Blue Book

KCMC
PAEDIATRIC
MANAGEMENT SCHEDULES
AT HOSPITAL LEVEL
MARK SWAI, RAIMOS OLOMI,

GRACE KINABO
and other KCMC paediatricians, past and present
CPEP- KCMC PAEDIATRICS
MOSHI, TANZANIA 7th edition 2009
Copies of the KCMC Paediatric Management Schedules can
be obtained from:
CPEP OFFICE
KCMC PAEDIATRIC
DEPARTMENT
P.O.BOX 3010
MOSHI
KCMC Bookshop
Visiting address:
KCMC Library
Moshi, Tanzania
Acknowledgement
This current edition of management schedules has been the cumulative effort of
staff members of the KCMC paediatric department (past and present) building upon
inputs from other departments and centres as well as the foundation laid forth by
those who first conceived and implemented the idea of this unified management
schedule. Bo Baldwin and Zier Versulys are the giants on the shoulders of whom we
stood to continue producing subsequent editions, they having written the previous
editions.
The writing and compilation of this 7th edition was carried under the direct guidance of
Raimos M. S. Olomi MD, M.Med MPH

Associate Professor Paediatrics & Child Health KCMC
Mark E. P. Swai MD, M.Med Msc

Consultant Paediatrician, Chairman Continuing
Paediatric Education Programme,
Director of Hospital Services KCMC
Grace D. Kinabo MD, M.Med

Paediatrician, Head of Paediatric Department KCMC
Martina Oneko MD, M.Med

Consultant Paediatrician
Levina J. Msuya MD, M.Med

Paediatrician, Principal School of AMO General KCMC
Aisa M. Shayo MD, M.Med

Paediatrician KCMC
Blandina T. Mmbaga MD, M.Med

Paediatrician KCMC
Nicholaus Chotta MD
Resident Paediatric Department KCMC
Macrice Yakayashi MD
Anaelia Siya Temu MD

Rahim Damji MD
Khamis A. Abeid MD
Joseph Mukama MD
Mtagi Kibatala MD
Adili Haule MD
Judith Gwimile MD
Mark Waziri MBChB

Fadhili Mlagalila MD
Rune Philemon MD
Resident Paediatric Department KCMC, Editor
CONSULTANTS FROM OTHER DEPARTMENTS WITH MAJOR

CONTRIBUTIONS:
Prof. Elisante J. Massenga, Consultant

Dermatovenerologist.
Dr Bernadeta Shillio, Consultant Ophthalmologist.
Dr Aveline Matasha, Consultant ENT surgeon.

This 7th edition of the KCMC Paediatric Management Schedules is a
publication of the Paediatric Department of the Kilimanjaro Christian Medical
Centre (KCMC) and is produced by the Continuing Paediatric Education
Programme (CPEP), Moshi, Tanzania.
CPEP is an organ of the KCMC paediatric department which aims at

the improvement of child health care in Northern Tanzania. At its
establishment in 1997, CPEP was funded by the Netherlands
Foundation for International Child Health (NFICH) and later by
Memisa Medicus Mundi (CORDAID) and the Inter-church
Organization for Development Cooperation (ICCO).
Currently the CPEP is funded by the Elizabeth Glaser Paediatric Aids
Foundation (EGPAF) through the Child Centred Family Care Clinic
(CCFCC) at KCMC.
ISBN 90-805753-1-3
7th edition 2009

© 2009 Continuing Paediatric Education Programme,
Editor: Mark Swai, Raimos Olomi, Grace Kinabo, Rune Philemon
Running title: ‘Paediatric Management Schedules’
Printed by: Moshi Lutheran Printing Press
Foreword to the 7th Edition
The necessity to produce the seventh edition of this

management schedule of some common children’s
diseases is the greatest compliment to the book itself.
Originally the schedules were written for doctors working
in the Paediatric Department of KCMC, and very soon
became very popular in district and regional hospitals in
Tanzania and the rest of Africa. It has served as a short
up-to date manual for doctors, nurses and other health
workers wishing to review quickly how prevention,
diagnosis and treatment of the most common health
problems of children are dealt with.
The management schedule focus on inpatient and out-

patient management of major causes of childhood
morbidity and mortality. Medical knowledge in handling
these conditions has not remained static. This has made
it inevitable that some of the sections of the
management schedule become newly written but
maintaining the similar pattern of outline.
About twenty years after the frst edition, KCMC has

become a teaching hospital of the Kilimanjaro Christian
Medical College. The curriculum for training of doctors at
the college allows students from the frst year of their
fve years of training to have direct contact with patients.
KCMC is also a training centre for Assistant Medical
Ofcers (AMOa, Intern doctors from dieerent medical
schools in-and outside the country, nurses and residents
in paediatrics. This management schedule presents an
up-to-date standardized clinical guidelines to the above
mentioned trainees based on a review of most recent
published scientifc fndings. It became an important
teaching tool during the continuing paediatric education
outreach visits to the hospitals surrounding KCMC.
The frst edition was written by Dr. Bo Balldin in
1971.Over the years there has been contribution from
many paediatricians within and out side the country. Two
former Duch consultants at KCMC, Dr.C.Versluys and
Dr.A.van Meurs contributed a lot for the production of the
5th edition. I was the chairman of the consensus meeting
which took place in Moshi in 1993.
This is however the frst time that only Tanzanian

paediatricians like Prof.Raimos Olomi, Drs.Levina Msuya,
Martina Oneko, Aisa Shayo and Dr.Grace Kinabo (Head of
Paediatrics Departmenta Residents like Drs Adili Haule,
Fadhili Mlagalila, Judith Gwimile, Mtagi Kibatala, Joseph
Mukama, Macrice Yakayashi, Nicolas Chotta, Rahim
Damji, Khamis Abeid, Anaelia Temu and Mark Waziri
made valuable contributions in the reviewing the book.
Other contributors outside the Paediatrics Department
are Prof.Elisante Masenga (Dermatologista, Dr. Bernadeta
Shilio (Paediatric Ophthalmologista and Dr. Aveline
Matasha (ENT Specialistsa. Dr. Rune Philemon from the
paediatric department has done excellent editorial work.
It is my wish therefore to congratulate all fellow

paediatricians and contributors from the other
departments for the hard work. It is my sincere hope that
this new edition will serve the purpose in providing best
review of treatment to our children and enjoy even a
greater popularity among the health professionals who
have dedicated their life in treating sick children.
Mark E. Swai
KCMC, MOSHI
2009
CONTENTS
Listed according to WHO classification of diseases (ICD-10 1992)
(see also alphabethical index at the back)
page:
INFECTIONS (I)
1. Typhoid fever…………….…………………………..…........ 1
2. Amoebiasis ……………………………………………......... 6
3. Diarrhoeal diseases ………………………………………... 10
4. Tuberculosis………………………………........................... 18
5. Pertussis ………………………………………………......... 28
6. Measles …………………………………………………....... 32
7. Rabies………………………………………………….......... 36
8. AIDS ……………………………………………………......... 40
9. Malaria……………………………………………………...... 50
10. Helminthiasis………………………………........................ 57
TUMOURS (II)
11. Some common tumours
11.1 Burkitt’s lymphoma…………………………......... 66
11.2 Wilms tumour ……………………......................... 70
11.3 Kaposi’s sarcoma………………………………….. 72
BLOOD DISEASES (III)

12. Anaemia ………………………………………………….... 75
NUTRITIONAL DISEASES (IV)

13. Malnutrition ………………………………………………..... 82
NEUROLOGICAL DISEASES, SENSE ORGANS (VIII)
14. Bacterial Meningitis incl. Septicaemia……………………. 96
15. Convulsions ……………………………………………........ 104

16. Cerebral palsy ……………………………………………..... 115
17. Some eye diseases in children
17.1 Prevention …………………………....................... 121
17.2 Ophthalmia neonatorum …………………………. 121
17.3 Trachoma …………………………........................ 122
17.4 Xerophthalmia ……………………........................ 123
17.5 White pupil ……………………………………........ 124
17.6 Eye injuries ……………………………………...…. 125
17.7 Some rules about treatment of eye diseases...... 125
18. Otitis media ……………………………………………......... 127
CIRCULATION TRACT DISEASES (IX)

19 Congestive Cardiac Failure, Cardiac arrhythmias ……… 131
20. Rheumatic heart disease ……………………………….…..139
RESPIRATORY TRACT DISEASES: ARI (X)

21. Acute tonsillitis, sore throat ………………………………... 114
22. Acute obstructive laryngitis (croup) ……………………….. 146
23. Pneumonia ………………………...……………………....... 151
24. Lower airway obstruction (bronchiolitis, asthma) ………. 160
DIGESTIVE TRACT DISEASES (XI)

25. Jaundice beyond neonatal period ……………………….... 165
26. Hepatosplenomegaly ………………………..…………....... 170
27. Hepatic failure ……………………………………………..... 174
SKIN DISEASES (XII)

28. Five common skin diseases ……………………………..... 179
MUSCULOSKELETAL DISEASES (XIII)
29. Osteomyelitis and septic arthritis ………………………..... 187
GENITO-URINARY TRACT DISEASES (XIV)

30. Glomerulopathies (renal failure, nephritis and nephrosis).
193
31. Urinary tract infection …………………………………….....203
THE NEWBORN (XV)

32. General care of the newborn …………………………...…. 208
33. The low-birth-weight infant ……………………………..…..215
34. Asphyxia in the newborn ………………………………..…. 223
35. Neonatal respiratory disorders …………………….…….... 226
36. Convulsions in the newborn …………………………….….232
37. Neonatal tetanus ………………………………………….... 233
38. Other severe bacterial infections in the
newborn (incl meningitis)……………................................ 236
39. Necrotizing enterocolitis in the newborn …………………. 242
40. Neonatal jaundice …………………………………………...244
CONGENITAL ANOMALIES AND SURGERY (XVII)

41. Some paediatric surgical conditions
41.1 Introduction ……………………………………....... 251
41.2 Suppurative pericarditis ………………………..….252
41.3 Intestinal obstruction in the
newborn…………………………………………......254
41.4 Intestinal obstruction in infancy/childhood …….. 256
41.5 Peritonitis …………………………………….......... 258
41.6 Appendicitis ………………………………………...260
41.7 Haemorrhage from gastrointestinal tract…….... 261
41.8 Abdominal mass ………………............................ 263
41.9 Congenital malformations (specified below)
41.10 Cleft lip, cleft palate ……………........................... 265
41.11 Congenital oesophageal atresia ………………. 265
41.12 Diaphragmatic hernia in neonates ……………... 266
41.13 Patent ductus arteriosus ……………………....... 267
41.14 Tetralogy of Fallot ……………….......................... 267
41.15 Omphalocele …………………………………….....268
41.16 Gastroschisis …………………………………........269
41.17 Prune-Belly syndrome …………………….…....... 269
41.18 Hypospadia ……………………….........................270
41.19 Cryptorchism……………………………….............270
41.20 Congenital club foot (Talipes Equinovarus) ……. 270
41.21 Hydrocephalus …………………………………..... 272
41.22 Spina Bifida, (myelo-)meningocele………………. 274
ACCIDENTS, POISONING (XIX)
42. Intoxications………………………………………………..... 279

43. Burns ……………………………………………………........285
GENERAL TREATMENT
44.a Coma, general …………………………….………………... 295
44.b Diabetic keto-acidosis/coma ..…………………………..… 302
45 Shock ………………………………………………………....307
46. Intravenous fluid therapy ………………..…………………. 313
47 Paediatric procedures
47.1 Oxygen therapy…………………………………..... 318
47.2 Pleural tap ……………………………………....... 319
47.3 Pericardiocentesis ………………......................... 320
47.4 Peritoneal tap/infusion ………………………….....321
47.5 Peritoneal dialysis……………….………..…....... 321
47.6 Lumbar puncture……………………………….......323
47.7 Intramuscular injection ………………………....... 325
47.8 Intraosseous infusion ……………........................ 326
47.9 Gastric lavage ……………………........................ 327
47.10 Gram stain ……………………………….……....... 328
47.11 Staining of acid fast bacilli ……………………...... 329
PHARMACOLOGY
48. Paediatric drug dosage ……………………………………..331
Paediatric drug list ………………………………………......333
49. CHARTS AND TABLES

49.1 Observation – Fluid Balance Chart …………....... 348
49.2 Intra-uterine growth chart ……………………...... 349
49.3 Some normal laboratory values in children …….. 350
49.4 Blood pressure………………………………..........352
49.5 Pulse rate ………………………............................354
49.6 Headcircumference boys ……………………….... 355
49.7 Headcircumference girls …………....................... 356
49.8 Growth monitoring charts and tables……………. 257
49.9 WHO diarrhoea management chart
plans A, B and C ………………………………….. 381
49.10 Tanzania vaccination schedule ……………….... 384
49.11 WHO paediatric clinical staging of HIV/AIDS…… 385
49.12 PMTCT regimen…………………………………… 387
50. Neonatal Resuscitation……………………………………...389

ABBREVIATIONS USED
ANC Absolute Neutrophil Count
BSA Body Surface Area
DNA Deoxyribonucleic Acid
FBP Full Blood Picture
h hour
Hb Haemoglobin
Ht Height
ID inner diameter
IM intramuscular
IT intrathecal
IV intravenous
LBW Low Birth Weight
m2 square metre
meq milli equivalent
mo Months
OD outer diameter
OI opportunistic infection
PCR Polymerase Chain Reaction
SC subcutaneous
WT weight
< less than
> more than
KCMC, PAEDIATRICS 1 TYPHOID FEVER
1 TYPHOID FEVER
1.1 PREVENTION
MAIN POINTS IN HEALTH EDUCATION

 Proper use of latrirines.
 Wash hands before feeding.
 Protect food from flies.
 Use boiled water if possible.
1.2 CAUSE
Salmonella typhi and Salmonella paratyphi, Gram neg. rods.
Incubation time: 10-20 days.
1.3 SIGNS AND SYMPTOMS

Prodromal Week 1 Week 2 Week 3
General Headache Apathy Mental confusion

CNS Vomiting Meningism Disorientation
Temperature Normal Stepwise up Continuously high Stepwise down
Lungs Bronchitis Bronchopneumonia
Heart Bradycardia Tachycardia
(rare)
Abdomen Splenomegaly Abdominal Bleeding,
Hepatomegaly distension, Perforation
tenderness
Stool Constipation "Pea soup" Blood
(rare) diarrhoea
Skin Rose spots (rare in
pigmentedskin)
Severity of symptoms varies greatly from child to child. Typhoid fever can present
atypically in young children with shock and hypothermia
1
1.4 IMPORTANT ACTIONS TO BE TAKEN BEFORE
ADMISSION
Refer to hospital early when the child is not improving on
treatment, e.g. fever for more than 5 days.
1.5 DIAGNOSIS
Suspect typhoid fever in any severe or prolonged febrile illness
even if antibiotics have been given.
BLOOD

Culture of blood is positive during the first week.

WBC often low in uncomplicated cases, never above 16.000/
mm3

Widal-test may be positive in the second week, rising in
second test (2 weeks later). False negative as well as false
positive tests occur frequently. Slide tests unreliable. Tube
tests with rising titres do contribute to diagnosis.
STOOL
 Culture of stool is positive in the second or third week.
 Blood often seen.
X-RAY
In perforation of bowel, free air in abdomen may be seen.
2
1.6 TREATMENT
GENERAL CARE
 Barrier nursing in all suspected cases.
 Bed linen and clothes should be soaked in lysol or chloramine
for 2 hours, and then boiled in water, after use.
 Ensure adequate food and fluid intakes daily.
 Also solid food can be given.
 Look regularly for complications, check temperature, pulse
rate, breath rate, abdomen, parotid gland, etc 4 hourly.
 Do not use aspirin or laxatives.
 If the child has high fever (≥39 °C) give paracetamol
 Monitor haemoglobin or haematocrit levels
DRUGS
Chloramphenicol 50 mg/kg/day in 4 doses orally for 14 days! In severe cases
100 mg/kg/day in 4 doses orally or IV (initially)
or
Amoxicillin 100 mg/kg/day in 3 doses orally for 3 weeks
If poor response to Chloramphenicol by 48 hours

Ampicillin 200 mg/kg/day in 4 divided doses
In case of resistance or no response in 5 days change to 3rd

generation cephalosporins
Ceftriaxone 80 mg/kg/day single dose IM,IV for 14 days
or
Cefotaxime 150 mg/kg/day IM,IV in 3-4 doses for 14 days
or if not available:
Ciprofloxacin 15-30 mg/kg/day in 2 doses oral or IV for 7 days
3
TREATMENT OF COMPLICATIONS
INTESTINAL PERFORATION
 Usually during second or third week. Vomiting, distension of
abdomen, rigidity of abdominal muscles, toxic appearance,
increased pulse rate. Sometimes hypothermia and
hypovolemia.
 Operate within 24 hours. Hourly gastric aspiration.
 IV fluids. High doses of Chloramphenicol IV and via gastric
tube + Metronidazole IV. For doses see 41.5.
 Patient may also present with paralytic ileus mimicking
intestinal perforation. It can be distinguished by lack of air
under the diaphragm on an erect abdominal x-ray
INTESTINAL HAEMORRHAGE
 Usually during third week. Sudden onset of shock.
 Blood transfusion, followed by IV fluid.
PNEUMONIA
 Pneumonia is a frequent complication.
 Rarely lung abscesses, pleural effusion, or empyema can
occur
MYOCARDITIS
 Often in severe toxic cases. Tachycardia, cardiomegaly,
triple-rhythm, ECG changes. Congested cardiac failure may
be seen in severe anaemia or glomerulonephritis.
 Strict bed rest. Restrict parenteral fluids.
OTHER COMPLICATIONS
 Acute cholecystitis, jaundice, pyelonephritis,
glomerulonephritis, hepatitis, haemolytic anaemia, arthritis,
osteomyelitis are rare complications.
 Treat symptomatically in addition to the treatment of typhoid
fever.
4
1.7 FOLLOW UP
Relapses may occur, 10-20%. Usually 2 weeks after

discontinuation of antibiotics. Relapse rate increases if antibiotic
course is shorter than 14 days. Some become chronic carriers. If
relapse occurs, treatment remains the same as for first attack.
5
KCMC, PAEDIATRICS 2 AMOEBIASIS
________________________________________________________
2 AMOEBIASIS
2.1 PREVENTION
 Hygiene most important. Wash hands after defecation and
before feeding the child.
 Proper use latrine.
 Boil water. It will kill the cysts.
 Keep food protected from flies.
 Regular examination of food handlers
2.2 CAUSE
Entamoeba histolytica.
Trophozoites are seen in acute disease and cysts are seen in
carriers

INTESTINAL AMOEBIC DYSENTERY
 In acute stage diarrhoea, usually with some slight blood and
mucus, fever, abdominal pain.
 The chronic recurrent stage is often asymptomatic combined
with periodic bouts of diarrhoea with loose or liquid stool for a
day.
EXTRAINTESTINAL AMOEBIASIS
 Liver abscess, most often in right liver lobe. Should be
suspected in children, who live in endemic areas. Enlarged,
6
________________________________________________________
tender liver. Shoulder pain. Fever. Oedema and tenderness
of the skin above the abscess. Rales at right lung base.
 In case of rupture of the abscess: amoebic empyema,
pericarditis,
hepatobronchial fistula, peritonitis. Can also have
hematogenous spread to the brain and lungs.

ADMISSION
 Rehydration.
 Quick referral in suspected cases of liver abscess.
2.5 DIAGNOSIS
INTESTINAL FORM
 In dysentery: freshly passed stool may show motile
trophozoites with ingested red cells. Cysts may also be seen.
Treat suspected cases even with negative stool result.
 In chronic carrier stage: cysts only.
LIVER ABSCESS
BLOOD - ESR almost always high.

- WBC increased.
- Anaemia common.
X-RAY - Raised hemi-diaphragm in right
lobe liver abscess.
ULTRASONIC LIVER SCAN - If available, best method.
7
________________________________________________________
2.6 TREATMENT
Drugs
Dose: Side effects:
Metronidazole 50mg/kg/day in 3 Gastrointestinal symptoms
doses orally for 7 days metallic taste, dizziness.
in dysentery, 50 Urine may be red.
mg/kg/day in 3 doses
orally for 10 days in
liver abscess
Tinidazole 50-60 mg/kg/day one Gastrointestinal symptoms
dose orally for 3 days
in colitis 5days in liver
abscess
Chloroquine 10 mg/kg/day in 1 Pruritus, gastro-intestinal
dose orally for 14 days symptoms, headache
Effective in tissue
TREATMENT OF AMOEBIC DYSENTERY

 Metronidazole usually enough. Chloroquine may be added in
severe cases.
 If child leaves endemic area metronidazole is followed by
diloxanide furoate 20 mg/kg/d in 3 doses for 10 days or
paromomycin 25-35mg/kg/day in 3 doses for 7days.
TREATMENT OF LIVER ABSCESS AND OTHER

EXTRAINTESTINAL FORMS
 Metronidazole plus Chloroquine for 14 days.
 Aspiration of liver abscess may be necessary.
Indications:
 swelling of the ribcage or abdominal wall
 marked local tenderness
 a raised diaphragm on X-ray Abscesses may be see on
ultrasonography
8
________________________________________________________
 failure of drugs
Use a wide-bore needle syringe and 3-way tap at the point of
maximum tenderness or under ultrasound guidance. Aspirate
to dryness, if necessary several times. Surgical drainage for
difficult to access abscess.
2.7 FOLLOW UP
 Ensure good nutrition.
 Come back early if relapse.
9
KCMC, PAEDIATRICS 3 DIARRHOEAL
DISEASES
_________________________________________________________
3 DIARRHOEAL DISEASES
3.1 PREVENTION

 Provide good hygiene and sanitation: Wash hands with soap
after using the toilet. Proper use of latrine. Clean playground
for crawling infants. Cover food and water. Dispose rubbish
properly. Wash hands before food preparation.
 Ensure good nutrition: Breastfeeding. Mixed weaning foods.
Vitamin A rich food. Do not stop feeding during diarrhoea.
 Visit MCH clinic regularly to get immunisation against all
diseases and detect malnutrition.
3.2 CAUSES:
DIARRHOEA WITH BLOOD

WITH FEVER: WITHOUT FEVER:
Bacill.dysentery, Shigella Schistosomiasis
Campylobacter jejuni Trichuris
Yersinia enterocolitica Amoebic dysentery
Salmonella infections, Intussusception
if severe Acute ulcerative colitis
Enterocolitis necroticans
10
DISEASES
_________________________________________________________
DIARRHOEA WITHOUT BLOOD

WITH FEVER: WITHOUT FEVER:
Malaria E. coli
Childhood infections of Cholera
all kinds Food poisoning
Measles Clostridium perfringens
Rotavirus (most common Giardiasis
cause) Malnutrition
Salmonellosis Improper weaning
PERSISTENT DIARRHOEA
More than 14 days or more than 14 diarrhoea-days in a month.
May follow an acute attack. Often associated with early weaning,
bottle feeding, malnutrition, malabsorption or immunodeficiency.
Small bowel bacterial overgrowth, villous atrophy, vitamin A-
deficiency may contribute! Think of AIDS if diarrhoea > 30 days.
Vomiting, watery stools (3 or more per day), melaena, fever.

Dehydration which may lead to shock.
11
DISEASES
_________________________________________________________
ASSESSMENT OF DEGREE DEHYDRATION (WHO)

Classification Signs or Symptoms Treatment
Severe Two or more of the following Give fluid for severe
signs: dehydration (plan C)
 Lethargy/unconsciousness
 Sunken eyes
 Unable to drink or drinks
poorly
 Skin pinch goes back very
slowly (≥2 seconds)
Some Two or more of the following  Give fluid and food
dehydration signs: (plan B)
 Restless, irritability  After rehydration,
 Sunken eyes advise mother on
 Drinks eagerly, thirsty home treatment and
 Skin pinch goes back when to return
slowly  Follow up in 5 days
No Not enough signs to classify as  Give fluid and food
dehydration some or severe dehydration (plan A)
 Advise mother when
to return immediately
 Follow up in 5 days
12
DISEASES
_________________________________________________________
ADDITIONAL IMPORTANT CRITERIA USED FOR CLINICAL

JUDGEMENT
No dehydration Some dehydration Severe dehydration
Urine normal Small amount no urine for 6 h
Mouth, tongue wet Dry very dry
Pulse normal Faster very fast, weak
Fontanel (infants) normal Sunken very sunken

ADMISSION
HOME TREATMENT
Common recommendations for home treatment:
 Continue breastfeeding and solid food in frequent small
meals.
 Give the child more fluid than usual, preferably ORS (Oral
Rehydration Solution) or if not available the mother should
be advised to give a cereal gruel or if not possible plain clean
water. Home made salt/sugar mixtures are now discouraged
because of frequent errors (danger: hypernatraemia).
 Go to health centre if the child does not improve in 3 days,
has a fever or if there are bloody stools.
13
DISEASES
_________________________________________________________
REHYDRATION WITH ORS SOLUTION AT HEALTH CENTRE

OR OPD
Oresol and similar "WHO" solutions will give per litre: 90 mmol
Na+, 20 mmol K+, 80 mmol Cl-, 30 mmol HCO3-, 20 g glucose =
110 mmol/l.
ORAL REHYDRATION WORKS ON THE PHYSIOLOGICAL MECHANISM

OF SODIUM AND GLUCOSE CO-TRANSPORT ACROSS THE INTESTINAL
MUCOSA. THEREFORE THE COMPOSITION OF THE FLUIDS IS OF
GREAT IMPORTANCE.
REFER EARLY
 Children who do not respond to treatment.
 Children with bloody diarrhoea and toxic appearance.
 Children with convulsions.
 Children with abdominal distension.
 Children with oliguria after 3 hours of treatment.
 Children who cannot drink and vomit a lot
 Children with persistent diarrhoea.
3.5 DIAGNOSIS
CLINICAL ASSESSMENT
See above. In addition measure blood pressure. Also look for
other signs of infections and malnutrition.
BLOOD
 Exclude malaria.
 Electrolyte analysis can be very helpful in severe and chronic
cases of diarrhoea.
Na > 150 mmol/l = hypertonic dehydration (see 46.4)
14
DISEASES
_________________________________________________________
Na < 120 mmol/l = hypotonic dehydration.
STOOL EXAMINATION
 Fresh stool for amoebiasis, bacillary dysentery,
schistosomiasis, giardiasis.
 Culture of bloody stool and when cholera is suspected.
3.6 TREATMENT
REHYDRATION AND EARLY FEEDING CONSTITUTE THE

TREATMENT OF DIARRHOEA. ANTIBIOTICS ARE RARELY NEEDED.
FLUID THERAPY
 In ‘some dehydration’ start or continue to give ORS solution.
Nasogastric tube can be used.
 When IV solution is needed: See chapter 46 on IV Fluid
Therapy in children.
 If no IV can be started: intra-osseous or intraperitoneal
infusions can save lives: See chapter 47.
DRUGS
The majority of children with diarrhoea should not have
antibiotics because:
 Mostly viral origin of the diarrhoea, antibiotics have no effect.
 If bacterial origin, the treatment may prolong carriage.
 Disturbance of gut flora may occur.
 Risk for resistance.
Anti-emetics and anti-diarrhoeal drugs have no place in the

treatment of diarrhoea and can be dangerous.
15
DISEASES
_________________________________________________________
CHOLERA
Tetracycline 50 mg/kg/day in 4 doses orally for 3 days
Doxycycline 5 mg/kg single dose

or
Cotrimoxazole (TMP/SMZ) 10/50 mg/kg/day in 2 doses orally for 3 days
Chloramphenicol 12.5 mg/kg every six hours
Erythromycin 50 mg/kg/day (max 4g/day)
SHIGELLA (and other causes of bacillary dysentery) is now resistant to

many drugs. Geographical differences must be known. In case
of outbreak, sensitivity studies should be done.
Cotrimoxazole (TMP/SMZ) 10/50 mg/kg/day in 2 doses orally for 5 days

or
Nalidixic acid 60 mg/kg/day in 4 doses orally for 5 days
or
Ciprofloxacin 15-30 mg/kg/day in 2 doses oral or IV for 7 days
(see warning Ch 48)
In resistant and very severe cases try:
Ceftriaxone 50 mg/kg/day single dose IM,IV for 2-5 days

or
Cefotaxime 150 mg/kg/day IM,IV in 3-4 doses for 5 days
16
DISEASES
_________________________________________________________
AMOEBIASIS
Metronidazole 30-50 mg/kg/day in 3 doses orally for 10 days
or
Tinidazole 50-60 mg/kg single dose orally for 3 days
GIARDIASIS
Metronidazole 30 mg/kg/day in 3 doses orally for 5 days

or
Tinidazole 25-50 mg/kg single dose orally for 10 days
NUTRITION
Food should be given as soon as possible. In persistent diarrhoea
give food with high calorie content (cereal, legumes, meat, egg
white, etc.). Lactose should be reduced. Continue to give extra
food for several weeks. Ensure weight gain.
3.7 FOLLOW UP
 Before discharge, explain to the parents about diarrhoea and

be sure that they know what to do next time the child gets
diarrhoea.
 Discuss the preventive measures that could be taken at
home.
 Advise the parents to give the child extra food, especially
Vitamin A rich, at home for the next month. High priority!
 Measure growth at MCH clinic after 1 month.
17
KCMC, PAEDIATRICS 4 TUBERCULOSIS
_________________________________________________________
4 TUBERCULOSIS
4.1 DEFINITION
Chronic infectious disease caused acid fast bacilli of the genus
mycobacterium (commonly mycobacterium tuberculosis, but also
M. bovis and M. afrcanum).
4.2 PREVENTION
 Give BCG vaccination at birth in full term baby, when 2.5kg in
preterm or when no BCG scar.
 Ensure good nutrition and hygiene.
 Reduce overcrowding.
 Regular visits to MCH clinic.
 Prevent HIV infection.
 Give chemo-prophylaxis soon after the child has got in contact
with infected adult.
 Tuberculosis surveillance and community awareness of the
disease.
4.3 CAUSE
Mycobacterium tuberculosis. Also M. Bovis and M. africanum in
immunocompromised
18
_________________________________________________________

Think of tuberculosis, in case of:
GENERAL HISTORY, SIGNS AND SYMPTOMS
 Chronic cough for more than 30 days.
 Positive family history. Contact with TB patient.
 Suspected AIDS.
 Prolonged fever.
 Failure to thrive
 Cases of malnutrition failing to respond to adequate nutritional
and anti-infective treatment.
 Failure to return to health after infections, particularly after
measles, whooping cough or streptococcal infection.
 Erythema nodosum.
LOCALIZING SIGNS AND SYMPTOMS

 Chronic cough, respiratory wheezing and wasting.
 Febrile illness with pleural pain and effusion.
 Pneumonia not improving in spite of adequate treatment.
 Chronic swelling of lymph nodes.
 Abdominal swelling with ascites.
 Chronic painful swelling in a weight-bearing joint.
 Refusal to bend, stiff painful back, spinal deformity and
paraplegia.
 Unexplained change of temperament, irritability and fever,
vomiting, headache, convulsions, meningeal signs, cranial
nerve involvement and finally paralysis and coma.
 Signs of space-occupying intracranial tumour.
 Painless haematuria or sterile pyuria.

ADMISSION
19
_________________________________________________________
AT HEALTH CENTRE
 In case of tuberculosis in an adult, examine and follow up the
children and the family.
 Refer chronically ill children early to hospital e.g. cough for
more than 30 days.
AT DISTRICT HOSPITAL
Refer coughing children who do not respond to antibiotics within 2
weeks, and those who have some symptoms mentioned above.
4.6 DIAGNOSIS
NOTE:
 A HISTORY OF A POSITIVE TB CONTACT IS A VERY POSITIVE MARKER.
 ONLY 15% OF TB CHILDREN HAVE A POSITIVE SMEAR, SO A NEGATIVE
SMEAR DOES NOT EXCLUDE PULMONARY TB.
 THERE ARE NO TYPICAL RADIOLOGICAL FEATURES FOR PTB
20
_________________________________________________________
SCORE CHART FOR THE DIAGNOSIS OF

TUBERCULOSIS IN CHILDREN
SCORE IF OR SYMPTOM IS PRESENT
0 1 2 3 4 Score
GENERAL FEATURES
Duration of <2 2-4weeks >4 weeks
illness weeks
Failure to thrive Weight No weight Weight loss
or weight loss gain gain
TB contact None Reported Proven Proven
not proven smear + or smear +
extra-
pulmonary
TB
Tuberculin test Positive
Malnutrition Not improved
after 4 weeks
Chronic infant Recurrent No response
disease to antibiotic
LOCAL FEATURE
Chest x-ray TB
suggestive
features e.g.
infiltration,
cavity or hilar
lymphnodes
Lymphnodes Cervical,
sub-
mandibular
Swelling of Suggestive
bone or joint features on
x-ray
Ascites Without With
abdominal abdominal
mass mass
Meningitis Chronic CNS
signs
Angle deformity x-ray
of the spine features
TOTAL SCORE
A score of 9 or more indicates a high likelihood of tuberculosis
TUBERCULIN TEST
21
_________________________________________________________
The Mantoux test is performed by intradermal injection of 5 TU =

0.1 ml 1:2.000 diluted OT or 0.1 ml PPD (strength 0,0001 mg per
dose) on the antero-lateral part of the lower arm using a special
Mantoux syringe. Read after 72 hours depending on the solution
used.
Measure the diameter of the induration: consider positive if

 ≥5mm immunocompromised or recent contact
 ≥10mm and high risk, <4 years
 ≥15mm and no risk factors
A negative test does not exclude tuberculosis:

 if the test is performed before the hypersensitivity has
developed (may take 10 weeks after infection).
 if the child is anergic after measles, in severe malnutrition,
during steroid or cytotoxic drug therapy or in miliary
tuberculosis or HIV/AIDS.
An unequivocal (6-10 mm) reaction may occur in atypical

mycobacterial infections and within 3 yr. after BCG. Prior BCG
vaccination is not a good reason to omit a Mantoux test if TB is
suspected.
SMEAR
In children Repeated acid fast bacilli (AFB)
smear and culture from sputum, gastric aspirate,
effusion, CSF or pus.
X-RAY
Serial X-ray of lungs is more helpful than only one examination.
Primary focus may be difficult to see. Common X-ray findings:
22
_________________________________________________________
enlarged lymph nodes, effusion, cavitation, consolidation,

atelectasis, calcification, miliary "snowstorm". X-ray of abdomen
may show calcified lymph nodes in abdominal TB.
OTHER EXAMINATIONS
 Blood: ESR is not specific. It is raised in most cases but
normal ESR does not exclude TB.
Hb.
 Urine: in selected cases.
 CSF: in selected cases. Low sugar plus lymphocytosis in TB
meningitis.
 Biopsy of lymph node, synovia, bone-marrow, pleura.
 Ophthalmoscopy: choroidal tubercles often present in
military TB
 Laparoscopy in suspected abdominal TB.
23
_________________________________________________________
4.7 TREATMENT
DRUGS
Dose: Side effects:
Isoniazid (H) Prophylactic: 5mg/kg Neuropathy, more common in HIV.
Good penetration Curative:10-(15 in severe Add Pyridoxine 2 mg/kg to
into all tissues. cases) mg/kg/day, max malnourished children.
(R150 mg/H 300-(500 severe inf.) mg, Hepatitis
100mg in one oral dose. When
combination: given twice weekly 20-25
Rimactazid) mg/kg/dose.
Streptomycin (S) 15 mg/kg/day max 1 g Damage to 8th cranial nerve (rare):

Is replaced by One IM dose. discontinue drug. Rash, fever:
other drugs. Can reduce dose.
still be used in
meningitis, miliary
and bone TB
during admission.
Rifampicin (R) 10-15 mg/kg/day max Hepatotoxicity rarely in children.

Good penetration 600 mg one oral dose More common in combination with
to CNS before breakfast. INH usually within the first 3 months
Expensive. of therapy.
Leucopenia, thrombocytopenia.
Body fluids may get red in overdose.
Pyrazinamide (Z) 25 mg/kg/day, one oral Hepatitis. Gastrointestinal
dose, reactions. Flu-like symptoms.
max 2 g. Anaemia.
Ethambutol (E) 15 mg/kg/day. Retrobulbar neuritis, blurring vision:
Max dose 1 g, one oral in that case stop drug. Difficult to
dose. asses in preschool children.
24
_________________________________________________________
Prednisolone (P)Indications: 2 mg/kg od for 2-3 weeks then tapered over 2-

- severe TB (meningitis, miliary) 3weeks.
- grossly enlarged lymph nodes
Category I New sputum smear positive PTB & severe

EPTB
Category II Relapse, treatment failure & Sputum smear

positive return after default
Category III New sputum smear negative and less severe

EPTB
Category IV Chronic cases
SEVERE EPTB LESS SEVERE EPTB

Meningitis Lymphnode
Milliary Unilateral pleural effusion
Pericarditis Bone (other than spine)
Bilateral or extensive unilateral Peripheral joint
effusion)
Spinal Adrenal gland
Intestinal
Genitor-urinary tract
25
_________________________________________________________
TREATMENT SCHEDULES
CLINICAL STATE COMBINATION OF DRUGS
Healthy newborn born to INH prophylaxis for 6mo +
mother with active Breastfeeding
tuberculosis and with After 6 mo  Mantoux/clin. exam
treatment <2 mo before neg.  BCG
delivery pos.  full treatment
Healthy, Mantoux neg. INH 6 mo prophylaxis + good

child in close contact nutrition
with active adult TB After 6 mo  Mantoux/clin.exam
neg.  BCG
pos.  full treatment
Category I patients RHZE 2 months then

RH 4 months or
EH 6 months
(add prednisone in
meningitis/miliary TB)
Category II RHZES 2 months

RHZE 1 month
RHE 5 months
Category III RHZE 2 months then

RH 4 months or
EH 6 months
HIV AND TB: Refer to HIV treatment guidelines
4.8 FOLLOW UP
26
_________________________________________________________
 The child could be discharged and registered with the District

TB/Leprosy co-ordinator, when infection is under control and
there is weight gain.
 Regular weight checks and supply of enough drugs are
essential.
 Case-finding in the child’s family.
27
KCMC, PAEDIATRICS 5 PERTUSSIS
_________________________________________________________
5 PERTUSSIS
5.1 DEFINITION
A prolonged, severe and distressing disease of children.
5.2 PREVENTION

 Immunize against pertussis.
 Give DPT immunization in a child not immunized.
 Try to protect young infants from coughing children.
 Give erythromycin12.5mg/kg for 10 days to exposed infants
less than 6 months
5.3 CAUSE
Bordetella pertussis, mainly. A toxin causes the paroxysmal
cough.
Bardotella parapertussis is an occasional cause with milder
syndrome
STAGES
Catarrhal stage 1 - 3 weeks (mild cough,
coryza, fever)
Paroxysmal stage 2 - 4 weeks (paroxysmal cough)
Convalescent stage 4 - 12 weeks
28
_________________________________________________________
COUGH
Typical paroxysmal expiratory cough followed by a high pitched
inspiratory noise, "the whoop", which can be missing in infants.
Coughing is accompanied by cyanosis, sweating, prostration and
exhaustion
VOMITING
Commonly follows a paroxysmal cough. Makes feeding difficult.
COMPLICATIONS
 Apnoea in very young infants and sudden death.
 Pneumonia.
 Atelectasis
 Intercurrent viral respiratory infection
 Otitis media
 Chronic bronchiectasis
 Seizures
 Epistaxisis and sub-conjunctival bleeding.
 Intracerebral bleeding.
 Hypoglycaemia.
 Malnutrition.
 Neurologic squeal, encephalopathy.
 Rectal prolapse.

ADMISSION
 Infants below 3-6 months may need intensive hospital care.
 The nutritional status should be followed. Feed in many small
meals. Give advice to the mother how to do this.
 If diagnosis is not sure, send for early assessment.
 Foreign body should be ruled out.
 In case of complications, especially in small children, refer
early.
29
_________________________________________________________
5.6 DIAGNOSIS
 Clinical findings and history usually enough.

 WBC: often leucocytosis and relative lymphocytosis, up to
90%.
 Bardotella pertussis from nasopharyngeal swab or nasal
wash.
 Chest X ray thickened bronchi
5.7 TREATMENT
ANTIBIOTICS
Dose: Comments:
Erythromycin 40-50 mg/kg/day in 4 doses Most effective
Or orally for 14 days within first week.
Azithromycin 10 mg/kg OD for 3 days Eradicates the
bacteria, but may
not shorten the
course.
100mg/kg/day in 4 doses for 10 days
Ampicillin Erythromycin
intolerant patients
Cotrimoxazole 36 mg/kg/day in 2 doses orally for 14 In pneumonia

days
Chloramphenical 25mg/kg in 3 doses In case of fever
30
_________________________________________________________
SUPPORTIVE THERAPY
 Oxygen may be needed for very young infants with severe
attacks, especially during the attack.
 Feeding. Very important. Many small meals if the child has
many paroxysmal attacks, or continuous drip feeding by
nasogastric tube in severe cases.
 Fluid IV may be needed if the child is vomiting much, see
chapter 46 on IV Fluid Therapy.
 Corticosteroids may be tried for encephalopathy and in
severe coughing attacks. Prednisolone 2 mg/kg/day in one
morning dose for some days to see if there is any effect.
 Give Vitamin A capsules, below 1 year 100.000 U, above 1
year 200 000 U for 2 days.
5.8 FOLLOW UP
 The nutritional status should be carefully followed after
discharge.
 If the child is not recovering from "pertussis" within 2-3
months, send for assessment. TB should be ruled out.
Whooping cough may be followed by habitual cough.
31
KCMC, PAEDIATRICS 6 MEASLES
__________________________________________________________________
6 MEASLES
6.1 PREVENTION
 Immunize against measles at 9 months. Give
simultaneously Vitamin A
100,000 I.U.
 Do not postpone immunization because of moderate
intercurrent disease.
 In case of measles contact: immunize non-immunized
children above 6 months on admission (if 6-9 months on
admission: make sure revaccination takes place at 9
months).
 Pay regular visits to MCH clinic for growth monitoring.
 Ensure good nutrition including Vitamin A rich food.
 Five days before and after rash the child is still infectious
and should be isolated
6.2 CAUSE
Measles virus, an RNA virus.

 Incubation period: 8-21days
o Fever and flu/ coryza like symptoms
 Prodromal phase
o Cough, laryngo-tracheo-bronchitis,
bronchopneumonia.
o Stomatitis, Koplik's spots in mouth.
o Conjunctivitis/ xerophthalmia with photophobia
 Rash
32
__________________________________________________________________
o Macula-papular rash with desquamation
o Otitis media.
o Gastroenteritis – dehydration.
o Encephalopathy (rare).

ADMISSION
Admit to hospital for proper treatment if the child has:

 General danger signs such as lethargy, inability to drink,
convulsions.
 Malnutrition.
 Bronchopneumonia, moderate or severe.
 Laryngo-tracheo-bronchitis.
 Deep or extensive mouth ulcer.
 Dehydration, vomiting for more than 24 hours.
 Xerophthalmia.
 Other contributing factors, such as anaemia.
 Neutropenia below 1.000/mm3 is a serious sign.
6.5 DIAGNOSIS
 Clinical mainly. Don't forget to examine the eyes daily.
 X-ray chest in bronchopneumonia, especially if there is
failure of treatment (suspect TB).
 Serology. Measles specific IgM 3days after eruption of
rash
6.6 TREATMENT
Supportive care
Fever: antipyretics if temp 39°C or above
33
__________________________________________________________________
NUTRITION
 The most important part, especially in malnourished
children.
 Treat children with PEM according to rules in chapter 13
on PEM. Nasogastric tube may be needed.
 Vitamin A should be given to all children with measles.
Dose: see chapter 13 on PEM. Give less if the 9 month
supplement has recently been given.
 Breastfeeding should be encouraged, also during illness.
FLUID
Rehydrate dehydrated children, see chapter 3 on Diarrhoeal
Diseases. Check daily for signs of dehydration. In case of
high fever and hyperventilation the maintenance fluid amount
is increased.
ANTIBIOTICS
Treat all bacterial complications.
 Pneumonia, see chapter 23 on Pneumonia. In early stage
virus - later bacteria. The pneumonia is sometimes very
severe. Penicillin plus Gentamicin may then be tried.
Oxygen may be needed.
 Otitis media, see chapter 18 on Otitis Media.
CARE OF THE MOUTH

Clean the child's mouth with clean water 4 times a day. Apply
gentian violet 0.5% to sores.
TREATMENT OF LARYNGOTRACHEOBRONCHITIS
For treatment of measles LTB see viral croup in chapter 22 on
Acute Obstructive Laryngitis. In addition nasotracheal
intubation may be of help if it lasts only for 1-2 days.
CARE OF EYES AND SKIN
34
__________________________________________________________________
Daily washing and inspection.
Secondary bacterial infection may require antibiotic eye
ointment. See chapter 17 on Eye Diseases.
6.7 COMPLICATIONS
EARLY: diarrhoea, ottitis media, pneumonia, croup,
mouth ulcers, conjunctivitis
LATE: cancrum oris, malnutrition, tubeculosis,
myocarditis, keratitis, xerophthalmia, subacute
sclerosing pan-encephalitis
TREATMENT OF ENCEPHALOPATHY
See chapter 44 on Coma.
6.8 FOLLOW UP
NUTRITION
Important with very good nutrition at least for 2 months after
measles. Breastfeeding. Also daily Vitamin A rich food.
MCH VISITS
Monthly for 2-3 months, then according to general condition.
EARLY REFERRAL IF THE CHILD GETS NEW SYMPTOMS
TB is often seen after measles. Should be dealt with early.
Postmeasles- chronic persistent diarrhoea.
35
KCMC, PAEDIATRICS 7 RABIES
___________________________________________________________________
7 RABIES
7.1 PREVENTION
 Vaccinate domestic animals, eliminate stray animals.
 Give pre-exposure vaccination to certain people e.g.
veterinary personnel, health worker caring for rabies
patients.
 Immediate adequate wound toilet.
 Take immediate actions when bitten by suspected animal,
see 7.4 below.
7.2 CAUSE
Rabies virus that is found in the saliva of infected animals e.g.
dogs, cats, foxes, skunks, bats, mongooses, jackals.
Licking can be contagious through wounded skin or intact
mucous membrane.
The virus travels from the bite along nerves to the central
nervous system.

Incubation period is from (4)-9 days to 2 years, usually 20-90
days. Shorter in proximal bites near CNS and after severe
bites.
PRODROMAL STAGE
Pain or paraesthesia at the site of the bite, general malaise,
headache, fever. Lasts for 1-4 days.
RAPID DEVELOPMENT OF COMPLEX NEUROLOGICAL

PICTURE
36
___________________________________________________________________
 Behavioural changes, excitement, photophobia, sensitivity
to noise, depression, anxiety.
 Hydrophobia, laryngospasm, dribbling of saliva.
 Apnoea, death after 5-10 days.
PARALYTIC RABIES
Less common. Acute progressive ascending myelitis, flaccid
paralysis, root pain. Death may be delayed up to four weeks.

