.
2. Use the E-C clamp technique to lift the jaw against the mask, pressing and sealing the mask on
the face. The third, fourth and fifth fingers of one hand (forming an “E”) are positioned along the
jaw to lift it upwards. Next, the thumb and index finger of the same hand (forming a “C”) make a
seal to hold the mask to the face. Avoid pressure on the soft tissues underneath the chin because
this can push the tongue into the posterior pharynx, resulting in airway compression and
obstruction.
3. With the other hand, squeeze the ventilation bag until the chest rises. Deliver each breath over 1
second. Make sure the chest rises with each breath. Avoid excessive ventilation.
4. Place a nasogastric tube open to air if you need to ventilate for an extended period of time.
5. Continue to monitor vital signs and SpO2 during ventilation.
30
Treating causes of distress: foreign body (choking)

Choking is characterised by the sudden onset of respiratory distress associated with coughing,
gagging or stridor.
Suspect choking caused by a foreign body if:

• The onset was very sudden.
• There are no other signs of illness.
• There are clues to alert the rescuer: for example, a history of eating or playing with small
items immediately prior to the onset of symptoms.
First, assess the severity:
If the child is coughing effectively, then no external manoeuvres are necessary. Encourage the child
to cough and monitor continuously.
If the child’s coughing is, or is becoming, ineffective, shout for help immediately and determine the
child’s conscious level. (See Figure 2.2.2, Choking algorithm.)
Table 2.2.1 Ineffective versus effective cough

Ineffective coughing Effective cough
Unable to vocalise Crying or verbal response to questions
Quiet or silent cough Loud cough
Unable to breathe Able to take a breath before coughing
Cyanosis Fully responsive
Decreasing level of consciousness
31
2. Triage and ABCDE
Figure 2.2.2 Choking algorithm
Effective cough*/capable of speaking

Yes
Conscious
No Yes
5 back blows
Open airway Encourage coughing
See diagram on next page
5 chest thrusts or
Bag and mask abdominal thrusts
Do not give back blows
Give 5 breaths (according to age)
See diagram on next page
Check for foreign body

Assess and repeat Reassess continuously
Begin CPR
* Effective cough means that the child is moving air and that a cough can be heard.
Coughing is the most effective way to dislodge a foreign body, so do not interfere.
32
Conscious child with choking

If the child is still conscious but has an absent or ineffective coughing, give five back blows. If back
blows do not relieve choking, give five chest thrusts (to infants) or five abdominal thrusts (to
children).
External manoeuvres for infants (< 1 year)
External manoeuvres for children (> 1 year) without effective cough/incapable of speaking
33
2. Triage and ABCDE
Unconscious child with choking
• Place him or her on a firm, flat surface.

• Call for help.
• Do not leave the child at this stage.
• Open the airway.
- Open the mouth and look for any obvious object.
- If one is seen, make an attempt to remove it with a single finger sweep.
- Do not attempt blind or repeated finger sweeps.
• Rescue breaths:
- Open the airway and attempt five rescue breaths.
- Assess the effectiveness of each breath: If a breath does not make the chest rise,
reposition the head before making the next attempt.
• If there is no response, immediately begin CPR.
Evaluation of Circulation (C)

Assess circulation by evaluating the following:
• Heart rate (see Chapter 1.1, Vital Signs)
• Pulses (both peripheral and central)
• Capillary refill time
• Skin colour and temperature (cold skin, pallor, cyanosis, etc.)
• Blood pressure (see Chapter 1.1, Vital Signs)
The child’s level of consciousness will help you evaluate blood flow to the brain. Urine output can
also help you evaluate blood flow to the kidneys. Use your evaluation to identify signs of poor
perfusion: weak peripheral pulses, delayed capillary refill time, changes in skin colour (pale, mottled
or cyanotic), cool skin, decreased level of consciousness and decreased urine output.
There are two types of pulses: central and peripheral.

• Central pulses include femoral, axillary, brachial, carotid
• Peripheral pulses include radial, dorsalis pedis and posterior tibial.
Axillary or brachial (for children

younger than 1 year)
Carotid (for children older than 1

year)
34
In shock, blood flow (i.e., perfusion) often decreases. The decrease in perfusion starts in the hands
and feet with the loss of peripheral pulses. It then extends toward the trunk, with eventual
weakening of central pulses. A cold environment can also constrict the blood vessels.
Capillary refill time (CRT)

Capillary refill time is the time it takes for blood to return to tissue that has been blanched with
pressure. Normal capillary refill time (beyond newborn age) at the finger is ≤ 3 seconds. Capillary
refill reflects circulation to the skin. Abnormalities in capillary refill may indicate problems with
peripheral perfusion. To evaluate capillary refill:
1. Lift the child’s finger slightly above the level of the heart.
2. Press on the skin (soft pad) of the finger for 5 seconds, then release.
3. Count the number of seconds until the skin colour returns.
Causes of delayed or prolonged CRT include dehydration, shock and hypothermia.
Skin colour and temperature

When blood flow decreases (poor perfusion), the hands and feet are typically affected first. They may
become cool, pale, mottled or cyanotic. If the condition worsens, the skin over the arms, legs and
trunk will then become cool with poor colour.
Blood pressure
Always check blood pressure in all critical patients.
Hypotension in the child is a sign of severe shock (decompensated shock). In the very young child, it
might be helpful to use an automatic/electric blood pressure machine with age-appropriate cuff to
ensure accurate readings.
After your assessment, try to identify the type and severity of the circulatory problem.
Shock criteria are all 3 of:

• Cold extremities
• Weak OR fast (or slow*) pulse
• CRT >3 seconds
*Bradycardia may be a feature of pre-terminal shock.
If signs of shock are present, attempt to determine the type of shock.

• Hypovolaemic shock:
- Shock + signs of severe dehydration
- Shock + bleeding/haemorrhage
• Septic shock: Shock + sepsis (without severe dehydration)
• Anaphylactic shock: Shock + allergen exposure
• Cardiogenic shock: Shock + cardiac disease
Degrees of shock (in reality a continuum):

• Compensated shock (blood pressure is normal for the age)
• Decompensated or hypotensive shock (blood pressure is low for the age)
• Cardiac arrest (see CPR protocol)
35
2. Triage and ABCDE
In shock, hypotension is a pre-terminal event: the patient could die within minutes.
Look for signs of severe dehydration (in context of fluid loss) – two or more of the following:
• lethargy or unconsciousness
• sunken eyes
• unable to drink or drinks poorly
• skin pinch goes back very slowly (≥ 2 seconds)
Management of circulation (C)

If no central pulse after 10 seconds, OR if the pulse is < 60 beats/minute with signs of poor perfusion,
despite adequate ventilation and oxygenation, add chest compressions.
Chest compressions in Infants

The technique for chest compressions in infants is slightly different to that in older children.
Two-finger chest compression technique in infant
Two-thumb encircling hands chest compression in infant (two-person technique)
The immediate goal when managing shock is to support the circulatory system to improve perfusion.
• If the patient is in haemorrhagic shock, immediately stop any bleeding.
• Provide high-flow oxygen with a non-rebreathing mask, if available.
36
• Ensure vascular access (IV/IO). Do not waste time looking for a vein (allow 90 seconds before
going to IO).
• Check glucose, Hb and RDT (if in endemic malaria area).
• Follow shock protocol
• Reassess ABCD at least every 10 minutes until the patient is stable.
• Look for the causes of shock.
Evaluation of disability (D)
The disability assessment is a quick evaluation of neurologic function. Clinical signs of brain function
are important signs of poor perfusion and oxygen delivery, linked to respiratory problems
(respiratory distress), circulatory problems (shock) or both.
You should note the child’s level of consciousness, muscle tone and pupil response to light. A sudden
or severe decrease in oxygen delivery in the brain may produce a decreased level of consciousness,
seizures, loss of muscle tone and decreased pupil response to light.
Evaluate disability using the following:

• AVPU Paediatric Response Scale (see Chapter 1.1, Vital Signs)
• Response of pupils to light
• Blood glucose test
Management of disability (D)

Neurologic functions are linked to respiratory and circulatory functions. Depending on the results of
your evaluation, the following actions could be taken:
• support the respiratory system as needed
• support airways
• provide oxygen and assist ventilation as needed
• support the circulatory system as needed
• ensure vascular access (iv/io)
• administer fluid bolus if shock is present
• check glucose
• administer diazepam if child is having seizures (see seizure protocols)
• look for the causes (see altered level of consciousness protocol).
Secondary Assessment
Complete the secondary assessment with a focused medical history, using the SAMPLE mnemonic as
a guide.
SAMPLE stands for:

• Signs and symptoms
• Allergies
• Medication
• Past medical history
• Last meal
• Events leading to presentation
At the end of the history taking, perform a complete physical examination.
37
2. Triage and ABCDE
2.3. Paediatric Early Warning System (PEWS)

The Paediatric Early Warning System (PEWS) is a scoring system for sick children to facilitate
observation by the medical staff. It serves to reduce the incidence of life-threatening events by
anticipating critical complications before they occur.
Benefits
• Reduce incidence of emergency resuscitation (resulting from respiratory arrest/cardiac
arrest/shock) via early detection of warning signs and implementation of treatment
• Reduce morbidity and mortality associated with respiratory/cardiac arrest and shock
• Detect children at risk of deterioration during their hospital stay
• Improve objectivity of criteria for medical evaluation
• Improve interaction among paediatric services/staff
• Provide concrete evidence of clinical changes in the form of a score, which in turn empowers
nurses to overcome barriers, communicate their concerns and take action
• Provide less-experienced nurses with helpful age-based reference ranges for vital signs of
hospitalised children
Limitations
• In some patients, the PEWS may not help with decision-making. This includes patients who
are very stable and have a low likelihood of deterioration, patients with abnormal physiology
at baseline who consistently have very high PEWS scores and patients experiencing
neurologic deterioration.
• Personnel need to be trained in order to implement it correctly.
• Initially, PEWS can slow down nursing activities.
Figure 2.3.1 The PEWS concept
Death 1 hour
Cardio pulmonary arrest
Identify Intervene
Increased care needs
Severity of Illness
Routine care needs
Time
PEWS consists of three assessment categories (neurologic status [level of consciousness],
cardiovascular and respiratory), with each category scored on a scale from 0 to 3 based on the
patient’s vital signs (see Table 2.3.1, PEWS scoring). Higher scores represent poorer patient status.
38
Table 2.3.1 PEWS scoring

Score 0 1 2 3 Total
Category
Neurologic status (level Playing, smiling, Irritable but Irritable and Lethargic, _/3
of consciousness—AVPU) alert consolable inconsolable confused or in
(A in AVPU) coma
Abnormal Abnormally
behaviour somnolent Reduced
(A in AVPU) (V in AVPU) response to pain
(P or U in AVPU)
Cardiovascular (colour, Pink/good colour Pale Grey Grey and _/3
capillary refill time [CRT] and CRT 1–2 seconds mottled
and heart rate) CRT ≥3 seconds CRT >4 seconds
CRT >5 seconds
Tachycardia <20 Tachycardia
beats/min 20–30 beats/min Tachycardia of
above normal above normal >30 beats/min
parameters parameters above normal
parameters or
bradycardia
Respiratory Respiration and RR RR >10 RR >20 RR below _/3
(respiratory rate [RR], normal, no breaths/min breaths/min above normal
respirations and retractions and above normal normal parameters parameters
oxygen saturation) no signs of parameters,
respiratory distress Moderate
Using accessory retractions
muscles, mild Severe
retractions retractions or
SpO2 <90% grunting
SpO2 90%–95%
Oxygen needs <3 SpO2 <80%
L/min
Oxygen needs
>3 L/min
-
Central cyanosis
Total score (neurologic + cardiovascular + respiratory) _/9
Give 2 extra points for every 15 minutes of nebulization or in cases of persistent vomiting after any surgical
intervention.
One single criterion in each cell is enough to give the corresponding points.
Adapted from: Monaghan, A. (2005). Detecting and managing deterioration in children. Pediatric Nursing, 17, 32–35.
Actions based on PEWS score will vary depending on location. For regular MSF projects with inpatient
paediatric capacity, follow the comprehensive PEWS guidelines (Table 2.3.2). For emergency MSF
projects, follow the simplified PEWS guidelines (Table 2.3.3). These actions should be tailored
according to the project and the services existing at the project.
39
2. Triage and ABCDE
Table 2.3.2 Comprehensive PEWS guidelines
Score Colour Action

0–2 points Green No other intervention needed.
Take vital signs as per protocol in the service (at least four times per day).
3 points Yellow Nurse must notify his or her supervisor.
Treatment must be verified.
Take vital signs four times per day (every 6 hours).
4 points Yellow Nurse must notify his or her supervisor and the treating doctor.
Treatment must be verified and vital signs charts have to be reassessed.
Take vital signs six times per day (every 4 hours).
5 points Orange Nurse must notify his or her supervisor and the treating doctor.
Patient has to be revaluated clinically, along with medical indications and
vital signs. Take vital signs eight times per day (every 3 hours).
Patient should be located in a medicalised ward (e.g., not in Nut phase).
6 points Orange Nurse must notify his or her supervisor and the treating doctor immediately.
The doctor has to revaluate the patient and indications, and the nurse has to
revaluate vital signs.
Patient should be placed in an intermediary care unit or ward within 30
minutes.
Reassess clinical history in the new patient location.
Take vital signs 12 times per day (every 2 hours).
>7 points Red Patient to be transferred immediately to the intensive care unit (ICU) or
emergency ward (ER) within 5–10 minutes.
The nurse’s supervisor and the attending doctor are informed of the transfer
after the patient has been received in the ICU.
Take vital signs before transfer and at admission to the ICU.
Maintain vital signs frequency as per protocol in the ICU (every 1 or 2 hours).
40
Table 2.3.3 Simplified PEWS guidelines
Score Colour Action

0–2 points Green No additional intervention needed outside of regular medical indications.
Take vital signs six times per day (every four hours).
3–5 points Orange Nurse must notify his or her supervisor.

Treatment must be verified and vital signs charts have to be reassessed.
Take vital signs eight times per day (every three hours).
>6 points Red Transfer the patient to the intensive care unit.
Nurse must notify his or her supervisor.
The patient must be clinically assessed and his or her treatment verified.
Take vital signs 12 times per day (every 2 hours).
Notify your supervisor if you see that a child’s PEWS score has increased more than three points in the last 24 hours.
Figure 2.3.2, PEWS form: 3–11 months, provides an example of age-specific PEWS scoring. For a full
set of PEWS charts according to age, please see Chapter 9.5, PEWS Charts. If these forms are used,
PEWS is integrated inside the monitoring sheet of the patient.
Note that the age-specific forms are constantly being updated to adapt them to MSF projects’ reality.
Please contact your paediatric advisor to obtain the most up-to-date forms for your project and the
respective age ranges.
41
2. Triage and ABCDE
Figure 2.3.2 PEWS form: 3–11 months
42
3. Management of Syndromes and Diseases
3.1. Respiratory Problems and Otitis..................................................................................................... 44
3.2. Shock and Circulatory Impairment ................................................................................................. 73
3.3. Gastrointestinal Disorders .............................................................................................................. 83
3.4. Renal Disorders............................................................................................................................... 93
3.5. Metabolic Disorders ..................................................................................................................... 104
3.6. Fever and Sepsis ........................................................................................................................... 107
3.7. Blood Disorders ............................................................................................................................ 114
3.8. Neurological Disorders ................................................................................................................. 129
3.9. Bone and Joint Problems .............................................................................................................. 147
3.10. Skin Problems ............................................................................................................................. 155
3.11. Malaria........................................................................................................................................ 164
3.12. Meningitis ................................................................................................................................... 181
3.13. Tetanus ....................................................................................................................................... 187
3.14. Typhoid Fever ............................................................................................................................. 193
43
3.1. Respiratory Problems and Otitis

Upper Respiratory Infection (Common Cold) ........................................................................................ 45
Pneumonia............................................................................................................................................. 46
Empyema ............................................................................................................................................... 50
Croup (Laryngotracheitits/laryngotracheobronchititis) ........................................................................ 52
Bronchiolitis ........................................................................................................................................... 56
Asthma................................................................................................................................................... 58
Sinusitis .................................................................................................................................................. 65
Pertussis (Whooping Cough) ................................................................................................................. 67
Otitis Media ........................................................................................................................................... 70
Note: In this section a 2-month age cut off is used.

For infants < 60 days, refer to Neonatal Guidelines (e.g. late onset neonatal pneumonia etc).
44
Upper Respiratory Infection (Common Cold)
Causes
An upper respiratory infection (also known as the common cold) is an acute, self-limiting viral
infection caused by over 100 different viruses. It can also be an early sign of multiple other diseases.
Clinical Signs and Assessment

Symptoms of an upper respiratory include sneezing, cough, nasal congestion and discharge (which
may be purulent for up to two weeks, even if it is viral), sore throat, headache and low-grade fever.
Rarely patients may present with diarrhoea. A cold is most contagious in the first three days post
infection.
Assess the general condition of the child, including taking his or her weight. Examine the tympanic
membranes with an otoscope to check for infection. If the child is coughing or wheezing, listen to his
or her breathing and chest sounds with a stethoscope.
Treatment or Management
There are no specific treatments for viral upper respiratory infections. Encourage fluids and stress
the importance of ensuring that the child remains well hydrated. Caregivers can use saline nose
drops and a bulb syringe to clear accumulated nasal secretions. Also, recommend that caregivers and
other members of the household wash their hands with soap, if water is available, to help limit
transmission.
Antibiotics should not be administered unless the child has developed sinusitis or pneumonia. Do not
prescribe vitamin C or recommend cough or cold medications, as these are not effective at reducing
either the symptoms or the duration of the illness. Do not prescribe antihistamines unless there is an
allergic component to the symptoms or in the history. Treat for fever only if the child is
uncomfortable or the fever is high.
Check the immunisation status of the child. If he or she is incompletely immunised, refer the family
to the local EPI (Extended Program of Immunisation) or immunise the child during the visit.
Remember that a cold is not a contraindication to vaccination.
Complications
Possible complications of upper respiratory infections include the following:
• Otitis media
• Sinusitis (thick, purulent discharge for longer than 2 weeks)
• Pneumonia
• Asthma and wheezing
45
Pneumonia
Pneumonia is an acute inflammation of the lung, usually (but not always) caused by infections. In
developing countries, pneumonia is not only more prevalent but is more severe, accounting for more
than 2 million deaths annually; pneumonia is the number one killer of children (younger than age 5
years) in these countries.
Causes
Pneumonia can be caused by infectious or non-infectious agents (aspiration of food or gastric acid,
foreign bodies, etc.). Most cases of pneumonia are caused by microorganisms (bacteria, virus, fungi
and occasionally parasites). In children aged 2 months to 5 years in developing countries, bacterial
infections are the most common cause of pneumonia.
Table 3.1.1 Causes of pneumonia
Major Bacterial Causes Other Causes Viral causes

Haemophilus Influenzae If HIV+ or suspicion of HIV Influenza and measles
Streptococcus pneumoniae • Pneumocystis jirovecii, formerly
Salmonella spp. called Pneumocystis carinii
Klebsiella pneumoniae • Chlamydia trachomatis (in afebrile
Staphylococcus aureus (important infants 1–4 months of age)
cause in certain regions)
Mycobacterium tuberculosis
(especially in children who are HIV
positive, malnourished or exposed to
adults with TB)
Mycoplasma pneumoniae (atypical

pneumonia; in children older than 5
years)

The combination of fever, cough and/or difficulty breathing (e.g., tachypnoea, increased work of
breathing) is suggestive of pneumonia. Young infants may present with difficulty feeding,
restlessness or irritability, vomiting and diarrhoea. Older children may complain of pleuritic chest
pain and occasionally abdominal pain (pain from the lower lobes) and nuchal rigidity (pain from
upper lobes).
46
Severity assessment
It is important to differentiate simple pneumonia (Table 3.1.2, Definition of pneumonia) from severe
pneumonia (Table 3.1.3, Definition of severe pneumonia).
Table 3.1.2 Definition of pneumonia
Cough or difficulty in breathing in addition to at least one of the following:

• fast breathing
- 50 breaths/min in a child aged 2–11 months
- 40 breaths/min in a child aged 1–5 years
• chest auscultation signs (physical exam by doctor or medical assistant only):
- decreased breath sounds
- bronchial breath sounds
- inspiratory crackles (also called rales and crepitations heard on auscultation).
Table 3.1.3 Definition of severe pneumonia
A diagnosis of pneumonia plus any of the following:

• oxygen saturation (SpO2) <90% or central cyanosis (most important)
• inability to breastfeed or drink
• vomiting everything (all foods and liquids)
• lethargy or reduced level of consciousness
• appears severely ill or toxic
• severe respiratory distress (defined as rapid breathing in conjunction with nasal flaring, abnormal
positioning, chest retractions or severe indrawing, abdominal breathing or grunting.
Diagnosis
The diagnosis of pneumonia can be made clinically in children with fever, signs of infection and
symptoms of respiratory distress on physical examination. The presence of tachypnoea, nasal flaring,
grunting, retractions, crackles and decreased breath sounds increase the likelihood of pneumonia.
The absence of tachypnoea is helpful in excluding pneumonia; the absence of the other signs does
not exclude pneumonia.
Simple Pneumonia
Treatment of simple pneumonia in children older than 2 months includes antibiotics (see Table 3.1.4,
Antibiotic treatment of simple pneumonia). Supply O2 if SpO2 is below 90%, and in all cases of SCD.
Treat for fever if the child is uncomfortable. Follow up 48 to 72 hours after the initial examination to
reassess the child’s status and ensure that the parents are properly administering medication.
47
Test for malaria if in an endemic area (both may be present simultaneously) and consider the
possibility of tuberculosis if the child has a long history of symptoms and a consistent low-grade
fever. Children younger than 2 months of age should be admitted for treatment, along with children
younger than 1 year if there are concerns regarding the ability of the parents to treat or if the
parents cannot bring the child back for a follow-up examination.
Table 3.1.4 Antibiotic treatment of simple pneumonia
Amoxicillin 30 mg/kg/dose 3x/day PO (or 50 mg/kg/dose 2x/day)
Follow up in 48–72 hours
Case 1 Case 2 Case 3

Signs of severe pneumonia (see
Child is improving No improvement Table 3.2.3)
Finish course of amoxicillin for Finish course of amoxicillin for Treat for severe pneumonia
total of 5 days total of 5 days and add
azithromycin 10 mg/kg x 5 days PO
Severe Pneumonia
If you suspect a child has severe pneumonia, follow ABCD (see Chapter 2.2) and admit the child to
the ICU once stable.
Provide respiratory support (supply O2 if SpO2 is below 94%), treat fever to improve comfort and
ensure analgesic administration if chest pain is present. Administer antibiotics (see Table 3.1.5,
Antibiotic treatment of severe pneumonia); do not give cough syrup, as it is not effective. Provide
fluid maintenance over the first 24 to 48 hours to prevent dehydration and ensure adequate caloric
intake to prevent hypoglycaemia.
Complementary Care
Test for malaria if in endemic area. Test Hb if pallor is present. If the child is wheezing, administer
salbutamol (see asthma protocol). If the child is severely malnourished, administer a small volume of
F75 with a nasogastric tube. If the child is experiencing severe respiratory distress, make him or her NPO.
48
Table 3.1.5 Antibiotic treatment of severe pneumonia
Day Ceftriaxone† IV or IM 50 mg/kg/dose 1x/day

1–3 Alternatively: Ampicillin IV or IM 50–70 mg/kg/dose 3x/day and gentamycin IV or IM 5 mg/kg 1x/day

Child improves* and can take Child does not improve* or
PO medicine deteriorates
Stop ceftriaxone and start Ceftriaxone 50 mg/kg/dose 1x/day
amoxicillin/clavulanic acid (7:1 and cloxacillin 25 mg/kg/dose 4x/day
or 8:1) 50 mg/kg/dose 2x/day of IV
the amoxicillin component
Day
If there is a high suspicion of
4–6 If ampicillin + gentamycin was aspiration pneumonia (i.e., in
given, start amoxicillin children who have been fed with a
50mg/kg/dose 2x/day and feeding tube or who have
complete 7–10 days of swallowing difficulties), add
treatment metronidazole 10 mg/kg/dose
3x/day instead of cloxacillin
Child improves* and can take PO Child does not improve*
medicine: start amoxicillin and Obtain a chest X-ray
Day clavulanic acid 50 mg/kg/dose Consider possible empyema
7–10 2x/day of the amoxicillin component (see Chapter 3.1),
for 10 days tuberculosis (see MSF TB
guideline) or HIV
Always consider TB (see
MSF tuberculosis guidelines)
In HIV-positive patients or
Any those with a clinical
time diagnosis of HIV, consider
pneumocystis and start
trimethoprim sulphate (see
HIV guidelines)
*Improvement is indicated by the following: improved respiratory distress, diminished fever,

improvement in SpO2 level or less oxygen is required to maintain saturation, improved ability to drink
and or eat and improved activity
†
Same dose of cetriaxone for patients with severe malnutrition, HIV or measles
Complications
If the child has bacterial pneumonia (such as staphylococcal pneumonia), it can lead to empyema
(see next section).
If the child’s condition does not improve within 48 hours or complications are suspected, acquire a
chest X-ray if possible.
49
Empyema
Causes
Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall
(pleural space). It is a complication of a bacterial pneumonia, most often staphylococcal pneumonia
(which is itself a classic complication of measles).

Presenting symptoms include persistent fever and/or cough, chest pain and dyspnoea. Children with
empyema may lie on the affected side to decrease their pain. Empyema should be considered in
children who have shown no improvement after treatment for community-acquired pneumonia
(with 48–72 hours). Addition signs include an ill-appearing child with known pneumonia or signs of
pneumonia plus the following:
• shallow respirations to minimise pain
• decreased air movement heard on auscultation
• dullness to percussion
• increased resonance of voice sounds (due to enhanced transmission)
• rarely severe respiratory distress, sepsis and shock
• possibly a pleural rub on the side of the fluid collection.
Diagnosis
If possible, diagnose with X-ray and ultrasound to visualise the fluid. If imaging is not available,
perform a pleural puncture to obtain fluid for Gram stain if that is available. Always consider
tuberculosis in cases of empyema.
Management
Children with empyema and/or staphylococcal pneumonia should be hospitalised, preferably in the
ICU, and stabilised. Treat any fever to improve the patient’s comfort and provide analgesia if pain
(such as chest pain) is present and oxygen if SpO2 is <94%. If the child is in severe respiratory distress,
make him or her NPO.
Test for malaria in endemic areas and check haemoglobin if pallor is present. Ensure adequate fluid
and caloric intake over the first 24–48 hours, as there is a risk of dehydration and hypoglycaemia. Do
not provide cough syrup, as it is unhelpful. Monitor the patient’s vital signs according to his or her
condition.
50
Antibiotics
Antibiotics should be administered per the following protocol:
• ceftriaxone 50 mg/kg/dose 1x/day for a minimum of 3 days, plus cloxacillin 25 mg/kg/dose
4x/day IV, or
• amoxicillin/clavulanic acid IV
- child 1–3 months of age: 30 mg/kg/dose 2x/day IV
- child older than 3 months: 30 mg/kg/dose 3x/day IV
Treat for at least seven days IV and until afebrile for three days. If tolerating PO medication, switch to
amoxicillin/clavulanic acid 7:1 or 8:1 PO 50 mg/kg/dose of the amoxicillin component 2x/day for 10–
14 days of total treatment.
If confirmed MRSA: clindamycin IV 10mg/kg/dose 3x/day +/- gentamycin 5 mg/kg IV 1x/day
If slow improvement despite antibiotics, consider tuberculosis (see MSF TB guidelines).
In the event of large empyema: same treatment but switch to the oral route after 7 days with no
fever and treat for 3 weeks. However, the definite treatment of a large empyema is the placement of
a chest tube or repeated removal of the pus via other means.
• If a physician familiar with the procedure and anaesthesia/surgery is available, schedule the
child for chest tube insertion under anaesthesia in the operating room.
• If surgery/anaesthesia not available but a physician trained to perform the procedure is, use
IM ketamine for sedation (see Chapter 7.10, Ketamine Use) and place a chest tube (see
Chapter 8.5, Chest Tube Placement).
• If the child is unstable or no one with experience in the insertion of a chest tube is available,
perform repeated pleural punctures for drainage (see Chapter 8.7, Pleural Puncture).
51
Croup (Laryngotracheitis/laryngotracheobronchitis)
Causes
Croup is a respiratory illness, most commonly caused by viruses. Parainfluenza virus type 1 is the
most common cause of croup; other causes include respiratory syncytial virus and influenza virus.
Bacterial infection may occur secondarily.
Croup is also called laryngotracheitis, or laryngotracheobronchitis if accompanied by wheezing. It is

called laryngitis when hoarseness is the only symptom, as in older children.

Croup is characterised by inspiratory stridor, cough and hoarseness. A barking cough is the hallmark
of croup among infants and young children, whereas hoarseness predominates in older children.
It occurs mostly in children between the ages 6 and 36 months.
Clinical Presentation
Croup begins gradually, usually with symptoms of a common cold (runny nose, etc.). The next day the
child develops a fever, hoarseness, barking cough and stridor. Respiratory distress increases as upper
airway obstruction worsens. Rapid progression or signs of lower airway involvement suggests a more
serious illness (such as epiglottitis). The cough usually resolves within three days.
History
The following signs indicate increased severity:
• Sudden onset of symptoms
• Rapidly progressing symptoms (inspiratory stridor at rest after <12 hours of illness)
• Previous episodes of croup
Physical examination
The evaluation of the child with croup aims at assessing the severity of the condition and excluding
other causes of upper airway obstruction.
Allow the child to choose the position in which he or she is most comfortable. This often is sitting in a
parent’s lap. Do not stress the child, as this may worsen his or her condition. Allow the child to
breastfeed.
If the child is cooperative and can open his or her mouth, examine the oropharynx, but without the
use of a tongue depressor.
52
Signs of croup or laryngotracheitis include tachypnoea and prolonged inspiration. Signs of severe
croup, implying a need for oxygen, include the following:
• Chest wall (suprasternal, subcostal and intercostal) retractions and inspiratory stridor at rest
• Depressed level of consciousness (AVPU; see Chapter 2.1, Triage Protocol)
• Restless or anxious behaviour
• Hypoxia and cyanosis
• Severe tachypnoea
• Very hoarse voice
• Decreased or absent breath sounds
• Signs of dehydration
Spasmodic Croup
Spasmodic croup is characterised by the sudden onset of inspiratory stridor at night, short duration
(several hours) and sudden cessation. Spasmodic croup recurs frequently and is also called "allergic
croup."
Diagnosis
The diagnosis of croup is clinical, based upon the presence of a barking cough and stridor. Neither
radiographs nor laboratory tests are necessary to make the diagnosis.
The differential diagnosis of croup includes other causes of stridor and/or respiratory distress such as
acute epiglottitis, diphtheria, peritonsillar and retropharyngeal abscesses and foreign body
aspiration. (See Figure 3.1.1, Croup diagnosis flowchart.)
In cases of mild croup (i.e., the child does not have signs of severity, is drinking well and has a SpO2
>94%), give dexamethasone PO 0.5 mg/kg x 1 dose (maximum dose 10 mg). If necessary, the
intravenous preparation can be given orally once mixed with syrup or juice. Treat any fever for the
child’s comfort.
Although croup usually is a mild and self-limiting illness, significant upper airway obstruction and
respiratory distress can occur.
In cases of moderate and severe croup, or in those cases where the child is at risk of dehydration
and/or the family lives far from the hospital, hospitalise the child, preferably in the ICU, and stabilise
his or her condition. Provide respiratory support (including oxygen if SpO2 < 94%). Ensure adequate
caloric and fluid intake. Monitor vital signs according to the child’s condition.
Administer dexamethasone (0.6 mg/kg, maximum of 10 mg) PO if the child can drink, IV if the child
has an IV for rehydration or IM if the child does not have an IV and cannot drink.
53
In addition, administer epinephrine via a nebulizer every 15 to 20 minutes as needed. Prepare the
epinephrine (0.5 mL/kg per dose of 1 mg/mL [for a maximum of 5 mL]) as follows:
• example: 10 kg child
• dose: 0.5 mL/kg of IV preparation (1 mg/mL)
• 10 kg x 0.5 mL/kg = 5 mL epinephrine
Add sufficient NaCl 0.9% to obtain a total of 4 or 5 ml in the nebulizing chamber.
If HR >200 beats/min, stop epinephrine until tachycardia resolves.
Differential diagnoses
In severely ill, septic children, consider epiglottitis or bacterial tracheitis, which are life-threatening
conditions.
Epiglottitis is distinguished from croup by the absence of a barking cough and the presence of anxiety
that is out of proportion to the degree of respiratory distress. It is also indicated by a rapid onset of
symptoms. The child is highly febrile, pale, toxic and ill appearing. Because of the swollen epiglottis,
the child will have difficulty swallowing and is often drooling, with a soft inspiratory stridor.
Bacterial tracheitis should be suspected if the child’s croup gets much worse, a high fever develops,
the child has a toxic appearance, or there is increasing respiratory distress secondary to tracheal
obstruction from purulent secretions (pus often drains out of the mouth, nose or both). The croupy
cough and absence of drooling may help to distinguish it from epiglottitis.
In such cases, do not ask or force the child to lie down and do not upset the child. Call an
anaesthetist, if available, to intubate and, once the airway is secure, obtain access for IV ceftriaxone.
In most MSF settings an anaesthetist will not be available. Here, the priority is to keep the child calm
with minimal disturbance. Put the child in a quiet well-observed area (ideally ICU), sit upright, nil by
mouth, insert IV cannula in order to give intravenous maintenance infusion, ceftriaxone IV,
dexamethasone IV-0.4 mg/kg/dose to repeat after 4 hours, then after 6 hours (but note priority is to
keep the child calm). Maintain close observation of patient and vital signs, and if stridor increases,
the patient becomes restless, and if signs deteriorate, then provide positive pressure bag and mask
and repeat as often as necessary.
54
Inspiratory stridor
Evaluate and treat ABCD If history of allergy and exposure to allergen,

O2 via mask or nasal prongs and keep child sitting see chapter on Sepsis and Shock
calmly on parent’s lap (Anaphylaxis and Anaphylactic shock)
Monitor
Barking cough
No Yes
Severely ill/Septic
Severely ill/Septic
Yes No
History of choking/aspiration and/or

X-Ray evidence of foreign body No Yes
Swollen tonsils Drooling,
and/or neck stiffness muffled voice Yes No
± red pharynx suggests
suggests epiglottitis
retropharyngeal or History of stridor
Figure 3.1.1. Croup diagnosis flowchart
peritonsillar abscess shortly after birth

Laryngotracheitis (viral) Bacterial Tracheitis
most common
Yes No
Child seated with parent.
Life threatening - See text If stridor or SpO2 < 90%
Laryngomalacia give dexamethasone (IV, IM, PO)
Tracheomalacia and nebulised adrenalin Child seated with parent
Give antibiotics Antibiotics
Call surgeon or Observe at home Inspiratory stridor unchanged or Monitor closely
refer if unstable worse
if stable
55
Repeat nebulised adrenalin
Bronchiolitis
Causes
Bronchiolitis is an infection of the lower respiratory tract, common in children younger than 12
months (up to 2 years) characterised by acute inflammation and oedema of smaller airways
(bronchioles), leading to increased mucus production and bronchospasm. Bronchiolitis is a viral
disease, with the majority (>70%) of cases caused by respiratory syncytial virus (RSV). As this is a
seasonal infection, several patients may present during the same time period.

Patients initially present with a runny nose (clear secretions), reduced appetite and fever, later
developing tachypnoea, apnoea, respiratory distress, irritability, wheezing and crepitations; this can
result in respiratory exhaustion and a silent chest (a sign of severity as it indicates no air movement).
Symptoms usually peak at day 2 or 3 of the illness and resolve over 7–10 days. However, cough may
last for several weeks.
Risk factors for bronchiolitis include prematurity, congenital heart disease and neurological
conditions.
Severe disease is characterised by irritability or lethargy, respiratory distress (accessory muscle use
and chest indrawing), inability to feed, SpO2 <90% and frequent or prolonged apnoea.
If the patient is very young or if his or her condition is severe, hospitalise and monitor closely.
Position the patient about 30 degrees upright and provide oxygen via nasal prongs, keeping SpO2
greater than 90%, especially in cases of fever, known hemoglobinopathies or increased work of
breathing. Ensure adequate fluid intake; IV fluids might be needed as reduced fluid intake and losses
from fever and tachypnoea can lead to dehydration. However, provide a tight fluid regime, such as
two-thirds of maintenance fluids. If no infusion pump is available, consider intermittent
administration instead.
As there is a high risk for apnoea, especially in the very young or very sick, continuous or near-
continuous monitoring is paramount (SpO2, RR, HR). Use an apnoea monitor if available.
If the patient’s condition is severe, consider withholding orals feeds during the first day to reduce the
risk of aspiration. After 24 hours, provide frequent small feeds and position the patient upright at 30
degrees or on his or her mother’s lap during and after feeds. Oral feeds are preferred, so switch away
from NG tube feedings as soon as possible. Consider gentle nasal irrigation or oropharyngeal suction
prior to feeds as necessary.
56
Do not prescribe corticoids. Salbutamol is not recommended, although it can be considered on a

case-by-case basis for children with severe disease. Discontinue use if there is no effect.
Routine antibiotic use is not recommended. However, certain situations indicate consideration,
including:
• Bacterial secondary or co-infection is suspected
• Ill-appearing child
• New onset of fever and clinical deterioration after at least two days of hospitalisation
Monitor patients with suspected bacterial infection closely for respiratory rate, SpO2 and signs of
respiratory exhaustion. Place the patient in a separate area or far enough away from other patients
to avoid infection of other patients. If there is more than one patient, cohort them together in the
same area. Ensure universal precautions, particularly hand washing before and after handling the
patient, to avoid nosocomial infections. Consider using gowns for patient care if feasible.
If you suspect bacterial infection during the hospital stay, consider aspiration pneumonia if the
patient had been on oral feeds.
If the patient is hospitalised or sick for a longer period of time, verify nutrition status prior to
discharge and treat accordingly.
Complications
Possible complications of bronchiolitis include bacterial infection and respiratory exhaustion. Possible
sequelae include bronchiectasis.
57
Asthma
Causes
Asthma is a chronic, inflammatory lung disease characterised by symptoms of cough, wheezing,
shortness of breath and chest tightness caused by airway narrowing that is partially or completely
reversible by medications (salbutamol). These symptoms are caused by airflow obstruction resulting
from narrowing of airways from smooth muscle constriction, mucous plugs in the airways and/or wall
thickening from inflammation.

Patients presenting with asthma may have the following signs and symptoms:
• decreased air entry or wheezing on auscultation
• sometimes wheezing is audible without stethoscope
• a prolonged expiratory phase on auscultation
• dry cough
• respiratory distress
• increased anterior-posterior diameter of the chest due to air trapping (see Figure 3.1.2, Air
trapping)
Figure 3.1.2. Air trapping
Other causes of wheezing include bronchiolitis (in children younger than 2 years; caused by a viral
infection and not responsive to salbutamol), bacterial tracheitis (more inspiratory stridor than
expiratory wheezing), foreign body aspiration (history or CXR diagnosis), cardiac disease, congenital
anomalies and gastro-oesophageal reflux.
The severity of an asthma attack can range from mild to critical. See Table 3.1.6, Acute asthma
severity guidelines, for severity indicators.
58
Table 3.1.6 Acute asthma severity guidelines

Mild Moderate Severe Critical
Mental state Normal Normal Agitated Confused/drowsy
Accessory muscles use None Minor Moderate Maximal/exhaustion
Oxygen saturation in
>96% 93%–96% 90%–93% <90%
room air
Note: If the attack is severe or critical, the ability to talk is reduced.
Diagnosis
Asthma diagnosis is based on history, physical examination and spirometry (if available). Asthma is
indicated in instances of wheezing and/or respiratory distress that improve with salbutamol, with or
without fast breathing and chest indrawing (retractions). If there is sudden onset of wheezing and/or
symptoms associated with certain external factors (smoke, animals, etc.) or triggered by physical
exercise, these can also be indicators of asthma.
If a patient presents with the above symptoms plus a fever, treat for pneumonia.
Acute Asthma Attack

(See also Figure 3.1.6, Asthma treatment algorithm, at the end of this section.)
Place the patient is a position of comfort, often half-sitting.
Mild/moderate
Administer salbutamol, four puffs via spacer (see below) 1x, then review after 20 minutes. If the
patient responds poorly, repeat treatment every 20 minutes for 1 hour.
In addition, give prednisolone tablet 2 mg/kg/day on day one or dexamethasone 0.6 mg/kg 1x/day
PO (equally effective given PO and IV or IM) for 1–3 days.
Severe
• If SpO2 <94%, provide oxygen; where possible, use O2-powered nebulizer with facial mask (6–
8 L/min)
• Administer salbutamol four puffs (if child weights >10 kg, give 6–8 puffs) via spacer as above
every 20 minutes; preferred treatment is via nebulizer (younger than 5 years: 1 mL = 2 mg of
the 5 mg in 2.5-mL nebulizer solution; older than 5 years: 2.5 mL [5 mg]). If possible, use an
O2-powered continuous nebulizer. (Note that the salbutamol nebulizer solution is not the
same as the injection solution.)
59
• Add ipratropium bromide into the same nebulizer solution for simultaneous inhalation:
younger than 5 years: 0.25 mg (= 1 vial of the 0.25 mg/mL inhalation solution); older than 5
years: 2 vials (0.5 mg). Repeat up to three times together with salbutamol inhalation.
• Dexamethasone 0.5 mg/kg/day IV once daily in one dose should be given for at least three
days; if possible, replace with prednisolone 2 mg/kg/day tablet from day 2, for 3–10 days
maximum treatment.
If the patient deteriorates or shows no signs of improvement, he or she should be considered a

critical patient and must be admitted to intensive care and senior staff must be involved in care.
Critical
If the patient shows no improvement in a severe asthma attack after the treatment described above
or if he or she is experiencing a life-threatening asthma attack (signs include exhaustion, drowsiness
or SpO2 <90%), continue treatment as above and add magnesium sulphate 40 mg/kg over 20 minutes
(infusion pump diluted in NaCl 0.9%); monitor continuously (including BP, as there is a risk of
hypotension). If continuous monitoring is not possible, monitor vital signs, BP and neurological status
every 10 minutes for at least 1 hour. In case of hypotension, provide additional fluid bolus (10 mL/kg
RL) over 20 minutes. If no improvement after 20 minutes, administer epinephrine 0.01 mg/kg IM.
Observe the patient for two hours after stabilisation. Monitor SpO2 at all times. Initiate inhaled
steroids based upon classification of severity and/or control (see Table 3.1.7, Non-acute asthma
severity guidelines).
Once stabilised and able to use puffer and spacer, begin planning for ongoing treatment (see Table
3.1.8, Stepwise approach to ongoing therapy). Asthma education must be provided prior to
discharge, including an explanation of uses of different sprays (beclometasone and salbutamol).
No need to taper corticosteroids unless the child has been on them for longer than one week.
Non-acute Asthma Management
Table 3.1.7 Non-acute asthma severity guidelines
Intermittent Mild persistent Moderate persistent Severe persistent

>2 days/week but
Symptoms ≤2 days/week Daily Throughout the day
not daily
Night time
0 1–2x/month 3–4x/month >1x/week
awakening
Interfere with
None Minor limitation Some limitation Extremely limited
normal activity
60
Table 3.1.8 Stepwise approach to ongoing therapy

Intermittent Persistent asthma daily medication
asthma Mild persistent Moderate persistent Severe persistent
Salbutamol 4 puffs Low-dose inhaled Medium-dose inhaled High-dose inhaled
inhaler as needed; corticosteroid corticosteroid corticosteroid
max 4 times per Beclometasone 0.05 Beclometasone 0.05 See below
day mg/puff, 1–2 puffs 2x/day mg/puff, 2–4 puffs 2x/day
or or beclometasone 0.10
beclometasone 0.10 beclometasone 0.10 mg/puff
mg/puff, 1 puff 2x/day mg/puff, 1–2 puffs 2x/day 2-4 puffs 2x/day
Ongoing Management
Priorities for asthma management include education and patient support. While the patient is still in
the hospital, monitor vital signs every four hours until the child is stable, then check 4x/day.
Teaching
Explain the use of and the indication for different inhalers. Discuss the signs and symptoms of an
attack; potential triggers to avoid, such as dust, cold and smoke; and the treatment used, both in
hospital and the regime to follow at home. Provide an “action plan” for the parent/patient to follow
in case of an attack at home. Provide one spacer and appropriate sprays to the child when they are
discharged and schedule a follow-up appointment if possible and appropriate.
Explain, demonstrate and ask both mother and patient to show how to use a spacer.
• Always use the spacer when using a “puffer” (metered dose inhaler [MDI]).
• Children younger than 3 years of age should use a facemask with the spacer, one big enough
to provide a seal around mouth and nose.
• Children old enough may use a mouthpiece, provided they can coordinate it.
• The child should take four breaths per puff. There is no need to take ‘deep breaths.’
• Shake the spacer vigorously before the first and between each puff. If the child is distressed,
shaking it vigorously before the first puff is sufficient.
• Ensure that inhalations are administered on time.
Inhaled corticosteroids are the most effective medications for long-term control of persistent
asthma. Because ICSs are inhaled, they go right to the lungs and have few systemic side effects. They
should be taken every day to prevent asthma symptoms and attacks. Mouth irritation and thrush
(yeast infection), which may be associated with them, can be avoided by rinsing the mouth with
water and spitting after each use.
Document all medications in the child’s treatment booklet.
61
Use of spacer for the treatment of asthma

A spacer is usually an open-ended tube or bag that is of sufficient volume to allow the aerosol from
the metered dose inhaler (MDI) (“puffer”) to expand, the propellant to evaporate, and large particles
to settle.
Figure 3.1.3 Use of spacer for the treatment of asthma in children
The use of spacer is recommended for all children except those in severe respiratory distress, in
whom a nebulizer is recommended.
Figure 3.1.4 A spacer with a mask is recommended for younger children, especially < 3 years old
Use of an MDI (“puffer”) with chamber is the preferred method for administering bronchodilators to
infants and children with acute asthma at home, as well as in the emergency department and
hospital (except in cases of severe respiratory distress, in whom a nebulizer is recommended).
62
Figure 3.1.5 Types of spacers

1. 500-mL modified plastic soft drink bottle or empty IV flask (if no commercial spacer is available)
• Cut the bottle, then tape the end to make the edges smooth.
• Adapt the salbutamol to the nozzle of the bottle with tape.
• Prior to use, prime the spacer with two puffs of salbutamol or other inhaled steroid to be
delivered.
• Wash the spacer in a solution of one drop of dishwashing detergent in 1 L of water to reduce
the electrostatic charge within the plastic spacer. Do not rinse and let air dry.
• Do not rinse prior to use.
• This treatment improves drug delivery
• Note that plastic spacers have electrostatic charges within the chamber that attract particles
and significantly reduce drug delivery to the lungs.
2. “Vortex,” a non-electrostatic metal spacer; ideal for

hospital use.
3. Spacer and child mask (reusable for individual use only).
63
Figure 3.1.6 Asthma treatment algorithm
Acute exacerbation of
asthma
Check vital signs

Give O2 (target SpO2 > 92%)
Insert IV catheter
Nebulised bronchodilators Corticosteroid

Whenever possible use O2 powered nebulizer + facial IV hydrocortisone:
mask (6 to 8 L/min O2 flow needed) 4 mg/kg (max 100 mg) repeated 4
hourly
Nebulised salbutamol or IV (or IM) dexamethasone:
• children older than 5 years: 5 mg 0.6 mg/kg (max 16 mg)
and
• children younger than 5 years: 2 mg or, if oral is possible, PO prednisolone:
+ nebulised ipratropium 2 mg/kg (max 60 mg)
• children older than 5 years: 0.5 mg
• children younger than 5 years : 0.25 mg
Repeat every 20 minutes as needed
Improvement in 1 hour?
No Yes
IV magnesium sulphate 40 mg/kg At least 2 hours of observation

Administer in NaCl 0.9% or D5% over 20 minutes.
Monitor BP and vital signs. Salbutamol 4 puffs every 4 hours for
24 to 48 hours (as soon as the patient
Continue nebulised salbutamol every 20 minutes as is able to use hand-held inhalor or
needed spacers, use them instead of
nebulizers)
+/- IM epinephrine 0.01 mg/kg IM
Repeat after 20 minutes if needed. Oral prednisolone
2 mg/kg/day for 3 days (maximum 60
mg)
Refer patient to ICU Consider discharge home with clinical

review in 48–72 hours
64
Sinusitis
Causes
Sinusitis is a bacterial infection of the sinuses, usually following an upper respiratory tract infection
(URTI) or common cold. Bacterial causes include Streptococcus pneumonia, Haemophilus influenza
and Moraxella catarrhalis.
The frontal and ethmoid sinuses are present at birth and continue to grow, although the frontal sinus
does not develop until the age of 7 years. The maxillary sinus develops in adolescence (see Figure
3.1.7, Sinus location).
Figure 3.1.7 Sinus location
Frontal
Ethmoid
Maxillary

Presenting symptoms include cough, sore throat, nasal symptoms (congestion or purulent drainage),
fever, headache, facial pain and swelling (less common in young children) and halitosis (bad breath;
also think of nasal foreign body in a child with halitosis).
Test for sinus tenderness (teeth pain; rare in young children) by tapping the upper molars or tapping
against the frontal or maxillary sinuses with one finger.
Acute Sinusitis
Purulent nasal drainage or congestion that is persistent without improvement for >10 but <30 days,
often with temperature ≥39°C (for more than 3–4 days) in an ill-appearing child.
Chronic Sinusitis
Sinusitis lasting >90 days with persistent symptoms (cough, rhinorrhoea and nasal obstruction).
65
Diagnosis
Diagnosis is clinical, based on clinical history and physical examination.
Risk factors for severe disease include HIV, malnutrition and other causes of immunosuppression.
Management
In cases of uncomplicated sinusitis, outpatient treatment includes amoxicillin/clavulanic acid PO 50
mg/kg/dose 2x/day for 5–7 days.
For sinusitis with complications or patients who are toxic appearing, admit the patient to the hospital
if there are any complications or if the patient appears severely ill.
Antibiotic treatment for complicated sinusitis is as follows:

• Amoxicillin/clavulanic acid IV 50 mg/kg/dose 3x/day (dose calculated on amoxicillin
component), or
• Ceftriaxone 50mg/kg/dose 2x/day (maximum 2 g) IV/IM
Treat until the child is drinking well. At that point, switch to amoxicillin/clavulanic acid (7:1 or 8:1) for
5–7 days of total treatment.
Symptomatic treatment includes saline nasal irrigation, painkillers and antipyretics.
Complications
Potential complications of sinusitis include the following:
• Periorbital and orbital cellulitis (swelling and redness of the lids/periorbital area), proptosis
(protrusion of an eye) or limitation of eye movement: can lead to vision loss
• Meningitis
• Intracranial abscess: Symptoms include headache, photophobia, vomiting, altered
consciousness +/- focal neurologic deficits
• Sepsis
• Osteomyelitis of the frontal bone associated with a subperiosteal abscess (forehead or scalp
swelling and tenderness, headache, photophobia, fever, vomiting and lethargy)
66
Pertussis (Whooping Cough)
Causes
Pertussis is a highly contagious, acute respiratory illness caused by the bacterium Bordetella
pertussis, with a high mortality in infants. The incubation period for B. pertussis is most typically 7 to
10 days and the transmission occurs via coughing and hand-to-mouth contact. The risk of
transmission is greatest during the catarrhal stage and patients with pertussis are considered
infectious until they have completed five days of appropriate antibiotic treatment.
Pertussis is a vaccine-preventable disease and immunisation against pertussis is included in all

vaccination calendars worldwide.
Pertussis is a notifiable disease.