ADMISSION
 Try to catch the biting animal, lock it up and contact a
veterinarian and start post exposure vaccination. If the
animal is still alive after 10 days, rabies can be excluded
and stop post exposure vaccination. Indication for early
(before 10 days after bite) post exposure vaccination
becomes stronger if:
 The risk of rabies increases if the bites are severe
or/and are proximal, e.g. in the face, arm.
 The child is bitten by a wild animal.
 Unprovoked animal bite.
 If the dog is not vaccinated
7.5 DIAGNOSIS
May be difficult if the incubation period is long. Ask about
animal bites.
37
___________________________________________________________________
7.6 POSTEXPOSURE TREATMENT

Category Type of Contact with a Suspect or Recommended
Confirmed Rabid animal Treatment
Touching or feeding of animals; licks None, if reliable case
I on intact skin history is available
Nibbling of uncovered skin; minor Administer vaccine

scratches or abrasions without immediately; stop
bleeding; licks on broken skin treatment if animal
II remains healthy
throughout an
observation period of 10
days or if animal is
euthanized and found to
be negative for rabies by
appropriate laboratory
techniques
Administer rabies
Single or multiple transdermal bites or immune globulin and
scratches; contamination of mucous vaccine immediately;
III membrane with saliva (i.e. licks) stop treatment if animal
remains healthy
throughout an
observation period of 10
days or if animal is killed
humanely and found to
be negative for rabies by
appropriate laboratory
techniques
38
___________________________________________________________________
LOCAL TREATMENT
Clean the wound thoroughly with soap and water or strong
antiseptic solution, e.g. iodine. No primary suturing. Tetanus
vaccination.
POSTEXPOSURE VACCINATION
 Give if possible Human Diploid Cell (HDC) vaccine as soon
as decided upon IM: 1ml 0, 3,7,14 and 28 days post
exposure, deltoid muscle.
 Stop treatment if the animal is alive after 10 days.
 For other vaccines and intradermal use (more economical
especially if more than one person involved) see dose
recommended by manufacturers.
IMMUNOGLOBULIN
In large wounds especially in the head and neck, try to give
human antirabies immunoglobulin 10 IU/kg IM plus 10 IU/kg as
infiltrate around the wounds.
TREATMENT WHEN SYMPTOMS HAVE APPEARED

Survival not possible. No reason for referral.
BARRIER NURSING
The saliva of the child is contagious. All efforts should be made
to comfort and be close to the dying child.
SEDATION
Chlorpromazine 4 mg/kg/day IM in 3-4 doses
and
Phenobarbitone 15-20 mg/kg IV as loading
dose
from day 2: 6 mg/kg/d IM or IV
39
KCMC, PAEDIATRICS 8 AIDS
_____________________________________________________________________
8 PAEDIATRIC HIV/AIDS
Transmission of HIV infection from a pregnant woman to her infant, is the
main source of HIV infection in infants and children worldwide.
• Acquisition of HIV in infants can occur
– In utero (5 – 10%)
– Intrapartum (10 – 15%)
– Post-natally through breast feeding (5 -20%)
• Infection in infants leads to rapid disease course compared to
adults
– Majority develop symptoms by 12 months
– 50% mortality by 2 years of life
– 75% mortality by 5 years of life
8.1 PREVENTION
Major PMTCT interventions should include:
 Counseling and Testing at a Reproductive and Child Health
Services setting
 Provision of ARV prophylaxis to the HIV positive mother
and her infant to prevent Mother to Child Transmission (MTCT)
 Infant feeding counseling and support
 Safer delivery practices
Antenatal care
 Group information session discussing PMTCT and HIV testing
 Individual post-test counseling when HIV test results are received
 ARV treatment or prophylaxis according to PMTCT protocol
 Follow-up ANC visits, with treatment and support for women who
are HIV-infected
Labour & delivery
40
_____________________________________________________________________
 HIV testing and counseling during labor and delivery
 Prevent prolonged labour, unnecessary procedures such as
episiotomy without proper indication.
 ART according to PMTCT protocol
Ongoing reproductive and child health care

 Follow-up visits, with treatment and support for women who are
HIV-infected and their children according to protocol
PMCTC REGIMEN
Refer to table on chapter 49
8.2 CAUSE
Infection with Human Immunodeficiency Virus, HIV type 1 or
type2.

The clinical expression of HIV infection in children is highly
variable. Some
HIV-positive children develop severe HIV-related signs and
symptoms in the
first year of life. Other HIV-positive children may remain
asymptomatic or mildly symptomatic for more than a year and
may survive for several years.
 General: failure to thrive weight loss or a gradual but steady
deterioration in weight gain from the expected growth, as
indicated in the child’s growth card. Suspect HIV particularly
in breastfed infants <6 months old who fail to thrive. Other
general features include malnutrition, recurrent fever, hepato-
splenomegaly, anaemia, generalised lymphadenopathy,
chronic diarrhoea.
 Respiratory: chronic suppurative otitis media, persistent
cough, tuberculosis, interstitial pneumonia (X-ray:
41
_____________________________________________________________________
reticulonodular shadowing sometimes with mediastinal
lymphadenopathy), Pneumocystis pneumonia.
 Skin, mucous membranes: bilateral recurrent parotid
swelling, oral candidiasis beyond neonatal period (often also
oesophageal), persistent mucocutaneous herpes infection,
generalised dermatitis, pruritis, Kaposi’s sarcoma.
 Septicaemia, often Salmonella, may be recurrent.
 Recurrent severe bacterial infection: three or more severe
episodes of a bacterial infection (such as pneumonia,
meningitis, sepsis, cellulitis) in the past 12 months.
 Encephalopathy: developmental delay, cognitive impairment,
ataxia.
 Urinary tract infection.
 Rarely seen: nephropathy, cardiomyopathy, malignancy.
Strongly suspect HIV infection if the following are present: pneumocystis

pneumonia, oesophageal candiasis, lymphoid interstitial pneumonia,
Kaposi’s sarcoma. These conditions are very specific to HIV-infected
children. Acquired recto-vaginal fistula in girls is also very specific but rare

ADMISSION
Provider initiated counselling and testing for all children.
8.5 DIAGNOSIS
ANTIBODY TESTS
An antibody test will be positive in a child of an HIV-positive
mother, even if the child is not infected by the virus. Non-infected
children become negative between 15-18 months. A child above
42
_____________________________________________________________________
18 months of age with a positive antibody test should be consider
positive and staged (refer chapter 49 for clinical staging)
VIRUS DETECTION
The Polymerase Chain Reaction (PCR) and viral cultures detect
the virus early
Every HIV-exposed baby should have a DNA PCR test at
4 - 6 weeks of life
Or
At first contact with health facility (if >4 weeks of age)
If the HIV DNA PCR result is POSITIVE the baby is

HIV-INFECTED
If PCR is negative and the baby is breast feeding, PCR should be
repeated 6 weeks after cessation of breastfeeding.
PRESUMPTIVE DIAGNOSIS
A presumptive diagnosis of severe HIV disease should be made
if:
• An infant < 18 months has an HIV antibody test positive
AND:
• Has diagnosis of any AIDS-indicator condition(s) OR
• Symptomatic with two or more of the following:
- Oral thrush
- Severe pneumonia
- Severe sepsis
• Other factors that support the diagnosis include:
- Recent HIV -related maternal death
- Advanced HIV disease in the mother
- CD4< 25%
The HIV status should be confirmed as soon as possible.
Presumptive diagnosis should NOT be done in children >18
months old. In these infants HIV infection must be confirmed
or excluded using widely available antibody tests.
43
_____________________________________________________________________
8.6 TREATMENT
ANTIRETROVIRAL THERAPY
Refer to national guideline for eligibility and treatment.
OTHER TREATMENTS
COTRIMOXAZOLE PROPHYLAXIS
Refer to national guideline.
NUTRITION
Tanzania’s guidelines promote the parents’ right to choose how
they want to feed their infant; the healthcare worker's job is to
support their choice
FEEDING OPTIONS:
The option of not breastfeeding should be discussed with the
mother.
Breastfeeding increases the risk of vertical transmission
significantly, closely related to the duration of the breast feeding.
Exclusive Breastfeeding: feeding the infant ONLY breast milk.

Until 6 months of age, infant is NOT given anything else besides
breast milk.
Exception: prescribed medicines or vitamin and mineral
supplements.
Replacement Feeding: NEVER feed the infant breast milk. An
infant is given a breast milk substitute such as commercial infant
formula or modified animal milk.
Recipe for approximately 1 litre adjusted cow’s milk formula:
44
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 Infants below 2 weeks: cows milk 500 ml, water 500 ml,
sugar 50 grams and cooking oil 10 ml.
 Infants 2 weeks-6 months: cows milk 650 ml, water 350 ml
and sugar 50 grams.
 All infants fed with this milk substitute need additional
Vitamins (Cod liver oil 5 ml/day) and additional Ferrous
sulphate (3 mg elementary Fe/kg/d)
Mixed Feeding: Mixed Feeding: infant is breastfed and ALSO
given other liquids such as water, tea, formula, cow’s milk or
foods such as porridge or rice. This option carries high risk of
HIV transmission and should be discouraged
VACCINATIONS
All vaccinations should be given as scheduled.
BCG should not be given to a child who has symptoms of HIV.
HIV infected children should receive measles vaccine at 6 months
of age and a repeat at 9months.
TREATMENT FOR OPPORTUNISTIC INFECTIONS:
TUBERCULOSIS
In HIV- infected children with Tuberculosis the initiation of Tb
treatment is the priority.
Children with disease stage 4: start ARV within 2-8 weeks after
start of anti-Tb
Stage 3 with severe or advanced immunodeficiency start ARV
within 2-8 weeks as above
Stage 3 with mild or non significant immune suppression wait and
observe, start ARV when CD4 is below the threshold
Treat as per national policy.
45
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TREATMENT OF OTHER OPPORTUNISTIC INFECTIONS
CRYPTOCOCCAL MENINGITIS
 Amphotericin B 0.5 mg/kg/day once daily or 1 mg/kg/day
every other day, IV infusion over 2-6 hours, for 6 weeks (In
critically ill patients with normal serum creatinine: combine
with Flucytosine 100 mg/kg/day, orally in 4 doses, if
available.) or if AMP B not feasible give the less effective
Fluconazole 6 mg/kg, orally, once daily for 6 weeks.
 After treatment-phase: maintenance with Fluconazole 100 mg
(3-6 mg/kg/d) orally, once daily, indefinitely.
TOXOPLASMA INFECTION
 Pyrimethamine 2 mg/kg (max 50 mg), orally, once daily for 2
days, followed by maintenance 1mg/kg (max 25 mg) orally,
once daily, indefinitely and
 Sulfadiazine 75 mg/kg/d (max 4 gram), orally, first day.
Followed by maintenance 100 mg/kg/d, orally in 2 doses,
indefinitely and
 Folic Acid 5 mg once daily, indefinitely.
PNEUMOCYSTIS JIROVECI (CARINII) PNEUMONIA

 Trimethoprim/Sulfamethoxazole (TMP/SMX) 20/100
mg/kg/day orally in 3-4 doses for 3 weeks or 15/75 mg/kg/d
IV if oral treatment not possible
(equally effective). If TMP/SMX contraindicated or if no
clinical improvement after 1 week: Pentamidine 4 mg/kg IV
once daily for 2 weeks.
 Followed by prophylaxis of 5/25 mg/kg/d (=5 mg TMP) once
daily every other day, indefinitely or if contraindicated
Pentamidine 10 mg/kg (max 300 mg), aerosolized in closed
face mask, once a month, indefinitely or if this is not feasible,
Dapsone 2 mg/kg/d, orally, once daily, indefinitely.
 In critically ill patients with low oxygen saturation add
Prednisolone 2 mg/kg/day in one daily oral dose for first 10
days than tapering off for 10 days.
46
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Kaposi’s Sarcoma
See chapter 11 on malignancy
IRIS
• IRIS ( immune reconstitution inflammatory syndrome) is A
spectrum of clinical signs and symptoms resulting from the
[body’s] restored ability to mount an inflammatory response
associated with immune recovery
• The likelihood and severity of IRIS correlates with two
interrelated factors:
• The extent of CD4+ T-cell immune suppression prior
to the initiation ART
• The degree of viral suppression and immune
recovery following the initiation of ART
Management Principles of IRIS
• Consider other possible aetiologies
• Continue ART if possible
• Interrupt if life threatening
• Attempt to diagnose infection or condition responsible for
IRIS
• Initiate disease-specific therapy (such as TB
treatment), if not already in place
• Provide anti-inflammatory therapy
 Steroids
PSYCHOLOGICAL CARE
Is essential both to the child and to the family.
8.7 FOLLOW UP
47
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 The family must know where to go for help when the child is
getting worse. Cooperation between different levels of
medical care has to be worked out.
 Often a child is the first case diagnosed in a family and
subsequently siblings and parents are found to be positive.
 The doctor should be active in stimulating community-based
action.
 The future of the family, including family planning and
contraception, should be actively discussed.
 Follow up of exposed children should include:
 At birth (for infants born at home)-wt, head
circumference, height, physical exam.
 At age 1-2 wks-for infant feeding counsel-wt, feeding
amount
 At age 6, 10, 14 wks-for DNA PCR testing, immunization
and feeding counseling
 After age 14wks, monthly through 12 months-for
monitoring of growth and development and checking for
HIV features
 After 12 months, every 3 months through 24 months
 At 18 months a confirmatory HIV laboratory test if no Ag-
based test
 Mothers: wt, OI, STDs, Behaviour change
 Family planning
48
KCMC, PAEDIATRICS 9 MALARIA
__________________________________________________________________
9 MALARIA
9.1 PREVENTION
 Protect against mosquitoes: windows, insecticide impregnated
mosquito-net even during the day when sleeping.
 Eliminate breeding places for mosquitoes.
 Mosquito bite avoidance. Use repellents, long clothing,
mosquito mesh, and insecticide treated nets.
 Vector control. Indoor spraying, eliminate mosquito breeding
sites
 Anti-malarial chemoprophylaxis. Especially for children with
sickle cell disease, non-immune children and children with
tropical splenomegally syndrome
9.2 CAUSE
Plasmodium falciparum is the most common in Tanzania (90%).
Other plasmodia species; vivax, ovale, malariae; also cause
disease.

UNCOMPLICATED MALARIA
Malaria attacks are very common in young children in endemic
areas. Attacks are characterised by fever, "malaise", fatigue,
sometimes vomiting, diarrhoea, poor appetite,
hepatosplenomegally, anaemia, joint pains, headache. Older
children, that have achieved semi-immunity, may have
asymptomatic infection.
An uncomplicated malaria attack can become severe malaria.
SEVERE MALARIA IN CHILDREN
50
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CEREBRAL MALARIA
Is severe falciparum malaria with coma. If coma was preceded by
convulsions, it should persist for more than 30 minutes.
Mainly in children < 5 yr. Fever, headache, vomiting, drowsiness.
Convulsions herald onset of neurological disease. Deterioration
can be within hours. Hypoglycaemia major risk. 10% of survivors
get severe neurological sequelae, hemiparesis, epilepsy, cortical
blindness.
SEVERE ANAEMIA
Hb < 7g/dl. Peak age group 1-2 yr. Rapid deterioration during a
malaria attack. Probably caused by longstanding low grade
parasitaemia.
HYPERPARASITAEMIA
> 5% of erythrocytes infected or > 250,000 parasites/mm 3.or
>5000/200wbc
SEVERE RESPIRATORY DISTRESS
Predicts high mortality caused by pulmonary oedema or metabolic
acidosis.
CONVULSIONS (repeated generalized convulsions more than 2
times within 24 hours) May be the first sign of cerebral malaria.
HYPOGLYCAEMIA
Must be detected and treated.
PROSTRATION
SHOCK
UNCOMMON SYMPTOMS
Renal failure, jaundice. Macroscopic haemoglobinuria,
Disseminated Intravascular Coagulation (DIC) and other bleeding
disorders.
51
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ADMISSION
In endemic areas malaria should be suspected in children with
symptoms listed above. Prompt treatment and always check blood
slide, blood glucose (rapid malaria test in severe cases).
9.5 DIAGNOSIS
HISTORY AND CLINICAL EXAM
Look for danger signs and signs of co-infections
LABORATORY INVESTIGATIONS
Blood films, thick and thin. A single negative blood slide does not
rule out malaria. Repeat at least twice in case of high suspicion of
malaria.
Rapid Diagnostic tests are qualitative techniques based on
detection of malaria parasite antigens.
Other Laboratory investigations: if indicated
9.6 TREATMENT
In serious disease (e.g. suspicion about cerebral malaria and in

severe malaria) treatment should be given even when blood slides
are negative.
Uncomplicated malaria
52
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First line: Artemether (20mg)-Lumefantrine (120mg) (ALu)

Dose; 1.5-12 mg/kg twice a day for three days. .
Kg Age Day 1 Day 2 Day 3
0 hrs 8 hrs morning Evening morning evening
5-15kg 3mo-3yrs 1 1 1 1 1 1
15-25kg 3 -8 yrs 2 2 2 2 2 2
25-35kg 8-12yrs 3 3 3 3 3 3
> 35 kg > 12 yrs 4 4 4 4 4 4
Contraindications;-
 Child less than 5kg or less than 3 months
 Give quinine instead
Second line: Quinine 10 mg/kg/dose orally 8 hourly for 7days
Drugs: Dose: Side effects:

Quinine sulphate (only) 10 mg/kg/dose 3 times a day orally Giddiness, ringing in
for 7-10 days ears, nausea,
haemolytic anaemia
or
Quinine sulphate 10mg/kg/dose 3 times a day for 3
days
or followed by:
ALu doses as above for 3days
CEREBRAL AND SEVERE MALARIA

Quinine is the drug of choice
Dose: 10 mg/kg/dose of quinine in 10 mls/kg of 5% dextrose /DNS
Infused over 4 hours and repeated every 8 hours
53
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It is given intravenously until the child is able to take it (mostly 3
days), duration 7 days
Or full dose of ALu after incomplete dose of quinine.
Quinine doses should be 7 mg/kg body weight in patients

with impaired renal function.
In non-responding cases Arthemeter has been used with good
results.
Dose:- 3.2 mg/kg (loading dose) I.M followed by 1.6 mg/kg I.M
daily for 6 days.
NEONATAL MALARIA:
 Broad spectrum antibiotic.
 Parenteral quinine 10mg/kg 8-12 hourly till the baby is able to
breast-feed, then oral quinine is given to complete 7 days
treatment
 If a neonate is not able to breast feed, give 10% glucose IV
60ml/kg/24 hours
 Give blood transfusion if HB is <10g/dl
54
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SUPPORTIVE THERAPY IN CASE OF
COMA Exclude meningitis. Don't give

corticosteroids, mannitol, or heparin. With
effective antimalarial treatment recovery
within 2-3 days. Restrict fluid to
maintenance. Monitor urine output.
HYPERPYREXIA Avoid warm clothing.

Paracetamol 15 mg/kg/dose orally.
CONVULSIONS Diazepam rectally or paraldehyde or

Phenobarbitone. See chapter 15
on Convulsions. If post convulsive
drowsiness persists > 1h,cerebral
malaria is most likely.
SEVERE ANAEMIA May be caused by haemolysis; give
blood transfusion (on strict indications, life
saving). See chapter 12 on Anaemia.
Treat anaemia patients with fever as
malaria, even when blood slide is
negative.
ACUTE RENAL FAILURE Strict fluid balance if urinary output is less

than 0.5 ml/kg/h. Peritoneal dialysis may
be necessary in anuria. See chapter 47
on Paediatric Procedures.
BLEEDING DISORDERS & DIC Vitamin K injection. Fresh whole blood.
55
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HYPOGLYCAEMIA IV Dextrose 5% 10 ml/kg

10% 5 ml/kg
25% 2 ml/kg
Thereafter change Quinine/dextrose 5%
IV to Quinine/dextrose 10%. Oral feeds.
GRAM NEG. SEPTICAEMIA Antibiotics: see 14.8 treatment of

septicaemia.
9.7 FOLLOW UP
 Drug prophylaxis of malaria should only be used by visitors,

not for indigenous population, except pregnant women and
children with sickle cell disease.
 Children with cerebral malaria should be followed up after 4
weeks
56
KCMC, PAEDIATRICS 10 HELMINTHIASIS
_______________________________________________________________________
10 HELMINTHIASIS
10.1 PREVENTION
This is principally done by interruption of the lifecycle of the worm
at specific points. Hence the life history of common worms should
be understood.
Older infants and children should be dewormed every 3-6months.

 Proper use of latrines for disposal of faeces. Discourage use
of fresh human faeces for manure.
 Avoid soiling clothes with stool.
 Improve hand hygiene. Clean hands after defecation and
before eating. Cut nails short.
 Wear shoes for protection against hookworm.
 Avoid eating raw meat, fish, and vegetables.
 Avoid close contacts with dogs, cats/deworm dogs and cats.
 Avoid bathing in water harbouring Bilharzia.
10.2 CAUSES, SIGNS AND SYMPTOMS
ASCARIS LUMBRICOIDES
 The larval stage gives rise to respiratory symptoms (Loeffler
syndrome) such as; pneumonitis with cough, fever, pulmonary
infiltration and wheezing for a few days. Suspect in case of
skin allergies (especially wheals), recurrent cough, and vague
abdominal pain.
 The established infection in the small intestines can give
gastrointestinal discomfort, vomiting, and heavy infestation
may lead to intestinal obstruction.
57
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 Migration of the adult worm to almost any part of the body
can cause local pathologies such as; volvulus and gangrene
of the bowel, intussusception, appendicitis, intestinal
perforation and peritonitis, cholangitis, acute cholecystitis,
obstructive jaundice, perforation of bile ducts, liver abscess,
pancreatitis. Worms can also migrate to trachea, larynx,
paranasal sinuses, etc.
HOOKWORM
Ancylostoma duodenale or Necator americanus.
 The larval penetration of the skin can give itchy papules.
During passage through the lungs, there could be cough,
wheezing, but less severe than with Ascaris.
 The adult worms in small intestine cause iron deficiency
anaemia (due to blood loss, 0.03 ml/day/worm and 0.15
ml/day/worm for A. duodenale and N. americanus
respectively). Symptoms: Burning sensation in the stomach,
anaemia, Pica. see chapter 12 on Anaemia.
TRICHURIS TRICHIURA
Diarrhoea with some blood, but without fever. Rectal prolapse,
tenesmus. Anaemia which can lead to cardiac failure, and oedema
in heavy infections.
ENTEROBIUS VERMICULARIS (OXYURIS)

Pruritus ani. Sleep disturbance.
STRONGYLOIDES STERCORALIS
 The filariform larva penetrates the skin and gives a creeping
eruption on the trunk. Sometimes oedema, urticaria. Also
symptoms from lungs (pneumonitis); cough, wheezing.
58
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 The adult worms may cause abdominal pain, diarrhoea and
steatorrhoea.
 Hyperinfection syndrome occurs in children on treatment
with corticosteroids, anticancer drugs and malnourished
children and can be fatal. It presents with diarrhoea, paralytic
ileus, Gram neg septicaemia, pulmonary (larval) symptoms,
serious effusions and bacterial peritonitis. Also symptoms from
brain. No eosinophilia.
TRICHINELLA SPIRALIS
 Infection occurs by eating the encapsulated larvae form in
poorly cooked pork.
 Adult worm penetrates bowel wall, enter the circulation and
are deposited in muscles. Patients develop fever, muscle pain,
facial oedema and have marked eosinophilia.
TAPEWORMS
TAENIA SOLIUM (PORK TAPEWORM) AND TAENIA
SAGINATA (BEEF TAPEWORM)
 The cysticerci (larval stage) in muscles and subcutaneous
tissues may give small swellings beneath the skin which may
calcify (X-ray). Cerebral cysticercosis may cause epilepsy.
 The adult worm can give slight abdominal discomfort.
ECHINOCOCCUS GRANULOSUS (HYDATID)

 Hydatid cysts develop from eggs ingested from infected dog
faeces. The cysts are mainly in the liver and lung causing
mechanical effects when they grow, e.g. painful enlargement
of the liver and cough, breathlessness.
 Secondary complication from infections and rupture of cysts.
59
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SCHISTOSOMA
SCHISTOSOMA HAEMATOBIUM, MANSONI

 Cercaria in water penetrates human skin give rise to itchy
papular rash.
 Schistosomule grow the in liver.
 Adult worms:
 S. mansoni inhabit lower mesenteric veins and eggs in
faeces. Granulomata, polyps develop in the colon and
rectum. Initially no symptoms, mild anaemia,
hepatomegaly. Katayama fever after 20-60 days with
urticaria, eosinophilia, diarrhoea, hepatosplenomegaly,
cough and wheeze may occur in heavy infection in non-
indigenous population. Severe cases with fibrosis of liver
leading to portal hypertension with hepatosplenomegaly,
oesophageal varices.
 S. haematobium inhabit veins surrounding bladder.
Passage of their eggs gives rise to haematuria,
granulomata which may obstruct ureters, thickened
bladder wall.
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ADMISSION
Recognition of severe anaemia and heavy infection in time.
10.5 DIAGNOSIS
 Stool examination most important.
 Urine for Schistosoma haematobium eggs. Best to collect
urine at in the morning (or before 2pm)
 Blood Hb, eosinophilia.
 Serology for schistosomiasis.
 Rectal biopsy for Schistosoma mansoni.
 X-ray in selected cases.
 Ultrasound to detect "pipestem" fibrosis of liver.
10.6 TREATMENT
DRUGS
Dose: Side effects:
Piperazine Ascaris treatment: Rarely side effects.

50 mg/kg in single dose orally. Maximum Vomiting blurred
4 g. vision. Do not give
Repeat after 2 days. in renal or liver
Enterobius treatment: disease or in
50 mg/kg/d in 2 doses epilepsy.
orally for 7 days.
Levamisole (Ketrax) 2.5 mg/kg orally. Repeat after 2 weeks. Nausea, vomiting.
Thiabendazole 50 mg/kg/day in 2 doses orally for 2 days. Nausea, vomiting,

vertigo, headache.
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Mebendazole 200 mg/day in 2 doses

(Vermox) orally for 3 days crushed and chewed. Side effects rare.
Below 2 yr. ½ dose.
Albendazole Ascaris: 400 mg once orally

Tapeworm:15 mg/kg orally in 3 doses for Side effects rare.
28 days
Niclosamide Children < 20 kg: 1 g

20-30 kg: 1,5 g Side effects rare
> 30 kg: 2 g
Praziquantel S. haematobium and Rarely. Headache,

(Biltricide) S. mansoni: 40 mg/kg single dose orally. dizziness, nausea,
Taenia: 10-20 mg/kg as single dose orally vomiting, fever,
sweating.
Metrifonate S. haematobium only. Nausea, vomiting,

(Bilarcil) 7.5 mg/kg one dose orally. To be repeated headache.
2-3 times, at intervals of 2 weeks. Cheap
Oxamniquine S. mansoni only. 30 mg/kg/day in 2 doses Dizziness,

Vansil orally for 2 days. drowsiness,
headache. Urine
may be red.
62
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RECOMMENDED DRUGS IN DIFFERENT CONDITIONS

Ascari Hook Trichuris Enterob Strongyl Tape Schistos
Piperazine ++ (+) - ++ - - (+)
Levamisole ++ +(+) (+) - + - -
Thiabendazole + + ++ (+) ++ - -
Albendazole + + (+) + + ++ -
Mebendazole ++ ++ ++ ++ + ++ -
Niclosamide - - - - - ++ ++
Praziquantel - - - - - ++ ++
Metrifonate - - - - - - ++
Oxamniquine - - - - -- ++
The drug underlined is recommended as the most suitable drug,

either because of the price or lack of good alternatives.
TREATMENT OF OTHER PARASITES NOT INCLUDED ABOVE

Filariasis, onchocerciasis and trypanosomiasis (see relevant
textbooks).
TREATMENT OF ASCARIS INTESTINAL OBSTRUCTION

 Nothing by mouth.
 Gastric suction.
 Pass nasogastric tube with Piperazine:
150 mg/kg initially, 65 mg/kg every 12 hours, 6 times
 Surgery if the child gets worse.
SURGERY
May be needed in several complicated ascaris infections and in
63
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hydatid cyst.
LOEFFLER SYNDROME:
Symptoms in larval stage  treat worms after 4 weeks.
10.7 FOLLOW UP
Nothing special, but advise mother about preventive measures.
64
KCMC, PAEDIATRICS 11 SOME COMMON TUMOURS
__________________________________________________________________________
11 SOME COMMON TUMOURS

GENERAL REMARKS REGARDING CHILDREN WITH
MALIGNANCIES
 Childhood cancers tend to differ more than those that occur in adults.
Most occur sporadically and are rarely associated with increased host
susceptibility. Not all cancers can be treated. Our general policy is to
give specific treatment to those who can clearly benefit in view of:
 a relatively good medical prognosis
 likelihood that treatment schedules will be adhered to
This is decided within a group of consultants and residents according
to pre-set criteria. Others will receive symptomatic treatment only.
 Apart from a general workup (including screening for infections) and

staging, the following factors should be taken into account prior to the
start of any cytostatic treatment:
 Adequate pain management
 hydration state
 blood picture (including Hb, neutrophils, platelets)
 imaging (including ultrasound, x-rays, CT-scan, etc)
 renal function tests
 liver function tests
 general nutritional status
 HIV test
 counselling of parents on treatment and proper followup
65
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11.1 BURKITT'S LYMPHOMA

(For other lymphomas see textbooks)
CAUSE
Cause is unknown but it is associated with Epstein Barr virus and is
prevalent in malaria endemic areas.
SIGNS AND SYMPTOMS

Is a fast growing tumour, usually presenting as a jaw or facial bone
tumour and can as well present as an abdominal tumour. It commonly
involves kidneys, ovaries, lymph nodes, breast, bone marrow,
mesentery and meninges. Paraspinal tumour may cause paraplegia.
There is very rare involvement of the peripheral lymph nodes in
contrast with the other malignant lymphomas and leukaemia. In
advanced stage it may spread to the Central Nervous System or
bone-marrow.
IMPORTANT ACTIONS TO BE TAKEN BEFORE ADMISSION

Quick referral once tumour is suspected.
DIAGNOSIS
 Needle aspiration for cytology shows "starry sky" picture;
cytology gives characteristic appearance of abnormal vacuolised
lymphoid cells.
 Staging and evaluation of the extent of the tumour is very
valuable, but the size also is important even in single abdominal
site involvement.
 Staging should include bone marrow-aspiration, CSF
examination and chest x-ray.
STAGING AND PROGNOSIS:
66
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Staging is according to the St. Jude Staging System for childhood
non-Hodgkin lymphoma
Stage I: A single tumour (extranodal) or single anatomic area
(nodal), with the exclusion of mediastinum or
abdomen
Stage II: A single tumour (extranodal) with regional node
involvement
Two or more nodal areas on the same side as the
diaphragm
Two single (extranodal) tumours with or without
regional node involvement on the same side of the
diaphragm
A primary GIT tumour, usually in the ileocecal area,
with or without involvement of associated mesenteric
nodes only, which must be grossly (>90%) resected
Stage III: Two single tumours (extranodal) on opposite sides of
the diaphragm
Two or more nodal areas above and below the
diaphragm
Any primary intrathoracic tumour (mediastinal,
pleural, or thymic)
Any extensive primary intraabdominal disease
Stage IV: Any of the above, with initial involvement of central
nervous system or bone marrow at time of
diagnosis
67
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TREATMENT
CHEMOTHERAPY
1. Cyclophosphamide: 40 mg/kg/dose or 1000 mg/m2 IV to 1200
mg/m2 IV infusion in 100 ml of 5% Dextrose strictly IV within 30
minutes. Thereafter flush with 5DNS 1.5 to 3L/day according to
child’s weight and urine output. Repeat once every two weeks.
2. Vincristine (Oncovin): 0.05 -0.07 mg/kg /dose IV or 1.5 mg/m 2 -

2.0 mg/m2 IV.Strictly IV. By slow push over 1 minute. preferably
diluted with NS to make a solution containing 1mg/ml given into a
tubing of fast running infusion of NS. Once every two weeks.
NB: IT administration is fatal.
3. Methotraxate IV; Attention to preparation strength :( 25mg/cc)

0.7 -2mg/kg/dose orally or IV or 75 mg/m 2 IV once every two weeks.
By bolus IV or infusion over 3 to 24 hrs.
4. Methotraxate IT; Use a low volume preservative free preparation.

(2.5 – 5 mg/ml)
Dose according to age:
< 2 yrs. 5mg
2 – 10 yrs. 10mg
>-10 yrs 15 mg
Given weekly as indicated below.
5. Allopurinol 10- 20mg/kg orally in divided doses max

400mg/day.preferably after food 1-2 days before starting
chemotherapy.
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Recommended schedule for Burkitt’s lymphoma chemotherapy.

Name…………………………
Hosp number…………………
Age……
Sex………..
Wt………….kgs
Ht…………..Cms
BSA…………..M²
Diagnosis………………
Staging…………………
Starting date……………
FBP….HB (Min 7g/L) ……………ANC………(Min 1000 cells)
Hydration………..
Allopurinol……….
Date For burkitt’s lymphoma
Drug dose route Week 1 2 3 4 5 6 7 9 11
Cyclophosphamid IV x x x x x x
e
Vincristine IV x x x x x x
Methotraxate IV x x x x x x
Methotraxate IT x x x x x x
Notes:
1. IT methotraxate is given weekly for prophylaxis in the first three cycles at weekly
intervals i.e. 6 doses.
2. If there is CNS involvement IT methotraxate is given in all six cycles i.e. 12 doses
at weekly interval.
3. Take CSF for cytology before giving ITMTX, until it is negative on two successive
tests (in CNS involvement).
4. Amount of ITMTX amount should be equivalent to amount of CSF taken for
cytology.
69
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TOXICITY OF CHEMOTHERAPY
 Nausea and vomiting: diarrhoea is common.
 Bone marrow depression (anaemia, bleeding, infections). Start
next course if neutrophil count is above 1000/mm 3 and platelets
above 100000/mm3.
 Hyperuricaemia with renal failure: after a rapid destruction of the
tumour. Prevent by Allopurinol and plenty of fluids.
 Haemorrhagic cystitis from Endoxan: prevent by good hydration.
 Endoxan is cardiotoxic.
 Alopecia is common but reversible.
11.2 WILMS TUMOUR

Is a malignant renal tumour derived embryonic cells. It is also called
nephroblastoma
SIGNS AND SYMPTOMS

 Usually unilateral abdominal mass (kidney), not crossing the
midline, see chapter 41 about Abdominal Mass.
 Few general complaints (abdominal pain).
 Quite often hypertension.
 Sometimes haematuria.
 Sometimes associated with congenital malformations (iris, ear,
hemihypertrophy).

Quick referral in early stages.
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STAGING:
I Tumour limited to the kidney and completely
resected.
II Tumour extends to the pseudocapsule, paraaortic
glands or renal vein, but completely resected.
III Residual non-haematogenous tumour confined to the
abdomen. Tumour left at operation or spillage at
operation.
IV Haematogenous spread to lungs liver and brain.
V Bilateral renal involvement.
TREATMENT
CHEMOTHERAPY (after screening for/treating infections)
For stage I and II
 Actinomycin D slow push = 1 minute 1.5 mg/m2 IV (make sure:
strictly intravenous). Given for 5 consecutive days and repeat at 6
weeks, and 3, 7, 9 and 12 months later.
 Vincristine slow push = 1 minute 1.5mg/m2 (makes sure: strictly
intravenous). Given on day 1 and day 5 weekly for 7 cycles.
For stage III, IV & V
 Actinomycin : as above
 Vinctristine: as above
 Doxorubicin: once every three months for twelve months
PRECAUTIONS IN CHEMOTHERAPY
 Prevent dehydration.
 In children < 10 kg give only 2/3 of dose cytostatics.
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RADIOTHERAPY
Postoperative radiotherapy to the tumour bed except in children
below 2 yr. with localised early stage tumour.
SURGERY
Nephrectomy with early ligation of the renal pedicle. Proper
inspection of the contralateral kidney. Liver examination for
metastasis. Regional lymph nodes should be excised. Tumour
spillage decreases prognosis significantly.
11.3 KAPOSI`S SARCOMA

GENERAL REMARKS
• KAPOSI’S SARCOMA:Is a spindle-cell tumour thought to be derived
from endothelial cell lineage and is caused by human herpes virus 8
(HHV8).
• The tumour is highly vascular containing abnormally dense and
irregular blood vessels, which leak red blood cells into the
surrounding tissue and give the tumour its Dark colour
• It became more widely known as one of the AIDS defining illnesses in
the 1980
• HIV serology should be done in all patients with Kaposis sarcoma, if
status unknown
SIGNS AND SYMPTOMS

 Lesions may involve the; skin, oral mucosa , lymph nodes and
visceral organs.
 Most patients present with cutaneous disease
 Cutaneous lesions may occur at any location but typically are
concentrated on the lower extremities and the head and neck region
 Lesions may have macular, popular, nodular, or plaque like
appearances and may assume a brown ,pink, red ,or violaceous
colour and may be difficult to distinguish in dark skinned individuals
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 Nearly all lesions are palpable and non pruritic . May range in size
from several millimeters to several centimeters in diameter
 Mucous membrane involvement is common (palate, gingival,
conjuctiva). Ulcerated or bulky tumour may interfere with speech and
mastication
 Tumour associated lymphedema (elephantoid), typically manifested
by lower extremity or facial swelling, thought to occur secondary to
obstruction of lymphatic channels
 Occasionally visceral disease may precede cutaneous manifestations
 Lesions can occur in the GIT(often asymptomatic), and present with
dysphagia, nausea, vomiting, abdominal pain ,haematemesis,
melena, bowel obstruction,
 When lesions are in the lungs may present with cough, dyspnoea,
hemoptysis, chest pain (difficult to distinguish from other diseases)
DIAGNOSIS
 Mainly clinical
 Punch biopsy of the skin
 Endoscopic biopsy (OGD, Colonoscopy, Transbronchial)
 FNAC for lymphadenopathic lesions
 CXR for pulmonary lesions
 CD4 counts and Viral load for patients with HIV
STAGING
 No staging system has been accepted, several have been
proposed
TREATMENT
CHEMOTHERAPY
Use a combination of the following in each cycle and can be
repeated after three months
Vincristine: 1.5- 2mg/m2 IV for 3 alternate days
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Bleomycin: 10- 20 units/m2 / dose twice a week
ANTIRETROVIRAL THERAPY:
With the widespread use of ART, there has been a 68% fall in the
incidence of KS
ART alone can result in regression of mucocutaneous lesions as well
as visceral disease and maintaining remission
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KCMC, PAEDIATRICS 12 ANAEMIA
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12 ANAEMIA
12.1 PREVENTION
 Promote breastfeeding and mixed weaning food, containing
some meat or fish and dark green leafy vegetables (only
cooked for a short time), fruits (during meals!); prolonged use of
cow's milk only will lead to anaemia. Avoid tea during meals.
Growth monitoring is essential.
 Immunize against the eight diseases in EPI programme.
 Good hygiene and proper use of latrines to prevent infections
and infestations.
 Use mosquito nets to prevent malaria.
 Give supplementary iron to premature infants, (age 6 wks-6 mo)
and to twins.
12.2 CAUSES
BLOOD LOSS
 In neonates: foeto-maternal or twin-twin transfusion, umbilical
cord bleeding, etc.
 Acute bleeding from open wound, epistaxis, oesophageal
varices etc.
 Chronic blood loss: hookworm, etc.
RED CELL DESTRUCTION

 Malaria (major cause).
 Haemoglobinopathies: Sickle cell disease, thalassaemia.
 G6-PD deficiency (rare) triggered by: Primaquine,
Cotrimoxazole, Chloramphenicol, Aspirin, Vitamin K, Ascorbic
acid, Fava bean.
 Rh isoimmunisation, ABO incompatibility and autoantibodies.
 Hypersplenism, e.g. Tropical Splenomegaly Syndrome.
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REDUCED PRODUCTION
 Hypoplastic and aplastic anaemia.
 Malignancy: leukaemia and other bone marrow infiltrative
diseases.
 Deficiency anaemias: Iron, folic acid, vitamin B12, protein.
 Infections.
 Chronic diseases e.g. uraemia, hypothyroidism, Tb.

May be vague and non-specific. Irritability, anorexia. Pallor,
moderate splenomegally, soft ejection systolic murmur. Signs of
cardiac failure and oedema in severe cases. Jaundice in
haemolytic anaemia. In sickle cell anaemia (see below: 12.6);
hepatosplenomegaly, bossing of the skull. In sickle cell disease
crisis: limb- or abdominal pain.