The classic presentation of pertussis includes paroxysms of coughing, an inspiratory whoop and post-
tussive vomiting. Classic pertussis is divided into three stages:
1. Catarrhal stage (1–2 weeks): Initially, symptoms are similar to the common cold (runny nose,
cough). In contrast to the common cold, the cough in pertussis gradually worsens instead of
improving.
2. Paroxysmal stage – ‘characteristic’ (2–8 weeks): Cough increases in severity. The paroxysmal
cough is distinctive: a long series of coughs between which there is little or no inspiratory
effort. The child may gag, develop cyanosis and appear to be struggling for breath. Paroxysms
of coughing can develop spontaneously or be precipitated by external stimuli. They are more
bothersome at night. The whoop and post-tussive vomiting are frequent, but not always
present.
3. Convalescent stage (2–4 weeks): The child improves but may continue to cough for several
days.
Diagnosis
Based on the clinical history and physical examination.
67
Management
The following are indications for hospitalisation of the child with pertussis:
• Respiratory distress and/or pneumonia
• Young age (younger than 6 months)
• Apnoea and cyanosis
• Seizure and impaired consciousness
• Inability to feed
The patient should be isolated and staff should follow strict infection control measures (mask, gown,
isolated room, no visitors, etc.) See Infection Control in Health Care Settings 2006.
Antibiotic Treatment
Antimicrobial therapy can shorten the duration of symptoms and decrease possibility of transmission
to close contacts.
Follow national protocol if present. Immediately administer macrolide antibiotics for all suspected
and confirmed cases:
• azithromycin PO 10 mg/kg/dose 1x/day x 5 days (max 500 mg/day), or
• erythromycin PO 15 mg/kg/dose 3x/day for 7 days (second choice).
For children who do not tolerate macrolides, give co-trimoxazole 20 mg/kg/dose SMX/4 mg/kg/dose
of TMP: 2x/day for 14 days. Do not use in infants younger than 1 month because of the risk of
kernicterus.
Supportive Care
• Place the child in a semi-reclining position.
• Provide oxygen as needed (in cases of apnoea, cyanosis, SpO2 <90%)
• Do not perform any deep suction (as it increases the risk of paroxysmal cough). If secretions
are present, gently wipe the mouth and the nose with gauze.
• Ensure adequate fluids and caloric intake (risk of weight loss). Give small and frequent oral
feeds if possible. Some patients need intravenous or nasogastric feeding.
• Monitor the vital signs according to the clinical condition and record weight, urine output
and oral intake
• Do not administer salbutamol, corticosteroids or antitussives.
Post-exposure Prophylaxis
Antibiotic prophylaxis (same treatment as for suspect cases) is recommended for unvaccinated or
incompletely vaccinated infants younger than 6 months who have had contact with a suspect case.
68
Discharge Criteria
Most infants will continue to have coughing spells after discharge. Minimum criteria for discharge
include the following:
• No apnoea or need for oxygen supplementation in last 48 hours.
• The infant can tolerate coughing episodes without becoming hypoxic and/or bradycardic.
• The infant can feed enough to gain weight.
• Caregivers can care for child at home and are comfortable with the child's condition.
• Consider food supplements for several weeks after discharge, especially if weight loss occurs
during hospital stay.
Complications
Complications are most common in young infants and in the paroxysmal stage. These include apnoea
(frequent cause of death in infants), severe pneumonia and weight loss secondary to feeding
difficulties. Other complications include seizures, encephalopathy, difficulty sleeping, pneumothorax,
epistaxis, subconjunctival haemorrhage, subdural haematoma, rectal prolapse, urinary incontinence
and rib fracture.
69
Otitis Media
Acute Otitis Media (AOM)
Causes
Acute otitis media (AOM) is a short-term inflammation of the middle ear. Viral upper respiratory
infection is the most common predisposing factor for the development of AOM. Bacteria found in the
middle ear in AOM include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus
influenzae and Moraxella catarrhalis.

Children with AOM, particularly infants, may present with non-specific symptoms and signs (e.g.,
fever, fussiness, headache, anorexia, vomiting and diarrhoea). Specific findings of AOM or
complications/sequelae of AOM include ear pain, otorrhea, bulging of the tympanic membrane,
hearing loss, vertigo, nystagmus, tinnitus, swelling about the ear and facial paralysis.
Diagnosis
Diagnosis is based on the clinical history (ear pain, ear tugging, etc.) and evidence of middle ear
inflammation (bulging and erythema of the tympanic membrane) and middle ear effusion at the
otoscopic exam.
Management
Treatment includes antibiotic therapy: amoxicillin 45–50 mg/kg/dose 2x/day PO x 5 days. If the
patient still has a fever and ear pain after 48 hours, stop amoxicillin and give amoxicillin/clavulanic
acid PO (7:1 or 8:1) 50 mg/kg/dose x 2 doses/day for 5 days. If the patient is allergic to penicillins,
give azithromycin 10mg/kg/dose PO 1x/day x 3 days
Ear irrigation and application of ear drops are contraindicated. Wipe any drainage with a cotton swab
or clean tissue or gauze. Treat fevers to improve the patient’s level of comfort; treat pain with
paracetamol or ibuprofen. Ensure the patient has adequate fluid and caloric intake at home.
Complications
Complications include chronic suppurative otitis media, meningitis, mastoiditis and brain abscess.
70
Chronic Suppurative Otitis Media (CSOM)

CSOM is the result of an initial episode of acute otitis media and is characterised by a persistent (≥14
days) discharge from the middle ear through a tympanic perforation. Malnutrition, HIV and TB are
risk factors for CSOM.
Treatment of CSOM is as follows:
• Treat at home if the child has no danger signs or other complications.
• Irrigate and clean the ear with cleaning/irrigating solutions 3x/day.
• Treat with ciprofloxacin eardrops (0.3% ear drops): For the child older than 1 year, 2–3 drops
in the affected ear 2x/day for 2–4 weeks total. Prescribe for the initial 2 weeks and ask the
parent to return for follow-up and next 2 weeks’ prescription.
Oral antibiotics do not improve the outcome.
If child does not respond to ciprofloxacin ear drops for >30 days, think of tuberculosis and re-evaluate.
Mastoiditis
Acute mastoiditis is a complication of AOM in which purulent material accumulates within the
mastoid cavities. Otitis produces mastoiditis by either contiguous or haematogenous spread.
Characteristic features of coalescent mastoiditis include postauricular abnormalities (tenderness,

erythema, swelling, fluctuance, mass and protrusion of the auricle [See Figure 3.1.8, Mastoiditis
presentation]). Most patients also have fever and ear pain. Clinical diagnosis is required.
Figure 3.1.8 Mastoiditis presentation
71
Treatment includes hospitalisation and 7–10 days of antibiotics.

• Ceftriaxone IV 75 mg/kg/dose 1x/day, and
• Clindamycin IV 10 mg/kg/dose 3x/day (if not available, add cloxacillin IV 50 mg/kg/dose
4x/day which covers Staphylococcus [but not MRSA])
• Then add Ciprofloxacin PO 15 mg/kg/dose 2x/day if there is a high level of suspicion of
pseudomonas
• Switch to oral antibiotic when there is clear improvement and continue treatment for a total
of 4 weeks:
- amoxicillin/clavulanic acid PO (7:1 or 8:1) PO 50 mg/kg/dose 2x/day, and
- clindamycin PO 10 mg/kg/dose 3x/day
• If pseudomonas, also add ciprofloxacin PO 15 mg/kg/dose 2x/day
In addition, clean the ear canal (as with acute otitis media) and treat fever and pain for the patient’s
comfort. Refer to an ear, nose and throat specialist if possible (contact medical referent).
72
3.2. Shock and Circulatory Impairment

Shock .................................................................................................................................................... 74
Circulatory Impairment ........................................................................................................................ 76
Anaphylaxis and Anaphylactic Shock .................................................................................................... 77
Haemorrhagic Shock ............................................................................................................................. 81
73
Shock
Children with signs of severe illness and impaired perfusion need to be treated urgently.
Signs of shock are:

• Weak OR fast (or slow1) pulse
• CRT > 3 seconds
Note that these guidelines distinguish between shock and circulatory impairment, which have
different protocols reflecting different management strategies.
Thus:
• If the child has all 3 of the above signs together, treat as shock.
• If the child has only 2 signs, treat as circulatory impairment.
The leading causes of shock in our settings are hypovolaemia and sepsis. Hypovolaemic shock is a
state of hypo-perfusion arising from excessive fluid loss, which can be from a variety of sources,
including severe dehydration (from vomiting/diarrhoea or poor oral intake), or insensible fluid losses
from burns. Fluid loss stemming from excessive blood loss (haemorrhagic shock) is considered
separately. The pathophysiology of shock is often multifactorial. For our purposes, we consider septic
shock to be shock plus sepsis (shock with fever or hypothermia without severe dehydration). Note
that this definition is different to the classic definition of septic shock used in high resource settings
(where more diagnostic means are available). In the shock algorithm, the pathway forks depending
whether severe dehydration is present or not – and in all cases the fluid bolus recommendations
hinge on the haemoglobin levels.
Note that there are separate sections on anaphylactic shock and haemorrhagic shock. Dengue is
increasingly important in Africa and mainly effects children. For the management of dengue septic
shock (DSS) please refer to the MSF Clinical Guidelines 2016.
Shock should be treated in either an intensive care unit or emergency room. Please refer to the shock
algorithm. When using the algorithm, check and document the child’s vital signs every 15 minutes
until the child has been stable for 1 hour. Then, continue monitoring vital signs (depending on the
child’s condition and progress), neurological status (for changes in level of consciousness or new
signs or seizures) and glucose (4x/day).
1
Dengue may cause bradycardia
74
Figure 3.2.1 Management of shock
Criteria1: all 3 of: cold extremities + fast (or slow2) OR weak pulse + CRT > 3 seconds
1
A convulsing child may have these features  stop convulsion then reassess for shock criteria.
2
Dengue/Pre-terminal shock may have bradycardia.
Exit protocol and treat accordingly (separate guidelines) if:

• Cardiogenic shock/cardiac failure* prior to fluid treatment (Note: this is a rare diagnosis in MSF settings)
• Trauma (haemorrhagic shock)
• Severe burns
• Weigh rapidly
• Start oxygen
• Elevate legs, mark the liver borders
• Secure IV or IO
• Check RDTs malaria, Hb, glucose (and treat accordingly)
• Give IV Ceftriaxone
Monitor fluid input/output; monitor weight; measure vital signs every 15 minutes and document
WITH severe dehydration WITHOUT severe dehydration
Hb < 6 g/dL Hb ≥ 6 g/dL Hb < 6 g/dL Hb 6-10g/dL Hb > 10 g/dL
• Transfuse Non-SAM: • Transfuse • Maintenance • Bolus 10 ml/kg
PRBC 15ml/kg (or WB • 20 ml/kg of RL as fast as PRBC 15ml/kg 100% with of RL over 30
20ml/kg) over 3hr possible (max 3 bolus) (or WB D5%RL min
• If out of shock: 70 ml/kg 20ml/kg) over
• Maintenance • Reassess, if still
D5%/RL 3hr
200% with D5%RL while signs of shock
over 5hr < 1y
awaiting blood and reduce • Maintenance repeat bolus
over 2.5hr > 1y
to 100% once transfusion 100% (max 3 boluses
• Oral rehydration (ORS) when
starts (2 iv lines) with D5%RL in total)
circulatory impairment
while awaiting
• Then reassess shock and resolved
blood
hydration: SAM:
proceed according to Hb • 15 ml/kg of RL over 1 hour
level (max 2 bolus)  Consider hydrocortisone 2mg/kg slow injection – then:
• If out of shock or max bolus:
• Oral rehydration when First 24hr: 1mg/kg/dose X 4/day
D5%/RL 1.5-2 X maintenance 24-48hr: 0.5mg/kg/dose x 4/day
circulatory impairment
depending on ongoing losses
has resolved, as soon as
tolerated – even if • Reassess every 2 hrs: when
transfusion ongoing circulatory impairment When shock resolved or max bolus given 
resolved, start ReSoMal Maintenance fluids, for SAM start F75 as per protocol
For SAM start F75 when no longer in circulatory impairment when no longer in circulatory impairment
• Reassess regularly for signs of shock, dehydration, cardiac failure/ fluid overload*
• Repeat glucose at 30, 60, 120, 180 min at minimum and Hb after transfusion, bolus and at 120 min
In selected programs with confirmed expertise and sufficient HR – via separate IV lines – consult respective protocols:
• Start thiamine slow IV: 100 mg in SAM (or in contexts with high malnutrition prevalence) – see Chapter 7.7
• If systolic BP < (2 x age) + 70  Peripheral IVI/IO adrenalin** -- start with 0.1mcg/kg/min – see Chapter 7.6
• If no improvement after transfusion/fluid management, consider 10% calcium gluconate 1 ml/kg by slow IV or IO infusion
over 5 min (NB: Do not mix with other drugs)
* Cardiac failure (CF) / Fluid overload (FO) ** Adrenaline only to be used in settings where BP
Check for onset of hepatomegaly + bilateral basal crackles, monitoring (dynamap) and infusion pump available and
arrhythmia, gallop: sufficient staff for close monitoring present. Use separate IV
 stop IV infusion / transfusion; give furosemide 1 mg/kg x line. To be discussed with respective medical advisor/RMP
1 to 2 times; put patient in sitting position, maintain oxygen. for each project – Refer to protocol
75
Circulatory Impairment
Children who show signs of severe illness and have signs of circulatory impairment need to be
treated urgently.
Signs of circulatory impairment2 include:
• Weak OR fast (or slow3) pulse
• CRT > 3 seconds
If (and only if) the child has all 3 signs together, treat as shock (see protocol above).
If the child has only 2 signs, treat as circulatory impairment (this protocol).
Perform ABCD evaluation and act accordingly.
Management:
• Start oxygen (1-2L for infants and 2-4L for older children and titrate later, targeting SpO2 ≥ 94%).
• Secure IV.
• RDT malaria, Hb, glucose (and treat accordingly).
• If suspicion of severe infection, consider IV Ceftriaxone (100mg/kg).
• Reassess vital signs every 15 -30 minutes.
• Assess for underlying diagnoses/conditions and treat according to respective protocol.
• If Hb is < 6 g/dl, transfuse: 15ml/kg PC (or 20ml/kg WB, if PC not available) over 3 hours.
• If child is dehydrated start treatment according to dehydration protocol but regularly re-
check Hb for necessity of transfusion. Start oral rehydration as soon as child tolerates oral
fluids.
• If child is not dehydrated but unable to drink, provide 100% maintenance fluids with D5%RL
(Chapter 3.3) or F75 via nasogastric tube for SAM, continue close monitoring and reassess
regularly to establish diagnosis.
• Reassess Hb and Glucose at 60 and 120 minutes and act according to results.
2
The convulsing child may have these features: first stop convulsion, then reassess.
3
Dengue may cause bradycardia.
76
Anaphylaxis and Anaphylactic Shock
Causes
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can present as respiratory
distress or shock, and can lead to cardiac arrest. Anaphylaxis occurs after exposure to an allergen
(usually to foods, insects or medicines) to which a person is already sensitive.
Anaphylactic shock is shock in the presence of anaphylaxis.

Children presenting with anaphylaxis often have a history of exposure to an allergen, such as
medication (antibiotics most frequently), food, insect bite, latex gloves and anaesthetic. Most
children will have had a previous allergic reaction and/or history of asthma.
The symptoms of anaphylaxis are potentially life threatening.

• Difficulty with or noisy breathing
• Swelling of tongue/tightness of throat
• Difficulty talking/hoarse voice
• Cyanosis
• Agitation
• Pale and floppy in young children
• Respiratory distress/wheezing/stridor
• Shock
• Collapse/loss of consciousness/cardiac arrest
• Hypotension
In some case, anaphylaxis is preceded by the following allergic symptoms:

• burning/itching in mouth/throat
• nausea/abdominal pain/diarrhoea
• sweating
• hives/flushing/urticarial rash
• conjunctival injection.
77
Management
Anaphylaxis
Give epinephrine/adrenaline IM 0.01 mg/kg, use undiluted solution (1 mg/mL) in a 1-mL syringe and
administer into the mid-anterolateral thigh. The IM dose of epinephrine/adrenaline does not need to
be calculated exactly in anaphylaxis. Use the following chart: (Table 3.2.1, IM Dose of
epinephrine/adrenaline (1 mg/mL)).
Table 3.2.1 IM Dose of epinephrine/adrenaline (1 mg/mL)

Age/weight Dose of 1 mg/mL epinephrine
<6 years or <25 kg 0.15mL
6–12 years or 25–40 kg 0.3 mL
>12 years or ≥40 kg 0.5 mL
If the patient does not improve, repeat every five minutes for a maximum of three doses.
If a 1-mL syringe not available: add 1 mL of 1 mg/mL epinephrine to 9 mL of NaCl 0.9% for 0.1 mg/mL
solution, then administer as follows: (Table 3.2.1, IM Dose of epinephrine/adrenaline (0.1 mg/mL)
Table 3.2.2 IM Dose of epinephrine/adrenaline (0.1 mg/mL)

Age/weight Dose of 0.1 mg/mL epinephrine
<6 years or <25 kg 1.5 mL
6–12 years or 25–40 kg 3 mL
>12 years or ≥40 kg 5 mL
If continued symptoms of stridor predominate, add nebulized epinephrine/adrenaline as follows:

• Dose: 0.5 mL/kg of 1 mg/mL IV solution to a maximum of 5 mL.
• Do not dilute epinephrine; give via nebulizer over 15 minutes.
• Repeat every 15 to 20 minutes. If severe tachycardia appears, stop epinephrine until
tachycardia resolves.
• How to mix epinephrine for nebulizer use:
- Example: 10-kg child
- Dose: 0.5 mL/kg of MSF stock IV preparation (1 mg/mL)
- 10 kg x 0.5 mL/kg = 5 mL epinephrine
- Do not dilute, administer via nebulizer.
In cases of severe wheezing and respiratory distress, administer nebulized salbutamol.

• Where possible, use an O2-powered nebulizer with facial mask (6–8 L/min) or an electrical
nebulizer and keep O2 nasal prongs in place.
• Dosing: If the patient weighs <30 kg, give 2.5 mg (equal to 1.25 mL of 2 mg/mL salbutamol
solution). Add 2–3 mL of NaCl 0.9% and give via nebulizer. If the patient weighs >30 kg, given
5 mg (equal to 2.5 mL of 2 mg/mL salbutamol solution) via the same method.
• If possible, give nebulized treatment concurrently with oxygen at a flow rate of > 5 L/min.
78
• If very severe wheezing, repeat treatment without interruption to give continuous nebulizer
treatment for up to 1 hour. Continue until symptoms of wheezing and respiratory distress
improve.
• As wheezing improves, decrease frequency of salbutamol to every hour, then every 2 hours,
and then every 4 hours.
• If there is no nebulizer or if symptoms are not severe, give salbutamol via metered dose-
inhaler (MDI) with spacer (see Chapter 3.1, Respiratory Problems and Otitis, section on
asthma for spacer use):
- 2–4 puffs every 10 minutes 3x, then
- 2–4 puffs every 30 minutes 2x, then
- 2–4 puffs every hour
- Gradually space out to every 6 hours as wheezing improves.
Reminder: If the patient is experiencing severe wheezing and/or severe respiratory distress, the use
of a nebulizer, not a spacer, is preferred.
In all children with anaphylaxis, IV hydrocortisone or dexamethasone as follows:

• IV hydrocortisone 2 mg/kg/dose every 12 hours, or
• IV dexamethasone (0.5 mg/kg, maximum of 10 mg)
Anaphylactic Shock
Use the ABCD approach to stabilise the patient. Support and/or open the airways and provide oxygen
(high-flow oxygen with a non-rebreathing mask, if available); if not breathing, assist ventilation with a
bag-mask device. Ensure vascular access (IV/IO).
Immediately administer epinephrine/adrenaline IM 0.01 mg/kg, as above for anaphylaxis. Repeat up

to three times. In addition, give bolus of 20 mL/kg RL or NaCl 0.9% via an IV; repeat up to two times if
the child is in shock. If no improvement after two boluses, give a third bolus.
If there is still no improvement, give a second dose of IV/IO epinephrine. In addition, give IV
hydrocortisone 2 mg/kg/dose every 12 hours (not immediately effective) or IV dexamethasone (0.5
mg/kg, maximum of 10 mg) IV.
If an electric pump is available and personnel are trained and experienced in its use and the patient is
still in shock, a continuous infusion of 1:1000 IV adrenaline 0.1–1 mcg/kg/minute can be given. If
possible, a vital sign monitor (HR, RR and BP) should be used.
The epinephrine dilution for intravenous infusion should contain 0.1 mg/mL and may be labelled
1:10,000. Dose is 0.1–1mcg/kg/min IV infusion; start with 0.1 mcg/kg/min (see Chapter 7.6, How to
Mix Epinephrine Drip). It should be titrated to affect the blood pressure; if possible, use a cardio-
respiratory monitor, otherwise monitor BP every 5–10 minutes.
After the initial stabilisation, monitor vital signs, SpO2, level of consciousness and urinary output
every 30 minutes, then hourly. As soon as the patient’s condition improves, gradually reduce the
infusion.
79
Figure 3.2.2 Algorithm for anaphylactic shock
Evaluate and treat ABCD signs. Obtain short history of exposure to allergen: medications (antibiotics, etc.),
insect bites or stings, food and/or traditional medicines.
Symptoms and signs of allergy

• Burning/itching in mouth/throat
• Nausea/abdominal pain/diarrhoea
• Sweating/hives/flushing/urticarial rash
• Conjunctival injection
Symptoms and signs of anaphylaxis

First: Then worse: Worst of all:
Difficulty breathing Wheezing Respiratory distress
Noisy breathing Rapid onset of airway oedema Cyanosis
Agitation
Management
Remove offending agent/allergen immediately
• Start oxygen; elevate legs
• Epinephrine (adrenaline) IM dose: 0.01 mg/kg, use undiluted solution (1 mg/mL)
• Place IV/IO (check glucose)
• Add nebulized epinephrine/adrenaline if upper airway severely affected (stridor)
• If wheezing does not improve with adrenaline, treat with salbutamol inhaler (four puffs) or nebulized
salbutamol
• IV hydrocortisone 2 mg/kg/dose every 12 hours (not immediately effective) or IV dexamethasone (0.5
mg/kg, maximum of 10 mg) IV
Treat shock with bolus of 20 mL/kg RL IV/IO or 20 mL/kg NaCl 0.9% if RL not available. Repeat bolus 2x if
shock persists. Monitor for fluid overload.
• Repeat epinephrine/adrenaline IM every 5 minutes (max 3 times)

• If no improvement, use continuous infusion of 1:1000 IV adrenaline 0.1–1 mcg/kg/min, but only if an
electric pump and personnel familiar with its use are available. If possible, use cardio-respiratory and
BP monitoring.
• Monitor vital signs, SpO2, level of consciousness and urinary output
80
Haemorrhagic Shock
Causes
Haemorrhagic shock is shock in conjunction with clinical signs of haemorrhage (external and/or
internal blood less) plus haemoglobin (Hb) <8 mg/dL (<10 mg/dL in cases of severe head injury or
child younger than 3 months). Drop in Hb may not be present in early stages (see below).
The blood loss leading to haemorrhagic shock can be caused by trauma, gastrointestinal bleeding,
splenic rupture (due to severe sickle cell disease, malaria or trauma) or diffuse bleeding due to
haemorrhagic fever or dengue shock.
Please note that haemoglobin may be initially normal in haemorrhagic shock, as it may take while for
the child’s body to equilibrate and the haemoglobin levels to reflect the blood loss. Repeat the
haemoglobin test in 30–60 minutes if it is initially normal. If the child has active, ongoing, severe
bleeding, treat as haemorrhagic shock even if haemoglobin initially ≥8 g/dL.
Diagnosis
Laboratory analysis should include the following:
• Haemoglobin
• Blood group
• Urine for dipstick (grossly bloody urine suggests kidney damage)
• Glucose (and/or treat for hypoglycaemia).
If available, perform the following additional testing:

• complete blood count and platelets
• blood lactate
• serum electrolytes, blood urea nitrogen and serum creatinine.
• PT, PTT (disseminated intravascular coagulation)
Immediately stop any visible bleeding (via compression, tourniquet, surgical haemostasis or surgery
[take the child to the operating room immediately if severe trauma]). Utilise the ABCD approach to
stabilise the patient, including:
• supporting or opening the airways
• providing oxygen (high-flow oxygen with non-rebreathing mask, if available)
• assisting ventilation with bag-valve mask if not breathing
• ensuring vascular access
• checking and recording vital signs, and estimating weight.
Determine blood type and cross match, and order blood. Give a bolus 20 mL/kg RL or NaCl 0.9%
IV/IO; repeat bolus 3x if needed or until blood is available.
81
If still in shock, transfuse 20 mL/kg whole blood (WB) as fast as possible, or 20 mL/kg packed red
blood cells only if WB is not available (see Chapter 8.1, Blood Transfusions). Repeat as needed until
satisfactory peripheral perfusion is obtained. Keep the patient warm. Insert a nasogastric tube (take
caution with head trauma) open to air.
Once the patient is stable, perform an accurate anamneses and physical examination.
82
3.3. Gastrointestinal Disorders

Diarrhoea, Vomiting and Dehydration .................................................................................................. 84
83
Diarrhoea, Vomiting and Dehydration
Causes
Diarrhoea is the passage of more than three loose or watery stools in a 24-hour period.
There are three clinical types of diarrhoea:
• acute watery diarrhoea: last several hours or days;
• acute bloody diarrhoea: also called dysentery; and
• persistent diarrhoea: longer than 2 weeks.
Medical staff must examine a fresh stool in order to make the diagnosis of bloody diarrhoea.
Stool should be evaluated for all of the following characteristics:
• loose or watery
• grossly bloody (contains visible red blood)
• blood is mixed in the stool and not just streaks on the surface of a formed stool (as in the
case of anal fissure).
Most cases of acute diarrhoea in developing countries are caused by infectious gastroenteritis. Less
commonly, acute diarrhoea can be a symptom of a systemic infection or an intra-abdominal surgical
emergency.
Acute diarrhoea can also be classified as watery versus bloody diarrhoea.
Causes of acute watery diarrhoea (not an exhaustive list):

• Viruses: Rotavirus (most common pathogen among children <2 years old), enteric adenovirus
(enterovirus), measles
• Bacteria: Enterotoxigenic Escherichia coli (ETEC; common among children >2 years old),
Campylobacter jejuni, Vibrio cholera, Yersinia enterocolitica, Aeromonas
• Parasites: Giardia lamblia (most common), Cryptosporidium (children <2 years old and HIV)
Causes of bloody diarrhoea (dysentery):

• Bacteria: Shigella species (most common pathogen in children), enterohaemorrhagic E. coli,
Campylobacter jejuni, Salmonella species (typhoid fever and non-typhoid Salmonella),
Clostridium difficile
• Parasites: Entamoeba histolytica, schistosomiasis (suspect if in an endemic area)
Causes of mixed diarrhoea (watery and bloody):

• Non-typhoid Salmonella causes both watery and bloody diarrhoea with frequent mucus.
Diarrhoea is a common symptom of other diseases.

• Systemic infections associated with diarrhoea include influenza, measles, haemorrhagic
fever, HIV and malaria.
• Serious bacterial infections associated with diarrhoea include pneumonia, urinary tract
infection, meningitis and sepsis.
• Surgical emergencies such as intussusception or appendicitis also may present with
diarrhoea. These concomitant illnesses are major causes of mortality among children brought
to medical attention for acute diarrhoea.
84

The assessment of the child with diarrhoea can be divided into four components:
1. classification of the type of diarrhoeal illness
2. assessment of hydration status
3. assessment of nutritional status
4. assessment of comorbidity.
The assessment of a child with diarrhoea should include:

• Duration: acute (<14 days) or persistent (>14 days)
• Frequency: <3x day or >3x day?
• Consistency of stools: Loose or watery? Presence of mucous? Blood? Rice-water appearance
(cholera)?
• Associated signs and symptoms: Fever? Vomiting? Abdominal pain? Toxic appearance?
• Associated condition: Malaria? Pneumonia? HIV?
• Nutritional status: Malnourished? Well-nourished?
• Immune status of the child: Immunocompromised (HIV)?
• History of recent drug use (particularly antibiotics), including traditional medicines
• Family history; social and living conditions
Most children with acute diarrhoea do not require laboratory testing. Patients with seizures or
altered consciousness should have glucose and electrolyte assessment, if possible.
Hydration Status
Dehydration is a major cause of mortality, which can occur if the initial dehydration status is
underestimated and/or because the extent of ongoing fluid loss is underappreciated.
Evaluate all children with diarrhoea for dehydration, regardless of the actual number of stools or
their water content (see Table 3.3.1, Clinical classification of dehydration [WHO], and Figure 3.3.1,
Physical manifestations of dehydration). Deaths associated with diarrhoea are mainly due to dehydration.
Table 3.3.1 Clinical classification of dehydration (WHO)
Classification Signs or symptoms

Two or more of the following signs:
• lethargy or unconsciousness
Severe dehydration • sunken eyes
• unable to drink or drinks poorly
• skin pinch goes back very slowly (≥ 2 sec)
Two or more of the following signs:
• restlessness, irritability
Some dehydration • sunken eyes
• drinks eagerly, thirsty
• skin pinch goes back slowly
No dehydration Not enough signs to classify as some or severe dehydration
85
Figure 3.3.1 Physical signs of dehydration
Watery stool Dry mouth
Little or no urine
Sleepy
Sunken eyes Weak rapid pulse

Low BP
A pinch of the skin
goes slowly back
Skin pinch: Pinch the abdominal skin to assess skin turgor. Skin pinch goes back very slowly (≥2 seconds)
in severe dehydration. Note: This sign is not reliable in children with severe acute malnutrition (SAM).
Figure 3.3.2 Skin pinch
Dehydration in SAM
Dehydration is difficult to diagnose in malnourished children because malnutrition often masks the
classic signs:
• Kwashiorkor: Hypovolaemia/shock can be masked by oedema
• Marasmus: The skin fold test has no value if the subcutaneous tissue has completely
disappeared because the persistent and doughy character applies to this subcutaneous tissue
(deep pinch). Eyes can be deeply sunken without dehydration.
Look for a history of repeated vomiting or copious watery diarrhoea. Thirst, irritability and agitation
may also be manifestations of dehydration. Weight loss can be used as an indicator if weight before
the onset of diarrhoea is known. Assume that all children with SAM who have watery diarrhoea have
some dehydration. Due to the clinical presentation of children with SAM, severe dehydration is easily
over-diagnosed.
86
Treatment consists of correcting fluid losses through rehydration, administering appropriate
nutrition, administering zinc supplementation and managing associated diseases.
Principle of treatment: fluids+ zinc (except for malnourished children, as it is contained in their
therapeutic food) + early feeding (to alleviate the risk of falling into malnutrition)
Fluid Management
The approach to fluid management depends on the degree of dehydration and consists of two
phases: replacement (replenish deficits in water and electrolytes lost) and maintenance (replace
ongoing losses of water and electrolytes).
There are two types of rehydration fluids available in MSF projects:

1. Oral rehydration solution (ORS): ORS with low osmolality is a mixture of water, salts and
glucose. Treatment with ORS is the first-line therapy in non-SAM patients who have mild to
moderate dehydration. Give the first cup of ORS at the hospital and ensure that the child is not
vomiting all fluids.
2. ReSoMal: ReSoMal is an oral rehydration solution (ORS) developed for use in severely
malnourished children. It consists of the standard WHO-ORS that has been modified by
decreasing the sodium and increasing the potassium concentrations. ReSoMal is a
rehydration solution that is to be used as prescribed. It is not intended for simple thirst, for
which water is the better solution.
Fluid administration according to degree of dehydration and nutritional status
Mild dehydration
Replace fluids lost with each loose stool or vomiting with ORS or ReSoMal for SAM (see Table 3.3.2,
Rehydration to replace ongoing losses in stool/vomit in non-SAM and SAM), or use WHO Plan A.
Table 3.3.2 Rehydration to replace ongoing losses in stool/vomit in non-SAM and SAM
Non-SAM Child with SAM
Weight
mL of ORS to be given mL of ReSoMal to be given
(kg)
(10 mL/kg for each loose stool) (5 mL/kg for each loose stool)
<5 50 25
5–10 100 50
10–20 200 100
>20 300 200
Teach and encourage the parent to give the child as much fluid as they will take.
Feed the child (early feeding)

• If breastfed, continue to breast feed as frequently and as long as the child will take the
recommended amount of ORS or clean water in addition to breast milk.
• If not exclusively breastfed: ORS and food-based fluids (such as soup, rice water and yoghurt
drinks) or clean water.
• If SAM, hospitalise and replace ReSoMal with equivalent volumes of F75 or F100 at feeding time.
87
Moderate dehydration
Non-SAM
Give the recommended amount of ORS in the clinic or hospital for four hours (see Table 3.3.3,
Rehydration in non-SAM with moderate dehydration).
Child should continue to breastfeed while they are receiving ORS (see previous)
Table 3.3.3 Rehydration in non-SAM with moderate dehydration (WHO Plan B)
ORS 75 mL/kg over 4 hours

10 to 12 to 14 to 16–
Weight (kg) <4 4 to <6 6 to <8 8 to <10
<12 <14 <16 20
Volume per
75 95 130 170 205 245 280 340
hour (mL)
Volume to give
300 375 525 675 825 975 1125 1350
in 4 hours (mL)
Note: Admit children who have dehydration and are younger than 4 months and/or less than 4 kg to
the hospital. Management in these children should be tailored to the child’s individual status.
SAM
Admit to the hospital for rehydration. Start with ReSoMal to treat dehydration: 20 mL/kg/hour for
first 2 hours, then 10 mL/kg/hour thereafter (on doctor’s orders; See Table 3.3.4, Rehydration in SAM
with moderate dehydration). Re-evaluate every two hours and reassess clinical progress and weight
prior to continuing treatment; adjust treatment to clinical evolution.
Table 3.3.4 Rehydration in SAM with moderate (or severe) dehydration
First 2 hours: 20 mL/kg/hour After 2 hours: 10 mL/kg/hour

Weight
(kg) mL to give every 15 min mL to give every 30 min
mL/hour mL/hour
PO or NGT* PO or NGT*
2 40 10 20 10
3 60 15 30 15
4 80 20 40 20
5 100 25 50 25
6 120 30 60 30
7 140 35 70 35
8 160 40 80 40
9 180 45 90 45
10 200 50 100 50
11 220 55 110 55
12 240 60 120 60
13 260 65 130 65
14 280 70 140 70
*If the child does not tolerate oral fluids, give fluids via nasogastric tube (NGT); ensure child is in a
semi-reclined position or sitting upright to avoid aspiration.
88
Note: Rehydration does not substitute or preclude from starting feeding; at the hours when
therapeutic milk is given, SAM children should receive both milk and rehydration solution.
ReSoMal should be stopped if any of the following signs develop:
• respiratory rate or heart rate increases
• oedema appears (eyelids and/or lower extremities)
• abdomen becomes distended.
Clinical improvement during treatment is the best indicator of treatment response.
Severe dehydration
• Admit to the hospital for stabilisation.
• Use ABCD approach.
• If in shock, refer to shock protocol (chapter 3.2) and figure 3.2.1.
• If not in shock:
o Non-SAM: Start IV fluids immediately; if child can drink, give ORS by mouth while
drip is being set up. For iv rehydration follow table 3.3.5. below.
o SAM: Treat as moderate dehydration (table 3.3.4.). If child does not tolerate
oral/NGT fluids and/or is clinically instable, start IV fluids. For 2 hours give D5%/RL, 2
x maintenance fluids or more depending on ongoing losses and clinical condition.
Monitor closely (ER or ICU) for deterioration, shock of fluid overload and treat
accordingly. Give oral rehydration (ReSoMal) and feeds as soon as possible.
• If possible, monitor urine output.
• Test glucose and treat hypoglycaemia if present.
Table 3.3.5 Rehydration in severe dehydration (WHO Plan C)

Give 100 ml/kg Ringer’s lactate solution (or, if not available, normal saline), divided as follows:
Age First give 30 ml/kg in: Then give 70 ml/kg in:
Infants
1 hour 5 hours
(< 12 months)
Children
30 minutes 2½ hours
> 12 months
Reassess the child every 15–30 min.

If hydration status is not improving, give the IV drip more rapidly.
Monitor continuously for signs of fluid overload:
• increased RR by ≥10 breaths/min into the tachypnoeic range, or
• increased HR by ≥20 beats/min into the tachycardic range.
PLUS any one of the following:
• new or worsening hypoxia (decrease in SpO2 by >5%)
• new onset of rales and/or pulmonary oedema (fine crackles in lung fields)
• new galloping heart rhythm
• increased liver size (liver size must have been marked with pen on arrival)
• new peripheral oedema and/or puffy eyelids.
Also, give ORS (about 5 ml/kg per h) as soon as the child is awake and alert and can tolerate a
nasogastric tube or take fluids (usually after 3–4 hr in infants and 1–2 hr in children).
Reassess an infant after 6 hr and a child after 3 hr: reclassify dehydration, then choose the
appropriate plan (e.g. plan B or repeat Plan C) to continue treatment.
89
After resuscitation
Continue ORS PO or NGT as outlined in the tables above (depending on state of hydration and
nutrition). However, if child has decreased consciousness or is intolerant of nasogastric tube because
of vomiting, give 1.5x maintenance fluids (1.0 x in SAM) IV for 24 hours then switch to standard
maintenance.
Do not give antimotility agents (atropine, loperamide and tincture of opium), as they increase the risk
paralytic ileus. Do not give antiemetics (chlorpromazine, promethazine and metoclopramide) due to
the risk of extrapyramidal reactions and respiratory depression.
Treat other causes of diarrhoea (malaria, measles, etc.) if present.
In non-SAM children, administer zinc. Zinc supplementation reduces the severity and duration of
diarrhoea and reduces the incidence of subsequent episodes of diarrhoea for several months. (Do
not use in SAM as zinc is already contained in ready-to-use therapeutic food (RUTF).
For all diarrhoea (both watery and/or bloody) if child <5 years:
• For child 6–59 months: 20 mg/day x 10 days
• For child <6 months: 10 mg/day x 10 days
Other considerations
• Evaluate all children with persistent diarrhoea for malnutrition and HIV.
• Feeding:
- Encourage early resumption of food to prevent malnutrition.
- Infants with diarrhoea should breast feed as soon as possible.
- Children older than 6 months with diarrhoea should be encouraged to take solid foods
immediately after initial dehydration is corrected; for children with SAM, reintroduce
feeds with F75 in the first 12 hours as soon as clinical condition stabilises.
Antibiotics
Antibiotics are not indicated for most children with acute watery diarrhoea. Suspected cholera is an
important exception in which antibiotic therapy is useful.
Antibiotics are indicated for children with acute bloody diarrhoea and verified blood in stool. Empiric
antibiotic therapy for acute bloody diarrhoea should be targeted against Shigella species.
Severe illness
If the child is severely ill, hospitalise and treat for presumptive shigellosis (Shigella is the most
frequent cause of dysentery) with ceftriaxone IV/IM 75 mg/kg/day 2x/day (maximum 2 g) for 2–5
days. If no improvement (treatment failure defined by persistent fever, grossly bloody stools or
unchanged stool frequency by day 3 of therapy), antibiotic-resistant infection or an alternative
infectious aetiology should be considered (Amoebiasis; Clostridium difficile, etc.). Stop ceftriaxone IV
and start ciprofloxacin 30 mg/kg/day PO (divided twice daily) for 3 days + metronidazole 30
mg/kg/day PO in divided doses 3x/day for 7–10 days.
90
Non-severe illness
If child is well appearing and has bloody stools, give ciprofloxacin 30 mg/kg/day PO (divided twice
daily) for 3 days (per doctor’s prescription). If the child is not improved in 3 days, continue or switch
to ceftriaxone and add tinidazole 50 mg/kg for 3 days or metronidazole 30 mg/kg/day PO in divided
doses 3x/day for 5 days.
Persistent diarrhoea
Persistent diarrhoea is defined as loose or watery stools occurring at least three times a day for more
than 14 days despite treatment; the change in stool consistency is more important than stool
frequency.
Treatment includes albendazole for three days. If HIV is possible, consider co-trimoxazole prophylaxis
(especially if SAM) and provide access to VCT and ARV.
Giardia lamblia
Giardia lamblia is the most common parasite in the world. The highest rates of infection occur among
children younger than 5 years. Suspect G. lamblia in cases of diarrhoea (sudden in onset; initially may
be watery), malaise, nausea/vomiting, foul-smelling and fatty stools (steatorrhea), abdominal cramps
and bloating and weight loss; fever occurs occasionally.
Treatment includes tinidazole 50 mg/kg (max 2 g) single dose PO or metronidazole 10 mg/kg/dose

3x/day PO (max 2 g) x 3 days.
Amoebiasis
Amoebiasis is a cause of both persistent and bloody diarrhoea, but it is an unusual cause of bloody
diarrhoea in young children.
Amoebic dysentery is characterised by diarrhoea (usually bloody), abdominal pain and tenesmus.
Amoebic liver abscess is characterised by a painful, enlarged liver; possible mild jaundice; poor
appetite and weight loss; nausea and vomiting; and intermittent fever, sweating or chills.
Treat for amoebiasis only if Shigella has been treated for without clinical improvement. Give
tinidazole 50 mg/kg 1x/day PO (max 2 g) x 3 days (for intestinal amoebiasis and hepatic amoebiasis)
or x 5 days (for amoebic dysentery); metronidazole 15 mg/kg/dose 3x/day PO x 10 days can be given
for hepatic amoebiasis.
91
Figure 3.3.3 Algorithm for diarrhoea
Management of diarrhoea (excluding cholera)

Defined as ≥3 watery diarrhoeal stools over 24 hours
Assess and treat dehydration: ORS + zinc + continue breastfeeding
Temperature ≥39°C
No Yes
Bloody diarrhoea
Look for other causes of fever with diarrhoea:
malaria, pneumonia, meningitis, sepsis, etc.
No Yes Consider ATB treatment as per protocol
If also rebound: suspicion of peritonitis:
Diarrhoea >2 weeks Consider Shigella, Rule out surgical causes (appendicitis, perforation,
Salmonella, intussusception, obstruction)
intussusception, etc.
No Yes If none of the above are present, consider

hospitalisation
Treat Giardia: Tinidazole x 1 dose Assess and treat dehydration
Rehydration (ORS or other, depending on condition
and comorbidities)
Improved Zinc 20 mg per day x 10–14 days (10 mg per day for
infants <6 months old)
No Yes
Continue ORS and zinc and follow up in 48 hours if

Test for HIV not improved/diarrhoea continues or if child
Ensure adequate deteriorates
nutrition/avoid
malnutrition
92
3.4. Renal Disorders

Acute Cystitis ......................................................................................................................................... 94
Urinary Tract Infection (UTI) and Pyelonephritis .................................................................................. 95
Postinfectious Glomerulonephritis........................................................................................................ 98
Nephrotic Syndrome .......................................................................................................................... 100
93
Acute Cystitis
Causes
Cystitis is a lower urinary tract infection of the bladder in a child older than 2 years without fever. The
most common pathogen is Escherichia coli.

Patients with acute cystitis usually present with lower urinary tract symptoms, include:
• dysuria (pain on urination)
• frequency
• incontinence in a child who is toilet trained
• urgency
• enuresis in a child who does not routinely wet the bed at night
• abdominal or suprapubic pain
• haematuria.
Children with acute, uncomplicated cystitis usually do not have fever or systemic complaints. Fever
>38 degrees Celsius, chills or flank pain suggest upper urinary tract infection rather than acute
cystitis. In this case, treat as pyelonephritis.
Diagnosis
Cystitis is diagnosed via anamneses (fever, vomiting, urinary symptoms, etc.) physical examination
(flank pain, blood pressure, etc.) and laboratory tests.
• Urine dipstick:
- Nitrites indicate the presence of enterobacteria.
- Leukocytes indicate infection in the urine.
- If the dipstick is negative for both nitrites and leukocytes, a urinary tract infection is
excluded.
• If urine microscopy/culture is available, use it to confirm the infection and identify the
pathogen responsible.
Note: In areas where urinary schistosomiasis is endemic, consider schistosomiasis in children with
macroscopic haematuria or microscopic haematuria detected by dipstick test. The child may have
both a urinary tract infection and schistosomiasis. In addition, always test for malaria in malaria-
endemic areas.
Management
For acute uncomplicated cystitis in children >2 years of age, give cefixime PO 8 mg/kg 1x/day for 3
days or amoxicillin/clavulanic acid PO 20–25 mg/kg/dose 2x/day for 3 days.
94
Urinary Tract Infection (UTI) and Pyelonephritis
Causes
In children ≤2 years, it is difficult to differentiate pyelonephritis, an upper urinary tract infection of
the kidney, from acute cystitis, a lower urinary tract infection of the bladder that is characterised by
voiding-related symptoms without fever or other systemic signs. The most common causative
pathogen is Escherichia coli, followed by other enterobacteria.
In MSF contexts, febrile UTI will be assumed to be pyelonephritis in children <2 years of age. For the
management of acute cystitis in children older than 2 years, see the previous section (Acute Cystitis).

The manifestations of UTIs vary with age, being particularly non-specific in infancy. UTIs in infants
may cause fever, vomiting, diarrhoea, irritability and sepsis. Beyond 2 to 3 years of age, symptoms
more often point to the urinary tract. For all practical purposes, strict differentiation between upper
and lower tract diseases in children is not feasible in most cases, and children who are febrile should
be assumed to have pyelonephritis.
The most common symptoms in children with UTI/pyelonephritis include the following:
• unexplained crying in the young child
• dysuria, frequency or both
• new-onset urinary incontinence
• malodorous urine
• abdominal pain, particularly pain on percussion in flanks
• decreased appetite and general malaise
• ill-appearing child
• fever.
Diagnosis
UTIs/pyelonephritis are diagnosed via anamneses (fever, vomiting, urinary symptoms, etc.), physical
examination (flank pain, blood pressure, etc.) and laboratory tests.
• Urine dipstick:
- Nitrites indicate the presence of enterobacteria.
- Leukocytes indicate infection in the urine.
- If the dipstick is negative for both nitrites and leukocytes, a urinary tract infection is
excluded.
• If urine microscopy/culture is available, confirm the infection and identify the pathogen
responsible.
Note: In areas where urinary schistosomiasis is endemic, consider schistosomiasis in children with
macroscopic haematuria or microscopic haematuria detected by dipstick test. The child may have
both a urinary tract infection and schistosomiasis. In addition, always test for malaria in malaria-
endemic areas.
95
Management
Children younger than 2 years with a febrile UTI or pyelonephritis should be hospitalised. Administer
ceftriaxone 50 mg/kg 1x/day (maximum 2 g) IV/IM until the child can tolerate oral medication.
Reassess the child daily.

• If improved (no more vomiting, eating and drinking, lack of fever, general appearance, urine
analysis improved) and PO after 48 hours of IV ceftriaxone, continue IV ceftriaxone for a total
of 3 days, then discharge on oral antibiotics as below.
• If not improved after 48 hours of IV ceftriaxone, add gentamycin 5 mg/kg/day IV 1x/day and
continue for at least 48 hours. Once improved and PO, discharge on oral antibiotics as below.
• If not improved by the 4th day of IV antibiotics, discontinue ceftriaxone and gentamycin and
give ciprofloxacin 10 mg/kg/dose 2x/day x 7 days (the child should remain in the hospital for
the entire treatment).
Supportive therapy includes ensuring adequate fluid and caloric intake if the child is NPO (see
Chapter 7.1, Maintenance Fluids), treating fever (to improve the patient’s comfort) and providing
analgesia if the child is in pain. Vital signs should be checked according to the patient’s clinical
condition, and urine output should be monitored daily.
Upon discharge, the patient should be prescribed cefixime PO 8 mg/kg/day for 7 days.
96
Figure 3.4.1 UTI treatment algorithm for children older than 30 days*
Temperature >39ºC for ≥48 hours in the absence of another source for fever
Evaluate for the presence of sepsis and treat
Urine dipstick obtain urine via clean catch, urine bag or procedure by skilled
clinician (bladder catheterisation or suprapubic aspiration)
Positive dipstick = leucocyte ≥++ and/or nitrite ++
Evaluate for the presence of sepsis and treat
Hospitalise and give ceftriaxone 50 mg/kg 1x/day (maximum dose: 2 g) x 2 days
No Improved after 48 hours? Yes
Add gentamycin IV/IM 5 mg/kg

Continue ceftriaxone for a total of 3 days
1x/day x 5 days
Improved 48 hours later?
Discharge when PO on cefixime 8 mg/kg

No Yes
1x/day for 7 days
Discontinue ceftriaxone and

gentamycin and switch to
ciprofloxacin PO 10 mg/kg/dose
2x/day x 7 days
*For infants younger than 30 days, see neonatal guidelines.
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Postinfectious Glomerulonephritis
Causes
Acute post-infectious glomerulonephritis (PIGN) is a reactive immunological process against the
kidney secondary to an infection (skin and throat diseases), classically caused by a Streptococcus
spp.; other bacteria also cause the syndrome (e.g., Staphylococcus aureus).
It is most common in children 5–12 years of age and is rare before the age of 3 years.

The typical clinical presentation of PIGN is an acute nephritic syndrome with macro- or microscopic
haematuria (red to brown urine), proteinuria, hypertension, oedema and renal function impairment
of variable degrees.
• In some cases, full-blown acute nephritic syndrome develops, which is characterised by red
to brown urine, proteinuria (up to +++), oedema, hypertension and an elevation in serum
creatinine.
• Generalised oedema is present in about two-thirds of children due to sodium and water
retention. In severe cases, fluid overload leads to respiratory distress due to pulmonary
oedema.
• Gross haematuria is present in about 30 to 50% of children. The urine looks smoky and tea or
cola coloured.
• Hypertension is usually present and varies from mild to severe.
Diagnosis
PIGN is typically diagnosed based upon the findings of acute nephritis and demonstration of a recent
group A beta-hemolytic streptococcal infection.
The following laboratory tests should be performed:

• urine dipstick for blood and protein
• microscopic urinalysis (if available)
• blood urea nitrogen (BUN) and creatinine (if available)
• electrolytes (if available)
• Strep A test (may not be positive if it has been longer than 2 weeks since pharyngitis)
Make a clinical diagnosis if the child has haematuria (≥ + blood on urine dipstick) and either oedema
or hypertension (See Table 3.4.1, Oedema documentation, for example of how to record the extent
of severity of oedema). Note that a history of streptococcal infection (pharyngitis, impetigo or
erysipelas) may not always be present (the child may have had an asymptomatic infection).
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Table 3.4.1 Oedema documentation

Patient Name:
Extent Severity
Face Moderate
Upper limbs Moderate
Hands Mild
Lower limbs Severe
Feet Severe
Management
There is no specific treatment for PIGN. Management is supportive and is focused upon treating the
fluid overload that causes the clinical complications of PIGN.
Treat persistent streptococcal infection (with penicillin or amoxicillin or, if the patient is allergic,
erythromycin). Sodium restriction (no added salt to any of the child’s food) should be implemented if
generalised oedema is present. Fluid restriction should not be attempted in children living in hot
countries who are not hospitalised as dehydration and renal failure may result.
In-hospital diuretic therapy is indicated for the reduction of blood pressure and treatment of
oedema. Give furosemide PO 1 mg/kg 1–2x/day; can repeat the dose in 6 hours if the child has not
urinated (See Table 4.4.2, Furosemide tablet dosage). If the child is NPO, give furosemide 1 mg/kg IV;
this can be repeated once in 2 hours. Give every 8 hours.
Note: Furosemide causes hypokalaemia. Give fluids containing potassium to any child on furosemide
and offer potassium-rich food such as white beans, dark green vegetables, fish, avocado and bananas.
Table 3.4.2 Furosemide tablet dosage
Age 1–5 years 5–15 years

Weight 8–15 kg 15–35 kg
40-mg tablet of furosemide 1/4 tablet ½ tablet
Hypertension will usually respond to diuretics. Monitor the patient closely according to his or her
clinical condition. Blood pressure and urinary output should be monitored daily, along with
electrolytes (if available and until the patient is stable). In addition, monitor serum creatinine once a
week (if available).
Resolution of symptoms
The clinical manifestations usually resolve quite rapidly once the infection is treated.
• The oedema resolves within a week as the child has a diuresis.
• The serum creatinine returns to the previous baseline by 3 to 4 weeks.
• The proteinuria may be much slower to recover.
• The outlook for most children is very good.
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Nephrotic Syndrome
Causes
Nephrotic syndrome is defined by the excretion of excessive amounts of protein into the urine,
oedema, hypoalbuminemia and hyperlipidaemia. The first two signs are generally used for a clinical
diagnosis.
Minimal change disease (MCD) is a very common form of nephrotic syndrome in children (especially
in those younger than 6 years) and the only form that can be managed in a general medical setting.