ADMISSION
As a rule we advise in rural hospitals:
 All children with anaemia to be checked for hookworm + to be
given Iron supplementation (5mg elementary Fe/kg/day = 25
mg hydrogenated ferrous sulfate or 15 mg desiccated ferrous
sulfate) for 3 months as an addition to proper food.
Contraindications to this rule are: sickle cell anaemia, acute
infections, acute stage Kwashiorkor.
 In case of tropical splenomegally associated anaemia: malaria

prophylaxis for 3 months is given as well. (Chloroquine or
Paludrine).
 Refer children with sickle cell crisis without delay.
12.5 DIAGNOSIS
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FIRST LINE TEST INFORMATION

 Haemoglobin Anaemia when
 Below 9.0g/dl at age ½-6yr.
 Below 12 g/dl at age 6-14yr.
 Reticulocytes Increased in red cell destruction

and after blood loss, if production is
intact.
Decreased in reduced red cell
production.
 Bloodfilm Morphology of red cells:

 microcytes: often in iron-
deficiency, blood loss
 macrocytes: Vitamin B12
deficiency. Folic acid deficiency
 special red cells or white cell
morphology pointing to specific
conditions e.g. sickle cell
anaemia, leukaemia.
 Indices MCH, MCV if possible
 Sickle cell test If possible Hb electrophoresis.
 Stool Hookworm, schistosomiasis.
 WBC Infection, hypofunction of bone

marrow.
SECOND LINE TEST INFORMATION
 Bone marrow Hypofunction, malignancy
 Platelets Pancytopenia, bleeding disorder,
infection, leukaemia
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 Coombs' test Autoimmune anaemia
 Haemoglobin Haemoglobinopathies
electrophoresis
 Bilirubin, indirect Haemolytic anaemia
 Blood culture Septicaemia
 X-ray skull Haemoglobinopathies e.g.
thalassaemia.
12.6 TREATMENT
DRUGS OF SUPPLEMENTATION
Dose Side effects
Ferrous sulfate 5 mg/kg/day elementary Fe, in 3 Give with fruits between meals
(check with your doses (if possible) orally for 3 for better absorption. Do not
pharmacist if mo. give in acute severe
hydrogenated or  Hydrogenat. Ferrous kwashiorkor or in severe
desiccated!) Sulfate 25 mg/kg/day infections.
 Desiccated Ferrous
Sulfate 15 mg/kg/day
Folic acid 5mg/day all ages Also to pregnant women and
(Fe deficiency anaemia: 14 d, after attacks of malaria and
haemolytic anaemia: lifelong) sickle cell disease crisis.
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BLOOD TRANSFUSIONS
Should only be given on very strict, lifesaving indications.
If Hb < 5 g/100 ml and there are signs of cardiac failure or tissue
(brain) anoxia blood transfusion is indicated. Give 20 ml/kg full
blood or 10 ml/kg packed red cells. Blood transfusions (if not for
acute blood loss) to be given in not less than 4 and not more than 5
hours. In cardiac failure
Furosemide 1 mg/kg IV should be given before the blood
transfusion.
General considerations for blood transfusion (WHO)

 Acute blood loss, when 20-30% of the total blood volume has
been lost and bleeding is continuing
 Severe anaemia
 Septic shock (if IV fluids are insufficient to maintain adequate
circulation and in addition to antibiotic therapy)
 To provide plasma and platelets for clotting factors, if specific
blood components are not available
 Exchange transfusion in neonates with severe jaundice
TREATMENT OF HYPOPLASTIC ANAEMIA

Only mild cases will respond on androgen therapy.
Androgen e.g. 1-2 mg/kg/day orally
testosterone proprionate
and
Prednisolone 2mg/kg/day orally
in 3 divided doses
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TREATMENT OF SICKLE CELL CRISIS
DIFFERENT FORMS OF CRISES

 Acute splenic sequestration crisis. Increase in the size of the
spleen and falling Hb. Need urgent blood transfusion. Mother to
be informed to seek immediate medical attention if this happens
again.
 Acute vaso-occlusive episodes (intravascular sickling).
Symptoms: pain in affected area, in children often in the
extremities and abdomen, haematuria, hemiplegia and even
gross ischaemic damage to organs. Precipitated by: infections,
fever, hypoxia, shock, dehydration and exposure to cold. Need
pain relief, treatment for infection, optimal rehydration.
 Haemolytic crisis. May need blood transfusion.
 Aplastic crisis. May need blood transfusion.
anALGESICS
In mild cases
Aspirin or 40 mg/kg/day in 4 doses orally
Paracetamol 40 mg/kg/day in 4 doses orally
If poor effect, add
Codeine 0,5-1 mg/kg/dose orally
In severe cases
Morphine 0.15 mg/kg/dose SC every 2-4h. More often if needed.
FLUID
Oral or IV see chapter 3 on Diarrhoeal Diseases and chapter 46 on
IV Fluid Therapy. Correct acidosis.
ANTI-INFECTIOUS TREATMENT
Find the infection that might have initiated the crisis.
Pneumococcus, Haemophilus influenzae infections and
osteomyelitis with Salmonella or Staphylococcus most common.
Give treatment according to cause. See 14.8.
Children up to 5 yr. with sickle cell disease should be on malaria
chemo prophylaxis. (chloroquine)
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BLOOD TRANSFUSION
Should be used in sequestration or aplastic crisis. See blood
transfusion above. Because of HIV and risk of overloading with Iron,
be very careful to order blood transfusions.
ADDITIONAL TREATMENT OF DISEASES CAUSING ANAEMIA

Depending upon cause. E.g. hookworm, malaria, etc.
Fever plus anaemia should be treated as malaria in endemic areas.
12.7 FOLLOW UP
 Nutrition education important. The child should have food rich in
green leaves, meat, liver, cereals, and fruits, at home.
 If the cause of anaemia is not clear, the child should come back
after 4 weeks to detect falling Hb with risk of cardiac failure.
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KCMC, PAEDIATRICS 13 MALNUTRITION
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13 MALNUTRITION
13.1 PREVENTION

FOOD
Exclusive Breastfeeding for 4-6 months, then mixed weaning foods
and continued breastfeeding. After every episode of infection extra
food should be given to the child. Increase food production.
REGULAR VISITS TO MCH CLINIC
Growth monitoring, immunisation, health education to the parents.
OTHER IMPORTANT FACTORS
Improved socio-economic condition for the family, less work-load for
the mother before delivery and first year after, etc.
PREVENTION OF MALNUTRITION IS THE KEY TO BETTER HEALTH

AMONG CHILDREN!
13.2 CAUSES
 Lack of enough food, which has many different reasons.
Poverty is the most important one. Social inequity, alcoholism,
one parent families.
 Repeated infections. Chronic illness e.g. cerebral palsy,
HIV/AIDS. Poor hygiene, overcrowding.
 Lack of sufficient RCH services.
 Lack of knowledge, caretaker illiteracy.
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CLINICAL SIGNS COMMENTS:
 Growth failure: See classification of malnutrition

below
Muscle wasting: Best seen on mid-
upper arm circumference
 Fat wasting: Oedema may hide it
 Oedema: In kwashiorkor
 Hair changes: Depigmentation, easily pulled out,
flag sign
 Skin: Pale. Patches of skin can be
peeled off: flaky paint dermatitis,
ulcers.
 Mouth: Oral thrush, angular stomatitis
 Appetite: Often poor. Some times better in
marasmic children.
 Apathy: In severe cases extreme irritability
 Loose stools: Sometimes watery
 Anaemia: Often
 Vitamin deficiencies: Sometimes. Vitamin A-deficiency
most important.
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CLASSIFICATION OF MALNUTRITION
Weight For Height Edema Absent Edema Present
< 70% Marasmus Marasmic-Kwashiorkor

(Severe Malnutririon)
70-79% Moderate malnutrion Kwashiorkor
>80% Kwashiorkior

ADMISSION
HEALTH CENTRE LEVEL
Weighing of children must be performed regularly and the result
plotted on a growth chart that the mother keeps. Nutritional advice
should be given at every visit. Actions should be taken when weight
is not sufficiently increasing. The child to be referred to hospital for
assessment in order to rule out disease contributing to the
malnutrition.
DISTRICT LEVEL
For children with moderate malnutrition need extra and frequent
feeding. For children with severe malnutrition see guidelines below
and refer incase of failure.
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13. 5 DIAGNOSIS
Severe acute malnutrition (SAM) is defined as a weight for height of
< 70% (or –3SD below the median), OR, MUAC <11.5 cm (children
aged 6 months to 5 years), OR, edematous malnutrition
(kwashiorkor) at ANY weight for height. Weight for age should not
be used as criteria for admission or treatment, as it often reflects
stunting rather than wasting.
Moderate malnutrition is defined as a weight for height between 70-
80%, without edema, or, MUAC >11.5-<12.5 cm, and should be
managed in the outpatient setting.
INVESTIGATIONS ON ARRIVAL TO HOSPITAL

 Weight and height and classification of malnutrition.
 Hb, Malaria bloodslide in endemic areas, blood sugar. Stool
for eggs and parasites. Urine, CXR if tuberculosis cannot be
ruled out. Mantoux, maybe false negative in malnutrition.
 Try to find infections, which may be contributing to malnutrition.
 Urine and blood culture, if possible.
 Get a detailed social history to find out the socio-economic
causes behind Malnutrition, as well as a proper medical history.
 Serology for HIV
13.6 TREATMENT
Step 1: Prevent/Treat Hypoglycaemia
Diagnosis:
 RBG < 3 mmol
 Hypothermia (<35.5 C)
 Drowsiness; change in level of consciousness
Treatment:
 If conscious: 50 ml 10% glucose solution or formula
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 If unconscious or convulsing: IV 10% glucose solution, 5
ml/kg body weight
 If IV access cannot be established quickly, give 50 ml of
10% glucose solution by nasogastric tube
Prevention:
 Feed starter formula (F75) immediately
 Feed every 3 hours day and night (every 2 hours if the child
is very ill)
 Keep the child warm to preserve glucose
 Start antibiotics immediately
 Repeat blood sugar after 30 minutes and after 2 hours. If
again low, repeat the previous treatment.
Step 2: Prevent/Treat Hypothermia

Diagnosis:
 Axillary temperature < 35 C
 Rectal temperature < 35.5 C
Prevention and Treatment:

 Feed immediately (rehydrate first if necessary)
 Dress in warm clothes, cover the head, wrap in blanket; or
skin to skin contact with caregiver, place a heat source or a
lamp nearby.
 Monitor temperature every 2 hours until rewarmed (36.5 C)
Step 3: Prevent/Treat Dehydration

DIAGNOSIS IS A CHALLENGE IN THE SEVERELY
MALNOURISHED BECAUSE:
 Many overlapping signs of severe malnutrition and severe
dehydration:
 Skin pinch slow
 Eyes sunken
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 Dry mouth
Assume that all children with watery diarrhea may have some
dehydration.
Look for signs of shock, refer chapter 45 on shock.
Treatment and Prevention:
DO NOT USE IV FLUIDS FOR REHYDRATION IN THE

SEVERELY MALNOURISED, EXCEPT IN CASES OF SHOCK!
 Rehydrate orally or by NGT with ReSoMal

 (Rehydration Solution for Malnutrition)
 Treat: 5 ml/kg ReSoMal every 30 minutes x 2 hours (orally
or NGT)
 Then 5-10 ml/kg/hour for the next 4-10 hours
 Monitor closely for signs of overhydration (which may cause
heart failure)
 Increase in respiratory rate by > 5/minute AND/OR
 Increase in pulse rate by > 15/minute
STOP ReSoMal immediately if these appear and reassess
after one hour
 Prevent: 50-100 ml ReSoMal after each loose motion
Problems with Standard ORS:

 High in sodium and low in potassium
 Severely malnourished children are salt-sensitive and
potassium-deficient; thus, standard ORS can be dangerous
for them
Recipe for ReSoMal

Ingredient Amount
Water 2 litres
WHO-ORS One 1-L
packet
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Sucrose (sugar) 50 g
Electrolyte/Mineral Solution* 40 ml
*If no EMS, use 45 ml of KCl solution instead (1 mEq of potassium = 1 ml)
Step 4: Correct Electrolyte Imbalances

 Severely malnourished children have excess body
sodium and
deficiencies of potassium and magnesium
 If F-75/F-100 NOT available, give:
o Extra Potassium: 3-4 mmol/kg/day
o Extra Magnesium: 0.4-0.6 mmol/kg/day
 Otherwise these electrolytes are present in sufficient amounts in
therapeutic milk
 When rehydrating, give low sodium fluid (ReSoMal)
 Prepare food without salt
Step 5: Treat/Prevent Infections

 Signs of infection often masked
 Broad-spectrum antibiotics are given routinely on admission
 If the child appears to have no complications:
o Cotrimoxazole (if not on prophylaxis) or Amoxicillin
o Ampicillin and Gentamycin
o Chloramphenicol added after 48 hours if no
improvement
o Measles vaccine if the child is > or equal to 6 months
not immunized or of the child is > 9 months and had
been vaccinated before the age of 9 months, but delay
vaccination if the child is in shock or has advanced
AIDS.
If the child appears severely ill or has complications:

SEPTICAEMIA TREATMENT
Penicillin G 150.000-300.000 U/kg/day, in 4 doses IV
and
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Chloramphenicol 75 mg/kg/day in 4 doses orally IV
or
Ampicillin 100-200 mg/kg/day, in 4 doses IV
and
Chloramphenicol 75 mg/kg/day in 4 doses orally IV
or
and
Gentamicin Below 5 yr.: 7½ mg/kg/day
5-10 yr.: 6 mg/kg/day
more than 10 yr.: 4½ mg/kg/day
in 3 doses IM or IV
If indicated add:
Metronidazole In persistent diarrhoea to combat small bowel
bacterial overgrowth 30 mg/kg/day in 3 doses
orally for 5 d can be added.
WORMS
Should be treated according to stool-analysis result.
See chapter 10 on Helminthiasis.
Step 6: Correct Micronutrient Deficiencies

 All severely malnourished children have vitamin and mineral
deficiencies
 Give on admission:
o Vitamin A on days 1&2: < 6 months, 50,000 IU OD; 6-12
months, 100,000 IU OD; older children, 200,000 IU OD(do
not give if child received in previous one month)
o Multivitamin supplement daily, for at least two weeks
o Folic acid, 5 mg on day 1; then 1 mg/day, for two weeks
o Zinc, 10 mg OD if < 6 months; 20 mg OD if > 6 months, x 2
weeks
o Copper (if available): 0.3 mg/kg/day x 2 weeks
 Iron (NOT given initially but typically after child is completely stable
and/or nearing discharge)
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Vitamin A Should be given to all cases of malnutrition.
1st day: below 1 yr. 100.000 IU above 1yr. 200.000
IU orally
2nd day: below 1 yr. 100.000 IU, above 1 yr.
200.000 IU orally.
Folic acid: 2.5 mg/day
Multivitamins May be given daily for 4 weeks, orally.
Iron: (After oedema has Ferrous sulfate (dehydrogenated): 25 mg/kg/day in 2
disappeared and child is gaining doses between meals. (5mg elementary iron/kg/d)
weight!)
Step 7: Start Cautious Feeding

 The severely malnourished child has:
 Fragile physiological state
 Reduced homeostatic capacity
 Feedings in the stabilization phase are:
 Small and frequent (3 hourly)
 Low osmolarity and low lactose
 130 ml/kg/day (100 ml/kg/day if severe edema)
 Provide 100 kcal/kg/day and 1-1.5 g protein/kg/day
 Starter formula: F75 = 75 kcal/100 ml and 0.9 g
protein/100 ml
 No weight gain expected
 Weight loss expected if kwashiorkor
Step 8: Give Catch-Up Diet

 Once child is:
o Clinically stable
o Finishing all 3 hourly feeds/has appetite
o Edema (if present initially) is mostly gone
 He can be moved onto F-100
 F-100: 100 kcal/100 ml; 2.9 g protein/100 ml
 Replace F-100 for F-75: same amount (130 ml/kg.day) for at least
48 hours
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 Then gradually increase F-100 by ~10 ml/feed until some remains
uneaten
 Usually occurs at 200 ml/kg/day
 Target weight gain is at least 10 g/kg/day
 When feeding well on F-100, start Plumpy Nut:
o < 10 kg: 1 sachet/day
o 10-20 kg: 2 sachets/day
o > 20 kg: 3 sachets/day
Step 9: Sensory Stimulation

 With severe malnutrition there is delayed mental and behavioral
development
 Provide:
o Tender loving care
o A cheerful, stimulating environment
o Structured play therapy – 15-30 min/day
o Physical activity when child is well enough
o Maternal involvement
Step 10: Discharge/Follow-Up

 Ideally, a child will be 85% weight/length, though many children can
safely be discharged prior to this if:
o They have completed antibiotic treatment and are clinically
well
o They have a good appetite
o They have shown good weight gain
o They should have lost most if not all of their edema (if
kwashiorkor)
o Their caregiver is reliable
o Their caregiver has resources to feed the child
 Discharge home on RUTF (Ready to Use Therapeutic Food, such
as Plumpy Nut) with follow-up every 2 weeks until “cure” (wt/ht >
85% on two consecutive visits)
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 Always give patients a two-week supply to last until their follow-up
date
 Plumpy Nut: What is it exactly?
o Fortified peanut butter, equivalent to F100
o 500 kcal/sachet
o Low water content means long shelf life
o No refrigeration or preparation required
o Can be mixed with milk, porridge, etc., or eaten plain
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COMPLICATIONS AND CHALLENGES

1. Shock
 The severely malnourished child in shock:
o Give 15 ml/kg over one hour using one of the following (in
order of preference):
 Ringer’s lactate with 5% dextrose
 Half-normal saline with 5% dextrose
 Ringer’s lactate
o Measure pulse and breathing every 10 minutes
o Pulse and respiratory rate will fall with improvement
o If improvement:
 Give repeat 15 ml/kg over one hour
 Then switch to oral or NG rehydration with
ReSoMal 10 ml/kg/hour up to 10 hours
 Initiate refeeding with F-75
o If no improvement after first 15 ml/kg, assume septic shock:
 Give maintenance fluid (4 ml/kg/hour)
 Transfuse whole blood 10 ml/kg slowly
 Initiate refeeding and start antibiotics
2. Severe Anemia:
 Hb < 4 g/dl
 Hb > 4 g/dl and signs of heart failure
 Transfusion must be given slower and of smaller volume
o Whole blood, 10 ml/kg over 3 hours (or packed red cells, 5-
7mls/kg if in heart failure)
o Furosemide, 1 mg/kg IV at start of transfusion
o Monitor pulse and respiratory rate every 15 minutes during
transfusion
o Increase by > 5 breaths/minute or pulse by > 25
beats/minute, transfuse more slowly
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3. Failure to Respond:
 Poor weight gain during rehabilitation phase:
o Poor: < 5 g/kg/day
o Moderate: 5-10 g/kg/day
o Good: > 10 g/kg/day
 Possible causes:
o Are night feeds given?
o Is child vomiting? Finishing feeds?
o Are there untreated infections?
o HIV/AIDS?
o Tuberculosis?
o Psychological problems?
4. Admitting and Feeding the Severely Malnourished Child < 6 Months:

 Admission Criteria:
o Weight/length < 70%, OR
o Bilateral edema at any weight for length, OR
o Infant too weak to suck effectively (at any weight for length)
 Feeding:
o There are no separate phases for breast-fed infants < 6 months
o Allow child to breastfeed every 3 hours for at least 20 minutes,
more if wanted
o 30 minutes to 1 hour after breastfeeding, give a maintenance
amount of DILUTE F-100 (130 ml/kg/day, divided into 8 three-
hourly feeds)
o F-75 is typically not used for infants < 6 months, unless they
have bilateral edema (in which case it is used until edema has
resolved, then moving onto dilute F-100)
o Plumpy Nut is NOT appropriate for children < 6 months
 Preparation of dilute F-100:
o One packet of F-100 with 2.7 L of water (instead of usual 2 L
water)
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13.7 FOLLOW UP
DISCUSSION ABOUT THE CAUSES OF MALNUTRITION IN

HOSPITAL
During the time at hospital doctors and nurses should discuss with
the parents about Malnutrition and the causes in their special case
in detail. Especially about what could be done at home to prevent
further malnutrition.
RCH FOLLOW UP
Very important with monthly growth monitoring, immunization, etc.
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KCMC, PAEDIATRICS 14 BACTERIAL MENINGITIS
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14 Bacterial MENINGITIS
Including treatment of septicaemia
14.1 PREVENTION
Good nutrition.
Vaccination against Haemophilus influenzae and BCG vaccination
14.2 CAUSES
Group B streptococcus First month mainly
E. Coli, Proteus, First month mainly
Klebsiella, Listeria First month mainly
Haemophilus influenzae Mainly 1 mo - 4 yr. age (up
to 12 yr.)
Streptococcus pneumoniae Mainly 1 mo - 4 yr. age, but
may occur later, also in
adults
Neisseria meningitidis Mainly 1 mo - adulthood
(meningococci)
Staphylococci Mainly after penetrating
head injury and VP-Shunt
Mycobacterium tuberculosis see chapter TB

Infants 0-3months
 Initial signs indistinguishable from those of neonatal sepsis (see
chapter 38).
 Neurological manifestations may follow: bulging fontanelle,
seizures, lethargy, neck stiffness (very late!).
CHILDREN MORE THAN 2-3 MONTHS
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Look for a history of:
Vomiting or inability to drink or breastfeed, headache or pain in back
of neck, convulsions, irritability, recent head injury.
On examination, look for:
 Stiff neck, and /or bulging fontanelle, positive Kernig or
Brudzinski sign
 Repeated convulsions
 Lethargy or irritability
 Petechial rash or purpura
 Evidence of head trauma suggesting possibility of a recent
skull fracture.
Also, look for any of the following signs of raised intracranial
pressure:
 Unequal pupils
 Rigid posture or posturing
 Focal paralysis in any of the limbs or trunk
 Irregular breathing.
COMPLICATIONS
May occur from a few days to a few weeks after onset.
 Brain abscess Focal neurologic signs,

impaired consciousness, WBC high
 Subdural effusion Deep tendon reflexes increased.
 Hydrocephalus Head circumference increasing
(before fontanelles close)
 Hearing loss Evaluate latest on discharge
 Paresis, ataxia Observation, neurological
examination
 Vision impairment Evaluate during hospital stay and on
discharge
 Septic shock See chapter 45 on Shock
 If fever/other signs Check: treatment adequate?
ongoing after 3-4 days Consider: subdural effusion,
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of treatment other focus of infection (bone, joint,
ears)

ADMISSION
 Suspect meningitis in all sick children with toxic appearance of
unknown aetiology.
 Give chloramphenicol and refer to hospital promptly.
 Convulsing children with fever should also be sent immediately
for assessment.
14.5 DIAGNOSIS
LUMBAR PUNCTURE SHOULD BE DONE IMMEDIATELY IN ANY CHILD

WITH THE SLIGHTEST SUSPICION OF MENINGITIS.
THE DIAGNOSIS MENINGITIS SHOULD BE MADE +

THE TREATMENT SHOULD BE STARTED WITHIN 1 HOUR.
CSF
 For technique of lumbar puncture: see chapter 47, Paediatric
Procedures. Even without a functioning laboratory a lumbar
puncture may reveal diagnosis: turbid CSF in a clean tube!
 A Random Blood Glucose should be obtained just before the

lumbar puncture in order to compare blood and CSF Glucose.
 Cells, protein, sugar, Gram stain and in suspected cases
examination for acid-fast-bacillus (TB). Cell-count result should
be known within ½-1 hour. Normal CSF values: see chapter 49
 Culture if possible.
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 Four reasons for delaying lumbar puncture exist: (1) Clinically
significant cardiorespiratory compromise (2) Signs of
significantly increased intracranial pressure (e.g., retinal
changes, unequal pupils or focal neurological signs on exam (3)
Local infection/ defects at site of lumbar puncture (4) Bleeding
disorders.
FULL BLOOD COUNT
BLOOD CULTURE IF POSSIBLE
MALARIA SLIDE
In endemic areas to rule out cerebral malaria.
14.6 TREATMENT OF BACTERIAL MENINGITIS BEYOND

NEONATAL PERIOD (neonatal meningitis see ch.38)
GENERAL CARE
 Vital signs should be monitored hourly during first days.
 Feeding is important. If mother is breastfeeding, she should
express breast milk. As soon as the child can suck and eat
without risk for aspiration, normal food should be given.
 Head circumference (HC), should be measured on arrival and
twice a week.
ANTIBIOTICS
Penicillin G 300 - 400.000 U kg/day
in 4 doses preferably IV (or IM)
Ampicillin 200-300 mg/kg/day in 4 doses IV
Chloramphenicol 100 mg/kg/day in 4 doses IV (IM during referral)

Cefotaxime 200 mg/kg/day IM,IV in 3-4 doses
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Ceftriaxone 100 mg/kg/day IM,IV in one dose
Ceftazidime especially for 150 mg/kg/day IV in 3 doses

Pseudomonas meningitis
DURATION OF TREATMENT Pneumococci 10-14 days

Hemophilus 10 days
Meningogoccus 7 days
If aetiology unknown + as a general rule: 14
days
Gram negatives: 3 weeks
Always 7 days IV, thereafter consider oral treatment if child is well provided
complete adherence to therapy can be guaranteed
Antituberculosis drugs, see chapter 4 on Tuberculosis.
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COMBINATION OF ANTIBIOTICS
 Unknown aetiology: Ampicillin + Chloramphenicol
(Including, “blind start”) (= treatment of first choice)
Or
Penicillin G + Chloramphenicol
Or
Cephalosporines (3rd generation
only)
 Haemophilus influenzae Ampicillin + Chloramphenicol
 Pneumococci Penicillin G + Chloramphenicol
in case of therapeutic failure
add Rifampicin 20 mg/kg/day in 2
doses orally or switch to 3rd
generation Cephalosporines
 Meningococci Penicillin G, 7 days only
 Tuberculosis See chapter 4 on Tuberculosis.
FLUID
Intravenous fluid may be needed during the first days. NB! Give the
daily maintenance but not more! Monitor carefully for signs of fluid
overload.
If serum sodium is below 135 mmol/l; Reduce fluid intake to 80% of
maintenance. If below 125mmol/l; keep the vein open. Give
maintenance via NG-tube or orally as soon as it is safe (no risk of
aspiration)
See chapter 46 on IV Fluid Therapy.
TREATMENT OF CONVULSIONS
See chapter 15 on Convulsions. Treat convulsions until they have
stopped.
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TREATMENT OF CEREBRAL OEDEMA

 Elevate the head about 30 degrees. Most important measure!
 Mannitol 0.25-1 g/kg/dose IV over 20 minutes
o May be repeated after 2 hours if no response
14.7 FOLLOW UP
Important to do out-patient follow up to exclude complications such

as hydrocephalus. Measure head circumference to see if
hydrocephalus develops. Community based rehabilitation can be of
help, if permanent squeals are seen.
14.8 TREATMENT OF SEPTICAEMIA

TREATMENT OF SHOCK: See chapter 45
ANTIMICROBIAL TREATMENT
Meningitis is often combined with septicaemia. The antibiotic
treatment of the two conditions is often identical, but gentamicin can
be used in septicaemia because the insufficient penetration into
CNS does not play a role here. Several other antibiotics are given in
a somewhat lower dose.
ANTIBIOTICS
Gentamicin 5mg/kg IM or IV
Penicillin G 150.000-300.000 U/kg/day, in 4 doses IV
Chloramphenicol 75 mg/kg/day, in 4 doses orally or IV
Cefotaxime 150 mg/kg/d IM,IV in 3-4 doses
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Ceftriaxone 50-75 mg/kg/d IM,IV in one dose
Ceftazidime especially for 150 mg/kg/d IM,IV in 3 doses

Pseudomonas
COMBINATION OF DRUGS
Ampicillin + Chloramphenicol
Or
Ampicillin + Gentamicin especially in Gram negative septicaemia.
Or
Penicillin G + Chloramphenicol
Or
Cephalosporines 3rd generation (e.g. those above) if no response
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KCMC, PAEDIATRICS 15 CONVULSIONS
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15 CONVULSIONS and other seizures

(newborn see 36)
15.1 PREVENTION
 Try to get good antenatal care, safe delivery and prevent low
birth weight
 Immunize against TB, DPT, Measles, Polio, Haemophilus
influenzae.
 Prevent accidents which could damage the child's brain
 Reduce presence of mosquitoes
 Prevent severe dehydration
 Prevent intoxications
15.2 CAUSES
COMMON CAUSES SIGNS AND SYMPTOMS SOME
INVESTIGATIONS
2-3% of all children. Family history of
febrile convulsions. 5 months-5 yr.
When fever is rising. Less than 15 min. Rule out other
Generalised tonic clonic. No causes of
Simple febrile neurological deficit afterwards. convulsions if
convulsions Conscious after the postictal phase. needed. LP has to
Cause of fever outside CNS. be done unless
meningitis can be
excluded beyond
doubt.
Differentiate from
complex febrile
convulsions.
A febrile convulsion (no CNS-cause can

be identified) not fitting into the strict
definition of simple febrile convulsion:
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Complex febrile duration longer than 15 minutes, or Always rule out
convulsions occurring repeatedly within 24 hours or CNS infection by
partial/unilateral features. LP.
Meningitis See chapter 14 on Bacterial Meningitis. LP: many cells, high

protein, low sugar in
bacterial meningitis.
Encephalitis Coma, various neurological signs. LP: few cells, high

protein, normal
sugar.
Splenomegaly, no or slight meningeal Blood slide usually,

Cerebral malaria signs. Disturbance of consciousness. but not always,
positive
Intoxication History important, pupil size. Gastric lavage.
Tetanus Trismus, clear sensorium. These are Wound to be found.

not real seizures but rather muscular
spasms
Epilepsy History of repeated convulsion, cerebral If fever, rule out

palsy sometimes. other causes to
convulsion than
epilepsy.
Trauma History, other signs of trauma. Fundi:

haemorrhage. LP.
X-ray skull.
Hypoglycaemia Tremor, paleness, known diabetic. Blood sugar low.
LESS COMMON SIGNS AND SYMPTOMS SOME

CAUSES INVESTIGATIONS
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Metabolic problem
Chvostek (facial) pos. Lust
Hypocalcaemia (peroneal) pos. Blood calcium low.
Carpopedal spasm. Sometimes
rickets.
Diarrhoea, vomiting. Blood sodium > 150

Severe dehydration Clinical signs of dehydration. mmol/l in hypertonic
dehydration or during
too rapid rehydration
with rapid Na-shift.
Reye syndrome Hepatomegaly, bleeding, increased Bilirubine raised,

intracranial pressure. blood-pressure low.
Infection
Pertussis History of cough, whooping. WBC increased,

encephalopathy lymphocytosis.
Low grade fever

Tuberculoma meningismus, slow onset. Mantoux, CT-scan
Think of HIV.
Cryptococcosis Meningismus, low grade fever, LP. Biopsy skin or

severe frontal headache. Think of lymph node.
HIV.
Toxoplasmosis Mainly newborn, hydrocephalus. X-ray skull:

Think of HIV. calcification.
Chorioretinitis.
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Space occ. lesions

Subdural effusion
mainly in neonatal Failure to thrive, focal Transillumination of
period and during neurological signs, focal seizures. Skull, ultrasound, CT-
treatment for scan.
meningitis.
Tumour cerebri Signs of intracranial Fundoscopy X-ray

pressure, focal neurological skull, CT-scan.
signs.
Other causes
Acute hemiplegia in X-ray chest, Blood

Cerebro vascular congenital heart disease slide, Hb (may have
accidents sickle cell disease polycythaemia),
endocarditis: fever, Blood culture, CT-
murmur, heart failure scan.
Degenerative brain Progressive loss of functions. Fundi may be

disease abnormal.
Neurocutaneous Portwine nevus, café-au-lait X-ray skull, foramina

syndromes spots, fibroma. optici narrowed, CT-
scan.
Some definitions to prevent confusion: seizure is the general term;

convulsions are tonic-clonic seizures. Epilepsy = recurrent afebrile
convulsions, symptomatic if cause known, idiopathic if cause
unknown.
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TYPES OF SEIZURES (acc. to International Classification)
GENERALISED SEIZURES
 Tonic clonic (grand mal): twitching of the whole body + loss of
consciousness, often stool/urine incontinence, postictal sleep.
 Atonic: sudden loss of muscle tone causing drop attacks.
Duration only a few seconds.
 Tonic: stiffening of the whole body without any focal
predominance.

 Myoclonic: sudden non-rhythmical muscular jerks, duration few
seconds, often in series.
 Absences (petit mal): sudden cessation of voluntary activity
and unconsciousness of short duration (less than 30 seconds),
usually age
4-10 yr.
PARTIAL (FOCAL) SEIZURES (always point to a localised brain problem)

 Simple: motoric, sensory signs on one side of the body without
loss of consciousness.
 Complex (psychomotor): often aura. Consciousness impaired
but rarely completely lost. Motor symptoms: chewing,
swallowing, licking, stereotyped manner of movement, or
twitching/stiffening of one side of the body.
 Partial but secondarily generalised: generalisation after
partial seizure (or distinct aura).
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ADMISSION
A convulsing child should be referred as soon as possible if there
are problems with proper diagnosis and treatment. Especially
important in case of suspected meningitis and cerebral malaria.
Give rectal diazepam (Valium) (see below).
DIAGNOSIS
CLINICAL
Very careful history and examination including blood pressure and
fundoscopy. Ask parents for a "calendar of convulsions" if they are
repeated.
LABORATORY EXAMINATION
See also section 15.2 on causes above.
BLOOD Hb, WBC, blood film for malaria,

sickle cell. Blood sugar. Urea and
electrolytes in selected cases.
URINE Protein, blood, glucose, sediment.
CSF (If meningitis cannot be excluded).
X-RAY SKULL In selected cases.
CT-scan In selected cases.
EEG In selected cases. Can only be
performed in a few centres.
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15.6 TREATMENT
GENERAL RULES
 Clear airway. The child should lie on the side (left lateral0.
 Give oxygen.
 Do not try to stop convulsion by holding the patient.
 Treat the underlying disease.
 Treat all convulsions vigorously and until they have subsided.
Prolonged convulsions (and status epilepticus) may give brain
damage.
TREATMENT OF ACUTE SEIZURES

DRUGS Dose: Remarks:
0.25-0.5 (max!) mg/kg at 5mg/minute slowly IV Immediate onset.
until the convulsion stops. May cause severe
Diazepam Age ½ yr.- 2 yr.: max 5 mg respiratory
2 yr. - 10 yr.: max 10 mg depression.
older: max 15 mg
May be repeated after 10 minutes, unless the
child has apnoea.
Or rectally Avoid IM
Age below 3 yr.: 5 mg, older: 10 mg administration; this
is slower than rectal
administration.
Paraldehyde 0.15 ml/kg IM or rectally. Not to be given in

1g/ml May be repeated after 15 min. pulmonary oedema
or severe
pneumonia.
50 mg/kg rectally. May be repeated after 15
Chloralhydrate min.Maximum 1 gram single dose.
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Onset after
15 mg/kg IV in normal saline diluted 1:10 over 20 20-40
minutes. Not faster than 1 mg/kg/min. minutes.
Phenytoin Maintenance after 6 h: 4-8 mg/kg/day in 2 doses
(the older the child the lower the dose/kg)
Loading dose: 10-15 -20 mg/kg

IV not faster than 1 mg/kg/min. If additional
Phenobarbital After 6 h: 5 mg/kg/d in 1-2 doses. Neonatal dose Diazepam
see chapter 36 on Convulsions in the newborn. must be given,
it should be
done with
great care.
In status
Pentobarbital Loading dose : 2-5 mg/kg epilepticus if
drip Maintenance : 1-2 mg/kg/h no response
(anaesthesia) to the other
drugs. Only in
intensive care
unit.
Mechanical
ventilation
needed.
TREATMENT PLAN IN STATUS EPILEPTICUS

(= seizure longer than 30 minutes)
 Diazepam rectally or IV
if no effect
 Repeat Diazepam after 15 min
if no effect
 Give Phenobarbital or Phenytoin IV after 10 min
if no effect
 Call the anaesthesiologist. Consider Pentobarbital-drip
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MANAGEMENT/PROPHYLAXIS FEBRILE CONVULSIONS:

 Management after febrile convulsion:
o find cause (usually including LP)
o Paracetamol 15 mg/kg/dose for every fever and try to
prevent fever in these children.
o abortion febrile convulsion, if re-occurring, with rectal
Diazepam (Valium) 0.3-0.5mg/kg
 Management complex febrile convulsions:
Recurrent (once or more per month) seizures associated with
fever presenting like ‘complex febrile convulsions’ (see 15.2)
should be regarded as epileptic seizures and treated
accordingly. Which means that:
o An organic cause has to be ruled out
o The treatment guidelines for epilepsy apply.
TREATMENT OF EPILEPSY
GENERAL RULES:
Some of the drugs are seldom available. Prescribe only drugs with
a secured supply for a longer time.
Always start anti-epileptic treatment with low doses and increase
until patient is seizure free as long as there are no side effects.
Explain to the parents and the patient that the drugs must be taken
regularly and for a long time.
INDICATIONS FOR DRUGS IN EPILEPSY
First choice in all seizure types (except absence seizures)
 Phenobarbitone 3-5 mg/kg/day in one night time
dose. Main side effects:
Hyperactivity paradoxical,
hypotension, anaemia (give folic
acid)
 Phenytoin Sometimes better in partial (focal)
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seizures, second choice when
phenobarbitone not working or side
effects.
4-8 mg/kg/day in one or two doses.
Side effects: Gum hypertrophy,
hirsutism, unsteadiness of gait,
anaemia.
 Carbamazepine Third choice. Very effective in
partial seizures. Introduce slowly!
10-20 mg/kg/day in two or three
doses. Side effects: rash initially
drowsiness weight gain.
 Na-Valproate Third choice. Very effective in
generalised seizures. First choice
for absence seizures 20-30 mg/kg/day
two or three doses. Side effect: weight
gain. Very rarely (in first 6 months):
acute liver failure.
 Ethosuccimide Good for absence seizures only.
Often not available. 15-30 mg/kg/day
in 2 doses.
WHEN TO STOP ANTICONVULSANT LONG-TERM THERAPY?
 Neonatal convulsions:
Stop (taper) medication if seizure free for 3 months. Note that
anti-epileptic maintenance treatment after a neonatal
convulsion is not started routinely but on clinical indication only
(see 36.3).
 Older children:
Stop (taper) medication if seizure free for 1-2 yr. if seizure
control was difficult, it may be wise to wait longer.
15.7 FOLLOW UP
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 Children with epilepsy must be careful with fire places, traffic,
and deep water.
 Regular supply of drugs is important. Go for new supply in good
time, before drugs are finished. Abrupt stop of medication may
cause convulsion.
 A child with epilepsy should go to school, unless there are very
special reasons. Inquire about this on follow up visits.
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KCMC, PAEDIATRICS 16 CEREBRAL PALSY
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16 CEREBRAL PALSY
16.1 PREVENTION
 Promote safe motherhood e.g. good antenatal care, competent
care of high risk pregnancies, prevention of prematurity.
Prevention of malnutrition in female children and women
(prevents LBW).
 Immunize against pertussis, measles, Haemophilus influenzae.
 Promote early recognition and treatment of meningitis
16.2 CAUSES
DEFINITION
Cerebral palsy is a term applied to any condition which consists of
abnormalities of movement and posture caused by a non-
progressive lesion of the immature brain. Although the lesion is
static and non-progressive, the symptoms may change according
to the age of the child. The clinical picture includes spasticity,
muscle weakness, poor coordination, involuntary movements,
ataxia. Additional dysfunctions are common.
SEARCH FOR CAUSES

 Prenatal:
Hereditary, malformation of the brain, rubella, syphilis,
toxoplasmosis, herpes, excess radiation, prematurity,
asphyxia.
 Perinatal (birth - 7th day):
Asphyxia, intracranial bleeding, anoxia caused by placenta
praevia, abruptio placenta, jaundice, infections.
 Postnatal (8th day - 2 yr. in a child earlier considered
healthy): Meningitis, encephalopathies e.g. pertussis, cerebral
malaria, trauma.
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 Unknown Origin:
Normal pre-, peri- and post natal history and a birth weight
above 2500 gm.
EARLY SIGNS OF CEREBRAL PALSY

 Feeding difficulties, inability to suck or swallow.
 Failure to fix gaze when feeding, delayed smiling.
 Abnormality of muscle tone, usually hypotonus, floppiness.
 Behaviour abnormalities, irritability, lack of interest, sleep
disturbances.
 Delayed milestones.
CLINICAL DISTRIBUTION OF MOTOR INVOLVEMENT

 Monoplegia One limb only involved
 Hemiplegia Paresis of one side of the body
 Diplegia Spastic paresis, more in legs than arms
 Quadriplegia Severe paresis of both legs and arms
 Paraplegia Legs only involved this is not specific for
CP, usually a sign of spinal lesions
NATURE OF MOTOR DYSFUNCTION

SPASTICITY
Hypertonic muscles, increased reflexes, paresis, tendency to
develop contractures.
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DYSKINESIA
Impairment of voluntary movement.
 Dystonia with fluctuating muscle tone. Movements are
hypokinetic and may result in bizarre postures.
 Hyperkinesia with too much movement, involuntary and
abnormal postures of two different kinds.
o Athetosis Slow twisting movements of hands and
arms.
o Chorea Rapid jerky movements, mainly of
proximal parts of arms and legs.
Neonatal reflexes persist.
Sometimes there is a combination:
choreoathetosis.
ATAXIA
Difficulties with co-ordination of movements, balance, tremor, low
muscle tonus. Flaccid during infancy.
ADDITIONAL DYSFUNCTIONS
 Mental retardation. More common in spastic quadriplegia. NB:
many children with strange pattern of movement have normal
intelligence.
 Speech disorders.
 Difficulties in chewing, swallowing. Drooling.
 Hearing impairment, common in kernicterus and athetosis.
 Strabismus, refractive errors and blindness.
 Epilepsy, increased risk in spastic cerebral palsy.
 Orthopaedic problems e.g. dislocation of the hip, tightness of
Achilles’ tendon, scoliosis.
 Growth retardation, partly because of feeding problems,
vomiting, neglect.
 Behaviour problems, learning disorders, disturbance of
perception, attention deficit.
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ADMISSION
Admission is required if a child with CP gets a medical condition.
This might happen more often due to vulnerability of the child.
 Create awareness in the community of problems and
possibilities connected to the care of these children. Instead of
hiding them, parents should be encouraged to seek advice of
how to take care of their children and promote their
development in the best way.
 Introduce the concept of Community Based Rehabilitation
(CBR) in the geographic area where you are working.
 Refer all children with cerebral palsy at least once to a skilled
physiotherapist/occupational therapist for assessment and
advice to the parents. The referral should be as early as
possible but at least within the first 10-18 months.
16.5 DIAGNOSIS
Mainly clinical. Teamwork with physiotherapist / occupational
therapist is advisable. Do not forget to look for "additional
dysfunctions".
16.6 TREATMENT
Rehabilitation is the treatment of choice taking into account that it
is neither an active nor a progressive lesion.
PARENTAL COUNSELLING
There is no cure for cerebral palsy but the parents should learn
how to help the child to live as rewarding and satisfying a life as
possible, including close relations to other people. Build on what
the child can do, don't focus only on what cannot be done.
Good cooperation with a community health worker skilled in CBR is
essential.
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REHABILITATION MAY INVOLVE SEVERAL DISCIPLINES
Physiotherapy: to improve motor function.
Occupational therapy: to improve activities of daily living.
Speech therapy: to improve speech and communication.
Community or social worker: to improve social interaction,
education of family and community.
Doctor: to diagnose, co-ordinate treatment and setting of
objectives.
SURGERY
Mainly to prevent deformities, release contractures, improve
function and facilitate the care of the child.
DRUGS
Anticonvulsive mainly, see chapter 15 on Convulsions.
Nutritional supplements e.g. ferrous sulphate, folate, vitamin D may
be necessary. Nutritional counselling is essential.
EDUCATION
Many children can attend normal school if transport to the school
can be arranged and the community supports the family in their
ambition to help the child to get a profession.
Children with speech problems may learn other ways of
communication e.g. by using a special picture board.
Hearing impaired children may attend special schools for the deaf.
16.7 FOLLOW UP AND COMMUNITY REHABILITATION

PROGRAMME
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The goal is a life-style for the child and family which is personally
satisfying and attracts respect from others.
 Ideally a CBR programme should assist the parents in their
care of the child. Some children living nearby a physiotherapy
department might be seen there on a regular basis and the
parents could get training. A health worker should regularly
visit the family. WHO's manual, "Training the Disabled Person
in the Community" or D. Werner’s, "Disabled Village Children"
(www.dinf.ne.jp/../dwe00201.html) could be of great help in
their work.
 Community resources and awareness should be mobilized.
 Parents need support and encouragement not to give up hope
and continue to invest time to do exercises even though
progress might be slow.
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KCMC, PAEDIATRICS 17 SOME EYE DISEASES
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17 SOME EYE DISEASES

17.1 PREVENTION
 Immunize against measles.
 Ensure good nutrition, including Vitamin A, especially for 1-2
months after each episode of infectious diseases.
 Keep good hygiene. Wash the child every day. Clean the eyes,
keep flies and other insects away.
17.2 OPHTHALMIA NEONATORUM

PROPHYLAXIS
CLEANING THE BABY’S EYE BEFORE THEY OPEN, IS THE BEST
PROPHYLACTIC!
USE A STERILE SWAB, WET SALINE, FOR EACH EYE
After cleaning the eyes, instil one drop of 2.5% Povidone iodine or
some Tetracycline 1% ointment to each eye. If povidone is not
available, Silvernitrate 1% (fresh, kept in closed container,
preferable one dose vials in view of danger of more concentrated
solutions!) is effective, although some babies develop a transient
chemical conjunctivitis.
AETIOLOGY
The Gonococcus is the most dangerous organism, but other
organisms can also seriously damage the eye, e.g. Chlamydia
trachomatis.
DIAGNOSIS
Any eye with pus: take a smear and perform Gram stain if possible.
TREATMENT
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 Clean off pus.
 Instil Erythromycin or Tetracycline 1% eye ointment every 1/2
hour for 24 hours, then 2 hourly, then 4 hourly. Clean eye
before instilling the ointment. If you suspect gonorrhoea, give
ceftriaxone 25-50mg/kg IV or IM as a single dose and treat
the parents.
 If there is no obvious improvement in 48 hours, refer to an eye
specialist
17.3 TRACHOMA
ETIOLOGY
Chlamydia trachomatis. Transmission from infected persons by
flies, fingers or contaminated cloths.
DIAGNOSIS
Trachoma – simplified WHO grading classification.
TF: follicular trachoma, presence of ≥ 5 follicles in the upper tarsal
conjunctive of at least 0.5mm.
TI: Inflammatory trachoma, pronounced inflammatory thickening of

the upper tarsal conjunctiva that obscures more than half of the
normal deep tarsal vessels.
TS: Trachomatous scarring, the presence of easily visible scarring

in the tarsal conjunctiva.
TT: Trichiasis, evidence of at least one eyelash touching the

globe, evidence of recent removal of in-turned eyelashes is also
graded as TT.
CO: Corneal opacity, the presence of easily visible corneal opacity

which obscures at least part of the papillary margin.
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TREATMENT
For active stage, (TF and TI) Antibiotics are given to minimize
reinfection
Azithromycin 20mg/kg orally single dose
Or
Tetracycline 1% ointment twice daily for 6 weeks
Or
Erythromycin 40 mg/kg/day in 2 doses orally, 2-3 weeks.
For stage TT, lid surgery is the treatment of choice.
17.4 XEROPHTHALMIA
AETIOLOGY
Vitamin A deficiency. To avoid this give breastfeeding, multi-mixture
weaning food (containing some fat) and Vitamin A rich food, e.g.
fruits, dark green leaves, especially after an acute illness.
DIAGNOSIS
Inspect cornea. Lissamine green 1% may be used.
According to WHO classification the following stages are seen:
 Night blindness (XN) commonly observed by the mother.
 Conjunctival xerosis (XIA). Dryness. Smoky pigmentation.
 Bitot's spots (XIB). Patches of xerosis with foamy material.
 Corneal xerosis (X2). Dry hazy appearances of the cornea.
 Corneal ulceration (X3A). A disintegration of the cornea, deep
or superficial < 1/3 of the corneal surface.
 Keratomalacia (X3B). Rapidly destructive necrosis > 1/3 of the
corneal surface  collapse of the eye.
 Corneal scars (XS). End result of healed corneal disease.
TREATMENT
VITAMIN A
 Day one Vitamin A 200.000 IU orally
 Next day Vitamin A 200.000 IU orally
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 After 1 week Vitamin A 200.000 IU orally
 After 1 month Vitamin A 200.000 IU orally
Children below 1 year or below 8 kg should have half the dose.
INITIAL CARE OF CORNEAL ULCERATION
 Atropine 1% eye drops once per day.
 A topical antibiotic e.g. Tetracycline/ Chloramphenicol ointment
every hour.
 Immediate referral to eye specialist.
17.5 WHITE PUPIL

AETIOLOGY
A white pupil, cat's eye reflex or leucocoria always means there is
something seriously wrong with the eye, such as:
 Congenital Cataract which needs treating early before
nystagmus develops, after which only poor vision can be
achieved, despite good surgery.
 Retinoblastoma. This highly malignant growth of the retina
carries an almost 100% mortality, whereas, early treatment,
before the tumour goes outside the eye, can result in 85% cure
rates.
 Screening: check for red reflex in every new born. If red
reflex absent or white pupil, refer immediately
17.6 INJURIES TO THE EYE

PREVENTION
Injuries cause loss of vision, and are usually preventable. Supervise
children at play.
TREATMENT
 If an injury occurs, do not delay - the first 24 hours are vital.
Remember that someone (including a child), who has lost one
eye is more likely to have a second accident. So special care is
needed.
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 When referring an injury: put antibiotic and Atropine 1% in the
eye and apply a pad with strapping. During transport only.
17.7 SOME RULES ABOUT TREATMENT OF EYE

DISEASES
 Never use "traditional medicine" or unknown medication.
They are likely to do more harm than good.
 Any red eye, white pupil or injuring are ophthalmological
emergencies – REFER IMMEDIATELY.
 If a "Red eye" does not get better in 5 days: it may be due to a
foreign body and, in any case, refer to an expert.
 Parenteral antibiotics are rarely needed for eye treatment. If
local antibiotics are properly applied, a simple infection should
clear up easily. If not, the diagnosis is usually wrong.
 It is often difficult to examine a child. Do not hesitate to give a
short anaesthetic to allow you to examine thoroughly.
 No fundus examination can be carried out without full dilatation
and a quiet patient. (Cyclopentolate 1% or Tropicamide is the
best drug to use)
 Never give local or systemic steroids for an eye condition. It
could cause loss of sight (e.g. with Herpes Simplex Keratitis) or
severe ocular side effects.
 Don't give specific treatment without a specific diagnosis. If in
any doubt, refer to an expert.
A YOUNG BLIND CHILD IS A TRAGEDY, ESPECIALLY IF THIS

WAS CAUSED BY WRONG THERAPY OR DELAY.
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KCMC, PAEDIATRICS 18 OTITIS MEDIA
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18 OTITIS MEDIA
18.1 PREVENTION
 Immunize against measles, Haemophilus influenzae.
 Reduce, if possible, the frequency of acute respiratory infection
- less overcrowding, etc.
 Ensure good nutrition, including Vitamin A.
18.2 CAUSES
Most common causes of acute otitis media are Streptococcus
pneumoniae (pneumococcus), Haemophilus influenzae (younger
children), Group A Streptococcus, Moraxella catarrhalis. In chronic
otitis media the Isolates are often Gram neg. bacteria, or
Staphylococcus aureus or even fungi. Predisposing factors: URTI,
adenoids, allergic rhinitis

ACUTE OTITIS MEDIA
 Fever, usually pain in the ear. Preauricular pressure usually
hurts. Pressure sensation in the ear. Diarrhoea and vomiting is
common in smaller children.
 Purulent discharge after perforation.
 Complications: mastoiditis, meningitis, thrombosis of sinus,
facial nerve palsy.
CHRONIC SEROUS OTITIS MEDIA (GLUE EARS)

Characterized by sensation of fullness in ears, muffled hearing and
tinnitus.
CHRONIC SUPPURATIVE OTITIS MEDIA

 Chronic discharge for more than 2 weeks (warning sign!).
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 Slight to severe deafness.
 Perforation of tympanic membrane
 Source of intracranial and extracranial complications