A presumptive diagnosis of MCD can be made based upon clinical findings: presence of oedema and
hyperproteinuria with normal renal function and absence of hypertension and severe haematuria.
Oedema is the major clinical sign and varies in location based on position and activity. Upon awaking,
the child has periorbital oedema. Over the day, periorbital oedema decreases and oedema of the legs
increases. The oedema is soft, pitting and painless. As oedema worsens, it may localise to the back
and genitals and progress to generalised oedema with ascites and pleural effusions. In a child
presenting with oedema, look for hyperproteinuria by urine dipstick.
Oliguria may be present; evaluate for intravascular volume depletion (measure BP, HR and CRT).
In a child previously treated for nephrotic syndrome, relapse is defined as reappearance of

proteinuria and oedema any time after successful steroid treatment.
Differential Diagnosis
The main differential diagnosis for nephrotic syndrome is kwashiorkor (see Table 3.4.3, Nephrotic
syndrome vs. kwashiorkor).
Table 3.4.3 Nephrotic syndrome vs. kwashiorkor

Nephrotic syndrome Kwashiorkor
Oedema of the hands/feet, followed
Oedema of the face, followed by
by face
legs
Oedema Ascites rare
Ascites common
Generalised oedema depends on
Generalised oedema frequent
severity
Urine dipstick Protein +++ Protein negative or +
Skin/hair changes No Common
Mental state Clear, attentive Irritable, inattentive, apathetic
Other differential diagnoses include other causes of generalised oedema (Vitamin B1 deficiency,
heart failure, protein-losing enteropathy, anaphylaxis, etc.).
100
Diagnosis
Laboratory testing includes both urine and blood tests.
Urine tests:
• Measure protein: Perform a urine dipstick test on two voided urine samples. Urinary
dipsticks may vary depending on manufacturer, but nephrotic-range proteinuria is equal to
or greater than +++ (or equal to or greater than 300 mg/dL [30 g/L]).
• Haematuria: In case of macroscopic haematuria or haematuria on dipstick (equal to or
greater than ++), consider glomerulonephritis and other causes, such as schistosomiasis in
endemic areas.
Blood tests (if available):

• creatinine and blood urea nitrogen
• serum sodium (hyponatremia is possible)
• serum albumin concentration less than 30 g/L (usually not available).
• presence of hyperlipidaemia (but cholesterol testing usually not available).
Confirmatory diagnosis would require a renal biopsy.
Management
Note: Children younger than 1 year and older than 10 years, children with third relapse/frequent
relapses/corticosteroid-resistant nephrotic syndrome or mixed nephrotic and nephritic clinical
picture require further investigations (renal biopsy, etc.) and specialised advice and management.
Corticosteroid treatment
Most children with MCD respond to corticosteroids; however, they should only be used if all the
following criteria are met:
• nephrotic-range proteinuria, haematuria less than ++ and no macroscopic haematuria
• between 1 and 10 years of age
• blood pressure is within normal range for age
• no bacterial infections (any infections should be treated prior to steroid administration)
• active tuberculosis excluded or treatment has been initiated.
Initial therapy
Give prednisolone or prednisone PO 2 mg/kg once daily in the morning for 6 weeks (maximum 60
mg/day), then reduce to 1.5 mg/kg every other day for 6 weeks. Complete all 12 weeks of treatment
regardless of clinical or laboratory improvement. After 12 weeks, taper by 0.5 mg/kg every other
week over 8 weeks for a total length of treatment of 4.5 months. If the child develops symptoms of
gastritis, treat with omeprazole PO 0.7 to 1 mg/kg once daily.
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First or second relapse

Give prednisolone or prednisone PO 2 mg/kg once daily in the morning (maximum 60 mg/day) until
proteinuria is negative or trace for 3 consecutive days. Once proteinuria is acceptable, give 1.5 mg/kg
every other day for 4 weeks, then taper as above.
Other considerations
Nutrition, fluid intake, nursing and follow-up
• Instruct parent(s) to give the child a no-salt-added, balanced diet that is adequate in proteins
and calories.
• Do not restrict fluids (risk of thrombosis due to hypercoagulability).
• If oedema is very severe or in cases of renal failure or hyponatremia, fluids may initially be
restricted (e.g., 75% of usual oral intake) while monitoring urine output.
• Encourage the child to walk and play to prevent thromboembolism.
• Discharge the child when stable, follow up monthly and record weight at each visit.
• If the child has a fever, abdominal pain, respiratory distress or signs of thromboembolism,
seek medical advice.
Infection management
Treat infections as soon as they appear, but do not give prophylactic antibiotics.
Immunisation
For children younger than 5 years, check that the patient has received all EPI vaccines, including
Haemophilus influenza type B, conjugated pneumococcal vaccine and (if in an endemic area)
meningococcal A conjugate vaccine.
For children older than 5 years, administer tetanus, measles, pneumococcal conjugate and (if in an
endemic area) meningococcal A conjugate vaccine.
Complications
Children with nephrotic syndrome are at increased risk of thromboembolism, severe bacterial
infections (in particular due to Streptococcus pneumonia) and malnutrition. Untreated nephrotic
syndrome may lead to renal failure.
Management of complications
In cases of severe respiratory distress/failure (due to pleural effusions or marked ascites):
• Place the patient in a semi-recumbent position and administer oxygen.
• Perform removal of ascites or pleural fluid under aseptic conditions and with adequate pain
management. Remove only the volume of fluid sufficient to alleviate symptoms (removal of
large volumes of fluid can cause shock).
• If such a procedure cannot be performed, treat with diuretics as for oedema, below.
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For severe oedema (i.e. eyes swollen shut):

• Administer diuretics with caution and only if circulation is good (warm hands, no tachycardia,
strong pulse, adequate capillary refill).
- Give furosemide PO 1 mg/kg/day in two divided doses plus spironolactone PO 2 mg/kg/day
in 2 divided doses until symptoms resolve.
• While the patient is on diuretics, monitor for dehydration, thromboembolic complications
and hypokalaemia (if available).
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3.5. Metabolic Disorders

Hypoglycaemia .................................................................................................................................... 105
104
3.5. Metabolic Disorders
Hypoglycaemia
Note: The following information is to be used for children between the ages of 1 month and 5 years.
For neonates, refer to MSF neonatal care guidelines.
Causes
Neonates and young children are unable to maintain normal plasma glucose concentrations after
even a short fast (24–36 hours). These children are at a greater risk of hypoglycaemia if their oral
intake is interrupted.
Hypoglycaemia in infants and children requires prompt recognition and treatment to prevent
permanent neurologic sequelae.
All severely sick children should have their blood glucose tested when admitted to the hospital; if
that is not possible, treat for hypoglycaemia as suggested below. In endemic areas, the patient has to
be tested for malaria.
Common causes of hypoglycaemia include malaria; dehydration; anorexia, fasting and malnutrition;
sepsis and bacterial infection; incorrect management of a known diabetic; and toxic ingestions such
as ethanol, methanol and ethylene glycol.

Signs of hypoglycaemia include irritability, jitteriness, feeding problems, lethargy, cyanosis,
tachypnoea, hypothermia, weakness, seizures and coma. However, keep in mind that these signs are
not specific for hypoglycaemia and may be early manifestations of a number of other disorders,
including sepsis, malaria and respiratory distress syndrome.
Diagnosis
Hypoglycaemia is diagnosed via blood glucose levels. The cut-off points for treatment of
hypoglycaemia in MSF settings are as follows:
• Neonate (younger than 30 days): blood glucose ≤45 mg/dL (2.5 mmol/L)
• All other children: blood glucose ≤60 mg/dL (3.3. mmol/L)
105
Treatment of hypoglycaemia varies with the degree of hypoglycaemia and the associated symptoms.
For children who are conscious and are able to drink and swallow safely, provide treatment orally.
• Give a sugar-containing drink or snack by mouth, such as:
- 1–2 teaspoons of table sugar moistened with water
- 60 mL fruit juice, milk, therapeutic milk (if SAM) or breast milk
- 5–10 mL honey
- 10 mL/kg of D10% orally or via NGT (with child in semi-seated position)
- 1 mL/kg of D50% under the tongue (D50% is only given orally, never via IV)
• If the child is conscious and able to eat, feed the child as soon as possible.
• Repeat blood glucose test in 15 to 30 minutes.
• If the child is still hypoglycaemic, administer a bolus (5 mL/kg) of D10% IV and start
maintenance fluids with D10%-RL (see Chapter 7).
If the child is unconscious or cannot drink, obtain IV/IO access and treat as follows:
• Administer an IV bolus of D10% 2 mL/kg over 2–3 minutes (never use Glucose 50% without
diluting it).
• After the IV bolus, start maintenance fluids with D5%-RL, unless already on maintenance
D5%/RL, in which case change maintenance to D10%/RL.
• Repeat blood glucose test in 30 minutes.
• Repeat IV bolus of 2 mL/kg D10% if still hypoglycaemic after 30 minutes, followed by
maintenance of D10%/RL.
• (See Chapter 7 for how to prepare fluids).
If there is a delay in obtaining IV/IO access, an unconscious child can be given 10 mL/kg D10% via
NGT (sit the child upright).
Monitoring
Initially, blood glucose should be tested every 30 minutes and the IV rate adjusted until glucose is
stable between 70 and 120 mg/dL (3.9 to 6.7 mmol/L) for two subsequent measurements.
Thereafter, check glucose every 2 to 3 hours until it is stable for another two consecutive
measurements.
106
3.6. Fever and Sepsis

Fever and Sepsis .................................................................................................................................. 108
107
Fever and Sepsis
Introduction
Fever is considered (for all ages) when temperature ≥38 degrees Celsius. Fever is not an illness itself,
but a physiologic response to illness.
Sepsis is a clinical syndrome resulting from severe infection. It includes inflammation, immune
dysfunction, impaired circulation in the capillaries and oxygen debt, and can therefore lead to
major/multiple organ failure (MOF) and death.

Note that, for fever lasting >3 days, there is an increased risk of bacteraemia, which may lead to
sepsis.
Determine if the child is immunocompetent (risk for HIV, known HIV-positive child, severe acute
malnutrition, sickle cell anaemia) and if the child is completely immunised.
Examine the febrile child, looking for the signs and symptoms listed below:
• increased HR, increased RR, SpO2 ≤95%, nasal flaring, retractions or use of accessory muscles,
rales or decreased breath sounds (pneumonia)
• runny nose and/or cough (croup, bronchiolitis)
• lesions in the oropharynx (Herpes or Coxsackie virus)
• ear pain (otitis media)
• sore throat (pharyngitis, tonsillitis)
• abdominal tenderness (appendicitis, peritonitis)
• pain with bone palpation or passive joint range of motion (septic arthritis, osteomyelitis)
• skin findings, such as petechiae or purpura (meningococcemia, dengue or other viral
illnesses)
• red, warm, tender skin (cellulitis, abscess)
• rash (measles, varicella, roseola, drug reaction)
• stiff neck (meningitis), seizures, altered mental state
• history of diarrhoea or vomiting (gastroenteritis)
• pain on urination and/or back and flank pain (cystitis, pyelonephritis)
• anaemia, jaundice, generalised body pain (sickle cell disease).
Sepsis can be diagnosed in a child with systemic inflammatory response (SIRS) accompanied by
suspected or proven infection. A diagnosis of SIRS is made if the child presents with both of the
following:
• Fever or hypothermia (temperature >38.5 degrees Celsius or <36 degrees Celsius) or elevated
leukocyte (WBC) count (if appropriate testing is available)
• Tachycardia, bradycardia (in children younger than 1 year) or tachypnoea
108
A presumptive diagnosis of sepsis in MSF settings can be made based on the clinical presentation of
fever or hypothermia in a severely ill/prostrate child (as in these cases we would always have a
suspicion of infection). Determine if the child is severely ill or appears toxic, indicated by any one of
the following: weak cry, poor tone (floppy), impaired consciousness, does not interact with the
environment, unfocused gaze or unresponsive stare or is inconsolable. Consider common sources of
sepsis and their signs, as listed in Table 3.6.1.
Table 3.6.1 Evaluation of common sources of sepsis
Suspected site Symptoms/signs

Pharyngeal inflammation plus exudate and/or swelling and
Upper respiratory tract
lymphadenopathy
Productive cough, pleuritic chest pain, tachypnoea, consolidative
Lower respiratory tract
auscultatory findings
Urinary tract Fever, urgency, dysuria, loin pain
Indwelling pleural catheter Redness or drainage at insertion site
Wound or burn Inflammation, oedema, erythema, discharge of pus

Erythema, oedema, lymphangitis, cellulitis, abscess, infectious rash (as
Skin/soft tissue
in herpes or measles), petechiae, or purpura
Central nervous system Signs of meningeal irritation, seizures
Gastrointestinal Abdominal pain, distension, diarrhoea and vomiting
Intra-abdominal Specific abdominal symptoms/signs

Girls: Lower abdominal pain, vaginal discharge
Genital tract
Boys: Dysuria, frequency, urgency, incontinence, cloudy urine
Joint and bone Bone or joint swelling, pain, warmth, decreased range of motion
Management
Fever is an important clinical sign, most often of underlying disease. The first step in the
management of fever is to determine its cause.
Rapid recognition and treatment of sepsis improves outcomes. Antibiotics must be chosen judiciously
according to presumed aetiology.
If a source is not evident

If the child is “well” appearing (not severely ill):
• Test for malaria if endemic.
• Urine dipstick; if positive, treat for UTI.
• Do not automatically treat with antibiotics if there is no obvious infection source and reason
to do so.
• Provide paracetamol for the child’s comfort.
• Advise follow-up return in 24 hours if fever persists.
• Advise to complete immunisation.
109
If the child is ill appearing, do the following (regardless of immunisation status):

• ABCD (NB, if septic shock then refer to shock section).
• Admit to hospital.
• Give malaria test (even if malaria test is positive, continue with investigations in list below).
• Check haemoglobin if malaria is positive or if severely ill or pale.
• Urine dipstick; if positive, treat for UTI.
• Obtain white blood cell count (if available).
• Perform blood culture if available (minority).
• If respiratory signs, perform CXR (if available).
• If signs of meningitis or if child is younger than 1 year of age and ill appearing, and CSF testing
is available and there are no contraindications, perform a lumbar puncture.
• Give empirical treatment with ceftriaxone IV/IM 50 mg/kg/dose 1x/day (maximum dose 2 g;
100 mg/kg/day if suspicion of meningitis)
• If any of the exams above reveal indication of specific disease, treat accordingly.
• For sepsis without shock, administer maintenance fluids.
Antibiotics
Administer antibiotics promptly to all children with sepsis and septic shock.
If the child is in septic shock, the antibiotic of choice will most likely be ceftriaxone, especially if the
sepsis is of unknown origin. The first dose can be given rapidly.
If possible, adjust according to specific condition (see Table 3.6.2, Antibiotics for sepsis in a child
older than 2 months).
Duration of therapy should be determined by the child’s clinical condition and response to
treatment. Treat IV/IM for at least three days (except for CNS infection, where IV treatment is
preferred for entire course of treatment). If child is improving and is eating and drinking, switch to
oral relay; in the case of ceftriaxone or ampicillin + gentamycin, this is most likely
amoxicillin/clavulanic acid PO to complete a total of 7–10 day of antibiotics. In case of sepsis of
intestinal origin, the oral switch should be to ciprofloxacin +/- metronidazole (duration of treatment
depends on pathology, please refer to respective chapter for more specific information).
110
Table 3.6.2 Antibiotics for sepsis in a child older than 2 months
Source Antibiotic therapy

Sepsis of unknown
origin
Ceftriaxone IV or IM 100 mg/kg/day divided into one or two doses
(See Chapter 3.2,
Sepsis and Shock)
Urinary tract
Ceftriaxone IV 50 mg/kg 1x/day (maximum dose 2 g)
(See Chapter 3.4,
Add gentamycin IM/IV 5 mg/kg/dose 1x/day if not afebrile after 48 hours of ceftriaxone
Renal Disorders)
Intra-abdominal Ceftriaxone IV 75 mg/kg 1x/day (maximum dose 2 g) and metronidazole IV 10 mg/kg/dose
(peritonitis) 3x/day
Gastrointestinal
(See Chapter 3.3,
Ceftriaxone IV 75 mg/kg 1x/day (maximum dose: 2 g)
Gastrointestinal
Disorders)
Ceftriaxone 50 mg/kg 1x/day (maximum dose 2 g)
Respiratory tract
(Give the same dose for patients with SAM, HIV and measles)
(See Chapter 3.1,
Respiratory Problems
If there is a suspicion of aspiration pneumonia, add metronidazole IV 10 mg/kg/dose 3x/day
and Otitis)
or clindamycin IV 10 mg/kg/dose 3x/day
Ceftriaxone IV 100 mg/kg/day divided in one or two doses (maximum dose 2 g) and
Skin and soft tissue cloxacillin IV 50 mg/kg/dose 4x/day
(See Chapter 3.10,
Skin Problems) If no response after 48 hours, stop cloxacillin IV and add clindamycin IV 10mg/kg/dose 3x/day
(if MRSA is suspected)
Bone and joint

Ceftriaxone IV 100 mg/kg/day divided in one or two doses (maximum dose 2 g) and
(See Chapter 3.9, Bone
clindamycin IV 10 mg/kg/dose 3x/day
and Joint Problems)
Central nervous
system
Ceftriaxone IV 100 mg/kg/day one or two doses (maximum dose 2 g)
(See Chapter 3.12,
Meningitis)
If child does not improve in 48 hours:

• Check if the patient is receiving antibiotics correctly (time, route, dosage, etc.).
• Re-examine the child and consider other diagnoses (HIV, TB, fungal and viral infection, fluid collection, etc.).
• Consult the medical advisor.
Once the cause is known and addressed, the main reason to treat the fever itself is to improve the
child’s comfort (as indicated by decreased activity level, decreased fluid intake, etc.). There is no
evidence that reducing fever reduces the morbidity or mortality from a febrile illness (even malaria),
nor that treating fever decreases febrile seizures, fever makes the illness worse, or that fever ≥40
degrees Celsius is associated with brain damage. A potential benefit of fever is that it may slow the
growth of some bacteria and viruses. Potential harms include patient discomfort; increased
metabolic rate, O2 consumption, HR and RR; and risk of dehydration. Thus, routine treatment of fever
is not always necessary, but fever reduction may increase the child’s comfort. The easiest way to
treat a fever is to uncover and undress the child. Do not wrap the child in wet towels.
111
Antipyretics
Antipyretic agents can also be administered. Paracetamol and ibuprofen should be used with caution
in malnourished children (see below). Aspirin (acetyl salicylic acid) is not recommended for use in
children as an antipyretic.
Paracetamol
Paracetamol should be given 15–20 mg/kg per dose (maximum dose 800 mg) PO every 6–8 hours
(maximum 80 mg/kg per day or 4 g/day; see Table 3.6.3, Paracetamol dosing for non-SAM children).
In children with SAM, prescribe only if fever is causing distress to the child; the dosage in SAM
children is 10 mg/kg every 8 hours. Prescribe for a maximum of one day and re-evaluate the need for
antipyretics.
Paracetamol can be given orally or via nasogastric tube. Do not give IV unless oral not possible; the
principal indication for paracetamol IV in paediatrics is the child who is NPO and in pain or with a
fever before or after surgery.
Table 3.6.3 Paracetamol dosing for non-SAM children
Weight in kg Dose in mg 100-mg tablet Liquid 120 mg/5 mL: dose in mL

4 60 ½ 2.5
5 75 3/4 3
6–8 90–120 1 5
9–11 135–165 1½ 6
12–14 180–210 2 8
15–17 225 2½ 10
18–20 270 3 12
Ibuprofen
Ibuprofen should not be given to children younger than 6 months of age or those with severe
dehydration, renal failure or gastrointestinal bleeding.
Dose is 10 mg/kg per dose PO every 6 hours (maximum 40 mg/kg/day; see Table 3.6.4, Ibuprofen
dosing in non-SAM children) with milk or food (giving with food or milk helps reduce the risk of
gastrointestinal irritation). For children with SAM, do not give in Phase I; dose otherwise is 5 mg/kg
every 8 hours (see nutrition guidelines).
Table 3.6.4 Ibuprofen dosing in non-SAM children

Liquid 100 mg/5 mL
Weight in kg Dose in mg 200-mg tablet
Dose in mL
4–5 40–50 2
6–7 60–70 3 Not applicable
8–9 80–90 4
10–14 100–140 Not applicable ½
15–20 150 – 200 Not applicable 1
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External Cooling
Do not wrap the child in wet towels or cloths or use cold water, as this increases the child’s
discomfort. It can also cause a dangerous drop in the child’s core temperature (especially in SAM).
External cooling may be used in addition to paracetamol or ibuprofen in cases of heat
stroke/hyperthermia.
If using external cooling:

• Give paracetamol/ibuprofen at least 30 minutes before external cooling.
• Use comfortably warm water (around 30 degrees Celsius), not cold water.
• Wipe the child’s back or face gently.
• Do not use alcohol because its fumes are absorbed, resulting in toxicity.
113
3.7. Blood Disorders

Anaemia............................................................................................................................................... 115
Sickle Cell Disease ................................................................................................................................ 119
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Anaemia
Causes
In developing countries, it is a common finding and often results from multiple causes. Anaemia is
characterised by haemoglobin levels below 11 g/dL in children older than 6 months (<10 g/dL for
infants aged 2 to 6 months; see Table 3.7.1, Normal haemoglobin levels).
Table 3.7.1 Normal haemoglobin levels
Age Normal haemoglobin level (g/dl) Normal haematocrit %

Newborns to 2 months 13.5–20 40.5–60
2–6 months* 10–18 30–54
6 months to 2 years 11–13.5 31.5–40.5
2 to 12 years 11.5–13.5 34.5–40.5
*Haemoglobin of 10 in a 2- to 6-month-old infant is not considered anaemia
The low haemoglobin levels that indicate anaemia are generally caused one of three ways: decreased
production of red blood cells (RBCs), increased RBC destruction (also known as haemolytic anaemia)
and uncompensable loss of RBCs.
Decreased production of RBCs

• Marrow failure
- Congenital diseases
- Acquired diseases (HIV, TB, chronic infectious/inflammatory diseases, Parvovirus B,
malignancies, drugs)
• Disorders of RBC maturation
- Congenital (thalassemia syndromes, G6PD deficiency)
- Nutritional deficiency (iron, vitamin B12, folic acid)
• Malnutrition
Increased RBC destruction (haemolytic anaemia)

• RBC disorders (sickle-cell disease, thalassemia, G6PD deficiency)
• Malaria
• Bacterial infection
• Autoimmune haemolytic anaemia
• Drug induced
Loss of RBC
• Acute: haemorrhage (trauma; bleeding of GI tract)
• Chronic: parasitic diseases (hookworm, whipworm)
In children <1 year of age, the causes can be congenital:

• Maternal malaria and HIV cause intrauterine growth retardation, which is associated with
anaemia.
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• Maternal iron deficiency during pregnancy increases risk of anaemia in the infant.
• Premature delivery
• Haemoglinopathies and G6PD deficiency

The clinical signs and symptoms of anaemia vary based on the age of the child, the aetiology, the
speed of its development and/or the nature (chronic vs acute) of anaemia. A thorough history and
physical examination are important in evaluating the child with anaemia.
History
When evaluating the history, review the current symptoms of the patient, but also ask targeted
questions regarding family history. In addition, events at birth and during the neonatal period may
provide important clues.
• Severity and initiation of symptoms: Common symptoms include lethargy, tachycardia and
pallor. Anaemic infants may present with irritability and poor oral intake. Because of the
body’s compensatory abilities, patients with chronic anaemia may have few or no symptoms
in contrast to patients with acute anaemia with similar haemoglobin values.
• Ask questions relating to haemolytic episodes (changes in urine colour, scleral icterus or
jaundice).
• Prior anaemic episodes and transfusions
• Ask questions relating to possible blood loss (GI tract, epistaxis, etc.).
• Underlying medical conditions (HIV, TB, malaria, worms, etc.)
• Prior drug or toxin exposure (include traditional medicine)
• Enquire about diet and nutritional status.
• Family history (sickle cell disease; TB; HIV)
• Birth history
Physical Examination
Areas of particular importance include the skin, eyes, mouth, face (sickle cell disease and
thalassemia), chest, hands and abdomen.
Look for:
• pallor (palms, soles, mucous membranes, lips, conjunctivae, nail beds)
• facial features: maxilla protrusion and predominance convex profiles (sickle cell); maxilla
hyperplasia, flat nasal bridge, frontal bossing (thalassemia)
• signs of haemolysis: scleral icterus, jaundice, hepatosplenomegaly
• splenomegaly (malaria, sickle cell, malignancies, Kala Azar, etc.)
• heart murmur (increased flow from anaemia)
• signs of malnutrition or micronutrient deficiency
• signs of acute infection or sepsis
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Diagnosis
Anaemia is diagnosed via haemoglobin levels. The following levels are for children older than 2
months (for anaemia in the neonatal period, see neonatal guidelines).
• Anaemia: haemoglobin (Hb) <11 g/dL (< 10 g/dL for infants 2–6 months of age)
• Moderate anaemia: Hb <9 g/dL
• Severe anaemia: Hb 7 g/dL
• Very severe anaemia: acute drop in Hb to severe anaemia or Hb <4 g/dL (asymptomatic) or
Hb <6 g/dL (with symptoms)
Note that these values are not synonymous with need for transfusion; for transfusion indications, see
below.
In addition to Hb, the following laboratory tests should be performed:

• Malaria test (if endemic)
• Urine dipstick
• Complete blood count including reticulocyte count (if available) and blood smear to evaluate
shape of blood cells
• If considering transfusion: blood group including type and cross-match
Management
Emergency treatment of very severe anaemia:
• Treat the cause of blood loss, if known (haemorrhage, etc.).
• If Hb <4 g/dL or Hb <6 g/dL with respiratory distress and/or shock and impaired
consciousness, transfuse blood immediately.
• If in a malaria-endemic zone, test and treat for malaria.
• If sickle cell disease is suspected or known, transfusion might be needed according to
symptoms.
Severe (non-emergency) and moderate anaemia are defined as Hb 6–9 g/dL or Hb 4–6 g/dL without
respiratory distress, shock or impaired consciousness. In these cases, look for and treat the cause(s)
of the anaemia.
• Test for malaria and treat if present.
• Evaluate for sepsis if clinically indicated.
• Check for chronic diseases (TB, HIV, other chronic infections).
• Treat parasites (see below).
• Evaluate and treat for potential malnutrition and micronutrient deficiency.
• Prescribe anaemia medications (see Table 3.7.2, Treatment for non-emergent anaemia)
In most MSF fields, the types of anaemia cannot be differentiated and treatment by cause is rarely
possible. Empiric treatment, particularly with iron, in cases of severe (non-symptomatic) or moderate
anaemia should only be given after stabilisation. Iron, in particular, if given to the acutely ill child, can
exacerbate malnutrition, infection and SAM.
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Side effects of anaemia medications:

• Iron: dark stools, constipation and gastric upset. Serious toxicity if overdose, keep out of
reach of children.
• Folic acid: mild gastric irritation, rash
• Vitamin B12: rash, allergy
• Vitamin A: serious toxicity if overdose, keep out of reach of children
Table 3.7.2 Treatment for anaemia
Iron–folate tablet: ideally given in combination with folic acid. Note: Iron is contraindicated in a child
who has received >2 transfusions within a year or who is acutely sick. For SAM children, follow
nutrition guidelines. Administer with vitamin C for improved absorption of iron. Take once in the
morning for one month.
I tab = 200 mg ferrous sulphate (65 mg elemental iron) + 400 mcg folic acid
Weight Iron–folate tablet Vitamin C, 250 mg tablet

<4 kg ½ tab/day 1 tab/day
4 to <8 kg ½ tab/day 1 tab/day
8–15 kg 1 tab/day 1 tab/day
Or, for a child who has received >2 transfusions within a year or who has recently (within the last 2
weeks) been transfused, give folic acid only (take once in the morning for 1 month). Life-long folate
administration is required in sickle cell anaemia.
Weight Folic acid, 5 mg tablet

<4 kg ½ tab/day
4 to <8 kg 1 tab/day
8–15 kg 1 tab/day
In addition, take vitamin B12, 1 mg PO 1x/day x 10 days plus albendazole (as follows) when the child
is no longer exclusively breastfed (usually children older than 6 months).
Weight Albendazole
<10 kg 200 mg as a single dose
>10 kg 400 mg as a single dose
Also give vitamin A (retinol) in a single dose (see below), except in the following cases:
• Infants younger than 6 months who are exclusively breastfed if the mother received one
dose in the previous 4 months
• Children who received a dose in the previous 6 months
• Children with severe acute malnutrition receiving therapeutic milk or food
Weight Vitamin A (retinol)

<6 kg 2 drops (50,000 IU)
6–8 kg 4 drops (100,000 IU)
>8 kg 1 capsule (200000 IU)
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Sickle Cell Disease
Causes
Sickle cell disease (SCD) is an inherited disorder that leads to the production of an abnormal
haemoglobin variant, haemoglobin S (HbS). This chronic disorder is marked by a tendency to deform
the red cell into a sickle shape, resulting in characteristic vaso-occlusive events and accelerated
haemolysis.
Prevalence of the disease (sick persons) in sub-Saharan Africa is 1% to 2% of the general population.
Sickle cell trait (usually carriers are asymptomatic) occurs when a child inherits a sickle gene from one
parent and a normal gene from the other parent. Sickle cell disease occurs when a child inherits a
sickle gene from each parent.

Signs of SCD begin to manifest starting at age 4–6 months, and can be categorised as either acute or
chronic (see Table 3.7.3, Clinical manifestations of SCD).
Table 3.7.3. Clinical Manifestations of SCD

Acute complications Chronic complications
• Acute painful crisis • Cardiomyopathies, myocardial infarction,
• Acute bacterial infections arrhythmia
• Acute chest syndrome • Haematuria, proteinuria leading to renal
• Acute splenic sequestration failure
• Aplastic crisis • Chronic cholelithiasis and liver disease
• Priapism • Retinopathy
• Acute central nervous system events • Leg ulcers
• Acute hepatic ischemia and/or sequestration • Bone infarction and necrosis
• Chronic lung disease
• Neurocognitive deficit
• Growth failure and delayed puberty
In regions where comprehensive care (immunisation, prophylactic antibiotics, etc.) is not available, as
in sub-Saharan Africa, infections (bacterial sepsis and malaria) are a leading cause of death, especially
in children younger than 5 years of age.
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Diagnosis
The diagnosis of SCD is based on the following:
• detailed history (previous hospitalisations and transfusions) of the child and family
• clinical examination
• level of haemoglobin
• Emmel’s test (does not differentiate between sickle cell trait and disease)
- If positive: Confirm the diagnosis with Hb electrophoresis and treat the patient as having
sickle cell disease, but stop specific treatment if the disease is not confirmed via
electrophoresis.
- If negative: Repeat the test. Treat as having sickle cell disease only if you have a strong
suspicion. In this case, confirm the diagnosis with the electrophoresis of Hb and stop
specific treatment if the disease is not confirmed.
• electrophoresis of Hb
• genetic testing.
In MSF settings, genetic testing and electrophoresis of Hb often are not available. If these tests are
not available in the field, where possible try to refer or send blood for testing.
Remember to test the child before a transfusion. Wait at least 60 days after a transfusion before
testing.
Most infants do not show any symptoms until they are about 4–6 months old (dactylitis, a painful
swelling of the hands and feet, is an early manifestation). Consider the diagnosis of SCD if the child
has the following:
• dactylitis
• severe anaemia (especially with history of previous transfusions)
• signs of chronic haemolytic anaemia (jaundice, hepatosplenomegaly, blackish urine)
• recurrent episodes of generalised pain and/or swelling and pain in the joints
• priapism (see below)
• leg ulcers (common after age 10 years).
Management
In MSF settings, the management of SCD is focused on the prevention and management of the most
common acute complications. Other medical approaches, such as repeated blood transfusions, are
not practicable in our fields. Treatment with hydroxyurea will hopefully be available for MSF in the
near future.
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Acute Painful Crisis (Vaso-Occlusive Crisis [VOC])

Painful crises are the most common type of vaso-occlusive events, especially after the age of 2 years.
Patients typically experience rapid onset of deep, gnawing, throbbing pain, sometimes accompanied
by local tenderness, erythema, warmth and swelling. The most commonly involved areas are the
lumbosacral spine, knee, shoulder, elbow and femur (although other areas of the body can be
affected as well). In children younger than 5 years of age, the small bones of the hands and feet are
often affected, even the distal phalanges.
Treat acute painful crises as follows:

• ABCD approach
• Test Hb and malaria (to exclude malaria as a cause).
• Rapidly initiate analgesic therapy (see Chapter 4, Pain Management).
• Hydration (see hydration protocol)
- Encourage drinking fluids. If the patient is not able to drink, provide maintenance IV fluids.
- If dehydrated, treat according protocol.
• In case of fever >38.5 degrees Celsius, see “Acute Bacterial Infections,” below.
• No blood transfusion unless there are other indications for transfusion.
• Encourage deep breathing exercises focusing on the inspiration phase (alveolar distension,
like with an incentive spirometer) every 1 to 2 hours while awake to reduce the risk of acute
chest syndrome (see below).
• If you are in a small health centre, weigh the risks of deterioration during transfer against the
expected benefits of hospital care.
It is difficult to differentiate between VOC and osteomyelitis. Consider osteomyelitis if a child with
signs of VOC also shows the following symptoms:
• Fever and local signs of inflammation (even discrete)
• Pain is localised and persists for more the 48–72 hours
• Treat acute osteomyelitis with IV ceftriaxone for at least 7 days, then switch to oral
ciprofloxacin (see Chapter 3.9, Bone and Joint Problems).
Acute Bacterial Infections

Children with SCD are more susceptible to malaria and invasive bacterial infections (sepsis,
meningitis, pneumonia, osteomyelitis), particularly encapsulated organisms (e.g., S. pneumoniae and
H. influenzae) and Salmonellae because they have a non-functional spleen and a decreased immune
response. Fever (or hypothermia) can be the first indication of a serious and sometimes life-
threatening infection in patients with SCD. Children with SCD and fever need immediate medical
attention.
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Management
• Accurate history for symptoms of systemic or local infection
• Accurate physical examination focused on:
- ABCD approach
- Pallor and splenomegaly (aplastic crisis, splenic sequestration)
- Signs of localised infection (pneumonia, gastroenteritis, osteomyelitis, arthritis, etc.)
- Neurological infection (stroke, meningitis, etc.)
• Investigations (if available): malaria test, complete blood cell count, reticulocyte count,
culture (haemo, liquor, etc.)
• For systemic infections: Administer ceftriaxone 50 to 100 mg/kg/day (depending on severity
of disease; see Chapter 3.2, Sepsis and Shock and Chapter 3.13, Meningitis), either as a single
dose or divided into two doses.
• For acute osteomyelitis, prescribe ciprofloxacin (see above).
• Inpatient vs outpatient treatment: Treat all children with SCD and infections as inpatients for
at least the first 48 hours, then discharge or keep at the hospital according to the following
criteria:
- Treat as outpatient if:
▪ The child is well and has a simple, localised infection (otitis, pharyngitis, etc.)
▪ The child is older than 2 years of age
▪ T <39 degrees Celsius
▪ Hb >5 g/dL
▪ No signs of acute haemolysis (pallor, jaundice, blackish urine)
▪ No signs of splenic sequestration (sudden splenic enlargement and drop of Hb
level)
▪ No co-existing complications
▪ Caregivers are now confident they can take care of the child
- Treat as inpatient if:
▪ The child is seriously sick and/or has a fever without focus.
▪ There are signs of systemic toxicity, meningitis and/or respiratory and
haemodynamic instability.
▪ The child has been admitted in the past for serious diseases (sepsis, meningitis,
etc.)
▪ The child is younger than 2 years of age
▪ T ≥39 degrees Celsius
▪ Hb <5 g/dL
▪ Signs of acute haemolysis, splenic sequestration or other co-existing
complications
▪ Caregivers are not able to provide care for the child
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Acute Chest Syndrome (ACS)

ACS is a common and serious complication at any age (it is the leading cause of death in adolescents).
A patient with suspicion of ACS should be treated in hospital whenever possible. ACS is characterised
by chest pain, fever and respiratory symptoms (clinically resembles pneumonia) + decreased SpO2
(<95%). It can develop suddenly or insidiously, during hospitalisation as symptoms of vaso-occlusive
crisis and occurs with increased frequency in people with asthma or prior ACS events. Consider ACS
in a SCD child with respiratory symptoms, irrespective of fever.
Treatment
• Hospitalisation and close monitoring (severe anaemia, bronchospasm, etc.)
• Test Hb and malaria (to exclude malaria as a cause)
• Hydration (see hydration protocol, but decrease intake to 70% or two-thirds of usual needs)
• Pain control (see Chapter 4, Pain Management)
• Supplemental oxygen (to maintain SpO2 >95%)
• Administer ceftriaxone IV 50 mg/kg/day as a single dose or divided into two for 7–10 days
(even without fever)
• Administer azithromycin PO 10 mg/kg 1x/day for 5 days. If azithromycin is not available, use
Erythromycin PO (10 mg/kg/dose 6x/day)
• If bronchospasm, treat with salbutamol MDI with spacer as follows:
- Weight 5 to 10 kg: 4 puffs
- Weight 10 to 20 kg: 6 puffs
- Weight >20 kg: 8 puffs
- The dose can be repeated every 20 to 30 minutes for the first three doses, and then
every 1 to 4 hours as needed.
• Give simple blood transfusion (10 to 15 mL/kg red blood cells [not 20 mL/kg of packed red
blood cells due to the risk of hyperviscosity]) only if Hb <9 g/dL.
• Encourage deep breathing exercises, focusing on inspiration phase (see above) if possible
every hour while awake.
Acute Severe Anaemia

Nearly all people with SCD have chronic anaemia, but individual baseline haemoglobin values vary
widely. Acute anaemia is defined as a decline of >2 g/dL in Hb concentration below the patient
baseline value. It can have the following causes: splenic sequestration, aplastic episode and acute
haemolysis.
In MSF settings, the diagnosis of those complications is a challenge, and there is usually no
knowledge of a patient’s baseline. The diagnosis is based on the history and physical examination. If
available, check complete blood count and reticulocyte count. The decision regarding blood
transfusion in this case (simple blood transfusion: 10 to 15 mL/kg red blood cells [not 20 mL/kg of
packed red blood cells due to the risk of hyperviscosity]) will be based on clinical signs and not on
haemoglobin.
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Splenic Sequestration (clinical exam – increased spleen)

Splenic sequestration is the sudden, rapid and massive enlargement of the spleen, with trapping of a
considerable portion of the red-cell mass. An increased spleen will be felt on physical examination,
and patients suddenly become weak, pale and dyspnoeic, with a rapidly distending abdomen, left-
sided abdominal pain, vomiting and hypovolaemic shock. Investigations, if available, show a sharp
decline in Hb level, reticulocytosis (distinguishing it from the aplastic crisis) and thrombocytopenia.
Management of splenic sequestration

• ABCD approach
• If hypovolaemic shock:
- Carefully administer a bolus of 10 mL/kg RL or NaCl 0.9% IV/IO (to be repeated once only
if absolutely needed and blood is not available)
- Determine blood type and cross-match; order blood.
- Immediately transfuse 10 mL/kg of packed red blood cells as fast as possible. Further
transfusion is not recommended, as the sequestered blood is available to re-enter the
circulation. The key is to maintain euvolaemia while avoiding hyperviscosity.
- Close monitoring of vital signs and haemoglobin
• For acute splenic sequestration and severe anaemia with signs of decompensation, transfuse
to raise the haemoglobin to a stable level while avoiding overtransfusion
- Start with 10 mL/kg packed red blood cells and repeat if still signs of decompensation.
- Close monitoring of vital signs and haemoglobin
• Close monitoring of Hb every 4 hours until stable
• In case of fever >38.5 degrees Celsius, see “Acute Bacterial Infections,” above.
• Provide supportive care as needed.
Aplastic Crisis (clinical exam – normal or not palpable spleen)

The usual clinical picture of aplastic crisis is characterised by gradual onset of fatigue, shortness of
breath and sometimes syncope (sudden and brief loss of consciousness associated with loss of
postural tone and spontaneous recovery). Fever is quite common. Physical examination may reveal
signs of decompensation. The Hb value is usually far below the patient’s baseline level, and the
reticulocyte count is reduced or even zero. The most common cause is a viral infection.
Management of an aplastic crisis

• ABCD approach
• Immediate transfusion (see transfusion protocol) if severe anaemia with signs of
decompensation with the aim of reaching Hb 9 g/dL
• Close monitoring of Hb every 4 hours until stabilisation and control at day 5 (most often, a
second transfusion is needed because of the absence of production of red cells)
• In case of fever >38.5 degrees Celsius, see “Acute Bacterial Infections,” above.
• Provide supportive care as needed.
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Acute Stroke
Acute stroke presents as a sudden onset of weakness, impairment of language and sometimes
seizures or coma and results in adverse motor and cognitive sequelae. It is secondary to stenosis or
occlusion of the internal carotid or middle cerebral artery, but acute chest syndrome, acute aplastic
crisis or other acute anaemic events may precipitate events.
Management of acute stroke

• ABCD approach
• Check Hb and malaria (to exclude cerebral malaria as a cause)
• Administer ceftriaxone 100 mg/kg/day in a single dose or divided in two (if there is suspicion
of meningitis).
• Give supplemental oxygen (to maintain SpO2 >95%).
• Immediate blood transfusion (10–15 mL/kg of packed red blood cells) if Hb <9 g/dL to reach 9
to 10 g/dL
• Treat fever if present.
• Close monitoring of Hb and glycaemia every four hours until stable.
Priapism
Priapism is a sustained, unwanted, painful erection lasting more than four hours. Prompt recognition
and initiation of conservative medical management may resolve the swelling and limit the need for
more aggressive and invasive intervention. Delayed diagnosis and therapy can result in impotence.
Management of priapism
• Pain control
• Hydration (see hydration protocol)
- Encourage drinking fluids. If the patient is not able to drink, provide maintenance IV
fluids,
- If dehydrated, treat according to protocol
- Hyperhydration should be avoided.
• Apply warm compresses, replacing as needed.
• If priapism persists for fewer than 3 hours:
- Etilefrine (alpha agonist) injection 10 mg locally on the lateral side of the corpus
cavernous with surveillance of blood pressure for the first 20 minutes (normal action
after 15 minutes). Can be repeated once if not effective initially.
• If priapism persists beyond 3 hours: contact the paediatric advisor/surgical advisor to
alleviate corpus cavernous tension by drainage (no lavage) under local anaesthesia until red
blood is obtained, combined with another local injection of etilefrine (10 mg) after
strangulation (garrot) of the base of the penis (can be repeated after 20 minutes if
necessary).
• In the following hours or days, if the priapism recurs or there is no improvement, three to
four local injections of etilefrine per day until improvement.
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Ambulatory management of intermittent priapism (IP) crises

Management of IP crises is aimed at preventing severe acute priapism in SCD children.
Consult as soon as the number of episodes of IP exceeds two per month.
Initial management includes application of warm compresses, effort, ejaculation and pain control.
Start oral etilefrine as soon as intermittent episodes have a negative impact on daily life and/or
become more frequent; see dosage above for acute priapism.
Prevention of SCD Acute Complications

Where possible, children with SCD should follow a life-long health care maintenance program.
• Regular clinic visits every 4–8 weeks to check for malnutrition
• Appropriate vaccinations (especially against Pneumococcus, Meningococcus and H. influenza
B); at age 2 years, give vaccination against pneumococcal infection, preferably with 23 valent
non-conjugate vaccine; if not available, give conjugate vaccine (PCV 10 or 13)
• Antibiotic prophylaxis:
- First choice: phenoxymethylpenicillin PO (life-long treatment), 50,000 to 100,000
IU/kg/day in two divided doses:
▪ Children younger than 1 year of age: 62.5 mg twice daily
▪ Children 1–5 years of age: 125 mg twice daily
▪ Children older than 5 years of age: 250 mg twice daily
- Second choice: amoxicillin PO 20 mg/kg/day daily
▪ Children aged 2 months to 5 years: 20 mg/kg/day in two divided doses every 12
hours (maximum dose: 250 mg/dose)
▪ Children older than 6 years and adolescents: 250 mg every 12 hours
• Antimalarial chemoprevention in malaria-endemic areas (>5% malaria prevalence)— check to
see if there is a national protocol:
- Mefloquine PO
- Children >5 kg: 5 mg/kg once weekly.
- Not to be given in case of fever or severe illness. In this case, investigate the cause and
treat accordingly.
- Contact paediatric and/or malaria advisors to discuss other approaches according to
national protocols, if relevant.
• Folic acid PO (for chronic haemolytic anaemia)
- Children younger than 1 year: 2.5 mg/day
- Children 1 year or older: 5 mg/day
• Zinc sulphate PO on a case-by-case basis
- Children younger than 6 months: 10 mg/day
- Children 6 months and older: 20mg/kg day
• Provide a three-day course of paracetamol PO to the family in case of mild, acute pain.
• Presurgical transfusion in case of urgent or planned surgery to be evaluated on a case-by-
case basis.
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The following information should be provided to the patient and his or her family to help with
disease management.
• SCD is a life-threatening, chronic disease
• Adherence to long-term therapies (antibiotic and malaria) is paramount in the management
of SCD.
• Regular visits are important for your child. Respect the appointments given, especially for the
vaccinations.
• Take your child to the doctor if:
- he or she has a fever or other signs of infection
- he or she has pain that doesn’t get better after it is treated at home with paracetamol
- he has an erection that lasts longer than 2 hours
- he or she has trouble breathing
- he or she has symptoms such as seizures or confusion
- his or her belly is getting bigger (doctor has to explain how to check for this)
• Keep your child well hydrated.
Hydroxyurea
Hydroxyurea (HU) is currently not routinely available in MSF programs. It should only be used upon
approval of the desk and medical advisor in selected programs.
Hydroxyurea can significantly improve the clinical course of disease in patients with frequent
symptoms related to SCD, including vaso-occlusive complications (VOC) and chronic anaemia <7 g/dL,
even in malaria-endemic areas. It increases the production of foetal haemoglobin, which decreases
the sickling of erythrocytes.
Prior to administering HU, ensure SCD has been confirmed as a diagnosis and correct SAM and any
iron deficiency (small MCV compared to the norm). HU, once started, should be continued as a life-
long treatment. Counselling and availability of the drug should be ensured for the foreseeable future
if HU treatment is considered in a program.
Clinical and laboratory follow-up should be carried out every 3 months (see below).
Indications for starting HU treatment

HU treatment should be considered if any of the following occur:
• >3 VOC or painful episodes leading to admission per year, or frequent less-severe VOC
creating a serious handicap in everyday life
• >2 acute painful chest episodes or one very severe ACS
• Chronic anaemia <7 g/dL (also in malaria-endemic areas lasting beyond 3 months after
treatment of malaria and supplementary folic acid)
• Priapism
• Acute stroke in the absence of transfusion program
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Dosage
• Initial dose of 15 mg/kg once daily; increase by 5 mg/kg after 6–8 weeks of treatment only in
cases of insufficient pain control or acute events (dose until a clinical effect is achieved and
bone marrow toxicity is avoided, remaining below 30 mg/kg/day).
• Clinical response takes up to 6 months. If no response, wait for 6 months prior to
discontinuation of treatment.
Surveillance
• HU is generally quite well tolerated.

• Potential side effects are bone marrow depression and renal and liver toxicity, but the
benefits outweigh the risks.
• Laboratory tests (at baseline and 1 month after each change in HU dosage): Hb, WCC + diff,
platelets, reticulocytes, creatinine and transaminases
- Every 3 to 4 months: Hb, WCC + diff, platelets, reticulocytes
• In case of side effects (anaemia <7 g/dL with reticulocytes <80,000 to 100,000/mm 3 or WCC
<2000 to 4000/mm3) discontinue HU until lab test improvement, then reinstitute HU at a
reduced dose (5 mg/kg lower than previous dose, or more as necessary).
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3.8. Neurological Disorders

Altered Level of Consciousness ........................................................................................................... 130
Seizures................................................................................................................................................ 133
Epilepsy................................................................................................................................................ 139
129
Altered Level of Consciousness
Causes
An altered level of consciousness (LOC) is any deviation from being fully awake and responsive.
Causes of altered LOC are varied and include both medical and traumatic causes. See Figure 3.8.1,
Algorithm for treatment of altered level of consciousness, for common causes of altered LOC.
Depressed consciousness represents an acute, life-threatening emergency, requiring prompt
intervention for preservation of life and brain function.

There are many levels of altered consciousness, ranging from fully awake but disoriented to the
completely unresponsive child. Coma refers to the most profound level of unconsciousness, while
lethargy, obtundation and stupor refer to states in which arousal is somewhat less impaired.
A child presenting with an altered LOC should be assessed following ABCD, looking for potential
causes for the change in consciousness. The child should also be evaluated using one of the following
consciousness scales (see Chapter 1.1, Vital Signs, for additional information regarding the use and
scoring of these scales):
• AVPU
• Blantyre Coma Scale (often used for cerebral malaria)
• Paediatric and Adult Glasgow Coma Scale (GCS)
Diagnosis
Diagnosis of altered LOC is based on the results of the previously mentioned scales. A score <15 on
the GCS, <4 on the Blantyre Coma Scale or a core of V/P/U on the AVPU indicates depressed
consciousness.
Management
Treatment of altered LOC involves stabilising the patient and determining and treating the cause of
the altered LOC. See Figure 3.8.1, Algorithm for treatment of altered level of consciousness, for
specific treatments of common causes of altered LOC.
• Stabilise the patient via ABCD approach and record vital signs.
- Support and open the airway (stabilise cervical spine if trauma is suspected)
- Clear airways (suction) if indicated
- Provide O2
- Assist ventilation with bag-mask device if the patient is not breathing.
- Ensure vascular access (IV/IO) and administer IV bolus according to protocol if patient is
in shock.
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- Perform a quick evaluation of neurological status (AVPU) and check pupils. Look for
convulsions and treat with diazepam if present.
- Check glucose and treat hypoglycaemia if present.
- Check Hb if pallor is present.
- Check RDT malaria in endemic areas and treat if positive.
- Check urine dipstick and look for glucose (ketoacidosis).
- Expose the entire body and look for signs of sepsis, meningism, trauma, etc.
- Treat fever if present.
• Perform an accurate patient history (include questions regarding the use of traditional
remedies) and physical examination.
• Perform a lumbar puncture if not contraindicated and you suspect meningitis.
• Immediately administer artesunate if malaria RDT is positive.
• Immediately administer ceftriaxone if suspicion of sepsis/meningitis.
• Admit the patient to the ICU and provide supportive care (nursing care, oxygen, fluid
maintenance, monitoring).
131
Figure 3.8.1 Algorithm for treatment of altered level of consciousness
Glasgow Coma Scale <15, Blantyre Coma Scale <4 or V/P/U on AVPU scale
Evaluate and treat ABCD, look for problems (see list below, can be more than one)
Ask about Monitor Examine child

Check • Duration Temperature Meningism
• Glucose • Vomiting RR/HR/BP/SpO2 Posture/tone
• Haemoglobin • Headache/fever If GCS if <12, recheck Pupils/eyes
• Malaria • Convulsions
at least every 25 Muscle tone/
• Urine dipstick • Trauma
minutes; if GCS 12– movements
• Medications
• Traditional 14, recheck at least Reflexes and
remedies hourly response to pain
1. Hypoglycaemic coma: Glucose <45 mg/dL (2.5 mmol/L) in neonates and <60 mg/dL (3.3 mmol/L)
in all children, including SAM: Treat immediately.
2. Shock: Presents with all three of following: Cold extremities; Weak OR fast (or slow) pulse; CRT
> 3 seconds: Treat immediately.
3. Sepsis: T >38 degrees Celsius or <36 degrees Celsius plus tachycardia and/or tachypnoea: Treat
for sepsis
4. Trauma: Recognised from history and physical examination
5. Diabetic ketoacidosis: Glucose >200 mg/dL and presence of ketones in urine: Treat for diabetic
ketoacidosis
6. Meningitis and encephalitis: Signs of meningitis or encephalitis (focal seizure and/or focal
neurologic signs): Treat with IV antibiotics for meningitis or other depending on cause
(encephalitis)
7. Neurologic coma: Status epilepticus (convulsions lasting >30 minutes [see next section,
Seizures]), postictal state (reduced consciousness within 1 hour of seizure + not hypoglycaemic)
or reduced consciousness with transient focal neurologic symptoms
8. Cerebral malaria: Positive malaria test plus cerebral signs (impaired consciousness or malarial
retinopathy): Treat for malaria
9. Toxic ingestion: History or suspicion of ingestion and/or pin-point pupils, excess salivation,
flushing, severe agitation, hypertension or vomiting: Treat with naloxone
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Seizures
Causes
A convulsion or seizure is a temporary disturbance in brain function in which groups of nerve cells in the
brain signal abnormally and excessively. During a seizure, the following can (but do not always) occur:
• changes in awareness or sensation such as loss of consciousness (unlike chills or trembling)
• involuntary movements, most often jerking motion of arms and/or legs but also subtle
twitching of the face or hand
• other changes in behaviour (lip smacking, staring away).
Usually, a seizure lasts from a few seconds to a few minutes. Common causes of seizures include:
• high fever (note: a febrile seizure is a diagnosis of exclusion—no malaria, no meningitis, etc.)
• cerebral malaria, meningitis, encephalitis or sepsis
• parasites such as neurocysticercosis
• drugs, intoxication or poisoning
• metabolic abnormalities such as hypoglycaemia, hyponatremia and other electrolyte
abnormities
• intracranial bleeding; head trauma (concussion); ischemia, including acute hypoxic episodes
Clinical states that look like a seizure but are not seizures:
• Trembling or shivering (putting your hand on the child’s trembling arm or leg stops the
shaking; in a seizure, the arm will continue to move)
• Myoclonus is a jerking movement, usually of the legs, that occurs most commonly when a
child is falling asleep.
• Tics are not seizures (the child is always awake); they are relatively brief, sudden, rapid and
intermittent movements (motor tics) or sounds (vocal tics).
• Stereotypies are repetitive, purposeless actions such as head banging, head rolling, body
rocking and hand flapping.
• Syncope or fainting is not a seizure, even though the child may lose consciousness.
• Breath-holding spells are not seizures. The child will be angry, have pain, cry or for some
other reason fall to the ground and hold their breath; their arms and legs may jerk, but as
soon as the child loses consciousness briefly they relax and return to normal.
The classification of seizure is very complex: seizures can be general (with loss of consciousness) or
partial (without loss of consciousness, an unusual type of seizure). Generalised seizures are the most
common in sick children.