ADMISSION
 The diagnosis of otitis media should be thought of in children
with common cold and fever and signs of pain, irritability.
 For children with a cold or nasal discharge or sore throat
without swollen tender lymph nodes, give only Paracetamol,
and no antibiotics.
 With ear discharge for more than 2 weeks, give no antibiotics;
only clean away the discharge (dry wicking). Show the parents
how to do this daily and see the child back after 2 weeks. If
no improvement, refer to specialist.
EXAMINE THE EARS IN ALL CHILDREN WITH FEVER
18.5 DIAGNOSIS
ACUTE OTITIS
Otoscopy is the best method. Red, sometimes bulging ear-drum
with loss of reflex and movements of the drum. Perforation may be
seen.
Clinical signs may sometimes be obvious and enough.
Pressure against mastoid bone, behind the ear is painful in
mastoiditis.
CHRONIC SEROUS OTITIS (GLUE EARS)

Otoscopy reveals an opaque tympanic membrane with decreased
mobility.
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CHRONIC OTITIS
Otoscopy is necessary for proper diagnosis and treatment of
perforation, granulation tissue, polyps, cholesteatoma. Thick
discharge is sometimes found.
18.6 TREATMENT
ACUTE OTITIS MEDIA
ANTIBIOTICS
Amoxicillin 80mg/kg/day in 2 doses for 7 days,
In children < 2 years for 10 days
or 50 mg/kg/day in 3 doses orally for
Penicillin V 7 days. Use for older children only
or Azithromycin 10mg/kg on day 1, then 5mg/kg
once a day for 3-5 days
OTHER TREATMENT
Ephedrine 0,25-0,5% nose drops one drop in each nostril 3-4 times
daily for 3 days
Paracetamol for pain 50 mg/kg/d in 3-4 days
Paracentesis may be necessary in treatment failure.
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CHRONIC SEROUS OTITIS MEDIA

 Management: evaluation for respiratory allergy, obstructive
adenoid, immunodeficiency.
 Treatment: Myringotomy by ENT specialist, with
tympanostomy, and tube insertion may prevent subsequent
accumulation of middle ear fluids and improve hearing.
CHRONIC SUPPURATIVE OTITIS MEDIA
 Aural toilet (DRY WICKING):
The parents and patient should be instructed how to dry out the
child's ear at home:
o Roll clean absorbent paper or cloth into a wick.
o Place the wick in the child's ear for 1 minute.
o Remove the wick and replace it with a clean one every
minute until the ear is dry.
o Tell the mother to do this at least 3 times a day
o Continue cleaning once daily until all debris is removed.
 Eardrops Chloramphenicol 5% Hydrocortisone 1 % or Boric
acid 1.5% in spirit 20%.
 Refer to ENT-specialist
o If the ear does not clear up within 3 months.
o If otoscopy shows granulation tissue, polyps,
cholesteatoma, or unsafe
perforation (attic, marginal).
18.7 FOLLOW UP
 Very important to follow up the patient until no discharge is
found and there is normal hearing.
 In acute otitis media after completion of antibiotics (7days), the
child should be re-evaluated.
130
KCMC, PAEDIATRICS 19 CONGESTIVE CARDIAC FAILURE (CCF)
AND CARDIAC ARRHYTHMIAS
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19 CONGESTIVE CARDIAC FAILURE (CCF)

Definition: congestive cardiac failure is a state in which the heart can not
deliver adequate cardiac output to meet normal body requirements
19.1 PREVENTION
 Prevent rheumatic heart disease. See chapter 20 on Rheumatic
Heart Disease.
 Prevention of anemia and malaria
19.2 CAUSES
 Severe anaemia (note: also other “high output failure”
 Thyrotoxicosis).
 Congenital heart diseases.
 Rheumatic heart disease.
 Supraventricular tachycardia.
 Myocarditis, cardiomyopathies e.g. endomyocardial fibrosis,
glycogen storage disease, fibroelastosis.
 Pericardial effusion and constriction.
 Hypertension, e.g. acute glomerulonephritis.
 Over hydration because of IV fluids.
 Severe pneumonia and anoxia.
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In older children
 Fatigue, exercise intolerance
 Increased sweating in infants. Restlessness. Sleeplessness.
 Oliguria.
 Tachycardia, 140-180/min. In supraventricular tachycardia
often 200/min. Sometimes bradycardia. Normal values see
49.5.
 Tachypnoea – dyspnoea.
 Tender Hepatomegaly. Liver more than 2-3 cm below costae.
Ascites.
 Cardiomegaly, difficult to evaluate without X-ray.
 Triple-rhythm, 3rd sound, especially in myocarditis, gallop
rhythm.
 Pulmonary fine crepitations at the bases of lungs. Cough.
 Peripheral oedema hands, feet, eyelids, genitalia.
 Increased venous pressure, best seen in the jugular veins in
sitting position.
 In hospitalized patients: sudden increase in weight.
 Increased jugular venous pressure
Signs and symptoms for infants

 May be difficult
 Feeding difficulties, failure to suck, poor crying
 Tachpnea
 Cardiomegally,hepatomegally
 Fatigability
 Nasal flaring
19.4 IMPORTANT ACTIONS PRIOR TO ADMISSION
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Give diuretics then early referral to hospital that can give adequate
care.
19.5 DIAGNOSIS
 Proper history taking and examination
 Clinical usually enough. Blood pressure important to measure.
 investigations
 Hb.
 Chest X-ray for better diagnosis of Cardiomegaly, (heart
shadow
>50% of width of chest), may indicate CCF.
 Electrocardiography (ECG) can contribute and should in
fact be done prior to echocardiography for better
diagnosis.
 Echocardiography.
 Pay attention to other underlying causes: renal diseases,
malaria, hookworm, etc.
19.6 TREATMENT
TREATMENT OF CONGESTIVE CARDIAC FAILURE

SUPPORTIVE CARE
 Comfort the child. Sitting position or prop up position
 Sedation may sometimes be necessary:
Morphine 0.1-0.2 mg/kg SC
 Oxygen 2 L/min, humidified, in cases of dyspnoea and
cyanosis.
FEEDING
Careful feeding supervised by a nurse. Tube-feeding may be
necessary. Reduce total amount of fluid by 25%. Secure sufficient
calories.
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DIURETICS
 Furosemide 1-2mg/kg IM or IV. The dose may be repeated
after 6-8. hours
 Parenterally 2-3 times daily with a maximum of 5-8 mg/kg/d or
orally 2-4 mg/kg/d in 1-3 doses.
 Chlorothiazide (preferred for continuation of treatment after
start with furosemide) 20mg/kg/day in 2 doses orally.
Both diuretics lead to loss of Sodium Chloride, Potassium,
Magnesium and Calcium. For Potassium loss: add bananas in diet
or Slow K 600 mg once daily orally. For Magnesium loss: add
Magnesium sulphate 30-60 mg/kg/dose.
BLOODTRANSFUSION
In severe anaemia give 10 ml/kg packed red cells or 20mls/kg
whole blood in 4-5h after the furosemide. See chapter 12 on
Anaemia.
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DIGOXIN (if the above is not sufficient or in severe cardiac failure)

Total oral Dose: Maintenance
Digitalization: mg/kg/day 1 dose:
mg/kg/day
Preterm 0.02 0.005
Full term
- 2 months 0.03 0.008-0.010
- 2-24 months 0.04-0.05 0.010-0.012
- More than 24 0.03-0.04 0.008-0.010
months - give ½ of the dose in 1-2 doses/day
immediately, ¼ after 8 h
(check pulse rate first), ¼
after 16 h
- IV dose = 75% of oral dose
Children above 10 yr. 0.01 0.002-0.005
Check pulse rate before next dose

 Reduce dose by 50% in end stage renal failure
Signs of digitalis toxicity: anorexia, nausea, vomiting, diarrhoea,
slow pulse below 60/min in infants and 50/min in children,
atrioventricular block, arrhythmia, supraventricular tachycardia,
hypokalaemia (ECG: low T waves + U waves). Action to be taken:
Stop Digoxin in hypokalaemia, give Potassium chloride (dose: 100
mg/kg orally) and treat arrhythmia, see below.
.
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TRY IN INTRACTABLE CASES OF CCF

 Captopril (if available): always start with lowest dose and increase
according to response. Side effect: Hypotension and
Hyperkalaemia.
Doses Captopril (2-4 doses/day):
Neonates 0.05-0.1 mg/kg/dose max 0.5mg/kg/day
Infants 0.15-0.3mg/kg/dose  max 6mg/kg/day
Children 0.3-0.5 mg/kg/dose  max 6mg/kg/day
 Hydralazine 0.1-0.2 mg/kg/dose IV 3-4 doses/day
(second choice) max 3.5 g/kg/day.
Continue 0.75-1 mg/kg/day orally in 2-4
divided doses, max 7.5 mg/kg/day
TREATMENT OF CARDIAC ARRHYTHMIAS (strip ECG

needed!)
SINUS TACHYCARDIA (SUPRAVENTRICULARTACHYCARDIA)
(Note: treat cause first, sinus tachycardia often being just a reaction and
even a good one!)
Dose: Side effects:
Propanolol Loading dose: Hypotension, heart
IV 0,01-0,02 mg/kg over 10 minutes. Blocks, bronchospasm.
May be repeated if no
effect after 20-30 minutes Warning:
up to 3-4 times daily. Do not use in cardiac
Daily dose: failure. Use digoxin instead.
1-8 mg/kg/d orally in 4 doses.
Amiodarone 10-15/kg/day in 1-2 doses for 2 weeks then Hypothyroidism, heart
reduce to 2-5 mg/kg /day failure hypertension
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
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Ice bag on forehead or other vagotonic manoeuvres e.g. pressure
on carotids or eyeballs or valsalva or if this fails, consider
cardioversion or medication:
Dose: Side effects:
Digoxin See above
Propanolol See above In older
children
BRADYCARDIA:
DEFINITION: below 70/min in neonates (note:
rule out frst if not due to hypoxia!), <70-80/min
in infants & children:
Dose: Side effects:
Dopamine 7-10 micrograms/kg/min diluted with dextrose Tachycardia,
5% at 6 micrograms/ml and given as infusion gangrene.
into large veins under IC conditions.(Can be
repeated)maximum 0.5 mg/kg
Atropine 0,01-0,02 mg/kg IV or IM
TREATMENT OF VENTRICULAR ARRHYTHMIA

Dose: Side effects:
Lidocaine Loading dose: CNS effect,
1 mg/kg IV rapidly may be confusion, coma.
repeated after 5-10 min. twice. AV block  asystole.
Maintenance:
0,03-0,05 mg/kg/min, IV infusion.
Procainamide 15-50 mg/kg/d in 4 doses orally for Hypotension, cardiac
maintenance only. failure. CNS
disturbance.
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19.7 FOLLOW UP
 In chronic heart diseases new attacks of heart failure should be
treated early.
 There is a need for extra calorie-rich food for children with chronic
cardiac disease.
 If secondary to rheumatic heart disease give prophylaxis
138
KCMC, PAEDIATRICS 20 RHEUMATIC HEART DISEASE
_________________________________________________________________________
20 RHEUMATIC HEART DISEASE

20.1 PREVENTION
MAIN POINTS IN HEALTH EDUCATION:
 Avoid overcrowding.
 Give early treatment of streptococcal infections
(tonsilopharyngitis) with Penicillin.
 Prevent recurrence of streptococcal infections by prophylactic
long acting Penicillin e.g. monthly injection.
 Maintain good nutritional status
20.2 CAUSE
Group A beta-haemolytic streptococci causes tissue damage of the
heart 10- 30 later, most likely through an immune hyper-response.
Peak occurrence is between 5-15 years of age.

 Myocarditis and endocarditis with soft mid-diastolic and/or
systolic murmur at apex are often the first signs of acute
rheumatic heart disease.
 Pericarditis sometimes with a rub and retrosternal pain.
 Tachycardia at rest.
 Endocarditis continues with damage of mitral aortic and
tricuspid valves, mitral valve being commonly affected leading
to heart failure.
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ADMISSION
If in cardiac failure, Furosemide 1mg/kg IM/IV.
20.5 DIAGNOSIS
RHD IS A PART OF RHEUMATIC FEVER. JONES' CRITERIA
FOR ACUTE RHEUMATIC FEVER (ARF):
MAJOR CRITERIA MINOR CRITERIA
 carditis  fever
 polyarthritis  arthralgia
 chorea  prolonged P-R interval on ECG
 erythema marginatum  previous history of rheumatic
 subcutaneous nodules fever or rheumatic heart disease
 raised ESR or C Reactive
Protein.
Diagnosis is made when; either 2 major or 1 major and 2 minor

criteria are reached with evidence of preceding streptococcal
infection (Resent scarlet fever, Positive throat culture, Increased
antistreptolysin O titre).
Chorea on its own can be conclusive proof of ARF even with
negative ASOT or history of pharyngitis
LABORATORY
 Hb, WBC, ESR.
 Throatculture can be positive in about 25%.
 Antistreptolysin titre can be positive in about 80%.
 Chest X-ray.
 ECG in the acute stage. Should be followed regularly.
 Echocardiogram.
20.6 TREATMENT
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TREATMENT OF ACUTE EPISODE OF RHD
ANTIBIOTICS
Benzathine penicillin 600.000 U in children below 30kgs (or <6 years).
1.200.000 U above 30kgs (or >6 years), IM
injection single dose.
or
Procaine penicillin 50.000 U/kg/day in one dose IM for 10 days.
Alternative in proven penicillin
allergy:Erythromycin 40 mg/kg/day in 2 doses orally for 10 days.
Antibiotic treatment to be followed by antibiotic prophylaxis see 20.7
SALICYLATES
Acetoacetylic acid (Aspirin) in mild 80-100 mg/kg/day in 2-3 doses orally1-2 weeks or
to moderate carditis (combined until ESR is normal and child clinically doing well.
with antiacid)
CORTICOSTEROIDS
2 mg/kg/day in one morning dose orally, in
Prednisolone severe carditis only. Slow reduction when the
child is doing well and ESR is decreasing. When
tapering off start Aspirin overlapping with the
prednisolone and maintain the prednisolone until
ESR normal. Treatment of cardiac failure see
chapter 19.
TREATMENT OF CHOREA
Haloperidol 0.025mg to 0.05 mg/kg/day can be given orally
in divided doses
Phenobarbitone 3 to 5mg/kg/day in milder cases
BEDREST
Until the rheumatic activity has been low for 1-2 weeks and ESR
is normal.
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INFECTIVE ENDOCARDITIS IN RHD
 May occur if no prophylaxis is given.
 Usually caused by Streptococcus Viridans, Staphylococcus
aureus, pseudomonas, etc.
 Symptoms:
Unexplained low grade fever, anaemia, weight loss,
splenomegaly, change of murmur or development of a new
murmur. Haematuria, nephritis.
 Investigations:
Serial blood culture, ESR and Echocardiography.
 Antibiotic treatment:
Benzyl penicillin 300.000 U/kg/day in 4 doses IV
and
Gentamicin 5-6 mg/kg/day in 3 doses IV or IM
Or if staph suspected
Cloxacillin 100 mg/kg/day in 3 doses IV, for 2
weeks, later orally
and
Gentamicin 5-6 mg/kg/day in 3 doses IV or IM
Continue for 6 weeks and 2 negative blood cultures with one

week interval or up to 6 weeks.
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TREATMENT OF CHRONIC RHD

 Treatment of recurrent acute episodes
 Operative treatment of valve defects is the only curative
treatment. Operation of mitral stenosis can be performed at
KCMC.
20.7 FOLLOW UP/SECONDARY PROPHILAXIS

 No carditis
◦ At least 5 years after ARF or until age 18
 Mild mitral regurgitation
◦ At least 10 years after ARF or until age 25
 Severe valvular disease
◦ Life-long
DRUGS for prophylaxis,

 Penicillin V 250mg PO BD or;
 Benzathine penicillin G
≤20kg: 600,000 units IM 4-weekly
>20kg: 1.2 million units IM 4-weekly
◦ 3-weekly injections may be more effective at preventing
recurrences
 Erythromycin 250mg PO BD if penicillin-allergic
 Amoxicillin 50mg/kg PO TDS
 Before dental extraction or any type of surgery in patients with RHD,
give oral Amoxicillin or Erythromycin 1 hour prior to and 6 hours
after surgery; and in abdominal surgery add Gentamicin.
143
KCMC, PAEDIATRICS 21 ACUTE TONSILLITIS, SORE THROAT
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_
21 ACUTE TONSILLITIS, SORE THROAT

21.1 PREVENTION
 Avoid overcrowding and too much air pollution.
21.2 CAUSES
 Virus, most common cause e.g. Adenovirus, Coxsackie, Epstein-
Barr.
 Bacteria, usually group A beta-haemolytic Streptococcus, but also
Pneumococcus, Staphylococcus.

It is clinically not possible to distinguish between streptococcal and
viral sore throat, but some clinical characteristics may be helpful:
CLINICAL
CHARACTERISTICS STREP. THROAT NON-STREP THROAT
Age 5-15 All ages
Mode of onset Sudden Gradually
Initial symptoms Sore throat, painful swelling Mild sore throat
Fever High Not so high
Redness, oedema, exudate
from pharynx and tonsils,
Throat large tonsils, punctate Redness of the
haemorrhages in the soft pharynx, sometimes
palate exudate
Tender anterior cervical
Other signs lymph nodes, erosion of the Cough, hoarseness,
edges of the nostrils, signs of watery nasal secretion,
scarlet fever conjunctivitis
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KCMC, PAEDIATRICS 21 ACUTE TONSILLITIS, SORE THROAT
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_
ADMISSION
Most patients are treated as outpatients. Early treatment on suspicion,
promote full treatment.
21.5 DIAGNOSIS
 Clinical usually enough.
 Culture of throat secretion most reliable.
 Anti-streptolysin O-titre may support the diagnosis of strep. throat,
but is rarely needed.
21.6 TREATMENT
When streptococcal infection is suspected.
Penicillin V 25 mg/kg/day in 3 doses for 10 days
or
Procaine penicillin 50.000 IU/kg/day IM once daily for 10 days
or less than 30 kg bodyweight:
Benzathine penicillin 600.000 – 900.000 IU IM once
30 kg or more: 1.200.000 IU IM once
or in penicillin allergy
Erythromycin 40 mg/kg/day in 2-4 doses for 10 days orally
21.7 FOLLOW UP
Inform the parents to come back early if clinical signs reappear.
145
KCMC, PAEDIATRICS 22 ACUTE OBSTRUCTIVE LARYNGITIS
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22 ACUTE OBSTRUCTIVE LARYNGITIS

1. Acute Epiglottitis
2. Viral Croup (Subglottic)
3. Diphtheria
22.1 PREVENTION
Immunization against diphtheria, measles and Haemophilus
influenzae.
22.2 CAUSES
A. Acute Epiglottitis Haemophilus influenzae
B. Viral Croup Usually parainfluenza virus,

Measles
C. Bacterial Corynebacterium diphtheriae

Croup-Diphteria
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A B C
EPIGLOTTITIS VIRAL CROUP DIPHTHERIA
Onset rapid gradual gradual
Fever, toxic +++ +(+) ++(+)

appearance
Inspiratory stridor +++ +(++) ++(+)
Refusal to eat, +++ + ++

drooling
Barking cough - +++ (+)
Epiglottis swollen +++ - +

red
Tonsils, pharynx, (+) + +++

uvula, odor
Cervical lymph
nodes - + +++
(Bull-neck)
Gray white
membranes, mouth - - +++
Palatal paralysis - - +++

nasal regurg.
Myocarditis, renal
involvement - - +++
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ADMISSION
 Any child with inspiratory stridor should be carefully observed:
heart rate, respiratory rate, temperature, alertness, cyanosis,
air hunger, stridor, etc.
Do not examine the throat of the patient unless facilities for
rapid intubations are at hand. Even simple depression of the
tongue with a spatula can give a reflectory constriction of the
glottis which could kill the child.
 Early referral necessary when the signs and symptoms get
worse. The child should sit up, head a bit deflected, held close
to the parent or relative during the transport, which must be as
quick as possible.
22.5 DIAGNOSIS
Clinical usually enough. Examine the throat with great care in
particular if epiglottitis is suspected!
Examine ears. If diagnosis is not obvious: X-ray, think also of
foreign body, retropharyngeal abscess.
22.6 TREATMENT
GENERAL RULES
 Comfort the child, who should sit up.
 Fluid is best given IV in severe cases. See chapter 46 on IV
Fluid Therapy.
TREATMENT OF EPIGLOTTITIS (A)

 Chloramphenicol 100 mg/kg/day in 4 doses IV (later oral).
Or
Ceftriaxone 100 mg/kg/day Should be given immediately.
 Oxygen, humidified (don’t be fooled by the pink colour)
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 Careful monitoring of respiration, heart rate, alertness.
 Intubation or tracheostomy may be needed to save life, but
postoperative care is difficult. Nasotracheal intubation with a
tube 0.5-1mm smaller than normally used for the age is
associated with less postintubation sequel .
TREATMENT OF VIRAL CROUP (B)

 Hydrocortisone 5 mg/kg single dose IV. or IM. May be
repeated after 2 h.
Or
Dexamethasone 0.6mg/kg IV or oral as single dose, max.10mg
 Adrenaline (epinephrine) 1 :1000, 1mg/ml by nebulizer is

effective. 0.5ml/kg/dose (max 5ml) by nebulization over
15minutes (If racemic epinephrine give 1/10 of dose)
 Normal saline nebulization 2 ml as often as needed is
effective
 Ensure proper hydration of the child.
 Steam may be tried. The child should sit close to the mother
and not be forced to inspire the steam.
 Humidified Oxygen (but don’t be fooled by absence of
cyanosis).
 If worse, intubation may be needed.
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TREATMENT OF DIPHTERIA (C)

 Isolate the patient, if possible.
 Diphteria antitoxin 40.000 --> 80.000 U IM, IV over
60 minutes as soon as possible
 Procaine penicillin 25-50.000 IU/kg/day in 2 doses IM
for 14 days.
Or
Erythromycin 40 mg/kg/day orally in 3 doses for
14 days.
 Treatment of myocarditis, see chapter 19 on Congestive
Cardiac Failure. Bed rest.
22.7 FOLLOW UP
 Think of other children in the family. Immunize against
diphtheria.
 Everybody who has received less than 3 doses of diphtheria
vaccine or who has received his last vaccine more than 5
years ago should be vaccinated.
 Close contacts to diphtheria patients should receive one dose
of Benzathine penicillin 600.000 - 1.200.000 U IM or
Erythromycin 40 mg/kg/day orally in 3 doses for 7 days.
150
KCMC, PAEDIATRICS 23 PNEUMONIA
________________________________________________________________________
23 PNEUMONIA
23.1 PREVENTION
 Prevent low birth weight by good antenatal care and less
workload for mother.
 Immunize against tuberculosis, pertussis, diphtheria, measles.
 Ensure breastfeeding, good nutrition, Vitamin A rich food.
 Reduce smoke (incl. use of kerosene and indoor cooking) and
overcrowding in the home.
 Give health education; parents should recognize early signs of
pneumonia.
 Treat helminthic infestations
 Start cotrimoxazole prophylaxis in HIV exposed infants from 4
weeks of age
23.2 CAUSES
CHARACTERISTICS OF ORGANISMS
AGE GROUP ORGANISMS
Group B Streptococcus,
Neonates Gram negative organisms (E. coli, Klebsiela)
Less common: CMV, HSV, Chlamydia, Listeria, Bordetella
pertusis
<5 Years Streptococcus pneumoniae
Haemophilus Influenzae
Group A Streptococcus
Staphylococcus aureus (especially post measles)
Bordetella pertussis
Viral: RSV, measles, influenza, adenovirus, parainfluenza
School age Streptoocccus pneumoniae,Mycoplasma, Chlamydia
Viral pneumonias as above
VIRUS
 RSV
151
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Respiratory Syncytial Virus. In early infancy it may be serious.
 Measles
Gives pneumonitis especially in malnourished children.
Many viruses give only a mild disease in infants and young
children.
 HIV and AIDS-related
Lymphoid Interstitial Pneumonitis (LIP), Pneumocystis Carinii
Pneumonia (PCP), Secondary pneumonia due to bacteria and
fungi.
 Chlamydia
In young infants mainly.
BACTERIA (main causes)

 Streptococcus pneumoniae (pneumococcus)
Gram pos Diplococci.
Infants, young children. Fever, leucocytosis, cough.
Infants and malnourished children may have hypothermia.
Localized chest pain, meningism, abdominal pain may occur.
 Haemophilus influenzae
Gram neg rods.
3 months - 4 yr. Segmental or lobular, often empyema,
pneumatocele, usually more severe than pneumococcal
infection.
 Staphylococcus aureus
Gram pos. cocci.
Mainly below the age of two years. Also seen as complication
at older age. High fever, respiratory distress, toxaemia,
abdominal distension may mimic paralytic ileus (if possible
take chest X-ray in those cases).
Often in one lung. Pneumatocele, empyema, purulent
pericarditis may occur. Septicaemia, osteomyelitis.
 Streptococcus
152
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o Group B: in neonatal period, immediate treatment needed.
o Beta-hemolytic group A, gram pos.: mainly younger
children, patchy or disseminated infiltrates. Often
empyema, pneumatocele, pneumothorax.
 Klebsiella pneumoniae
Gram neg. rods.Mainly neonatal period, and in severe
malnutrition, measles immunocompromised
 Mycoplasma pneumoniae
Children more than 5 yr old usually. Gradually worse. Hacking
cough may last many weeks, but the child is not very ill.
 Mycobacterium tuberculosis
See chapter 4 on Tuberculosis. Very important to think of TB in
children with pneumonia, who do not respond to treatment and
who look ill, malnourished.
153
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CLINICAL SIGNS AND STAGING OF ARI ACCORDING TO
WHO GUIDELINES
CLASSIFICATION SIGN/SYMPTOM
Central cyanosis
VERY SEVERE Severe respiratory distress (e.g. head nodding)
PNEUMONIA Inability to drink
SEVERE PNEUMONIA Chest indrawing
PNEUMONIA Fast breathing

Definite crackles on auscultation
NO PNEUMONIA. No signs of pneumonia, severe pneumonia or very

CAUGH OR COLD severe pneumonia
Normal respiratory rates:

<2Months <60 breaths per minute
2-11Months <50 breaths per minute
1-5Years <40 breaths per minute
ASSOCIATED SYMPTOMS
 meningism lobar pneumonia/meningitis
 abdominal pain often Gram negegatives
paralytic ileus
 osteomyelitis, sepsis often Staphylococcus aureus
 malnutrition exclude TB, HIV
 cyanosis heart disease
 hepatomegaly cardiac failure
154
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Features of BRONCHOPNEUMONIA and its complications
Chest Mediastinal Percussion Breath Voice Added
Movements shift note sounds sounds x) Sounds
Pneumonic Reduced on Dull Bronchial Increased Crackles

consolidation side affected whispering
pectoriloguy
Collapse Reduced on Towards Dull Bronchial Increased None early,
Due to side affected side of whispering coarse
peripheral lesion pectoriloguy crepitations
obstruction later
e.g.
atelectasis
Pleural Reduced on Towards Stony dull Diminished Reduced or None or
effusion side affected opposite or absent. absent. pleural rub
(or empyema) side Bronchial Increased
at upper above the level
level of fluid
Pneumothorax Reduced or Towards Hyper- Vesicular Reduced 0

absent on opposite Resonance reduced or
side affected side absent
Bronchiectasis Reduced on Towards Impaired, Low Increased Coarse

side affected side of Dull pitched crepitations
lesion Bronchial
x
Voice sounds: The child repeats words such as "one", nane-nane and/or tisa-
tisa. Listen to the chest with the stethoscope. If the words are heard as if they
were close to the ears and are distinct, the voice sounds are increased - even a
whisper is heard distinctly. Pectoriloguy: transmission of spoken words through
the chest wall.
155
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ADMISSION
AT HEALTH CENTRE
Important to recognize the signs of severity in ARI and take
correct actions:
 Severe pneumonia: Admission to hospital which can
Give second-line treatment and
oxygen. Prior to referral give
Benzyl penicillin or PPF in proper
dose.
 Moderate pneumonia: First line treatment  home 
follow up  if no improvement
after 2 days refer to hospital.
 Mild ARI (no pneumonia) Home care, health education to
parents.
 Cough for more than Refer to hospital for assessment.
30 days.
IN HOSPITALS: refer to higher level

 If adequate treatment cannot be given.
 If the child does not respond to treatment within 1 week.
23.5 DIAGNOSIS
HISTORY AND CLINICAL EXAMINATION
Usually enough in obvious cases. Look also for extra-pulmonary
signs from heart, brain, skeleton, joints, etc.
156
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X-RAY
Not needed if diagnosis is clear and the patient responds to
treatment. Needed in complications (effusion, pneumatocele,
abscess, TB) and failure of treatment.
BLOOD
Full blood picture
Blood culture
Repeated ESR and Hb show the progress of treatment.
MANTOUX TEST
If poor response to treatment always consider TB. See chapter 4
on Tuberculosis.
23.6 TREATMENT
PNEUMONIA
First line treatment
Cotrimoxazole (TMP/SMX) 8/40 mg/kg/day in 2 doses orally. Above age 2 mo only.
Or
Amoxicillin 50 mg/kg/day in 3 doses orally
Or
Procaine penicillin 50.000 U/kg/day once daily IM
Treat for 5-7 days. If no response after 2 days refer to hospital!
SEVERE PNEUMONIA
Second line treatment
Benzyl penicillin 200.000 IU/kg/day in 3-4 doses IM or IV
or
Ampicillin 100-200 mg/kg/day in 4 doses IM or IV
In very severe forms of pneumonia add:

Gentamicin - below one month:
Especially below 6 months 5 mg/kg/day IV or IM
157
________________________________________________________________________
or
Chloramphenicol (50)-100 mg/kg/day in 4 doses orally or IV
If not responding and abscess/empyema excluded, change to

3rd generation Cephalosporines
Cefotaxime 150 mg/kg/day in 3-4 doses for 7 days
or
Ceftriaxone 50-75 mg/kg/day once daily for 7 days
If staphylococcus aureus suspected (e.g. empyema,

pneumatocele), treat for at least 3weeks.
Cloxacillin
or (second choice) 50-100 mg/kg/day in 3 doses orally or IV (IM)
Erythromycin 40-50 mg/kg/day in 4 doses orally
alternatives:
Methicillin 200 mg/kg/day in 4 doses IV or IM
or
Clindamycin 25 mg/kg/day in 4 doses orally
SUPPORTIVE MEASURES
 Humidified oxygen in severe cases 0.5-1.0 l/min, by nasal
prongs/catheter.
 Treat in cardiac failure. See chapter 19 on Congestive Cardiac
Failure.
 Fluid needed IV if the child has severe dyspnoea and cannot
drink. Give daily need plus extra for fever and hyperventilation,
but avoid over hydration. See chapter 46 on IV Fluid Therapy.
 Give food as soon as possible. Treat as for malnourished
children, see chapter 13 on malnutrition. Nasogastric drip
feeding may be needed initially.
 Physiotherapy often helpful: changing of position, drainage,

percussion.
 Vitamin A to measles, HIV and malnutrition.
158
________________________________________________________________________
TREATMENT OF COMPLICATIONS
 Regular monitoring of temperature, pulse rate, breath rate and
signs of complication. (See above)
 In case of pleural effusion or empyema perform pleural tap,
see chapter 47 on Paediatric Procedures. Consider surgical
drain (usually during 1st week) if a single tap did not cure the
empyema. Longstanding antibiotics (3-4 weeks).
 In case of pneumothorax apply continuous suction.
 Atelectasis and bronchiectasis need physiotherapy.
23.7 FOLLOW UP
 Weigh the child at discharge, enter the weight on the growth

chart. Check weight at MCH clinic after 3-4 weeks.
 Advise on extra food for the child at home. Vitamin A rich food.
 Give health education to parents: How to detect pneumonia
early next time.
159
KCMC, PAEDIATRICS 24 LOWER AIRWAY OBSTRUCTION
(bronchiolitis, asthma)
_______________________________________________________________________
24 LOWER AIRWAY OBSTRUCTION

(BRONCHIOLITIS, ASTHMA)
24.1 PREVENTION
 Asthma: reduce air pollution, smoke, dust etc.
 Bronchiolitis: Prevent overcrowding to reduce RSV infection.
24.2 CAUSES & PATHOLOGY

 Common features: Oedema and inflammation of bronchial
mucosa, constriction of bronchial smooth muscles in particular
in asthma, hypersecretion by mucous glands. Hyperinflation.
 Respiratory syncytial virus (RSV) is the most common cause
of bronchiolitis, which is an infectious disease mainly of infants
below one year. Bronchospasm is then not a major component
but hypersecretion may be excessive.
 In asthma there is usually a genetic predisposition. Many
things may provoke the attack, such as special allergens, ARI,
irritants in the air, exercise. Some have bronchial hyper-
reactivity. Mainly children >1 yr. Repeated attacks.
 Larval stage of some worms (e.g. ascaris) can give asthmatic
symptoms for a few days.

Dyspnoea with bilateral wheezing. Prolongation of expiration
and hyperinflation of chest. Cough. Cyanosis in severe cases. Fine
rales over both lungs can be heard in bronchiolitis.
In asthma wheezing and prolonged expiration are often more
pronounced and a good response to anti-asthmatic treatment is
characteristic. There is also absence of fever and good response
to bronchodilators
160
_______________________________________________________________________

ADMISSION
 Refer children with rapid breathing or wheezing and inability to
drink.
 Try to find out what is causing the symptoms.
24.5 DIAGNOSIS
 Clinical signs. Careful history. Rule out cardiac asthma, also
with wheezing but adrenaline may make it worse.
 Eosinophilia often seen in blood and sputum (asthma).
24.6 TREATMENT
ACUTE ASTHMATIC ATTACK
POSITION
Let the child choose the most comfortable sitting position.
FLUID
Children with respiratory distress need maintenance fluid IV. See
OXYGEN
All children with significant respiratory distress need humidified
oxygen.
DRUGS
 Inhalation
The best way to give anti-asthmatic drugs is through
inhalation. This can be done with the help of either a
o Nebulizer or
o Metered dose inhaler, (MDI/ spray) either without or
better with a spacer. A simple spacer can be made
locally from a plastic 500 ml soft drinks bottle. Cut a hole
in the base of the bottle to fit an MDI mouthpiece, seal
161
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with glue if possible. Give 2 puffs of the inhalable drug and
inhale it through the open bottleneck by 5-7 normal
inhalations. For smaller children cut off the bottleneck and
cover mouth and nose when giving the drug.
Dose Indications
2 puffs in spacer regardless of age, 3-4
Salbutamol times/day. First line drug,
spray if available.
For 0.10-0.15 mg/kg/dose dilute with 2 ml normal
Salbutamol saline may be given 4 hourly. First line drug,
nebulisation if available.
 Parenteral/oral
Dose Remarks
0.01 mg/kg per dose
Adrenaline in 1:1000 (1 mg/ml) solution. Usually 0.2-0.4 mg First line drug if
(Epinephrine) SC. May be repeated after 30-60 minutes 2-3 salbutamol for
times. inhalation is not
available.
Loading dose (if not pre-treated with If salbutamol and
aminophylline): adrenaline
6 mg/kg IV slowly over 10 minutes. effects are
Aminophylline Maintenance dose: insufficient
0.9 mg/kg/h IV.
Aminophylline drip for 3 hrs: 2.7 mg/kg in 5%
dextrose 20 ml/kg. Speed 2 drops/kg/min Supervision of
Oral dose 5mg/kg/dose 6 hourly. the drip must be
meticulous
5mg/kg/dose IV. Addition for severe

Hydrocortisone May be repeated every 6 h for 1- 2 days. cases only.
or No effect in
Prednisolone 1-2 mg/kg/day orally for 3days bronchiolitis.
Effect after several
hours only.
162
_______________________________________________________________________
If you can stop within
1 week no tapering
off needed
Antibiotics See chapter 23 on Pneumonia In case of fever,

clear infectious
component or
bronchopneumonia.
TREATMENT PLAN FOR BRONCHIOLITIS

Many infants can be managed at home.
Feeding difficulties herald deterioration and the child should be
taken to health centre or hospital.
 In more severe cases admit, give good nursing care.
 Give humidified oxygen via nasal catheter, mask or in head-
box. See chapter 47 on Paediatric Procedures.
 Nebulization of 2 ml saline as often as needed may be helpful.
 Ensure daily fluid intake which often has to be increased
because of fever and hyperventilation. IV may be needed. See
 In severe cases pneumonia treatment should be tried as
secondary bacterial infections may occur. See treatment of
severe pneumonia in chapter 23.
 Pharyngeal suction every 2 h can be tried. Suction through a
naso-endotracheal tube is more effective and should be tried
in severe cases.
 Artificial ventilation will be necessary for respiratory failure.
LONGTERM TREATMENT OF ASTHMA

Salbutamol 0.3 mg/kg/day in 3 doses orally as maintenance. If available
salbutamol for inhalation is even better. See above.
If not enough response:
add corticosteroids for a short period.
1 - 2 mg/kg one daily oral dose 1 - 3 weeks, to avoid side effect.
Prednisolone Withdraw gradually (several weeks) if given more than 1 week.
163
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Or Inhalation steroid twice daily for 3 months, then evaluate. Rinse
Budesonide or similar mouth after spraying to prevent oral thrush. If available,
introduce it early in the treatment plan.
If not enough response:
Add
1- 2 yr. age: 16 mg/kg/day in 3 doses orally
Theophylline 3- 6 yr. age: 13 mg/kg/day in 3 doses orally
7 -12 yr. age: 10 mg/kg/day in 3 doses orally
older: 8 mg/kg/day
Ephedrine is a much less effective drug than those above.
Dose 3 mg/kg/day in 3 doses orally.
24.7 FOLLOW UP
 Advise to remove known causes of allergy, e.g. dogs, cats,
etc. Keep away from smoke.
 See all children with chronic asthma regularly. Supply enough
with drugs. Check the knowledge of child and parents about
asthma.
 Children with asthma should attend school and be allowed to
play in a normal way.
164
KCMC, PAEDIATRICS 25 JAUNDICE BEYOND NEONATAL
PERIOD
___________________________________________________________________
25 JAUNDICE BEYOND NEONATAL

PERIOD
25.1 AETIOLOGY
HAEMOLYTIC
EXTRINSIC CAUSES
 Infectious, e.g. malaria, septicaemia.
 Immunologic.
 Toxic.
 Haemolytic uraemic syndrome.
INTRINSIC RED BLOOD CELL PATHOLOGY

 Haemoglobinopathies, e.g. sickle cell disease,
thalassemia.
 Enzyme deficiencies, e.g. G6-PD deficiency.
 Hereditary spherocytosis.
HEPATOCELLULAR
HEPATITIS
Hepatitis A ,B and C.., yellow fever, infectious mononucleosis,
relapsing fever, leptospirosis, septicaemia, typhoid fever, liver
abscess, brucellosis,.
HEPATOSIS
 Toxic, e.g. heavy metals.
 Metabolic: e.g. hypothyroidism, galactosemia
 Drugs, e.g. INH.Nevirapine
CIRRHOSIS
OBSTRUCTIVE
EXTRAHEPATIC
 Migrating ascaris.
165
PERIOD
___________________________________________________________________
 Intra-abdominal neoplasms.
 Cholelithiasis (particularly in chronic haemolysis),
cholangitis.
 Biliary tract malformation, inflammation.
INTRAHEPATIC
 Chlorpromazine cholestatic jaundice.
 Biliary tract malformation.
25.2 INVESTIGATIONS
FIRST LINE TESTS: INTERPRETATION:
Indirect (unconjugated) Increased in haemolytic

causes,
A Serum bilirubin defect conjugation (rare).
direct,(conjugated),
water-soluble Increased in liver disease or
obstruction.
B Reticulocytes Reticulosis in Increased in accelerated

peripheral circulation. erythropoesis, e.g. recovery
phase after anaemia,
continuous haemolysis.
C Amino
transferases in Inside many cells, also Increased in liver cell
Serum liver cells. Releases in damage. ALAT more
ASAT (GOT) case of cell damage. specific.
ALAT (GPT)
D Serum Alkaline In membranes, also in Increased synthesis in or

phosphatase the epithelium of bile obstructive of bile flow
in serum. canaliculi. either caused
(intra- or extrahepatic).
166
PERIOD
___________________________________________________________________
SECOND LINE TESTS INTERPRETATION:
E Tests of Coombs' test Positive in autoimmune

haemolysis, Sickle cell test disease.
see Hb-electrophoresis Sickle cell disease
also chapter 12 Osmotic fragility Haemoglobinopathies
Anaemia. increased: spherocytosis
decreased: thalassaemia
F Serology In suspected infections Cause of infection

albumin globulin
hepatitis: low normal

G Serum-electro Serum protein or low
phoresis estimation cirrhosis: low raised
chronic/active
disease: low very
high
H Liver biopsy Usually gives the

diagnosis.
Ultrasound
I Hepatic imaging CT scan
MRI
Cholangiography
FLOW OF INVESTIGATION
Letters refer to tests described above in text
A (bilirubin)
Mainly indirect Mainly direct
167
PERIOD
___________________________________________________________________
Haemolytic? Rare failure in C (ASAT, D (alk.ph)
conjugation? ALAT)
B (reticulocytes)
(rare) failure in
Conjugation
Increased Normal or low High High
(rare) haemolysis
within bone-marrow
Intravascular Hepatocellular Obstruction?

haemolysis damage?
E
F, G, H G and/or H
and/or I
Cause of Hepatitis, Extrahepatic or

haemolysis cirrhosis,toxic intrahepatic
hepatosis obstruction
INVESTIGATIONS PRIOR TO REFERRAL

Haemolytic Obstructive
Bilirubin 0 ++++
Urine
Urobilinogen ++++ 0
Stool Colour Dark White
168
KCMC, PAEDIATRICS 26 HEPATOSPLENOMEGALY
_______________________________________________________________________
26 HEPATOSPLENOMEGALY
26.1 DEFINITION
Liver more than 2 cm below the costal margin in infants.
Palpable spleen at any age group.
26.2 SOME CAUSES OF HEPATOSPLENOMEGALY

HM = hepatomegaly; SM = splenomegaly; LFT = liver function
tests.
COMMON HM SM OTHER SIGNS, INVESTIGATIONS
CAUSES SYMPTOMS
Malaria,
Tropical + ++ Fever, etc. Blood slide,
splenomegaly liver biopsy
syndrome
Diarrhoea, sometimes
Schistosomiasis + ++ bloody, haematuria. Eggs in stool, rectal snip,
Portal hypertension. eggs in urine,
eosinophilia
Infectious + (+) Anorexia, fever, tender liver, LFT pathology, WBC,
hepatitis jaundice. Leucopenia, serology
HIV + + See chapter 8. See chapter 8.

Dysentery, abdominal pain, Stool examination may
Amoebiasis + - enlarged, sometimes tender be positive for amoeba,
bulging liver. aspiration from liver
abscess. Ultrasound.
Brucellosis + + Fever, arthritis. Serology

WBC  leucopenia, low
Typhoid + + Fever, abdominal pain. platelet
blood culture, Widal,
serology
Septicaemia (+) + Toxic appearance, fever, Blood culture,

petechiae. WBC  leucocytosis
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_______________________________________________________________________
Sickle cell + +,- Crisis, bone pain, anaemia, Sickle cell test or Hb-
disease bossing, Jaundice electrophoresis
History, tachycardia (gallop),

raised Central venous
Cardiac failure + - pressure, tender liver, Ultrasound, X-ray
ascites.
Kwashiorkor + - History, signs of PEM, other Usually not needed to

precipitating disease. test: low albumin.
LESS
CAUSES SYMPTOMS
Infections
Blood-stained rhinitis,
snuffling of nose, hoarse
Congenital + + voice, dermatitis, X-ray leg. Serology mother
Syphilis pseudoparalysis, dactylitis, and child.
swollen arm or leg. thrombocytopenia
Micro- or hydrocephalus,

Congenital + - jaundice, X-ray skull, fundoscopy,
Toxoplasmosis lymphadenopathy, Serology,
chorioretinitis. thrombocytopenia,
Recurrent fever, cough

Visceral larva + + wheeze, contact dogs, Eosinophilia
migrans cats.
Laparoscopy/laparotomy,
Tuberculosis + + Fever, toxaemia, tuberculin test,
lymphadenopathy, ascites. examination of ascites.
culture
Abdominal pains/palpable Abdominal X-ray, CT scan

Echinococcus + - cystic masses, altered ultrasound, eosinophilia,
level of consciousness. hypergammaglobulinaemia
.
Hb low. WBC 
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_______________________________________________________________________
Kala-Azar leucopenia.
(Visceral + ++ Endemic areas Electrophoresis: albumin
leishmaniosis) low,
gammaglob very high.
Bone-marrow aspiration
Splenic aspiration in skilled
hands, children > 5 yr.
serology for HIV
Relapsing fever + + Episodes of high fever, Spirochetes visible on

(Borrelia) jaundice, petecheal bloodslide.
haemorrhage.
Infectious + + Fever, lymphadenopathy, Atypical lymphocytes, Paul

mononucleosis tonsillitis. Bunnell or Monotest.
Subacute
Infective bacterial Fever, changing heart
endocarditis - + murmur, haematuria, Serial blood cultures.
splinter haemorrhages.
Blood diseases
Hb, platelets low,
bone-marrow, peripheral.
Leukaemia + + Bone pain, anaemia Often
lymphadenopathy, fever. leucocytosis/thrombocytop
enia, chest X ray. Cytology
Thalassemia + + Anaemia, bossing of skull. X-ray skull (hair on end).