During a seizure, the child may present with loss of tone, loss of consciousness, abnormal vital signs,
eye deviation (child appears to be looking away), abrupt change in behaviour accompanied by pallor
and cyanosis, tonic (stiff extended limbs, child bites down) movements, clonic (rhythmic jerking)
movements and often loss of bladder control.
133
Febrile Seizures
Febrile seizures are seizures that occur in children aged 1 month to 6 years (most common in children
12 to 18 months old) who have temperatures >38 degrees Celsius and a rapid change in body
temperature. These children will present without central nervous system infection or acute
metabolic abnormalities (such as hypoglycaemia and other electrolyte imbalances), and they will
have no history of afebrile seizures. Febrile seizures are common and have no long-term neurologic
consequences (fever in itself is not harmful, nor are brief [<5 minutes] seizures). Note: If fever and
< 2 months old, refer to Neonatal Guidelines.
Febrile seizures are classified as either simple or complex. Simple febrile seizures are the most
common, lasting <15 minutes and are generalised (tonic-clonic). Complex febrile seizures are focal
seizures that last for longer than 15 minutes and/or occur multiple times within 24 hours.
Status Epilepticus
Status epilepticus is a situation in which a seizure lasts for >30 minutes or there are repeated seizures
without the child regaining consciousness between them.
Treatment is indicated in the following situations:
• Any seizure lasting >5 minutes
• Any child who has more than one seizure within a 5-minute interval
• Any child with more than three febrile seizures in 24 hours
For simple febrile seizures, look for and treat the cause of the fever. You can also treat the fever to
improve the child’s comfort. Prophylactic long-term anticonvulsants are not indicated in febrile
seizures, even if they are recurrent. Consider lumbar puncture if child is under 1-year-old, has
meningeal signs or appears severely ill.
134
• Support and/or open airways (ABCD)

• Provide oxygen
• Assist ventilation with bag-mask device if not breathing
• Check glucose/treat hypoglycaemia.
• Administer anticonvulsants according to protocols (see Table 3.8.1, Treatment of seizures in
a child older than 1 month of age; Table 3.8.2, How to administer anticonvulsants; and
Chapter 7.9, Phenobarbital and Phenytoin).
• Treat fever if present.
• Look for the causes: Check RDT malaria in endemic area and investigate for other causes
(meningitis, poisoning, sepsis, trauma, etc.).
• Do not treat seizures once they have stopped. Following a seizure, a child may be in the
postictal state (the altered state of consciousness after an epileptic seizure). This usually lasts
between 5 and 30 minutes, but sometimes lasts longer in the case of larger or more severe
seizures, and is characterised by drowsiness, confusion, nausea, hypertension, headache or
migraine and other disorienting symptoms. The child usually does not remember the seizure.
Table 3.8.1 Treatment of seizures in a child older than 1 month of age
Only treat with anticonvulsants if the seizure lasts >5 minutes or if there are more than two seizures in
5 minutes
If no IV access, but IM or PR is available IV available
Give one of the following: Give diazepam 0.3 mg/kg IV (max 10 mg/dose)
• Midazolam 0.2 mg/kg in
buccal/nasal mucosa via syringe
(only when 5 mg/ml available)
• Midazolam 0.2 mg/kg IM
• Diazepam 0.5 mg/kg rectal PR
If the child is still having a seizure, repeat If the child is still having a seizure, repeat diazepam IV
midazolam 0.2 mg/kg IM or diazepam 0.5
mg/kg rectal (PR)
Transfer to hospital If the child is still having a seizure and continuous cardiac
During transfer: monitoring is available, give phenytoin 20mg/kg slow IV
• Have a secure IV over 30 minutes, not faster than 1mg/kg/minute (see
• Protect airway Appendix 7.8 Administration of phenytoin infusion).
• Administer O2 if available
• NPO (nothing by mouth) If phenytoin not possible (no monitoring available) or
• Bring diazepam dose in case of the child is still having seizure after phenytoin, given
need phenobarbital 15 mg/kg slow IV over 20 minutes. (See
• Bring an Ambu bag and Appendix 7.8 Administration of phenobarbital infusion).
emergency box.
This can be repeated once after 30 minutes if there is no
response, but monitoring for respiratory depression is
mandatory.
135
Phenytoin can cause hypotension and cardiac arrhythmias. However, these complications are not
common in children and can be minimised by an infusion rate that does not exceed 1 mg/kg/minute.
Also, phenytoin must not be infused along with a glucose-containing fluid. Venous extravasation
must be avoided as this can cause tissue inflammation and necrosis.
Maintenance dose should be used 12 hours after loading dose.

• Phenytoin: Only give a maintenance dose of phenytoin if it was used right after diazepam; do
not continue if phenobarbital was used.
- Phenytoin maintenance dose: 4 mg/kg/dose 2x/day PO or IV if child cannot take PO
- Continue for 3 days, then stop if child has no more seizures. If seizures persist, continue
phenytoin for 7 days and wean progressively over 3 days.
• Phenobarbital: 1.5 mg/kg/dose 2x/day PO (preferred) or IV/IM if child cannot take PO.
- Continue for 3 days, then stop if child has no more seizures. If seizures persist, continue
phenobarbital for 7 days and wean progressively over 3 days.
- Dose may need to be increased (2.5–5 mg/kg/dose 2x/day) to control seizures
Monitoring
The intensity of monitoring required depends on the drugs used to control the seizure.
Place the child in the recovery position and confirm there is no evidence of noisy breathing. Begin
monitoring all vital signs (including AVPU and SpO2) immediately after the seizure has ended.
Respiratory monitoring should be performed for all patients, especially after phenobarbital
administration; always have an Ambu bag with correct facemask available. Cardiac monitoring (HR
and rhythm and BP) should be performed for all patients who received phenytoin.
Complications
Systemic complication of seizure include the following:
• Hypoxemia: Can lead to more seizures. Treat with oxygen.
• Acidosis: Lactic acidosis and respiratory acidosis frequently accompany prolonged seizures.
• Abnormal glucose: Blood glucose concentration initially can go up in status epilepticus, but
prolonged seizures lead to hypoglycaemia. Always measure glucose and treat hypoglycaemia.
• Prolonged seizures (>1 hour) can be fatal. These seizures should be considered medical
emergencies and can also lead to long-term neurologic sequelae (cerebral palsy, etc.).
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Table 3.8.2 How to administer anticonvulsants
Diazepam
• 10-mg ampoule (5 mg/mL, 2 mL) over 2 minutes IV or PR (not IM)

• Injectable solution may be used PO or PR
• PR or IV: dilute 2mL (10 mg) of diazepam in 8 mL of 5% glucose or NaCl 0.9%
• PR: Use a syringe without a needle or cut a nasogastric tube, CH8, to a length of 2–3 cm
and attach it to the tip of the syringe.
• Diazepam may cause pain at IV site
• May also cause hypotension and respiratory depression, particularly IV if it is injected too
fast or if large doses are given. Side effects will be worse if combined with other drugs
that act on the central nervous system, such as opioids and phenobarbital.
Midazolam
• 5-mg ampoule (1mg/mL, 5 mL) for IM, IV, buccal or nasal

• Dose: 0.2–0.5 mg/kg
• Injectable solution may be used PO or buccal/nasal route (see above)
• May also cause abundant secretions and/or respiratory depression/apnoea, so be able to
gently suction and assist with Ambu bag and mask (see Chapter 7.7, Midazolam and
Diazepam for Sedation)
• Monitoring:
- Monitor vital signs, consciousness level, airway patency and respiration until
recovery is complete
- Chest motion must be visualised at all times
- Record dose/time of midazolam on administration and vital signs on monitoring
chart
137
Figure 3.8.2 Seizures in a child older than 1 month
Evaluate ABCD; check oxygen/airway/ventilation; place child in lateral position; check

glucose/treat hypoglycaemia; after seizure has been controlled, treat fever and assess
the need for antibiotics and antimalarials
Seizure >5 minutes or >2 seizures in 5 minutes
No Yes
Observe child for further seizures Arrange/plan transfer to hospital ICU or

emergency care area
If only IM or PR available IV available
Midazolam 0.2 mg/kg in buccal/nasal mucosa via Diazepam 0.3 mg/kg IV (max 10 mg/dose)
syringe, or
Midazolam 0.2 mg/kg IM, or
AFTER 5 MINUTES
Diazepam 0.5 mg/kg PR
If child is still having a seizure: Repeat diazepam IV
AFTER 5 MINUTES
AFTER 10 MINUTES Either:
If child is still having a seizure: Repeat midazolam If the child is still having a seizure: Phenytoin 20
PR or repeat diazepam PR mg/kg slow IV over 20 minutes if continuous
cardiac monitoring is available (see text).
Or:
Transfer to hospital (If cardiac monitoring is not available)
During transfer: Phenobarbital 15 mg/kg slow IV over 20 minutes.
• Have a secure IV
• Protect airway
AFTER 30 MINUTES
• O2 if available
If the child is still having a seizure:
• NPO (nothing by mouth)
Give phenobarbital 15 mg/kg slow IV over 20
• Bring diazepam dose in case of need.
minutes (monitoring for respiratory depression
Bring an Ambu bag and emergency box.
mandatory).
138
Epilepsy
Causes
Epilepsy is a chronic neurological disorder characterised by recurrent, unprovoked seizures. Most
(70% to 80%) of cases of epilepsy are idiopathic in nature (cause is unknown, but presumed to be
genetic). Cerebral damage (congenital, previous infections or trauma) and cerebral tumours are
additional causes.

There are three types of epileptic seizures: generalised, focal and unknown (epileptic spasms).
In generalised seizures, electrical discharge arises from both hemispheres. Consciousness is impaired
and motor manifestations are often bilateral. Seizures can be convulsive and not convulsive
(“absence seizures”).
• Absence seizures: Transient loss of consciousness, with an abrupt onset and termination,
unaccompanied by motor phenomena except for some flickering of the eyelids and minor
alteration in muscle tone.
• Myoclonic seizures: Brief, often repetitive, jerking movements of the limbs, neck or trunk.
• Tonic seizures: Generalised increased tone.
• Tonic-clonic seizures (most common): Rhythmical contraction of muscle groups following the
tonic phase.
• Atonic seizures: Often combined with a myoclonic jerk, followed by a transient loss of muscle
tone causing a sudden fall to the floor or drop of the head.
In focal (partial) seizures, discharge arises from one or part of one hemisphere. They may be
discretely localised or more widely distributed. A focal seizure may or may not be associated with
impaired consciousness or awareness during the attack and may be followed by generalised tonic-
clonic seizure. Focal seizure manifestations depend on the part of the brain where the discharge
originates:
• motor symptoms: motor activity, sometimes with an anatomic spread or “march of activity”
(Jacksonian); turning of the eyes, head and/or trunk; vocalisation; or arrest of speech
• sensory symptoms: paraesthesia, vertigo, gustatory and olfactory symptoms and visual
phenomena such as flashing lights
• autonomic symptoms: epigastric "rising" sensation, sweating, etc.
• psychic symptoms: dysphasia, feelings of familiarity ("deja vu"), distortions of time, affective
changes (particularly fear), illusions and hallucinations. Such seizures are often referred to as
“auras.”
In many children, especially those younger than 5 years, it may be unclear whether a seizure is
generalised or focal.
139
Diagnosis
The diagnosis of epilepsy is based on a detailed history (previous seizures and their management,
family and perinatal history, past medical history) of the child and family as well as on the clinical
examination, especially the neurological exam (look for conditions co-existing with epilepsy, such as
cerebral palsy, etc.). In MSF settings, further investigations such as detailed laboratory investigations,
electroencephalogram and neuro-imaging are normally not available.
Criteria for diagnosis of epilepsy

• Clinical definition of epilepsy: Epilepsy is defined as having had two or more unprovoked (not
linked to any acute medical event) seizures
• Exclude all causes of non-epileptic seizures (e.g. acute diseases, head trauma,
hypoglycaemia)
• Exclude other disorders such as syncope (sudden and brief loss of consciousness associated
with loss of postural tone and spontaneous recovery), breath-holding spells and psychogenic
seizures.
If there is no paediatrician available, contact the Paediatric Advisor to confirm diagnosis and design a
treatment plan.
As epilepsy treatment is a long-term treatment, it needs to be established that the family is willing to
give the treatment and come for consultation on a regular basis. It is recommended to offer
counselling to family and patient.
The most common seizures in childhood are of the generalised tonic-clonic type. The main four
antiepileptic drugs (AEDs)—phenobarbital, phenytoin, carbamazepine and valproate—are almost
equally effective for these seizures (see Figure 3.8.3, Epilepsy in childhood). In cases of non-
convulsive “absence seizures,” use valproate as first-line treatment.
Guiding principles to start antiepileptic treatment:

• Carefully establish diagnosis.
• Start treatment with one drug.
- Phenobarbital is the most cost-effective drug and should be considered as first-line
treatment.
• Check for co-existing clinical conditions (heart, renal, hepatic failure, etc.) and contraindications
for the drugs or interactions with other medications the patient might be taking.
• A starting dose of phenobarbital (3 mg/kg once a day) is given for 3–4 weeks.
• For the majority of patients, the starting dose is not enough to reach complete seizure
control. Gradually increase dosage with increments at regular intervals (add 1 mg/kg every
3–4 weeks) until complete seizure control (minimum maintenance dose), until side effects
(see below) appear or until the maximum dosage has been reached (maximum dose of
phenobarbital: 8 mg/kg/day). Severe “intoxication” side effects appearing at the beginning of
the treatment can indicate too rapid an increase in dosing.
140
• If phenobarbital is not well tolerated (side effects) or if the maximum tolerated dose does
not lead to seizure control, substitute it with another anticonvulsant (phenytoin).
• Phenytoin (see Table 3.8.3, Oral antiepileptics available in MSF projects) should be added and
phenobarbital continued at the level before the side effects appeared. When phenytoin
becomes effective, phenobarbital is gradually withdrawn.
• If phenytoin is not well tolerated (side effects) or if the maximum tolerated dose does not
lead to seizure control, contact the Paediatric Advisor before introducing other
anticonvulsants.
• In case of acute withdrawal symptoms such as recurrence of seizures, use diazepam (see
previous section, Seizures).
• Both epilepsy and AEDs are associated with adverse effects on bone health.
The antiepileptic drugs available in MSF settings are kept in the following types and dosages:
Phenobarbital: Tabs: 50 mg
Drops: 5.4% 1 mg/drop (3 drops/kg), 30-mL bottle
IV: 54.75 mg/mL, 4-mL powder vial + solvent
IV: 200 mg/mL, 1-mL vial
Phenytoin: Tabs: 100 mg

IV: 50 mg/mL, 5-mL vial (to also be used off label: 0.1 mL/kg PO)
Carbamazine: Tabs: 200 mg (to be reserved for children >20 kg as exact dosage is difficult)
Sodium valproate: IV: 200 mg/mL, 40-mL bottle 40 mL (for children <20 kg)
Enteric coated tabs: 200 mg
Enteric coated tabs: 500 mg
(See Table 3.8.3, Oral antiepileptics available in MSF projects.)
141
Table 3.8.3 Oral antiepileptics available in MSF projects

Maximum
Drug Starting dose Contraindications Side effects
dose
Phenobarbital 3 mg/kg 1x/day 8 mg/kg/day Lopinavir/ritonavir* Systemic side
Oral drops: (2x/day in (antiretroviral effects
5.4%, 1 infants) therapy) Nausea, rash
mg/drop; 30-mL Increase Artemether, Neurotoxic side
bottle gradually: add 1 lumefantrine, effects
50-mg tab mg/kg at regular chloramphenicol, Alteration of sleep
First
60-mg tab intervals( 3–4 praziquantel cycles, sedation,
line
weeks), up to lethargy,
minimum behavioural
maintenance changes,
dose hyperactivity,
ataxia, tolerance,
dependence
Phenytoin 5 mg/kg once a 8 mg/kg/day Lopinavir/ritonavir* Systemic side
100-mg tab day (maximum (antiretroviral effects
dose: 300 mg) therapy) Gingival
Increase Artemether, hypertrophy, rash
gradually: add 1 doxycycline, Neurotoxic side
Second
mg/kg at regular fluconazole, effects
line
intervals (3–4 isoniazid, Confusion, slurred
weeks) up to praziquantel, co- speech, double
minimum trimoxazole, vision, ataxia
maintenance quinine,
dose clarithromycin
Carbamazepine 5 mg/kg 2x/day 35 Lopinavir/ritonavir* Systemic side
200-mg tab Increase mg/kg/day (antiretroviral effects
gradually: add 5 therapy) Nausea, vomiting,
mg/kg every Phenytoin, diarrhoea,
week up to artemether, hyponatremia,
Third minimum doxycycline, rash, pruritus
line maintenance isoniazid, Neurotoxic side
dose praziquantel, effects
clarithromycin, Drowsiness,
quinine dizziness, blurred
or double vision,
lethargy, headache
Valproate 10 mg/kg 2x/day 60 Carbapenem, Systemic side
sodium Increase mg/kg/day mefloquine, effects
200-mg enteric gradually: add 5 macrolide Weight gain,
coated tab mg/kg every nausea, vomiting,
Fourth
500-mg enteric week up to hair loss, easy
line
coated tab minimum bruising
maintenance Neurotoxic side
dose effects
Tremor, dizziness
*Antiretroviral therapy: If the child is on ARVs, contact paediatric advisor prior to initiating treatment.
142
Facts to be discussed with the patient and the family:

• Epilepsy is a medical disorder that can be improved with medical treatment.
• In order for the drugs to be effective, they have to be taken for many years, possibly life long.
• It may take several days to a few weeks before the drugs show any effect.
• Do not modify or change the doses prescribed.
• Do not stop drugs suddenly. Sudden discontinuation may result in life-threatening status
epilepticus.
• Discontinuation of the drugs will result in recurrence of the seizures.
• Children with epilepsy are more likely to have seizures when they are sick.
• The disease is not contagious and anyone can touch the person while he or she is having a
seizure (e.g., to remove him from the danger of fire or water).
• Children need to participate as fully as possible in the normal activities of their peers, at
school, at play, in the home and preparing for employment.
• Overprotection is not helpful in a child’s upbringing, but reasonable precautions should be
taken if there are still occasional seizures (e.g., protection from fire, swimming under
supervision, not climbing trees).
• In the event of seizure: place the child on his or her side, move the child away from potential
hazards, do not try to stop the child’s movements, do not put anything in the child’s mouth
and stay with the child until the seizures ends. Seek medical advice.
Criteria to stop antiepileptic drugs:

• Gradual withdrawal of antiepileptic drug therapy should be considered in most children after
2 years without seizures regardless of the aetiology of the seizures.
• Children with co-existing conditions (cerebral palsy, etc.) with epilepsy are at risk of recurrent
intractable seizures after discontinuing antiepileptic drugs.
• If no paediatrician is available in the field, contact the Paediatric Advisor prior to
discontinuation of treatment.
Monitoring and Follow-up of Epilepsy Patient

During the first visit:
• Record the patient in the epilepsy register (if you do not have one, create one) and open a
new follow-up file (see Figure 3.8.4, Patient file—epilepsy and Figure 3.8.5, Follow-up visit
record—epilepsy): History and clinical examination (including weight), type and frequency of
seizures, treatment plan and follow-up
• Provide counselling for patient and relatives (medical and social aspects)
• Fill and give a record card to the patient/relatives (see Figure 3.8.6, Patient record card—
epilepsy).
- Name, address and contact (relative) of patient
- Registration number
- Current medication
- Frequency of seizures since last visit
- Next appointment
• Keep an appointment book in the facility.
143
• Provide a “safety stock” of medication in case the family cannot come back on the day of the
follow-up appointment.
Follow-up visits should be scheduled as follows:

• second visit after 1 week (to check for side effects)
• third visit after 1 month (to check for side effects, compliance and response to treatment)
• next visits should be monthly until seizures are under control, then every 3 months
Figure 3.8.3 Treating epilepsy in childhood
Establish diagnosis
Start phenobarbital 3 mg/kg
Increase by 1 mg/kg every 3–4 weeks

until seizures are controlled or
maximum dose reached
Seizures controlled?
Yes No
Keep phenobarbital dose Maximum dose reached or side effects not

Follow up regularly tolerated
Add phenytoin
Keep phenobarbital at last tolerated level
Maintain phenobarbital at previous dose

Stepwise increase phenytoin until seizures
are controlled or maximum dose reached
Seizures controlled?
Yes No
Keep phenytoin dose Contact Medical Advisor

Slowly phase out phenobarbital
Follow up regularly
144
Figure 3.8.4 Patient file – epilepsy
145
Figure 3.8.5 Follow-up visit record – epilepsy
Follow up visit
Epilepsy
Registration No: Name:
Address: Date:
Type of Epilepsy: Type of Epilepsy:
Treatment Plan:
Comments: Next Appointment:
Doctor:
Figure 3.8.6 Patient record card – epilepsy
Patient Record Card

Epilepsy
Registration No: Name:
Address: Date:
Type of Epilepsy:
Treatment Plan:
Frequency of Epilepsy:
Doctor: Next appointment:
146
3.9. Bone and Joint Problems

Osteomyelitis and Septic Arthritis ....................................................................................................... 148
147
Osteomyelitis and Septic Arthritis
Osteomyelitis
Acute osteomyelitis is an infection of bone that is usually caused by bacteria. Microorganisms can be
introduced to bone in three ways: bacteraemia (haematogenous spread; most common); direct
spread, usually from trauma (open fractures, war wounds, etc.); or local invasion from a
neighbouring infected site (mouth, skin ulcer, etc.). In MSF settings, children may present late
because of misdiagnosis and undertreatment.
The most common sites are the metaphysis of the long bones (femur, tibia and humerus), although
any bone may be affected. Usually a single site of bone is involved, but osteomyelitis can be multi-
focal (multiple bone involvement).
Figure 3.9.1 Common sites of osteomyelitis
Adult Child
Diaphysis
Diaphysis
Metaphysis
Physis
Epiphysis (growth plate)
Metaphysis
The causative bacteria include the following:

• Staphylococcus aureus: most common pathogen
• Salmonella species (especially in children with sickle cell disease or malnutrition)
• Group A streptococcus, Haemophilus Influenzae B, Mycobacterium tuberculosis,
Mycobacterium ulcerans (Buruli ulcer)
• Group B streptococcus and Neisseria gonorrhoea, especially in neonates
Risk factors for osteomyelitis include malnutrition, sickle cell disease, tuberculosis, puncture by
thorns, frequent dental and skin infections and intraosseous needle access under non-sterile
conditions. Malaria increases the risk of Salmonella sepsis, which increases the risk of septic arthritis
and osteomyelitis.
148
Chronic osteomyelitis is a chronic infection of bone characterised by the presence of bone necrosis,
also called sequestrum formation (see Figure 3.9.2, Sequestrum formation). Chronic drainage and
fistula formation can also occur. In the MSF setting, chronic osteomyelitis is defined as lasting longer
than 2 weeks.
Figure 3.9.2 Sequestrum formation
A sequestrum is seen representing fragments of devitalised bone.
Septic arthritis
Septic arthritis is a serious joint infection that can lead to devastating complications; it can destroy
the joint in period of days if untreated. The knee is the joint most commonly affected (40%) followed
by the hip (20%) (especially in younger children); ankle (15%); and elbow, wrist or shoulder.
Microorganisms (bacteria, fungi, viruses) can enter the joint space by haematogenous spread, direct
inoculation or extension of a contiguous focus of infection.
Most cases of septic arthritis are caused by bacteria and usually result from haematogenous spread
of Staphylococcus aureus from an open wound or mucosal lesion. The bacterial pathogens
responsible are the mostly the same as in osteomyelitis (do not forget TB).
Osteomyelitis
Initial symptoms of osteomyelitis can be non-specific and subtle (e.g., malaise, low-grade fever) and a
high index of suspicion is required for early diagnosis. Once the infection becomes established in the
bone, symptoms are more localised. Children with osteomyelitis usually present with fever,
constitutional symptoms (irritability, decreased appetite, decreased activity), and focal findings of
bone inflammation (warmth, swelling, point tenderness) and limitation of function (e.g., limp, limited
use of extremity).
149
Figure 3.9.3 Osteomyelitis physical examination
During the physical exam, the child will demonstrate a

limp, localised pain over the metaphysis of a bone and
pain on movement (the most common sign). Soft-tissue
redness/swelling may not be present and may appear
late. In pelvic (hip) osteomyelitis, elicit pain by
simultaneously putting the hip in flexion, abduction and
external rotation (see left).
Septic Arthritis
In infants, the typical presentation is one of irritability, anorexia, cellulitis, or fever without an
infectious source of entry. The manifestations of joint involvement include reduced movement of the
limb concerned, aversion to passive movement, adoption of certain positions to reduce pain (antalgic
position), and unilateral swelling of buttock or perineal area.
Older children usually present with fever, systemic symptoms, joint swelling, sensitivity and reduced
movement of the affected joint, but the joint signs can be subtle.
The examination should focus on: joint swelling or warmth, reduced joint movement, antalgic
position, pinpoint tenderness or pain on minimal movement, palpation of all bones and joints,
examination of movement of all joints, examination of the skin, and a search for another infectious
source or point of entry
Diagnosis
Any child unwilling to move a limb or bear weight fully, or with spontaneous pain or a persistent limp
and tenderness should be considered to have osteomyelitis or septic arthritis until proven otherwise.
Osteomyelitis
The diagnosis often is unclear at the initial evaluation. A high index of suspicion and monitoring of
the clinical course are essential to establishing the diagnosis, especially in MSF settings where there
is a lack of diagnostic tools (especially MRI and scintigraphy). An accurate history and physical
examination are crucial. Look always for potential contact with TB and screen for sickle cell disease.
• Laboratory evaluation (if available): Blood tests (CBC, ESR, CRP, etc. ) and blood culture
(before starting antibiotics)
• Imaging: Early signs on X-ray:
• X-ray of affected area (AP and LL view): Initially, the X-ray can be normal.
• X-ray at 2–3 days: periosteal reaction
• Imaging: Late signs on X-ray:
• Osteopenia, lytic lesions
• Osseous sequestrum (intraosseous abscess): sign of chronic osteomyelitis
• Ultrasound evaluation may help identify joint effusion and differentiate from septic arthritis.
150
Septic Arthritis
Diagnosis of septic arthritis is similar to that of osteomyelitis.
• Laboratory evaluation (if available): blood test (CBC, ESR, CRP, etc.)
• Imaging
- X-ray of affected joint, looking for joint-space widening, joint effusion, soft tissue swelling
or subluxation/dislocation of joint
- Ultrasound (if available) is useful in determining if fluid is present in the joint and in
guiding needle aspiration of the joint
• Arthrocentesis: Aspiration of synovial fluid under anaesthesia and strict asepsis (in the
operating room if possible.
- White blood cell count (WBC) >50,000/mm3 in joint fluid confirms diagnosis of septic
arthritis
- When pus is aspirated and trained personnel are present, a formal drainage procedure
can be carried out at the same sitting.
Osteomyelitis
Treatment of osteomyelitis is depending on whether the infection is acute or chronic (see Table 3.9.1
below)
Table 3.9.1 Classification of osteomyelitis
Classification Characteristics Treatment

Acute osteomyelitis Local and systemic signs, but no
Antibiotics for 4–6 weeks
(history <2 weeks) dead bone (no sequestrum on X-ray)
Subacute osteomyelitis Local and systemic signs, but no
Treat as acute osteomyelitis
(history 2–6 weeks) dead bone (no sequestrum on X-ray)
Subacute osteomyelitis Local and systemic signs plus dead Surgical drainage if surgeon is
(history 2–6 weeks) bone (sequestrum on X-ray) available*
Chronic localised History of untreated /inadequately
Surgical wide drainage and
osteomyelitis treated osteomyelitis
removal of sequestra; antibiotics
(history >6 weeks or Abscess or sinus tract formation plus
not required
recurrent osteomyelitis) sequestrum on X-ray
Chronic systemic Surgical wide drainage and
Chronic osteomyelitis plus systemic
osteomyelitis removal of sequestra plus
symptoms
(history >6 weeks) antibiotics
*If surgery is not available, treat as acute osteomyelitis and re-evaluate after 4 and 6 weeks of symptoms.
If at 4 or 6 weeks there is X-ray evidence of chronic osteomyelitis, discuss with medical supervisor the
possibility of referral for surgery (the decision is context specific).
151
Acute osteomyelitis
• Immobilisation of the affected extremity may relieve pain and prevent fractures.
• Initial treatment with antibiotics IV/IM (see Table 3.9.2, Treatment of osteomyelitis for a
child younger than 5 years; Table 3.9.3, Treatment of osteomyelitis for a child older than 5
years; and Table 3.9.4, Medications and dosage).
- For immunocompromised children and children with sickle cell disease, empiric
treatment should always target Salmonella spp. in addition to S. aureus.
- The potential adverse musculoskeletal effects of fluoroquinolones are balanced against
the significant risks of incomplete treatment for acute osteomyelitis.
- If MRSA and the isolate is sensitive to clindamycin then change from cloxacillin IV to
clindamycin IV. If the MRSA is sensitive only to vancomycin, cease IV cloxacillin and
commence IV vancomycin (authorisation needed from Medical Coordinator).
Table 3.9.2 Treatment of osteomyelitis in child < 5 years except for child with SCD4
Initial treatment Switch to oral therapy if child is Switch to oral therapy if child is
not immunocompromised immunocompromised (SAM or HIV)
IV cloxacillin + IV Amoxicillin/clavulanic acid or cephalexin PO +
Amoxicillin clavulanic acid PO to
ceftriaxone for ciprofloxacin PO to complete 4 weeks of
complete 4 weeks of treatment
minimum 7 days treatment
Table 3.9.3 Treatment of osteomyelitis in child > 5 years except for child with SCD
Situation First-line treatment Switch to oral therapy

Cephalexin PO
Fully immunised, stable child IV cloxacillin for minimum 7 days
to complete 4 weeks of treatment
Unstable, incompletely immunised IV clindamycin + IV ceftriaxone for Clindamycin + cefixime PO
or immunocompromised child minimum 7 days to complete 6 weeks of treatment
Table 3.9.4 Medications and dosage

Drug Dosage
50 mg/kg/dose of amoxicillin component given every 12
Amoxicillin clavulanate (7:1 or 8:1 formulation)
hours
Cloxacillin IV 50 mg/kg/dose given every 6 hours
Clindamycin IV/PO 10 mg/kg/dose given every 8 hours
Ceftriaxone IV 50 mg/kg/dose given every 12 hours
Cephalexin PO 40 mg/kg/dose given every 8 hours
Ciprofloxacin PO 15 mg/kg/dose given every 12 hours
4
In SCD use IV ceftriaxone, then switch to oral ciprofloxacin as first-line treatment, see chapter on SCD.
152
If all five of the following are met, consider switching to PO medication:

1. Child has completed at least 14 days of IV/IM treatment
2. Child is clinically improved
3. Child has been afebrile for at least 72 hours
4. Child has demonstrated ability to take oral medication without a problem in the hospital
5. Caregiver is able to reliably give the medication to the child
Remember that antibiotics administered orally for haematogenous osteomyelitis must be given in
higher doses than those used for treatment of other infections.
Patients who are not responding to treatment as expected require re-evaluation and adjustment of
therapy. Discuss the case with the medical advisor. In any case, always consider and exclude TB (see
MSF tuberculosis guidelines).
Chronic localised osteomyelitis

Treatment for chronic, localised osteomyelitis is surgical removal (debridement) of the sequestrum
and the dead tissue around it because the sequestrum serves as a source of infection.
Recurrent or tuberculosis osteomyelitis also requires surgery; these cases should be discussed with
senior medical staff (Medical Referent, Medical Coordinator).
Chronic systemic osteomyelitis

Surgical debridement is required for chronic systemic osteomyelitis, plus antibiotic treatment of
systemic sepsis. Treatment should be discussed with senior medical staff (Medical Referent, Medical
Coordinator), as eradication of the infection is difficult, complications are frequent and therapy will
require extensive/long-term wound management.
Follow-up
• Monitor symptoms: fever and pain with movement should improve within 7 days (usually as
soon as 3–4 days).
• X-ray the affected limb at the end of treatment to confirm improvement.
• Involve physical therapy if available, or contact the Medical Supervisor for advice and/or
referral.
• If possible, follow up at 2 weeks and 3 months after discharge.
153
Septic Arthritis
• Urgent joint drainage and decompression are necessary to treat septic arthritis; refer to
surgery if possible.
• Administer antibiotics (same choice of drugs as in osteomyelitis) IV for the first 5 days, then
PO for a total of 2 weeks of treatment.
• Joint immobilisation (for 1–2 days) to decrease local irritation
• Begin rehabilitation therapy of affected joint after 2 days to decrease the development of
fibrous adhesions (contact Physiotherapy Referent).
• If no or only questionable surgery options are available, discuss with the Medical Advisor
how to best proceed.
Ongoing management of children hospitalised with osteomyelitis or joint sepsis

• Provide mobility aid (crutches, walking stick, etc.).
• Gently perform passive mobilisation of the limb when prescribed by the Medical Officer.
• Ensure the child receives analgesia regularly.
• Help the child and parent determine ways to continue normal activities (washing, dressing,
mobilising) while avoiding use of the affected limb during the acute phase.
Complications
The outcome is usually good for uncomplicated cases that are diagnosed early and treated
appropriately, although 5% to 10% of patients may experience recurrence. Treatment duration of
less than 4 weeks and poor adherence has been associated with treatment failure and chronic
osteomyelitis.
154
3.10. Skin Problems
3.10. Skin Problems

Scabies ................................................................................................................................................. 156
Impetigo .............................................................................................................................................. 158
Cellulitis ............................................................................................................................................... 160
Periorbital and Orbital Cellulitis .......................................................................................................... 162
155
Scabies
Causes
Scabies is an infestation of the skin by the mite Sarcoptes scabiei. Transmission is primarily via direct
and prolonged skin-to-skin contact with an infected individual. Transmission also occurs via shared
clothing and bedding.
Overcrowded living conditions and poverty are associated with a higher prevalence of scabies.
Scabies tends to peak in colder seasons, probably due to increased crowding and prolonged survival
of mites away from the host in cooler temperatures. Young children and the elderly are most
frequently affected.

Scabies usually presents with severe itching, often worse at night, and typical skin lesions
(erythematous papules, vesicular eruption, scabies burrows and nodules) in a characteristic
distribution:
• sides and webs of the fingers
• wrists
• extensor aspects of the elbows
• axillary folds
• skin around the nipples
• periumbilical areas, waist
• male genitalia
• surface of the knees
• buttocks and adjacent thighs
• lateral and posterior aspects of the feet.
• The head is spared except in very young children.
Secondary lesions resulting from scratching (excoriations, crust) or super-infection (impetigo) may
coexist.
Diagnosis
The combination of a pruritic eruption with characteristic lesions and distribution with family
involvement strongly suggests the diagnosis.
156
3.10. Skin Problems
Patients with scabies should be treated both for symptom relief and prevention of transmission.
Treatment of secondary bacterial infection, if present (see following section, Impetigo), should be
initiated 24 to 48 hours before use of topical scabicides.
Topical treatment with scabicides is as follows:

• In children older than 2 months, apply 5% permethrin cream from head to toe; leave on for
8–14 hours before washing off with water. For infants, also apply on the hairline, neck, scalp,
temple and forehead; a second application 1 to 2 weeks later is recommended. Cotton mitts
(gloves) or socks on the hands of infants and young children at bedtime will prevent them
from rubbing the cream into their eyes or mouth. Do not apply to broken or inflamed skin.
• If 5% permethrin is not available, use benzyl benzoate 25% lotion. For children younger than
12 years, the lotion must be diluted before use.:
- Child younger than 2 years: 1 part 25% lotion + 3 parts water. Rinse off after 12 hours (6
hours for infants younger than 6 months)
- Child 2 years and older: 1 part 25% lotion + 1 part water. Rinse off after 24 hours.
- A second application reduces the risk of treatment failure (e.g., after 24 hours with a
rinse between the two applications, or two successive applications, 10 minutes apart,
when the first application has dried, with a rinse after 24 hours). A second application is
not recommended in children younger than 2 years.
Oral treatment with ivermectin PO (200 mcg/kg as single dose repeated after 2 weeks) is an
alternative to topical treatment for children weighing >15 kg. It is more practical than topical
treatment (e.g., in case of an epidemic or for treating contacts) and can be started right away in the
case of secondary infection. Remember that ivermectin it is not recommended for children smaller
than 15 kg and pregnant women.
• 15–24 kg: 1 tab of ivermectin 3-mg tab (as single dose repeated after 2 weeks)
• 25–35 kg: 2 tabs of ivermectin 3-mg tab (as single dose repeated after 2 weeks)
• 36–50 kg: 3 tabs of ivermectin 3-mg tab (as single dose repeated after 2 weeks)
• >51 kg: 4 tabs of ivermectin 3-mg tab (as single dose repeated after 2 weeks)
Patients with crusted scabies (scaly rashes, slight itching and thick crusts of skin that contain
thousands of mites) must be treated simultaneously with oral ivermectin and topical 5% permethrin
(if >15 kg and not pregnant). In patients with crusted scabies, suspect immune deficiency.
Treat itching with chlorphenamine PO:

• Chid younger than 2 years: 1 mg twice daily
• Child aged 2 to 6 years: 1 mg every 4–6 hours
• Child older than 6 years: 2 mg every 4–6 hours
Close contacts of the patient should be treated simultaneously, even in the absence of symptoms. In
addition, clothes and bedding should be washed (at ≥60 degrees Celsius) then dried in the sun;
alternatively, they can be exposed to sunlight or sealed in a plastic bag for 72 hours.
157
Impetigo
Causes
Impetigo is a contagious bacterial infection of the skin caused by beta-haemolytic Streptococcus
(Group A Streptococcus) or Staphylococcus aureus. It is most common in children ages 2–5 years. It is
often the result of infection at sites of minor skin trauma, such as abrasions; insect bites; eczema;
and herpes, chickenpox or scabies.
Risk factors include poverty, crowding and poor hygiene.
Non-bullous Impetigo
Non-bullous impetigo is the most common form of impetigo. Lesions begin as papules that progress
to vesicles surrounded by erythema. Subsequently, they become pustules that enlarge and rapidly
break down to form thick, adherent crusts with a characteristic golden appearance; this usually
evolves over the time of about one week. Lesions usually involve the face and extremities. Multiple
lesions may develop, but tend to remain well localised. Regional lymphadenitis may occur, although
systemic symptoms are usually absent.
Bullous Impetigo
Bullous impetigo is common in young children. The vesicles enlarge to form flaccid bullae with clear,
yellow fluid, which later becomes darker and more turbid; ruptured bullae leave a thin brown crust.
Usually there are fewer lesions than in non-bullous impetigo and the trunk is more frequently
affected.
Ecthyma
Ecthyma is an ulcerative form of impetigo; the lesions extend through the epidermis and deep into
the dermis. The lesions consist of ‘punched-out’ ulcers covered with a yellow crust, surrounded by
raised violaceous margins.
This should not be confused with ecthyma gangrenosum (EG), a cutaneous manifestation of a
systemic infection of Pseudomonas aeruginosa with secondary septic emboli. EG is usually seen in
immunocompromised patients (neutropenia).
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3.10. Skin Problems
For localised impetigo, defined three or less lesions on the same region of the body:
• Wash affected areas with warm, soapy water and try to clean off any crusts.
• Apply mupirocin cream 3–4x/day for 5–7 days.
• Keep fingernails short.
For extensive (simple) impetigo, defined as more than three lesions or impetigo on more than one
region of the body (as in cases of bullous impetigo or ecthyma):
• Treat locally as above.
• In addition, treat with oral antibiotics: cephalexin PO 25 mg/kg/dose 2x/day for 7 days or
amoxicillin/clavulanic acid PO 7:1 or 8:1; 50 mg/kg/dose of the amoxicillin component 2x/day
for 7 days.
Complications
Possible complications of impetigo include abscess, cellulitis, osteomyelitis, sepsis, poststreptococcal
glomerulonephritis and rheumatic fever.
159
Cellulitis
Causes
Cellulitis is a localised or diffuse inflammation of connective tissue and of the dermal and
subcutaneous layers of the skin. An often-concurrent condition is erysipelas, which is a more
superficial infection of the dermis and upper subcutaneous layer of the skin that presents clinically
with a well-defined edge.
Both cellulitis and erysipelas are caused by beta-haemolytic streptococci; additional causes for
cellulitis include Staphylococcus aureus and (rarely) gram-negative aerobic bacilli. Risk factors for
acquiring cellulitis or erysipelas include disruption to the skin barrier, insect bites, abrasions,
penetrating wounds, eczema, preexisting skin infections (such as impetigo or tinea pedis) and
varicella exposure.

In cellulitis, the skin is red, warm and painful. Other signs are include fever, chills, purulent drainage
or exudate from a puncture site. The most common site of infection is the lower extremities,
although periorbital cellulitis (see next section, Periorbital cellulitis), buccal cellulitis and perianal
cellulitis are also common.
Diagnosis
Diagnosis is based on the clinical findings and evidence.
It is important to distinguish between cellulitis and skin abscess, as skin abscess may look like
cellulitis and this may delay diagnosis and appropriate surgical incision and drainage. An abscess is a
localised collection of pus. One sign of an abscess is an area of fluctuance; that is, when you apply
gentle digital pressure over the area, you can push and feel a ‘give,’ indicating the presence of fluid
underneath. Another sign is that an abscess often seems to ‘point’; that is, the skin starts to thin from
the pressure of the fluid underneath. An abscess rarely has systemic signs (like malaise and fever)
Treatment
Elevate the affected area and clean the wound (if wound is identifiable) with copious irrigation with
clean water or saline.
Antibiotics
If the child has a fever, administer cloxacillin IV 50 mg/kg/dose 4x/day. If the child does not improve
after 48 hours, stop cloxacillin and start clindamycin IV 10mg/kg/dose 3x/day. When the child is
clinically improving, switch to oral therapy with cephalexin PO (in children older than 1 year) 25
mg/kg/dose 2x/day for 5–7 days (maximum dose 4 g/day) or amoxicillin/clavulanic acid PO 50
mg/kg/dose of the amoxicillin component 2x/day. If the child was treated with clindamycin IV, switch
to clindamycin PO 10mg/kg/dose 3x/day.
160
3.10. Skin Problems
If the child is afebrile, start immediately with cephalexin PO as above (in children older than 1 year)
or amoxicillin/clavulanic acid PO (see previous).
If child has been bitten by a cat, dog or human, use amoxicillin/clavulanic acid as described
previously.
If the child is not fully vaccinated, tetanus vaccination should be given for all bites, and considered for
all entry wounds.
Supportive care includes treating fever and providing analgesia, if fever or pain is present, to improve
the patient’s comfort.
Complications
Potential complications of cellulitis include lymphangitis (red line or streak going up the arm or leg)
and inflammation of regional lymph nodes (red, painful, swollen).
161
Periorbital and Orbital Cellulitis
Causes
Periorbital cellulitis (preseptal) is an infection of the eyelid and surrounding structures that does not
involve the orbit (fat and muscles of the eye). Common causative pathogens include Haemophilus
Influenzae (ask about immunisation status), Staphylococcus aureus, Mycobacterium tuberculosis
(especially in cases of spontaneous formation of a fistula with minimal inflammation plus infection
unresponsiveness to antibiotics or other signs of systemic tuberculosis) and anthrax (rarely, but
consider if the periorbital cellulitis is ulcerative and eschar forming and the child has a history of
contact with anthrax-infected animals or animal products).

Patients with periorbital cellulitis present with eye pain, swelling and redness.
Orbital cellulitis is usually a complication of a sinus infection; signs include the following:
• ophthalmoplegia (paralysis or partial paralysis of eye movements)
• pain with eye movements
• proptosis (protrusion of the eye ball; see Figure 3.10.1, Orbital cellulitis)
Figure 3.10.1 Orbital cellulitis
It is very important to differentiate between periorbital and orbital cellulitis because orbital cellulitis
can lead to blindness.
162
3.10. Skin Problems
Diagnosis
Diagnosis of periorbital cellulitis is based on history (insect bite, local face and/or eyelid trauma) and
physical examination.
Hospitalise all children with suspected or confirmed orbital cellulitis and any children with periorbital
cellulitis who are younger than 1 year of age and/or appear severely ill.
Treat with IV antibiotics until the child is afebrile for at least 24 hours, has no pain on eye movement
and full range of eye movement and has no restrictions of vision (if it is possible to examine).
For the fully immunised child with periorbital cellulitis

• Cloxacillin PO 50 mg/kg/dose 4x/day, or
• Amoxicillin/clavulanic acid PO 50 mg/kg/dose of the Amoxicillin component 2x/day 5–7 days
For children who are incompletely immunised and/or have orbital cellulitis
• Give ceftriaxone IV/IM 100 mg/kg/day divided in one or two doses (maximum dose 2 g) for 5
days + cloxacillin IV 50 mg/kg/dose 4x/day for maximum of 12 days.
• If after 48 hours the child is not improving, stop cloxacillin IV and start clindamycin IV 10
mg/kg/dose 3x/day.
• Once the child has fulfilled the criteria for IV treatment (listed previously), then switch to
amoxicillin/clavulanic acid PO as for fully immunised child with periorbital cellulitis only to
complete seven days of treatment.
- Switch to clindamycin PO (10 mg/kg/dose 3x/day) if the child was on clindamycin IV.
Protect eye from further irritation and do not allow child to rub or scratch it (if necessary, apply a
patch made from gauze or a homemade shield).
163
3.11. Malaria
Malaria Testing .................................................................................................................................... 165
Malaria................................................................................................................................................. 169
Cerebral Malaria Treatment Algorithm ............................................................................................... 176
Malaria in Young Infants...................................................................................................................... 177
164
3.11. Malaria
Malaria Testing
MSF RDT malaria testing kits test for Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale
and Plasmodium malariae. The test has three different lines (C, Pf, Pan) for the differential detection
of the various microorganisms responsible:
• The C line serves as the internal control line.
• The Pf line is used in the detection of HRPII of P. falciparum.
• The Pan pLDH line detects the pan pLDH protein of P. falciparum, P. vivax, P. ovale and P.
malariae.
Malaria testing kits must be kept within the temperature range specified on the box. Always check
the expiration date prior to use.
Before starting testing, wash your hands or disinfect them with an alcohol-based solution. Don non-
sterile gloves.
Procedure
• Place the testing device on a flat surface
• Check and record the name, age and date of birth of the child to be tested.
• Disinfect the child’s finger with alcohol or povidone iodine.
• Prick his or her finger carefully.
• Wipe off the first drop of blood with a piece of gauze and discard.
• Hold the transfer loop (provided) and touch the tip to the drop of blood. The blood will fill
the loop. The sample is ready to be placed on the cassette.
165
• Add the whole blood just collected with the loop into the sample well of the cassette.
• Add four drops of buffer into the square buffer well, keeping the bottle vertical. Record the
time that the buffer was added.
Interpretation
Read the result within 15 to 30 minutes. The background should be clear. Do not interpret results
after 30 minutes, as it may lead to a false-positive diagnosis.
166
3.11. Malaria
Possible Results
1. Positive C line and Pf line and negative Pan line

The presence of two coloured lines (C and Pf) indicates a positive result for P. falciparum. The control
line tells you the test worked properly and you can trust the result.
The positive Pf line with a negative Pan line (with positive C line) can be seen in two situations:
1. The child had a recent Pf infection and was correctly treated. As the HRPII remains detectable
longer than the pan pLDH, this may be a false-positive Pf line.
2. As the sensitivity for the pan pLDH (Pan line) is lower than the sensitivity of the HRPII (Pf line),
this result can occur in a P. falciparum–infected child with a low level of parasitemia.
- The Pan line is then a false-negative result.
The result should be interpreted as positive, but may indicate prior infection; alternatively,
microscopy can be performed if available for confirmation.
2. C line, Pf line and Pan line are all positive

This result indicates either a P. falciparum–only infection or a mixed infection of P. falciparum and
one or more infections with P. vivax, P. ovale and/or P. malariae.
3. Positive C line and Pan line and negative Pf line

• The presence of two coloured lines (C and Pan) indicates a positive result for P. vivax, P.
malariae or P. ovale.
• The control line tells you the test worked properly and you can trust the result.
• The Pf line is absent, indicating that the child does not have P. falciparum.
167
4. Positive C line only

The presence of only one line at the control line (C line) indicates a negative result. The test worked
properly and you can trust the results, but the patient does not have any form of malaria.
5. Negative C line
The test is invalid if the control line does not appear. If this occurs, the test should be repeated using
a new cassette.
168
3.11. Malaria
Malaria
Causes
Malaria is a parasitic infection caused by protozoa transmitted to humans via the bite of female
Anopheles mosquitoes. Transmission can also occur by parasite-infected blood and transplacentally.
Most infections are due to four species: Plasmodium falciparum, Plasmodium vivax, Plasmodium
ovale and Plasmodium malariae. All species may cause uncomplicated malaria; severe malaria
(defined by the presence of major organ malfunction) is almost always due to P. falciparum.