Hb electrophoresis.
Jaundice, anaemia,
Erythroblastosis + + ascites, anasarca See chapter 40 on
fetalis cardiomegaly. Neonatal Jaundice.
LESS
CAUSES SYMPTOMS
Circulation
disorders
172
_______________________________________________________________________
History of omphalitis or LFT normal,

Portal vein + + umbilical vessel hypersplenism,
thrombosis catheterization, oesophageal varices in X-
haematemesis. ray barium meal.
Other
conditions
involving liver
Preceding viral or toxic
Cirrhosis; toxic, hepatitis, ascites, LFT pathology,
infectious or + + portal hypertension, liver biopsy.
biliary oesophageal varices.
Autoimmune + + Joint pain, fever, renal and ESR high, Coombs' test,
disease other systemic electrophoresis: gamma
involvement. globulin raised. LE cells.
Malignancy
primary or + - Loss of weight, low grade Liver biopsy.
secondary fever, jaundice.
Bone-marrow, liver biopsy,
Metabolic, e.g. eye examination, X-ray
Gaucher, Hurler, + + Anaemia, bone pain bone, thrombocytopenia,
Reye syndrome elevated liver enzymes
Sudden epigastric pain,
Veno occlusive + - ascites. Cirrhosis. Portal Liver biopsy.
disease hypertension.
173
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27 HEPATIC FAILURE
27.1 PREVENTION
 Hepatitis B vaccination to be promoted
 Don’t overdose paracetamol
 Avoid salicylates in children if possible
27.2 CAUSES
ACUTE HEPATIC FAILURE
Clinical syndrome resulting from massive hepatocytes necrosis or
severe
functional impairment hepatocytes
INFECTIONS
Viral hepatitis A, B, C, D, E other viruses – EBV, Herpes simplex,
adenovirus enterovirus, CMV, Varicella zoster, HIV, yellow fever
septicaemia, Leptospiroisis.
OTHER CAUSES
E.g. Halothane, mushroom poisoning, valproic acid, Reye syndrome,
salicylates, INH, paracetamol overdose, herbal remedies and
traditional medicine.
CHRONIC LIVER DISEASES

INFECTIONS
Chronic hepatitis, viral infections
OTHER CAUSES
Cirrhosis, metabolic, Galactosemia, Wilson disease etc.
174
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ACUTE LIVER FAILURE
Fever Fetor hepaticus
Anorexia Haemorrhagic tendency
Vomiting Progressive jaundice
Abdominal pain Cardiac abnormalities
Rapid decrease in liver size Renal dysfunction
Liver impalpable Hypoglycaemia
Encephalopathy, coma Bleeding abnormalities
Flapping tremor
CHRONIC LIVER FAILURE

Oedema Ascites Signs of portal hypertension
Hepatosplenomegaly, firm Jaundice may occur
Diarrhoea
COMPLICATIONS
Sepsis
Severe haemorrhage
Aplastic anaemia
Renal failure
27.4 IMPORTANT ACTIONS TO BE TAKEN

BEFORE ADMISSION
Children with deepening jaundice and some signs as mentioned
above should be referred early for assessment.
Collect blood in periphery. Avoid IM injection and femoral puncture
175
_______________________________________________________________________
27.5 DIAGNOSIS
TO CONFIRM DIAGNOSIS
Bilirubin, aminotransferases (liver enzymes markedly increases)
prothrombin time (prolonged), blood sugar, albumin electrolytes,
urea, Hepatitis serology.
TO FIND THE CAUSE

From the history and clinical examination the most likely diagnosis
can be complied. To confirm the diagnosis additional investigations
can be made but they will rarely affect the treatment or outcome of
the disease.
27.6 TREATMENT
1. GENERAL CARE (SUPPORTIVE CARE)
 Monitor carefully vital signs and fluid balance
 Pass a nasogastric tube to identify gastrointestinal bleeding
 Avoid sedatives, tranquilizers.
 Paying close affection to doesn’t have infection (UTI, ARI)
 Frequent repeated neurological examinations
TREATMENT OF BLEEDING
 Fresh blood or plasma, see chapter 12 on Anaemia.
 Vitamin K 1-3 mg s/c start for prevention
 In severe cases 5-10 mg / dose IV or s/c
 Infusion must be slow (1 min). May be repeated after 3-5 h.
 In case of acute bleeding 5-10g / dose IV/sc
 For gastrointestinal bleeding prevention any H2-blockers
(cimetidine, ranitidine).
176
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2. NUTRITION
 Use nasogastric tube
 Low protein intake, 0-0.5g/kg
 Restrict protein in the acute phase the low protein in
improvement phase to balance growth.
 High calorie intake, or at least daily requirement
Use Dextrose or milk
 Avoid hypoglycemia
3. FLUID
Avoid over hydration leading to cerebral oedema: Be
particularly careful in case of oliguria. Avoid sodium in the acute
stage; give Dextrose 10% with potassium.
TREATMENT OF HYPOKALAEMIA
Signs of severe hypokalaemia are: muscle weakness,
hypotonia, even paralysis, bradycardia, depressed tendon
reflexes. Potassium is needed in large amount, even up to 0.5
meq/kg/day hour IV or 3-6 meq/kg/day (watch IV carefully), but
cardiac status must then be carefully checked, best by ECG.
Otherwise give orally 100 mg/kg, and follow pulse rate.
4. TREATMENT OF METABOLIC DERRAGEMENT

Fluids
Potassium
Nutrition
5. TREATMENT OF BLEEDING
177
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6. TREATMENT OF ENCEPHALOPATHY [COMA]

Restrict proteins
Clean the gut with several enemas
Give Gentamycin or neomycin [50-100mg/kg/day]
Reduce enteric bacteria and therefore reduce ammonia
production Lactulose 4mls/kg/day [may go up to 90mls/day]
Infants 2.5-10mls/day
Treatment of seizure with Phenytoin [or Phenobarbitone]
Patients with decerebrate or decorticate posturing can be treated
with Mannitol 0.5-1mg/kg/dose over 30minutes
Flumenzyl may reverse the hepatic encephalopathy 0.01/kg stat
max 0.2mg
27.7 FOLLOW UP
Depending upon the cause of disease. Relapses must be
referred early to the same hospital.
178
KCMC, PAEDIATRICS 28 FIVE COMMON SKIN DISEASES
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28 FIVE COMMON SKIN DISEASES

28.1 PREVENTION

 Daily washing with soap and water of the whole body is the
most important.
 Reduce overcrowding, if feasible.
 Ensure good nutrition, including well balanced food.
28.2 CAUSES
Infective causes of skin diseases are mainly impetigo, scabies,

and superficial fungal infections. These have a high. These have a
high communicability. Non- infectious causes are mainly
eczematous disorders.
IMPETIGO
Superficial infection of the skin caused usually by staphylococci,
or rarely by β-haemolytic streptococci. It is very contagious. It
presents as vesicular, pustular with crusts. Removal of the crusts
leaves a weeping surface with a lot of bacteria. The bullous type
of impetigo in the newborn known as pemphigus neonatorum is a
dangerous condition that can lead to septicaemia and
haemorrhagic nephritis.
SCABIES
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Female mite of Sarcoptes scabiei forms a burrow in the skin.
Allergic itching, especially during night time. Classical primary
eruptions are pruritic papules, vesicles and pustules masked by
secondary excoriations, eczematisation, crusting and secondary
pyogenic changes. In older children lesions tend to involve the
finger webs, side of finger, wrists, axillae, penis and lower
buttocks. In infants and younger children distribution commonly
includes palms, soles, head, neck and face. Often atypical clinical
presentation. Small children may present with symptoms in palms
and soles only.
SUPERFICIAL FUNGAL INFECTIONS

Clinically, fungal diseases may affect different anatomical areas of
the body.
 Ringworm of the trunk: Tinea corporis. Circular patches which
spread out peripherally with raised borders with small
vesicles, healing in the centre and so forming the rings from
which the disease derives its name.
 Ringworm of the scalp: Tinea capitis. Circumscribed single or
multiple patches with hair loss in which the remaining hairs
are broken.
 Athlete's foot: Tinea pedum. Characterized by erosion,
maceration, fissuring and itching of the interdigital spaces.
 Ringworm of the groin (T. cruris)
 Ringworm of the nails (Onychomycosis)
PAPULAR URTICARIA
Seropapular, itching. Very common in small children. Popular
urticaria is itself not contagious but it often ends up with secondary
bacterial infection which can be infectious. Bites of insects make

sensitized areas of the skin to flare up. Common sensitizers are
insect bites, but ecto and endoparasites play some immunological
role.
180
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ECZEMA / DERMATITIS
Small groups of papules or vesicles on reddened, infiltrated base,
itching, in acute stage weeping and crusting, in chronic stage dry,
scaling. Not contagious. In infancy a special form of eczema,
seborrhoeic dermatitis, is seen: "cradle cap".

ADMISSION
Most of these diseases should be treated at a health centre or at
district level. As they may appear in patients admitted to referral
hospital for other reasons, they are mentioned in this manual.
28.5 DIAGNOSIS
 Usually clinical.
 Bacterial culture and sensitivity testing from pyogenic lesions
(pus swab).
 Direct microscopic examination.
 Scrapings for 10-20% Potassium hydroxide (KOH)
examination from actively spreading border to look for fungal
elements, e.g. septate hyphae, yeast cells or pseudomycelia.
28.6 TREATMENT
DERMATOLOGICAL PREPARATIONS
PREPARATION USE
SOLUTIONS
181
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o Carbon-fuchsin solution (cartellani’s o Fungal infections, candidal
paint) infections
o Whitfield’s solution o Dry interdigital mycoses
o Sodium thiosulphate solution o Pityriasis vesicolar
POWDERS
o Basic powder (zinc oxide, bentonite, Absorbent, soothing and protective;
talcum) especially over the intertriginous
areas
LOTIONS
o Calamine o Anti pruritic and coolant
o Potassium permanganate o Infected dermatoses
o Aluminium acetate o Infected dermatoses
o 3%vioform o Infected dermatoses
PASTES
o Zinc oxide paste Protective, absorbent, anti
inflammatory
SPECIFIC MANAGEMENT
IMPETIGO
 Remove all crusts with soap and water or PP soaks
beforehand.
 For more dry lesions Vaseline with 2% sulphur and 2%
salicylic acid is helpful or when more extensive apply (if
available) antibiotic ointment such as Fucidin, Bacitracin or
Neomycin application. If lesions are very wet, Gentian Violet
0.5% should be used.
 Systemic antibiotics should only be used in systemic
involvement, for suspected resistant strains,
immunosuppression, neonatal impetigo (see 32.3) and an
epidemic (or smaller outbreaks) of acute glomerulonephritis.
 Correct predisposing factors and concurrent infections.
Impetigo never comes alone.
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SCABIES
 General rules of treatment
 Good initial scrub with water and soap.
 Application preferably done at night (remains on skin
better and disinfects bed-linen) for three consecutive
nights.
 After completion take a final bath, change bed-clothes,
sheets and pillow covers. Clothes should be washed and
dried in hot sun or ironed.
 Try to treat all household or community members all over
the body at the same time.
 Do not merely treat without appropriate health education
to parents.
 Treatment in neonates and infants
BBE is a strong conjunctival irritant and may cause
convulsions if ingested. If used at all, it should be in the
strength of 6.25% for three consecutive nights (whole body
including head and face) proceeded by bath. Vaseline, or
better Zinc cream with 3% precipitated sulphur, applied nightly
to entire body (incl. head and face) for three nights is a very
effective, safe and well tolerated alternative treatment for
infantile scabies.
 Treatment of older children

In older children BBE 12.5% (half strength emulsion) should
be applied thoroughly from neck downward to all areas for
three successive nights, with special attention to the hands,
feet and intertriginous areas. For post-scabietic itching:
Calamine lotion.
SUPERFICIAL FUNGAL DISEASE
 Whitfield's ointment is a cheap and effective medication for a
dry surface. Vaseline with 5% sulphur and 5% salicylic acid is
183
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a good alternative. Gentian Violet can be used for candida
infections on skin and mucous membranes.
 Griseofulvin should be added in widespread (more than 25%
of surface) and resistant cases. Very good for tinea capitis.
Dose: microsized 10(-20) mg/kg/d in 1-2 dose orally for 4-6
weeks, depending upon responses. If ultra-microsized reduce
dose to half.
 For Athlete's foot Castellani's paint, which should be used with
caution, is most effective on moist surfaces. Potassium
permanganate solution can also be used for antiseptic foot
bathing and soaks to dry up the condition. When dry,
Whitfield's ointment is indicated. Hair should be clipped or
shaved from the affected patches. After 4 weeks the hair
should be cut for the second time thus removing all the
infected remnants.
 To prevent spreading of the disease all contacts should be
examined and the source of the infection located (animal
source?)
PAPULAR URTICARIA
Clean the body, control secondary infection and try to identify and
remove the source of insect bites. Calamine lotion and oral
antihistamines may be tried. If underlying intestinal parasites are
suspected treat with antihelmintics (see chapter 10)
ECZEMA/DERMATITIS
The choice of the initial topical treatment in all eczematous
conditions depends on the stage of the eruption and not on its
cause.
 Acute wet lesions
Should be treated with wet soaks (Potassium permanganate
1:5.000 solution, N-saline solution or clean tap water in which
3 small
teaspoons of salt are dissolved per litre). Keep wet until
eczema starts to dry up.
 Acute drying-up lesions
184
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Hydrocortisone 0.5-1% cream (cream contains more water).
More powerful corticosteroids, especially double-fluorinated
ones, should be avoided, unless you are able to supervise the
short term use of these potentially harmful ointments very
strictly.
 Acute dry lesions
Hydrocortisone 0.5-1% ointment (ointment contains more oil).
 Dry, chronic lesions
First 0.5-1% Hydrocortisone ointment, then Zinc paste with
5% coal tar if available. For "cradle cap": salicylic acid with 2%
vaseline.
 Avoid alkaline soaps and frequent washing/bathing.
Rinse clothes and beddings with plenty of water after being
washed with washing powder.
 Assist mother to accept the disease.
 Keep the child as cool as possible, cotton underwear/clothes
best.
 Especially in long term treatment use during the day:
yellow vaseline, vegetable oil (e.g. peanut, coconut) or animal
fat (e.g. sheep). At night time: apply Cortisone ointment, if
needed at all.
 Stress the importance of breaking the maintaining vicious itch-
scratch cycle.
28.7 FOLLOW UP
No specific.
185
KCMC, PAEDIATRICS 29 OSTEOMYELITIS AND SEPTIC
ARTHRITIS
________________________________________________________________________
29 OSTEOMYELITIS AND SEPTIC

ARTHRITIS
29.1 PREVENTION
 Avoid skin infection. Treatment of small infected wounds. See
also chapter 28 on Skin Diseases.
 Aseptic technique when taking blood or giving injections
(femoral puncture should be the last resort).
 Ensure good nutrition
29.2 CAUSES AND PATHOLOGY

BACTERIA
Staphylococcus aureus is the most common cause. Also Group B
streptococci (neonates), pneumococci, E. coli, Pseudomonas,
Hemophilus influenzae, and other Gram-negatives (neonates).
Salmonella in children with sickle cell disease.
187
ARTHRITIS
________________________________________________________________________
PATHOGENESIS
INFECTION IN
METAPHYSIS
ABSCESS IN BONE ABSCESS IN

MARROW PERIOSTEUM
SINUS
BLOCKAGE OF NUTRIENT
ARTERY
DEAD BONE,
(SEQUESTRUM)
FRACTURE
188
ARTHRITIS
________________________________________________________________________

ACUTE FORM
 High fever, illness (sometimes localizing symptoms only).
 Localized tenderness over metaphyseal area in early phase.
 Marked redness, swelling and distinct tenderness over the
affected bone, mainly femur and tibia. Remember: pyomyositis
is very rare in Tanzanian children.
 In arthritis pain and reduced movements are seen. In smaller
joints also redness and swelling. Early detection essential.
 Limping, restricted movement, e.g. in hip involvement.
 Treatment with antibiotics for other reasons may suppress
some symptoms of osteomyelitis and delay the diagnosis.
CHRONIC FORM
 "Pathological fractures".
 Sinuses dripping pus.
 Not so much pain.
 Longstanding cases may show kidney involvement,
amyloidosis.

ADMISSION
Early recognition of triad: limp + fever + tenderness over bone
should result in immediate treatment. Refer at once to a hospital,
which has got effective antibiotics.
EVERY HOUR OF DELAY CAUSES MORE DEAD BONE!
29.5 DIAGNOSIS
189
ARTHRITIS
________________________________________________________________________
CLINICAL (Often sufficient).
LABORATORY
 ESR, WBC, Hb, Bloodslide
 Sickling test if sickle cell disease is suspected
 Blood culture if possible (before treatment).
 Bone aspiration: Culture and gram stain of bacteria.
 Joint aspiration in septic arthritis. Culture and Gram stain of
bacteria.
IMAGING
Ultrasound is essential in diagnosis of acute osteomyelitis.
X-ray changes can be seen after 10-14 days and thus is mainly for
chronic cases.
29.6 TREATMENT
Start IV antibiotics as soon as diagnosis of osteomyelitis is

made (see doses below)
Splint the limb to minimize pain
SURGICAL DRAINAGE (osteomyelitis always to be presented
to orthopaedic surgeon in order to consider early drainage!)
ACUTE OSTEOMYELITIS IS AN EMERGENCY!
 Traction for hips to comfort and prevent subluxation.

 Drill the outer shell of the bone into medullary cavity to release
the pus.
 Irrigate the bone intramedullary through an inflow catheter with
normal saline, with or without Chloramphenicol 0.5% for one
week. Use a large suction outflow catheter from the
190
ARTHRITIS
________________________________________________________________________
subperiosteal space. Connect to continuous suction if possible.
In septic arthritis apply urgent open drainage of the joint.
Irrigate for 2 days.
ANTIBIOTICS
IMMEDIATE, PARENTERAL TREATMENT for 1-2 weeks.

Effective mainly within 48 hours after onset of symptoms.
Cloxacillin 100-200 mg/kg/day IM or IV in 3 doses
Consider adding:
Chloramphenicol
(If staphylococcal. Infection is not the most 100 mg/kg/day IV or orally
likely and in a child with sickle cell
disease).
For neonates: doses, see chapter 38

Cloxacillin plus Gentamicin
Alternative antibiotics:
Clindamycin 20-40 mg/kg/day IV in 3 doses slow
infusion over 1-2 h
Cefuroxim 100-150 mg/kg/day in 3 doses especially
in Gram neg bacteria.
Ceftriaxone 50-80 mg/kg/day IV
191
ARTHRITIS
________________________________________________________________________
CONTINUED ORAL TREATMENT for 4-6 weeks.
Cloxacillin 50-100 mg/kg/day in 3 doses until all

signs of the inflammation are gone or at
least for 6 weeks.
Or
Clindamycin 10-20 mg/kg/day in 3 doses.
TREATMENT OF CHRONIC OSTEOMYELITIS

 Anti-tetanus vaccination.
 Surgical removal of sequestrum, when involucrum is strong
enough. Wait at least 3 months after onset of symptoms.
 Antibiotics according to Gram stain or culture (see above). Give
usually only for 1 week around operation.
29.7 FOLLOW UP
After 2 months to see the results of treatment and observe the
function of the part of the body that was infected.
192
KCMC, PAEDIATRICS 30 GLOMERULOPATHIES AND RENAL FAILURE
__________________________________________________________________________
30 GLOMERULOPATHIES AND RENAL

FAILURE
30.1 PREVENTION

 Diagnose early or properly treat throat and skin infections
including scabies
 Prevent malaria.
 Prevent Typhoid fever and immunize against Hepatitis B.
30.2 CAUSES & PATHOLOGY

Complexes of antibody-antigen (infection, auto-antigen) are
deposited in the glomeruli, which will be damaged. This is the most
common cause.
INFECTIONS
 Streptococcus in skin (often after scabies) or throat
 T. pallidum
 Malaria (Plasmodium malariae, nephrotic syndrome mainly)
 Hepatitis and other virus
 Schistosoma mansoni (nephrotic syndrome)
 Typhoid nephrotic syndrome
OTHER CAUSES
 Systemic lupus erythematosus
 Sickle cell disease
 Insect bites
 Drugs
 Heavy metals Hg, Pb (nephrotic syndrome)
 Unknown causes (e.g. minimal change nephrotic syndrome)
193
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NEPHRITIS NEPHROSIS
 Haematuria,  Proteinuria, >50mg/kg/day
Protein in 24 hour urine or
3+/4+ protein on urinary
dipsticks
 Oedema caused by oliguria  Oedema caused by
hypoalbuminaemia
 Hypertension   Sometimes hypertension
encephalopathy and/or mild haematuria
 Proteinuria, mild  Pneumococcal peritonitis
Shock
 Casts in urine  Hypercholesterolemia
 Headache, restlessness
 Convulsion
 Oliguria < 1ml/kg/hr - renal failure
Presentation as pure nephrosis is mainly caused by minimal change
Glomerulonephritis which responds best to steroid therapy

ADMISSION
 Children with nephritis should have early referral to hospital,
especially in case of hypertension (measure BP) and oliguria
(measure urine output).
 Children with oedema should be correctly diagnosed: differentiate
between PEM - Cardiac failure - nephrotic syndrome and
nephritis. Refer early according to the diagnosis.
Avoid the use of steroids before diagnosis is established
30.5 DIAGNOSIS
194
__________________________________________________________________________
In developing countries, Glomerulopathies present frequently as a mixed

picture between Nephrosis and Nephritis
BLOOD PRESSURE, appropriate cuff (covering 2/3 of upper arm)
Table of diagnostic features:

Lab parameter Acute Glomerulonephritis Nephrotic Syndrome
Urine WBC normal to slightly elevated normal to slightly
elevated
Urine red cells Macro- or Microhematuria few RBC
Urine Casts red cell casts absent
Urine Protein 1+/2+ 3+/4+, >50mg/kg/day
(24 hour urine
collection)
Serum Elevated normal
Creatinine
Se- Albumin Normal reduced
Se- Cholesterol Normal elevated
Se- Electrolytes Na- reduced, K- increased Mostly normal
ADD: ASOT to confirm Post-streptococcal Glomerulonephritis, FBP in
both diseases, esp. to rule out Haemolytic Uremic Syndrome
195
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X-RAY CHEST: May be of help in cardiomegaly and congestion of

lungs, but not necessary.
ECG: For estimation of K+, this is useful in oliguria.
ULTRA-SOUND
30.6 TREATMENT
TREATMENT OF ACUTE GLOMERULONEPHRITIS
 Supportive treatment
 Monitor body weight, blood pressure (4 hourly day & night),
fluid intake and output daily
 Diet and caloric intake

 Limit salt intake (no added salt) until fluid overload is resolved
 Restrict protein intake – use high quality protein
 High caloric intake is required until blood urea <20mmol/l
otherwise risk of acidosis
o 100kcal/kg/d for 1st 10 kg body weight;
o 50kcal/kg/d from 11-20 kg body weight
o 20kcal/kg/d for every kg above 20kg b wt
 FLUID
In case of oliguria it is very important not to over-hydrate. See chapter
46 on IV Fluid Therapy for calculation of maintenance fluid. Give 25%
of maintenance (see 46.1), plus the amount of urine passed on
previous day plus ongoing losses. Be careful with sodium and
potassium intake in oedema, hypertension and oliguria.
196
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PENICILLIN
Procaine penicillin to treat infection focus 60.000 IU//kg in one dose IM for 10 days
Or
Oral Pen V 50mg/kg/day in 3 dose
TREATMENT OF HYPERTENSION
If systolic pressure > 140 or diastolic pressure > 95 mm Hg.
 In milder cases:
Drugs Dose Side effects
1 -2mg/kg/dose, PO or iv, can be
Furosemide repeated to a maximum of Hypokalaemia
6mg/kg/day
If not enough effect, add one of the below
1 mg/kg/day in 3 doses orally, May be
Hydralazine increased to 7½ mg/kg/day in 3 For moderately severe
doses. Or 0.1-0.3 mg/kg/dose iv hypertension. Side effect
tachycardia.
0,01- 0,02 mg/kg/day orally in 2
Reserpine doses May produce CNS
Depression.
0,25-0,5 mg/kg/dose, maximum 10mg hypotension, tachycardia,
Nifedipine per dose dizziness, syncope
 In acute severe crisis, if available:

1-3 mg/kg/dose in very rapid IV
injection. Max 150mg
Diazoxide May be repeated after 15-20 minutes. Hypotension
Hypotension, tachycardia,
Nitroprusside 0.3-0.5 mcg/kg/min IV thyroid suppression,
seizure
197
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TREATMENT OF HYPERKALAEMIA (> 7 meq/l)

(Tall T-waves, widened QRS, flat P-wave on ECG.)
 Remove all sources of potassium
 Calciumgluconate 10% 0.5 ml/kg very slowly IV
 Insulin 0.1 unit/kg SC
 Dextrose infusion 0.5 g/kg, IV e.g. 5 ml/kg
simultaneous with insulin 10% dextrose, 2 ml/kg 25%
If needed repeat the Insulin/dextrose combination every 2 hours as
long as the hyperkalaemia persists.
TREATMENT PLAN IN ACUTE RENAL FAILURE

Oliguria commonly defined as less than 400ml/m²/24 hrs. Rule of
thumb: start worrying if urine production less than 1 ml/kg/hour.
CAUSES
 Pre-renal: dehydration, shock, severe haemorrhage, trauma,
burns.
 Renal: glomerulopathies, acute tubular necrosis, disseminated
intravascular coagulation.
 Post renal: urinary tract obstruction
MANAGEMENT
 General care and nutrition are very important. (See above)
 Fluid output and input must be monitored with great care.
 If it is difficult to distinguish between pre-renal and renal cause of
oliguria give a trial dose of Furosemide 2 mg/kg IV at a rate of 4
mg/min after a fluid bolus ( Normal Saline or Ringer’s Lactate)of
20ml/kg, unless hypertension is present:
If oliguria persists give a dose once only 10 mg/kg IV. If diuresis
starts the cause is most likely pre-renal. If furosemide fails to
induce diuresis then give mannitol 0.5-1 g/kg IV over 30 minutes.
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If pre-renal: give IV (e.g. normal saline) and oral fluid to correct
dehydration/circulation. Monitor urine amount and watch for signs
of over-hydration.
 Electrolytes in serum have to be checked if the oliguria lasts for
several days. In case of hyperkalaemia, refer to treatment above.
In case of hypocalcaemia/hyperphosphataemia; take dietary
measures including giving Vit D.
 Other symptoms e.g. hypertension, see above.
Convulsions, see chapter 15 on Convulsions.
 Peritoneal dialysis may be tried in intractable congestive heart
failure, hypertension, hyperkalaemia and in CNS disturbances.
See chapter 47 for Peritoneal Dialysis.
SPECIFIC TREATMENT OF NEPHROTIC SYNDROME
Management of presumed MCNS

Initial episode only:
 Prednisone 2mg/kg/day (60-80mg max.) for 6 weeks then
 Reduce to 2mg/kg/day on alternate days for 4 weeks then
 Taper off completely over a period of 2 weeks
First few relapses:
 Prednisone 2mg/kg/day (60-80mg max.) until early morning
dipstick proteinuria is negative
 or trace for 3 days then
 Taper off completely over a period of 2 weeks
Frequent relapses: (2/more relapses within 6months of initial

response to treatment or 4/more relapses within 12 months of initial
response to treatment)
 Prednisone 2mg/kg/day (60-80mg max.) until early morning
dipstick proteinuria is negative or trace for 3 days then
199
__________________________________________________________________________
 Taper down to 0.1- 0.5 mg/kg on alternate mornings for 3-6
months
N.B
 Steroids are contraindicated in case of uncontrolled
hypertension and infection e.g. hepatitis, peritonitis, etc.
 Enalapril can be used in the patients where steroids are
contraindicated
 Patients with NS and haematuria should fulfil the criteria for
diagnosis of NS before starting steroids
 Suspect malarial nephrotic syndrome mainly in children above
2 yr., age peak 4-5 yr. Often fever early in the course with
spikes every 72 h caused by plasmodium malariae. Often
hepatosplenomegaly.
Relapse on the above regime (steroid dependent) / toxicity on lower

dose
 Levamisole 2.5mg/kg on alternate days for 6 – 18 months (is
started when prednisone has produced remission i.e. urine
albumin shows nil or trace for 3 days consecutively) or
 Cyclophosphamide 2mg/kg/day for 8 – 12 weeks or
 Chlorambucil 0.2mg/kg/day for 8 – 12 weeks or
 Cyclosporin 5 – 6 mg/kg/day for 1 – 2 years
 The above are started while patients are on steroid therapy, then
tapered off gradually during the course of treatment
In patients with Steroid resistant Nephrotic syndrome a trial of:
 Cyclophosphamide 2mg/kg/day for 8 – 12 weeks or
 Cyclosporin 5 – 6 mg/kg/day for 1 – 2 years or
 High dose pulse methylprednisone (in combination with alkylating
agent) tapering off over 72 months.
CYCLOPHOSPHAMIDE
Indication: Dose: Side effects:
Steroid dependent
relapser on 2.5-3 mg/kg/day orally for Loss of hair, cystitis. If WBC
200
__________________________________________________________________________
steroid/steroid toxic 2 months below 2.500/mm3 stop
cases. treatment temporarily.
Usually in combination
with:
Prednisolone 2-3 mg/kg/d in one dose
every other morning, orally
for 6-8 weeks.
DIURETICS
In severe oedema:
Plasma 20 ml/kg
and 30 min later
1 mg/kg IV
Furosemide May be repeated every
8-24 h.
COMPLICATIONS
 Infections (Cellulitis, Spontaneous bacterial peritonitis especially
due to pneumococcus and E.coli)
 Thromboembolic phenomenon
 Cardiovascular diseases
 Bone diseases
 Renal failure
30.7 FOLLOW UP
 Relapses may occur, especially in nephrotic syndrome and
should be referred early for treatment. Some parents may be
instructed to measure proteinuria at home and on first sign of
relapse, to start Prednisolone at home.
 The nutritional status should be followed over the next 2-3
months after discharge.
201
KCMC, PAEDIATRICS 31 URINARY TRACT INFECTION
________________________________________________________________________
31 URINARY TRACT INFECTION

31.1 PREVENTION
Clean perineum (Especially in girls from pubis downwards and not
vice versa)
Frequent change of diapers
31.2 CAUSES
 Ascending infection from periurethral area or haematogenous.
 E. coli mainly. Other bacteria such as Klebsiella, Proteus,
enterococci, Pseudomonas, Staphylococcus mainly in
obstruction of urinary tract.
 Reflux of urine and malformation predispose for urinary tract
infection (UTI).

NEONATES
Failure to thrive. Loss of weight more than 10%, jaundice, cyanotic
spells, apathy.
INFANTS
Fever, vomiting, irritability, diarrhoea, sepsis, failure to thrive.
CHILDREN
LOW UTI, CYSTITIS
Slight fever, dysuria, frequency.
HIGH UTI, PYELONEPHRITIS
High fever, flank pain or pain around umbilicus, anorexia.
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ADMISSION
 Think of UTI in case of unexplained fever and abdominal pain
and failure to thrive.
 Be very careful when collecting urine; try to get a clean
specimen before starting the treatment.
 Refer relapsing cases of UTI. BP should be taken in particular
in relapsing cases.
31.5 DIAGNOSIS
URINE
COLLECTION OF URINE
 Clean genitalia around the urethral opening. Continue to clean
also the skin around. Use clean water.
 Midstream urine is best.
 Plastic bags may be used for small children, if the skin has
been carefully cleaned. In small boys also the preputium
should be rinsed carefully with lukewarm water 2-3 times. As
soon as the child has passed urine, the bag should be
removed and sent to the laboratory. A clean glass container
could also be used. The mother must observe the naked small
child and collect urine as soon as the child starts to void.
 Suprapubic bladder aspiration can be done in small infants.
The skin is punctured about 1 cm above pubic bone in the
middle line. The 0.7 mm needle attached to a syringe is
pushed perpendicularly to the skin to a depth of 2-3 cm. The
urine is aspirated into the syringe.
 The urine should be examined at once, if it cannot be kept in
a refrigerator at 4°C.
EXAMINATION OF SEDIMENT
 WBC. More than 15/high power field in centrifuged urine is
suggestive of UTI. Absence of WBC does not exclude
204
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pyelonephritis. Pyuria is a sign of inflammation in genital region
or urinary tract.
 Haematuria is often found in UTI, especially in lower infection.
 Casts point to high UTI.
 Bacteria. Gram stain on sediment in fresh (< 1 hour outside
refrigerator) urine.
CULTURE OF URINE
The specimen should be without contaminating bacteria from skin
and faeces or container. Cultures should if possible be taken
before the treatment is started. Positive culture: > 100,000
bacteria/mm3.
DIP STICK
Positive leukocytes and nitrites on a urine dip stick are strongly
suggestive of UTI
BLOOD
ESR, or CRP if available, can be used to differentiate high (more
dangerous) UTI from low. ESR and CRP values are usually raised
in high UTI.
X-RAY AND ULTRASOUND

Ultrasound of the kidneys should be done as first investigation
according to age related guidelines below. Ultrasound can detect
dilated renal pelvis and bladder retention.
If enough facilities exist, intravenous pyelogram and if possible a
voiding cystourethrography should be performed in children with
Recurrent UTI or abnormalities on Ultrasound These
investigations are done for early identification of patients at risk for
renal damage, e.g. vesicourethral reflex, obstruction urinary tract,

other malformations and to detect signs of earlier damage to the
kidneys.
Age 0-2 yr. all children  after first UTI
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Boys older than 2 yr.  after first pyelonephritis
 after second cystitis
Girls older than 2 yr.  after 1st-2nd pyelonephritis
 after 3rd-5th cystitis
The risk of kidney damage caused by UTI is mainly before the age
of 4 yr. The risk increases with repeated pyelonephritis and late
treatment.
31.6 TREATMENT
INFANTS 0-4 MONTHS
Ampicillin and Gentamicin. Dose see chapter 38 on Infections in
the newborn. Intravenous or intramuscular treatment should be
given until improvement is seen, then continue orally with
Amoxicillin 50 mg/kg/d in 3 doses. Therapy should be given for 10-
14 days. Amikacin (infants /children: 30 mg/kg/d IM, IV in 3 doses
for 10-14 days, neonates see 38.5) should be considered in case
of Gentamicin resistance.
OLDER INFANTS AND CHILDREN

PYELONEPHRITIS (HIGH UTI)
Cotrimoxazole (TMP, SMX) 6/30 mg/kg/day in 2 doses orally for 14 days
or
Amoxycillin/Clavulanic Acid 40 mg/kg/day orally in 3 doses 14 days
Alternatives: Gentamicin, first + second generation cephalosporin
After an operation on kidneys Nitrofurantoin may be given for 1-2 months.
Dose 1-2 mg/kg/day orally.
CYSTITIS (LOW UTI)

Nitrofurantoin 3-5 mg/kg/day in 2 doses orally for 7 days
Cotrimoxazole 6/30 mg/kg/day in 2 doses orally for 7 days
31.7 FOLLOW UP
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 14 days after completion of treatment, there should be a
control of the sediment and in case of suspected failure of
treatment, a new culture.
 Children with repeated UTI, especially children below 5 years,
must be assessed at referral hospital for proper investigation,
see section on X-ray/US above, if this has not been done
already.
 Parents must recognize early signs of UTI and bring the child
to hospital when there is a relapse.
207
KCMC, PAEDIATRICS 32 GENERAL CARE OF THE NEWBORN
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32 GENERAL CARE OF THE NEWBORN

32.1 PRENATAL PREVENTION OF NEONATAL
PROBLEMS
 Prevent preterm delivery and low birth weight (LBW) children,
through regular antenatal care, nutritional supplementation
and reduced workload for the pregnant woman.
 Refer high-risk pregnancy to hospital in good time before
delivery.
 Promote birth interval of at least 3 yr.
 All pregnant mothers should be immunized against tetanus.
See Tanzania vaccination schedule in chapter 49.
 Prevention of mother to child transmission of HIV among HIV
infected mothers
 Prevention of congenitally acquired infections
32.2 MAJOR POINTS IN THE CARE OF THE NEWBORN

 Keep the airway clear.
 Keep the newborn warm.
If possible keep the newborn naked between the mother's
breasts, under her clothes, during the transport to referral
hospital (kangaroo method).
 Introduce early feeding.
Latest after 4-6 h. Discourage to give a healthy child other
fluid than breastmilk.
 Keep mother and child together.
Do not separate the child from the mother. Even a very sick
child needs its mother, who should be allowed to see and
touch her child regularly.
 Give Vitamin K1.
0.5mg IM for preterm baby and 1mg IM for term baby
 Prevent infections.
208
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o Wash hands carefully with soap prior to handling newborn
babies and dry with clean towel or toilet paper.
o The cord is cut with new razorblade, left uncovered and if
necessary cleaned with spirit (alcohol 70%).
o After cleaning the eyes instil one drop of 2.5% Povidone
iodine or some Tetracycline 1% ointment to each eye. If
not available Silver nitrate 1% (fresh, kept in closed
container, preferable one dose vials in view of danger of
more concentrated solutions!) is effective, although some
20% of the babies develop a transient chemical
conjunctivitis.
o Consider 750 U ATS to prevent neonatal tetanus if the
mother is not vaccinated. If ATS not available give
penicillin.
o BCG and other vaccinations according to schedule.
o Breastfeeding.
209
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32.3 SOME COMMON PROBLEMS IN THE NEWBORN

PROBLEM ACTION DANGER
Isolate from other newborns
Skin sores (impetigo 1% aqueous Gentian violet. Epidemic of septicaemia
neonatorum) If spreading or improper and other infections with
follow up: systemic streptococci and
antibiotics. staphylococci in ward.
If mild clean with saline.
If severe, try to exclude
gonococcal c. and if possible also
Conjunctivitis chlamydia. Blindness.
Instil erythromycin or
tetracycline 1% eye
chloromphenical
ointment, see Ch 17.
Cephalhaematoma Hands off. Inappropriate action may

induce infection.
Normal swelling of Hands off as well. Inappropriate action may

breasts induce infection.
Between feeds first week May take weeks and

Brachial (Erbs) palsy arm to be immobilized 90 months to restore and
abducted in shoulder, 90° in between contracture
flexed in elbow, supination. can occur.
From 2nd week onward
careful active and passive
exercises.
Small one with thin

Extra digits connection: tie off.
Thicker: surgery.
Inappropriate action may
"Nylon teeth" Epstein pearls are normal. induce infection.
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32.4 ORAL FEEDING IN NEWBORNS (BOTH TERM AND
PRETERM)
BREASTMILK
Try in the sick ones with 20 ml/kg on the first day in frequent
feeds, increasing to 80 ml/kg at the end of the second day. If
necessary, give additional dextrose 10% IV. If the child tolerates
the oral feeding, continue with only breast milk.
Feeding option for infants born to HIV positive mothers are

discussed in section 8.6
METHODS OF FEEDING
 Breastfeeding should be tried whenever possible. (The ability
to suckle is often not well developed before week 33-35).
 Spoon-feeding is possible even to very immature infants,
since the ability to swallow fluids is developed early (before
week 25).
 Nasogastric tube feeding is the method of choice in preterm
and very sick babies. The appropriate length of the tube is
measured from the nose, via the ear, down to the lower part of
sternum. The tube is exchanged every 2-3 days. If the tube is
causing irritation in the nostrils and thereby making breathing
difficult, it may be put down through the mouth.
 Bottle feeding to be discouraged.
 Expressed breastmilk
During a short illness of the infant or separation from the
mother, lactation can still be maintained with proper
management:
 Re-establishment of lactation
In the absence of efficient suckling the volume of breast-milk
may diminish despite manual expression. Re-establishment of
lactation may be necessary. This is done by putting the child
to each breast for about 5 minutes every 2-3 hours. Try to get
the mother relaxed. Massage of breasts should be tried.
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REPLACEMENT FOR BREASTMILK (200 ML), SOME
SUGGESTIONS:
Refer to section 8.6 for feeding alternatives and preparation of

cow’s milk for infant feeding
RECOMMENDED VOLUMES AND FREQUENCIES OF MILK

FEEDS. (See also chapter 33)
DAY PRETERM SGA (ORAL/IV) FULLTERM FULLTERM (IV)
(ORAL/IV) (ORAL)
1 60ml/kg 60ml/kg 8 x 10ml 40 ml/kg
2 80ml/kg 80ml/kg 8 x 20ml 60ml/kg
6-9 160ml/kg 160ml/kg 8 x 60-70ml Max 175 ml/kg
10-14 180-200ml/kg 180-200ml/kg
Max 200ml/kg Max 200ml/kg
Comments:
 If possible early breastfeeding or enteral feeding with expressed breast
milk (EBM)
 In some VLBW babies (<1.5kg) especially SGA, amount of milk may be
increased more rapidly (if tolerates!) and up to 220-250ml/kg
212
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Frequency of feeding
 Bodyweight <1.5kg and age <10 days 2hourly
 Bodyweight <1.5kg and age >10 days 2 or 3 hourly
 Bodyweight <2.0kg and SGA. Initially 2 hourly (Risk of
hypoglycemia)
 Bodyweight >1.5kg and AGA 3hourly
In some infants, especially small-for-dates, it may be necessary to

increase to 220 or 250 ml/kg/day. In newborns > 2½ kg starting
with 30 ml/kg/day and increasing to 150 ml/kg/day is usually
sufficient. If possible feed on demand. In breastfeeding the
possibility to feed much more frequently and liberally is a distinct
advantage. If the amount desired is not reached consider adding
parenteral fluids especially in small preterm, SFD and sick
newborns.
32.5 PARENTERAL FEEDING IN SICK NEWBORNS

(BOTH TERM AND PRETERM)
 Energy kcal/kg: (1 kcal=4.2 K-joules)
60 maintenance, 90 to make growth possible.
 Calcium 75mg/kg/day
 Sodium: 2 meq (mmol)/kg
 Potassium: 2 meq (mmol)/kg. Omit on Day 1, or if
Potassium in serum is above 5.5.
Increase daily amount to 3-4 meq/kg if
potassium is < 3-2.5 meq/l.
 Amino acid: 2g/kg, only to be given if 60 kcal
(=15g Glucose)/kg, can be given also.
 Glucose 12 g/kg can usually be metabolized, up
to 15-18g/kg can be tried if blood
glucose and urine glucose permits.
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EXAMPLE OF PARENTERAL FEEDING WITHOUT FAT
(* with stepwise addition of calories and amino acids, see below)
VOLUME AND MONITORING
Volume: 60-90-120-150 ml/kg on day 1-2-3-4 to 7. Try 170 ml/kg
after week 1.
STEPWISE ADDITION OF CALORIES AND AMINOACIDS IN

EXCEPTIONAL CASES
ROUTE OF INFUSION
The fluids should be given through a scalp vein or in a peripheral
vein.
214
KCMC, PAEDIATRICS 33 THE LOW-BIRTH-WEIGHT INFANT
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33 THE LOW-BIRTH-WEIGHT INFANT

33.1 Definition
Can be defined as a birth weight less than the expected for the
gestational age. Can be subdivided into low birth weight (LBWT), very
low birth weight (VLBW) and extremely low birth weight (ELBW)
 LBWT - < 2500g or less (prematurity/SGA)
 VLBW - < 1500g
 ELBW - < 1000g
33.2 ESTIMATION OF GESTATIONAL AGE (FINNSTRÖM)

All LBW-infants should have their maturation estimated.
SEE CHART ON NEXT PAGE
Points Gestational age

Weeks
7 27
8 28
9 29
10 30
11 31
12 32
13 33
14 33
15 34
16 35
17 36
18 37
19 38
20 39
21 40
22 41
23 42
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SCORE
1 2 3 4
Breast 5 mm 5-10 mm 10 mm
tissue
Breast Hardly Well Edge of

nipples Visible defined aerola lifted
Skin Big vessel Some veins A few vessels No vessels

vessels visible over and branches visible visible
abdomen visible
Hair Thin and Thick

woolly silk-like hair
Do not reach Reaching Reaches or

Finger the fingertip finger-tip but passes finger-
nails distal and not tip. Distal and
distinct distinct nails
hard
Ear Starts to be
Cartilage No cartilage Cartilage in Cartilage in cartilage in the
(see next in antitragus antitragus antihelix whole ear also
page) in helix
Some lines
Skin No lines No lines in the over the The whole sole
lines in Visible back 2/3 of the force 2/3 of the has lines
sole of foot foot
foot
216
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33.3 SPECIAL PROBLEMS OF THE SMALL FOR DATE/
PRETERM
 If placental insufficiency is the cause the risk of perinatal
asphyxia is greatly increased: anticipate during delivery.
 If a congenital abnormality or intra-uterine infection is the
cause: diagnose.
 Hypoglycaemia is likely to occur especially if adequate feeding
is not started during the first hours of life. If this is not possible
give IV glucose as specified below. In case of convulsion,
apnoea or blood glucose below 40 mg% give 5 ml glucose 10%
stat IV to be followed by maintenance glucose 10% 70 ml/kg/d
additional to normal feeding. Make sure to give adequate oral
feedings as soon as possible, since this offers almost twice as
many calories/ml. In case of continuing low blood glucose levels
(below 40 mg %) increase glucose input to 1½ x and 2 x. Make
sure drip is functioning ok. If necessary then add Prednisone 2
mg/kg/d or Hydrocortisone 10 mg/kg/d in 3 divided doses +
investigate cause.
 The small size can have problems resembling those of the
preterm, but usually a bit less.
33.4 SPECIAL PROBLEMS OF THE PRETERM

The main problems of the preterm are similar to those of any new
born but are more severe.
 How to start efficient respiration.
 How to keep warm.
 How to drink.
 How to be cared for by the mother.
 How to fight infection.
 How to survive once at home.
33.5 MANAGEMENT OF THE LOW BIRTH WEIGHT INFANT
AT BIRTH
217
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 Clear nasopharynx, oxygen PRN. In case of respiratory problems
see asphyxia, respiratory disorders.
 Give vitamin K1 ½ mg,
 After cleaning the eyes instil one drop of 2.5% Povidone iodine or
some Tetracycline 1% ointment to each eye.
 Consider giving 750 ATS on indication. If not available give
penicillin
 Keep dry and warm.
 As a rule of thumb: a healthy LBW-infant > 35 weeks gestational
age and > 2000 gram can, with special care, remain with mother.
The smaller ones and those with problems should go to a
premature-nursery. Baby and mother should sleep together if
there is no premature unit
 Physical examination and careful history.
TEMPERATURE CONTROL
All newborns are very sensitive to changes in the environmental
temperature. Cold-stress increases the mortality. Cold increases
oxygen consumption and utilisation of caloric reserves.
 Use LOW READING THERMOMETERS, check temperature 2-4
hourly and in case of hypothermia ½ hourly.
 Keep infant away from cold windows and keep the room warm.
 Dress the infant in several layers of clothes (including a hat and
socks).
 Keep the infant dry.
 Baby and mother should sleep together if there is no preterm unit
in the centre
A newborn with a given birthweight and gestational age will require

the following (neutral) thermal environment (note the effect of light
clothing and a draft-free environment):
Gestational age 27w 31w 34w 36w-
Birthweight (grams) 1000 1500 2000 > 2500
NAKED IN INCUBATOR:
day 1 (degrees C) 36 35 34 32
day 30 33 32 32 32
218
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WARMLY CLOTHED AND
COVERED IN
DRAFTFREE COT: 32 28 27 26
day 1 (degrees C) 25 24 24 24
day 30
PRACTICAL RECOMMENDATIONS (nursing protocols)

 Preterms should wear light clothing including socks.
 Since working in rooms at temperatures above 28 o C is very
unpleasant for staff and promotes absenteeism, preterm below
1500 grams can in absence of incubators best be nursed warmly
clothed and covered (including a hat and socks) in a 28 o C room
with individual additional warmth guaranteed by:
 Heated cots, (for instance Moshi Warm Cot, detailed
drawing on request at KCMC
 Draft-free cots with hot water bottles frequently being
exchanged. Warm water mattresses are very effective but
expensive and vulnerable in our setting.
 Kangaroo method.
 The ambient temperature around the baby should be gradually
normalized as the child reaches the time of discharge.
A PRETERM IS TOO COLD UNLESS PROVEN OTHERWISE BY:

- A TEMPERATURE OF 37 °C EVERY SIX HOURS
- CHECKING IF HANDS AND FEET FEEL WARM
FEEDING THE LOW BIRTH WEIGHT INFANT (nursing protocols)

If the baby is not yet able to breastfeed, feeding by cup and spoon or
syringe is given or on indication by indwelling nasogastric tube of
small size (oral tube in case of respiratory distress). See also chapter
32 on General care of the newborn.
NOTE: CHECK WEIGHT 3 X A WEEK AND RECORD GRAPHICALLY

PROPER FEEDING SHOULD RESULT IN PROPER GROWTH:
- BACK ON BIRTHWEIGHT BY DAY 10
- BELOW 2000 GRAMS 10% INCREASE OF BODYWEIGHT PER WEEK
219
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- OVER 2000 GRAMS 150-200 GRAMS/WEEK
- PARALLEL TO INTRA-UTERINE GROWTHSCURVES (SEE 49.2).
220
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HOW TO PREVENT INFECTION? (nursing protocols)

Since infection is a major cause of death in the (always
immunocompromized) premature and because the pathogenic
organisms usually reach the baby by the hands that care for them,
the best way to attack the problems is:
 Rigorous sticking to rules regarding hand washing and short
nails. In case of grossly dirty hands: scrub with soap outside the
nursery prior to normal routine. In the nursery normal soap will
do.
 Preterm babies are quickly bathed with water and soap when
necessary
 Normal hygiene in ward. Proper mats at entrance to clean shoes.
Only father and mother.
 Isolate infected babies by barrier-nursing especially in case of
skin-infections and diarrhoea.
IF A PRETERM DIES FROM PREMATURITY, IT’S A PITY

IF A PRETERM DIES FROM HOSPITAL INFECTION, IT’S A SHAME
HOW TO SURVIVE ONCE AT HOME?