Think malaria if the child presents with fever (or history of fever in the previous 48 hours) and is in an
endemic area. Rapid, effective antimalarial treatment and supportive care improve outcomes in
severe malaria. Children may present late and death from severe malaria can occur within hours of
presentation, so it is important to treat children rapidly. In areas with high prevalence of malaria, a
child with a positive malaria test may also have other, concomitant illnesses, so always exclude other
cause in a child presenting with fever.
Uncomplicated Malaria
Defined as a confirmed parasitological diagnosis of malaria without signs of severity (organ
dysfunction). The most common signs/symptoms are fever, chills, sweating, abdominal pain,
diarrhoea and vomiting, headache, pallor from anaemia, malaise, anorexia or nausea, muscular aches.
Severe Malaria
Severe malaria is a confirmed parasitological diagnosis of malaria plus the presence of one or more of
the signs listed in Table 3.11.1, Clinical and laboratory signs of severe malaria.
Table 3.11.1 Clinical and laboratory signs of severe malaria
Clinical signs Laboratory signs

- Severe pallor (anaemia; Hb ≤5 g/dL) - Hypoglycaemia
- Impaired consciousness (VPU on APVU; <3 on - Metabolic acidosis (plasma bicarbonate <15
Blantyre) mmol/L)
- Prostration - Hyperlactataemia (lactate >5 mmol/L)
- Multiple convulsions (≥2 in 24 hours; focal or - Severe anaemia (Hb <5 g/dL, haematocrit <15%)
general) - Haemoglobinuria (urine dip stick positive for
- Respiratory distress, especially deep breathing (sign blood)
of acidosis) - Hyperparasitaemia: (>10% of RBC or 500,000
- Shock parasites/mcl)
- Jaundice (yellow conjunctivae and/or palms) - Renal impairment
- Haemoglobinuria (dark/red urine) - Pulmonary oedema (X-ray confirmation)
- Abnormal bleeding in skin (petechiae, bruising), - Disseminated intravascular coagulation (DIC)
conjunctivae, nose or gums, or blood in stools
- Acute renal failure: urine output <1mL/kg/hour
despite adequate hydration
169
Severe malaria can occur with any organ dysfunction. The two most common manifestations in high
transmission areas are cerebral malaria and severe malarial anaemia.
Cerebral malaria (mean age 4 years in highly endemic areas)

Cerebral malaria is defined as either of the following:
• Confirmed parasitological diagnosis of malaria plus impaired consciousness or coma
(Blantyre Coma Scale <3 or Glasgow Coma Scale <11) with no other identifiable cause (no
hypoglycaemia, no postictal state, no meningitis)
• Confirmed parasitological diagnosis of malaria plus coma lasting >30 minutes after a seizure
(do not forget that the child may also have meningitis)
Note: Seizures in the absence of impaired consciousness are not a criterion for cerebral malaria. If a
child is postictal (i.e., in a transient coma following a seizure for a maximum of ≤30 minutes), this is
not cerebral malaria.
In MSF field operations with expertise in ophthalmologic exams, malarial retinopathy is

pathognomonic for cerebral malaria in children with parasitological and clinical diagnosis of malaria.
Evaluate the optic fundi after instilling two drops of a mydriatic agent such as tropicamide (in MSF
Essential drugs) for pupillary dilatation. Examination should be performed via direct
ophthalmoscope. Features of malarial retinopathy include white-centred haemorrhages, vessel
changes and whitened areas of the retina and can be accompanied by papilledema.
Severe malarial anaemia (mean age 18 months in highly endemic areas)

Severe malarial anaemia is defined as confirmed parasitological diagnosis of malaria (either RDT or
microscopy) plus haemoglobin concentration <5 g/dL or haematocrit <15%. Children with severe
anaemia may present with or without altered consciousness. In endemic areas, haemoglobin
concentration may decrease gradually over the course of repeated malaria infections, so a child can
be fully alert with haemoglobin concentrations of 2 to 3 g/dL (haematocrit <10%).
Diagnosis
Severe malaria can mimic or occur concomitant to other diseases that are also common in malaria-
endemic countries. The most important of these are meningitis, sepsis, severe pneumonia and
typhoid fever.
Laboratory Diagnosis
• Confirm clinical suspicion of malaria by a parasitological diagnosis: microscopy or rapid
diagnostic test (RDT)
• All children suspected of malaria in an endemic zone must have an RDT or microscopy.
• If testing not available and severe malaria is suspected, do not delay treatment.
• If the child presents clinically with severe malaria (see Table 3.11.1, Clinical and laboratory
signs of severe malaria) and RDT is negative, treat for severe malaria but continue to look for
other causes of fever. Review the clinical case with the paediatrician or senior clinician.
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3.11. Malaria
RDTs detect different proteins (antigens) produced by the parasites. There are two RDTs that are
commonly used in MSF fields: HRP2 and pan pLDH.
• HRP2 tests (most currently available) have a high sensitivity and specificity for P. falciparum
infections but may remain positive up to 42 days after the start of anti-malarial treatment.
Patients should be asked whether they have been treated for malaria in the previous 1-2
months, and if so, other possible diagnoses should be considered. If a patient who has been
adherent to anti-malarial treatment has a positive HRP2 test within 6 weeks of a prior
infection, perform microscopy if available.
• Pan pLDH tests (currently only recommended in high transmission areas) also have a high
sensitivity and specificity, but lower than that of HRP2. Pan pLDH tests can identify infections
by P. falciparum, P. vivax, P. malariae and P. ovale. These tests become negative within 2-4
days after the start of treatment, so they are more useful in identifying current infections in
areas of high transmission.
Microscopy should be utilised where possible, although quality is not ensured in all projects.
• Thick blood films enable parasite detection and quantification; thin blood films enable
species identification, quantification of and monitoring of parasitaemia.
• Hyperparasitaemia (see definition previously) is associated with a severe clinical presentation
of malaria and indicates severe malaria. Hyperparasitaemia will depend on the intensity of
transmission.
All children with suspicion of severe malaria, in addition to parasitological diagnosis, should have the
following labs run:
• haemoglobin (Hb): for transfusion indications (see below)
• blood glucose: for hypoglycaemia
• urine dipstick: haemoglobinuria (urine dipstick positive for blood)
Table 3.11.2 Summary of diagnosis and treatment of P. Falciparum malaria

Severe malaria
Uncomplicated All types of severe
malaria malaria Severe malarial anaemia (SMA)
(except SMA)
Artesunate IV
ACT PO for 3 days Artesunate IV Transfusion if Hb <4 g/dL,
LP if indicated or <6 g/dL with signs of decompensation (respiratory
Required lab tests: distress, shock, impaired consciousness)
RDT
Antibiotics for all patients Antibiotics for all patients if < 2 years of age
Required Labs: RDT, Hb, glucose
171
Uncomplicated Malaria
(For neonatal malaria and malaria in children <5 kg, see Neonatal malaria protocol.)
Treatment of uncomplicated P. falciparum malaria (for all doses, see Chapter 7, Table 7.5.1):
• Children ≥5kg: Artemisinin-based combination therapy (ACT) PO for 3 days
• Prefer fixed dose combinations (FDC) over co-blisters
• Take into account the national protocols, knowledge of local resistance patterns and
availability of ACT when making the choice of an ACT (note that ASAQ is contraindicated in an
HIV-positive child on antiretrovirals due to neutropenia and/or possible increased toxicity)
• Although P. falciparum is resistant to chloroquine (CQ) in most of our settings (Africa, South
America, South-East Asia and Oceania), it appears to remain sensitive to CQ in Haiti and the
Dominican Republic. In these regions, CQ remains the first-line treatment (see non-
falciparum malaria).
• If child cannot take PO because of vomiting, give IV or IM artesunate (if not available, give IM
artemether) and as soon as the child can take oral medication, complete with 3-day course of
ACT.
• If only quinine is available (rare)
- Children: ≤50 kg: 10 mg/kg/dose PO every 8 hours for 7 days
– Children: >50 kg: 600 mg/dose PO every 8 hours for 7 days
Treatment of non-falciparum malaria: Chloroquine (CQ) PO 10 mg base/kg once daily OD D1, D2 and
5 mg/kg base on D3. In general, P. vivax remains sensitive to CQ but resistance is found in PNG,
Solomon Islands, Burma, India, Indonesia and East Timor. In these regions, follow national
recommendations. P. vivax and P. ovale can cause relapses due to dormant parasites in the liver. A
treatment with primaquine can be given to eliminate these parasites, after the initial treatment with
CQ. However, this treatment is reserved for patients living in areas where reinfection is unlikely, i.e.
non-endemic or low transmission areas.
Severe Malaria
• Initial assessment and management of a severely ill child
• Hospitalise
• If the child is in the dispensary: stabilise, then transfer to a hospital (see Table 3.11.3, pre-
hospital management of malaria, and Table 3.11.4, Hospital management of malaria)
• ABCD approach and treatment as for any severely ill child
• Check for hypoxia (SpO2 <94%); if yes, give oxygen
• Hyperthermia, hypothermia
• IV/IO access
• Maintenance fluids
• Test for hypoglycaemia
• Convulsions: treat if lasting >5 minutes or if more than two seizures in 5 minutes (see
Chapter 3.8, Neurological Disorders, for information regarding seizures)
• Severe anaemia (type and cross-match, prepare for transfusion, follow transfusion
guidelines)
• Haemoglobinuria: ensure that the patient is well hydrated and continues to urinate (a
minimum of 1 mL/kg/hour)
• Consider sepsis and antibiotic therapy (see below)
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3.11. Malaria
Table 3.11.3 Pre-hospital management of malaria

Before transfer to hospital
(See appendices for dosage information)
No injectable (IV/IM) No injectable (IV/IM)

Injectable (IV or IM) No injectable (IV/IM)
artesunate available; artesunate available;
artesunate available: artesunate or
IM artemether available IM artemether available
All ill children artemether available
and child is not in shock and child is in shock
First dose of
First dose of
artesunate IV; if IV Rectal artesunate Rectal artesunate
artemether IM
not possible, give IM suppository suppository
(Loading/first dose;
(Appendix, Tables (Appendix, Table 7.5.4) (Appendix, Table 7.5.4)
Appendix, Table 7.5.3)
7.5.2 and 7.5.3)
Note time and dose of administration of medication in the medical record or transfer sheet
Table 3.11.4 Hospital management of malaria
IV/IO can be placed IV/IO cannot be placed

First line (best) Artesunate IV/IO (Table 7.5.2) Artesunate IM (Table 7.5.2)
Child is not
Second line Artemether IM (Table 7.5.3) Artemether IM (Table 7.5.3)
in shock
Third line Quinine IV (Table 7.5.5) Quinine IM (Table 7.5.5)
Child is in First line (best) Artesunate IV/IO (Table 7.5.2) Artesunate IM (Table 7.5.2)
shock Second line Quinine IV (Table 7.5.5) Quinine IM (Table 7.5.5)
• Specific treatment for severe malaria with injectable drugs should be maintained for a
minimum of 24 hours (artesunate: three doses; artemether: two doses; quinine: three doses)
and completed with a three-day course of ACT once the child is improved, alert and able to
swallow oral medications.
• Please note: There is no minimum interval between the last artesunate injection and the first
dose of an oral ACT: it can be given 1–2 hours after the third injection of artesunate if the
child is improved and able to swallow oral medications.
• If child has completed 7 days of artesunate, artemether or quinine, there is no need for ACT.
Severe Malarial Anaemia

Children with severe malarial anaemia should be handled as little as possible to prevent cardiac
failure.
Indications for transfusion:

• If Hb <4 g/dL, or if <6 g/dL plus respiratory distress and/or shock and/or impaired
consciousness.
Note: If Hb <6 and Shock: refer to Chapter 3.2, Shock and circulatory impairment
• If parasitaemia >2% or 100,000 parasites/mcL in low-intensity transmission areas, or >5% or
250,000 parasites/mcL in areas of high stable malaria transmission intensity
173
• In certain clinical cases of acute ongoing haemolysis, it may be necessary to transfuse sooner
or give a second transfusion as indicated clinically. If possible, ensure that the second
transfusion is from the same donor as the first in order to minimise risk. These cases must be
discussed with a senior clinician.
• See Appendix, Table 7.5.6 and Chapter 8.1, Blood Transfusions, for additional information.
Severe Malaria and Sepsis

In children, sepsis and severe malaria may be associated and can be confused. A child with malaria or
severe malaria may fail to improve or worsen because of an undiagnosed bacterial infection. Many
bacteria have been cultured from the blood of children with severe malaria, but nontyphoidal
salmonellae (NTS) are the commonest. Table 3.11.1 lists the different categories of severe malaria.
Severe malarial anaemia (SMA) (Hb ≤ 5g/dL) is the category with the strongest relationship with NTS,
with a higher risk of invasive bacterial infection in younger children. Although patients with SMA
often respond well to transfusion and antimalarials, we recommend systematic IV ceftriaxone
treatment only in those patients with SMA who are less than two years old. Patients in other
categories of severe malaria should all receive IV ceftriaxone regardless of age.
• Ceftriaxone IV/IM 100 mg/kg/day divided into 1 or 2 doses (maximum dose: 2 g) for 3–5
days. Consider switching to amoxicillin/clavulanic acid PO when child is well, has been
afebrile for 24 hours and is eating and drinking to complete a total of 7 days of antibiotics.
• Amoxicillin/clavulanic acid 7:1 or 8:1: 50 mg/kg/dose of the amoxicillin component 2x/day
Cerebral Malaria
• Any child at risk of increased intracranial pressure should be on 2/3 maintenance fluids.
• For antimalarials, see treatment of severe malaria, above.
• Cerebral malaria and bacterial meningitis: if the child has a contraindication to lumbar
puncture (LP), treat for meningitis and cerebral malaria on day 1, then when the child
improves perform LP in all children admitted with impaired consciousness who remain in
critical condition. If the child remains comatose and LP can never be performed, see Table
3.11.5, Lumbar puncture results and treatment in cerebral malaria.
• LP can be performed if all of the following apply:
• A doctor trained to perform the procedure is available
• Laboratory personnel skilled in cerebrospinal fluid analysis are available
• No contraindications to LP (for contraindications see Chapter 3.12, Meningitis)
• LP excludes bacterial meningitis if white blood cells in cerebrospinal fluid (CSF) < 10 cells/mm3
and/or CSF point of care lactate available and <3.75 mmol/L (100% sensitivity).
• If LP confirms meningitis, treat with ceftriaxone IV 100 mg/kg/day for 10 days.
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3.11. Malaria
Table 3.11.5 Lumbar puncture results and treatment in cerebral malaria
LP performed on day 2–3 when child with LP cannot be performed because

cerebral malaria has improved child does not improve after 3 days
LP confirms bacterial meningitis LP excludes bacterial meningitis
Treat for meningitis:
IV ceftriaxone IV/IM 100
IV ceftriaxone 100mg/kg/day x 10 IV ceftriaxone
mg/kg/dose 1x/day
days (see Chapter 3.12, Meningitis) 100 mg/kg/day x 10 days
(maximum dose: 2 g)
+ IV antimalarial treatment + IV antimalarial treatment
x 3–5 days; treat for sepsis + IV
antimalarial treatment
Monitoring
Monitor vital signs every 15–30 minutes if the child is unstable, or every 2, 4 or 6 hours, depending
on the clinical course. Routine vital signs can be taken once the child is stable.
Place a clean, dry towel or surgical mask under the child and ask the caregiver to notify the nurse of
any urine output. If in an advanced setting (ICU), insert a urinary catheter. Urine output should be ≥1
mL/kg/hour.
• Dipstick urine once every 24 hours
• Look for haemolysis if on quinine; if present, stop and go to ACT PO/NGT
• If urine output <1 mL/kg/hour for >6 hours, give furosemide 1 mg/kg
- If still no urine 1 hour later: stop all fluids (the child is in renal failure)
Monitor the child for signs of fluid overload.

• Increased RR by ≥10 breaths/minute into the tachypnoeic range, or
• Heart rate increases by ≥20 beats/min into the tachycardic range, plus any one of the
following:
- new or worsening hypoxia (decrease in SpO2 by >5%)
- new onset of rales and/or pulmonary oedema (fine crackles in lung fields)
- new galloping heart rhythm
- increased liver size (liver size must have been marked with pen on arrival)
- new peripheral oedema (puffy eye lids)
- look for associated pneumonia (if found, administer ceftriaxone).
See Chapter 6, Enteral Nutrition for Non-SAM Children and Chapter 7.1, Maintenance Fluids, for
information regarding feeds and fluids.
Discharge
Children who have received their first dose of oral ACT should be observed for at least 1 hour after
administration; if no adverse effects, they can then be discharged home with good instructions on
how to take the remaining oral drugs (to avoid longer hospitalisation than needed). All children
recovering from the anaemic form of malaria should receive folic acid for anaemia upon discharge.
175
Figure 3.11.1 Cerebral Malaria Treatment Algorithm
Cerebral malaria (see malaria protocol for definition)
Child has a Blantyre score of <3 (definition of cerebral malaria)

and also has a contraindication for lumbar puncture: treat for
meningitis + malaria with ceftriaxone 100 mg/kg/day and
antimalarials (see malaria protocol)
Lumbar puncture (LP) is possible* on day 2 or 3

(see previous section, Malaria, for details)
No Yes
Assume meningitis + Lumbar puncture is negative for meningitis:

malaria CSF WBC <10 cells and/or
CSF Point of Care Lactate <3.75 mmol/L
*Child is clinically sufficiently stable for LP

plus laboratory analysis of CSF is available No Yes
and LP is not contraindicated
Meningitis + malaria Not meningitis + malaria; possible

Give ceftriaxone IV 100 mg/kg/day for other bacterial infection
10 days + antimalarials Give ceftriaxone IV/IM 100
mg/kg/day for 3–5 days (maximum
dose 2 g) or other antibiotic
*Child is clinically sufficiently stable for LP plus laboratory analysis of depending on clinical situation) +
CSF is available and LP is not contraindicated antimalarials
176
3.11. Malaria
Malaria in Young Infants (< 2 month of age)
Causes
Congenital malaria is malaria in the first week of life (0–7 days), which can be acquired trans-
placentally (vertical transmission) or at the time of birth. Recent reports suggest that the prevalence
in sub-Saharan Africa ranges from 0% to 23%. It can occur in children born to clinically healthy
mothers who are delivered in malaria-endemic areas. All types of malaria can be transmitted
congenitally, but it is most often associated with Plasmodium falciparum and rarely with Plasmodium
vivax.
Neonatal malaria is acquired via mosquito bite or infected blood from day 8 to day 28 of life. It was
thought to be rare, especially in endemic areas, because of the protective effects of trans-placental
maternal antibodies and Hb F, but it may be more frequent than previously thought.
Infants with congenital or neonatal malaria may have a different clinical presentation to older
children, and diagnosis may be confused with other neonatal diseases due to an overlap of clinical
manifestations.
This section discusses malaria in young infants (< 2 months of age) because they are highly vulnerable
and will be diagnosed and treated in the same way as neonates.

Malaria during pregnancy has been known to cause miscarriage, perinatal death (stillbirth and early
neonatal death), premature birth, low birth weight and congenital malaria. Associated factors
include maternal fever during the third trimester, mother with severe anaemia, premature birth (<37
weeks’ gestation), low birth weight (<2500 g), fever at birth, and mother with peripheral
parasitaemia at delivery.
Signs of malaria in infants are non-specific and resemble sepsis. The following signs and symptoms in
infants younger than 2 months born to mothers in malaria-endemic areas (regardless of maternal
arrival or length of stay in endemic area) should be suspicious for malaria:
• fever (more common in malaria) or hypothermia (more common in sepsis)
• poor feeding/inability to breast feed
• abdominal distension
• pallor (anaemia)
• lethargy, irritability, seizures, coma
• cough and/or respiratory distress, apnoea
• hepatosplenomegaly
• jaundice
• poor perfusion of shock
177
Diagnosis
In endemic areas, microscopy (thin and thick blood smear) or rapid diagnostic test (RDT) should be
performed to confirm suspected malaria.
• Systematic routine testing of all newborns in high-prevalence areas is not recommended (as
some neonates clear parasitaemia spontaneously).
• Perform microscopy or RDT in newborns with maternal malaria during the third trimester or
at delivery.
• Perform microscopy or RDT in all infants younger than 2 months with suspected sepsis or
with the previous signs.
• Repeat microscopy or RDT at 24 and 48 hours if initial tests are negative, but malaria is still
clinically suspected; low levels of malarial parasitaemia can occur in infants younger than 2
months.
General Considerations
• Admit all infants younger than 2 months with positive malaria test or signs of malaria/sepsis
to hospital.
• Treat all infants younger than 2 months presenting with signs of sepsis/malaria (see above
signs and symptoms) with antibiotics.
• Treat infants younger than 2 months with positive malaria testing with antimalarials.
- Do not treat infants with negative malaria tests (microscopy or RDT) with antimalarials.
• Malaria in symptomatic neonates/infants younger than 2 months should always be treated
as severe malaria because of their vulnerability, need for more precise dosing and possible
absorption differences in all medications.
• In case of persistent symptoms and negative testing, repeat malaria testing after 12, 24 and
48 hours. In some exceptional cases with a high suspicion of malaria, taking into account
associated factors, after consultation with a senior clinician malaria treatment can be
considered despite a negative test.
• Transfuse blood if Hb is <7 g/dL or <10 g/dL plus respiratory distress or shock. Treat other
complications according to protocols.
• See the treatment algorithm at the end of this section for additional information.
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3.11. Malaria
Antimalarials
First-line treatment
First-line treatment for symptomatic infants is artesunate IV/IM for 7 days (monotherapy); IV is
always preferable, but IM is acceptable if IV is not available (see Appendix, Table 7.5.7, Artesunate).
Administer slow IV/IM artesunate 3 mg/kg at diagnosis, and then again at hours 12 and 24. After the
third dose, give 3 mg/kg IV/IM once a day for 6 days to complete a total of 7 days of treatment. After
a minimum of three doses of IV/IM artesunate, if clinical condition allows, consider switching to an
oral ACT for 3 days.
If infant is asymptomatic, see section on ACT, below.
Rectal artesunate: Emergency treatment before referral by community health workers in

communities in malaria-endemic area; should be given to all neonates with suspected neonatal
sepsis/malaria after the initial clinical exam before referral.
Second-line treatment
Second-line treatment is artemether IM for 7 days (3.2 mg/kg on the first day [D1] then 1.6 mg/kg
per day from D2 to D7; see Appendix, Table 7.5.8, Artemether dosage using paediatric vials).
Artemether should be given only if artesunate is not available, IV access is not possible, or in very
isolated contexts with no skilled staff (the advantage of artemether in limited-resource settings is
that it is ready to use) and in the absence of signs of shock (normal HR with no associated pathology,
extremities warm and pink, normal pulses, CRT <3 seconds and normal SpO2 with no associated
respiratory diseases).
Third-line treatment
Third-line treatment in symptomatic infants or first-line therapy in asymptomatic infants is
artemisinin-based combination therapy (ACT).
There are few studies of ACTs in infants <5 kg. Artemisinin compounds are known to be safe;
therefore safety and tolerability depend on the other medication(s) in co-formulations. (Note:
Primaquine is contraindicated in children younger than 4 years; avoid pyrimethamine in the first few
weeks because of hyperbilirubinaemia.)
Accurate dosing is difficult, and special dilutions need to be prepared (see Appendix, Table 7.5.9, AS-
AQ dilutions and Table 7.5.10, AL dilutions) and they must be administered immediately after
preparation as they are unstable.
ACT should be given in the hospital under the following circumstances: as an oral relay to injectable
Artesunate or IM Artemether or if the infant is alert and breastfeeding well but it is not possible to
complete the full course IV/IM.
There is currently no scientific evidence to support the use of artemether-lumefantrine over

artesunate-amodiaquine, so follow National Protocols.
179
Figure 3.11.2 Algorithm for malaria in young infants
Malaria in infants younger than 2 months
Signs and symptoms of malaria/sepsis present?
No Yes
Test only if maternal malaria during third ABCD; stabilise the infant; check O2 and glucose
trimester or at delivery
Malaria smear positive in infant (RDT Treat sepsis with IV/IM antibiotics
positive only if smear not available) Test for malaria
Antimalarials: ACT PO in hospital for 3

Malaria smear positive in infant (RDT positive only if smear
days
not available)
IV/IM antibiotics if infant develops any

sign of sepsis No Yes
Continue IV/IM antibiotics

Antimalarials IV/IM
No antimalarials
Retest for malaria at 12 hours
Malaria smear positive in infant (RDT positive only if smear

not available)
No Yes
Continue IV/IM antibiotics Antimalarials IV/IM
No antimalarials Continue IV/IM antibiotics
Retest for malaria at 24 and 48 hours
If 24- or 48-hour tests are positive, start

antimalarials
180
3.12. Meningitis
3.12. Meningitis
Causes
Meningitis is an infection of the tissues surrounding the brain and spinal cord. Suspected bacterial
meningitis is a medical emergency, and rapid diagnosis and treatment improves outcomes. The
mortality rate of bacterial meningitis remains high, especially in limited-resource settings.
The three leading causes of bacterial meningitis—Streptococcus pneumoniae, Haemophilus

influenzae B and Neisseria meningitidis are vaccine preventable. In immunocompromised hosts (HIV-
positive and malnourished children), there is a higher percentage of gram-negative bacilli, especially
Salmonella spp., and also higher incidence of tuberculosis. In children with sickle cell anaemia,
Salmonella and Staphylococcus aureus are more frequent.
In the Sahel region during the dry season, there are epidemics of meningococcal meningitis (Neisseria
meningitidis A, C or W135), but unless identification of the bacterial pathogen by culture is available,
do not assume that the child has meningococcal meningitis, as other bacterial pathogens are possible,
especially in young children.

Acute bacterial meningitis has two patterns of presentation:
• progressive development of meningitis over one or several days, sometimes preceded by a
febrile illness or upper respiratory infection
• acute and fulminant course with manifestations of sepsis and meningitis developing rapidly
over several hours. The rapidly progressive form is frequently associated with severe brain
oedema.
Presentation is variable, but children most commonly present with the following:
• Fever, nausea, vomiting, anorexia, irritability (often the presenting sign in young infants),
photophobia, lethargy, confusion, coma, respiratory distress and seizures (mostly
generalised)
• Meningeal signs (not always present, especially in young infants):
- Back pain
- Nuchal rigidity (stiff neck); absent in comatose patients or those with focal or diffuse
neurologic deficits and may occur late, particularly in young children
- Kernig’s sign
- Brudzinski’s sign
• Altered consciousness is present in the majority of children
• Signs of increased intracranial pressure: headache in older children, irritability and bulging
fontanels or splitting of the cranial sutures in infants
• Palsies (or paralysis) of the third, fourth and sixth cranial nerves (abnormal eye movements)
181
• Focal (abnormal) neurologic findings (hemiparesis, quadriparesis, facial palsy, visual field
defects)
• Petechiae and purpura can occur in fulminant meningococcal sepsis.
Bacterial Meningitis
Consider acute bacterial meningitis in any child who presents with fever and signs of meningeal
inflammation. In infants, the clinical manifestations may include fever and non-specific signs (see
above). Previous receipt of oral antibiotics does not affect the clinical presentation of acute bacterial
meningitis, so do not exclude the possibility because the child was previously treated with oral
antibiotics.
Cerebral malaria is always in the differential diagnosis in endemic regions, but bacterial meningitis is
frequently misdiagnosed as malaria in endemic regions.
Differential diagnoses:
• Viral meningitis or encephalitis
• Cerebral malaria
• Toxic ingestion
• Tuberculous meningitis
• Cryptococcal meningitis
Tuberculous Meningitis (see also MSF TB guidelines)

Consider tuberculous meningitis if any of the following is present:
• Fever for >14 days or fever for >7 days and a family member has TB.
• A chest X-ray suggests TB.
• The patient is unconscious despite 7 days of treatment for bacterial meningitis.
• The patient is known to have HIV infection or is exposed to HIV.
• The CSF has a moderately high white blood cell count (typically <500 white cells per mL,
mostly lymphocytes), elevated protein (0.8–4 g/L) and low glucose (<1.5 mmol/L), or this
pattern persists despite adequate treatment for bacterial meningitis.
Cryptococcal Meningitis (see also MSF HIV guidelines)

Consider cryptococcal meningitis in older children with known or suspected HIV or immuno-
suppression. Children will present with meningitis with altered mental status.
• Perform a lumbar puncture. The opening pressure may be elevated, but CSF cell count,
glucose and protein may be virtually normal. (See Table 3.12.1, Cerebrospinal fluid findings.)
• Analyse CSF with India ink preparation or, if available, do a rapid CSF cryptococcal antigen
latex agglutination test.
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3.12. Meningitis
Viral Meningoencephalitis and Encephalitis

Encephalitis is inflammation of the brain tissue. A child with encephalitis may present with altered
mental status, behaviour or personality changes, motor or sensory deficits such as hemiparesis and
paresthesias, speech or movement disorders or seizures (often focal). The viruses responsible for
most encephalitis seen in MSF contexts include the measles virus, herpes simplex, HIV and the rabies
virus.
In MSF contexts, the only treatable encephalitis is herpes simplex virus encephalitis. Suspect herpes if
the child has a vesicular rash (small blisters) or there is a history of contact with herpes simplex.
Children with herpes encephalitis usually present with acute focal neurologic findings (<1 week in
duration), including focal cranial nerve deficits or focal seizures, plus the above signs of encephalitis;
fever is also present in the majority of children.
Diagnosis
Diagnosis is made on the basis of full history, examination (including immunisation history) and CSF
laboratory analysis.
If there are no contraindications (see below), perform a lumbar puncture (LP) to obtain cerebrospinal
fluid (CSF).
Contraindications for immediate LP:

• obvious signs of increased intracranial pressure (other than bulging fontanelle): decerebrate
or decorticate posturing, absent doll’s eye reflex, abnormal respiratory pattern, unequal
pupil size or dilatation of pupils
• focal neurologic signs
• focal seizures or seizures within previous 30 minutes
• bradycardia
• severe cardiopulmonary compromise that possibly requires prompt resuscitation measures
(shock)
• obvious bleeding disorder
• skin infection over the site for LP.
Laboratory Tests
Testing includes CSF for gram stain and CSF cell count (if available; see Table 3.12.1, Cerebrospinal
fluid findings), blood glucose and haemoglobin (if pallor is present).
If CSF glucose is available, calculate the ratio of CSF glucose to blood glucose; in bacterial meningitis,
it will be <0.6 (glucometer cannot be used to test CSF glucose as it is not sufficiently accurate).
183
Table 3.12.1 Cerebrospinal fluid findings

Opening WBC
Protein in Other
pressure in cm Aspect CSF glucose leukocytes/m
mg/dL tests
H2O m3
Pandy
>2/3 of blood
Normal CSF 10–28; mean 19 Clear <5 negative
glucose
<40
Gram
Very low: Pandy
Bacterial Turbid, stain
Very elevated <10 mg/dL (0.6 >10 positive
meningitis cloudy shows
mmol/L) 100–500
bacteria
10–700, Pandy Gram
Normal to slight
Viral meningitis Clear Usually normal mainly negative stain
elevation
lymphocytes 50–250 negative
Low: 10–45 Pandy
Clear or <500, mainly Acid fast
TB meningitis Elevated mg/dL (0.6– positive
yellowish lymphocytes bacillus +
2.5 mmol/L) >250
Cryptococcal Low: 10–45
<800, mainly Pandy
meningitis* Very elevated Clear mg/dL (0.6-2.5 India Ink
lymphocytes negative
mmol/L)
*Mainly in patients with severe immunocompromise, such as AIDS
Diagnosis is made with any of the following:

• CSF WBC ≥10
• Liquor is turbid
• Pandy test is positive (treat for bacterial meningitis)
All children with suspected or confirmed meningitis must be admitted to the intensive care unit.
• ABCD approach (stabilise the patient)
- Support and manage airways and breathing as needed
- Support and manage circulation as needed (ensure vascular access)
- Support and manage neurological system (perform lumbar puncture and check glucose)
• Immediately administer antibiotics IV
• Provide supportive care as needed (oxygen, fluid maintenance and caloric intake)
• Monitoring according to clinical condition
184
3.12. Meningitis
Bacterial Meningitis
For bacterial meningitis, give ceftriaxone 100 mg/kg/day IV loading dose (within 30 minutes of arrival
to the health facility); continue with 100 mg/kg/day in one or, if possible, two divided doses. If gram
stain is available and a gram-negative rod is observed, add gentamycin IV/IM 7.5 mg/kg/day 1x/day
for 5 days.
The length of treatment in non-epidemic situations depends on the pathogen, if it is known:

• Neisseria meningitidis: 5–7 days
• Haemophilus influenzae: 7–10 days
• Streptococcus pneumoniae: 10–14 days
• Group B streptococcus and Listeria: 14–21 days
• Gram-negative bacilli: 21 days
If the pathogen is unknown (the most frequent case in MSF settings), the length of treatment should
be as follows:
• Children younger than 3 months: 21 days IV
• Children older than 3 months: 10 days IV, extend treatment if fever persists past 10 days. You
may shorten course of ceftriaxone to 7 days if child is making an uncomplicated recovery.
In context of meningitis epidemics, WHO recommends a five-day course with ceftriaxone for children
older than 2 months with suspected bacterial meningitis.
Glucocorticoids (Dexamethasone)
These are no longer recommended as evidence shows no benefit in children with meningitis.
Tuberculous Meningitis (see MSF TB Guidelines)
Cryptococcal Meningitis (see MSF HIV Guidelines)

Give amphotericin B IV 1 mg/kg 1x/day and fluconazole PO 6–12 mg/kg/dose 1x/day for 14 days. If
fluconazole is given alone, give PO 6–12 mg/kg/dose 1x/day for 8–10 weeks.
Viral Meningitis
If you suspect herpes encephalitis and CSF ≥10 WBC, still treat for bacterial meningitis with
ceftriaxone and add acyclovir IV 20 mg/kg/dose every 8 hours for 21 days.
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Supportive care
• For the first 24 hours, the child should be on two-thirds maintenance fluids (see Chapter 7.1,
Maintenance Fluids).
• Insert NGT and gradually start enteral feeding after 24–48 hours (see Chapter 6, Enteral
Nutrition for Non-SAM Children)
• If the child can feed orally but consciousness level remains impaired, nurse the child in the
recovery position
• Treat fever if present (to improve the patient’s comfort)
• Treat seizures if present
• Provide standard nursing care, especially if the patient is in a coma
• If fully conscious, support the child with his or her head looking straight in front.
• In case of reduced consciousness, prepare to protect the airway by facilitating saliva drainage
from the child’s mouth while in the recovery position or using mechanical suction to clear the
child’s mouth and throat of debris.
• Ensure the child receives analgesia in case of headache.
• Maintain a quiet environment for the child.
Monitoring
• Take vital signs and monitor urine output according to the clinical condition of the patient.
• Document a complete neurologic examination daily, looking for eye paralysis and arm and
leg weakness
• Measure head circumference every 3–4 days in child younger than 18 months, looking for
hydrocephalus as a complication of meningitis
Complications
Fever usually lasts 4–6 days, and persistence of fever beyond 8 days may indicate inadequate
treatment, development of nosocomial infection (infected intravenous catheters, urinary tract
infection, viral infection) or development of a complication (pericarditis, pneumonia, arthritis).
If the child is improving clinically but has a persistent fever, continue therapy. If the child is not
improving clinically and has a persistent fever, look for the causes listed above and repeat the LP.
Persistent neurologic sequelae are common in children who survive an episode of bacterial
meningitis. Hearing loss and motor and cognitive impairment are the most common consequences in
Africa. Hydrocephalus can also be a complication of meningitis.
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3.13. Tetanus
3.13. Tetanus
Causes
Tetanus is a nervous system disorder characterised by muscle spasms. It is caused by the toxin-
producing anaerobe, Clostridium tetani, which is found in the soil and in human and animal
excrement.
In developing countries, tetanus remains endemic in children who have not received the appropriate
postexposure prophylaxis with tetanus immune globulin and in infants born to unvaccinated or
incompletely vaccinated mothers. The incidence increases following natural disasters and in conflict
and post-conflict contexts.
Tetanus-prone injuries include the following:

• splinters and other puncture wounds
• gunshot wounds
• compound fractures
• burns
• unsterile intramuscular or subcutaneous injections.

The incubation period for tetanus ranges from two days to several months, with a mean incubation
period of eight days. The further the wound is from the brain, the longer the incubation period.
There are four forms of tetanus.

• Generalised tetanus
• Neonatal tetanus
• Local tetanus (rare): Child has contractions in one extremity or body region; this usually
evolves into generalised tetanus.
• Cephalic tetanus: Children with injuries to the head and neck may have tetanus involving the
cranial nerves. (This can be misdiagnosed as a stroke). Cephalic tetanus also usually evolves
into generalised tetanus.
Treat both local and cephalic tetanus as generalised tetanus.
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Generalised Tetanus
Generalised tetanus is the most common and most severe form of tetanus and is characterised by
the following signs:
• Trismus (locked jaw) is present in one-half of patients.
• Early phase: irritability, restlessness, sweating and tachycardia.
• Arrhythmias, unstable blood pressure and fever (late phase)
• The child is awake and fully conscious.
• Tonic contraction of skeletal muscles and intermittent intense muscular spasms, triggered by
loud noises, physical contact or light. These generalised muscle spasms are life threatening,
as they can cause respiratory failure, lead to aspiration and induce generalised exhaustion in
the patient. The contractions and spasms are intensely painful and responsible for the classic
clinical findings of tetanus: stiff neck; opisthotonus; risus sardonicus; a board-like, rigid
abdomen; dysphagia; apnoea; and respiratory failure linked to upper airway obstruction (see
Figure 3.13.1)
Figure 3.13.1 Opisthotonus, risus sardonicus and rigid abdomen
Left: Opisthotonus Right: Risus sardonicus and board-like rigid abdomen.
The severity and duration of the illness are variable and depend on the amount of tetanus toxin that
reaches the central nervous system and the levels of anti-tetanus antibodies already present in the
patient. In general, the quicker the appearance of spasms after the initial injury, the worse the
disease. The illness normally lasts between four and six weeks, but can be longer; symptoms may
continue to worsen for up to two weeks after onset.
Diagnosis
Diagnosis is based on history and classic clinical findings. Always think about possible associated
meningitis (and consider lumbar puncture for confirmation).
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3.13. Tetanus
Treatment consists of supportive measures including airway management, wound cleaning and
excision of devitalised tissue, neutralisation of unbound tetanus toxin antibiotics, control of muscle
spasms, pain management, treatment of associated infections and nutrition.
Supportive Treatment
• Hospitalise the child in the intensive care unit, if possible in a quiet room/place where all
stimuli are minimised (light, noise and handling) without compromising surveillance
• Ensure adequate fluids and caloric intake through IV fluid maintenance and enteral feeding
by NGT.
• Treat fever if it is present to improve the patient’s comfort.
• Provide analgesia for the pain.
• Monitor the child’s respirations as closely as possible (cardiorespiratory monitor and oxygen
saturation if available) because they can have periods of apnoea and airway obstruction.
• Keep suction and bag and mask at the bedside at all times. Suction with caution, as this can
provoke spasms.
Neutralisation of Unbound Toxin

• Human tetanus immune globulin (HTIG) dose: 250 IU (wound <24 hours old) or 500 IU
(wound >24 hours old) as a single dose for neonates, children and adults, to be injected IM in
two separate sites using two different syringes.
• Administer HTIG at a different site to the tetanus toxoid vaccine.
Halting Toxin Production

• Wound control: Clean, irrigate and debride the wound to prevent further production of
toxin; in children, this is generally performed under general anaesthesia if possible. Use
clean, loose dressing. Do not use occlusive dressings.
• Antibiotics
- Administer metronidazole IV 7.5 mg/kg every 8 hours for 7 days
- Alternative: Benzyl penicillin (penicillin G) IV
▪ Infants: 125,000 IU/kg/day (75 mg/kg/day) in three injections every 8 hours for 7–10
days
▪ Children: 200,000 to 400,000 IU/kg/day (120 to 240 mg/kg/day) in four injections
every 6 hours for 7–10 days
▪ Maximum dose: 10 million IU/day (6 g/day)
- Switch to oral penicillin V 15 mg/kg/dose 4x/day (maximum dose: 2 g/day) if the child
can swallow without difficulty or has improved and has a nasogastric tube in place.
- If mixed infection (sepsis, skin infection, etc.) is suspected, add ceftriaxone IV and/or
cloxacillin IV, or others according to protocols
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Control of Muscle Spasms

Diazepam 5 mg/mL (10-mg vial, 5 mg/mL, 2-mL dose; see Table 3.13.1, Diazepam aqueous IV
solution) is generally effective in controlling rigidity and spasms and providing a sedative effect.
Titrate the dose as indicated below. If available, use emulsion rather than aqueous diazepam for
injection in children younger than 3 years of age as it is less toxic and less painful during injection. Do
not use the emulsion intrarectally.
Children older than 2 months: 0.1 to 0.3 mg/kg slow IV injection (3–5 minutes) or intrarectal
administration to be repeated every 1–4 hours, depending on the severity and persistence of spasms,
as long as respiratory rate ≥20 breaths/min for children younger than 6 years and ≥15 breaths/min
for children aged 6 to 15 years. If, despite diazepam hourly, spasms persist, administer continuous
infusion.
Diazepam continuous IV infusion: 0.125 mg to 0.5 mg/kg/hour (3 to 12 mg/kg every 24 hours); see
Table 3.13.2, Diazepam continuous IV. If symptoms persist, increase by 0.1 mg/kg/hour as long as
respiratory rate ≥20 breaths/min for children younger than 6 years and ≥15 breaths/min for children
aged 6 to 15 years.
Do not stop treatment abruptly; when the spasms are controlled, gradually decrease the rate of
infusion until it is discontinued. An abrupt stop in medication can cause tetanic spasms.
Table 3.13.1 Diazepam aqueous IV solution
ITC code: DINJDIAZ1A Diazepam 5 mg/mL, vial of 2 mL

• 10-mg ampoule (5 mg/mL, 2 mL) for very slow IV or per rectum (PR), not IM
• Aqueous IV solution may be used PO (orally) or PR (emulsion not for PR use)
• PR or IV: dilute 2 mL (10 mg) of aqueous diazepam in 8 mL of 5% glucose or NaCl 0.9%
• PR: use a syringe without a needle or (preferably) cut a nasogastric tube, CH8, to a length of 2–3 cm
and attach it to the tip of the syringe. Do not administer if the child is in liver failure.
• Diazepam (aqueous) may cause pain at IV site.
• May also cause hypotension and respiratory depression, particularly via IV if injected too quickly, if
large doses are given or if combined with opioids or phenobarbital
• Diazepam emulsion IV (not IR) was introduced in the MSF ITC with a specific code and does not
have benzyl alcohol and propylene glycol, as both substances potentially toxic for neonates (severe
apnoea) and children younger than 3 years, particularly when using high doses. Emulsion is dosed
the same way as the aqueous presentation and requires the same surveillance and precautions.
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3.13. Tetanus
Table 3.13.2 Diazepam continuous IV
A continuous IV infusion of diazepam requires the following:

• Use of a dedicated vein (no other infusion/injection in this vein), avoiding the antecubital fossa if
possible; if the antecubital fossa must be used, use a splint to stabilize IV.
• Use of an electric syringe pump (or infusion pump) if available
• Progressive increase and adaptation of doses according to clinical response
• Intensive monitoring of drug administration, particularly during syringe changes
• Monitoring of “ABCD” including respiratory rate, saturation, level of consciousness, as there is a risk
of increased sedation when combined with drugs acting on the central nervous system, especially
opioids.
Example of continuous infusion in infants (diazepam 0.3 mg/kg/hour in an infant of 3.3 kg):
Hourly rate: 1 mg/hour. In a 50-mL syringe, dilute 1 vial of diazepam 10 mg (5 mg/mL, 2 mL) in 50 mL of 10%
glucose to obtain a solution containing 0.2 mg of diazepam per mL. For a rate of 1 mg/hour, administer the
solution (0.20 mg/mL) at a rate of 5 mL/hr. Count the volume of the infusion of diazepam as part of an
infant’s daily fluid intake.
If using a paediatric infusion set, remember that 1 mL = 60 drops, in a child of 3.3 kg: 0.3 mg/kg/hour = 1
mg/hour = 5 mL/hour = 120 mL/24 hours = 5 drops/minute
In the absence of an electric syringe, dilution in an infusion bag may be considered. Weigh the risks associated
with this mode of administration (accidental bolus or insufficient dose). The infusion should be monitored
closely to avoid any change, however small, of the prescribed rate.
Pain Control
Control the painful spasms with oral morphine by NGT (oral drops) or IV morphine. Respiratory
depression is made worse by morphine; refer to Chapter 4, Pain Management, for dosing and risks.
Prepare an emergency trolley in the tetanus ward, containing an Ambu mask, oxygen, pulse oximeter
and suction bulb or electric suction (electric suction preferred for older children) and antidotes
(flumazenil, naloxone). In the case of respiratory depression, provide supportive breathing.
Prevention
Tetanus does not confer immunity following recovery from acute illness. All patients with tetanus
should receive active immunisation with a total of three doses of tetanus and diphtheria toxoid
spaced at least two weeks apart, commencing immediately upon diagnosis (see Table 3.13.3, Post-
exposure prophylaxis).
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Table 3.13.3 Post-exposure prophylaxis

Complete immunisation (three or more Incomplete immunisation
Risk doses); time since last dose: (fewer than three doses) or
<5 years 5–10 years >10 years unknown immunisation status
One tetanus Start series of >3 tetanus
Minor clean wound Nothing Nothing
booster vaccines
Start series of >3 tetanus
One tetanus One tetanus
All other wounds Nothing vaccines and administer human
booster booster
tetanus immune globulin
For routine immunisation, consult MSF clinical guidelines chapter on tetanus.
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3.14. Typhoid Fever
3.14. Typhoid Fever
Causes
Typhoid fever is a severe systemic illness, marked by fever and abdominal pain, which is caused by
Salmonella enterica serotype Typhi (formerly Salmonella typhi). Paratyphoid fever caused by
Salmonella enterica serotypes Paratyphi A, B and C is indistinguishable clinically. Typhoid and
paratyphoid fever, also known as enteric fever, will be collectively referred to as typhoid fever in this
chapter. Note: non-typhoidal salmonella (NTS), a frequent cause of bacteraemia and anaemia in
children living in areas of high malarial transmission, refers to illnesses caused by all other serotypes
of Salmonella.
Typhoid fever is most prevalent in impoverished areas that are overcrowded, with poor access to
sanitation. Transmission is via the faecal–oral route and is common in household contacts.
Asymptomatic chronic carriers may transmit the disease.
Clinical Signs and Symptoms

Onset of symptoms is between 5 and 21 days after ingestion of contaminated food or water.
The majority of patients with typhoid fever present with abdominal pain, fevers and chills.
Classical illness progression

• First week: Fever, bacteraemia and chills.
• Second week: Abdominal pain develops with either constipation (one-third of patients) or
diarrhoea (more frequent in young children).
• Third week: Hepatosplenomegaly, intestinal bleeding, intestinal perforation and septic shock.
Occasionally, children present with the following:

• rose spots (faint-coloured macules on the trunk and abdomen, which may be difficult to see
on dark skin), cough, pneumonia.
Other systems can be affected, but this is rare.
In the absence of acute complications or death from overwhelming sepsis, symptoms gradually
resolve over weeks to months.
Diagnosis
In most MSF settings, cultures are not available. Make a diagnosis or treat for presumptive enteric
fever if the following are present: child appears toxic or severely ill and/or lives in an endemic area
with fever lasting more than 1 week without other obvious cause, and/or severe abdominal pain.
Differential diagnoses include malaria, amoebiasis, dengue fever, leishmaniasis, bacterial

gastroenteritis, tuberculosis and pneumonia.
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Laboratory tests
• Do not use Widal test as sensitivity and specificity are poor
• Relative leucopoenia (normal white cell count despite bacteraemia)
• Blood cultures (10 mL necessary) and stool cultures during first two weeks
Hospitalise and isolate (refer to infection control guidelines) the child if he or she has severe systemic
illness, cannot take oral medication and is not able to eat and drink.
Antibiotic therapy
• First line: Cefixime PO 15–20 mg/kg/day in two divided doses for 7 days
• If cefixime is not available, give ciprofloxiacin PO 30 mg/kg/day in two divided doses for 5–7
days .
• If suspicion of resistance or child is not able to swallow, give ceftriaxone IV 75 mg/kg/day for
10–14 days
• If perforation or peritonitis is suspected, add metronidazole IV 10 mg/kg 3x/ day
• Note: Fever persists for 4 to 5 days after the start of treatment, even if the antibiotic is
effective.
• For children older than 3 months with severe systemic illness with septic shock, coma, or
intestinal haemorrhage, give dexamethasone 3 mg/kg IV followed by 1 mg/kg IV every 6
hours for a total of 48 hours.
• Supportive care in case of severe systemic illness:
- Ensure adequate fluids and caloric intake by IV fluids or NGT
- Provide oxygen as needed
- Treat fever with antipyretics to improve patient’s comfort
- Treat pain if present, but do not used fixed-time doses (risk of masking the symptoms of
peritonism)
• Monitor vital signs according to clinical condition of patient
• Standard precautions and complementary precautions for contact transmission for staff and
relatives (refer to infection control guidelines)
• Consider disinfection of faeces with 2% chlorine (refer to infection control guidelines)
Complications
Ileal perforation, which is rare in children younger than 5 years of age, usually occurs in the third
week of illness. Treatment is surgical. The child presents with the following:
• increasing abdominal pain, distended and/or rigid abdomen and signs of peritonitis such as
rebound tenderness
• can lead to bacteraemia and, if untreated, septic shock
If you suspect a typhoid perforation:

• Make child NPO and place an NGT open to air
• Insert a second IV line, if possible
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3.14. Typhoid Fever
• Immediately consult with the surgeon

• Assess the child for sepsis and shock and immediately start antibiotics
- Add metronidazole (see Antibiotic therapy, previous)
Relapse occurs even in immunocompetent individuals. It usually occurs 2–3 weeks after the
resolution of the fever and should be treated with a second, longer course of antibiotics.
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196
4. Pain Management
4. Pain Management ........................................................................................................................... 197
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4. Pain Management
4.1 Pain Management

Pain is as an unpleasant somatic or visceral sensation associated with actual, potential or perceived
tissue damage. Assessment and management of pain are essential components of paediatric care. In
children, especially in young children, it can be challenging to identify the presence and severity of
pain, and to treat pain adequately. The use of assessment tools based on cognitive ability can be
helpful to ensure that children of all ages receive adequate pain control.
It is important to introduce pain assessment as a routine activity in all paediatric hospital care and to
ensure that pain is taken seriously by the entire medical team. Routinely provide EVENDOL and/or
FACEs and/or simple verbal pain scales as a part of patient charts.
Assessment of Pain Severity and Cognition

In children, the severity of pain can be assessed in two ways:
1. behavioural scales (such as EVENDOL scale)
2. self-reporting (such as FACES).
Behavioural Scales
For children who are unable to self-report, several behavioural observational scales are available for
infants and non-verbal children. Although behavioural measures are useful, they can be overly
sensitive to fear or anxiety in the acute setting and can under rate persistent pain. Health care
personnel and caregivers can provide reports for infants and young or cognitively impaired children.
Self-reporting
Validated self-report measures are available for most children aged 4 years and older and involve
photos or drawings of faces.
• Young children (3–8 years): Some children as young as 3 years are capable of quantifying pain
and are able to translate it into a visual representation. In this age group, pain is quantified
by using visual analogue pain scales based on a series of faces showing an increase in distress
or pain.
• Older children (8–11): Pain assessment in this age group is generally performed using visual
analogue tools that rate the intensity of pain on a horizontal or numeric scale (e.g., 0 to 10
scale).
• Adolescents (age 12 years and older) can rate their pain using a numerical rating scale
without the use of an accessory pain assessment tool. Detailed information regarding the
pain, a description of the quality of the pain (stabbing/dull, etc.), location and radiation,
intensity, duration and constancy, frequency and factors that worsen or relieve pain, can be
obtained.
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4.1. Pain Management
Tools for Pain Assessment
Observational Assessment of Pain

Observational assessments can be used in children aged 2 months to 7 years (and older if the child
unable to self-evaluate the pain because of cognitive impairment or other condition).
EVENDOL pain scale

The EVENDOL pain scale is an observational scale assessing the following five features, considering a
range of scores from 0 (no pain) to 3 (strong or permanent pain) for each:
• Vocal or verbal expression
• Facial expression
• Movements
• Postures
• Interaction with the environment
The scores for each of the five features are summed, and pain severity is determined as follows
(maximum score = 15):
• Score of 1–3: Mild pain
• Score of 4-7: Moderate pain
• Score of 8–15: Severe pain
It is important to repeat the pain assessment regularly after medication and/or analgesia are
administered to assess whether the treatment was adequate.
See Figure 4.1.3, EVENDOL pain scale, and Figure 4.1.4, Example of completed EVENDOL pain scale,
at the end of the chapter for more information.
Self-reported Assessment of Pain
FACES Pain Scale Revised (FPS-R)

The FACES Pain Scale (see Figure 4.1.1) is for use in children aged 3 years and older.
Figure 4.1.1 FACES Pain Scale
1 2 3 4 5 6
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4. Pain Management
The child selects the face that best corresponds to the intensity of their pain. To use, show the faces
to the child and explain that the face on the left has the least pain and the one on the right has the
most pain. Score the faces from 1 to 6 (1 = least pain, 6 = most pain). A score of 3 or greater requires
treatment; severity is scored as follows:
• Score 1–2: No or very minimal pain
• Score 3–4: Mild pain
• Score 5–6: Moderate to severe pain
Self-reported simple verbal scale

Pain can also be self-reported using a simple numerical system, as shown in Figure 4.1.2, Self-
reported simple verbal scale.
Figure 4.1.2. Self-reported simple verbal scale
Pain Intensity No pain Mild pain Moderate pain Severe pain
Score 0 1 2 3
Score 0 + ++ +++
A score 2 or 3 requires treatment.
Management of Pain
In most cases, children who self-report pain (or have been assessed as having pain) should receive
pain relief.
General Recommendations for Management of Pain

The main goals of paediatric pain management are to reduce, control and prevent pain in children.
• Assess and record pain level at first assessment.
• Consider pain as one of the vital signs that should be reassessed at regular intervals.
• Regularly assess pain and its severity throughout the course of the disease.
• Use assessment instruments to record baseline pain and monitor treatment.
• Identify and control the source of the pain.
• Treat the pain as promptly as possible.
• Give analgesics in advance of painful procedures.
• Give analgesics before pain recurs (try to be ahead of the pain).
• Use non-pharmacologic measures (e.g., cognitive, behavioural, physical and supportive
therapies) in combination with pharmacologic therapy.
• Administer analgesic therapy for moderate and severe pain around the clock, including
sufficient analgesia to allow the child to sleep through the night.
• If at all possible, use oral analgesics to avoid painful routes of administration.
• Anticipate and treat adverse effects of analgesia (such as constipation from the use of
opioids).
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Treatment of Pain
The choice of analgesic depends on pain intensity and the child's response to previously administered
agents. The steps approach is as follows:
• Mild pain: non-pharmacologic measures plus paracetamol or ibuprofen (either alone or in
combination)
• Moderate pain: tramadol (in combination with paracetamol)
• Severe pain: a strong opioid, such as morphine, is recommended (in combination with
paracetamol)
Non-pharmacologic Therapy
Non-pharmacologic therapy helps to control pain by providing an element of distraction from the
physical pain, and can be used in children experiencing mild pain. Two interventions are often more
effective than one:
• drawing and playing
• listening to music or singing
• physical measures: massage, applying ice locally, occasionally heat
• distraction: recalling of favourite place; counting backwards by serial sevens
• blowing soap bubbles
• breathing exercises: provide a quiet, calm environment; slow inhalation and long exhalation;
guided imagery to relax parts of the body).
Pharmacologic Therapy
Local anaesthetics
Local anaesthetics should be used prior to invasive, potentially painful procedures. Anaesthesia can
be provided by injection or applied topically.
• EMLA cream (Transitory Z code DEXTZFR0063; mixture of lidocaine 2.5% and prilocaine 2.5%
in a cream base):
- Recommended for use with planned procedures, like planned lumbar puncture or other
invasive procedures.
- Not recommended for use prior to insertion of IV catheters or emergency procedures.
- Apply half of a 4-g tube of EMLA cream to the skin. Cover the cream with an occlusive
dressing and wait for 45 to 60 minutes. Analgesic effects last for up to 4 hours after
removal of the cream.
- Adverse reactions: transient skin irritation
• Lidocaine 1% (10 mg/mL)
- To be used for small surgical procedures.
- Infiltrate subcutaneously in the area involved with a small-bore needle (e.g., 25 gauge
needle) in a small-volume syringe (e.g., 3 ml).
- Do not exceed 3 mg/kg/injection, or 0.3 mL/kg/injection.
- Do not use via IV.
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4. Pain Management
Non-opioid Analgesics
The two main non-opioids used in MSF settings are paracetamol and ibuprofen.
Paracetamol
Paracetamol can be used in children with all levels of pain intensity and can be given in conjunction
with other, stronger analgesics. It is contraindicated in patients with severe hepatic disease.
• Administration: Oral (or via nasogastric tube) or IV.
• Dose PO: 15 mg/kg/dose every 6 hours (maximum daily dose: 80 mg/kg)
• Dose IV
- <10 kg: 7.5mg/kg/dose every 6 hours
– >10 kg: 15mg/kg/dose every 6 hours
Ibuprofen
Ibuprofen is a non-steroidal antiinflammatory drug (NSAID) and is more effective than paracetamol in
reducing pain related to inflammation. It is contraindicated in infants younger than 3 months and children
with bleeding or coagulation defects, history of severe asthma or severe hepatic or renal impairment.
• Administration: Oral (with milk or food)
• Dose: 10 mg/kg/dose every 6–8 hours (maximum daily dose: 40 mg/kg)
• Side effects: gastrointestinal irritation
Opioid analgesics
Children with moderate pain are generally treated with a weak oral opioid (like tramadol) or, in cases
of chronic pain, low oral doses of long-acting, stronger opioids. Codeine is no longer recommended in
children because it is ineffective in approximately one-third of patients.
The treatment should be tailored to each child and opioid analgesics should be titrated (adjusted
according to response) on an individual basis.
Tramadol
Tramadol should be used for moderate pain, predominantly for procedures such as dressing changes,
or for severe pain when morphine is not available. It is contraindicated in children with severe
respiratory distress and the risk of or known seizures (epilepsy, head injury, meningitis). Do not
administer tramadol with or shortly before or after morphine.
• Administration: Oral or IV
• Dose: 1–2 mg/kg every 4–6 hours (maximum daily dose: 400 mg)
• Availability:
- 50-mg caps
- 100 mg/mL 40 drops
– 50-mg/mL ampoule
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Note: The use of tramadol is not approved for use in children in some countries; however, even there
it continues to be used off-label. We recommend its use as long as indications and contraindications
are respected.
Morphine
Morphine is the opioid of choice for treating severe pain. It is contraindicated in children with severe
respiratory distress, severe liver failure, non-stabilised epilepsy and raised intracranial pressure. It
should not be given in combination with other opioid analgesics (tramadol) or with other drugs that
actively affect the CNS (benzodiazepines, neuroleptics, antihistamines and phenobarbital/phenytoin)
because of the increased risk of sedation. Always provide additional monitoring for these patients.
Administration: Oral, IV, IM, SC, IO

• Dose:
- Oral: 0.1–0.3 mg/kg every 3–4 hours
- IV: 0.1 mg/kg every 3–4 hours (in children younger than 6 months: 0.03 mg/kg)
• Available presentations (in MSF settings):
- 10-mg/mL vials (IV/IM/SC)
- 10-mg breakable tabs (normal/immediate release)
- 10-mg/5 mL oral solution
- 10-mg and 30-mg caps (slow/sustained release)
- 0.4 mg/mL ampoule
Initial dose
• Initiate treatment with the normal/immediate-release morphine (do not start with
slow/sustained release; this is used it for maintenance once the optimal dose for the patient
has been defined)
• Start with 0.05 to 0.1 mg/kg/dose every 4 hours; increase the dose progressively if needed by
50% increments up to a maximum of 0.2 mg/kg/dose (maximum daily dose: 1.2 mg/kg).
• After 48 hours, add up the total daily dose that the child has received in the past 24 hours and
replace it with slow-release morphine caps for continuous pain management (slow release is
contraindicated in SAM children; keep these children on normal/immediate-release morphine)
• Slow-release capsule can be mixed with sugar water or sweet juice.
• Add paracetamol (normal doses; see previous) for breakthrough pain.
• If pain still not controlled with this regimen, consider adding short-acting (immediate-
release) morphine for breakthrough pain (10% of total daily dose). Always consider the
increased risk of side effects with additional doses of morphine and the resulting increased
need for monitoring. Do not exceed the maximum daily dose of 1.2 mg/kg.
Side effects of morphine

• Respiratory depression: (very rare with oral morphine): reduce or withhold the next dose,
bag and mask ventilation with 100% oxygen if needed
• If severe respiratory depression (impossible to wake child up, respiratory pauses or apnoea),
give naloxone at dose for acute opioid overdose:
– Children <20kg or younger than 5 years: 0.1 mg/kg IV or IO (maximum 2 mg/dose)
203
4. Pain Management
– Children >20 kg or older than 5 years: 2 mg IV or IO

– Repeat every 3–5 minutes if necessary.
- If full reversal is not desired, then naloxone 1 ampoule 0.4 mg can be diluted in 20 mL of
NaCl 0.9% = solution of 20 mcg/mL. Then inject an IV bolus of 5 mcg/kg (0.25 mL/kg)
each minute until the RR is within normal limits for age. If no IV access, give 10 μg/kg by
IM or SC route – this dose can be repeated hourly if necessary.
• Constipation: begin laxative if morphine is needed for more than 48 hours.
• Nausea and vomiting: treat with ondansetron or metoclopramide
• Itching: treat with antihistamines
To administer morphine IV, take 1 mL of morphine (from 10-mg/mL vial) and add 9 mL of D5% or
D10% to obtain 10 mL, to make 10 mg in 10 mL = 1 mg/mL (if dose needs to be increased, consider a
more-concentrated dilution, especially for larger children).
For dosing, see Table 4.1.1, Morphine IV dosages. For small volumes use a 1-mL syringe to ensure
correct dosing.
Table 4.1.1 Morphine IV dosages
Weight Dose Volume of solution in mL

(kg) (mg) (dose: 0.1 mg/kg)
4 0.4 0.4
5 0.50 0.50
6 0.60 0.60
7 0.70 0.70
8 0.80 0.80
9 0.90 0.90
10 1 1
11 1.1 1.1
12 1.2 1.2
13 1.3 1.3
14 1.4 1.4
15 1.5 1.5
16 1.6 1.6
17 1.7 1.7
18 1.8 1.8
19 1.9 1.9
20 2 2
If the patient has been on morphine for a prolonged period of time, do not stop abruptly, but slowly
reduce the dose progressively. If in doubt, contact the paediatric advisor.
204
Ketamine
Ketamine is used for anaesthesia/sedation in children prior to painful procedures (major dressing
changes, sutures, incisions, drainage of abscesses, etc.). It can only be utilised in situations where
there are personnel trained in its use and monitoring equipment and dedicated care space are
available. It is contraindicated in children younger than 3 months and those who have an upper
airway infection or lung disease, known or suspected cardiovascular disease (including severe
hypertension), head injury with loss of consciousness, altered mental state, seizures or vomiting,
epilepsy, or psychosis. Ketamine should not be used prior to procedures involving deep body
structures, the oral cavity or pharynx.
• Administration: IV or IM
• Dosage for sedation (not general anaesthesia):
- IV: 1 mg/kg
- IM: 5 mg/kg
• Onset of action: 3 to 5 minutes
• Duration of action: 15 to 30 minutes
Keep the child NPO for at least 4 hours prior to using ketamine. Provide a calm setting to avoid
adverse reactions such as agitation, hallucinations or delirium as the sedation is wearing off. Keep a
paediatric Ambu bag at the bedside and monitor consciousness, RR and HR (BP when feasible) at
regular intervals during sedation and until the child is fully awake and responsive again. For further
information, see Chapter 7.10, Ketamine.
205
4. Pain Management
Figure 4.1.3 EVENDOL pain scale
206
Figure 4.1.4 Example of completed EVENDOL pain scale
207
4. Pain Management
208
5. Termination of Resuscitation and Palliative Care
5.1. Termination of Resuscitation ....................................................................................................... 210
5.2. Palliative and Comfort Care .......................................................................................................... 211
209
5.1. Termination of Resuscitation

Following cardiopulmonary resuscitation in MSF settings, a child’s chance of survival with good
neurological outcome is low. MSF protocols should be followed for all children presenting with
cardiac or respiratory arrest, but the physician in charge should always consider the child’s history
and his or her overall chances of recovery.
Palliative and comfort care should be considered in all MSF projects treating severely ill children (see
Chapter 5.2, Palliative and Comfort Care).
General recommendations
• If the patient has no cardiac activity after 10 minutes of ventilation plus cardiac compressions
plus adrenaline: stop all resuscitation efforts.
• If the patient has cardiac activity but no respirations, consider extending efforts to 30
minutes and reassess.
• If culturally appropriate and the family request it, ensure at least one family member is
present during the resuscitation efforts. If this is done, a staff member must be available to
support the family member during the resuscitation.
• After resuscitation is stopped, the physician needs to explain to the family that resuscitation
was stopped because further efforts were futile and would not have been in the best
interests of the child.
Exceptions
• If the physician in charge believes that there is a reversible medical reason for the respiratory
depression (e.g., drug effect) and if pulse and cardiac activity are stable with ventilation only
(bag-valve mask), the physician should consider continuing advanced resuscitation for
another 30 minutes.
• The physician in charge should communicate with the family and explain the decision to end
resuscitation efforts.
• If the child has a pulse but no respiratory effort:
- Maintain ventilation via Ambu bag only as long as there is competent staff available and
this activity does not compromise the care of other children.
- Do not ask the family to ventilate the child.
- Maintain this for a maximum of 2 hours. If the patient has not regained any spontaneous
ventilation in this time frame and/or if there is no option to transfer the child,
discontinue ventilation.
In the following cases, children could have a good prognosis if referred in time to appropriate
facilities; however, note that, in most MSF settings, transfer to a more appropriate facility is
exceptional:
• some head trauma
• toxic ingestions or medication overdose of a medication with a CNS depressant effect
• patient with severe asthma attack in respiratory insufficiency
The decision on how to proceed in these exceptional situations is always at the treating physician’s
discretion and, if possible, should be discussed with the Medical Team Leader or Medical Coordinator.
210
5.2. Palliative and Comfort Care

Palliative care is an approach aimed at providing quality of life for patients and their families facing
life-threatening illness that cannot be cured. This is done through the prevention and relief of
suffering. This should happen through early identification, assessment and treatment of pain and
other problems linked to physical and psychological wellbeing.
End-of-life care is specific palliative care applicable to terminal illness.
In typical MSF paediatric settings, we face two different scenarios where patients are not expected to
recover from their condition:
1. Terminal illness: most frequently an acute, life-threatening situation where end-of-life care is
applicable.
2. Mid- or long-term, potentially life-threatening illness: illness that has no prospect of recovery
in the current context, such as congenital heart disease, congenital malformations, cancer or
an illness that has led to irreversible cerebral damage (e.g., cerebral malaria or perinatal
asphyxia). In these situations, palliative care is applicable. It is important to discuss the
situation with the family and explain the lack of curative options in this context. If possible,
the development of partnerships with other adequate local organisations or institutions for
referral and follow-up should be established.
Medical care in both these situations will no longer aim for a cure, but will focus instead on providing
relief from symptoms such as pain or other conditions that lead to stress or anxiety. At this stage of
disease, the primary goal of medical care is to provide a quality of life that is appropriate for both the
child and the family. It is therefore important that each case is looked at individually.
MSF facilities are acute care facilities with little capacity to keep patients described under scenario 2,
above, for long periods of time. For those patients, unfortunately there may not be much that MSF
can offer other than symptomatic treatment.
Necessary Discussions
Health Staff
Once it has been established that there is little hope the patient will recover, the treating physician
will organise a meeting with other health care team members to plan the ongoing management of
the patient.
This crucial step should not be underestimated and difficulties might occur due to cultural barriers
and beliefs. Regular meetings should therefore be planned in order to follow the situation and make
adapted decisions as long as needed.
211
Family and Patient (when possible)

Once the health team is aware and decisions have been shared, the physician and another team
member (e.g., a nurse, preferably national staff) will then need to sit with the family to explain the
situation.
Every situation is different; however, in all cases allow for:

• privacy and confidentiality
• sufficient time for family–doctor conversation
• use of appropriate language
• transparency regarding prognosis.
Ensure that the family understands that the team will do everything to relieve the child’s symptoms
but that there is no prospect of recovery. Accepting this news might take some time and the family
might decide to take the child home.
Whether the child remains in MSF care or goes home, all efforts need to focus on providing enough
information and treatment to minimise the suffering of the child and the family, particularly in
contexts with little or no community health infrastructure.
Patient Care Plan

There is no standard protocol on how to best deliver palliative care, so each patient needs a plan that
suits his or her individual situation. The following should be considered when creating such a plan
(see Table 5.2.1, Palliative and end-of-life care, for a quick summary):
• Respiratory care
- Provide regular mouth hygiene (nursing care using saline water, mouth swabs, treating
mouth sores, etc.)
- Gentle suctioning can relieve distress from secretions in the mouth and airway
- Positioning (sometimes upright positioning can relieve breathing problems)
- Oxygen for comfort as required
• Pain relief is always appropriate: Assess pain regularly and ensure that pain relief is adequate
(see Chapter 4, Pain Management) using paracetamol and/or non-steroidal anti-
inflammatory drugs in combination with morphine as needed; use adjuvant therapy where
indicated (e.g., for neuropathic pain). The drugs should be given by the simplest, most
effective and least painful route—if possible, orally.
• Treat nausea and vomiting using metaclopramide or ondansetron.
• Prevent and relieve constipation (often an adverse effect of opioid use, reduced physical
activity, dehydration, etc.) with laxatives and softening agents where available.
• Treat anxiety with diazepam (2 mg 2–3x/day if the patient is older than 1 year).
• Treat any other symptoms, such as fever and convulsions.
• Do not deliver care that does not relate to improving the comfort of the child:
- Do not prescribe laboratory exams.
- Minimise invasive procedures such as IV lines.
- Gradually discontinue all invasive monitoring, such as oxygen saturation and vital signs
212
- Antibiotics: Antibiotics are usually not indicated in terminal illness; their use in non-
terminal illness (such as acute complications of non-terminal chronic disease) needs to
be discussed on a case-by-case basis.
• Feeding: Continue feeding. At this stage, often this is only possible using an NGT, and, in
most contexts, nasogastric feeds are not possible for home care. Discontinue nasogastric
feeds prior to discharge. If at all possible, teach the family to spoon feed the child.
- In some situations, parents will prefer to stay in hospital if feeding the child is not
possible without an NGT. In these cases, families need to understand that there is no
prospect of recovery and that the only reason for keeping the child in hospital is to feed
him or her. The doctor might need to explain this repeatedly to the family to avoid
nurturing false hopes.
• Ensure that the child is turned frequently (i.e., every 2–4 hours) to avoid bedsores; treat any
if they occur. Include the parents in care.
• Be culturally sensitive to traditions and customs that surround medical decisions and death in
the country where you are practicing (e.g., determine which family member is considered
“head of the family”).
• If the family prefers to take child home, provide instructions and medication (if possible) for
comfort care at home.
• Discuss the family’s plans for death of the child should it occur:
- On the day of the death, remove all lines and towel wash and wrap the child so that
parents can take the child home.
- If a child dies late in the day, consider that the parents may be far from home and unable
to travel at that time. Determine if the family prefers to keep the child with them or if
they prefer for the child to be left at the mortuary until the family can assume
responsibility for him or her.
- Ensure as much privacy for the family as possible.
• Do not avoid or neglect this patient and their family during ward rounds.
• Ensure that all staff know that resuscitation in case of cardiorespiratory arrest is not
indicated in this patient.
• Medical and nursing staff will also need support, as caring for dying children is stressful.
• Decide together with medical staff where this patient should be kept during his or her
hospital stay to ensure adequate care
213
Table 5.2.1 Palliative and end-of-life care
Action Yes No
Suctioning (gentle) X
Oxygen (via nasal prongs) X
Resuscitation measures (chest
compressions, bag-mask
X
ventilation, adrenaline, IV bolus
fluids)
Always; discuss with family to find
Pain relief
appropriate type of pain relief
Comfort and ease of care of the child;
Anticonvulsants
if possible, via PO or rectally
Nasogastric feeds Keep as long as in hospital; try oral feeds if at all possible
IV maintenance fluids Discontinue when end-of-life care is initiated
Discontinue IV antibiotics when end-of-life care is initiated. Oral
Antibiotics (IV or oral)
antibiotics may be an option in specific cases
Monitoring (oxygen saturation and
Discontinue when end-of-life care is initiated
vital signs)
Blood tests Discontinue when end-of-life care is initiated
Communicate with family members frequently and involve them in
Communication
all decisions regarding care of the patient
214
6. Enteral Nutrition for Non-SAM Children
6.1. Enteral Nutrition of Non-SAM cases (non-surgical cases) ............................................................ 216
(Note: for SAM children, please refer to MSF malnutrition guidelines.)
215
6.1 Enteral Nutrition for Non-SAM Children (non-

surgical cases)
Enteral nutrition is indicated in non-SAM children for whom adequate oral intake is impossible after
48 hours of IV maintenance fluids. The prescription for enteral feeds must be approved by the
hospital director or medical team leader (at field level) and the child must be hospitalised at ICU level.
Relative contraindications* for enteral feeding in children include: absent or diminished control of
the upper airway (completely comatose patient or Blantyre score ≤3) and refractory shock (persistent
hemodynamic instability).
Absolute contraindications include: active gastrointestinal bleeding and non-functional digestive

tract/paralytic ileus (absence of bowel sounds). If enteral feeding cannot be initiated due to
contraindications, continue IV maintenance fluids, re-evaluating ability to initiate enteral feeding
every 12 hours.
*Use of clinical judgement, weighing risk vs. benefit.
Nasogastric Tube Feeding Basics

• Remember to respect basic hygiene rules
- Simple hand washing or hand disinfection before all manipulations of NGT
- Wash the syringe with clean water after each bolus.
• Nasogastric tube size (flexible tube in call cases):
- Child <4 kg: CH 6
- Child 4–10 kg: CH 8
- Child 10–25 kg: CH 10
• Nasogastric tube monitoring:
- Ensure stable nasal fixation without exerting pressure on nostrils
- Clinical check to ensure intra-gastric position after tube insertion and before each feed:
constant length at point of nasal fixation, tube not coiled up in the mouth and aspiration
of gastric liquid (presence of liquid is an excellent indication of gastric placement, but its
absence does not exclude the possibility of correct placement — the stomach may
contain little or no liquid, or the tube may collapse under negative pressure)
- Hydroaeric “bubbling” sounds heard upon abdominal auscultation in the left upper
quadrant during rapid injection of 5–10 mL of air does not guarantee intra-gastric
positioning of the tube, and this test is never sufficient alone.
• Ensure proper patient positioning: Keep the patient in sitting or semi-sitting position by
elevating the head of the bed to at least 30 degrees.
• Flush the tube with 3–5 mL of water before and after administration of medications and
enteral feedings or if tube is blocked.
216
6.1. Enteral Nutrition for Non-SAM Children
Intermittent Enteral Nutrition

Intermittent feedings should be given through the NGT, ideally via syringe and gravity.
For children younger than 1 year, give expressed/pumped breast milk or Infant formula. For children
1 year of age and older, give Sondalis Junior (NFOS ENIC NP W05). If this is not available, use
reconstituted powdered whole milk – 100kcal/100mL – (though this must be approved by the
pharmacy team prior to administration). Give a bolus every four hours through the NGT (six
meals/day) by gravity or slow gentle injection to avoid filling the stomach too rapidly.
Upon initiation of enteral feeding via NGT, start with half of the volume goal and increase the volume
in stages over the first 24 hours, depending on gastric tolerance (see Table 6.1.1, Feeding volumes):
• Start enteral feeding with 50 mL/kg/day and decrease IV fluids to 50% of maintenance. Test
blood glucose every four hours. (If hypoglycaemia is present, treat as per protocol.)
• If initial feedings are tolerated after 24 hours, increase nasogastric feeds to 75 mL/kg/day
and stop IV maintenance fluids (but keep IV line running at 5 mL/hour for easy access). Test
blood glucose every 6–8 hours. (If hypoglycaemia is present, treat as per protocol.)
• If still tolerated after 24 additional hours (total of 48 hours after initiation), increase enteral
feeds to 100 mL/kg/day and stop IV.
• As long as feeding is tolerated, continue at 100 mL/kg/day until conscious and eating, or until
the team decides to discontinue enteral feeds (see Chapter 5.2, Palliative and comfort care).
• Average duration of enteral feeding is three days and it should not exceed five days. After
five days, the need must be re-evaluated and exceptions must be approved by the hospital
director or medical team leader (e.g., children recovering from tetanus).
Table 6.1.1 Feeding volumes

Bolus volume to be
Gradual initiation Daily volume
given every 4 hours
0–24 hours (Day 1) 50 mL/kg/day 8.5 mL/kg
24–48 hours (Day 2) 75 mL/kg/day 12.5 mL/kg
After 48 hours (Day 3 onwards) 100 mL/kg/day 16.5 mL/kg
Ensure that the child is tolerating the enteral nutrition:

• Examine the abdomen, looking for signs suggestive of poor tolerance (abdominal distension
and/or pain, bloating, ileus, constipation).
• Verify absence of significant diarrhoea.
• Verify absence of vomiting.
• Evaluate gastrointestinal transit (number and consistency of stools, appearance of blood or
mucous in stools).
Note: Measuring gastric residuals is not recommended for non-surgical patients.
217
In case child is not tolerating feeding – stop enteral feeding and initiate IV maintenance fluids. Re-
evaluate in 12 hours. When child is able to re-start enteral feeding, initiate at 50 mL/kg/day and
advance as per Table 6.1.1
Key Ordering Information

Code Sondalis Junior (or equivalent): NFOS ENIC NP W05
Order 42 crates per 100 children (1 crate = 12 bottles of 500 mL); cost = 1,285 euros (based on
average weight of 10 kg, average duration of enteral feeding 3 days).
218
7. Drugs, Fluid and Electrolyte Administration
7.1. Maintenance Fluids ...................................................................................................................... 220
7.2. Potassium in Intravenous Fluids ................................................................................................... 224
7.3. How to Switch from Parenteral to Oral Antibiotics ...................................................................... 226
7.4. Amoxicillin and Clavulanic Acid .................................................................................................... 227
7.5 Antimalarials .................................................................................................................................. 230
7.6. How to give Epinephrine infusion with a syringe pump............................................................... 239
7.7. Thiamine Protocol for children in shock with SAM or from areas with high SAM prevalence .... 241
7.8. Midazolam and Diazepam for Sedation ....................................................................................... 242
7.9. Phenobarbital and Phenytoin ....................................................................................................... 244
7.10. Ketamine..................................................................................................................................... 247
7.11. Oxygen Therapy .......................................................................................................................... 251
219
7. Drugs, Fluids and Electrolyte Administration
7.1. Maintenance Fluids

Maintenance fluids should be given to all children for whom oral intake is medically contraindicated,
including children with an altered level of consciousness who cannot eat or drink (most often
Glasgow Coma Score <8 or PU on AVPU scale), intractable vomiting despite nasogastric feeding, or
severe respiratory distress from malaria, asthma, pneumonia, bronchiolitis, etc. Fluid boluses might
be given in cases of shock or dehydration.
The first choice for maintenance fluids for all children (with and without malnutrition) is Dextrose
5%-Ringer’s Lactate (D5%-RL), a solution of non-diluted RL with 5% dextrose. See Table 7.1.1, for
instructions on how to mix D5%-RL, or its alternative (D5%-NaCl 0.9%). (Note: Dextrose 5% = Glucose
5% = D5% = G5%.)
The fluid used for bolus administration is RL or, if RL is not available, NaCl 0.9%); do not bolus with
glucose-containing fluids. D10% is used for hypoglycaemia (see Table 7.1.2). Never administer
Dextrose 50% (D50%) directly to a child. In rare cases where hypotonic fluids are indicated (child
recovering from acute renal failure or with head trauma with output of very dilute urine [specific
gravity <1.005]), D5%-½ RL or D5%- ½ NaCl 0.9%) may be used (see Table 7.1.3).
How to prepare maintenance fluids from MSF stock solutions

MSF stock solutions include the following:
• Ringer’s Lactate (RL): bags of 500 mL and 1000 mL
• NaCl 0.9%: bags of 100 mL, 250 mL, 500 mL and 1000 mL
• D5%: bags of 500 mL and 1000 mL
• D10%: bags of 500 mL or vials of 10 mL (Code: DINJGLUC1A1)
• D50%: bottle of 50 mL (Code: DINJGLUC5V5)
See the following tables for mixing instructions. (Note: Only use NaCl 0.9% if RL is not available.)
Table 7.1.1 D5%-RL/ NaCl 0.9% mixture

RL Add Dextrose D50% Final solution
500 mL remove 50 ml = 450 ml + 50 mL of D50% = 500 mL of D5%-RL
1000 mL  remove 100 ml = 900 ml + 100 mL of D50% = 1000 mL of D5%-RL
NS Add Dextrose 50% Final Solution
500mL  remove 50 ml = 450ml + 50 mL of D50% = 500 mL of D5%- NaCl 0.9%
1000mL  remove 100ml = 900 ml + 100 mL D50% = 1000 mL of D5%- NaCl 0.9%
100mL  remove 10 ml = 90 ml + 10 mL D50% = 100 mL D5%- NaCl 0.9%
220
Table 7.1.2 D10%-RL/ NaCl 0.9% mixture

RL Dextrose 50% Final solution
500 mL bag  remove 100 mL = 400 mL 100 mL of D50% 500 mL of D10%-RL
1000mL bag  remove 200 mL = 800 mL 200 mL of D50% 1000 mL of D10%-RL
NaCl 0.9% Dextrose 50% Final solution
500 mL bag  remove 100 mL = 400 mL 100 mL of D50% 500 mL of D10%-NaCl 0.9%
1000 mL bag  remove 200 mL = 800 mL 200 mL D50% 1000mL of D10%-NaCl 0.9%
Table 7.1.3 D5%-½RL/ NaCl 0.9% mixture

RL Dextrose Final solution
500 mL 500 mL of D10% 1000 mL of D5%-½RL
NaCl 0.9% Dextrose Final solution
500mL 500 mL of D10% 1000 mL of D5%-½NaCl 0.9%
The infusion rate for normal or 100% maintenance fluids (see Table 7.1.4, Infusion rates for 100%
maintenance IV fluids) can be calculated using the ‘4-2-1’ rule:
• For first 10 kg (0–10kg), give 4 mL/kg/hour; for example: 40 mL/hour for a 10-kg child
• For next 10 kg (10–20kg) add 2 mL/kg/hour; for example: a 20-kg child gets 40 mL/hour + 20
mL/hour = 60 mL/hour
• For each kg above 20 kg, add another 1 mL/kg/hour; for example: a 30-kg child gets 60
mL/hour + 10 mL/hour = 70 mL/hour
Table 7.1.4 Infusion rates for 100% maintenance IV fluids

Give D5%-RL
(Amounts rounded off for ease of administration)
Weight of Rate of infusion in mL/hour or drops/min Weight of Rate of infusion
child in kg using MSF paediatric microperfusor child in kg in mL/hour
3–3.9 15 22–22.9 65
4–4.9 20 23–23.9 65
5–5.9 25 24–24.9 65
6–6.9 30 25–25.9 65
7–7.9 30 26–26.9 65
8–8.9 35 27–27.9 70
9–9.9 40 28–28.9 70
10–10.9 40 29–29.9 70
11–11.9 45 30–30.9 70
12–12.9 45 31–31.9 70
13–13.9 45 32–32.9 75
14–14.9 50 33–33.9 75
15–15.9 50 34–34.9 75
16–16.9 55 35–35.9 75
17–17.9 55 36–36.9 75
18–18.9 55 37–37.9 80
19–19.9 60 38–38.9 80
20–20.9 60 39–39.9 80
221
If a child has had an episode of hypoglycaemia and needed a bolus of D10% for treatment and/or has
an episode of hypoglycaemia while on maintenance fluids of D5%-RL, use D10%-RL for maintenance
thereafter (D10 %-NaCl 0.9% Saline if RL not available).
When a child is being rehydrated after multiple episodes of diarrhoea or in cases of ongoing vomiting
or diarrhoea, use 1.5x (150%) maintenance IV fluids (see Table 7.1.5, Infusion rates for 150%
maintenance IV fluids, and Chapter 3.3, Gastrointestinal Disorders). Caution: use only 100% in SAM.

Give D5%-RL
Weight of Rate of infusion in mL/hour or drops/min Weight of child in Rate of infusion in
child in kg using MSF paediatric microperfusor kg mL/hour
3–3.9 20 22–22.9 95
4–4.9 25 23–23.9 95
5–5.9 35 24–24.9 95
6–6.9 40 25–25.9 100
7–7.9 45 26–26.9 100
8–8.9 50 27–27.9 100
9–9.9 55 28–28.9 105
10–10.9 60 29–29.9 105
11–11.9 65 30–30.9 105
12–12.9 70 31–31.9 105
13–13.9 70 32–32.9 110
14–14.9 75 33–33.9 110
15–15.9 75 34–34.9 110
16–16.9 80 35–35.9 115
17–17.9 85 36–36.9 115
18–18.9 85 37–37.9 115
19–19.9 90 38–38.9 120
20–20.9 90 39–39.9 120
In cases of increased intracranial pressure, cerebral malaria, pneumonia, meningitis and conditions
requiring fluid restriction, use 2/3x (70%) maintenance fluids (see Table 7.1.6, Infusion rates for 70%
maintenance IV fluids).
222

Give D5%-RL (in most children)
Weight of Rate of infusion in mL/hour or drops/min Weight of child in Rate of Infusion in
child in kg using MSF paediatric microperfusor kg mL/hour
3–3.9 10 22–22.9 45
4–4.9 15 23–23.9 45
5–5.9 15 24–24.9 45
6–6.9 20 25–25.9 45
7–7.9 20 26–26.9 45
8–8.9 25 27–27.9 45
9–9.9 25 28–28.9 50
10–10.9 30 29–29.9 50
11–11.9 30 30–30.9 50
12–12.9 30 31–31.9 50
13–13.9 35 32–32.9 50
14–14.9 35 33–33.9 50
15–15.9 35 34–34.9 50
16–16.9 35 35–35.9 55
17–17.9 40 36–36.9 55
18–18.9 40 37–37.9 55
19–19.9 40 38–38.9 55
20–20.9 40 39–39.9 55
For the addition of KCl, please see Chapter 7.2, Potassium in IV Fluids.
Monitoring
Regardless of the maintenance fluid administered, a child on intravenous fluids must be carefully
monitored for fluid overload. Signs of fluid overload include:
• increased RR by ≥10 breaths/minute
• increased HR pulse rate by ≥20 beats/min
PLUS any one of the following:
• new or worsening hypoxia = decrease in SpO2 by >5%
• new onset of rales and/or pulmonary oedema (fine crackles in lung fields)
• new galloping heart rhythm
• increased liver size (liver must have been marked with pen prior to fluid administration)
• new peripheral oedema and/or puffy eye lids.
If a child is showing signs of fluid overload, immediately stop all fluids.
Early feeding improves outcomes in paediatrics. As soon as it is possible (at 24 hours at the latest),
advance the child to feeds. If the child cannot drink, consider whether he or she is a candidate for
nasogastric feeds. If yes, start nasogastric feed, then check glucose after four hours. If the feeds are
well tolerated, stop IV fluids; recheck blood glucose again in four hours to ensure feeds are still
tolerated.
223
7.2. Potassium in Intravenous Fluids

The decision to add potassium chloride (KCl) to intravenous fluids in MSF settings should not be
taken lightly. Too much potassium IV can cause cardiac arrest in children, it is easy to miscalculate
potassium doses and potassium is caustic to veins (it burns them and causes thrombophlebitis) if the
fluids are run too fast through too small a vein. On the other hand, hypokalaemia can cause
respiratory depression and cardiac rhythm abnormalities.
Depending on the clinical context and the field, KCl may be added to maintenance fluids after a child
has been on IV fluids for >24 hours or in specific other circumstances (e.g., diabetic ketoacidosis).
Never inject KCl directly into the veins. Make sure the child is urinating before adding KCl to fluids.
KCl can only be added under direct supervision of a physician, who must verify that the appropriate
quantity of KCl has been added to the fluid, that it has been added correctly and that the fluid rate
administered to the child is correct. Each bag of IV fluids must have the date, the time and the
amount of KCl noted on the bag (see Figure 7.2.1, Example of bag label). The physician in charge of
paediatric service, in conjunction with the Medical Coordinator and the Medical Advisor, should
jointly decide whether it is appropriate for potassium to be added to IV fluids in a specific field.
One 10-mL ampoule of KCl 10% contains 13.4 mmol = 1.34 mmol/mL. Always double check that the
ampoules contain 10 mL of KCl 10%, as content and manufacturer may vary.
The potassium requirement for children is 2–3 mmol/kg/day. Maintenance KCl for a child is 2–3
mmol KCl/100 mL of IV fluids, or 20–30 mmol KCl per litre (see Table 7.2.1, KCl mixing for child
requiring 100% maintenance fluids, and Table 7.2.2, KCl mixing for child requiring 150% maintenance
fluids).
Table 7.2.1 KCl mixing for child requiring 100% maintenance fluids
Volume of KCl
D5%-RL or D10%-RL Final solution
10% to add
1000 mL (1 L) 20 mL (2 ampoules) D5%-RL + 26.8 mmol/L KCl
500 mL 10 mL (1 ampoule) or
250 mL 5 mL (½ ampoule) D10%-RL + 26.8 mmol/L KCl
In diabetic ketoacidosis only: mix 40 mmol/L of KCl

1000 mL (1 L) 30 mL (3 ampoules) D5%-RL + 40.2 mmol/L KCl
or
500 mL 15 mL (1.5 ampoules)
D10%-RL + 40.2 mmol/L KCl
Table 7.2.2. KCl mixing for child requiring 150% maintenance fluids
Volume of KCl
D5%-RL or D10%-RL Final solution
10% to add
1000 mL (1 L) 10 mL (1 ampoule) D5%-RL + 13.4 mmol/L KCl
or
500 mL 5 mL (½ ampoule)
D10%-RL + 13.4 mmol/L KCl
224
7.2. Potassium in Intravenous Fluids
Figure 7.2.1 Example of bag label
Child’s Name:
Ringer’s Lactate-NaCl 0.9%
Volume of the original bag ………….mL
Volume removed: ………………mL
G50 %: Volume added……….…… mL
KCL10 %: Volume added …………… mL
Rate of infusion: …………………….
Start time: ………………..
End time: ………………….
Signature (Dr):.…………….
Signature (Nurse): ……………..
Use from (Date and time): …………
Valid until (Date and time): ……………….
225
7.3. How to Switch from Parenteral to Oral Antibiotics

When the child is afebrile and eating and drinking well, change to oral medication (unless the
clinician’s prescription demands longer parenteral treatment).
Table 7.3.1 Choice of oral antibiotics for switch from IV treatment
Parenteral antibiotic Oral medication
Amoxicillin/clavulanic acid Amoxicillin/clavulanic acid

Ampicillin (if in combination with gentamycin, Amoxicillin
see gentamycin, below)
Cefazolin Cefalexin/cephalexin
Cefotaxime For pneumonia: amoxicillin-clavulanic acid
For urinary tract infection: cefixime
Ceftriaxone For pneumonia: amoxicillin-clavulanic acid
Clindamycin Clindamycin
Cloxacillin Amoxicillin/clavulanic acid

Cefalexin/cephalexin
Co-trimoxazole Co-trimoxazole
Erythromycin Clarithromycin
Fluconazole Fluconazole
Gentamycin For pneumonia: amoxicillin-clavulanic acid
Metronidazole Metronidazole
Penicillin: Benzathine benzyl penicillin (IM – not Penicillin V = Phenoxymethyl-penicillin
IV)
Benzyl penicillin (peni G, crystal peni)
Penicillin procaine/benzyl penicillin (IM – not IV)
226
7.4. Amoxicillin and Clavulanic Acid

Amoxicillin alone is still the drug of choice for otitis and pneumonia. It is recommended in a dose 45–
50 mg/kg/dose 2x/day (100 mg/kg/day; see Table 7.4.1, Amoxicillin oral suspension, and Table 7.4.2,
Amoxicillin tablets, for dosage information).
Table 7.4.1 Amoxicillin oral suspension
Amoxicillin 125 mg/5 mL powder oral suspension (100-mL bottle)

50 mg/kg/dose 2x/day (100 mg/kg/day)
Weight in kg Amoxicillin 125 mg/5 mL
Dose in mg Dose in mL
2x/day 2x/day
2 100 4
3 150 6
4 200 8
5 250 10
6 300 12
Table 7.4.2 Amoxicillin tablets
Amoxicillin 250-mg tablet: 50 mg/kg/dose 2x/day (100 mg/kg/day)

Weight in kg Amoxicillin 250-mg tablets
Dose in mg 2x/day Tablets 2x/day
2 100 ½
3 150 ½
4 200 1
5 250 1
6 300 1
7 350 1½
8 400 1½
9 450 2
10 500 2
11 550 2
12 600 2½
13 650 2½
14 700 3
15 750 3
227
Amoxicillin is combined with clavulanic acid for the treatment of resistant and recurrent otitis media
and pneumonia, particularly cases due to Streptococcus pneumoniae. Amoxicillin/clavulanic acid is
also frequently recommended when switching from intravenous therapy to oral treatment following
IV ceftriaxone.
The original/older formulations contained amoxicillin and clavulanic acid in a ratio of 4:1. This
formulation has too much clavulanate (leading to high incidence of diarrhoea) and insufficient
amoxicillin; MSF had removed the 4:1 formulations in 2013, but they might still be present in the
Ministry of Health structures or in the pharmacy stock. Newer formulations of amoxicillin-clavulanic
acid, with ratios of 7:1 or 8:1, are now recommended and should be prescribed where possible.
If Amoxicillin/clavulanic acid with a ratio of 4:1 is the only medication available in stock, amoxicillin
alone should be prescribed in addition to the 4:1 amoxicillin/clavulanic acid (see Table 7.4.3,
Amoxicillin/clavulanic acid 4:1 + amoxicillin dosing) so as to obtain a total daily dose of 100 mg/kg of
the amoxicillin component.
Table 7.4.3. Amoxicillin/clavulanic acid 4:1 + amoxicillin dosing
Amoxicillin/clavulanic acid 4:1 liquid

Amoxicillin
25 mg/kg/dose of the amoxicillin component
25 mg/kg/dose 2x/day
2x/day
Weight
(in kg) Amoxicillin 125 mg/5 mL
Amoxicillin 125 mg/5 mL
Clavulanic acid 31.25mg/5 mL
Dose in mg Dose in mL + Dose in mg Dose in mL
2x/day 2x/day 2x/day 2x/day
4 100 4 100 4
5 125 5 125 5
6 150 6 150 6
7 175 7 175 7
8 200 8 200 8
9 225 9 225 9
The following formulations of amoxicillin-clavulanic acid are available through MSF (ITC) as of 2015.
(See Table 7.4.4, Amoxicillin/clavulanic acid 7:1 or 8:1 dosing).
• Amoxicillin 500 mg and clavulanate 62.5 mg/5 mL, 60-mL suspension (8:1)
• Amoxicillin 400 mg and clavulanate 57 mg/5 mL, 70-mL suspension (7:1)
• Amoxicillin 500 mg and clavulanate 62.5 mg, non-breakable tablet (8:1)
• Amoxicillin 875 mg and clavulanate 125 mg, non-breakable tablet (7:1)
228
Table 7.4.4 Amoxicillin/clavulanic acid 7:1 or 8:1 dosing
50 mg/kg/dose of the amoxicillin component 2x/day

Liquid: Amoxicillin 500 mg and clavulanic Tablets: Amoxicillin 500
Weight in acid 62.5 mg/5 mL (8:1) mg/clavulanic acid 62.5 mg (8:1)
kg Dose in mg Dose in mL
Tablets 2x/day
2x/day 2x/day
2 100 1 N/A
3 150 1.5 N/A
4 200 2 N/A
5 250 2.5 N/A
6 300 3 N/A
7 350 3.5 N/A
8 400 4 1
9 450 4.5 1
10 500 5 1
11 550 5.5 1
12 600 6 2
13 650 6.5 2
14 700 7 2
15 750 7.5 2
Liquid: Amoxicillin 400mg and clavulanic acid 57mg/5 mL (7:1)
Weight in
kg Dose in mg Dose in mL
2x/day 2x/day
2 100 1.5
3 150 2
4 200 2.5
5 250 3
6 300 4
7 350 4.5
8 400 5
9 450 5.5
10 500 6
11 550 7
12 600 7.5
13 650 8
14 700 9
15 750 9.5
Adverse effects
• Diaper rash, skin rash, urticaria
• Abdominal discomfort, diarrhoea, loose stools, nausea, vomiting
Any child on antibiotics is vulnerable to a yeast infection. If the child presents with white patches in
their mouth and/or a beefy-red diaper rash, treat for Candida. In addition, all antibiotics can cause
allergic reactions; if the child develops a severe rash, hives or trouble breathing, bring him or her to a
doctor or hospital immediately.
229
7.5 Antimalarials
Table 7.5.1 Oral antimalarial treatment (children > 2 months)
ACT First line ACT according to efficacy locally. Presentation Dosage
First choice: Fixed dose combination (FDC) tablets of 20 D1, give first dose at 0 hour and 2nd dose at 8–12
Lumefantrine (AL)
Artemether/
mg artemether/120 mg lumefantrine hours. Next doses on D2 and D3 twice daily (am & pm)
Blister child <3 years (5 to 14 kg), 6 tab/blister ==> 1 tab twice daily on D1, D2, D3
Blister child 3–8 years (15 to 24 kg), 12 tab/blister ==> 2 tab twice daily on D1, D2, D3
Blister child 9–14 years (25 to 34 kg), 18 tab/blister ==> 3 tab twice daily on D1, D2, D3
Blister >14 years (>34 kg), 24 tab/blister ==> 4 tab twice daily on D1, D2, D3
First choice: FDC tablets
Blister child 2–11 months (4.5 to 8 kg), tab of AS 25 ==> 1 tab once daily on D1, D2, D3
mg/AQ base 67.5 mg, 3 tab/blister
Blister child 1–5 years (9 to 17 kg), tab of AS 50 mg/AQ ==> 1 tab once daily on D1, D2, D3
Artesunate/Amodiaquine
base 135 mg, 3 tab/blister

Blister child 6–13 years (18 to 35 kg), tab of AS 100 ==> 1 tab once daily on D1, D2, D3
mg/AQ base 270 mg, 3 tab/blister
(AS-AQ)
Blister >14 years (≥ 36 kg), tab of AS 100 mg/AQ base ==> 2 tab once daily on D1, D2, D3
270 mg, 6 tab/blister
Second Choice: Co-blister children ≤6 years, containing: 5-11 mo => ½ tab AS + ½ tab AQ daily D1, D2, D3
3 tab of AS 50 mg + 3 tab of AQ base 153 mg 1-6 years => 1 tab AS + 1 tab AQ daily on D1, D2, D3
Co-blister children 7–13 years, containing: 6 tab of AS => 2 tab AS + 2 tab AQ once daily on D1, D2, D3
50 mg + 6 tab of AQ base 153 mg
Co-blister ≥14 years, containing: 12 tab of AS 50 mg + ==> 4 tab AS + 4 tab AQ once daily on D1, D2, D3
12 tab of AQ base 153 mg
Second Choice: Co-blister children ≤6 years, containing: 2-11 months ==> ½ tab AS once daily on D1, D2, D3 +
Artesunate-Sulfadoxine/
3 tab of AS 50 mg + 1 tab of SP 500/25 mg ½ tab SP-single dose on D1

Pyrimethamine (AS-SP)
1-6 years ==> 1 tab AS once daily on D1, D2, D3 + 1

tab SP as a single dose on D1
Co-blister children 7–13 years, containing: 6 tab of AS ==> 2 tab AS once daily on D1, D2, D3 + 2 tab SP as a
50 mg + 2 tab of SP 500/25 mg single dose on D1
Co-blister ≥14 years, containing: 12 tab of AS 50 mg + 3 ==> 4 tab AS once daily on D1, D2, D3 + 3 tab SP as a
tab of SP 500/25 mg or single dose on D1
Co-blister ≥14 years, containing: 6 tab of AS 100 mg + 3 ==> 2 tab AS once daily on D1, D2, D3 + 3 tab SP as a
tab of SP 500/25 mg single dose on D1
Artesunate-Mefloquine
Blister children 6–11 months (5 to 8 kg), tab of AS 25 ==> 1 tab once daily on D1, D2, D3
mg/MQ 55 mg, 3 tab/blister
Blister children 1–6 years (9 to 17 kg), tab of AS 25 ==> 2 tab once daily on D1, D2, D3
(AS-MQ)

Blister children 7–12 years (18 to 29 kg), tab of AS 100 ==> 1 tab once daily on D1, D2, D3
Blister ≥13 years (≥ 30 kg), tab of AS 100 mg/MQ 220 ==> 2 tab once daily on D1, D2, D3
mg, 6 tab/blister
piperaquine (DHA/PPQ)
Blister children 5–12 kg, tab of 20 mg DHA/160 mg 5–6 kg ==> ½ tab once daily D1, D2, D3
Dihydroartemisinine-
PPQ, 3 tab/blister 7–12 kg ==> 1 tab once daily D1, D2, D3

Blister children 13–23 kg, tab of 40 mg DHA/320 mg ==> 1 tab once daily on D1, D2, D3
PPQ, 3 tab/blister
Blister children 24–35 kg, tab of 40 mg DHA/320 mg ==> 2 tab once daily on D1, D2, D3
PPQ, 6 tab/blister
Blister adolescents and adults 36–74 kg, tab of 40 mg ==> 3 tab once daily on D1, D2, D3
DHA/320 mg PPQ, 9 tab/blister
230
7.5. Antimalarials
Parenteral Administration of Artesunate

1 box of Artesun (artesunate produced by Guilin—DINJARTS6V) contains:
• 1 vial of 60 mg of artesunate powder
• 1 vial of 5% sodium bicarbonate 1 mL
• 1 vial of NaCl 0.9% 5 mL (water for injection is not an appropriate diluent).
Do not keep both artemether and artesunate in the same structure, to avoid the risk of erroneous IV
administration of artemether.
Dosage
The dosage of injectable artesunate differs according to weight.
• Patients weighing <20kg: 3.0 mg/kg
• Patients weighing ≥20kg: 2.4 mg/kg
Give artesunate at 0, 12 and 24 hours, then once every 24 hours until the patient can take oral
therapy. A course of parenteral artesunate has to be followed by a 3-day full course of ACT.
Administration Routes
Artesunate can be given either using the intravenous (IV) or intramuscular (IM) route. The
intravenous route is preferred over intramuscular administration.
For both IV and IM use, a two-step preparation is needed: reconstitution with sodium bicarbonate
and dilution with sodium chloride. The volume of sodium chloride to be used is different for the IV
and IM routes.
Once reconstituted, the artesunate solution is not stable and should be administered within 30
minutes. Because of the rapid degradation of the product, do not store the solution for longer than
30 minutes.
IV Administration of Artesunate
One vial of artesunate contains 60 mg of artesunate and will be prepared with 1 mL of 5% sodium
bicarbonate and 5 mL of NaCl 0.9%, so that the end solution contains 10 mg/mL of artesunate.
Procedure is:
• Peel off the top of the artesunate vial and disinfect the rubber, using 10% povidone iodine or
an alcohol swab.
• Open both ampoules so you can keep the syringe and needle in your hands during the process.
• Draw 1 mL of 5% sodium bicarbonate into a syringe and inject into the artesunate vial.
• Move your needle back slightly so it is no longer touching the liquid and withdraw all the air
from the vial. This is important to ensure adequate space in the vial to inject the saline.
• Shake until the artesunate powder is completely dissolved and the solution becomes clear
(normally within 1–2 minutes). Do not shake too vigorously to avoid foaming of the solution.
If the solution remains cloudy or a precipitate is present, the parenteral preparation should
be discarded.
231
• Draw 5 mL of NaCl 0.9% into a syringe and inject into the artesunate vial.
• Draw the required volume of artesunate from the vial (according to the precalculated dosing
schedule).
• The solution has to be administered slowly IV over 2–3 minutes.
The preferred route of intravenous administration is through the injection port of an infusion set,
using preferably 5% dextrose as infusion fluid, although NaCl 0.9% can be used as well. The infusion
needs to be stopped before injecting through the Y site.
It is recommended to flush the catheter with D5% or NaCl 0.9% to avoid leaving some of the
artesunate in the catheter. Flushing is also required before administration if the previous infusion
contained anything else than NaCl 0.9% or D5%, to avoid incompatibilities.
Alternative routes are direct IV or using a paediatric infusion set.
Never inject the artesunate into the perfusion bag. The administration is too slow and there is a risk
of degradation before everything is administered. Because of the short half-life, elimination from the
bloodstream might start even before everything is administered and the blood concentration might
be too low.
Note that, for patients ≥25 kg more than one vial of artesunate is needed, and that each vial requires
separate reconstitution, dilution and administration.
IM Administration of Artesunate
One vial of artesunate contains 60 mg of artesunate and will be prepared with 1 mL of 5% sodium
bicarbonate and 2 mL of NaCl 0.9%, so that the end solution contains 20 mg/mL of artesunate.
Procedure is:
• Peel off the top of the artesunate vial and disinfect the rubber with povidone iodine
10% or an alcohol swab.
• Draw 1 mL of 5% sodium bicarbonate into a syringe and inject into the artesunate vial.
• Move your needle back slightly so it is no longer touching the liquid and withdraw all the air
from the vial. This is important to ensure adequate space in the vial to inject the saline
solution.
• Shake until the artesunate powder is completely dissolved, and the solution becomes clear
(normally within 1–2 minutes). Do not shake too vigorously to avoid foaming of the solution.
If the solution remains cloudy or a precipitate is present, the parenteral preparation should
be discarded
• Draw 2 mL of NaCl 0.9% into a syringe and inject into the artesunate vial.
• Draw the required volume of artesunate from the vial (according to the precalculated dosing
schedule).
• Change the needle to an IM needle and give the artesunate through deep IM injection in the
anterior thigh.
Note that, as in IV administration, for patients ≥25 kg more than one vial of artesunate is needed,
and that each vial requires separate reconstitution, dilution and administration.
232
7.5. Antimalarials
Pre-calculated Dosing Schedule