WHEN TO DISCHARGE?
Although gestational age, ability to suck and to keep warm are better
indicators; 2000 grams can be used as a gross weight criterion for
discharge.
FOLLOW UP ARRANGEMENTS
Issue a growth-chart to the child before discharge and make sure
follow up can be arranged 1 week after discharge and at least (if
doing well) once a month. Check Hb at age 1 and 3 months. Make
sure BCG and oral polio vaccine will be given as soon as the child
weighs 2500 grams.
PRESCRIPTIONS
Issue a prescription for Iron and Vitamins-supplements from the age
of 6 weeks:
221
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Multivitamin drops 0.6 ml/day for 6 months containing 400 IU Vit. D if available
or
Cod liver oil 5 ml/day for 6 months
Folic acid 2,5 mg/day for 6 weeks
30 mg/day hydrogenated ferrous sulphate for 6 months, start 6
Ferrous sulphate w after birth (=recommended 2 mg elementary Fe/kg day,
check how much is present in the type of iron medication
available)
MOTHERS SPECIAL CARE

Discuss with mother in detail how she will take care of the child at
home regarding:
 Temperature
 Feeding
 Prevention of infection
 How to act if problems arise.
222
KCMC, PAEDIATRICS 34 ASPHYXIA IN THE NEWBORN
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34 BIRTH ASPHYXIA (NEONATAL

ENCEPHALOPATHY)
34.1 DEFINITION
State of hypoxia after birth resulting in Apgar score below 7 at 5 th
minute.
Neonatal encephalopathy is a syndrome characterized by
symptoms of central nervous system dysfunction in newborns born
at or near-term ( 36 weeks gestation).
34.2 DIAGNOSIS
An infant with neonatal encephalopathy may exhibit abnormal level
of consciousness, seizures, tone and reflex abnormalities, apnea,
and feeding difficulties. Two or more symptoms of encephalopathy
lasting over 24 hours often associated with a 5 minute Apgar
score <7 are essential for the diagnosis.
Use Apgar score.
SEE CHART ON NEXT PAGE
223
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Sign Score
0 1 2
Appearance Blue/pale Body pink; Completely pink

(colour) extremities blue
Pulse Absent < 100 > 100

(heart rate)
Grimace No response Grimace (some motion) Cry (withdraw)

(reflex
activity)
Activity Limp Some flexion of limbs Active motion

(muscle tone) (flaccid)
Respiration Absent Slow, irregular or Regular or

(respiratory gasping strong cry
effort)
34.3 CAUSES
Maternal Factors:
 Inadequate oxygenation of maternal blood
- hypoventilation during anaesthesia
- respiratory failure
- cyanotic heart disease
- severe anaemia/ Heart Failure
 Hypotension
- complication of spinal anaesthesia
- vena cava and Aorta compression by gravid uterus.
 Uterine tetany
- excessive Oxytocics
- lack of uterine relaxation to allow placental filling
224
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 Hypertension
 Eclampsia
 Maternal diabetes
Fetal factors:
 Malpresentation
 CPD
 Multiple Births
 Severe Fetal Anaemia- hydrops
 Prematurity
 Post maturity
 Infection –increase oxygen demand
Placental:
 Premature separation (abruptio)
 Placenta praevia
 Cord prolapse
 Cord knotting/entanglement/compression
 Twin to twin transfusion
 Bleeding
34.4 TREATMENT PLAN

See chapter 50 on neonatal resuscitation
225
KCMC, PAEDIATRICS 35 NEONATAL RESPIRATORY DISORDERS
_______________________________________________________________________
35 NEONATAL RESPIRATORY DISORDERS

35.1 DIFFERENTIAL DIAGNOSIS
CONDITION GESTATION CLINICAL HISTORY X-RAY
Respiratory Preterm Dyspnoea Preterm, Reticulogranular

distress Grunting Asphyxia
syndrome
Meconium Mature Meconium- Meconium-stained Streaky
aspiration stained skin liquor, asphyxia, atelectasis,
meconium in over-expanded
trachea lungs
Transient Often mature Tachypnoea, little Caesarean Section Fluid in fissures.

tachypnoea grunting Vascular
markings
Congenital Any Temp and WBC Infection in mother, Blotchy

pneumonia high or low, prolonged rupture of
hypotonia, early membranes, smelly
jaundice, apnoea liquor
Diaphragmatic Mature > Scaphoid Sudden Guts in
hernia preterm abdomen Dyspnoea thorax
Pneumothorax Usually mature Hyperresonant May be birth Diagnostic

if < 4 hours transillumination asphyxia and Erect
resuscitation position
Congenital Usually mature Big liver and -- May be normal
heart disease heart, cyanosis,
odd ECG,
murmur
Persistent Usually mature None of heart Mild asphyxia Big heart

transitional disease,
circulation ECG normal
226
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UNLESS YOU CAN PROVE THAT INFECTION IS NOT THE CAUSE OF
NEONATAL RESPIRATORY DISTRESS: GIVE ANTIBIOTICS!
35.2 IDIOPHATIC RESPIRATORY DISTRESS SYNDROME
ETIOLOGY
The syndrome is due to a deficiency of surfactant in the preterm
infant's lung. Perinatal asphyxia, cold and caesarean section
increase the risk. Please note: respiratory distress (RD) is a group
of symptoms; IRDS is a distinct clinical entity due to pulmonary
immaturity.
SIGNS AND SYMPTOMS

These signs/symptoms in combination with history and X-ray
provide you with the diagnosis IRDS:
TREATMENT
227
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The aim is to keep the infant alive and in good condition until it
starts to synthesize surfactant. Therefore: avoid hypoxemia,
academia and hypothermia, which inhibit the surfactant synthesis.
OXYGEN
Is the most important (and potentially a dangerous) part of the
treatment. See chapter 47 on Paediatric Procedures.
FLUID THERAPY
60 ml/kg 10% glucose per day until there is pulmonary
improvement. Then increase the amount of fluid to normal over 2-
3 days. Sodium is added after day 2 or if sodium in serum is low.
ACIDOSIS CORRECTION
Dose in meq (mmol) of NaHCO3 = Base deficit (meq/l or mmol/l) x
body weight (kg) x 0.1 during 3 h, repeat 1 x PRN if gas analysis is
possible, but take a base deficit rather as a signal of poor
oxygenation.
FEEDING
By the third day (or earlier) oral feeding can be started. Start giving
expressed breast milk by nasogastric tube. Amount: see above in
section on feeding and nutrition.
KEEP THE BABY WARM!
ANTIBIOTICS
Give antibiotics unless you can disprove intra-uterine (PROM!) or
postnatal infection causing a pneumonia that can mimic IRDS in
almost all respects.
35.3 RECURRENT APNOEA OF PREMATURITY

 Try first with repeated tactile stimulation of the child, e.g.
extension of the head, stimulation of soles, etc.
 If poor effect, continue with ventilation, e.g. bag-facemask
 Check out if anaemia, infection, hypoglycaemia, cerebral
haemorrhage can be the cause.
 In immaturity, try
Aminophylline Loading dose 5-7 mg/kg slowly IV. Maintenance dose
2-3 mg/kg/day every 12 hours orally for 3 days then
reconsider.
228
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or
Theophylline Loading dose 10 mg/kg IV or orally followed by maintenance
3-4 mg/kg/d in 2-3 doses orally.
35.4 RESPIRATORY DISORDERS NOT RESTRICTED TO

PRETERMS
DIAPHRAGMATIC HERNIA
See chapter 41 on Paediatric Surgical Conditions.
UPPER AIRWAY OBSTRUCTION

CHOANAL ATRESIA
Respiratory distress when mouth is closed. Diagnosis is made by
listening with a stethoscope over the nostrils when the child is
making breathing efforts or by trying nasal intubation. Since the
newborn is nose-breathing, this is an emergency! Insert an airway
or an endotracheal tube, until appropriate surgery can be carried
out on the posterior choanae.
PIERRE ROBIN SYNDROME
Micrognathia, sometimes midline cleft palate, glossoptosis.
Tongue is falling back and obstructing the airway. Insert a
nasogastric tube through nose - the cleft palate – oesophagus.
Nurse in prone position, tube feeding. In the long run the mandible
grows and the cleft palate can be repaired.
MECONIUM ASPIRATION
At delivery the meconium should be aspirated from the infant's
mouth, pharynx, larynx and bronchial tree, as much as possible.
The management follows the same principles as in Respiratory
Distress Syndrome. Broad spectrum antibiotics should be given.
229
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Steroids are of no value. Monitor fluid balance carefully, avoid fluid
overload.
TRANSIENT TACHYPNOEA OF THE NEWBORN

This condition affects mainly mature infants and is attributed to
delayed clearing of the fetal lung liquid after the onset of
respiration. Cyanosis is relieved by giving 30-40% oxygen.
Hyperinflation of the lungs is often noted. This benign illness lasts
about 24 hours. The diagnosis is more or less by exclusion.
PNEUMOTHORAX
Should be drained by inserting a thoracocentesis tube if causing
respiratory distress
(8 Fr. preterm, 10 Fr. term, 1 Fr. = 1/3 mm OD) between the 4th
and the 5th ribs in the anterior axillary line. The cannula is inserted
2-3 cm and connected to an underwater seal drain with 10-20 cm
H2O suction pressure. Leave the drain in situ, with applied suction
until the lung has been expanded for at least 24 hours. In case of
emergency or in a term child without other respiratory problems:
needle aspiration with a 19 Gauge needle (19G = 1 mm outer
diameter). Proof of air coming out in underwater seal.
PNEUMONIA
In particular after early rupture of membranes. Very difficult to
differentiate from other causes of respiratory distress in the
newborn. See 38.5
ASPIRATION
May occur at any time in the neonatal period.
Is more likely to involve the right upper lobe
X-ray:
Management:
 Prevention
 Suctioning
230
_______________________________________________________________________
 Oxygen
 Antibiotics
231
KCMC, PAEDIATRICS 36 CONVULSIONS IN THE NEWBORN
__________________________________________________________________
36 CONVULSIONS IN THE NEWBORN

36.1 AETIOLOGY
Major causes: Birth asphyxia (hypoxic ischemic encephalopathy)
infection (meningitis). Intraventricular haemorrhage, metabolic
(hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyper- or
hyponatraemia), kernicterus, congenital malformation.
36.2 DIAGNOSIS
Test if possible: blood glucose, electrolytes, calcium (prolonged
QT-interval on ECG?), white blood cell count and differential, blood
culture, lumbar puncture.
36.3 TREATMENT
GENERAL CARE
Turn the infant on its side, secure the airway, and gently aspirate
the pharynx if vomiting. Give oxygen by mask. If no glucose and Ca
determination are available; give 10% glucose 2 ml/kg stat followed
by continuous infusion of 10% glucose 70 ml/kg/day. Give also
calcium gluconate 100mg/kg STAT followed by 400mg/kg per day.
DRUGS
Loading dose: 20 mg/kg in 2 divided doses with ½ hour interval.
Phenobarbital Maintenance dose: if convulsions reoccur, give 3-5 mg/kg/d once daily
orally.
If Phenobarbital does not work give 20 mg/kg Phenytoin slowly IV at a
Phenytoin rate of 0.5 mg/kg/min in a running IV, which can take up to 30 min.
Continue with a maintenance of 3-5 mg/kg/day if seizures recurrent.
Diazepam 0. 25-1 mg/kg slowly IV or 3 mg rectally (IV solution can be used).
*Pyridoxine responsive seizures are rare but respond dramatically to Pyridoxine
100mg/kg IV
TREAT THE UNDERLYING DISORDER
232
KCMC, PAEDIATRICS 37 NEONATAL TETANUS
________________________________________________________________________
37 NEONATAL TETANUS
37.1 DEFINITION
An acute spastic paralytic illness caused by the neurotoxin
produced by clostridium tetani.
37.2 PREVENTION
 All women to receive tetanus toxoid. (See national guidelines)
 Umbilical care, (see care of newborn chapter 32).
 Consider 750IU ATS in all deliveries under poor hygienic
circumstances in particular if mother not vaccinated. If no ATS
available: give penicillin.
37.3 GENERAL CARE

 Give careful, but intensive care. Avoid sudden noise and jerky
movements. Ensure adequate nutritional support. Be very
careful with feeding through nasogastric tube, medicating,
measuring of temperature, etc.
 Suction and oxygen should be available beside the bed.
 Control of fluid and electrolyte balance.
 Careful observation of breathing and spasms should preferably
be carried out by one responsible nurse. Note the findings on
an observation chart.
233
________________________________________________________________________
SEDATION SCHEDULE
Initial dose Maintenance Number of doses/day
Phenobarbitone 15-20 mg/kg IV 5 mg/kg/day IV 2

or orally
Diazepam 2-5 mg/kg IV 2-8 mg 4

(or more)/kg/day
IV or orally
Chlorpromazine 25 mg/day orally 2
Special tetanus care list (example) Weight: 3 kg day 3

Diazepam Phenobarbitone Chlorpromazine Feeding Side Convuls
mg mg mg ml 0 -> +++
9 am 5 30 R
12 md 7,5 30 L
3 pm 5 30 R
6 pm 12,5 30 L
9 pm 5 30 R
12 mn 7,5 30 L
3 am 5 30 R
6 am 12,5 30 L
If the spasms are increasing, give an extra dose Phenobarbitone 5

mg/kg IV or IM. The dose of Diazepam may also be increased. Risk
of apnoea.
OTHER CARE
 ATS (ANTI TETANUS SERUM) 10.000 IU IM or ½ IM + ½ IV.
 Benzylpenicillin 100.000 IU/kg/day in 2 doses IV for 7 days.
234
________________________________________________________________________
 Clean umbilicus, keep dry.
 Nasogastric feeding 8 times/day.
 Carefully turn the child every 3 hours.
 Monitor and maintain normal body temperature.
AT DISCHARGE
 Vaccinate the child and mother against tetanus. Give
appointment to RCH clinic after 1 month.
 Advise the mother very strongly to come back for her own
booster vaccination against tetanus when she gets pregnant
again.
235
KCMC, PAEDIATRICS 38 OTHER SEVERE BACTERIAL INFECTIONS
IN THE NEWBORN
________________________________________________________________________
38 OTHER SEVERE BACTERIAL

INFECTIONS IN THE NEWBORN
Including meningitis
38.1 PREVENTION
 Do not damage mucous membranes or skin of the child.
Careful suction in nose and throat.
 Avoid invasive methods, if not absolutely necessary.
 Wash hands before handling the child. Avoid towels.
 Infected staff should not care for neonates.
 Use clean and sterile tools when caring for the neonates.
 Try to give the child breastmilk if no contraindication.
38.2 MOST COMMON PATHOGENS

E. coli, Group B streptococcus. Also Staphylococcus aureus and
albus, Pseudomonas and Listeria, candida.

Often very uncharacteristic and vague, such as:
 Temperature High or low
 Respiratory Apnoeic spells, retraction, grunting,
tachypnoea
 Circulatory Tachy- or bradycardia,
Hypotension, increased capillary
refill (>3 sec)
 Gastrointestinal Inability to suck, vomiting,
intolerance, abdominal distension
 Neurological Hypotonia, irritability, convulsions,
change of tone, lethargy (indicate
but do not prove meningitis)
236
IN THE NEWBORN
________________________________________________________________________
 Skin Jaundice, pallor, cyanosis purpura,
petechiae, sclerema.
 Focus of infection? Look for otitis media, infected
umbilicus, osteomyelitis, paralytic
ileus, UTI, etc.
 Metabolic Hypoglycemia or metabolic
acidosis
38.4 DIAGNOSIS
INVESTIGATIONS
Should be done immediately!
 Gram stain or Culture (if possible): blood, ear, skin lesions,
urine (by supra-pubic puncture or catheterisation) on late onset.
 CSF (incl direct Gram stain and culture).
 Thrombocytes (if possible), usually below 100.000.
 White blood count, often less than 5.000 with > 20% “bands”.
 X-ray chest and abdomen are often indicated.
 CRP
38.5 TREATMENT
ANTIBIOTICS
Should be started as soon as possible; take cultures first.
Treat first according to schedule then according to results.
237
IN THE NEWBORN
________________________________________________________________________
DOSAGE SEPTICAEMIA TREATMENT

Number of doses per 24 hours
Antibiotic mg/kg/dose IV First week of 2nd week and
age later
Benzyl penicillin
2000 g and above 50 (50.000IU) 3 4
<2000 g 25 (25.000IU) 2 4
Ampicillin 35 2 3
Cloxacillin 25 2 3
WITH
Gentamicin
full term 4,5 1 1
LBW <2500g, week1 3,5 1 -
LBW <2500g, week2+ 4,5 - 1
Amikacin
full term 7,5 2 2
LBW <2500, week 1 10 1 -
<2500, week2+ 7,5 - 2
OR WITH
Chloramphenicol
full term,>2000 25 1 2
LBW <2000 15 1 2
3rd generation cephalosporines:
Cefotaxime
full term 50 2 4
LBW 1200-2000 g 50 2 3
< 1200 g 50 2 2
238
IN THE NEWBORN
________________________________________________________________________
Ceftazidime
full term 50 3 3
LBW 1200 –2000 50 2 3
< 1200 g 50 2 2
Ceftriaxone
full term week 1 50 2 -
week 2+ 50 - 2
LBW< 2000g 50 2 2
Metronidazole oral 15mg/kg

loading then 2 -
Full term week 1 7,5 - 2
week 2+ 15 2 2
LBW 1200-2000 g 7,5 every 48 every 48 hours!
<1200 g 7,5 hours!
DOSAGE IN CASE OF MENINGITIS:
BENZYLPENICILLIN AND AMPICILLIN: DOUBLE DOSAGE

CHLORAMPHENICAL AND CEPHALOSPORINES: DOSAGE AS IN
SEPTICEMIA
GENTAMYCIN AND AMIKACIN ARE UNRELIABLE AS MENINGITIS
TREATMENT (FOR SEPTICAEMIA TREATMENT ONLY)
239
IN THE NEWBORN
________________________________________________________________________
COMBINATION OF ANTIBIOTICS 7-10 day in septicaemia, 14days in

meningitis
Duration in days
Ampicillin + Gentamicin
or 14
Septicaemia Benzyl + Gentamicin
penicillin
or +
Benzyl Chloramphenicol
penicillin
Benzyl + Gentamicin 7-10
Pneumonia penicillin
or + Gentamicin
Ampicillin
14-21
Benzyl
Meningitis penicillin + Gentamicin
or (chloramphenicol
Ampicillin is an alternative
but should not be
used in
premature/ low
birth weight
neonates)
Ceftazidime or
Cefotaxime or 14-21
Ceftriaxone
Osteomyelitis Cloxacillin + Gentamicin 3 weeks

7-10
Urinary Tract inf. Ampicillin + Gentamicin
(in severe
case)
240
IN THE NEWBORN
________________________________________________________________________
Ampicillin + Gentamicin
Necrotizing or 7-10
enterocolitis Ampicillin + Metronidazole
or
Gentamicin + Metronidazole
When staphylococcus
is suspected
(skin, surgery, late Cloxacillin + Gentamicin 14
onset sepsis)
NOTE: Change regime according to sensitivity patterns prevalent in the unit.
COMPLICATIONS AND SUPPORTIVE CARE

 Respiratory
 Cardiovascular
 Haematological
 CNS
 Metabolic
241
KCMC, PAEDIATRICS 39 NECROTIZING ENTEROCOLITIS
IN THE NEWBORN
___________________________________________________________________
39 NECROTIZING ENTEROCOLITIS
IN THE NEWBORN
39.1 PREVENTION
 Avoid rapid feeding
 Avoid syrup use in first week
 Avoid high volume feeds
39.2 CAUSE
 Conditions associated with ischemia and hypoperfusion
 Infections e.g. E. coli, Staph. epidermidis, Clostridia perfringes
 Prematurity
39.3 CLINICAL SIGNS AND SYMPTOMS

Common signs of NEC are:
 Abdominal distension or tenderness
 Intolerance of feeding
 Bile-stained vomit or bile stained fluid up the NGT
 Blood in stools
General signs of systemic upset are:

 Apnoeas
 Drowsy or unconscious
 Fever or hypothermia
39.4 DIAGNOSIS
242
KCMC, PAEDIATRICS 39 NECROTIZING ENTEROCOLITIS
IN THE NEWBORN
___________________________________________________________________
The diagnosis should be suspected in pre-term babies, who develop
sudden abdominal distension or ileus, often associated with bloody
or bile-stained gastric aspirates. Often a history of artificial feeding.
Bloody diarrhoea may be seen. Pneumatosis intestinalis on X-ray
confirms the diagnosis. Also in Hirschsprung's disease N.E.C. is a
dreaded complication.
39.5 TREATMENT
 Stop oral feeding.
 Use a nasogastric tube for drainage of stomach.
 Start parenteral feeding (often needed for 7-10 days), see
chapter 32.5.
 Additional treatment for shock and acidosis and electrolyte
abnormalities may be necessary. Fresh plasma. Large fluid
amounts may be needed. See chapter 45 on Shock.
 Culture of blood, urine, stool and CSF.
 Start antibiotics: see severe neonatal infections. Ampicillin and
Gentamicin or Ceftriaxone. Add metronidazole if suspect
perforation or peritonitis.
 Repeat abdominal X-ray (incl. lateral films) at least daily to
detect perforation as soon as possible.
 Laparotomy should be considered in cases not responding to
conservative treatment or showing deteriorating signs of
peritonitis or perforation.
 Monitor input and output and correct electrolyte imbalance
243
KCMC, PAEDIATRICS 40 NEONATAL JAUNDICE
________________________________________________________________________
40 NEONATAL JAUNDICE
40.1 PREVENTION
Prevent prematurity and infections
Proper antenatal and perinatal care
Anti D to mothers who are Rhesus negative after each pregnancy
(including abortions, miscarriage, ectopic pregnancy, hydatidform
mole), blunt trauma to abdomen during pregnancy, ante partum
haemorrhage during 3rd trimester and invasive procedures during
pregnancy and delivery
Some cases will be prevented by early introduction of breast milk
Screening of all new-borns
40.2 CAUSES
 Physiological Bilirubin less than Jaundice

150μmol/L (higher in preterm, onset after
day 1, peak levels of bilirubin around day 3
(up to day 7 for preterm, absence of
pathology as described below (a diagnosis
of exclusion).
 Haemolytic ABO, Rh immunization, G6-PD deficiency
 Hepatocellular Neonatal hepatitis, metabolic disorders.
 Obstructive Biliary atresia, choledochuscyst.
 Mixed Septicaemia, urinary tract infection,
malaria, drugs (sulphonamides),
dehydration, lack of food, acidosis, Down’s
syndrome, hypothyroidism, TORCHES,
maternal diabetes mellitus, birth trauma
244
________________________________________________________________________
<24 hours old 24 hours to 2 weeks old

Haemolytic Physiologic
Rhesus incompatibility Breast milk
ABO incompatibility Haemolytic
G6PD deficiency Infection
Hereditary spherocytosis Bruising
Congenital infections Gastrointestinal
obstruction
Polycythemia
Metabolic disorders
Liver enzyme defects
Crigler-Najjar syndrome
Older than 3 weeks- prolonged jaundice

Unconjugated:
Breast milk
Hypothyroidism
Conjugated:
Neonatal hepatitis syndrome
Biliary atresia

ADMISSION
 For hospitals where the bilirubin cannot be measured we
advise if possible to refer babies with jaundice on day one.
Also refer preterm babies with jaundice and term babies with
jaundice and appear less active less active.
 If the jaundice looks severe to the experienced eye in daylight,
reaches the hands and the legs below the knees or if the
245
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serum bilirubin is more than 15 mg/100 ml treatment/referral is
necessary.
40.4 DIAGNOSIS
The following are necessary to diagnose pathologic jaundice
 Complete history, including history of previous deliveries.
 Complete physical examination.
 Bilirubin, total and direct.
 Haemoglobin, haematocrit, reticulocytes, WBC, differential
count and RBC morphology.
 Blood group mother and child, direct Coombs on child.
 Urine for culture.
 Other cultures if needed.
Prolonged jaundice should be investigated according to chapter 25
Kenicterus is a complication of pathologic jaundice and presents

with the following symptoms:
 Phase I: Hypotonia, lethargy, high pitched cry, poor sucking
 Phase II: Hypertonia of extensor muscles with opisthotonus,
rigidity, abnormal eye movements (sunset eyes), retrocolis,
temperature instability, cycling movements of limbs and
seizures
 Phase III: hypotonia replaces hypertonia after approximately 1
week
Chronic bilirubin encephalopathy (first signs >4 months): dental
dysplasia, hearing loss, choreo-athetosis, cerebral palsy (spastic)
and learning difficulties
40.5 TREATMENT
PHOTOTHERAPY
246
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Indications, see below. Don't give phototherapy to children with
conjugated-bilirubin type of jaundice.
 Use full daylight (but be careful not to over expose the child
and cause sun burns) or several fluorescent light tubes, best
the blue light of 425-475 nm. placed 40 cm above child.
 Cover the eyes.
 Keep the baby as naked as possible. Turn him/her every hour.
 Control the temperature carefully. Risk of overheating or
hypothermia.
 Watch the fluid balance: give extra fluids (milk or dextrose
approx. 30% extra).
 Check bilirubin every day. When 24 hrs below 170μnol/L, stop
phototherapy. The skin colour becomes a very unreliable
indicator of bilirubin levels after phototherapy. Switch off the
light when taking blood for bilirubin estimation (otherwise false
low values).
IF URGENT EXCHANGE TRANSFUSION IS NEEDED

Take blood from the child for urgent Hb, WBC, differential, bilirubin,
blood group and direct Coomb's test. Take blood from the mother
for blood grouping urgently. Results must be available within 1-2
hours, blood for exchange ordered and the exchange transfusion
undertaken without further delay.
CHOICE OF BLOOD
In ABO-immunization O blood cells with Rh group identical to that
of the child (or Rh negative even if the child is Rh positive) should
preferably be used. Plasma of a donor with an ABO group identical
to that of the child can also be used. This plasma is low in
antibodies against the A and B blood cells of the child. In
emergency cases however O blood with the appropriate Rh group
can be used. In Rh-immunization Rh negative blood should be
used. The ABO blood group of the donor should be identical to that
of the child, but if concomitant ABO-immunization is not excluded
O blood should be used.
247
________________________________________________________________________
Other precautions: Acid-citrate is commonly used as an
anticoagulant and carries the risk for metabolic acidosis. Cross-
match with mother’s blood and in subsequent exchange
transfusions also (!) with the child's blood. The blood should be
fresh (not older then 3 days in fridge), properly checked for HIV,
etc. A malaria slide and (if relevant in the area) a sickle cell test
should be done.
PREPARATION OF THE CHILD
Sick infants may need attention to asphyxia, hypoglycaemia,
acidosis and temperature control before the exchange transfusion.
Empty stomach. The child is placed on a resuscitation-table with
radiant heater or on a heating mattress. A size 5-8 FG umbilical
vein catheter is inserted 6-7 cm into the umbilical vein. The
catheter should be filled with isotonic NaCl and joined to a 5 cc
syringe. When the catheter reaches the portal vein, blood is easily
aspirated. The venous catheter should not be left open to air; the
baby may cry and suck in air.
THE EXCHANGE TRANSFUSION

Infusion of albumin, 1g/kg one to two hours before the start of the
procedure helps extra vascular bilirubin into the circulation. Usually
10ml at a time for full term, 5ml for preterm. Venous pressure is
measured and kept on +7 cm. A precise account is kept of
amounts given and taken and pulse frequency. Exchange volume
160-180ml/kg. This corresponds to an 85% exchange of the
circulating blood volume. If ECG is available: control during
exchange transfusion. Stop the infusion if changes of QRS

complex or rhythm irregularities occur. When continuing, take great
care. Total time for the exchange: 60-120 minutes.
After every 100 ml exchange using blood that has been
anticoagulated with acid citrate, slowly inject 1 ml Calcium
gluconate 10% (to counteract the citrate binding). The high glucose
content in the ACD blood may lead to rebound hypoglycaemia,
248
________________________________________________________________________
therefore control blood glucose after the transfusion. Unless a
repeated exchange transfusion is anticipated within 12 hours or
other special indication is present to keep an umbilical vein infusion
going, the catheter is removed.
Exchange transfusion is a complex procedure and complications
should be anticipated. Common complications include technical
problems, air embolisation, thrombosis, volume overload or
depletion, electrolyte imbalance, hypoglycaemia, infection,
thrombocytopenia, cardiac arrhythmias, necrotizing enterocolitis
and hypothermia. Mortality can be anticipated in about 1%.
PHENOBARBITAL
Increases conjugation and excretion of bilirubin. It can be give to
mother during pregnancy if there is a risk of fetus developing
jaundice (rh incompatibility). It should how ever be used with great
caution and monitoring as it can lead to drowsyness, delayed
breast feeding and can delay sexual development of the child
249
________________________________________________________________________
INDICATIONS FOR PHOTOTHERAPY OR EXCHANGE

TRANSFUSION IN UNCONJUGATED (INDIRECT)
HYPERBILIRUBINAEMIA OF THE NEWBORN (if indirect not
available use total instead)
RISK FACTORS
Hyperbilirubinaemia should be treated with phototherapy/exchange
transfusion even on lower levels if any of the following risk
factors is present:
 Severe perinatal asphyxia, respiratory distress, acidosis.
 Hypothermia, sepsis or meningitis.
If the child has signs of central nervous system deterioration,

exchange transfusion should be done rather than phototherapy.
NOTE:
 Phototherapy should also be used after any exchange
transfusion.
Bilirubin should be checked after exchange transfusion or
phototherapy.
Serum <24 hrs 24-48 hrs 49-72 hrs >72 hrs

bilirubin <2.5 >2.5 <2. >2. <2. >2. <2. >2.5
μmol/L Kg Kg 5 5Kg 5Kg 5Kg 5Kg Kg
Kg
85-150 Phototherapy
if haemolysis
151- Exchange if Phototherapy
240 haemolysis
241- Exchange Phototherapy
320
>320 Exchange
NB: 1mg/dl = 17μmol/L
250
KCMC, PAEDIATRICS 41 PAEDIATRIC SURGERY/peritonitis,
appendicitis
___________________________________________________________
41 SOME PAEDIATRIC SURGICAL

CONDITIONS
41.1 INTRODUCTION
This manual deals only with the general principles of treatment of
surgical conditions. For more detailed discussion about the surgical
techniques other books have to be consulted, e.g. "Surgery" by
Peter Bewes, AMREF, or "Primary Surgery" by Maurice King,
OXFORD, or “a textbook of paediatric surgery” in the tropics, by
Festus A. Nwano, Macmillan or larger textbooks in paediatric
surgery.
PRE-OPERATIVE CARE
All children should, if time allows, be prepared pre-operatively:
 Avoid hypothermia, especially with premature and
neonates.
 Correct dehydration, acidosis, electrolyte disturbances.
 Correct anaemia - see chapter 12 on Anaemia.
 Give nothing orally. Use nasogastric tube for aspiration of
gastric content.
 Give premedication 4 h before operation according to
rules of the doctor responsible for anaesthesia, or
Diazepam 0.25 mg/kg
Atropine 0.015 mg/kg Always when
Ketamine anaesthesia is
used.
POST-OPERATIVE CARE
251
appendicitis
___________________________________________________________
 Avoid hypothermia.
 Monitor regularly vital signs such as pulse rate, respiratory
rate, blood pressure, temperature until the condition has
stabilized. Use a simple observation chart.
 Give IV fluid with reduced amount of maintenance fluid.
 Watch for specific post-operative complications.
 Allow parents to stay with the child.
 Give analgesia in big surgical procedures, e.g. pethidine.
41.2 SUPPURATIVE PERICARDITIS

CLINICAL FINDINGS
 Higher incidence in small children.
 History of and clinical signs of septicaemia. Toxic appearance.
 Precordial pain with dyspnoea.
 Cardiac tamponade: Pulsus paradoxicus, very low amplitude
during inspiration, hypotension.
 Auscultation: Pericardial friction rub-quiet heart sounds.
 Slight oedema of the eyelids and the lower extremities.
 Dilation of the external jugular vein (increased Central V. P. as
judged from increased Jugular Venous Pressure), and
enlargement of the liver.
LABORATORY
 Ultrasound, even if only "linear scanner" is used, will reveal
diagnosis immediately.
 X-ray of the chest: increased size of the pericardial shadow.
 ECG: low voltage, elevated S-T segments, T-wave inversion.

 Pus: most likely Staph. aureus.
 Haemorrhagic/turbid fluid: tuberculosis often (rupture of hilar
gland).
252
appendicitis
___________________________________________________________

 Early recognition important: In small children with septi caemia
pay attention to this severe complication.
Important symptoms: precordial pain and dyspnoea.
 Transfer the patient immediately to referral hospital.
AT REFERRAL LEVEL
 Confirm the diagnosis. Pay attention to other complications of
septicaemia, such as osteomyelitis, arthritis, empyema and
peritonitis.
 Puncture pericardial sac and culture aspirated fluids. See 47.3.
Use diazepam with care to avoid collapse or, if at all possible,
avoid it.
 In patients with massive pericardial effusion arrange with
drainage of the pericardial cavity with Central Catheter-O.D.:
1.7 mm and continuous suction 5 cm H2O.
 In cases with thick pus and a long history of the disease and/or
inadequate treatment, perform thoracotomy and
pericardectomy if possible.
 In all patients, combine surgery with medical management:
appropriate antibiotics, fluids therapy, diuretics, feeding, etc.
253
appendicitis
___________________________________________________________
41.3 INTESTINAL OBSTRUCTION IN THE NEWBORN

CAUSES AND PATHOGENESIS
MECHANICAL OBSTRUCTION
 Anorectal abnormalities
 Atresia or stenosis of the intestine
 Meconium peritonitis (in utero)
 (Inspissated) Meconium plug syndrome (rule out Hirschsprung
disease).
FUNCTIONAL OBSTRUCTION, e.g.
 Sepsis
 Postnatal peritonitis in necrotizing enterocolitis
 Hirschsprung disease
 Omphalitis, cellulitis.
DIAGNOSIS (early!)
CLINICAL
 Triad: Biliary vomiting + abdominal distention with peristaltic
waves on the abdominal wall + failure to pass meconium (not
always) within 24 hours after birth.
 Rectal examination: narrow rectal ampulla and absence of
normal meconium in mechanical intestinal obstruction.
Other signs and symptoms may be seen, such as jaundice,
meconium peritonitis with large abdominal distention,
respiratory distress due to pressure on the diaphragm.
X-RAY ABDOMEN
 Erect position: 3 air fluid levels or more.
 If not possible use lateral view with horizontal beam.
 Barium enema: may show narrow colon (microcolon) or dilated

colon with distal narrowed segment in Hirschprungs disease.
254
appendicitis
___________________________________________________________
AT HEALTH STATION by the midwife:

 Examine all newborns after delivery, especially those with low
birth weight, polyhydramnion.
 Recognise early the clinical triad and refer to hospital where
paediatric surgery can be performed.
 Give no oral feeding if intestinal obstruction is suspected.
 Keep the newborn warm during the transport e.g. naked
between mother's breasts, under her clothes: Kangaroo
technique.
AT REFERRING HOSPITAL:
 Confirm diagnosis.
 Nasogastric tube for abdominal decompression.
 Give parenteral fluid and acidosis correction.
 PREVENT HYPOTHERMIA!
 If it is not possible to operate, refer at once to a more central
hospital.
255
appendicitis
___________________________________________________________
TREATMENT
ANTIBIOTICS
Ampicillin Dosage see 38.5
and Dosage see 38.5

Gentamicin
And
Metronidazole in case of necrotising enterocolitis dosage see 38.5
SURGERY
 Intestinal atresia, meconium ileus: resection of 20-30 cm
dilated loop + end-to oblique anastomosis, but depends on
severity.
 In-utero-peritonitis: resection of cysts, and/or lysis of
adhesions plus intestinal resection, if bowel is necrotic.
41.4 INTESTINAL OBSTRUCTION IN INFANCY AND

CHILDHOOD
CAUSES
 Pyloric stenosis
 Duodenal bands
 Intussusception
 Mesenteric lymphadenitis with adhesions, late manifestation of
"in utero" peritonitis or peritoneal tuberculosis
 Ascaris
 Strangulated hernia
 Postoperative adhesions
 Hirschsprung's disease
 Malrotation with bands
CLINICAL MANIFESTATIONS
256
appendicitis
___________________________________________________________
PYLORIC STENOSIS
More often in males, projectile progressive vomiting,
hyperperistaltic waves may be seen in the child when observed in
good light after a meal, pyloric mass may be palpated. Failure to
thrive.
INTUSSUSCEPTION
Colicky and intermittent abdominal pains with vomiting, Black
currant-jelly stools + mucus. The mass of intussusceptum is
palpable in 50-60% of cases.
OTHER CAUSES
Colicky, abdominal pains, vomiting. Abdominal distension with
peristaltic waves of dilated intestinal loops, without passage of
stool and gases. Dehydration and finally fever.

 Transfer as soon as possible to hospital, where surgery on
infants can be safely performed.
 Give nothing orally. If possible fluid IV instead.
LABORATORY
 Blood: electrolytes in cases with dehydration.
 X-ray examination of the abdomen: many fluid levels.
 Ultrasound especially for pyloric stenosis.
257
appendicitis
___________________________________________________________
SURGICAL MANAGEMENT
INTUSSUSCEPTION
Within the first 24-36 hours of the onset, without abdominal
distension therapeutic barium enema reduction could be tried, max
90 cm H2O pressure. Hands off the abdomen.
If the reduction is not possible: operation. In cases with abdominal
distension, peritonitis or > 36 hours duration, laparatomy at once.
41.5 PERITONITIS
CAUSES
 Primary peritonitis
 Appendicular abscess leading to peritonitis
 Bowel perforation e.g. in typhoid
 Postanastomotic gastrointestinal leak
 Necrotizing enterocolitis
 Rupture of liver abscess
 Bacteria most commonly involved: Pneumococci, Group A
streptococci, Haemophilus influenzae, Gram neg. enteric
bact. and Staphylococci.
 Ascaris perforation.
CLINICAL FEATURES
 Toxic appearance, hyperthermia, restlessness or sometimes
lethargy, coldness of the extremities
 Pre-shock with peripheral collapse or evident shock
 Abdominal distension + bilious vomiting + abdominal pain
 Absence of bowel sounds
 Diarrhoea (semi-liquid and mucous stool)
258
KCMC, PAEDIATRICS 41 PAEDIATRIC
SURGERY/intest.
haemorrhage
________________________________________________________________________
 Oliguria
 Peritoneal tenderness, rigidity.

 Transfer at once to the best referral level.
 Give, if possible, Glucose 5% (or 10%) or NaCl 0.9% IV during
transportation, but nothing by mouth.
DIAGNOSIS
 X-ray examination of the abdomen, erect position: ileus +
thickness of the intestinal wall. Presence of fluid in the
abdominal cavity. Ground glass appearance.
 Puncture of the peritoneal cavity with a short-bevel needle for
aspiration of cloudy fluid or pus. Gram staining and culture.
MANAGEMENT
ANTIBIOTICS
Chloramphenicol 100 mg/kg/day IV in 4 doses

Or
Ampicillin 100 mg/kg/day IV in 4 doses
Gentamicin below 5yr.: 7.5 mg/kg/day IV
5-10 yr.: 6 mg/kg/day IV
>10yr.: 4.5 mg/kg/day IV in 2doses
and
Metronidazole 30-35 mg/kg/day orally in 3 doses
OPERATIVE PROCEDURE
Surgery depending upon the cause of peritonitis. Culture of the pus
+ peritoneal drainage.
259
SURGERY/intest.
haemorrhage
________________________________________________________________________
EARLY POSTOPERATIVE COMPLICATIONS

Adynamic ileus, postoperative abdominal distension
(essentially conservative treatment), Pelvic abscess, leakage from
operated area, wound infection and dehiscence.
41.6 APPENDICITIS
DIAGNOSIS
 Anorexia, nausea or vomiting.
 Continuous and spontaneous abdominal pain at the right lower
quadrant of the abdomen, starts often in the middle of the
abdomen. "Pain before fever".
 Fever.
 Leucocytosis sometimes.
 Persistent right lower quadrant abdominal tenderness: the
most important factor in establishing the diagnosis.
 Diagnosis difficult in infants. Quiet progress to perforation.
 Differential diagnosis: Lobar pneumonia, mesenteric adenitis.
Abnormalities of the upper urinary tract with UTI.
 Complication is appendicular mass-abscess-peritonitis.
 Don't forget rectal examination in suspected cases.

Early diagnosis important. Think of appendicitis in children with
sudden abdominal pain + fever.
SURGICAL MANAGEMENT
 Acute appendicitis without perforation: Appendectomy.
 Appendicular peritonitis: surgery is indicated, see section
formation with tachycardia and fever occur drainage is
mandatory.
 Postoperative complications:
260
SURGERY/intest.
haemorrhage
________________________________________________________________________
o Paralytic ileus: nasogastric tube, IV fluid therapy, with KCl
replacement.
o Pelvic abscess: abdominal pain and lower abdominal
distension, high fever, liquid stool + mucus, dysuria. Rectal
examination: painful mass.
o Early postoperative intestinal obstruction: Nasogastric
tube, IV fluid therapy, antibiotics - Wait and see. Rarely re-
operated.
41.7 HAEMORRHAGE FROM GASTROINTESTINAL TRACT

CAUSES
 Duodenal ulcer with erosion of a blood vessel
261
KCMC, PAEDIATRICS 41 SOME PAEDIATRIC
SURGICAL CONDITIONS
_________________________________________________________________
_________________
 Portal hypertension with rupture of oesophageal varices
 Haemobilia: necrotic haemorrhagic cholecystitis, haemorrhagic
cholangitis with or without communication with an intrahepatic
vessel. Triad: gastrointestinal bleeding + biliary colic +
jaundice.
 Hiatus hernia
 Intussusception
 Segmental polyposis of the colon
 Ulcerative colitis
 Meckel's diverticulum
 Familial rectocolic polyposis with bleeding from rectum and
chronic anaemia
 Anal fissures and haemorrhoids
 Dysenteries
 In neonates: Vit. K deficiency. Differentiate from swallowing
mother blood.
262
SURGERY/abdominal
mass
 Congenital vascular teleangiectasia of G.I.T.
DIAGNOSIS
 Clinical + history. Melaena or fresh blood.
 Hb
 X-ray of gastrointestinal tract
 Endoscopy.
TREATMENT
 Depends upon the cause. Surgery often required.
 Blood transfusion if massive bleeding.
263
SURGERY/abdominal
mass
41.8 ABDOMINAL MASS

Three quarters of all neonatal abdominal masses are due to
genital urinary anomalies. An abdominal mass in a neonate is
urological unless otherwise proved.
LOCALISATION OF THE MASS
RIGHT UPPER QUADRANT LEFT UPPER QUADRANT

of the abdomen. of the abdomen
 Hepatomegaly, see chapter 26 on  Splenomegaly, see
hepatosplenomegaly chapter 26 on
 Biliary tract cysts hepatosplenomegaly
MASS ORIGINATING FROM THE PELVIC MASSES

GASTROINTESTINAL TRACT(GIT)
 Duplication of GIT  Ovarian tumour or cyst
 Tuberculoma, in ileo-coecal area  Hydrocolpos (neonate)
 Intussusception  Hematocolpos (puberty)
 Mesenteric cyst  Megabladder
 Lymphosarcoma  Teratoma, intervesico-rectal or
 Trauma of the stomach saccrococcygeal
 Faecaloma  Rhabdomyosarcoma
 Actinomycosis
OTHER MASSES
 Burkitt's lymphoma
(rapidly growing)
 Nephroblastoma, Wilm’s tumor
 Neuroblastoma
 Cystic kidney
 Hydronephrosis
 Retroperitoneal teratoma
 Cystic lymphangioma
 Adrenal tumor: Cushing's
syndrome or phaeochromocytoma.
264
KCMC, PAEDIATRICS 41 PAEDIATRIC SURGERY
CLINICAL FINDINGS
 Accidental finding of a mass is common. After a fall, during the
washing of the child, etc.
 In early stage often only the mass is felt, with few symptoms,
later there may be rapid growth with deterioration of the
general condition of the child.
 Signs and symptoms depend upon the site and nature of the
tumour.