Note that in order to find the optimal balance between accuracy and simplicity, some of the volumes
(see Table 7.5.2, Dosing schedule for injectable artesunate) have been rounded up to the higher
level, taking into account the measurable volumes using the different syringes (1-2-5-10 cc). It is
proven that injectable artesunate has a wide therapeutic margin and an excellent safety profile. In
case of doubt, always use the recommended dosage of 3 mg/kg for children < 20 kg and 2.4 mg/kg
for patients of ≥20 kg.
Table 7.5.2 Dosing schedule for injectable artesunate (children > 2 months)
Dosing of artesunate
Artesunate Dose <20 kg Dose ≥20 kg Timing Route
First Dose On admission
Slow IV (2–3 minutes) or
Second Dose At 12 hours
3 mg/kg 2.4 mg/kg slow IM in anterior thigh
Third Dose At 24 hours if IV not possible
Subsequent doses Once daily until child takes PO (ACT)
Dosing of artesunate in children <20 kg: 3 mg/kg
Weight (kg) Dose for artesunate IV (10 mg/mL) Dose for artesunate IM (20 mg/mL)
<3 1 mL 0.5 mL
3 1.2 mL 0.6 mL
4 1.5 mL 0.8 mL
5 2 mL 1 mL
6–7 2.5 mL 1.2 mL
8–9 3 mL 1.5 mL
10–12 4 mL 2 mL
13–14 4.5 mL 2.5 mL
15–16 5 mL 2.5 mL
17–19 6 mL 3 mL
Dosing of artesunate in children ≥20 kg: 2.4 mg/kg
Weight (kg) Dose for artesunate IV (10 mg/mL) Dose for artesunate IM (20 mg/mL)
20–24 6 mL 3 mL
25–28 7 mL 3,5 mL
29–32 8 mL 4mL
33–36 9 mL 5mL
37–40 10 mL 5mL
41–44 11 mL 6mL
45–49 12 mL 6mL
50–54 13 mL 7mL
55–61 15 mL 8mL
62–66 16 mL 8mL
67–70 17 mL 9mL
71–75 18 mL 9mL
76–80 20 mL 10 mL
233
Table 7.5.3 Treatment with artemether
IM: Administer in anterior thigh

Do not use artemether IV (dangerous as it is an oily solution)
Loading (first) dose 3.2 mg/kg on admission (D1)
Maintenance (subsequent) doses 1.6 mg/kg once daily
Change to oral ACT as soon as the patient can swallow (after a minimum of 24 hours [two doses] if used
for treatment of severe malaria)
Volume to be administered depending on concentration
80-mg ampule artemether (80 mg/mL, 1 mL)

20-mg ampule artemether (20mg/mL, 1 mL)
Use a 1-mL syringe graduated in 0.01 mL when the dose required is less than 1 mL.
Weight in kg Loading dose Maintenance dose Loading dose Maintenance dose

(3.2 mg/kg on D1) (1.6 mg/kg/day) (3.2 mg/kg on D1) (1.6 mg/kg/day)
<3 0.5 mL 0.3 mL - -
3–4 0.8 mL 0.4 mL - -
5–6 1.2 mL 0.6 mL - -
7–9 1.6 mL 0.8 mL - -
10–14 2.5 mL 1.2 mL - -
15–19 3.2 mL 1.6 mL - -
20–29 - - 1.2 mL 0.6 mL
30–39 - - 1.6 mL 0.8 mL
40–49 - - 2 mL 1 mL
50–59 - - 2.5 mL 1.2 mL
After treatment with IM artemether, give a 3-day course of ACT
Table 7.5.4 Dosing for rectal artesunate

Weight in kg 50-mg artesunate suppository 200-mg artesunate suppository
3–5 1 -
6–10 2 -
11–20 - 1
21–40 - 2
234
7.5. Antimalarials
Table 7.5.5 Treatment with quinine

Quinine IV
600 mg of quinine dihydrochloride in 2-mL ampule (300 mg/mL),
to be diluted in 5% glucose for slow infusion (never inject undiluted)
Dose expressed in quinine

salt; this is the same for Time of
quinine hydrochloride or Method of administration
administration
for quinine formate
Dissolved in 10mL/kg G5% or G10% if

On admission;
child<20 kg,
Loading dose 20 mg/kg administered over 4
hours 250 mL G5% if child >20 kg
Then infusion of RL–5% glucose at maintenance over 4 hours
8 hours after the Dissolved in 10 mL/kg G5% or G10%

first dose; if child <20 kg,
Maintenance dose 10 mg/kg
administered over 4
hours 250 mL G5% or G10% if child >20 kg
Alternate quinine over 4 hours and RL–G5% or RL–G10% over 4 hours
Note
Do not administer a loading dose to patients who have received oral quinine, mefloquine or halofantrine within
the previous 24 hours; instead, start with maintenance dose.
Administer either a 3-day course of ACT or oral quinine (± doxycycline or clindamycin) to complete 7 days of
treatment as soon as the patient can tolerate oral treatment.
If the combination artesunate-mefloquine is used as oral completion treatment following IV quinine, an interval
of 12 hours should elapse between the last dose of quinine and the administration of mefloquine
Dose according to weight in kg (loading/first dose is double the maintenance dose)
Maintenance 3 to <6 6 to <10 10 to <15 15 to <20 20–29 kg

dose 0.2 mL + 0.3 mL + 0.5 mL + 0.6 mL +
1mL +
of quinine 50 mL D5% 100 mL D5% or 150 mL D5% or 200 mL D5%
300mL D5% or D10%
hydrochloride or D10% D10% D10% or D10%
Quinine IM
Administer quinine IM only via deep IM injection into anterior thigh, and only when IV/IM artesunate and IM
artemether are not available, as IM Quinine is painful and causes inflammation at the injection site
DILUTION: 1/5 = 0.2 mL undiluted quinine dihydrochloride + 0.8 mL NaCl 0.9%: make a concentration of 60 mg
Quinine salt/mL
The diluted parenteral solution is better absorbed and less painful.
Loading dose: Give the loading dose split into two as 10 mg/kg of quinine salt into the anterior aspect of each
thigh
Maintenance: Continue with 10 mg/kg every 8 hours until oral medication is tolerated.
235
Transfusions
For children without severe acute malnutrition (non-SAM), give whole blood or packed red blood
cells (PRBCs): 20 mL/kg.
For children with SAM, give whole blood or PRBCs: 15 mL/kg.
If PRBCs prepared by centrifugation are not available, sedimented red cells can be prepared from
whole blood. PRBCs are generally preferred for children except in cases of haemorrhagic shock.
To prepare sedimented red cells, see Chapter 8.1, Blood Transfusions.
Table 7.5.6 Transfusion

non-SAM SAM
20 mL/kg at 5 mL/kg/hour 15 mL/kg at 5 mL/kg/hour
Weight Rate Rate
in kg Volume (drops/min) Volume (drops/min)
Duration Duration
(mL) 1 mL = 15 (mL) 1 mL = 15
drops drops
3 60 4 4 hours 45 4 3 hours
4 80 5 4 hours 60 5 3 hours
5 100 6 4 hours 75 6 3 hours
6 120 8 4 hours 90 7 3 hours
7 140 9 4 hours 105 9 3 hours
8 160 10 4 hours 120 10 3 hours
9 180 11 4 hours 135 11 3 hours
10 200 13 4 hours 150 12 3 hours
11 220 14 4 hours 165 14 3 hours
12 240 15 4 hours 180 15 3 hours
236
7.5. Antimalarials
Table 7.5.7 Artesunate in young infants (< 2 months)
Mixing artesunate for IV and IM administration: First, dissolve the powder (vial of 60 mg artesunate) in 1 mL of 5%
sodium bicarbonate regardless of IV or IM administration. Then, dissolve further as follows according to route (IV or IM)
For IV artesunate Add 5 mL of NaCl 0.9% to the vial for 6 mL of solution containing 10 mg of artesunate/mL
for IV injection
For IM artesunate Add 2mL of NaCl 0.9% to the vial for 3 mL of solution containing 20 mg of artesunate/mL
for IM injection
Dosing of artesunate
Artesunate Dose Timing Route
First dose On admission
Slow IV (2–3 minutes)
Second dose At 12 hours
3 mg/kg or slow IM in anterior thigh if
Third dose At 24 hours
IV not possible
Subsequent doses Once daily for 6 days
Dosing for IV injection: Artesunate solution 10 mg/mL
Use a 1-mL syringe graduated in 0.01 mL when the dose required is less than 1 mL.
Child’s weight in kg Dose in mL
1 to <1.5 0.5
1.5 to <2 0.6
2 to <3 0.9
3 to <4 1.2
4 to <5 1.5
5 to <6 1.8
Dosing for IM injection: Artesunate solution 20 mg/mL
Child’s weight in kg Dose in mL
1 to <1.5 0.2
1.5 to <2 0.3
2 to <3 0.45
3 to <4 0.6
4 to <5 0.75
5 to <6 0.9
Dosing for rectal artesunate (if IV/IM not available): 50-mg Recto cap (suppositories cannot be divided)
Weight 50-mg artesunate suppository
<5 kg 1
6–10 kg 2
Table 7.5.8 Artemether dosage in young infants (< 2 months) using paediatric vials
Weight D1: Artemether 3.2 mg/kg D2–D7: Artemether 1.6 mg/kg
<2 kg 6 mg 0.3 mL 3 mg 0.2 mL
2–2.9 kg 6 mg 0.3 mL 3 mg 0.2 mL
3–3.9 kg 10 mg 0.5 mL 5 mg 0.3 mL
4–4.9 kg 13 mg 0.6 mL 6 mg 0.3 mL
5 kg 16 mg 0.8 mL 8 mg 0.4 mL
237
Table 7.5.9 AS-AQ dilutions in young infants (< 2 months)
Artesunate-Amodiaquine (AS-AQ): Available formulations, soluble in water in 3 minutes*

Dilute one co-formulated tablet of AS-AQ (25 mg artesunate/67.5 mg amodiaquine co-formulation) in 2 mL of
clean water or sodium chloride.
Dose: AS: 5 mg/kg x 3 days; AQ: 10 mg/kg x 3 days.
Weight (kg) Dose (mL)
2.0–2.4 0.7
2.5–2.9 0.9
3.0–3.4 1.0
3.5–3.9 1.2
4.0–4.4 1.3
4.5–4.9 1.5
* In order to deliver the correct doses, ensure that you order the syringes for oral administration,
5mL syringes (order code ITC:SCTDSYR005-)
Table 7.5.10 AL dilutions in young infants (< 2 months)
Artemether-Lumefantrine (AL)
Dilute one tablet of AL (20 mg artemether/120 mg lumefantrine co-formulations) into 10 mL of clean water.
Dilution of AL (20 mg artemether/120 mg lumefantrine co-formulation) 1 mL = 2 mg of Artemether + 12 mg of
Lumefantrine.
Dosing: Artemether 1.7 mg/kg/dose; lumefantrine 12 mg/kg/dose x 2/day
Weight (kg) mL/Dose
2–2.4 kg 2.2 mL twice daily
2.5–2.9 kg 2.8 mL twice daily
4.5-4.9 kg 4.8 mL twice daily
* In order to deliver the correct doses, ensure that you order the syringes for oral administration,
5mL syringes (order code ITC:SCTDSYR005-).
238
7.6. How to give Epinephrine infusion
7.6. How to give Epinephrine infusion with a syringe

pump
Table 7.6.1 How to give Epinephrine infusion with a syringe pump
Dilute 1 ampoule of 1 mg = 1 mL epinephrine 1:1000 (1000 micrograms) in 100 mL of D5%RL or

Step 1 G5% NaCl 0.9% * to obtain a solution containing 10 micrograms of epinephrine/mL. Fill the
50-mL syringe of the syringe pump with this solution. Using this dilution, follow Step 2 and 3.
Step 2 Select the weight of the patient.
Program and check the infusion rate according to the weight of the patient and the
Step 3
microgram/kg/min desired (see below).
Example: Patient of 10 kg who needs epinephrine a 0.1 microgram/kg/min: infusion rate will
be 6 mL/hour.**
Target infusion rate Target infusion rate Target infusion rate Target infusion rate
   
Weight
0.1 mcg/kg/min 0.2 mcg/kg/min 0.3 mcg/kg/min 0.4 mcg/kg/min
(kg)
3 1.8 mL/hour 3.6 mL/hour 5.4 mL/hour 7.2 mL/hour
5 3 mL/hour 6 mL/hour 9 mL/hour 12 mL/hour
*See Maintenance Fluids chapter for mix of D5%RL and D5% NaCl 0.9%.
**Consider this volume in your overall daily fluid calculations and subtract from maintenance fluid.
239
Titrate dose and infusion rate every 2 hours according to clinical condition of the patient.
• If the patient has improved and recovered from shock, continue with the same rate for 2
more hours and then, if still stable, reduce to 50% every 2 hours until epinephrine has been
completely phased out.
• If the patient has not improved and is still in shock after 2 hours, increase the dose to
maximum of 0.4 mcg/kg/min and reassess after 2 hours.
- If the patient has improved and has recovered from shock, continue for 2 more hours
and then, if still stable, reduce (see above).
- If the patient has not improved and is still in shock after 2 hours, continue with the same
dose for 2 more hours and reassess (bad prognosis). Discuss with medical team how to
proceed.
Note: Epinephrine is a vesicant – ensure proper needle or catheter placement prior to and during
infusion to avoid extravasation. If extravasation occurs, switch quickly to epinephrine infusion via
another vein. Stop extravasated infusion immediately and disconnect (leave cannula/needle in
place), gently aspirate extravasated solution (do not flush the line), remove the needle/cannula and
elevate extremity. Apply dry warm compresses for comfort.
Adverse events include arrhythmias and pulmonary oedema.
240
7.7. Thiamine Protocol
7.7. Thiamine Protocol for children in shock with SAM

or from areas with high SAM prevalence
Table 7.7.1 Thiamine protocol for children in shock with SAM or from areas with high SAM prevalence
Shock (except 1. Slow IV infusion (30 min or 1 hour) - Never quick IV infusion (as part of
anaphylactic or initial phase of shock treatment):
haemorrhagic) < 13 years old: 100 mg 12-hourly for the first 48 hours
> 13 years old: 200 mg 12-hourly for the first 48 hours
If IV not possible: 100 mg (2 tabs) orally 12 hourly for the first 48 hours.
2. After 48 hours*, start maintenance dose 50 mg/day orally (or NGT) as

soon as possible and continue for 1 month even if the patient has been
discharged.
Dilution and Suggestions for Administration of IV Thiamine
IV: diluted in 1 hour’s worth of maintenance fluids.

100 mg = one complete 2ml vial
Dilute 2-4 mL (one or two complete vials), according to the dose to be given, in the volume
equivalent to 1 hour’s maintenance fluids. Only place the volume needed for 1 hour of
maintenance fluids in the IV paediatric perfusion set and add the thiamine to this volume only.
E.g. 10 kg child, maintenance rate 40 mL/h. Put 40 mL in the paediatric perfusion set and add
100 mg of thiamine (1 vial = 2mL = 100 mg) and give at 40 mL/hour (40 drops /minute) until the
total amount of fluid is finished.
Compatible with: Ringer Lactate. Mix solution RL/D5 or D10, and NaCl 0.9%.
Not compatible with: diazepam, erythromycin (macrolides), metronidazole, clindamycin,
furosemide, phenobarbital. For these drugs, do not infuse together – and rinse line between
injections.
Stock in pharmacy out of reach of light.
IV Treatment of Duration
*The solution to be injected contains aluminium, thus change to the oral route as soon as possible
(generally after 48 hours). The tablets do not contain aluminium.
DINJTHIA1A - for thiamine (vitamin B1), 50 mg/mL, 2 ml, amp. (Vial contains 100 mg in 2 mL).
DORATHIA5T- Thiamine hydrochloride (vitamin B1), 50 mg, tab.
241
7.8. Midazolam and Diazepam for Sedation

Midazolam has both anxiolytic and amnestic properties; however, it does not have analgesic
properties and must be combined with an analgesic (e.g. morphine) for pain relief (see Chapter 4,
Pain Management). After oral or sublingual administration, it has an onset of action of 5 to 10
minutes, with recovery occurring in approximately 60 minutes. Any child receiving midazolam must
have continuous oxygen saturation monitoring.
At least two people are required before midazolam can be used for sedation:
• A doctor/nurse who is competent to administer conscious sedation and monitor the patient:
- Must understand pharmacology and undesired effects of benzodiazepines
- Must be capable of performing basic airway management and cardiopulmonary
resuscitation
- Is present and dedicated to patient during procedure and recovery
• A second doctor/nurse who is competent to perform the procedure requiring sedation.
Preparation of patient
• Evaluate airway and cardiorespiratory status (auscultation is essential).
• Weigh the child.
• Explain the procedure to be performed and obtain consent from parent/caregiver.
• Apply monitoring and take baseline observations (HR, BP, SpO2, RR, consciousness level).
• Give oxygen to keep SpO2 ≥95%.
• Insert IV line if intravenous route is to be used for administration.
Preparation of equipment
• Self-inflating Ambu bag, facemasks and oral airways
• Simple O2 mask/nasal prongs, oxygen source (cylinder/extractor)
• Suction machine, connectors and suction catheters
• Syringes, needles, IV catheters
• Stethoscope, blood pressure cuff, pulse oximeter
Administration of midazolam for children older than 5 years:

• 0.05–0.1 mg/kg over 5 minutes IV or IM (maximum dose: 6 mg)
• 0.25–0.5 mg PO once
If midazolam is not available, diazepam can be administered instead:

• 0.2 mg/kg PO
• 0.05–0.1 mg/kg over 3–5 minutes IV
242
7.8. Midazolam and Diazepam for Sedation
Monitoring
• Monitor vital signs, consciousness level, airway patency and respiration until recovery is
complete.
• Chest movements must be visible at all times.
• Record dose and time of administration of midazolam and vital signs on monitoring chart.
Potential adverse effects

• Airway obstruction: Reposition head, lift jaw forward and up (see Chapter 2.3, Systematic
Approach to the Seriously Ill Child)
• Respiratory depression/apnoea: Assist ventilation with bag + mask
• Abundant secretions: Gentle, shallow oral suction (be careful not to cause laryngospasm)
• Regurgitation/vomiting: Lateral positioning, oral suction and ensure O2
• Excessive involuntary movement: Gentle restraint
- Prevent self-injury/falls
• Recovery agitation: Quiet environment
During the recovery period, which usually lasts between 90 and 150 minutes, continuously monitor
vital signs, consciousness level and pain score until recover is complete. Allow the child to wake up
slowly and spontaneously, avoid stimulation and watch out for sudden movements/falls.
Discharge is authorised if the child is conscious and alert, responds to simple orders, has not vomited
and vital signs are stable. The child is allowed to drink water on demand after 1.5 hours; food/milk
are acceptable after 2 hours. The child should not be allowed to walk around without assistance.
243
7.9. Phenobarbital and Phenytoin

Table 7.9.1 Administration of phenobarbital infusion
Table 7.9.2 Administration of phenytoin infusion
Note: For details on how to administer drugs in paediatric perfusor see Chapter 8.12.
244
7.9. Phenobarbital and Phenytoin
Table 7.9.1 Administration of phenobarbital infusion
Loading dose of phenobarbital: 15 mg/kg (maximum dose 1000 mg) Phenobarbital vial: 200 mg/ml
Dilute to a concentration of 20 mg/mL with NaCl 0.9% by adding 9 ml of NaCl 0.9% *
Do not inject IV faster than 1 mg/kg/minute (over 20 minutes)
Weight Loading Loading dose Volume of Total Time of Syringe Paediatric Infusion Set
(kg) dose (mL of diluted NaCl 0.9% to volume to infusion pump 1 mL = 60 micro-drops
(mg) vial*) add (mL) administer mL/h** microdrops/min***
1 15 0.8 9.2
2 30 1.5 8.5 Not possible (If syringe
Over 20 30
3 45 2.3 7.7 10 ml pump not available, give
minutes ml/hour
4 60 3 7 it IV slowly)
5 75 3.8 6.2
6 90 4.5 15.5
7 105 5.3 14.7 60 microdrops/minute*
Over 20 60
8 120 6 14 20 mL (1 microdrop every
minutes ml/hour
9 135 6.8 13.2 second)
10 150 7.5 12.5
11 165 8.3 21.7
12 180 9.0 21
13 195 9.8 20.2
14 210 10.5 19.5
15 225 11.3 18.7
16 240 12.0 18
17 255 12.8 17.2 90 microdrops/minute
Over 20 90
18 270 13.5 16.5 30 mL (1.5 microdrops every
minutes ml/hour
19 285 14.3 15.7 second)
20 300 15.0 15
21 315 15.8 14.2
22 330 16.5 13.5
23 345 17.3 12.7
24 360 18.0 12
25 375 18.8 11.2
26 390 19.5 20.5 Paediatric Infusion Set
27 405 20.3 19.7 microdrops/min
28 420 21.0 19
29 435 21.8 18.2
30 450 22.5 17.5
31 465 23.3 16.7
32 480 24.0 16
Over 20
33 495 24.8 15.2 40 mL
minutes
35 525 26.3 13.7
36 540 27.0 13
37 555 27.8 12,2
38 570 28.5 11.5
39 585 29.3 10.7
40 600 30.0 10
*Each vial of 200 mg/mL + 9 mL of NaCl 0.9% = 200 mg/10mL = 20 mg/mL
**Infusion with a syringe pump requires flushing with at least 5 mL of G5% or RL or NaCl 0.9% for the
medication to be given in total.
***Be aware that the "dead volume" of the paediatric infusion set is 15 mL. At the end you will need to rinse
the paediatric infusion set with 15 mL of NaCl 0.9% to be able to give the entire quantity of the medication.
245
Table 7.9.2 Administration of phenytoin infusion
Loading dose of phenytoin: 20 mg/kg (maximum dose 1000 mg)

Do not inject IV faster than 1 mg/kg/minute (over 20 minutes)
Phenytoin: 50 mg/mL in vial 5 mL
Weight Loading Loading Volume of Total Time of Syringe Paediatric Infusion Set
(kg) dose dose NaCl 0.9% volume to infusion pump 1 mL = 60 micro-drops
(mg) (mL) to add administer mL/h* microdrop/min**
(mL)
1 20 0.4 9.6
2 40 0.8 9.2 Not possible (If syringe
Over 20 30
3 60 1.2 8.8 10 mL pump not available, give
minutes mL/hour
4 80 1.6 8.4 it IV slowly)
5 100 2 8.0
6 120 2.4 17.6
7 140 2.8 17.2 60 microdrops/minute*
Over 20 60
8 160 3.2 16.8 20 mL (1 microdrop every
minutes mL/hour
9 180 3.6 16.4 second)
10 200 4 16.0
11 220 4.4 45.6 Paediatric Infusion Set
12 240 4.8 45.2 microdrops/min
13 260 5.2 44.8
14 280 5.6 44.4
15 300 6 44.0
16 320 6.4 43.6
17 340 6.8 43.2
Over 20
18 360 7.2 42.8 50 mL
minutes
20 400 8 42.0
21 420 8.4 41.6
22 440 8.8 41.2
23 460 9.2 40.8
24 480 9.6 40.4
25 500 10 40.0
26 520 10.4 89.6 Adult Infusion Set
27 540 10.8 89.2 drops/min
28 560 11.2 88.8
29 580 11.6 88.4
30 600 12 88.0
31 620 12.4 87.6
32 640 12.8 87.2
Over 20
33 660 13.2 86.8 100 mL
minutes 1mL = 20 drops
34 680 13.6 86.4
100 drops/minute
35 700 14 86.0
36 720 14.4 85.6
37 740 14.8 85.2
38 760 15.2 84.8
39 780 15.6 84.4
40 800 16 84.0
* Infusion with a syringe pump requires flushing with at least 5 mL of G5% or RL or NaCl 0.9% for the
medication to be given in total.
** Be aware that the "dead volume" of the paediatric infusion set is 15 mL. At the end you will need to rinse
the paediatric infusion set with 15 mL of NaCl 0.9% to be able to give the entire quantity of medication.
246
7.10. Ketamine
7.10. Ketamine
Warning: Ketamine is a potent anaesthetic drug that also provides analgesia and amnesia. It does not
reliably prevent any of the following complications:
• upper airway obstruction
• bronchopulmonary aspiration
• haemodynamic instability.
There are major risks to using ketamine for sedation/anaesthesia. The best person to administer
ketamine is a qualified anaesthetist; if no anaesthetist is available, ketamine should only be
administered by a doctor, nurse or trained paramedical technician who is competent in basic airway
management (not necessarily intubation) and resuscitation. All health personnel administering
ketamine are responsible for the care of the patient under deep sedation/anaesthesia until the
patient is fully awake. The person who administers the drug is also responsible for monitoring the
patient and treating any ketamine-related complications; the procedure requiring
sedation/anaesthesia must be performed by a second person.
Patients must be older than 3 months to receive ketamine. Ketamine should be used only for
moderately painful, brief (≤30 minutes) peripheral procedures (e.g., fracture/dislocation reduction,
abscess drainage, suturing of minor wounds lasting ≤30 minutes, drainage of ascites or empyema).
Do not use ketamine unless no lower-risk analgesic alternatives exist, or unless such an alternative
has failed.
At least two people are required before ketamine can be used for sedation
• A doctor/nurse who is competent to administer conscious sedation and monitor the patient:
- Must understand pharmacology and undesired effects of ketamine
- Must be capable of performing basic airway management and cardiopulmonary
resuscitation
- Is present and dedicated to patient during procedure and recovery
• A second doctor/nurse who is competent to perform the procedure requiring sedation
Contraindications to ketamine use

• Absence of trained personnel, monitoring equipment and dedicated care space
• Patient age younger than 3 months
• Procedures likely to last >30 minutes
• Procedures involving deep body structures, oral cavity or pharynx
• Patient history of any of the following:
- upper airway infection or lung disease
- known or suspected cardiovascular disease, including hypertension
- head injury with loss of consciousness, altered mental state, seizures or vomiting
- epilepsy
- psychosis.
247
Preparation of patient
• Evaluate airway and cardiorespiratory status
• Weigh the child.
• Explain the procedure to be performed and obtain consent from parent/caregiver.
• Apply monitoring and take baseline observations (HR, BP, SpO2, RR, consciousness level).
• Give oxygen to keep SpO2 ≥95%.
• Insert IV line if intravenous route is to be used for administration (not required).
Preparation of equipment
• Self-inflating Ambu bag, facemasks and oral airways
• Simple O2 mask/nasal prongs, oxygen source (cylinder/extractor)
• Suction machine, connectors and suction catheters
• Syringes, needles, IV catheters
• Stethoscope, blood pressure cuff, pulse oximeter
Ketamine is formulated in 10-mL vials of 50 mg/mL (see Table 7.10.1, Ketamine dilution for IV route).
For administration, an IV bolus is preferable, though IM injection is acceptable. Once administered,
avoid stimulation of the posterior pharynx. Gentle physical restraint may be needed to control
involuntary movements, and repositioning of the airway may be needed to correct airway obstruction.
For IV ketamine:
• Administer 1 mg/kg (see Table 7.10.2, Volume for IV administration by weight) by slow IV
injection over 1–2 minutes
• Onset of action: 1–2 minutes
• Duration of effective analgesia: 10–15 minutes
• One further dose of 0.5 mg/kg may be given after 5 minutes if initial analgesia is inadequate.
Table 7.10.1. Ketamine dilution for IV route
All children: 10-mL syringe

Dilute 100 mg (= 2 mL) with 8 mL NaCl 0.9%
Final concentration: 10 mg/mL
Table 7.10.2. Volume for IV administration by weight
5–9 kg 10–14 kg 15–19 kg 20–24 kg 25–29 kg 30–39 kg

Volume
0.5 1 1.5 2 2.5 3
(mL)
For IM ketamine:
• Administer 4–5 mg/kg by IM injection (note: IM ketamine is not diluted; see Table 7.10.3,
Volume for IM administration by weight)
• Onset of action: 5 minutes
• Duration of effective analgesia: 20–30 minutes
248
7.10. Ketamine
Table 7.10.3. Volume for IM administration by weight

5–9 kg 10–14 kg 15–19 kg 20–24 kg 25–29 kg 30–39 kg
Syringe size
2 2 2 2 5 5
(mL)
Volume (mL) 0.5 1 1.5 2 2.5 3
Prophylactic benzodiazepines (BZD) are not recommended for children. If considered necessary due
to excessive spontaneous movements or unpleasant reactions, use low-dose diazepam IV. Low-dose
BZD should be considered for all ages in cases of excessive spontaneous movements or unpleasant
emergence reactions.
Monitoring
• Monitor vital signs, consciousness level, airway patency and respiration until recovery is
complete.
• Chest movements must be visible at all times.
• Record dose and time of administration of ketamine and vital signs on monitoring chart
Effects of ketamine include a ‘dissociated’ neurological state, as well as the following:

• deep sedation / anaesthesia
- trance-like state
- open eyes, nystagmus/fixed gaze
- involuntary movements
• analgesia
• amnesia
• airway reflexes are usually preserved
• spontaneous respiration is usually preserved
• minimal haemodynamic changes
- tachycardia common
• emergence reactions
- hallucinations, nightmares
- agitation
Potential adverse effects

• Airway obstruction: Reposition head, lift jaw forward and up (see Chapter 2.3, Management
of the Seriously Ill Child)
• Respiratory depression/apnoea: Assist ventilation with bag and mask
• Abundant secretions: Gentle, shallow oral suction (be careful not to cause laryngospasm)
• Regurgitation/vomiting: Lateral positioning, oral suction and ensure O2
• Excessive involuntary movement: Gentle restraint, bolus benzodiazepines
- Prevent self-injury/falls
• Recovery agitation: Quiet environment, benzodiazepines
249
During the recovery period, which usually lasts between 60 and 140 minutes, continuously monitor
vital signs, consciousness level and pain score until recover is complete. Allow the child to wake up
slowly and spontaneously, avoid stimulation and watch out for sudden movements/falls.
Discharge is authorised if the child is conscious and alert, responds to simple orders, has not vomited
and vital signs are stable. The child is allowed to drink water on demand after 1.5 hours; food/milk
are acceptable after 2 hours. The child should not be allowed to walk around without assistance
before at least 2 hours have passed to prevent falls.
250
7.11. Oxygen Therapy

Oxygen (O2) is essential in the treatment of hypoxia. Oxygen may be delivered to the patient from
cylinders or from oxygen concentrators, although cylinders are only rarely recommended in MSF
settings, often for certain situations such as ambulance transport.
Oxygen itself is not flammable, but a higher concentration of oxygen will allow more or less anything
(even metal) to burn. Beware of fire and explosions.
Precautions
• Protect the oxygen from heat, sparks or flames.
• Do not smoke nearby.
• Do not use grease or oily products on the connections.
• Do not use solvents (alcohol, petrol) on the material.
Indications for Use
Oxygen therapy should be initiated in all children who present

with the following:
• Emergency signs ABCD (= triage RED see Table 2.1.1,

Triage priority categories)
• Severe pneumonia if SpO2 < 94%
• Simple pneumonia or bronchiolitis if SpO2 < 90%
Pulse oximetry can be used for continuous monitoring or

for a spot check.
251
Administration
There are two types of O2 delivery systems: low flow (nasal cannula and simple oxygen mask) and
high flow (non-rebreathing mask with reservoir). In addition, bag-and-mask ventilation can be used
for resuscitation and during anaesthesia. Regardless of the delivery system used, start with 1–2 L/min
and adjust as needed to keep the SpO2 >94%. Do not exceed 2 L/kg/min.
Nasal Cannula
Nasal cannula is the preferred method of oxygen administration for MSF settings. To apply, attach to
the child’s face with tape and/or secure behind the ears.
Nasal cannulae are used to deliver low-flow oxygen to spontaneously breathing patients. The actual
percentage of oxygen delivered to the patient via nasal cannula ranges from 25% to 40%. Use a flow
rate of ≤2 L/min for infants and ≤4 L/min for children.
Simple Oxygen Mask

Simple oxygen masks (see left) are used for patients
with spontaneous breathing and respiratory distress in
whom the oxygen provided via nasal cannula is
insufficient. Before use, personnel must be capable of
ensuring adequate flow (≥6 L). Actual oxygen delivered
is 35%–60%.
252
Non-Rebreathing Mask with Reservoir

Non-rebreathing masks are used in patients with
spontaneous breathing who are in severe respiratory
distress (respiratory failure) or any kind of shock.
Ensure that the flow of O2 (usually ≥10 L) is adequate to
maintain a fully inflated reservoir bag during the entire
respiratory cycle. Percentage oxygen delivered ranges
from 65% to 90%.
Humidification
No humidification is needed for standard flow rates or if oxygen given for < 2 hours. Therefore,
humidification is not needed in the emergency room (if < 2hr), and on the wards it is only needed for
flow rates >2 L/min in children < 2 years old and > 4 L/min in children > 2 years old. This means that
humidification is usually not needed in MSF settings.
Humidifiers can be a source of bacteria if they are not correctly used. They must be changed for each
new patient and every 24 hours for children with mid- or long-term oxygen needs. Humidifiers need
to be not only washed, but also disinfected and sterilised after each use (see Biomed User
Maintenance Protocol as some older humidifier models cannot be sterilised, so they should be
properly disinfected in the correct solution). The best water to be used in the humidifiers is distilled
water; if distilled water is not available, filtered or tap water can also be used as long as the tap
water is conforming to MSF norms for residual chlorine (chlorine is toxic, but residual quantities
according to MSF norms for water distribution systems are very low and will transfer to oxygen at
lower levels). The water should be changed at least once a day.
Oxygen Sources
In MSF settings, refillable cylinders must only be used for ambulance transport. They have great risks,
not only in relation to container pressure but also the quality of oxygen is often not guaranteed.
In precarious environments and MSF paediatric settings, the standard and the only suitable source of
oxygen is via oxygen concentrators (or extractors).
253
An oxygen concentrator (see MSF

document on oxygen concentrators) is
a machine that extracts oxygen from
atmospheric air. It can produce
between 5 and 10 L/min of gas with an
oxygen concentration of around 95%.
The oxygen extractor works on

electricity (the wattage is different
according to the concentrator; refer to
manual guide for more information).
The concentrator (at left) is shown with a

flow splitter that allows using one
concentrator for multiple children. It is
important to install the splitter correctly for
it to function properly:
• Connect the flow splitter to the
concentrator.
• Open all five valves to max.
• Turn on the concentrator.
• Adjust the concentrator to 5 to 10
L/min, depending on the
concentrator used.
When using a flow splitter, the flow meter of the oxygen concentrator is no longer used for flow
regulation, which is instead done using the individual connections of the flow splitter.
254
MSF has a 5-L/min and a 10-L/min concentrator in the

standard list. The 10-L model is the best suited for use
with the flow splitter. The 5-L model can be used, but
the flow splitter will never deliver more than 5 L.
To connect the flow splitter:

• Connect the flow splitter to the concentrator
using the green hose.
• Completely open the flow meter on the
concentrator.
• Close all but one of the flow meters on the flow
splitter.
• Switch on the concentrator and adjust the
open flow meter on the flow splitter to at least
1 L (for the 5-L/min concentrator) or 2 L (for
the 10-L/min concentrator).
Important points:
• The flow splitter will never deliver more than the maximum flow that the oxygen
concentrator can provide. If there are alarms for low oxygen, you may have to reduce the
flow from (some of) the patients.
• The flow meter on the oxygen concentrator may go above the red line slightly. Normally this
should be avoided, but with the flow splitter this is needed to overcome the additional
resistance from the flow splitter.
• Changing the flow to one connection will affect the other connections. It is important to
check each of the flow rates (and change the relevant flow meter if needed) each time any
adjustment is made or a patient is connected/disconnected.
• If no patients are connected to the flow splitter and the connections are closed, then the
flow is zero; turn off the concentrator to avoid an alarm signal.
You can also connect two concentrators to one splitter; this will give you 10 L/min instead of 5 L/min.
Maintenance is simple and involves cleaning the filters. Neglecting this simple maintenance will
significantly shorten the life span of the concentrator (see MSF procedures manual page and Biomed
User Maintenance Protocol).
Nursing Care Priorities

Monitor the child closely
• If the child requires oxygen, it means that his or her condition is poor.
• Check vital signs 4x/day (or as requested by the medical officer).
- Include observation of breathing difficulty (moderate or severe).
- Report abnormalities immediately to the medical officer.
255
Maintain the oxygen equipment

• Ensure the tubing and mask or prongs are clean (and single-use materials) and not shared
amongst children
• Ensure the TB filter is used on children with TB. This is an external antibacterial filter to avoid
retro-contamination of the concentrator (single-use/patient filter) placed between the exit
point of the O2 and the humidifier (see catalogue OTC kit concentrator TB).
• Ensure the concentrator is maintained according to the schedule (see www.msflogistique.org
and discuss with field logistician).
Protect the child from injury and infection

• Ensure the tubing does not cause pressure areas.
- Remove the tubing and taping once per shift to clean and dry the child’s skin.
• Replace the tubing and mask every 3–5 days with new, sterile materials if child is using
oxygen for a prolonged period.
• If the condition permits, encourage the child to drink or breastfeed regularly to avoid
excessive drying of the mouth.
256
8. Procedures
8.1. Blood Transfusions ....................................................................................................................... 258
8.2. IV Lines.......................................................................................................................................... 265
8.3. Intraosseous Access...................................................................................................................... 270
8.4. Finger Prick for Capillary Blood .................................................................................................... 277
8.5. Chest Tube Placement .................................................................................................................. 278
8.6. Decompression of Tension Pneumothorax .................................................................................. 282
8.7. Pleural Puncture ........................................................................................................................... 284
8.8. Lumbar Puncture .......................................................................................................................... 286
8.9. Paracentesis.................................................................................................................................. 290
8.10. Urine Collection .......................................................................................................................... 292
8.11. Paediatric Perfusor Use .............................................................................................................. 296
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8. Procedures
8.1. Blood Transfusions

(Please also see MSF Transfusion Guidelines.)
In general, transfuse a child to treat the symptoms of decompensated anaemia (including shock).
Always obtain the child’s medical history, including the cause of the anaemia (if possible, treat the
cause; see Chapter 3.7, Blood Disorders, for causes of and treatments for anaemia) and any previous
transfusions (dates and reasons for transfusion). If available, review old records.
Indications for Transfusion

Evaluate the need for a transfusion carefully, as transfusion carries significant risks of potential
infection and allergic and immune reactions.
• Transfuse if Hb <4 g/dL or if 4–6 g/dL with signs of decompensation (respiratory distress,
shock, impaired consciousness)
• For children with sickle cell anaemia, refer to Chapter 3.7, Blood Disorders, for specific
indications.
• In certain clinical cases of acute ongoing haemolysis, it may be necessary to transfuse sooner.
Check post-transfusion Hb after 48 hours (if context and resources allow):

• If Hb <4 g/dL or <6 g/dL with respiratory distress: re-transfuse (use same donor if possible)
• If >6 g/dL, treat for anaemia according to Table 3.7.2, Treatment for non-emergency anaemia
(see Chapter 3.7)
Whole Blood vs. Packed Red Blood Cells

Whole blood (WB) should be used in cases of acute haemorrhage, including haemorrhagic shock, and
coagulation disorders. Note that only ‘fresh whole blood’ (whole blood collected less than 4 hours
before and never refrigerated) includes functional coagulation factors and platelets.
Packed red blood cells (PRBC) should be used for all other causes of anaemia (acute or chronic),
including malaria, sickle cell disease and thalassemia, and in cases where there is risk of circulatory
overload (cardiac failure).
Packed red blood cells can be prepared by centrifugation in national or equipped regional blood
centres, or can be obtained in the field by sedimentation (see also MSF Transfusion Guidelines).
When PRBC by centrifugation are not available, PRBC by sedimentation (see Figure 8.1.1, Preparing
PRBC via sedimentation) are prepared from whole blood units that have been stored upright for at
least two nights, with the giving set outlet at the bottom in order to be able to transfuse only
concentrated red cells.
258
Figure 8.1.1 Preparing PRBC by sedimentation
Plasma and coagulant
Sedimented red blood cells
Transfusion Instructions
General instructions
• If possible, obtain blood from a known donor if no blood bank is available.
• Child does not need to be NPO (nothing per os) during the transfusion.
• Fever is not a contra-indication for acute transfusion.
• Blood group to transfuse:
- Young infants (younger than 2 months of age) have maternal IgG (which crosses the
placenta). PRBCs should be compatible with both mother and infant ABO and Rh groups
(refer to neonatal guidelines).
- In children older than 2 months, transfuse matched blood; avoid using group O whole
blood unless there are no other options.
• Perform ABO bedside compatibility test using the ABO bedside card using capillary blood at
bedside before starting transfusion.
• Check that the blood bags are well filled and, if in doubt, weigh the blood units. The expected
weight of a filled bag of whole blood is approximately:
- 200 g for 150-mL bags (range 180–215 g)
- 325 g for 250-mL bags (range 295–350 g)
- 560 g for 450-mL bags (range (515–610 g)
Volume of whole blood or PRBCs for SAM and non SAM children over 3 – 4 hours:
• Whole blood: 20 mL/kg
• PRBCs: 15 mL/kg
• But never more than one 450-mL blood unit before re-evaluation
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8. Procedures
Transfusion – when not in shock

Children not presenting with signs of shock, both non-SAM and SAM, can receive either whole blood
or PRBCs (see Table 8.1.1, Transfusion guidelines for all children without shock).
Table 8.1.1 Transfusion guidelines for all children without shock

Whole Blood (WB) PRBCs
Weight (kg) 20 mL/kg at 5 mL/kg/hour 15 mL/kg at 5 mL/kg/hour
Volume* (mL) Rate (drops/min) Duration Volume* (mL) Rate (drops/min) Duration
3 60 4 4 hours 45 4 3 hours
4 80 5 4 hours 60 5 3 hours
5 100 6 4 hours 75 6 3 hours
6 120 8 4 hours 90 7 3 hours
7 140 9 4 hours 105 9 3 hours
8 160 10 4 hours 120 10 3 hours
9 180 11 4 hours 135 11 3 hours
10 200 13 4 hours 150 12 3 hours
11 220 14 4 hours 165 14 3 hours
12 240 15 4 hours 180 15 3 hours
*1 mL of blood = 15 drops
Transfusion – in shock
For children, both non-SAM and SAM, with haemorrhagic shock, transfuse 20 mL/kg (or more) of
whole blood as quickly as possible. Blood can be transfused more rapidly if a blood pressure cuff is
wrapped around the blood bag and inflated.
Monitor HR and RR for decrease and check for the return of femoral pulses and improvement of CRT.
• If child is still in shock or acute distress: continue transfusing quickly.
• If child is no longer in shock or acute distress: slow down the transfusion.
For children, both non-SAM and SAM, with other forms of shock, if transfusion indicated (Hb < 6g/dL),
see Chapter 3.2, Shock and circulatory impairment.
Drip Rate for Blood Administration Set

Blood administration set delivers 15 drops of blood per millilitre. To calculate the drip rate, use the
following formula:
• Drops per minute of blood transfusion =
- Volume (mL) ÷ Time (hours) ÷ 4, or
- Volume (mL) x drops/mL (15) ÷ time (minutes)
• For children weighing 3–12 kg, these calculations have been done in Table 8.1.1, Transfusion
guidelines for all children without shock.
• Paediatric blood units can contain from 70 mL to 125 mL; single 150 mL, 250 mL and 450 mL
blood bags are available in MSF fields.
260
• In paediatrics, blood units usually contain a volume greater than the prescribed volume. For
example, for a child weighing 5 kg who must receive 100 mL WB, the blood bank may issue a
250-mL WB unit.
• Respect the duration of administration to ensure that the prescribed volume is administered
at the hourly rate of 5 mL/kg/hour.
• For example, in order to administer 100 mL of whole blood in a non-SAM child weighing 5 kg,
the transfusion must be set at 6 drops/min over 4 hours (see Table 8.1.1, Transfusion
guidelines for all children without shock). At the end of 4 hours, stop the transfusion, confirm
that 100 mL has been administered and discard the remaining blood with the blood bag.
Transfusion Reactions
For all transfusion reactions:
• complete a transfusion reaction form (see Figure 8.1.2, Transfusion reaction form)
• report all transfusion reactions to the Blood Transfusion Committee.
Febrile Non-Haemolytic Transfusion Reaction

Febrile non-haemolytic transfusion reaction (FNHTR) is the most common, especially if the child has
received previous transfusions. The reaction occurs within 1–6 hours of transfusion; symptoms
include fever, chills and mid shortness of breath.
If symptoms occur, immediately stop the transfusion and confirm that an acute haemolytic reaction
is not occurring. Treat the fever with paracetamol. If the child is stable and no other symptoms are
present after 30 minutes, restart transfusion, but only after physician approval.
Allergic Transfusion Reaction (IgE Mediated)

IgE-mediated allergic reactions can be either mild or severe. Mild reactions present with urticaria
(usually associated with pruritus), with no other symptoms, and should be treated with
diphenhydramine IV/IM 1–2 mg/kg (unless SAM and/or younger than 2 years).
Severe reactions are indicated by anaphylaxis and Quincke’s oedema. Immediately stop the
transfusion if there are signs of anaphylaxis, respiratory distress or wheezing. Follow ABCD approach
and anaphylaxis protocol (see Chapter 3.2, Sepsis and Shock, for more information regarding
anaphylaxis); do not restart this transfusion.
Transfusion Reactions Related to Possible Bacterial Contamination of Blood

Symptoms of bacterial contamination generally occur within 4 hours of transfusion and include the
following:
• fever (≥39 degrees Celsius), a change of ≥2 degrees Celsius from pretransfusion value or
hypothermia (<36 degrees Celsius)
• shaking, chills, rigors
• nausea, vomiting, tachycardia
• septic shock.
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8. Procedures
Immediately stop the transfusion and follow ABCD approach to stabilise the patient. Treat fever and
administer ceftriaxone 100 mg/kg/dose IV/IM.
Severe Immediate Haemolytic Reaction (ABO or Other Incompatibility or Immune Reaction)

Signs of a severe haemolytic reaction include fever and signs of intravascular haemolysis
(haemoglobinaemia, haemoglobinuria, acute anaemia). The danger is acute renal failure due to the
free haemoglobin released in plasma and disseminated intravascular coagulation (DIC).
Management
• Immediately stop the transfusion.

• Give IV hydration of RL 20 mL/kg over 30 minutes; repeat if needed.
• Do not discard bag containing the transfused cells.
• Repeat the ABO Rh D blood group of the blood unit.
• Repeat the ABO Rh D blood group on child’s blood.
• Repeat the cross-match.
• Check haemoglobin immediately and repeat in 1 hour.
• Check for plasmatic haemoglobinaemia (pink plasma indicating free Hb in the patient’s
plasma).
• Check for haemoglobinuria with a urine dipstick (suggestive of acute haemolytic reaction).
• Monitor for signs of shock.
Nursing Priorities
Double-check the transfusion with a colleague before administration.
• Confirm the condition of the blood to be transfused.
- If not delivered in a cold chain, confirm that fewer than 30 minutes have elapsed since
preparation or since removal from the cold chain.
- Confirm that the temperature and condition of the cold chain is between 2 degrees
Celsius and 8 degrees Celsius.
- Check that the packaging and tubing are undamaged and that there are no leaks.
- Check for visible clots or debris.
- Check expiry date.
• Confirm that the information on the blood unit, the blood delivery form and the child’s
medical file match.
- Check the identity of the child.
- Check that the ABO Rh D blood groups are correct and compatible.
• Verify ABO compatibility at the bedside (see MSF Transfusion Guidelines for instructions and
equipment for this procedure).
- Attach the ABO verification card to the child’s hospital chart.
262
Monitoring
During the first 15 minutes of the infusion, stay with the child in order to detect any warning signs.
Take vital signs strictly according to the following protocol and document on the specific sheet:
• Immediately before administration
• 5 minutes after the start of the transfusion
• Then every 15 minutes for the first hour
• After 60 minutes, check every 30 minutes until completion
• At completion of transfusion
In case of abnormality, stop infusion and call medical officer immediately.
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8. Procedures
Figure 8.1.2 Transfusion reaction form

TRANSFUSION REACTION FORM
Child’s name: Age: Sex: Patient’s file No.: Date :
Patient blood group: A__ B__ AB__ O__ Rh D Positive____ Negative_____
Blood unit group: A__ B__ AB__ O__ Rh D Positive____ Negative_____
Blood unit No.:
History of previous transfusion: Yes_____ No_____ Number________
Interval since the last transfusion in months_________
Indication for transfusion:
Time the reaction occurred after the transfusion started:
Volume transfused: _______mL
Signs and symptoms:
Type of transfusion reaction:
Blood unit sent to the lab for analysis: Yes_____ No_____
Results of the lab analysis
Physician name and signature:
Nurse name and signature:
264
8.2. IV Lines
8.2. IV Lines
Obtaining an intravenous (IV) line in a sick child can be difficult. The goal is to rapidly insert the
largest peripheral venous catheter possible. A peripheral IV should be tried if peripheral veins can be
readily seen or palpated; if attempts at obtaining IV access are unsuccessful within 90 seconds in a
critically ill child, an intraosseous line should be inserted instead (see Chapter 8.3, Intraosseous
Access). Use of a tourniquet, such as a rubber band or rubber glove, will make the veins appear more
easily.
The most common kind of IV catheter used in children is the over-the needle-catheter, which is
usually 22 to 24 gauge in newborns, infants and young children; 20-gauge catheters are used for
oldest children (older than 8 years) and adolescents.
Possible sites include the arms, hands and legs; the scalp and the external jugular can also be
considered (these are considered to be peripheral IVs; see Figure 8.2.1, Paediatric IV sites).
Figure 8.2.1 Paediatric IV sites
Scalp veins
External jugular vein
Antecubital veins
Veins on dorsum
of hand
Femoral vein
Ankle veins
265
8. Procedures
IV Sites
Scalp
If the IV is inserted in the head, the parents/caregivers must be reassured that it is safe and will not
hurt the child (see Figure 8.2.2, Inserting a scalp IV). A provider experienced in the procedure should
insert the scalp IV. The child’s head must be shaved with disposable razor only, not with a scalpel
blade. Be careful not to cannulate the arteries; if you have done so inadvertently, the scalp will
blanch when the IV is flushed and the arterial pulsation will be visible in the hub of the catheter.
Injecting medicine and fluids into an artery is dangerous because of the necrosis and arterial obstruction.
Figure 8.2.2 Inserting a scalp IV
Hands and Arms

The cephalic, basilic and median cubital veins can be cannulated to provide a route for rapid drug and
fluid delivery in children (see Figure 8.2.3, Upper extremity veins).
Figure 8.2.3 Upper extremity veins
Cephalic vein
Median cubital
vein
Basilic vein
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8.2. IV Lines
The most common sites in children are the back of the hand and the median antecubital vein. If the
antecubital vein is used, secure the line with the use of an arm board, as the child will have a natural
tendency to flex his or her elbow and kink the line, leading to extravasation of fluid. An arm board
can be fabricated with a piece of rigid material covered by gauze. Do not use adhesive tape in a
circular manner (around the arm), as there is a risk of blocking circulation (tourniquet effect).
Legs and Feet

If inserting an IV in a child’s legs, the great saphenous vein at the ankle is the best because, due to its
large size and consistent anatomy, it is the most accessible vein in the lower extremities (see Figure
8.2.4, Lower extremity veins). The veins of the dorsal arch also can be used.
Figure 8.2.4 Lower extremity veins
Great saphenous vein
Dorsal venous arch
Note: Femoral, internal jugular and other central catheters are not approved in MSF settings.
General Procedures
• Wash or disinfect your hands with alcohol-based solution.
• Prepare, on a clean tray, all the material needed for the procedure: gauzes, tape, film
dressing, steri-strips, iodine povidone 10% aqueous, gloves, alcohol-based solution, IV
catheter, tourniquet, sterile lock and a 2-mL syringe with NaCl 0.9% for flushing. In addition,
prepare the infusion and infusion set or diluted IV medicine.
• Choose a vein, with a tourniquet if necessary. Once the vein is chosen, remove the
tourniquet.
• Put on non-sterile gloves and disinfect a wide area around the puncture site with povidone
iodine 10% aqueous.
• Dry with new gauze and repeat the disinfection of the area with povidone iodine 10%
aqueous.
• Tie a tourniquet around the arm or leg, maintain the skin and immobilise the arm or leg.
267
8. Procedures
• Insert the IV through the vein you have located with the bevel up until you see blood flowing
back in the hub.
• Advance a few millimetres, then remove the needle and free backflow of blood should be
seen. Dispose of the needle immediately in a sharps container.
• Remove tourniquet, then flush the catheter with the 2-mL syringe of NaCl 0.9% (never use
water).
• Disconnect the syringe and tape the IV with the sterile lock.
• Tape the catheter firmly with sterile clear adhesive plastic dressing, if available.
• Secure with arm board, if necessary, and without tourniquet effect.
• Write the date of insertion on the IV dressing.
• Connect the infusion tubing to the IV catheter and start the infusion.
Possible Complications
The most common complication is extravasation of IV fluid, with local oedema of various levels of
concern. Extravasation of caustic fluids such as calcium, epinephrine or certain antibiotics can be
responsible for extended necrosis of the tissues around the extravasation.
Other possible complications are occlusion of the catheter, local/regional thrombophlebitis and cellulitis.
The inadvertent cannulation of an artery must be avoided as this can compromise the child’s
circulation and lead to limb loss (amputation) in the most severe cases.
Monitoring and Care

Be certain to document the date of insertion on the IV dressing and also in the child’s file.
Any intravenous catheter needs to be monitored before and after any injection of medication
(including NaCl 0.9% for flushing) and at least every 2–4 hours (2 to 4 times per nurse shift). The site
must be checked for redness, pain or swelling, that could indicate an infiltration of the IV or an
infection. If you notice any undesirable effects, immediately remove the IV line and disinfect the
insertion site.
The cannula should be fixed in place according to nursing protocol.

Best practices recommend use of sterile steri-strips for cannula
fixation and application of a sterile transparent dressing over the
insertion site. If no sterile transparent dressing available, use clean,
paper-protected adhesive (type Mefix).
Always confirm that the device is in place before use: flush the device with 2 to 3 mL of NaCl 0.9%
and confirm there is no swelling, whitening, redness or pain around the device. If there is any doubt
regarding the IV’s patency, withhold IV treatment and call the medical officer.
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8.2. IV Lines
Infection Control
To help prevent infection, be sure to regularly change the IV line (including the cannula and the
medication being infused).
• Changing the tubing (IV lines): Intravenous infusion lines used for prolonged periods should
be replaced with new, sterile material at least once per 3–4 days; this includes 3-way
extension taps and infusion set or syringe pump extension tubing.
• Changing the infusion: Infusions required for prolonged periods should be changed at least
once per 24 hours; this includes hydration and maintenance fluids and medication flasks and
bottles.
• Changing the cannula: The IV cannula should be changed every 3 to 5 days, according to
clinical signs and status of the child. Write the insertion date on the dressing and in the
child’s file.
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8. Procedures
8.3. Intraosseous Access

Intraosseous (IO) needle insertion is a quick, safe technique used to gain rapid vascular access in
critical situations. It utilises the soft marrow space inside long bones as a “non-collapsible vein” and
facilitates rapid absorption into the systemic circulation of administered emergency drugs/fluids.
IO access is indicated in cases of life-threatening situations where no IV line is possible within 90

seconds or three attempts, whichever is sooner (e.g., shock, cardiorespiratory arrest, major burns,
severe dehydration, etc.). All drugs and fluids given by the IV route can be given by the IO route.
Contraindications
• Fractured bone proximal to site of insertion (e.g., use humerus in cases of pelvic fracture)
• Recent IO needle in the same limb within last 24 hours
• Recent surgery near site of insertion
• Overlying infection at site of insertion (in case of burns, use non-burned limb if possible)
Pain
• The majority of children undergoing IO insertion will be unconscious, so pain will not be an
issue.
• Conscious children will feel minimal pain on insertion.
• In cases of significant pain on infusion, numb vessels by injecting 0.5 mL/kg 2% lidocaine IO
slowly (over 1 minute); allow 30 seconds for the lidocaine to take effect. Do not exceed 3 mL/kg.
Equipment
• EZ-IO gun and needles for motorised insertion (preferred method; see Figure 8.3.1,
Intraosseus gun).
Figure 8.3.1 Intraosseous gun
270
• If an IO gun is not available, use an intraosseous needle with trocar (18G for children, Figure
8.3.2, Manual trocar; see below for manual insertion).
Figure 8.3.2 Manual trocar
• EZ-IO Three-Needle Set: Length and colour are the only differences between these catheters
(see Figure 8.3.3, EZ-IO needle set).
Figure 8.3.3. EZ-IO needle set
Pink: For children 3 to 39 kg, EZ-IO PD 15-mm needle

Blue: For children >40kg,EZ-IO AD 25-mm needle
Yellow is not appropriate for paediatric use.
• Povidone iodine
• 2-mL, 5-mL, 10-mL and 20-mL syringes
• Flushed drip tubing, 500 mL of NaCl 0.9% or Ringer’s Lactate and 3-way tap connector (if
possible).
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8. Procedures
Sites for Insertion

Antero-medial surface of the proximal tibia: This is the preferred site, as it is broad and flat with thin
overlying skin (see Figure 8.3.4, Insertion into the proximal tibia). The insertion site on a child should
be 1–2 cm below and 2 cm medial to the tibial tuberosity (see Figure 8.3.5, Proximal tibial anatomy,
and Figure 8.3.6, Tibial tuberosity).
Figure 8.3.4 Insertion into the proximal tibia
Figure 8.3.5 Proximal tibia anatomy
Femur
Muscle
Patella
Tibia
Fibula Patellar
ligament
Tibial
tuberosity
272
Figure 8.3.6 Tibial tuberosity
Distal tibia: For use in children older than 3 years, the insertion site should be 3 cm above the medial
malleolus (see Figure 8.3.7, Distal tibia site).
Figure 8.3.7 Distal tibia site
Distal femur: The lateral surface of the distal femur is also an option.
Procedure
For motorised insertion

Note: Never place more than one IO access in the same bone.
• Once the site for insertion has been identified, hold or restrain the patient’s limb.
• Put on non-sterile gloves and clean and disinfect the skin with povidone iodine 10% in a
circular, wide area from centre to periphery.
• If the patient is conscious, provide local anaesthesia for the skin with 1% lidocaine.
• Install the proper needle on the IO gun.
• Drill smoothly at a 90° angle to the bone. Do not force.
• Remove the gun and the mandarin.
• If needed, take a blood sample prior to line connection.
• Set the purged IV line connected to a syringe (see Figure 8.3.8, Syringe flush with needle in
place).
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8. Procedures
Figure 8.3.8 Syringe flush with needle in place
In MSF contexts, IO access is mostly required in children with altered consciousness (V, P or U on
AVPU scale). Very rarely, alert children may need emergency IO, and flushes will be painful.
In these cases (and these cases alone), 1% or 2% intravenous, preservative-free lidocaine, without
adrenaline, has been shown to be effective in limiting or alleviating IO infusion pain and should be
given IO prior to flush.
The duration of the anaesthetic effect will vary among patients, and repeat doses may be necessary
to maintain the necessary effect. Additional surveillance for such patients is recommended.
For manual insertion

(See Figure 8.3.9, Manual IO insertion.)
• Insert needle at 90° angle to skin.
• Advance with a screwing/drilling motion (to-and-fro twisting plus adding pressure) through
the subcutaneous tissues until needle touches bone. Reduce pressure and continue to
advance needle until a “give” is felt as the hard cortex is penetrated. Stop immediately once
cortex is penetrated.
• Remove trocar.
• Attach a 2-mL syringe to needle and attempt to aspirate bone marrow in order to confirm a
good position. Aspiration is not always possible (especially in small children and shocked
patients). Sustained erect posture of needle and easy flushing of saline without visible
extravasation also confirm positioning.
• Flush needle hard and rapidly with a bolus of NaCl 0.9%. Use 5–10 mL in children. No flush =
no flow, and access has not been obtained.
274
Figure 8.3.9 Manual IO insertion
Apply lidocaine IO needle manual insertion
Manual needle insertion cross section Intraosseus IV line
After insertion of the needle

• Attach IV drip bag and flushed tubing.
• Secure IO to skin to avoid accidental displacement.
• Monitor for extravasation into subcutaneous tissue or muscle, compartment syndrome and
needle displacement.
• Verify needle position and state of limb every 15 minutes for first hour, then every 2–4 hours.
• Establish more definitive access when the patient is stable.
• Needle can be kept and used for a maximum of 24 hours.
• EZ-O removal: Continuously rotate the syringe clockwise while maintaining a 90° angle.
Potential complications
• Failure requiring removal
• Extravasation resulting in compartment syndrome
• Skin necrosis (rare)
• Infection (rare)
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8. Procedures
Monitoring
• Local pain, colour, pulse, paresthesias and paralysis (compartment syndrome)
• Liquid diffusion in the subcutaneous tissues
• Local or regional inflammation
• Breathing: RR and SpO2
• Circulation: HR, CRT, colour and temperature of hands and feet, pulses
• Remove IO as soon as an IV line can be secured adequately.
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8.4. Finger Prick for Capillary Blood
8.4. Finger Prick for Capillary Blood
Step 1: Collect supplies. Always Step 2: Position hand palm-side up. Step 3: Apply intermittent pressure
maintain proper precautions. Choose whichever finger is least to the finger to help the blood to
calloused. flow.
Step 4: Clean the fingertip with Step 5: Hold the finger and firmly Step 6: Firmly press the lancet to
alcohol. Start in the middle and place a new sterile lancet off-centre puncture the fingertip.
work outward to prevent on the fingertip.
contaminating the area.
Allow the area to dry.
Step 7: Wipe away the first drop of Step 8: Collect the specimen. Step 9: Apply a gauze pad or
blood with a sterile gauze pad or Blood may flow best if the finger is cotton ball to the puncture site
cotton ball. held lower than the elbow. until the bleeding stops.
Step 10: Properly dispose of all

contaminated supplies.
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8. Procedures
8.5. Chest Tube Placement

Insertion of a chest tube is a procedure that can only be performed by a doctor familiar with the
procedure in a field where a chest X-ray can be obtained to confirm correct tube placement.
Insertion of Chest Tube by Blunt Dissection Technique

Preparation for chest tube placement is the same as in thoracentesis.
• Ask a nurse to assist with the procedure.
• Have sharps container available.
• Obtain IV access and provide O2.
• Child should be NPO prior to the procedure.
• Explain the procedure to the patient and caregiver; obtain written consent if the child is
going to the operating room or receiving anaesthesia.
• The child should be lying down on the bed, with the head elevated 30º, if possible.
• Apply aseptic technique (sterile gloves, mask, cap).
• Disinfect the area with povidone iodine 10% in a large, circular motion from centre to
periphery.
• Give the child ketamine for sedation (see Chapter 7.10, Ketamine).
• Numb the area with lidocaine 1% (without epinephrine); inject 1–2 mL from a 2- or 5-mL
syringe with a 25-gauge needle.
Procedure
• A chest tube should be inserted in the mid-axillary line in the fifth intercostal space (at the
level of the nipple) on the superior aspect of the 6th rib (see Figure 8.5.1, Chest tube
placement).
278
Figure 8.5.1 Chest tube placement
• Use a scalpel to make a 1- to 2-cm incision through the skin and subcutaneous tissue along
the line of the intercostal space, just above the rib below (to avoid damaging the vessels that
lie under the lower edge of each rib; see Figure 8.5.2, Incision site).
Figure 8.5.2 Incision site
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8. Procedures
Figure 8.5.3 Close-up of incision
• Insert a Kelly clamp (see Figure 8.5.3, Close-up of incision).

• Push through the intercostal muscle superior to the rib with the Kelly clamp and enter the
pleural space; air or fluid may rush out.
• Spread the clamp to widen the area to allow for the chest tube.
• Remove clamp.
• Insert a gloved finger into the tract and ensure correct location.
• Using the Kelly clamp (forceps) attached to the chest tube as a guide, insert the chest tube
into the pleural space.
- If the tube is for air drainage, push the tube up and towards the head (turning the clamp
so that the curve is upward will assist with this guidance).
- If the tube is for fluid drainage, guide the tube towards the back and down (turning the
clamp so that the curve is down will assist with this guidance).
• Advance chest tube until all ports are within the pleural space.
• Suture tube to chest wall (ideally with sutures; anesthetise skin first and see below).
• Connect to drainage bag and open it. A single-use anti-reflux valve is used to allow the
escape of air in one direction (see Figure 8.5.4, Anti-reflux valve, and Figure 8.5.5, Image of
connected drainage container).
• Apply dressing around wound.
Figure 8.5.4 Anti-reflux valve
280
Figure 8.5.5 Image of connected drainage container
Sutures
Use non-reabsorbable suture material. Suture the drain to one of the edges of the wound and make
a knot to ensure that the connection is airtight (A). Then crisscross the suture material along the
drain and fasten with a knot (B). Attach a second suture to the skin and around the drain, leaving it
long and knotted (C). The additional suture is used to close the hole when the tube is pulled out. (See
Figure 8.5.6, Suturing.)
Figure 8.5.6 Suturing
A B C
Removal of the Drain

When the drainage is complete:
• Cut the knot of the additional suture and the knot fixed to the drain (see Figure 8.5.6).
• Make a bow with the additional suture.
• Ask the patient to hold his or her breath while an assistant removes the drain.
• Tie the knot and the additional suture will close the puncture wound.
Complications
• Improper positioning (tube will not drain): Obtain a chest X-ray after insertion to ensure
correct positioning.
• Pneumothorax
• Bleeding including haemothorax
• Infection
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8. Procedures
8.6. Decompression of Tension Pneumothorax

Tension pneumothorax is the life-threatening accumulation of air in the pleural cavity. It occurs in
cases of penetrating or non-penetrating thoracic trauma, including blast injuries or following a
traumatic delivery or resuscitation.
Clinical features
• Asymmetrical chest movement
• Respiratory distress and desaturation
• Tachycardia
• Hypotension
• Unilateral absence of breath sounds
• Distended neck veins
Treatment is immediate decompression, which should be performed by a physician.
Equipment
• Sterile gloves
• Povidone iodine 10% (disinfect with povidone 10% in a large circular motion from centre to
periphery)
• IV catheter appropriate for age (18–20G if child younger than 12 years)
• 2- and 5-mL syringes
Procedure
• Insert a large intravenous cannula with needle into the second intercostal space just above
the upper edge (in order to avoid vascular injury) of the third rib in the mid-clavicular line
(see Figure 8.6.1, Cannula placement).
• Attach a saline-filled syringe and attempt to aspirate as the cannula is advanced.
• The diagnosis is confirmed by a gush of air. The ability to easily aspirate air confirms the
diagnosis.
• Bubbles will be seen in the saline when the needle enters the pneumothorax.
282
8.6. Decompression of Tension Pneumothorax
Figure 8.6.1 Cannula placement
X = Second intercostal space, midclavicular line

C = Fifth intercostal space, anterior axillary line
• A chest drain/tube should be placed as soon as possible in most cases, if appropriately

trained medical personnel and material are available (see Chapter 8.5, Chest Tube
Placement).
• If not, patient should be transferred to an appropriate facility.
• In the event of failure to aspirate air, withdraw the needle but remember the procedure
itself may have caused a pneumothorax.
Figure 8.6.2 Child with pneumothorax decompression needle in place with oxygen mask
283
8. Procedures
8.7. Pleural Puncture

Pleural puncture (thoracentesis) is used to drain fluid from the pleural space; it can also be used to
collect pleural fluid for diagnostic purposes.
Procedure
• Ensure IV access.
• Provide oxygen and monitor SpO2.
• Child must be NPO after midnight the night before the procedure, as they may go to the
operating room.
• Pre-medicate with paracetamol IV 15 mg/kg (maximum dose 1 g).
• Explain the procedure to the child and family in simple terms that they understand.
• Clean the area with povidone iodine 10%.
• Have the child sit leaning forward with hands on the knees, or leaning supported by a table.
• Numb the insertion area with lidocaine 1% (without epinephrine): inject 1–2 mL from a 3-mL
syringe with a 25-gauge needle.
• Place a long 18–22 gauge needle on a large syringe.
• Insert the needle in the posterior axillary line in the eighth intercostal space (see Figure 8.7.1,
Needle insertion site).
Figure 8.7.1 Needle insertion site
• Puncture along the superior edge of the inferior rib (see Figure 8.7.2, Close-up of insertion site).
• Gently advance the needle perpendicular to the surface, while aspirating the syringe, until
fluid is collected. If the puncture fails, remove the needle (while aspirating continuously) and
start again one interspace up or down (do not attempt more than twice).
284
8.7. Pleural Puncture
Figure 8.7.2 Close-up of insertion site
• If aspirating for diagnostic purposes, confirm the presence of pus or sero-sanguinous or

serous fluid.
• 10 ml/kg can be aspirated slowly from a child, but the pus tends to re-accumulate unless a
chest tube is inserted (see Chapter 8.5, Chest Tube Placement).
Risks of thoracentesis
• Bleeding
• Laceration of lung or other underlying tissues
• Potential for need to remove additional fluid or air at a later time
285
8. Procedures
8.8. Lumbar Puncture

Lumbar puncture (LP) is used to collect cerebrospinal fluid (CSF) in patients with suspected meningitis
or encephalitis for testing. Only clinicians who are familiar with the procedure should perform a
lumbar puncture, with the assistance of a nurse.
Contraindications
• Obvious signs of increased intracranial pressure (other than bulging fontanelle): decerebrate
or decorticate posturing, absent doll’s eyes reflex, abnormal respiratory pattern, unequal
pupil size or dilatation of pupils
• Focal neurologic signs
• Focal seizures or seizures within the last 30 minutes
• Bradycardia
• Severe cardiopulmonary compromise that could possibly require prompt resuscitation
measures (shock)
• Obvious bleeding disorder
• Skin infection over the site for LP
If a child has suspicion of bacterial meningitis but any of the above, treat with antibiotics and perform
an LP in 2–3 days when the child's condition stabilises and the child has no other contraindications.
Preparation and Positioning

LP is a relatively simple and safe procedure, but it is frightening for most children and their families.
Be sure to explain the procedure and urgent indications to the caregiver and provide reassurance to
both the child and family.
The most important determinant of whether the lumbar puncture will be successful is how well the
child is held, so ensure that the child is immobilised as shown. Watch the child carefully and ensure
that they do not stop breathing.
An older child can be held either lying down (Figure 8.8.1, Holding an older child lying down) or
sitting up (Figure 8.8.2, Holding an older child sitting up) so that the physician can visualise an
imaginary line between the iliac crests would cross the spine to aid in positioning the needle at the L4
and L5 vertebrae.
286
Figure 8.8.1 Holding an older child lying down
Figure 8.8.2 Holding an older child sitting up
Equipment
• Spinal needle for LP, 22 G (0.7 x 40 mm)
• Povidone iodine 10%, solution, 200-mL bottle
• Sterile gloves
• Surgical mask
• 4 x 4 sterile compresses
• Lidocaine 1% (without epinephrine)
• Tubes for collection of CSF (non-sterile red-top blood tubes can be used if you are not
obtaining a CSF culture)
287
8. Procedures
Procedure
Wash and disinfect your hands with an alcohol-based solution. Put on sterile gloves and take
standard precautions.
Disinfect the insertion site with povidone 10% in a large circular motion from centre to periphery. At
L3–L5, carefully palpate the intravertebral space.
Anaesthesia
Oral sucrose for non-nutritive suction offered to infants in a syringe is safe and effective.
Local anaesthesia with 1% lidocaine should be used in children older than 3 months; anesthetise the
skin and subcutaneous tissues using 1–2 mL from a 3-mL syringe with a 25-gauge needle to raise a
bubble over the interspace and then to infiltrate the deeper subcutaneous tissue. If the LP is planned,
use EMLA if available (see Chapter 4, Pain Management).
Needle Insertion and CSF collection

• An imaginary line that connects the two posterior-superior iliac crests intersects the spine at
approximately the fourth lumbar vertebra (this landmark helps to locate the L3-L4 and L4-L5
interspaces).
• Hold the needle in your dominant hand.
• Advance the needle slowly through the spinous ligaments, aiming slightly towards the
umbilicus (see Figure 8.8.3, Needle insertion).
Figure 8.8.3 Needle insertion
288
• Once a slight “pop” is felt, remove the stylet slowly.

• Place the stylet on a sterile surface for later reinsertion.
• Let CSF drip out slowly and collect 1–2 mL, according to laboratory capabilities.
• If no CSF comes out, rotate the needle slowly; if there still is no CSF, reinsert the stylet and
advance very slowly (1 mm) and repeat the procedure.
• Note the pressure, colour and clarity of the CSF flow.
• Once CSF has been collected, replace the stylet prior to removing the needle.
• Apply compression to the area and apply a small protective dressing.
Monitoring
Monitor the child for 1–3 hours post-procedure. Vital signs, including AVPU, should be taken
immediately post-procedure and then as normal, 4x/day. If any signs are abnormal, inform the
medical officer immediately.
Ensure the sterile dressing is in place and clean and intact. The dressing should stay on until it falls off.
The child can remain in a position of comfort. He or she should not be too active (no running,
jumping, dancing, excitement), but movement is not limited. Advise the parent(s) to call the
nurse/medical officer for help if any of the following occur:
• fever
• abnormal consciousness/behaviour
• headache
• nausea/vomiting.
Complications of lumbar puncture

• Most common is headache, which can be minimised by having the child lie down after the
procedure.
• Cerebral herniation is the most serious complication of LP. This can occur when LP is
performed in a patient with increased intracranial pressure (ICP). Most cases occur within the
first 12 hours after LP.
• Infection: Meningitis can be induced if the LP is performed through a soft tissue infection at
the site of puncture or if unsterile equipment is used.
289
8. Procedures
8.9. Paracentesis
Paracentesis is used for the removal of fluid from the abdomen, either for diagnostic (sampling of
ascitic fluid to determine presence of internal bleeding following blunt abdominal trauma or
identification of infectious organism in spontaneous bacterial peritonitis) or therapeutic (removal of
the ascitic fluid from tense ascites that is causing shortness of breath that is not improved by diuretic
use) purposes. The procedure should only be performed by an experienced clinician with assistance
from a nurse.
Contraindications
• Intestinal perforation
• Infection of the abdominal wall
• Bleeding
• Recent intestinal tract surgery (<1 month prior)
Equipment
• Sterile gloves
• Povidone iodine 10%
• 23-gauge and 21-gauge needles with syringes
• Local anaesthetic (1% lidocaine)
• Large-bore (18-gauge) catheter
• Sterile container for fluid collection
Patient preparation
• Explain the need for and specifics of the procedure to the child and his or her parents or
caregiver.
• Position the child on his or her back on a treatment table.
Technique
• Practice rigorous asepsis: disinfect the abdomen with povidone iodine 10% in a large circular
motion from centre to periphery.
• Inject local anaesthetic, infiltrating the skin first and then penetrating into deeper layers.
• Perform a single puncture, perpendicular to the abdomen on a line joining the umbilicus and
the anterior superior iliac spine (usually on the left, to avoid perforation of the cecum, but
insert the needle on the right in case of massive splenomegaly).
• Insert the needle at a point mid-way between the umbilicus and the anterior superior iliac
spine (see Figure 8.9.1, Needle insertion).
290
8.9. Paracentesis
It is safe to remove 50–70 mL/kg over 1–2 hours, but only remove as much as needed to correct the
child’s shortness of breath. Monitor vital signs during fluid removal.
Risks
• Pneumoperitoenum
• Perforation of the intestine, liver or spleen
• Bleeding and infection
291
8. Procedures
8.10. Urine Collection

Urine analysis (either gross output, dipstick or laboratory testing) is used for the following:
• the diagnosis of urinary tract infection
• the monitoring of hydration and urine output in case of shock or sepsis
• detection/measurement of blood or protein in the urine as a sign of kidney disease
• the diagnosis of malarial complications
• evaluation of hyperbilirubinaemia and liver disease.
Methods
There are four main methods of urine collection in children: urine bag, voided sample, urinary
catheterisation and suprapubic aspiration. Catheterisation and aspiration are indicated in specific
cases, such as the need for a urine culture.
Urine Bag
The urine bag is the safest and easiest method to collect urine or measure urine output in children
(bags for both males and females exist: MSF codes SCTDBAGU3PB and SCTDBAGU3PG, respectively).
It can be placed on the child with an adhesive to collect urine for a dipstick. However, use of a urine
bag can be problematic in children with diarrhoea and children with fragile skin, such as in cases of
malnutrition.
Clean Voided Sample

If a child is conscious and toilet trained, he or she may void in a clean container.
Urinary Catheterisation
• For all children undergoing catheterisation, practice asepsis and wear sterile gloves.
• Restrain the child in the supine and frog-leg position.
• Clean the anterior urethra with a povidone scrub 4% or 7.5%, and then rinse and disinfect
with povidone 10%.
• A sterile lubricant/anaesthetic jelly is applied to the end of an appropriately sized catheter (5
French for children younger than 6 months, 8 French for those between 6 months and 10
years of age).
Boys
• The foreskin of the glans is retracted gently to permit complete visualisation of the urethral
meatus if the boy is uncircumcised. The foreskin must be repositioned after the procedure to
prevent paraphimosis.
• The urethra is straightened by using the non-dominant hand to hold the penis perpendicular
to the lower abdomen (see Figure 8.10.1, Catheter insertion in boys).
292
Figure 8.10.1 Catheter insertion in boys
• Apply and maintain gentle traction on the penis as you advance the catheter.
• Insert the catheter with your dominant hand until urine returns.
• Do not force the catheter.
• For monitoring and nursing care, please refer to nursing care guidelines.
Girls
• The urethra may be difficult to visualise in girls. An assistant often is needed to retract the
labia major (see Figure 8.10.2, Visualisation of the urethra in girls).
Figure 8.10.2 Visualisation of the urethra in girls
• Redundant tissue around the introitus can sometimes obscure the urethral meatus.
• Swab the area from front to back with povidone iodine solution to pool in the meatus,
making it easier to identify.
• Insert the catheter into the urethral meatus until urine returns (see Figure 8.10.3, Correctly
placed catheter).
293
8. Procedures
Figure 8.10.3 Correctly placed catheter

Balloon
Belly button
Urethra
Bladder
Catheter in
urethra
Vagina
Rectum
• If catheter is inadvertently placed in the vagina, leave it in place to serve as a landmark for
subsequent attempts.
• When the catheter is in the bladder, urine will flow (note that it can be slow).
• If the catheter is to remain in place (in case of monitoring urine output, in which case it
should not stay in place for longer than 24 hours), inflate the “ballonet” with EPPI.
• For monitoring and nursing care, please refer to nursing care guidelines.
• Do not make more than two attempts to place the catheter.
Suprapubic Aspiration
• Suprapubic bladder aspiration is a safe and effective method for obtaining urine specimens in
infants and children younger than 2 years, but it should only be performed by an experienced
clinician.
• Restrain the child in the supine and frog-leg position.
• Wear sterile gloves.
• The site for needle insertion, in the midline approximately 1–2 cm above the pubic symphysis
(see Figure 8.10.4, Visualisation of needle insertion site), is widely prepared with rigorous
asepsis: disinfect with povidone iodine 10% in a large circular motion from centre to
periphery.
• The urethral opening should be occluded just before needle insertion because the procedure
will stimulate urination in many children.
294
Figure 8.10.4 Visualisation of needle insertion site
Belly button
Bladder
Pubic symphysis
• A 3-cm, 22-gauge needle attached to a 3- or 5-mL syringe is inserted 1 or 2 cm above the

pubic symphysis. The needle should be angled 10 to 20 degrees towards the head (see Figure
8.10.5, Needle insertion). Advance the needle while pulling the plunger of the syringe,
creating suction in the syringe. The needle should be partially withdrawn and redirected at
an angle more perpendicular to the frontal plane if the initial attempt is unsuccessful.
10o – 20o
295
8. Procedures
8.11. Paediatric Perfusor Use

Figure 8.11.1 How to use a paediatric perfusor
1. Clamp the paediatric 2. Fill with infusion or infusion mix.

3. Add the drug.
perfusor.
4. Confirm the prescription;

8. Once the body after adding drug, fill in a label
of the perfusor is and stick this to perfusion set.
empty again, the
administration of
the drug has been
terminated. Drug and dilution
Starting time
Document this in Finishing time
the chart. Speed: drops/min
5. Rinse the tubing.

7. Once the perfusion body is empty, add
15mL of NaCl 0.9% to flush the tube. 6. Connect the perfusor to the child’s IV
Keep the same perfusion speed catheter and set the desired infusion speed.
(drops/min).
Figure 8.11.2 How to use a paediatric perfusor: e.g. phenobarbital loading dose for a child of 8kg
2. Fill with 14 mL of NaCl 0.9%. 3. Add 6 mL of diluted phenobarbital

1. Clamp the perfusor.
solution (concentration of 20 mg/mL).
8. Once the body is 4. Confirm prescription and

empty again, the dosage are identical; fill in and
drug administration stick a label to the perfusor
is finished. with start and end time and
drop rate (speed).
Document this in
the patient chart.
5. Flush the tubes.
7. Once the body of the perfusor is empty,

add 15 mL of NaCl 0.9% to flush the tubes. 6. Connect the perfusor to the child and set the
Keep the same perfusion speed as for the drop speed at 60 drops/min (1 drop/second).
drug (60 drops/min).
296
9. Appendix
9.1. Definitions .................................................................................................................................... 298
9.2. WHO Growth Charts ..................................................................................................................... 306
9.3. Developmental Milestones .......................................................................................................... 310
297
9. Appendix
9.1. Definitions
• Abdominal breathing, characterised by thoracoabdominal dissociation (in which the chest
collapses and the abdomen protrudes on inspiration), is a sign of respiratory muscle fatigue
seen in young children or in patients with poor muscle tone.
• Abnormal breath sounds: see Breath sounds
• Abnormal extension or flexion of the arms and legs may occur spontaneously or in response
to stimulation.
• Accessory muscle use is the use of accessory muscles (such as supraclavicular, intercostal
and/or substernal groups) to increase air entry in children with inadequate oxygenation or
ventilation.
• Airway obstruction is a blockage of respiration in the airway. It can be broadly classified into
being either in the upper airway or lower airway and can be partial or total. Total airway
obstruction is a life-threatening emergency
• Airway sounds are the sounds produced when a patient breathes. Abnormal airway sounds
that can be heard without a stethoscope are often an indication of respiratory distress; these
include stridor, snoring, grunting and wheezing.
• Altered consciousness is any condition that is significantly different from a normal waking
state and is usually temporary. Coma refers to the most profound level of unconsciousness.
• Anaemia is a decrease in number of red blood cells (RBCs) or a less-than-normal quantity of
haemoglobin in the blood.
• Anaphylaxis is an acute, life-threatening allergic reaction that may involve hives, airway
oedema, wheezing and shock.
• Anisocoria is the condition in which the pupils are not the same size. It suggests a brainstem
insult or a supratentorial lesion that is causing compression of the oculomotor nerve or
nucleus within the brainstem.
• Apnoea is the transient absence of breathing.
• Arthritis is a joint disorder that involves inflammation of one or more joints. Children can
have acute arthritis from infections (Septic arthritis) or inflammation (rheumatic fever).
• Ataxic respirations are breaths of irregular depth interrupted irregularly by periods of
apnoea, and they suggest central nervous system infection, injury or drug-induced
depression.
• Aura is a perceptual disturbance experienced by some with migraine or seizures before
either the headache or seizure begins. It often manifests as the perception of a strange light,
an unpleasant smell or confusing thoughts or experiences.
• Auscultation is the listening to the patient’s breathing with a stethoscope. It provides
important information regarding the aetiology of respiratory distress and localisation of the
underlying condition. Every effort should be made to quiet the infant or child during
auscultation.
• Bacterial tracheitis is a bacterial infection of the subglottic trachea, resulting in a thick,
purulent exudate that causes symptoms of upper airway obstruction. The bronchi and lungs
are typically involved, as well (i.e., bacterial tracheobronchitis).
298
9.1. Definitions
• Bilaterally fixed pupils is a condition in which neither of the patient’s pupils react to light. It
is seen with brainstem insults disrupting both the sympathetic and parasympathetic control
of the eyes.
• Blanching rash is a rash that disappears (turns white, or blanches) when you apply pressure
to it. Erythema is a type of blanching rash.
• Bowel and bladder incontinence is the inability to control one’s bowel or bladder
movements.
• Brain death criteria include coma, apnoea and absent brainstem reflexes. A diagnosis of
brain death specifically implies no chance of recovery and is synonymous with death in most
countries. Age-specific diagnostic criteria exist.
• Brainstem reflexes include pupillary responses to light, extraocular movements and corneal
reflexes.
• Breath sounds (respiratory sounds or lung sounds) are specific sounds generated by the
movement of air through the respiratory system. These may be easily audible or identified
through auscultation of the respiratory system through the lung fields with a stethoscope.
These include normal breath sounds and adventitious or ‘added’ sounds such as crackles,
wheezes, pleural friction rubs and stridor. See Table 9.1.1, Adventitious breath sounds.
Table 9.1.1 Adventitious breath sounds

Name Continuous/ Frequency/ Inspiratory/ Quality Associated
discontinuous pitch expiratory conditions
Wheeze (can be Continuous High pitched, Normally Whistling/ Diffuse wheezing:
heard without a with higher- expiratory, sibilant, asthma,
stethoscope pitched can be musical, bronchiolitis
when severe) wheezes inspiratory if hissing or shrill
indicative of very severe Unilateral wheezing:
more severe foreign body in the
obstruction lower airway
Rhonchi Continuous Harsh, low Both Snoring quality Airway obstruction
pitched from secretions,
oedema or
inflammation
Stridor Continuous High Inspiratory Whistling or Epiglottitis, croup,
barking foreign body
Inspiratory Intermittent High Inspiratory Whoop Whooping cough
gasp/whoop
Crackles/ Discontinuous High and soft Inspiratory, Cracking, Coarse crackles:
crepitations or and brief (fine) or low especially clicking, pneumonia
rales (coarse), non- when the rattling
musical child is crying Fine crackles:
and takes a pulmonary oedema
deep breath
in
• Bronchitis is a respiratory disease characterised by cough and purulent sputum production.

As it a disease of adults, mainly smokers, it will not be discussed in this book.
299
9. Appendix
• Brudzinski's neck sign is the appearance of involuntary lifting of the legs when lifting a
patient’s head off the couch, with the patient lying supine.
• Capillary refill time (CRT) is defined as the time taken for colour to return to an external
capillary bed after pressure is applied to cause blanching. It can be measured by holding a
hand higher than heart level, pressing the soft pad of a finger until it turns white and taking
note of the time needed for the colour to return once pressure is released.
CRT < 2 sec = normal; CRT 2-3 sec = (mildly) abnormal; CRT > 3 = sign of shock
• Carditis is the inflammation of the heart or its surroundings. It is usually studied and treated
by specifying it as one of the following:
- Pericarditis is the inflammation of the pericardium.
- Myocarditis is the inflammation of the heart muscle.
- Endocarditis is the inflammation of the endocardium.
• Catatonia is an altered state of consciousness marked by lack of response to stimulus, but
distinguished from coma by the preserved ability to maintain trunk and limb postures, even
the ability to sit or stand. See also Psychiatric unresponsiveness.
• Chest indrawing: when the chest wall goes in when the patient breathes in.
• Chorea, choreoathetosis or chorea minor (see Sydenham’s chorea) are abnormal,
involuntary movements. These movements are brief, semidirected and irregular (in that they
are not repetitive or rhythmic, but appear to flow from one muscle to the next). These
'dance-like' movements of chorea often occur with athetosis, which adds twisting and
writhing movements. Walking may become difficult and include odd postures and leg
movements.
• Coma is a state of ‘unarousable unresponsiveness,’ and is the most profound degree to
which arousal and consciousness are impaired.
• Coma sequelae are the complications that arise from coma. As coma is a transient state,
patients either recover, die or evolve into a more permanent state of impaired
consciousness.
• Complete paralysis is the inability to move or speak, while still retaining awareness.
Voluntary vertical eye movements and blinking may be retained. This condition is often
called the ‘locked-in’ state. Patients with acute lesions of the brainstem, particularly the
pons, may experience complete paralysis. Other causes of severe motor paralysis (e.g.,
Guillain-Barre syndrome, botulism) may also cause a similar condition.
• Conditions mistaken for coma are those conditions in which the child is unable to respond
voluntarily, despite maintaining some degree of arousal and awareness.
• Conjugate eye movement is the ability of the eyes to bilaterally fixate on a single object.
Abnormal eye movement, such as nystagmus (uncontrolled eye movement), suggests
seizure.
300
9.1. Definitions
• Consolability is the ability of an infant to be soothed or distracted by a parent or caregiver.

Crying is a non-specific symptom that can indicate anxiety or hunger, rather than severe
discomfort, and inconsolability is often a sign of a serious condition.
• Cough is a symptom that may be due to infection, inflammation, bronchospasm and/or
obstruction. The quality and duration of the cough provide clues to aetiology. A
barky/barking cough indicates subglottic tracheal obstruction, most commonly due to
laryngotracheitis. A staccato cough suggests pneumonia caused by Chlamydia or
Mycoplasma. A dry, tight cough may occur in patients with wheezing due to asthma or
bronchiolitis, whereas a loose, wet cough may indicate tracheal secretions or bacterial
pneumonia.
• Croup: See Laryngotracheitis and Laryngotracheobronchitis (LTB).
• Cyanosis is the bluish colouring on the skin, caused by inadequate oxygenation of the blood.
Peripheral cyanosis (cold and blue hands and feet) can be either normal or a sign of poor
circulation. Central cyanosis (cyanosis of the trunk) or blue tongue is always abnormal.
• Cystitis is an afebrile infection of the bladder in a child older than 2 years of age.
• Decerebrate posturing includes extension and internal rotation of the arms and legs and
implies brainstem involvement from a compressive or destructive process.
• Decorticate posturing produces adduction and flexion at the elbows, wrists and fingers, with
leg extension and rotation. Compared with decerebrate posturing, decorticate posturing
implies a more rostral and potentially less dire insult.
• Decreased breath sounds are any breath sounds that are less than normal. They are noted in
localised lung fields are the result of lower airways processes, such as pneumonia, pleural
effusion or atelectasis.
• Delirium is a reversible disturbance of consciousness with reduced ability to focus, sustain or
shift attention. Patients show both hyperactivity and diminished sleep. Confusion,
excitement, hallucinations and irritability are common. Delirium is caused by a subset of
conditions that can lead to coma, including medical conditions, substance intoxications and
medication side effects.
• Endocarditis: See carditis.
• Epiglottitis (supraglottitis) is an inflammation of the superior portion of the larynx and
supraglottic area, mostly of bacterial origin.
• Fundoscopy is the examination of the back of the eye with an ophthalmoscope.
• General appearance of a child is a characteristic of the initial impression of the child,
specifically referring to how sick is the child appears.
• Grunting is a sound at the end of expiration and is a sign of moderate to severe respiratory
distress in young infants and children with lower airway disease, such as pneumonia,
atelectasis or pulmonary oedema.
• Head lag is the delay in head movement when you pull an infant from a lying to a sitting
position (the head lags behind the trunk).
• Interactiveness is the level at which an infant or child socialises with his or her environment.
A child who will reach for a toy or exhibit developmentally appropriate stranger anxiety is
less worrisome than one who does not respond to a caregiver or appropriately resist
examination.
• Jaundice: See Scleral icterus.
301
9. Appendix
• Kernig’s sign is positive when the thigh is bent at the hip and knee at 90-degree angles, and
subsequent extension in the knee is painful (leading to resistance). This may indicate
subarachnoid haemorrhage or meningitis.
• Kussmaul respirations are deep, regular, sighing breaths that may be rapid, slow or normal
in rate and suggest metabolic acidosis, particularly diabetic ketoacidosis.
• Laryngitis is an inflammation of the larynx and manifests itself as hoarseness. It usually
occurs in older children and adults and, similar to laryngotracheitis, is frequently caused by a
viral infection.
• Laryngotracheitis a mostly viral inflammation of the larynx, trachea and subglottic area,
usually presenting with a typical barking cough and inspiratory stridor at rest.
• Laryngotracheobronchitis (LTB) is used in this text to refer to the simultaneous presence of
laryngotracheitis and wheezing. Inflammation of the larynx and trachea extends into the
bronchi, resulting in lower airway signs and often a more-severe illness than laryngotracheitis
alone.
• Lethargy, obtundation and stupor refer to states in which the child’s level of consciousness
is depressed. The child will have difficulty paying attention during an examination or fall
asleep when not stimulated, and will respond poorly (if at all) to questions and commands.
As these terms are imprecise, in clinical situations it is more useful to describe the patient's
responses to specific stimuli or use AVPU (see Chapter 1.1, Vital Signs).
• Level of consciousness refers to a child’s responsiveness. Anything other than awake and
alert should be considered an altered level of consciousness. Evaluation of level of
consciousness often uses the AVPU scale, which stands for Alert and awake, responds to
Verbal stimuli, responds to Painful stimuli or Unresponsive.
• Look/gaze refers to the ability of an infant or child to focus on people or objects in the
environment. An unresponsive or unfocused stare suggests an altered mental status.
• Lung sounds: See Breath sounds.
• Malarial retinopathy is damage to retina as a result of cerebral malaria (see Chapter 3.12,
Malaria).
• Meningeal signs, also known as meningism, are the triad of nuchal rigidity (neck stiffness),
photophobia (intolerance of bright light) and headache. It is a sign of irritation of the
meninges, such as in meningitis, subarachnoid haemorrhages and various other diseases.
• Meningismus is meningeal irritation or inflammation suggesting meningitis or subarachnoid
haemorrhage, and is demonstrated by passive resistance to neck flexion (nuchal rigidity),
involuntary knee flexion with forced hip flexion (Kernig’s sign) or involuntary hip and knee
flexion with forced neck flexion (Brudzinski’s sign). These signs are often absent in infants
and young children.
• Migratory arthritis is arthritis that moves from one joint to another. See Arthritis.
302
9.1. Definitions
• Motor responses are the involuntary movements performed in response to motor

examination in the comatose child.
• Muscle tone is the strength a child displays in terms of ability to move or maintain position.
Vigorous movement and normal muscle tone are reassuring. In comparison, children who are
seriously ill may have decreased muscle tone or appear limp and weak.
• Myocarditis: See Carditis.
• Nasal flaring is the exaggerated opening and closing of the nostrils. It is a subtle form of
severe accessory muscle use and is commonly seen in infants.
• Non-blanching rash is a rash that does not disappear when pressure is applied to it.
'Petechial' rashes, purpura and bleeding in the skin are examples of non-blanching rashes
• Nuchal rigidity is the inability to flex the neck forward due to rigidity of the neck muscles
(i.e., an inability to place the chin on the chest or limitation of passive neck flexion). If flexion
of the neck is painful but full range of motion is present, nuchal rigidity is absent.
• NPO is an abbreviation of ‘nil per os,’ meaning nothing by mouth.
• Obtundation: See Lethargy.
• Opisthotonos is abnormal posturing in which the head and heels arch backward in extreme
hyperextension and the body forms a reverse bow. It is most commonly seen in severe
tetanus and some forms of meningitis.
• Painful stimuli (e.g., pressure applied to nail bed or supraorbital ridge) are often used to
elicit motor responses in an unconscious child. Asymmetries may suggest involvement of the
corticospinal tracts in the cerebral hemisphere or brainstem. The presence of spontaneous or
purposeful limb movements (e.g., withdrawing from or pushing away a painful stimulus)
suggests a lighter depth of coma.
• Papilloedema is a swelling of the optic disc, seen on fundoscopic exam, that suggests
increased intracranial pressure of more than several hours’ duration.
• Pericardial rub is the sound produced when inflamed parietal and visceral pericardial
surfaces rub against each other. It is heard best between the apex and the sternum. It may
be difficult to distinguish from pleural rub.
• Pericarditis: See carditis.
• Persistent vegetative state (PVS) describes patients who are completely unconscious but
have spontaneous eye opening during cyclical periods of arousal. Such patients often have
reflexive vocalisations (sounds but not words), facial expressions and movements that can be
misinterpreted by hopeful observers as reflecting awareness of their internal or external
environment.
• Pharyngitis, also known as sore throat, is a bacterial or viral inflammation of the pharynx,
hypopharynx, uvula and tonsils.
• Pleural rub is a low-pitched, grating sound heard on inspiration and expiration that is caused
by the friction of inflamed pleural surfaces moving against each other during respiration. A
pleural rub may be associated with pneumonia or a lung abscess.
• Positioning refers to the way in which a child orients his or her body to maximise airway
opening when there is obstruction. For example, a child may assume the sniffing position
(neck flexed, head mildly extended) to align the airway axes and improve airflow. For older
children, the tripod position, in which the child is sitting up and leaning forward on
outstretched hands, may be preferred.
303
9. Appendix
• Priapism is a persistent (lasting longer than 4 hours) erection of the penis that is not
associated with sexual stimulation or desire.
• Prolonged expiratory phase, a reliable sign of obstructed lower airways that can occur with
or without wheezes, is an aberration from the normal respiratory cycle in which the
expiratory phase that is longer than the inspiratory phase.
• Psychiatric unresponsiveness and catatonia are unusual in very young patients, but may
occur in adolescents. These patients often resist passive eye opening, move to avoid noxious
stimuli, turn the eyes towards the floor regardless of which side they are lying on or have
non-epileptic seizures.
• Pupillary reflex is the involuntary response of the pupils to the presence of light. Pupils can
be either fixed or responsive and dilated or pinpoint. Small, reactive pupils can be seen with
metabolic disorders and certain intoxications. Sympathomimetic and anticholinergic drugs
cause dilated pupils.
• Respiratory pattern is a way of describing a child’s breathing (rapid or slow, deep or shallow)
and may provide a clue to the aetiology of respiratory distress. For example, rapid, shallow
breathing with prolonged exhalation is typically seen with air trapping, as occurs with asthma
or bronchiolitis. It may also result from chest or abdominal pain or chest wall dysfunction.
• Respiratory sounds: See Breath sounds.
• Retinal haemorrhage is the bleeding into the retina of the eye, and is commonly associated
with shaken baby syndrome.
• Retractions or chest indrawing: Lower chest wall indrawing is when the lower chest wall
goes in when the child breathes in. If only the soft tissue between the ribs or above the
clavicle goes in when the child breathes, this is not lower chest indrawing" (it is recession)
• Rhabdomyolysis is the breakdown of skeletal muscle as a result of insult. Myoglobin, a by-
product of damaged muscle cells, is excreted in the urine and may lead to kidney failure. The
muscle damage may be caused by injury, strenuous exercise, medications and infections.
• Rhinitis, also known as the common cold or upper respiratory infection (URI), is a viral
inflammation of the nasal mucosa.
• Rhinosinusitis, also known as sinusitis, is an inflammation of the nares and paranasal sinuses,
including the frontal, ethmoid, maxillary and sphenoid sinuses. Symptoms include purulent
nasal discharge for longer than 2 weeks.
• Scleral icterus or jaundice is a yellowish pigmentation of the skin, conjunctival membranes
over the sclerae (whites of the eyes) and other mucous membranes caused by
hyperbilirubinaemia (increased levels of bilirubin in the blood). The term jaundice comes
from the French word jaune, meaning yellow.
• Sepsis is a clinical complication of severe infection that includes inflammation, immune
dysfunction, impaired circulation in the capillaries and oxygen debt, which can lead to
major/multiple organ failure (MOF) and death.
• Sequential antibiotic therapy refers to the use of both intravenous and oral routes of
antibiotic administration. It is efficacious for the treatment of diseases caused by bacteria.
Completing treatment with oral therapy avoids the hazards of long-term intravenous
antibiotic administration, which may be significant. See Chapter 7.3, How to Switch from IV
to Oral Antibiotics.
• Severe sepsis is sepsis with acidosis, hypotension or both.
• Silent chest is the condition wherein asthma is so severe that air movement is poor, so that
wheezes may not be present.
304
9.1. Definitions
• Sinusitis: See Rhinosinusitis.

• Sydenham’s chorea or chorea minor (historically referred to as Saint Vitus Dance) is a
disorder characterised by rapid, uncoordinated jerking movements, primarily of the face,
hands and feet. Sydenham's chorea (SC) results from childhood infection with Group A beta-
hemolytic Streptococcus and is reported to occur in 20%–30% of patients with acute
rheumatic fever (ARF).
• Skin colour should be assessed in all patients to indicate quality of perfusion. (In highly
pigmented skin, check the inside of the lips or mucous membranes.) Abnormal skin colour
accompanies various medical conditions; see Table 9.1.2, Abnormal skin colour.
Table 9.1.2 Abnormal skin colour

Pale, mottled or
Blue Yellow Pale Cherry red Purple
ashen
Carbon
Hypoxia Jaundice Anaemia monoxide Bruising Poor perfusion
poisoning
Blood loss or Trauma;
Liver failure; Insufficient blood
Insufficient insufficient insufficient
immature circulation, shock,
oxygen blood platelets
liver function low blood pressure
production
• Skin examination (see Capillary refill time) is the assessment of the skin for signs of systemic
perfusion. The skin is an excellent indicator of systemic vascular resistance and the degree of
shunting that is necessary to maintain blood pressure. The nail beds, mucous membranes,
palms of the hands and soles of the feet are pink and warm in a child with normal
cardiorespiratory function. The skin may become cool if hypoxia or poor perfusion develops
(see Skin colour).
• Skin turgor, when abnormal, is also called ‘tenting.’ To elicit the sign, use the thumb and
index finger to pinch a small fold of skin on the lateral abdominal wall at the level of the
umbilicus. The fold should be promptly released and the time it takes to return to normal
form measured. Malnutrition may falsely prolong the recoil time.
• Spasmodic laryngotracheitis is the sudden onset of inspiratory stridor at night, of short
duration (several hours) and sudden cessation. It is often seen in the setting of a mild upper
respiratory infection, but without fever or inflammation, and is recurrent.
• Speech/cry is an important sign regarding the overall impression of child. A weak cry is an
important indication of serious illness. A hoarse or muffled voice suggests upper airway
obstruction.
• States of impaired consciousness range from full arousal and complete unresponsiveness.
• Stridor is a high-pitched musical breath sound resulting from turbulent airflow in the larynx.
It can be heard on inspiration in croup.
• Stupor: See lethargy.
• Tenesmus is the feeling of constantly needing to pass stools.
• Tone: See Muscle tone.
• Upper respiratory Tract infection (URTI): See Rhinitis.
305
9. Appendix
9.2. WHO Growth Charts
306
307
9. Appendix
308
309
9. Appendix
9.3. Developmental Milestones

Reproduced with from Lucci Lugee Liyeung (http://artlog.liyeung.com/)permission
310
311
9. Appendix
312
313

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PAEDIATRIC

Revision of first edition

Myrto Schaefer and Marie-Claude Bottineau

Editing of first edition: Heather Ehlers

2. Triage and ABCDE .............................................................................................................................. 17

3. Management of Syndromes and Diseases ........................................................................................ 43

4. Pain Management ........................................................................................................................... 197

5. Termination of Resuscitation and Palliative Care............................................................................ 209

6. Enteral Nutrition for Non-SAM Children (non-surgical cases) ........................................................ 215

7. Drugs, Fluid and Electrolyte Administration.................................................................................... 219

7.9. Phenobarbital and Phenytoin ....................................................................................................... 244

8. Procedures ....................................................................................................................................... 257

9. Appendix .......................................................................................................................................... 297

1.1. Paediatric Vital Signs ........................................................................................................................ 4

1.1. Paediatric Vital Signs

Heart rate (HR)

Respiratory rate (RR)

Table 1.1.1 Normal heart and respiratory rates by age

Oxygen saturation (SpO2)

Capillary refill time (CRT)

A patient rated as A or V is considered to be in good condition. A patient rated as P or U is considered

Blantyre Coma Score

Table 1.1.2 Blantyre Coma Score

Table 1.1.3 Interpretation of Blantyre Coma Scale

Paediatric and adult Glasgow Coma Scale (GCS)

Pain evaluation scales

Blood pressure (BP)

Table 1.1.6 Normal systolic blood pressure by age

Age SBP (mm Hg)*

1.2. The Paediatric History and Clinical Exam

II. History of Present Illness

III. Past Medical History

IV. Review of Systems

• Weight: Any recent changes

• Genitourinary: Any trouble with or changes in urination

General Approach to the Paediatric Clinical Exam

Order of Exam (From Least Distressing to Most Distressing)

Outline of a Paediatric Clinical Examination

Obtain an accurate weight, height and temperature.

III. Skin and lymphatic system

VIII. Mouth and throat

Deep tendon reflexes should also be tested.

Perform a developmental assessment.

Cranial nerve examination

IX and X: Test swallowing and for a gag reflex.

XV. Genitourinary tract

2.1. Triage Protocol including Assessment of

Table 2.1.1 Triage priority categories

• Child should be given priority in the queue so that he or

Assessment and Categorisation

Table 2.1.2 Emergency signs (ABCD)

Table 2.1.3 Completion of primary assessment

Exposure (E) • Treat hypothermia (survival blanket)

Procedures and Organisation of Triage

Setting up the Triage Area

Table 2.1.4 Necessary equipment for triage areas

Hand-washing facility and gloves

Triage is a dynamic process. Patients need to be re-evaluated regularly, irrespective of their

2.2. Management of the Seriously Ill Child

Figure 2.2.1 CPR algorithm

Shout for help • Give 1 breath every 3 seconds

One rescuer: Begin cycles of 30 compressions and 2 breaths

Two rescuers: Begin cycles of 15 compressions and 2 breaths