 Refer children with abdominal mass of unknown origin without
delay. Don't wait and see.
 Most masses in infancy originate from embryonic tissue with
high potency of malignancy. The prognosis is therefore better
than in older children, if they come in time.
See chapter 11 on Some Common Tumours.
DIAGNOSIS
Depends upon the site of the mass. Some common
investigations:
 X-ray: Plain abdomen, intravenous pyelogram, portogram.
 Scintigraphy and ultrasonic echography are often useful.
TREATMENT
SURGERY
Operation. Frozen section to be considered.
OTHER TREATMENT OF MALIGNANT TUMOURS
See chapter 11 on Some Common Tumours.
265
41.9 MAJOR CONGENITAL MALFORMATIONS

The ability to correct major congenital malformation is usually very
limited. The most experienced surgeons should be consulted.
Some rather common anomalies are specified below.
41.10 CLEFT LIP, CLEFT PALATE

SIGNS AND SYMPTOMS
Should not be missed at birth. Inspect always the palate of the
newborn.
ACTIONS TO BE TAKEN
FEEDING
Children with only cleft lip may usually be breastfed as usual. In
cleft palate teach the mother how to express her breastmilk and
how to feed the child with a teaspoon. Great care needed to avoid
aspiration. Check the weight every 14 day to detect failure of
growth.
SURGERY
Refer the patient when the weight is about 5 kg. Cleft lip is usually
closed at 6 months of age. Cleft palate has to be repaired in stages
starting at about 18 months of age.
41.11 CONGENITAL OESOPHAGEAL ATRESIA WITH

AND WITHOUT TRACHEO-OESOPHAGEAL
FISTULA
CLINICAL FEATURES
 Bubbling saliva around mouth and nostrils, already after birth.
 When the first feeding is offered: triad of choking, coughing
and cyanosis.
 Soft rubber catheter, No 8 Fr size, cannot be passed through
nose into stomach. Check with litmus paper and inflate air.
266
CONTRAINDICATIONS TO REFERRAL
 Low birth weight (below 1500 g)
 Multiple associated anomalies
 Pneumonia (bacterial and chemical), advanced.
ACTION TO BE TAKEN IN CASE OF REFERRAL

 Travel in upright position
 Nothing by mouth
 Suction of oro-pharyngeal secretion down to pouch of
oesophagus.
SURGICAL TREATMENT
 One stage repair or staged operations.
41.12 DIAPHRAGMATIC HERNIA IN NEONATES

CAUSE
Persistence of foramen of Bochdaleck with the so called
pleuroperitoneal canal and postero-lateral diaphragmatic hernia,
in 95% on the left side.
CLINICAL FEATURES
 After delivery, the newborn may seem to be normal, but
immediately the herniated stomach and small bowel are filled
with gas, dyspnoea and cyanosis develop. Tachypnoea, with
scaphoid abdomen.
 Displacement of the heart sounds to the opposite side.
267

Early recognition and transferral immediately to highest
referral level.
MANAGEMENT AT THE CENTRAL LEVEL

 Urgent X-ray of the chest
 Acidosis correction
 Endotracheal intubation and, if needed, assisted ventilation
 Surgical repair.
41.13 PATENT DUCTUS ARTERIOSUS

 Clinically usually asymptomatic or sometimes with repeated
infection of the respiratory tract. In severe cases cardiac
failure.
 "Waterhammer" pulse with large difference between systolic
and diastolic pressure (120/50).
 Continuous machinery murmur max. at pulmonary area, in
infants often only systolic murmur.
 Surgical repair may be done early.
NOTE: this non-cyanotic cardiac anomaly is included because of

the availability of surgery in KCMC. Other non-cyanotic conditions
can be treated symptomatically only (see CCF 19.6). Prevention of
subacute bacterial endocarditis prior to surgery and dental
extractions: see 20.7.
41.14 TETRALOGY OF FALLOT

The most common cyanotic cardiac malformation with diminished
pulmonary blood flow. 4 components in this malformation:
ventricular septal defect, aorta overriding the V.S.D., pulmonary
stenosis (generally infundibular), right ventricular hypertrophy.
Open heart surgery needed.
268
CLINICAL MANIFESTATIONS
Onset in the neonatal period, cyanosis and anoxic spells,
squatting, easy fatigability.
 Physical examination: clubbing, ejection murmur, located
along the mid and upper left sternal border.
 X-ray: Typical shape - "sabot" - wooden shoe.
 Surgical correction. Usually at 6-12 months of age.
 Management of anoxic spells:
 Place the child in knee-chest position
 Give oxygen
 Morphine sulphate 0.1-0.2 mg/kg SC or IM
 Sodium bicarbonate 1 meq/kg IV in severe cases
 Propanolol 0.1 mg/kg IV in protracted spells.
NOTE: this condition is included as an example of cyanotic

congenital heart disease. Surgery of these conditions is at present
impossible at KCMC. Symptomatic treatment only. Prevention SBE
prior to dental extraction/surgery, see 20.7.
41.15 OMPHALOCELE
CLINICAL FEATURES
 Translucent avascular sac at the base of the umbilical cord.
 Variation in size from a few cm in diameter to a huge sac
containing the entire midgut, stomach and liver with
(mushroom-shaped) or without a narrow neck.
 The umbilical cord emerges from the apex of the sac.
 Associated anomalies are often found.
IMPORTANT ACTIONS TO BE TAKEN BEFORE TRANSFER TO

REFERRAL LEVEL
 Apply Gentian violet 1% and aseptic dressing.
269
 Antibiotic, because of the high risk of bacterial invasion of the
peritoneal cavity through the membranes of omphalocele. See
chapter 38.5.
 Do not refer for conservative treatment only.
TREATMENT
 Diameter of the sac below 6 cm: Surgery.
 In cases with huge sac: conservative treatment, apply
Mercurochrome combined with appropriate antibiotics (culture
of the infected areas of the sac).
41.16 GASTROSCHISIS
 Protrusion of the bowel through a full-thickness defect in the
abdominal wall adjacent to the umbilical cord. Not covering
skin.
 Aseptic dressing and antibiotic before transfer to referral
centre.
41.17 PRUNE-BELLY SYNDROME

 Deficiency of abdominal muscles  markedly wrinkled skin of
abdomen.
 Urinary tract anomalies, widely dilated ureters leading to UTI.
 Cryptorchism.
 Refer to central level for assessment. Reconstructive surgery
may be necessary.
270
41.18 HYPOSPADIA
Abnormal location of the external urethra meatus on the ventral
aspect of the penis. Severe cases of hypospadia can be confused
with ambiguous genitalia. Such cases need to be referred to
urologist after 3 months. Rest may be referred after 6 months.
Advice: these children should NOT be circumcised.
41.19 CRYPTORCHISM
 In retentio testis the testicles cannot be brought down into the
scrotum. Careful physical examination should confirm this.
 Need review at 3, 6, 9 and 12 months as there can be
spontaneous descent after birth. Optimum time for operation is
between 6 months and 1 year.
41.20 CONGENITAL CLUB FOOT (TALIPES

EQUINOVARUS)
PATHOLOGY
The deformity includes forefoot adduction, heel varus inversion and
ankle equinus. There are wide variations in the grades of severity
from mild congenital clubfoot, with equinovarus position at birth,
resulting from an intrauterine position and to severe clubfoot
associated with spina bifida and myelomeningocele.
IMPORTANT ACTION TO BE TAKEN BEFORE ADMISSION

Refer the patient to orthopedic surgeon directly after birth for
assessment.
271
MANAGEMENT
FIRST WEEKS FROM DAY 1

 Start treatment on the first day of life with gentle passive
correction of the deformities proceeding from the forefoot
adduction to the heel varus, to the ankle equinus. Apply plaster
casts after gentle correction of the deformities
in the mentioned order with knee in flexion. This should be
done several times weekly for some weeks. Educate
mother on how to do it, also tell her treatment extends to
juvenile age.
FORTHCOMING MONTHS
 If available apply Denis Browne splint to which the feet are
strapped by adhesive and in which the affected foot is
progressively turned outward and into valgus. The adhesive
strapping is changed weekly for about 12 weeks.
 If available use Denis Browne boot splint which is to be worn
day and night for the ensuing 3 months. It is left off for longer
and longer periods of the day until the child is walking. It is
very important that the splint is used, at nights only, for at least
another year.
 If Denis Brown splints are not available continue applying POP
casts every three weeks. This method is know as serial
P.O.P.S.
The length of treatment depends on the grade of severity.
AFTER FIRST MONTHS
 Straight-last boots for day wear may be used in severe cases
until the age of 3 years, sometimes with the addition of an
outside sole wedge.
 Approximately 90% of congenital club feet respond
satisfactorily to this plan of treatment. Resistant, neglected and
recurrent club feet usually require operative treatment: surgical
repair depends on residual deformity.
272
INDICATION AND TIMING SURGERY

Club foot surgery (Soft Tissue Release STR) (Turco or Mackay
Procedures) or simple Elongation of Tendo-Achilles are
recommended when the child can physiologically use the foot,
therefore when he/she starts to actively stand and walk, i.e. age 9-
10 months. In this way recurrences in our environment are
minimised. Repeat surgery can also be indicated.
Age Type of surgery

0-5 yr. Soft Tissues(surgery STR)
6-14 yr. Bone surgery + STR
> 15 yr. Triple arthrodesis
41.21 HYDROCEPHALUS
CAUSES
 Postinfectious, very common after meningitis/sepsis in the first
month of life
 Congenital
 In combination with Spina Bifida
 Post hemorrhagic esp. in very low birth weight infants
 Occlusion due to brain tumour.
273

 In suspected Hydrocephalus rule out an ongoing infection and
measure headcircumference ( from prominence of forehead to
prominence of the occipital area) every week.
 If headcircumference is increasing abnormally ( see
headcircumference chart section 49.6 and 49.7 in this manual)
refer to centre where ventriculoperitoneal shunting is done.
 Lumbar puncture is contraincidated in Hydrocephalus
Clinical manifestations
 Headcircumference is trespassing the 98 th percentile or ( in
premature babies) changing from a low percentile to a
significantly higher one with signs of raised intracranial
pressure.
 Signs of raised intracranial pressure: bulging fontanel, sunset
phenomenon of eyes, high pitched cry, increased ankle clonus
and spastic diplegia, congested veins, vomiting, drowsiness,
loss of vision.
Management
Before surgery:
 Ultrasound brain
 Rule out ongoing infection and high protein in CSF by
ventricular tap, unless infection and intraventricular
hemorrhage are unlikely from history ( congenital
hydrocephalus).
 Ventricular tap has to be performed under aseptic conditions
and by someone who has been trained in the technique.
 Infection should be treated before shunting.
 CSF protein > 1.5 g/l is associated with high risk of Shunt
blockage. Repeat ventricular taps may reduce protein level.
 In case surgery is delayed in the presence of high pressure
Acetazolamide may reduce CSF production for a short period.
Doses up to 100mg/kg/day are recommended.
274
 Counsel parents before surgery on the cause of
Hydrocephalus, surgical procedure and signs of shunt
dysfunction
Surgery:
 All children with growing Hydrocephalus are offered
ventriculoperitoneal shunting after discussing with the parents
whether regular follow up is possible.
 Perioperative antibiotics are used to prevent immediate
postoperative infection in most cases.
FOLLOW UP
 1 month after discharge, later according to clinical problems
and distance to the hospital
 Parents living far should be given written instructions to the
local health institution: in case of suspected Shunt dysfunction
child needs to be referred back after first dose of anti-
meningitic drug.
 Most children with Hydrocephalus will need
neurodevelopmental follow up and Physio / Occupational
Therapy.
41.22 SPINA BIFIDA, MYELOMENINGOCELE/

MENINGOCELE
PREVENTION
All mothers of children with spina bifida should prior to forthcoming
pregnancies until the end of the first trimester, take Folic acid 5 mg
daily. Practically this means that when no contraceptives are used
Folic acid should be started.
CAUSE/ PATHOPHYSIOLOGY
Failure of closure of neural tube in the first 4 weeks of pregnancy.
Cause usually unknown, but (increase of) Folic acid intake reduces
the incidence.
275
SIGNS AND SYMPTOMS

 Swelling of the back at birth, sometimes presenting as an
open wound. Mostly lumbar or sacral, can be thoracic,
cervical or even occipital (encephalocele).
 Depending on level and involvement of spinal cord variable
motor impairment, sensory impairment, neurogenic bladder
(incontinence or retention may prevail) and neurogenic bowel.
 Hydrocephalus may be present at birth or develop after
closure of the spina bifida in 80% of the cases.
 Spina bifida occulta may be visible as a patch of hair or sinus
above the spinal cord. May have (or develop) bladder/bowel
problems or mild motor/sensory impairement due to “tethered
cord”.
 Often orthopaedic problems, talipes equinovarus.
 Most children with Spina Bifida of the lower back ( thoracic and
below) have a “Neurogenic bladder Spincter dysfunction”. If
untreated, 50% of them develop changes of the upper urinary
tract within their first 5 years of life.
IMPORTANT ACTIONS TO BE TAKEN IN CASE OF REFERRAL

 Counsel parents. Do not create unrealistic expectations.
 Sterile covering of open wound
 Look for signs of meningitis and refer to hospital after first anti-
meningitic dose.
 If possible refer within 72 hours after birth for further
evaluation, surgery, adequate care even if there is sensory/
motor loss or Hydrocephalus
 Always measure head-circumference prior to referral
Diagnosis
 Clinical level of impairment defines later prognosis. All patients
with Spina Bifida need to be clinically evaluated for: sensory level,
motor function, bladder/ bowel function, hydrocephalus,
orthopaedic problems.
276
 Additional diagnostic measures:
o Ultrasound of brain
o Ultrasound of kidneys ( at birth,3mo,6mo,12mo, then
yearly)
o Ultrasound of Cele only if skin is intact
o Urinalysis
o X-Ray spine only in selected cases
o For renal evaluation: retrograde cysturethrogram (in
experienced hands) and cystometry ( preferably at 3
months, not earlier than 1 month after back closure)
TREATMENT
General remark
Before treatment parents should be counseled regarding the
prognosis and necessity of life long medical follow up/ treatment
including several surgical interventions. Only if they are willing and
able to commit themselves to this, surgical treatment should be
started. Severe brain damage or combination with several serious
malformations may be a contraindication for surgical intervention.
Parents, who’s child is not operated should be given all help to
accept the diagnosis, including the offer to come back for follow up.
Good nursing care and parental care are of vital importance for the
well-being of children with spina bifida. They and their parents
deserve special support from the community.
Multidisciplinary actions:
 Surgical closure of meningomyelocele, VP shunting of
hydrocephalus either before or after closure.
 Orthopaedic corrections e.g. treatment talipes, stabilization
with calipers or braces.
 All children with Spina bifida from thoracic level downwards
need bladder evaluation. In case of a dangerous bladder
( hyperactive detrusor, high intravesical pressure, reflux,
hydronephrosis, recurrent UTI) clean intermittent
277
catheterization +/- anticholinergic medication ( Oxybutinine,
0.2mg/kg/dose, BD or TDS) should be started in infancy. Most
other children will need to start the same treatment when they
want to achieve continence at a later age.
 In the neonatal period, babies with urinary retention and
distended bladder need immediate treatment by clean
intermittent catheterization.
 Stool incontinence is a major social handicap for older
children. Treatment consists of regular stooling, probably with
manual evacuation of stool in the rectum.If necessary
emptying of rectum with small enema at home.
 Physiotherapy: achieve best possible ambulatory function with
the help of crutches and leg bracing. Most patients with
sensory/motor loss above L3 will require a wheelchair later in
life.
 Occupational therapy; often needed because of learning
disorders.
 Good nursing care.
 Paediatrician to diagnose, assess, co-ordinate and set
objectives.
FOLLOW-UP
Patients need follow-up if possible in a specialized clinic where all
the above services can be co-ordinated. Even children with no
sensory and motor loss have to be followed up for upper urinary
tract changes. See also: hydrocephalus 41.21
278
KCMC, PAEDIATRICS 42 INTOXICATIONS
_______________________________________________________________________
42 INTOXICATIONS
42.1 PREVENTION

 Know the common causes in your locality, their prevention and
treatment. In KCMC mostly intoxication by ingestion including:
kerosine, organophosphates, alcohol, herbal/traditional
medicaments, modern medicine. Also cassava roots, wild
fruits, seeds and flowers.
 Keep household cleaning supplies, medicines, chemicals and
insecticides out of reach and sight of the child. Lock them up
whenever possible. Store medicines and chemicals in original
containers and never in food or beverage containers. Discard
medicines left over after treatment course.
 Avoid use of unestablished herbal/ traditional medications and
misuse of modern medicines.
42.2/3 SIGNS, SYMPTOMS CAUSES

(suspected substance)
CNS depression coma Sedatives, tranquillizers, alcohol,
narcotics
Excitation, convulsion Nicotine, salicylate,
organophosphate
Hyperpyrexia Salicylate, atropine, contaminated
flour
Arrhythmias Digitalis, antidepressants
Hypotension Narcotics, antidepressants
Increased salivation Organophosphate, mushrooms
Decreased salivation Antihistamines, atropine
Hypoventilation CNS depressant
Hyperventilation Salicylate, nicotine
Special odour Alcohol, turpentine
279
_______________________________________________________________________
Mydriasis Cocaine, amphetamines, atropine
Miosis Narcotics, organophosphate
Vomiting Almost all toxic substances
Extra pyramidal movements Antihistamines
Burns around the mouth/stridor Corrosives

ADMISSION - FIRST AID
INHALED POISON
If gas, fumes or smoke have been inhaled, take the patient
immediately to fresh air.
POISONS ON THE SKIN OR CLOTHING

Remove the clothing and flood the involved parts with water, wash
with soap and rinse thoroughly. Very important in poisoning with
organophosphate, chlorinated hydrocarbons and weed killers.
SWALLOWED POISONS
If the substance is a household product or other chemicals, give
one glass of water. Do not induce vomiting at home.
POISONS IN THE EYE

Flush the eye with luke-warm water for 15 minutes or longer. Do
not cover the eye.
It is important to bring the chemical containers/left overs with the
patient to hospital.
42.5 DIAGNOSIS
 History most important
 Clinical, see above (42.2)
 Laboratory. Vomitus, urine and blood can be examined in
special laboratories.
42.6 TREATMENT
280
_______________________________________________________________________
GENERAL CARE
 Support breathing (give oxygen if necessary) and circulation
and register breath-rate, pulse, blood pressure.
 Monitor level of consciousness. Turn the unconscious child
regularly from side to side. See chapter 44 on Coma.
 Monitor fluid balance
PREVENTION OF ABSORPTION
INDUCE VOMITING
This is contra-indicated in patients who are comatose or
convulsing, who have lost the gag reflex, or who have ingested
strong acids, strong bases or Hydrocarbons e.g. kerosene.
Use syrup ipecac, 10mls for infants, 15ml in children 2-12yrs and
30ml in older children.
GASTRIC LAVAGE
If ingestion is less than 6 hours
If the patient is or becoming unconscious, or is convulsing, gastric
lavage should follow endotracheal intubation. Use warm saline
solution 10 mls/kg. Lavage until the returns have been clear. See
section 47.9.
CHARCOAL
Toxins are absorbed on its surface’ preventing absorption.
10 - 30 grams for a child and 30-100 grams for adolescent of
charcoal should be mixed with water. Let the child drink or give it at
the end of gastric lavage.
CATHARSIS
Used in conjunction with activated charcoal.
Sorbitol 1g/kg, Magnesium sulphate, 250 mg/kg orally,
ENHANCEMENT OF URINARY EXCRETION
DIURESIS
 Diuresis is useful in serious poisonings if the drug is excreted
in the urine in active form. With forced diuresis, urine flow
should increase to 3-6 ml/kg/h (normally 1-2 ml/kg/h). Give
 Extra fluid IV e.g. 5-7 litre/m2/day (see 48.2)
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5%dextrose alternating with 0.9%
saline
and
 Furosemide 2 mg/kg/dose IM or IV
In- and output must be carefully monitored.

 Alkaline diuresis may be tried for excretion of acids, e.g.
severe Salicylic acid intoxication.
 Sodium bicarbonate 1 meq/kg at once IV slow infusion
over 4 hours
There is a risk of Potassium deficiency in alkaline diuresis. 3-5

meq/kg/d may be needed.
DIALYSIS
Peritoneal dialysis may be considered in severe poisoning, that
does not respond to other therapy, especially if the patient is in
deep coma. Peritoneal dialysis, see chapter 47, Paediatric
Procedures, may have good effect in patients intoxicated with:
 barbiturates, especially long acting
 alcohols
 salicylates
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ANTIDOTES
Poison: Antidote: Dose:
Iron Desferoxamine 50 mg/kg/dose (max 1.0 g) orally or IV 5-15
mg/kg by infusion.
Organophosphate Atropine sulfate 0.05 mg/kg IV initial dose, thereafter 0.02
Insecticides mg/kg/IV every 15 minutes until there are
signs of atropinism (flushed face, fast pulse,
large pupils) then infusion should be
stopped.
Methanol Ethanol 1 g/kg IV (in 10% solution) loading dose
Ethylenglycol followed by 0.5 g/kg/dose every 4 hours.
Opiates Naloxone 0.1 mg/kg/dose IV. Max 2 mg. Repeat after

2 min. Continue until narcotic effect is no
longer present.
Paracetamol if risk of N-acetylcysteine, 140 mg/kg oral as loading dose followed by
hepatotoxicity, > 150 mucolytic drug, 70 mg/kg/dose every 4 hrs for up to 17
mg/kg intake doses. Should be given in 5% solution.
Avoid forced diuresis.
Digitalis glycosides Digibing One vial bind 0.6 mg digitalis
benzidiazepines Flumazenil 0.2 mg over 30 sec can be repeat
anticholinergic Physiostigimine 0.02mg/kg: slow push
Carbon monoxide 100% oxygen Nasal prongs,

Nasal catheter
Nasal pharyngeal
TREATMENT PLAN IN KEROSENE POISONING

 Do not perform gastric lavarge. If the child is vomiting, try
to prevent aspiration.
 Give supportive treatment with maintenance of hydration
and ventilation when necessary
 Observe the patient for 6 hours. Tell the parents to return
the child if signs of pneumonia appear.
 If child is symptomatic, admit
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 Give antibiotics in case of pneumonia
284
KCMC, PAEDIATRICS 43 BURNS
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43 BURNS
43.1 PREVENTION
 Prevention is very important and better than any treatment.
Many lethal and disabling burns for children are domestic
accidents, which could have been prevented quite easily.
 The target group for education is the family.
 Do not let children play close to open fire, hot water and
cooking area without supervision of grown-ups.
 Epileptic children especially should never be allowed to play
near fires. Epileptic mothers should not carry children when
cooking or handling hot water.
PREVENT BURNS!
WHAT SHOULD BE DONE IN YOUR AREA?
43.2 TYPES
 Dry heat.
 Scalds caused by hot liquids are even more common.
 Inhalation of hot gases.
 Chemical – strong acids and alkalis.
 Electricity usually involves deep structures in the body.
 Radiation burns from X-rays.
 Cold burns (frost bite).
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HISTORY
 Detailed history is important. Older children can tell with
accuracy what happened. What caused the burn? Where did it
happen, open space or closed rooms with smoke? What date
and time did it happen. We often can predict how bad the burn
will be, when we know what caused it. Flames and electricity
usually cause deeper burns than hot tea.
 Is the child epileptic, under regular medication? Is the mother
epileptic? What treatment has been given, local or systemic?

GENERAL EXAMINATION
 Check the Airway, Breathing and Circulation
 Look for signs of shock. (weak thready pulse, cold extremities
if not burned)
 Is the child breathing easily? (internal burns/inhalation or
trauma)
 Is the child in pain? They often are and need pain killers
without delay.
 What is the body weight?
LOCAL EXAMINATION OF THE BURNS

HOW DEEP IS THE BURN?
Not easy to diagnose and usually a mixture (i.e. 3rd degree in the
centre and 2nd degree in the periphery of the injury).
 A blister is usually a sign of a superficial burn.
 Black charred skin means a deep burn that will need grafting,
so does hard skin that feels like leather.
 If the burns are older: examine for signs of general or local
infections (temperature, shivering, pus around the burnt
surface area or around the scars).
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Depth of burn
GRADE CLINICAL PICTURE DEPTH OF TISSUE DAMAGE
I Redness (light coloured skin) Superficial damage of epithelium

change of texture (dark skin)
IIa Blisters, red underground, very Damage of epidermis and superficial

painful. dermis.
IIb Blisters, pale underground, painful Damage of dermis. Hair follicles and
glands are preserved.
III Burnt rests of epidermis, tissue Epidermis and dermis are completely
after cleaning white or pale, no destroyed.
pain
IV Charred Destroying of tissue underneath the

skin (fat, muscle, tendons bones etc).
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HOW WIDESPREAD IS THE BURN?
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Adding the percentages according to picture and table gives a
gross estimate of the burnt area.
Such a form should be available and be used if the child is
admitted in the ward. For a quick estimation: the palm of the
patient (not of the doctor) is about 1% of his body surface.

REFERRAL
FIRST AID
 Cooling the burn area or the whole body with water is the best
and most effective treatment. Running water or shower, under
a tap, from a tin etc, is better than dipping but any way will do.
Start as soon as possible and continue for 20-30 minutes even
during transport to hospital. This will remove the heat from the
tissue, prevent deeper burns and will relief the pain.
 Do not remove the cloth adherent to the wound .
 Do NOT encourage the application of local medicine,
(traditional or even from the pharmacy), gentian violet, sugar,
fat, fish sauce, sodium bicarbonate, tooth paste or anything
else. This will be done after cleaning at the hospital.
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AT HEALTH CENTRE OR DISTRICT HOSPITAL

PAIN RELIEF: VERY IMPORTANT
Ketamine 2-5 mg/kg IM or rectally even to a restless child and the IV
line can be put without stress.
Combined with
Midozolam 0.05-0.1 mg/kg IV
or with < 3yr. 5mg rectally
Diazepam older 10mg rectally
Or
1 mg/kg/dose IM may be repeated after
Pethidine 4-6 h
Or
0.1- 0.2 mg/kg IV (also together with midozolam)
Morphine May be repeated after 4–6 h
with dose 0.05-0.1 mg/kg IV
Note: The peripheral acting analgesics like paracetamol, aspirin,
metamizol are not sufficient for the initial analgesia.
IV FLUIDS
ANTIBIOTICS
LOCAL TREATMENT
Under the above analgesia or even anaesthesia
 Gently wash the burnt area (in severe burn the whole body)
with warm water, remove any dirt, clothing or dead skin
including blisters and all hair around the burn area and gently
dry. In the exposure method no dressing or ointment are used.
The burnt area is left to dry.
 A bed-cradle keeps the bedclothes off the area; the patient
must be in a warm environment (danger for hypothermia). For
small areas especially and the hands and feet, vaseline gauze,

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SSD cream, povidone iodine ointment and dressing can be
applied after cleaning.
Good function position and elevation of the limb are important.
Elevate it on pillows or in a sling. Each finger should be
bandaged separately.
 Dressing should be changed every 1-2 days, the exposed burn
area should be soaked and cleaned 1-2 times daily.
FLUID
Start with IV fluids as soon as possible before admission. See
below.
REFERRAL
 Extensive burns that involve more than 8-10% of body surface.
 All burns where face, hands, genitals are involved.
 Think of inhalation trauma in face and neck burns.
 Deep burns not healed in two weeks. They usually need
grafting.
 Flame burns of face and eyelids, nostrils.
 Late burns with contractures.
43.5 DIAGNOSIS
 Bronchoscopy (if available) in case of inhalation trauma.
 Haemoglobin or haematocrit and blood group in extensive
burns. Serum electrolytes if possible.
43.6 TREATMENT
FLUID
 All patients (except in minimal burns) need extra fluid because
of fluid losses in the burnt area. Just as in diarrhoeal diseases
one has to give this extra amount of fluid on top of the daily
fluid requirement. The fluid may be given orally or by
intravenous drip.
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 Children are more susceptible to dehydration and shock
because of small physiological reserves. They need an exact
calculated amount especially in the initial phase more than
adults.
 Ringer or Ringer’s lactate solution is the fluid of choice. Only in
burns with >40%, prolonged shock or early surgical treatment
colloidal solutions should be added.
SHOCK TREATMENT
20-30 ml/kg in first 30 minutes
DAILY FLUID REQUIREMENT:

MAINTENANCE + ESTIMATED LOSSES according to Parkland
formula
Maintenance: Estimated loss Estimated loss Estimated loss
day 1 day 2 day 3
*<10 kg :
100 ml/ kg
*10-20 kg: 4-5 ml/kg/% 3 ml/kg/% 1 ml/kg/%
1000 + 50 ml/kg burnt surface burnt surface burnt surface
* >20 kg :
1500 + 20
ml/kg
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LOCAL TREATMENT OF THE SKIN
GENERAL
See above "at Health Centre".
SKIN GRAFTING
Burns of I and IIa degrees heal normally within 2-2 ½ weeks.
Deeper burns will need a skin grafting.
The tendency nowadays is to graft the burns if possible after 3-6
days. Necrotic tissue can be removed through tangential excision.
This will prevent the inflammatory phase (starting 6-7 days after
the injury); will lead to early mobilisation and better functional and
cosmetic results. An evaluation of the general condition of the
child and the burnt area should be done on the 3-4 days by the
paediatrician and the surgeon.
ANTIBIOTICS
Fresh burns are clean and do not require antibiotics. Use them
only if the wounds are already infected or if there are signs of
generalized infection.
Take wound cultures on arrival and repeat after some days.
 Staph. aureus is the most common organism.
 Pseudomonas infection is very common in almost all
hospitals.
Cloxacillin 50-100 mg/kg/d In 3 doses orally, IV, IM
And GentamIcin (if 1 mo- 5 yr.: 7,5 mg/kg/d

Pseudomonas suspected) 5-10 yr.: 6 mg/kg/d
above 10 yr.: 4,5 mg/kg/d
given IM,IV in 3 doses
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OTHER TREATMENT
ANTITETANUS TREATMENT
Give antitetanus toxoid to non-vaccinated children: In previously
vaccinated older children give booster dose of tetanus toxoid, if
last vaccination is older than 5 years.
PHYSIOTHERAPY
Should start as early as possible with active and passive
movements, teaching of the mother and long time splinting to
prevent contractures.
43.7 FOLLOW UP
 See the patient again 2-3 months after discharge to rule out
contractures and infections, or still open wounds, control of
splinting etc.
 Repair of contractures not earlier than 6 months and only if the
scars are non-active.
 If the child has epilepsy, review the treatment.
See chapter 15 on Convulsions.
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KCMC, PAEDIATRICS 44 COMA GENERAL
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44 COMA GENERAL
44.1 PREVENTION
 Prevent accidents and intoxications.
 Recognize meningitis early.
 Recognize and treat severe malaria with second line
antimalarials.
44.2 CAUSES
TRAUMA METABOLIC
 Epidural haematoma  Diabetes mellitus,
 Subdural haematoma Hypoglycaemia
 Intracerebral haematoma  Uraemia
 Cerebral oedema  Hepatic failure
 Hypocalcaemia
 Hypo- or hypernatraemia
 Reye’s syndrome
 Prolonged hypoxia
INFECTIONS VASCULAR CAUSES

 Meningitis,  Subarachnoidal haemorrhage,
 Encephalitis/encephalopathy intracranial aneurysms
 Brain abscess  Thrombosis, emboli
 Malaria  Vasculitis
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INTOXICATION
 Alcohol
 Organophosphates
Drugs (e.g. Barbiturate, tricyclics, Aspirin)
 Herbal medications
 Heavy metals (e.g. Lead, mercury)
TUMOURS
 Supratentorial
 Infratentorial
EPILEPSY (status epilepticus)
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44.3 SIGNS AND SYMPTOMSLEVEL OF COMA
(There are different models for estimating the degree of coma. We
prefer this one).
GLASGOW COMA SCALE SCORE BLANTYRE COMA SCORE SCORE
Best motor response Best motor stimuli
None Localizes painful stimulus 2
Extension to pain 2 Withdraws limb from painful stimulus 1
Flexion to pain 3 No response or inappropriate 0
response
Withdrawal from pain 4
Localizes pain 5 Best verbal response
Obeys commands 6 Moan or abnormal cry with painful 2
stimulus
No vocal response to painful stimulus 1
Best verbal response 0
None 1 Eye movements
Moans to pain 2 Watches or follows 1
Persistent cries to pain 3 Fails to watch or follow 0
Inappropriate words 4
Appropriate words/phrases 5
Eye movements
None 1
Opens to pain 2
Opens to verbal commands 3
Opens spontaneously 4
AVPU is quicker and simpler in emergency situations

A alert
V responds to voice
P responds to pain
U unconscious
If the child is not awake and alert, try to rouse the child
talking or shaking the arm. If the child is not alert, but responds to
voice, he is lethargic. If there is no response, ask the mother if the
child has been abnormally sleepy or difficult to wake. Look if the
child responds to pain, or if he is unresponsive to a painful
stimulus. If this is the case, the child is in a coma (unconscious)
and needs emergency treatment.
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RESPIRATION
Kussmaul In acidosis
Cerebral
Cheyne Stokes hemispheric
dysfunction
Neurogenic Midbrain or upper

hyperventilation pons damage e.g.
( alkalosis) in severe head
injuries
Apneustic
breathing with
prolonged Pons damage
inspiratory
phase
Ataxic Medullary
respiration dysfunction
PUPILLARY REACTIONS
 Normal reacting pupils, are not seen in case of severe brain
stem dysfunction.
 Unequal, widely dilated, non-reacting pupil imply 3rd nerve
damage which implies tentorial herniation which requires
emergency measures to reduce intracranial pressure.
 Pinpoint pupils: pontine lesions and poisoning with opiates,
organophosphates.
 Mid position fixed pupils: midbrain damage.
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EYE MOVEMENTS
 Conjugate deviation of eyes suggests a destructive process
on the same side or an irritative process on the opposite side
of the cerebral hemisphere. Deviation of eyes to the same
side as hemiplegia indicates a pontine lesion.
 Downwards conjugated deviation: midbrain damage.
 Vertical dysconjugate gaze: midbrain or thalamic dysfunction.
 Corneal reflex. Loss suggests brain stem damage.
 "Doll's eye" phenomenon. If the head is briskly turned to one
side and the eyes turn in the opposite direction, the brain stem
is intact. Otherwise brain stem or oculomotor nerve damage.
MOTOR CHANGES
 Hypotonia, "cerebral shock", for the first 48-72 hours. Also in
spinal cord lesion or severe brain stem lesion.
 Hemiplegia.
 Decorticate posture: flexion of arm, wrist, finger, extension
lower extremities. In hemispherical damage.
 Decerebrate posture: extension of both upper and lower
extremities. Brain stem damage.
ADDITIONAL IMPORTANT SIGNS TO NOTICE

 Neck stiffness in meningitis.
 Scalp: contusion, signs of trauma.
 Eyes: chemosis, proptosis and periorbital oedema in
cavernous sinus thrombosis; periorbital ecchymosis in basilar
skull fracture.
 Congenital heart disease in case of embolism, brain abscess.
 Fever: infection, malaria.
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ADMISSION
 Early referral of comatose children.
 Ensure free airway. The child shall lie on his side.
 In endemic areas treat for malaria: see chapter 9 on Malaria.
 If meningitis is suspected, start antimeningitics immediately
before referral
44.5 DIAGNOSIS
HISTORY
Obtain brief history and observe vital signs before detailed history.
Very important to get a detailed history from the parents a bit later.
CLINICAL
 See signs and symptoms above
 Blood pressure, heart rate, respiratory rate, capillary refill, &
temperature
 Fundoscopy (should however not delay treatment of
meningitis or cerebral malaria): papillary oedema.
LABORATORY
 Blood: Na, K, blood sugar, malaria slide, Hb, WBC. In special
cases urea, bilirubin, liver tests, Ca ++, blood culture.
 X-ray skull, sinus and mastoid is sometimes indicated.
 Lumbar puncture. Is contra-indicated in case of papillary
oedema.
 Gastric juice in intoxications may sometimes be of help for
identifying the cause.
 Urine in diabetes mellitus.
44.6 TREATMENT
GENERAL CARE
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REGULAR MONITORING of
 level of consciousness
 pulse rate
 blood pressure
 breathing
 eye movements, pupillary reactions
 fluid balance, input and output, check bladder level bladder
level
 blood-sugar in some cases.
NURSING
 Turn the child 2 hourly from side to side to prevent pressure
sores.
 Ensure free airway.
 Every comatose patient should be fed by NGT.
FLUID
IV fluid usually needed. See chapter 46 on IV Fluid Therapy.
NB. Maintenance fluid in brain damage is only 75% of the normal
amount.
TREATMENT OF CEREBRAL OEDEMA
See chapter 14 on Bacterial Meningitis.
SPECIFIC TREATMENT
According the treatment of the underlying cause, see appropriate
sections in this guideline, e.g. Malaria, hypoglycaemia, etc.
44.7 FOLLOW UP
Follow up in three weeks time.
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KCMC, PAEDIATRICS 44b DIABETIC KETO-ACIDOSIS/COMA
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44b DIABETIC KETO-ACIDOSIS/COMA

44.1 PREVENTION
 Timely referral of children with symptoms of polydipsia, polyphagia,
polyuria.
 Promote breast feeding.
 Early referral of any diabetic child with febrile illness.
44.2 CAUSE/DEFINITION
State of metabolic derangement, secondary to absolute or relative
Insulin deficiency and stress hormones excess leading to:
 hyperglycaemia (>200 mg/dl or >11 mmol/l)
 ketonemia (>3mmol/l) or ketonuria
 metabolic acidosis (pH <7.3 or bicarbonate <15 mEq/l)

History of polyuria, polydipsia and weight loss. Significant
dehydration, lethargy, vomiting, abdominal pain, acidotic
(Kussmaul) respiration, and impaired level of consciousness (to
coma), shock. Acetone (or fruitlike) odour of the breath (Note:
some people are unable to smell acetone).
44.3 IMPORTANT ACTIONS PRIOR TO ADMISSION

If diagnosis of DKA is made as above, start IV fluids (0.9% normal
saline, amount see below), give 0.1 IU/kg regular (short acting)
insulin intramuscular and refer immediately.
If there is doubt whether the condition is due to hypo- or
hyperglycaemia, just start dextrose 5% solution, 6 ml/kg/hr (2
drops /kg/minute prior to referral).
44.4 DIAGNOSIS
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History of polydipsia, polyuria and polyphagia. Acidotic breathing.
Blood sugar (values of >200 mg/dl), ketonuria, ketonemia, plasma
bicarbonate <22mmol/l
44.5 TREATMENT
GENERAL RULES
 Perform a clinical evaluation to confirm the diagnosis and
determine its cause
 Weigh the patient and measure height or length to determine
surface area
 Correct dehydration
 Correct acidosis and reverse ketosis
 Restore blood glucose to near normal
 Avoid complications of therapy
 Identify and treat any precipitating event
 Screen and treat infections.
REHYDRATION/ELECTROLYTES
 1st and 2nd hours: 10–20 ml/kg body weight of 0.9% N/S
 If the child is in shock the above can be repeated.
THEN
 Deficit replacement with 0.9% saline or Ringer's lactate for at least
4-6 h
3-10kg: 100ml/kg
11-20kg: 1000ml + 50ml/kg for every kg above 10kg
>20kg: 1500ml + 20ml/kg for every kg above 20kg
 The rate of IV fluid should be calculated to rehydrate evenly

over at least 48 hours
When blood glucose has fallen below 300 mg/100 ml

(or 15 mmol/l) dextrose saline should be used.
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 Potassium 0.5 mmol/kg/h is added after adequate urine flow
starts. (40mEq/L of potassium chloride or potassium phosphate
added to the calculated rehydrating fluid)
 If bicarbonate is considered necessary, cautiously give
1-2 mmol/kg over 60 minutes.
INSULIN
 Give regular (= short acting) insulin 0.3U/kg as bolus IM/SC
then 0.1U/kg/h IM on presentation; repeat 1-2 hourly until
blood glucose level has fallen to 300 mg/100 ml (or 15 mmol/l),
then (0.25 IU/kg) 4-6 hourly, until resolution of DKA
 Alternatively; if insulin infusion is possible, Start insulin

infusion after the patient has received initial volume expansion;
i.e., approximately 1-2 hours after starting fluid replacement
therapy.
 0.3 U/kg/ start IM or SC then 0.1 U/kg/h at least
until
resolution of DKA
 Rate of fall of blood glucose should be in between 40-
90 mg/100 ml = 2-5mmol/l per hour, the risk of faster decline
being cerebral oedema.
 As long as there is ketonuria short acting insulin has to be
continued.
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MONITORING
 Accurate fluid balance must be recorded.
 Urine should be checked for glucose and ketones every
6 hours.
 Blood glucose should be checked at least before every insulin
administration.
 Vital signs such as pulse rate, breathing rate and blood
pressure should be performed every hour until the clinical
condition has improved. State of hydration and temperature to
be checked regularly.
 Check for signs of raised intracranial pressure. If there are
signs of raised intracranial pressure, reduce fluid
administration, give mannitol 0.25-1 gram/kg IV over 20
minutes and repeat if there is no initial response in 30 minutes
to 2 hours in suspected cerebral oedema.
FEEDING
Oral feeding usually to start as soon as child is conscious and able
to feed.
FURTHER MANAGEMENT
 Regular insulin (0.25 IU/kg, short acting) can be started
according to blood glucose level (and reduction of
glyco-/ketonuria). Start 4 hourly subcutaneous  6 hourly 8
hourly (before meals).
 The amount of insulin needed will gradually decrease once
acidosis and dehydration have subsided. We aim at 90-180
mg/100 ml = 5-10 mmol/l blood glucose levels.
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 Long acting insulin (Lente/insulatard/mixtard) can be
introduced when the patient is on oral feeding, off IV and has
no more ketone bodies in urine.
 Usually the final insulin need does not exceed 0.5 to 1.0 units
per kg per day.
 2/3 long acting insulin as morning dose and 1/3 evening dose.
 Short acting insulin before meals dose 0.1U/kg
 Diet and resumption of daily activities are as well aspects of
this management during admission.
44.6 FOLLOW UP
Newly diagnosed diabetic patient should be followed up closely
after hospital discharge.
Children with recurrent DKA should be evaluated for the cause
Early and active involvement of the parent in the treatment of the
child is essential to prevent relapses of ketoacidosis.
Education to be given to patients and parents should include
 Explanation of diagnosis and symptoms
 Basic diet advice
 Insulin need (immediate and long term)
 Blood sugar monitoring
 Signs, symptoms and management of hypo- and
hyperglycaemia.
 Sick days rules
 Psychological counselling to the child and the family
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KCMC, PAEDIATRICS 45 SHOCK
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45 SHOCK
45.1 DEFINITION
Acute circulatory dysfunction resulting in inadequate tissue
perfusion to meet the metabolic demands of vital organs. First
there will be some compensatory physiologic mechanisms, but with
progression of shock cell death will occur.
45.2 CAUSES AND CLASSIFICATION
HYPOVOLEMIC SHOCK
Loss of intravascular volume, e.g. through dehydration, extensive
burns, diabetes insipidus, nephritic syndrome bleeding, inadequate
intake in infants
CARDIOGENIC OR OBSTRUCTIVE SHOCK rare in children.

Depressed cardiac function e.g. in ischemic insult,
cardiomyopathy, congenital heart disease, myocarditis or
obstruction of venous return or cardiac outflow, e.g. cardiac
tamponade, cor-pulmonale, hypertension, tension-pneumothorax.
VASOGENIC (DISTRIBUTIVE) SHOCK

Results from massive decrease in systemic vascular resistance
COMBINED SHOCK
When different types of shock coexist e.g.
 Septic shock.
 Anaphylactic shock.
 Neurogenic shock.
 Toxic
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COMPENSATED SHOCK
The effectiveness of the body to compensate shock is dependent
upon the pre-existing cardiac and pulmonary status and the loss of
volume. Early signs:
 Pallor
 Cold nose, fingers, toes
 Prolonged capillary refill
 Normal blood pressure
 Heart rate slightly raised
UNCOMPENSATED SHOCK
 Thirst.
 Hypotension.
 Tachycardia.
 Sweating.
 Skin changes; low temperature, greyish pallor, mottled skin.
 Lethargy, especially in small children.
 Oliguria.

ADMISSION
 Rehydrate early and effectively, orally or intravenously, in
cases of dehydration. Use 20ml/kg of normal saline or ringers
lactate rapidly
 Raise the legs.
 Cover the child with a blanket to keep temperature.
 Refer early to hospital which can provide intensive care, in
unclear or severe cases.
45.5 DIAGNOSIS
HISTORY
Underlying disease, drug history, duration, symptoms of acute
illness, volume loss, mental status and urine output
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CLINICAL EVALUATION
See above.
LABORATORY
 Haematocrit, electrolytes. Full blood count, Blood culture in
patients with suspected sepsis.
 X-ray chest.
 Lumbar puncture when stable and if meningitis is suspected
 ECG when cardiac cause is suspected.
45.6 TREATMENT
GENERAL PRINCIPLES
AIRWAY
 Should be free.
 Oxygen by mask or prongs
FLUID
Normal saline (0.9%) or Ringer’s lactate solution 20ml/kg bolus
rapidly, or blood 10 -20mlkg in case of bleeding except in
cardiogenic shock, see below. In exceptional circumstances intra-
osseous infusion may save lives. See chapter 47.8 on special
paediatric procedures.
URINARY CATHETER
Sometimes needed to measure the urinary volumes.
NASOGASTRIC TUBE
INTENSIVE CARE MONITORING CHART

Should be filled in every 30-60 minutes.
TREATMENT OF HYPOVOLEMIC SHOCK
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FLUID
 Start as described above under General principles.
 If no response, repeat the same. Monitor urinary output, blood
pressure, pulse rate.
 If no response after 2 infusions, measure respiratory rate,
heart rate and capillary refill. Suspect other causes of shock
Continue IV fluids but watch out for cardiogenic shock.
BLOOD AND PLASMA
 In haemorrhage give whole blood 20 ml/kg or more.
 Fresh frozen plasma may be helpful in coagulation
dysfunction.
TREATMENT OF CARDIOGENIC SHOCK

FLUID
 Has to be given carefully. give NaCl 0.9% or Ringer's lactate
solution at a rate of 5 ml/kg over 30 min.
 Sodium bicarbonate 1-2 meq/kg IV (1 meq=1 mmol).
ARRYTHMIA TREATMENT
See chapter 19.6 on Congestive Cardiac Failure.
INOTROPIC AGENT
Dopamine 5-20 µg/kg/min IV in Control blood
See also chapter19a on dextrose or saline by pressure.
Congestive Cardiac Failure continuous infusion
Dobutamine 1-20 µg/kg/min
Epinephrine(adrenalin) 0.05 – 3µg/kg/min in cont. Causes peripheral
infusion vasoconstriction
OTHER MEASURES
 Pericardiocentesis in case of pericardial tamponade.
See chapter 47.3 on Paediatric Procedures.
 Thoracocentesis in case of tension pneumothorax.
TREATMENT OF SEPTIC SHOCK
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CLINICAL SIGNS
 Occurs in children with burns, catheters, malnutrition and
infections, e.g. peritonitis.
 Onset with fever, tachycardia, widening pulse pressure,
tachypnoea, warm dry skin, oliguria, hyperventilation due to
respiratory compensation of metabolic acidosis. Changes in
mental status. Later signs of "cold shock".
FLUID/ INOTROPIC AGENT see above
ANTIBIOTIC THERAPY IN INFANTS/CHILDREN see chapter 48 (neonates

see chapter 38.5) IN INFECTION OF UNKNOWN CAUSE
TREATMENT OF ANAPHYLACTIC SHOCK (VASOGENIC)

EPINEPHRINE (ADRENALINE) immediately 0.01-0.5 ml/kg/dose (1:1.000
solution = 1 mg/ml IM or in more severe conditions 0.1 ml/kg of
1:10.000 solution (0.1 mg/ml) IV. For refractory cases 1ml of
1:1000 solution added to 250 ml of 5% Dextrose in continuous
infusion.
and
CORTICOSTEROIDS (Effec is lacf).
Hydrocortisone 5 mg/kg IV once or if needed again after 6 h.
Methylprednisolone 1-2 mg/kg IV once or if needed again after 6 h.
ANTIHISTAMINE
Chlorpheniramine 0.25mg/kg/dose can be repeated up to four
times.
TREATMENT AGAINST HYPOTENSION
Fluid, plasma may be needed, see General principles (above).
BRONCHOSPASM
See chapter 24 on Lower Airway Obstruction.
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KCMC, PAEDIATRICS 46 INTRAVENOUS FLUID
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46 INTRAVENOUS FLUID
46.1 DAILY MAINTENANCE AMOUNT
WHAT EVERY CHILD NEEDS EVERY DAY (normal daily
maintenance):
CALCULATION:
3-10 kg: 100 ml/kg
11-20 kg: 1000 ml + 50 ml/kg above 10 kg
> 20 kg: 1500 ml + 20 ml/kg above 20 kg
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INCREASED NEED OF DAILY WATER
 Fever. For each degree C above 37.5 increase 10%
 Phototherapy of the newborn increase 30%
 Severe hyperventilation increase 30%
Diabetes. Urine-volume to be measured. Increase with excess
urine output
 Burns see chapter 43
 Gastrointestinal loss see chapter 46.2
DECREASED NEED OF DAILY WATER

 Acute brain damage, meningitis, encephalitis decrease
25%
 Post operative (first day) decrease 25%
 Oliguria or Anuria decrease 75%
 Congestive cardiac failure decrease 75%
ELECTROLYTES, DAILY NEED

Na+ 3 mmol/kg (mmol=meq)
K+ 2 mmol/kg (mmol-meq)
Cl- 2 mmol/kg (mmol=meq)
FLUID AMOUNTS IN REHYDRATION
A DEHYDRATED CHILD NEEDS:

REHYDRATION
+
REPLACEMENT OF ONGOING LOSSES
+
NORMAL DAILY MAINTENANCE
SEVERE DEHYDRATION / SHOCK

 Give for rehydration IV fluid immediately 100-(150) ml/kg. In
exceptional circumstances intra osseous or intraperitoneal
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infusions can save lives if in skilled hands see chapter 47 on
special Procedures in Paediatrics.
0 - 1 year > 1 year
30- (50) ml/kg first hour 30 ml/kg first half hour
70-(100) ml/kg next 5 hours 70 ml/kg next 2½ hours
 Give ORS 5 ml/kg/h in addition as soon as the child can drink.

 Reassess the infant after 6 h and the older child after 3 h if still
signs of severe dehydration: continue IV treatment. Continue
with ORS solution for ongoing losses and breast milk etc. for
daily maintenance:
 Ongoing losses, amount: for each watery stool give ORS
solution
< 1 yr. 20 - 50 ml
1-2 yr. 50 - 100 ml
3-10 yr. 100 - 200 ml
> 10 yr. 200 ml  as much as wanted
 Daily maintenance give breast milk, water, tea, diluted

cow’s milk etc. Amount for 24 hours: see 46.1.
Example:
 Calculation of total fluid need in a child with diarrhoea and
dehydration. E.g. 3 yrs, 12 kg, severe dehydration, 6 loose
stool/first day.
 Rehydration with lactated Ringer or NaCl:
12x100 = 1200 ml/4 h
 Compensate for ongoing losses with ORS:

6x100 = 600 ml/next 24 h
 Daily maintenance breast milk, water, tea etc:
1000 + (2x50) = 1100 ml/next 24 h
46.3 INTRAVENOUS FLUIDS
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There are many different kinds of fluids available. Each hospital
has to decide.
RINGER'S LACTATE SOLUTION (HARTMANN'S SOLUTION)

meq/l = mmol/l: Na+ 130; K+ 3; Cl- 109; lactate 28.
Supplies adequate concentration of Na + and K+ and corrects
acidosis. Very useful in rehydration in diarrhoea.
NORMAL SALINE
meq/l = mmol/l: Na+ 154; Cl- 154.
Very useful in the initial phase of intravenous fluid therapy,
especially in pre-shock conditions, but does not contain other
electrolytes than sodium and chloride.
GLUCOSE OR DEXTROSE SOLUTIONS

Mainly as maintenance fluid, provides some energy. Electrolytes
may be added, but calculate correctly.
D/Saline = Dextrose: normal Saline 1:4 good maintenance solution,
contains 33mmol NaCl/l + 4.3% Dextrose.
PLASMA OR BLOOD
In shock: 15-20 ml/kg.
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46.4 PRACTICAL SUGGESTIONS ABOUT IV FLUID

THERAPY
 For safe IV count drops/min and mark on a tape placed on the
bottle the expected volume to be used every 30 min.
 Calculate the total need (both maintenance and if relevant
rehydration amounts) of fluid and electrolytes (Na +, K+, Cl-) for
24 hours.
 In acute situations start with
 normal saline or lactated Ringer 20-30 ml/kg/h for 2 hrs, or
even faster
or
 plasma, 10-20 ml/kg for some hours
 For continued treatment, give e.g.
 Ringer's lactate solution: give the rest of the calculated
amount for 24 hours
or
 Glucose with addition of the daily need of electrolytes as
maintenance fluid.
or
 As soon as the child can take oral food and fluid, reduce
the IV part.
 Hypertonic dehydration should be fully rehydrated slowly
over 3 days. Give a solution of 25-50 Na + mmol/l = meq/l in
glucose (1/6 - 1/3 saline rest glucose 5%) adding K + 20-40
mmol/l = meq/l as soon as the child has passed urine.
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KCMC, PAEDIATRICS 7 SOME SPECIAL PROCEDURES IN PAEDIATRICS
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47 SOME SPECIAL PROCEDURES IN

PAEDIATRICS
47.1 OXYGEN THERAPY
GENERAL PRINCIPLES
Oxygen should be considered as a drug and only be given on the
right indication and in the right concentration! Especially to LBW
children, where retrolental fibroplasia is a major cause of blindness
and must be avoided.
OXYGEN ADMINISTRATION
LOW FLOW OXYGEN THROUGH A NASAL CATHETER
A flow of pre-warmed and humidified oxygen is passed through a
nasal catheter into the pharynx. The catheter should be inserted
several centimeters into the nose.
Flow of oxygen Fraction of oxygen in %

l/min
0.1 25
0.2 30
0.5 40
1.0 50
OXYGEN BY MASK
If loosely fitted and covering both nose and mouth almost 100%
oxygen can be given at 5 l/min. Oxygen by mask at some distance
is very unreliable and insufficient.
OXYGEN INTO A HEADBOX
A steadily high concentration can be achieved if oxygen is passed
into a head box kept over the head of the baby. The environmental
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oxygen concentration should be slightly above the concentration at
which the child becomes pale-cyanotic. If arterial blood gasses are
possible to measure: use this to conduct the therapy. More oxygen
(5 l/min) is consumed when given via a head box than when it is
given through a nasal catheter. Closely monitor the child and
reduce the amount of oxygen as the child gets better
47.2 PLEURAL TAP
 Choose the site. Best over stony dullness (but not into liver or
spleen). Posterior axillary line, around 6-8th rib space is often
suitable. Sitting position, if possible.
 Put in some local anaesthetic with a fine needle. Make a nick in
the skin with a scalpel blade.
 Take a 10 ml syringe with a 16-18 gauge needle, insert through
the nick incision, just above the margin of the rib, and push
gradually into the chest.
 Aspirate a little all the time. When the pleura are penetrated,
there is usually a sudden lack of resistance and the syringe will
fill with fluid.
 For tapping, a 3-way stopcock is needed.
 For drainage, insert instead a 12-16 French size catheter and
connect it for continuous suction, frequent intermittent
aspiration or for underwater drainage.
 As soon as the tap is finished, take out the needle and press a
swab on the puncture.
 Send the fluid for microscopy, staining for bacterial or/and
culture and biochemistry such as protein, LDH (if available).
47.3 PERICARDIOCENTESIS
INDICATIONS
 To collect pericardial fluid for diagnostic purpose.
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 To relieve tamponade, especially in case of suppurative
pericarditis.
TECHNIQUE
PREMEDICATION
30 minutes before the puncture, give:
Atropine sulfate 0.015 mg/kg SC

Pethidine 1 mg/kg IM
Do not give diazepam in tamponade: risk of circulatory collapse.

PROCEDURE AND FOLLOW UP
 The child should be lying supine, head and shoulder at an
angle of 45°.
 Site of puncture is just below the tip of xiphoid process. Infiltrate
with local anaesthetics.
 Take a 10 ml syringe with a 16-18 gauge needle and insert
perpendicularly to the skin, go through the muscle layer, direct
the needle in the direction of the left shoulder.
 Aspirate. When passing the pericardial sac there is a "give in"
feeling and the syringe will fill with fluid.
 For drainage (only at central level) insert a catheter and
connect it to continuous suction (5-10 cm H 2O).
 Send the fluid for microscopy, staining for bacteria or/and
culture and biochemistry (if possible).
 If ultrasound is available a parasternal/precordial puncture-site
can be selected.
47.4 PERITONEAL TAP/INFUSION

A peritoneal tap is done for analysis of ascites or for removal of
lager amounts of ascites. In exceptional circumstances
intraperitoneal infusions may be indicated if the IV route is
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impossible. In particular in case of shock the intraosseous route is
preferable if strict asepsis can be guaranteed, see 47.8. The site
could be at the midline or at a point two-thirds of the way along a
line between the umbilicus and the anterior superior iliac spine.
 The child is placed in a sitting or a lateral decubitus position.
 Clean the area at puncture site.
 Inject local anaesthetic at the puncture site.
 For aspiration a needle attached to a 20 ml syringe may be
enough but to remove larger quantities of fluid a trocart is
needed to make a hole large enough to insert a catheter.
 When the catheter is removed a butterfly tape or single suture
is used to close the wound.
47.5 PERITONEAL DIALYSIS
INDICATIONS
• Symptomatic fluid overload (pulmonary
oedema/Hypertension).
• Severe electrolyte imbalance
- Hyperkalemia
- Severe acidosis
• Toxicity
- Drug/poisoning
- Metabolic – i.e. hyperammonemia
 Uremia
- Rising BUN, uremic pericarditis or encephalopathy
TECHNIQUE
• Patient should be comfortable in supine position.
• Empty the bladder.
• Determine appropriate site
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• Inject local anaesthesia in the insertion site lateral to the umbilicus
• 2cm transverse incision
– Skin
– Anterior Rectus Sheath
– Posterior Rectus Sheath
• Purse-string suture in peritoneum
• Incise peritoneum & place catheter over stylet
• Tunnel catheter exit site 2cm away
• Dwell catheter
• Close and secure to skin
PD PRESCRIPTION
• Optimal exchange volume range: 600-1400 mL/m 2BSA
– Lower range for infants and neonates
– Frequent target given is ~1100-1200 mL/m 2
• Lower volumes when early catheter use
• 300 mL/m2 for 7-10 days
• When prescribing by body weight
– Start at 5-10 mL/kg/exchange
– Neonates: 15-30 mL/kg/exchange
– Maintenance at 30-50 mL/kg/exchange
STANDARD PERITONEAL DIALYSIS SOLUTION

Three types of Dialysate solution with 1.5%, 2.5%, 4.25% dextrose
– Standard and low Ca++ and Mg+
– Closely monitor Ca++
– Low Mg+ used most often
(Glucose % can under tight control of the fluid balance be gradually
increased to 4.25% for quick removal of water, electrolytes and/or
certain poisons).
47.6 LUMBAR PUNCTURE
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 The child should lie on its side with the back near the edge of a
table. An assistant flexes the spine by applying pressure
between the scapulae (not at the neck) and in popliteal fossae.
 Check the position of the back. It should be vertical to the floor
with a maximum arch in the lumbar area.
 Palpate the intervertebral space above L4. A line joining the
highest points of the two iliac crests passes just above L4.
 Clean the skin at the site of the planned puncture. Iodine.
 Stretch the skin slightly in order to make it seal of the puncture-
canal after removal of the needle.
 Insert a lumbar puncture needle perpendicular to the broad
plan of the back and slightly toward the patients head. When
the needle reaches the ligamentum flavum the stylet is
removed. Push the needle through the ligament and dura until
a "give" is felt and liquor drips from the needle.
 If the child is uncooperative, local anaesthesia may be given at
the puncture site. Neonates should sometimes be held in a
sitting position instead of lying down.
 The spinal fluid is collected into test tubes for microscopy and
estimation of sugar, protein. If possible some drops should fall
directly on a media for bacteriology.
 Remove the needle; cover the puncture site with a plaster for
some hours.
POSITION
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ANATOMY
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47.7 INTRAMUSCULAR INJECTION
 If possible give oral or intravenous treatment instead of

intramuscular.
 Before injecting, clean the skin with antiseptic solution.
 Use only sterile needles and syringes.
 Site of injection:
Lateral vastus muscle The injection should be made into

the middle part antero-lateral aspect of the thigh.
Do not inject close to the
knee joint.
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Ventral gluteal muscle The injection is made
between the index
and
middle finger
towards the iliac
crest at a
depth of 2-4 cm.
47. 8 INTRAOSSEOUS INFUSION

When it is difficult to set up an IV line quickly enough in an
emergency situation intra-osseous infusion may be used.
Substances are injected as rapidly as through intravenous routes.
The most common site for infusion is the tibia but also femur (lower
third) or iliac crest can be used. The medulla space serves as a
”noncollapsidal vein” and rapid infusions of crystalloid solutions,
blood products, resuscitation drugs, anticonvulsants, and antibiotics
can be done. Blood can also be taken from the marrow for
crossmatch and electrolyte estimation.
 The site for insertion of the needle is in the midline on the flat
surface of the tibia, about 2 cm below the tibial tuberosity. Do
not use a fractured bone.
 Use aseptic technique: clean the area, wrap with sterile towels
around if time allows, use gloves for the hands. Unless strict
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asepsis can be guaranteed during the entire transfusion the risk

of osteomyelitis remains substantial.
 Infiltrate with local anaesthetic at the puncture site and down to
the periosteum.
 Make a 2-3 mm skin incision with the scalpel over the puncture
site if time allows.
 A bone marrow needle with trocart is inserted in the incision
peripendicular to the bone but slightly away from the knee to
avoid the growth plate. Advance the needle through the bone
until it reaches the medullary cavity. A sudden lack of
resistance signals the entrance. A wide scalp-vein needle may
be tried in infants if bone marrow needle is not available.
 Remove the inner trocart and aspirate blood by using a 5 ml
syringe.
 Secure the needle in place with sterile gauze.
 Give boluses of fluid using even 50 ml syringes to push the fluid
in gently. Watch for subcutaneous swelling.
 The needle can be connected to drip but should be replaced by
an ordinary IV soon to reduce the risk of infection.
47.9 GASTRIC LAVAGE

 The patient should have a gag reflex. If not, perform
endotracheal intubation first.
 Immobilize child in a sheet.
 Place the child on its left side, with the head down.
 Insert largest calibre possible through "protector" (plastic ring to
prevent child from biting the lavage-tube).
 Lavage with large quantities of lukewarm water about 50-
100 ml each time for 5-6 times.
 Leave charcoal behind.
47.10 GRAM STAIN (HUCKER MODIFICATION)
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METHOD
 Fix smear by heat.
 Cover with crystal violet for 1 minute.
 Wash with water. Do not blot.
 Cover with Gram's iodine for 1 minute.
 Decolourize for 10-30 seconds with gentle agitation in acetone
(30 ml) and alcohol (70 ml).
 Lower for 10-30 seconds with safranin (2.5% solution in 95%
alcohol).
 Wash with water and let dry.
RESULT
COLOUR
 Gram pos
purple-blue organism
 Gram neg
red
POINTERS
 Gram pos cocci in pair
Pneumococci
 Gram pos cocci in chains
Streptococci
 Gram pos cocci in cluster
Staphylococci
 Gram neg rods

Enterobacteria, E. coli
 Gram neg small cocco-bacilli
Haemophilus influenzae
 Gram neg intracellular
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diplococci Meningococci
47.11 STAINING OF M. TUBERCULOSIS AND OTHER

ACID FAST BACILLI (ZIEHL-NEELSEN)
Tubercle bacilli and other AFB must be stained with a powerful
stain which will be retained when other material and organisms
are decolourized by acid. There are many variations of the Ziehl-
Neelsen method of staining and counterstaining. The following is
recommended by Cruikshank:
 A film is made from sputum, pus or centrifuged pleural or
peritoneal fluid, urine or CSF. It is dried and fixed by flaming
and placed on a rack.
The slide should be new or well cleaned and staining jar should
not be used.
 Cover the slide with strong carbol-fuchsin and warm until it
steams but does not boil or dry up. Continue staining with warm
dye for five minutes, adding more dye if necessary, keeping the
whole slide covered. Then wash with water.
 Cover the slide with 20 percent alcohol sulphuric acid. After a
minute wash and pour on more acid and repeat this until the
film looks only faintly pink. Then wash again in water.
 Cover slide with 95 percent alcohol for two minutes. This step
decolourises organisms which are not alcohol fast and should
always be done if urine is being examined. Tubercle bacilli are
both acid and alcohol fast.
 As an alternative to the steps with sulphuric acid and 95
percent alcohol 3 percent hydrochloric acid in industrial spirit

(95 percent alcohol) may be used. Wash with water.
 Counterstain with methylene blue for 15-20 seconds. Wash,
blot with clean paper and dry. Examine with oil immersion lens.
329
KCMC, PAEDIATRICS 48 PAEDIATRIC DRUG DOSAGE
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48 PAEDIATRIC DRUG DOSAGE

48.1 DOSAGE PER KILOGRAM BODY WEIGHT
 Most of the recommendations given in this manual are based
on mg/kg/day. If you are not familiar with this kind of dosage-
calculation, use the guidelines below, step by step. The
prescription to the nurse or the mother must be simple and
absolutely clear.
 Multiply the figure for the recommended dose mg/kg/day with
the figure for the child's body weight. Now you have the total
dose/day.
 Divide this figure by the number of doses for one day.
Now you have the amount to be given every time the child
shall have this medicine.
 Prescribe this dose in a simple way, using whole, half or
sometimes, if possible, a quarter of a tablet or teaspoon(s) for
liquid.
 For intramuscular or intravenous injection the dose must be
more exact in ml.
 Also the time when the medicine shall be distributed must be
clearly stated.
EXAMPLE
A child, weighing 13 kg, is going to take Nitrofurantoin tablets (only
100 mg tablets are available). The recommended dose is 3 mg/kg/
day, in 2 doses orally.
 Multiply with body weight 3 x 13 = 39 mg/d
 Divide by number of doses 39 : 2 = 19,5 mg
 Prescription: 1/4 tablet (= 25 mg) 2 times daily, 8 am and 8
pm.
48.2 DOSAGE PER M2 BODYSURFACE

Some doses of drugs and intravenous fluids can best be
calculated from body surface. Body surface relates directly to
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metabolism and % adult dose. Body surface can be estimated
from kg bodyweight and height as follows:
Draw a line through the child’s height (left side) and weight (right
side). The Surface Area in square metres can be read at the
intersection of this line with the S-A line. For instance a child with
height 133 cm and weight 28 kg will have a (body) Surface Area of
approximately 1 square metre. The normal body surface area at
birth, at age 18 mo, at age 9 years, in adults approximates: 0.2,
0.5, 1, respectively 1.73 square metres.
48.3 DOSAGE FOR CHILDREN COMPARED TO ADULTS
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(Simplified)
 10 kg  15 kg  25 kg  35 kg
0 - 1 yr. 1-3 yr. 3-7 yr. 7-12 yr. > 12 yr.
1/8 dose 1/4 dose 1/3 dose 1/2 dose Full adult dose
If you only know the dose for adults, use the rough
recommendations above.
48.4 DRUG LIST

Only common doses are given below. For full information in
special treatments see relevant chapters.
Usually mg/kg/d (d =day!) as in Acetosalicylic acid. Sometimes
mg/kg/dose as in Adrenaline.
Drug Indication/ Dosage Special Notes, Adverse

Route Reactions,
Contraindications
Analgesic dose: 30-50 mg/
Acetylsalicyli oral kg/day in 4 doses Risk of Reye’s syndrome
c acid Rheumatic disease: 80- in children below
(Aspirin) 100 mg/kg/day in 2-3 12years
doses
0.015 mg/kg/dose. May be
Adrenaline Sc/ spray repeated.
(Epinephrine) See 24.6
Taenia Solium, For Taenia/cysticercosis: Common reactions:

Albendazole Hydatid 15 mg/kg/day divided BD x abnormal LFTs,
Disease, 8-30 days; abdominal pain, nausea
Hookworm, For hydatid cyst disease:
Pinworm, 15mg/kg/day x 1-6 months;
Ascaris For Hookworm,
Pinworm, Ascaris: 400 mg
po x 1
Strongyloides: 400mg bd
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x3days
Apnea: Loading dose: 5  Serious reactions:

Aminophylline Apnea of mg/kg stat, then 2.5 mg/kg/ seizures, arrythmias
prematurity dose BD  Common reactions:
Asthma (when Asthma: Loading dose 6 diarrhea, irritability,
not responding mg/kg iv slowly over 20 restlessness
to Salbutamol) minutes; maintenance =
0.9 mg/kg/hour iv
15 mg/kg/dose tds for

Amoxycillin Bacterial bacterial infxns; 25
infections, mg/kg/dose BD for
(pneumonia, pneumonia; 80-90
otitis media, mg/kg/day divided BD for
etc) otitis media
Normal dose: 100

Ampicillin Bacterial mg/kg/day divided QID;
infections, High/Meningitic dose: 200-
including 300 mg/kg/day divided QID
meningitis
 NOT for children
Artemether/ Uncomplicated 5-<15 kg 1 tab BD x 3days; weighing less than 5 kg!
Lumefantrine malaria 15-<25kg 2 tabs BD x 3 Note: On day 1, doses
days; one and two should be
25-<35 kg 3 tabs BD x 3 given 8 hours apart; then
days; BD on second and third
≥ 35 kg 4 tabs BD x 3 days day
Atropine IV 0.01- 0.03 mg/kg at once.
sulphate See also 42.6
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Captopril Hypertension, Neonates: Start 0.01-0.05 Common reactions:

CCF mg/kg/day divided BD- Hyperkalemia,
QID; hypotension
Infants and children below
12years:
Start 0.15-0.3 mg/kg/dose
divided BD-QID
(max 6 mg/kg/day);
Children>12year:
12.5-25mg BD or TDS
(max 150mg/day)
Serious 50-75 mg/kg/day given OD Use with caution in

Ceftriaxone bacterial for bacterial infections; 100 neonates, as it can
infections, mg/kg/day OD for displace bilirubin from
including meningitis protein binding sites,
meningitis leading to
hyperbilirubinemia
Chloral hydrate Indication: for 30-50 mg/kg/dose. May be

sedation repeated.
50-75 mg/kg/day divided  Typically not used

Bacterial QID for bacterial in children less than one
Chloramphenicol infections, infections; month (and if so, dosing
including 100 mg/kg/day divided will be lower  consult
meningitis QID for meningitis neonatologist).
 Serious reactions::
aplastic anemia, gray
baby syndrome
Chloroquine Sickle cell 5mg/kg weekly

disease
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Oral Severe pneumonia,
Clindamycin osteomyelitis: 20-40
mg/kg/d in 4 doses
Maintenance
osteomyelitis:
10-20 mg/kg/d in 3 doses
Complicated For UTI: 6-10 mg/kg/day  Use with caution in

Ciprofloxacin UTI, serious iv BD, or 10-20 mg/kg po pediatric patients due to
bacterial BD; for serious bacterial concern of possible
infections infections: 20-30 cartilaginous damage
mg/kg/day divided BD
(max 400mg/day)
Cloxacillin Serious 50-100 mg/kg/day in 3 Exception:

bacterial divided doses Newborns in first week of
infections life: 50mg/kg/dose BD;
Particularly 2nd week and thereafter:
good against 50mg/kg/dose TDS
staphylococcus
Mild to Neonate 0.5-1mg/kg , 4-6 Contraindicated in acute

Codeine moderate pain/ hrly. respiratory
phosphate orally Child 1 month-12 yrs 0.5-1 deoression,paralytic
/rectally/sc/im. mg/kg, max. 240 mg daily. ileus,raised intracranial
Child >12 yrs 30-60 mg/kg, pressure or head injury
max 240 mg daily. and
phaeochromocytoma.
Bacterial Mild bacterial infections:  Serious reactions:

infections, 8-10 mg/kg/day divided Stevens Johnson
336
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Cotrimoxazole prophylaxis in TDS of TMP component; Syndrome, aplastic
HIV+ patients, Prophylaxis in HIV+: 2-6 anemia, hepatitis
PCP mos: 120 mg OD; 6 mos-  Common reactions:
pneumonia 5 years 240 mg OD; 5-14 allergic rash, GI upset
years 480 mg OD; >14
120 mg = 100 years 960 mg OD; PCP
mg Sulfa and Pneumonia: 15-20 mg/kg/
20 mg TMP day of TMP component
divided TDS x 21 days
240 mg = 200
mg Sulfa and
40 mg TMP
480 mg = 400
mg Sulfa and
80 mg TMP
Cyclophospha oral Nephrotic syndrome:

mide Orally 3mnth-18 yrs 2-
(Endoxan) 3mg/kg once daily for
eight wks
IV 3months-18yrs 500mg/
m2 once a month for six
months. See chapter 11
on Some Common
Tumours.
Dexamethasone For severe Dosing for severe croup is  For use in other
croup 0.15 mg/kg/dose in 1-2 inflammatory disorders,
divided cerebral edema; discuss
doses,max0.3mg/kg/day. with a resident or
(oral or IM) consultant
Convulsions, Convulsions: 0.3-0.4  Serious reactions:

Diazepam sedation mg/kg IV(max 20mg) respiratory depression,
(Valium) Sedation: 0.1-0.3 mg/kg cardiovascular collapse
orally x 1 dose 45-60 min  Common reactions:
before procedure drowsiness, fatigue,
confusion
337
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Digoxin Supraventricula Maintenance dose is  Serious reactions:

r arrhythmias typically 0.01 mg/kg/day digitalis toxicity, severe
and CCF divided BD for children < bradycardia, AV block
10; children >10, 0.005  For rapid
mg/kg/day OD. Always digitalization consult
check dosing with a pediatric drug formulary
Consultant or Resident
Pertussis, 40-50 mg/kg/day divided  Serious reactions:

Erythromycin Atypical TDS infantile hypertrophic
pneumonia, an pyloric stenosis
alternative to  Common reactions:
penicillins in nausea,
penicillin- vomiting,diarrhoea, abd
allergic pain
patients.
Ephedrine oral 3 mg/kg/d in 3 doses

hydrochloride
Treatment : elemental iron  Common reactions:

Fe deficiency 3-6 mg/kg(max 200 mg) nausea, dyspepsia,
Ferrous Sulfate anemia,prophyl daily in 2-3 divided doses constipation.
axis in LBW for 4 months.  Overdose can be
babies, orally. Prophylaxis: in LBW fatal.
infants, start 4-6 weeks of
life : 5mg/kg/day of
elemental iron for 6
months.
Oral and Candida: 6 mg/kg x 1;  Serious reactions:

Fluconazole esophageal then 3 mg/kg OD x 7 –14 hepatotoxicity
candidiasis; days; Crypto mening: 12  Common reactions:
cryptococcal mg/kg po x 1; then 6 nausea, vomiting,
meningitis. mg/kg OD x 12 weeks abdominal pain,
Orally/IV. rash,elevated liver
enzymes
Folic Acid FA deficiency 5 mg/day for all ages x 2 Common reactions:

anemia; weeks for Fe deficiency nausea, abdominal pain
338
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hemolytic anemia; lifelong for
anemia, hemolytic anemia,
supplement in Preterm neonates 0.5 mg
preterm once weekly.
neonates
Common reactions:
Furosemide Edema, CCF. 0.5-1 mg/kg IV Hypokalemia, electrolyte
Route: orally /IV 1-2 mg/kg PO imbalances
5 mg/kg OD for children >  Serious reactions:

Gentamicin Bacterial 1 month; for neonates, Ototoxicity,
infections follow neonatal protocols nephrotoxicity
 Note: does NOT
penetrate CSF
10-20 mg/kg/day (max 1  Serious reactions:

Griseofulvin Tinea capitis gm) in 1 or 2 doses x 4-6 Hepatotoxicity
weeks (give with food)  Note: interacts with
many TB and ARV
drugs;
Hypertension, Hypertension:  Serious reactions:

Hydralazine Severe CCF 1mg/kg/day divided TDS; Hypotension
Severe CCF: 0.1-0.2  Common reactions:
mg/kg/dose headache, tachycardia
Child 1 month – I year; 25 Contraindicated in

Severe acute mg tds. systemic infections
asthma, Child 1-6 yrs; 50 mg tds unless specific
Hydrocortisone hypersensitivity Child 6-12 yrs; 100mh tds. antimicrobial therapy
reaction,, Child 12-18 yrs 100- given.
angioedema IV, 500mg tds Common side
IM effects;dyspepsia with GI
perforation,osteoporosis,
adrenal
suppression,cushing´s
syndrome.
Ibuprofen Pain, fever, 10 mg/kg/dose every 6-8  Serious reactions:

inflammation/ hours prn GI bleeding/ulceration,
orally. NEC, haemorrhage.
339
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Ascaris; 2.5-3mg/kg (max

150mg) as a single dose  Contraindicated in
Hookworm ; 2.5mg/kg blood disorders.
Ascariasis, (max 150mg) as a single  Use with caution in
Levamisole hookworm dose repeat after 7 days in epilepsy(can induce
(Ketrax) orally. severe infection. seizures)
Nephrotic syndrome
1mth-18yrs; 2.5mg/kg
(max 150) on alternate
days
Lidocaine  Use lower doses in

hydrochloride. IV Arrhythmia: Loading dose: CCF and hepatic failure.
1-1,5 mg/kg Maintenance  Use with ECG
dose: 0,03-0,05 mg/kg/min monitoring with
resuscitation equipment
available.
 Contraindicated in
AV block.
Pinworms, 100 mg BD x 3 days., a  Limited safety data

Mebendazole whipworms, second dose may be for children < 2 years
hookworms, given after 2 weeks
etc.
Methicillin IV, IM 200 mg/kg/d in 4 doses  For penicillinase

producing
staphylococcus.
Metrifonate oral 7.5 mg/kg/d once daily

(Bilarcil)
Metronidazole Bacterial 7.5 mg/kg/dose TDS Common reactions:

infections for bacterial infections; nausea,
(anaerobes), 10 mg/kg/dose QID vomiting,anorexia.
Giardia, for amebiasis; Avoid alcohol
Amebiasis 5 mg/kg/dose TDS x 5
days for giardia
340
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Morphine Moderate to 0.1-0.2 mg/kg/dose given Serious Reactions:

severe 4-6 hourly Respiratory depression
pain(especially Side effects;nausea,
of visceral vomiting constipation,
origin). drowsiness
Do not use in infants < 3

Uncomplicated 15 mg/kg/dose QID x months.
Nalidixic Acid UTI, Dysentery 7days Use with caution in
seizure prone children,
G6PDd.
Avoid excessive sunlight
exposure.
Avoid use with NSAIDs
LBW/premature infants: 1  Give after

Nystatin Oral thrush ml po qid feeds/meals
(100,000 Infants: 2 ml po qid  Duration: use for
units/ml) Children: 5 ml po qid 48 hours after symptoms
resolve
Reversal of 0.1 mg/kg/dose. May be  Use with caution in

Naloxone respiratory and repeated every 2-3 min. CV disease.
hydrochloride CNS Note: new dose, much  Side effects;
depression in higher than previously! hypotension,hypertensio
newborn n,ventricular tachycardia
following and fibrillation,cardiac
maternal opioid arrest,pulmonary
use during oedema,dyspnoea.
labour./IV,
IM,SC.
Niclosamide Tapeworm 30 mg/kg/day in one dose,  An antiemetic may

(Yomesan) infections/orally see 10.6 be given before and a
laxative 2 hrs after dose.
3-5 mg/kg/d in 2  Do not use in

Acute Treatment; 3mnth-12yrs infants < 3 months,
Nitrofurantoin uncomplicated 750micrograms/kg 4times G6PD deficiency
UTI, prophylaxis daily  Side effects;
of UTI 12yrs-18yrs 50mg 4times anorexia,nausea,vomitin
daily can increase to g and diarrhoea
100mg 4times daily in
severe infection.
Prophylaxis;1 mg/kg at
341
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night.
Oxamniquin oral 30 mg/kg/d in 2 doses
Urinary Orally: Child 2-5 yrs; 1.25-  Use cautiously in

frequency, 2.5 mg 2-3 times daily. CCF,hyperthyroidism,
urgency and Child 5-18 yrs ;2.5-3 mg arrhythmias and
Oxybutynin incontinence,Ne bid to 5mg 2-3 times daily. tachycardia.
hydrochloride urogenic Intravesical ;child 2-18 yrs  Avoid in
bladder 5 mg 2-3 times daily. myasthenia
instability./orally gravis,urinary
or intravesical. retension,GI obstruction.
Pain, fever/ by 15 mg/kg/dose every 4-6  Serious reactions:

Paracetamol mouth or hours prn dose related
rectally. hepatotoxicity!
 Avoid larger doses.
Neonate 0.4ml/kg (max  Given rectally

Status 0.5ml) causes little respiratory
epilepticus/ IM, 1-3mnth 0.5ml as a single depression; useful where
Paraldehyde rectal dose facilities for resuscitation
3-6mnth 1ml as a single are poor.
dose
6mnth-1yr 1.5ml as a
single dose
1-2yrs 2ml as a single
dose
2-5yrs 3-4ml as a single
342
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dose
5-18yrs 5-10ml as a
single dose
Pencillin G Bacterial 100,000 IU/kg/day in 4  For neonates,

(benzylpenicillin infections, divided doses for bacterial check neonatal protocols
) meningitis(IV/IM infections; 250,000
) IU/kg/day in 4 divided
doses for meningitis
0.05 million units/kg IM q

Benzathine Rheumatic 3-4 weeks; typically, for  Max: 1.2 million
Penicillin fever children < 5 years, give units per dose
prophylaxis(IM) 0.6 MU and for children >
5 years, give 1.2 MU
Penicillin V Group A Strep; 50 mg/kg/day divided TDS  For Rheumatic

Rheumatic for acute infections fever prophylaxis: < 5
fever yrs 125 mg BD; > 5 yrs
prophylaxis 250 mg BD
(oral)
Procaïne For early and 50.000-100.000 IU/kg/d in

penicillin late latent 1-2 doses
syphilis/IM
343
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1 mg/kg/dose every 4-6  The injection

Pethidine Moderate to hrs if required. solution can be given
hydrochloride severe acute IVI; dilute in 5% Dextrose orally.
Pain/ORAL/IM/ or Normal saline give by  Serious reactions:
SC/ IV/IVI. continous infusion of 0.1- CNS/respiratory
0.4 mg/kg/hr, adjusted depression
according to response.
10-15 mg/kg IV loading  Serious reactions:

All forms of dose, diluted in water for Respiratory depression,
Phenobarbital/ epilepsy except injection to a Stevens Johnson
Phenobarbitone absence concentration of 20mg/ml syndrome
seizures, Status slowly over 20 minutes;  Common reactions:
Epilepticus. / then 5 mg/kg/day po nocte drowsiness,
Oral/IV. (at least 6 hours after lethargy,hyperkinesias,m
loading dose) egaloblastic anaemia..
 Avoid sudden
withdrawal.
All forms of 4-8 mg/kg/d in 2 doses  Side effects: GI;

epilepsy except In status epilepticus: 15 nausea,
Phenytoin absence mg/kg over 20 min. See anorexia,vomiting,
sodium seizures, Status 15.6 constipation,
Epilepticus. Newborn: see 36.3 CNS:
Acute insomnia,parasthesia,tre
symptomatic mor,nervousness,headac
seizures he,dizziness.
associated with Gingival hypertrophy and
head injury or tenderness, acne,
neurosurgery/ hirsutism.
Oral/IV.
 Use with caution in

Piperazine Threadworms 50 mg/kg/d in 1-2 doses. epileptics.
orally See 10.6  Side effects; GI
upset, allergic urticaria,
bronchospasm.
Praziquantel Schistosomiasis 20 mg/kg/dose , followed Caution in children < 4.
344
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after 4-6 hrs by 20mg/kg Of all schistosomicides it
for 1 day. is the most attractive for
In S.japonicum 20 it has high effectiveness,
mg/kg/dose tds for 1 day. low toxicity and broad -
spectrum activity.
Prednisolone Asthma, acute 1-2 mg/kg/day divided BD  If used for longer

Juvenile than 5 days, dose should
Rheumatoid be tapered off.
Arthritis,
Nephrotic
syndrome.
Allergic conditions: 0.1  Should not be used

mg/kg/dose po QID; in children < 2 due to risk
Allergic Nausea/Vomiting: 0.25-1 of respiratory depression
Promethazine conditions; mg/kg/dose QID prn  Always start with
nausea/vomiting lower dosing due to risk
of respiratory depression
and extra pyramidal side
effects
HTN: 1-5 mg/kg/day  Serious reactions:

Hypertension, divided QID; TOF spells: Stevens Johnson
Propanolol Tetralogy spells 4-8 mg/kg/day divided QID syndrome
(start at 2-4 mg/kg/day,  Common reactions:
and increase to above as Fatigue, dizziness,
needed) bradycardia, weakness,
nausea, etc.
Severe or 10 mg/kg/dose TDS x 7  Serious reactions:

Quinine Sulfate resistant days QT prolongation,
(oral) (nonsevere) arrhythmias
malaria Common reactions:
headache, tinnitus,
vertigo
Quinine Severe or 10 mg/kg/dose in 5%  Serious reactions:

Dihydrochloride cerebral malaria dextrose, 8 hourly x 9 Hypoglycemia, and many
(IV) doses or until patient is others (see above)
able to take po quinine
Salbutamol Asthma/ 2 puffs with spacer, 3-4 Common reactions:

Inhaler Reactive Airway times daily tremor, nervousness,
Disease tachycardia
345
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Streptomycin Resistant TB in 20 mg/kg/day in one daily  Dose related side
sulphate combination with dose (max 1 g) effects:
other drugs, ototoxicity,nephrotoxicity
adjunct to especially in kidney
doxycycline in failure patients.
treatment of Avoid use with ototoxic
brucellosis./IM diuretics-furosemide
Child 6 months -2yrs;  Side effects;

Theophylline Bronchodilator 12mg/kg every 12 hrs. tachycardia,palpitations,
in Chronic 2-6 yrs; 60-120mg/kg GI upset,
asthma every 12 hrs headache,insomnia and
management. 6-12 yrs; 125-250 mg convulsions(IV)
Orally. every 12 hrs  Caution in cardiac
12-18 yrs; 250-50 mg disease,HT,hyperthyroidi
every 12 hrs. sm,PUD, fever and
epilepsy.
Thiabendazole Orally for 50 mg/kg/day in 2

(Tiabendazole) strongyloidiasis doses(max 1.5 g)for 2-3  It is given to
and Cutaneous days, or 7 days in children over 1 month.
larva migrans disseminated infection.
Amoebiasis;
Orally for 50-60 mg/kg/day in one
Tinidazole intestinal daily dose (max. 2g) for 3
amoebiasis, days.  Gi side effects,oral
amoebic liver Amoebic liver abscess; mucositis.
involvement, 50-60mg/kg od for 5 days.
giardiasis and Trichomoniasis and
urogenital giardiasis; single dose of
trichomoniasis 50-75mg/kg (max 2gm)
repeat once if necessary.
Cholera 25-50 mg/kg/day in four  Note: Not for use

Tetracycline Chlamydia divided doses (for cholera, in children below12 yrs
Acne vulgaris treatment is 3d) due to deposition in
growing bone and teeth
causing dental staining.
Severe acute (<6 mos): 50,000 units po  Note: Make sure
346
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Vitamin A malnutrition (Wt/ OD x 2; (6-11 mos): patient has NOT
Ht <70%), 100,000 units po OD x 2; received in the previous
measles, or (>12 mos): 200,000 units 6 months!
other reason to po OD x 2
suspect vitamin
A deficiency
Vitamin K Neonatal Neonates: 1 mg, LBW: 0,5  IV should be

prophylaxis of mg avoided because of risk
vitamin-K Hypoprotrombinaemia: 0,5 of vascular collapse.
deficiency mg/kg/d or less
bleeding,
treatment of
haemorrhagic
disease of
newborn,
neonatal biliary
atresia and liver
disease. IM, oral
Zinc sulphate. Diarrhea (<6 mos) 10 mg (1/2 tab) Rarely any adverse
monohydrate. Malnutrition. OD x 10-14 days; events at recommended
(Paediatric Zinc (>6 mos) 20 mg (1 tab) dosages
tablets) OD x 10-14 days
**This drug list is not meant to be a comprehensive list, nor are all indications/side effects
listed. Medical students should always consult with a senior before filling in medication lists or
writing prescriptions.
**For neonates, always follow neonatal guidelines where differences exist between this list and
Neonatal protocols. Refer section 38 for neonatal dosages of common drugs
347
KCMC, PAEDIATRICS 49 CHARTS
AND TABLES
______________________________________________________________________________________
49 CHARTS AND TABLES

49.1 OBSERVATION - FLUID BALANCE CHART
348
AND TABLES
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49.2 INTRA-UTERINE GROWTH CHART
Reference: Lubchenco. University of Colorado Medical Centre.
349
AND TABLES
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49.3 SOME NORMAL LABORATORY VALUES IN CHILDREN

P = plasma, S = serum
Albumin (P) g/100 ml newborn 2-3.5

infant + child 4-5.3
Alkaline phosphatase U/l method-dependent,

total growing children 3-4 x adult values
ALAT = GOT (S) method-dependent, in general around adult values
ASAT = GOT (S) method-dependent, in general infants and

young children 1½-2 x adult values
Bilirubin (S) mg/100 ml Newborn day 1: < 6

day 2-5: < 12
> 10 days: < 1, 20% of which is conjugated
Calcium (S) newborn 8-12

mg/100 ml infants + children 9-11
Cerebral Spinal Fluid

cells/mm3 newborn < 25 mononuclear
< 10 polynuclear
< 1000 RBC
infants + children <5 mononuclear
<½ polynuclear
rare RBC
- protein mg/100 ml newborn day 1: 40-250

week 1: 40-120
> 10 days: 20- 45,
- glucose mg/100 ml 75% of serum glucose
Chloride (S,P) mmol=meq/l 98-100
Creatinine (S) mg/100 ml newborn 0.8-1.4

infant 0.2-0.4
child 0.3-0.7
E.S.R. < 10 mm/hour
Glucose mg/100 ml newborn day 1: 40-60

week 1: 50-90
infant + child 60-100
Haemoglobin g/100 ml newborn< 2 w: 13-20

infant 3 mo: 9-14
> 6 mo-6 yr.: 10-14
> 6 yr.: 11-16
Leucocytes (WBC) day 1: 9-30

x 1.000/mm3 month 1: 5-20
1-7 yr.: 6-16
> 7 yr.: 5-12
mean diff%
bands first days of life: 10%
thereafter < 5%
350
AND TABLES
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segm first 5 days > 50%

day 5-5 yr.: < 40%
> 5 yr.: 50-55%
lymphocytes first 5 days < 40%

day 5-5 yr.: 50-60%
> 5 yr.: 35-40%
monocytes around 5%
Platelet count > week 1 = adult 150-400

x 1.000/mm3
Reticulocyte count newborn day 1: < 6% (percentage nucleated RBC may be even higher)
as % RBC first 2 months: < 3%
later on: < 2%
Sodium (S) mmol=meq/l 135-145
Urea nitrogen (P,S) mg/ newborn > 1 week: < 12

100 ml thereafter: < 18
Potassium (S) mmol=meq/l 3.5-5.5
351
AND TABLES
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49.4 BLOOD PRESSURE

If the blood pressure cuff is too wide, too low readings will be the result; too narrow a cuff will produce
too high readings. The widths of the cuff should cover about 2/3 of the length of the upper arm. The
appropriate cuff for children is about 9 cm wide. If you cannot get hold of an officially manufactured
one you may make a textile cuff of this size yourself and just fold the rubber balloon from an adult type
blood pressure cuff double over its full length.
Average blood pressure readings depending on age:
Age Mean Systolic Mean Diastolic
+ 2SD + 2SD
1 month 80 + 16 46 + 16
6 months to 1 year 89 + 29 60 + 10
1 yr. 96 + 30 66 + 25
2 yr. 99 + 25 64 + 25
3 yr. 100 + 25 67 + 23
4 yr. 99 + 20 65 + 20
5 yr. 94 + 14 55 + 9
6 yr. 100 + 15 56 + 8
7 yr. 102 + 15 56 + 8
8 yr. 105 + 16 57 + 9
9 yr. 107 + 16 57 + 9
10 yr. 111 + 17 58 + 10
11 yr. 113 + 18 59 + 10
12 yr. 115 + 19 59 + 10
13 yr. 118 + 19 60 + 10
From Nadas A: Paediatric Cardiology, 2nd ed. Saunders, 1963. In this study the point of
muffling was taken as the diastolic pressure.
352
AND TABLES
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353
AND TABLES
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49.5 PULSE RATE

Average pulse rate depending on age:
Age Lower limits Average rates at rest/ Upper limits

min
Newborn 70 120 170
1-11 months 80 120 160
2 yr. 80 110 130
4 yr. 80 100 120
6 yr. 75 100 115
8 yr. 70 90 110
10 yr. 70 90 110
12 yr. 65 90 110
14 yr. 60 85 105
354
AND TABLES
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49.6 HEADCIRCUMFERENCE BOYS
355
AND TABLES
______________________________________________________________________________________
356
AND TABLES
______________________________________________________________________________________
49.7 GROWTH CHARTS AND TABLES
357
AND TABLES
______________________________________________________________________________________
358
AND TABLES
______________________________________________________________________________________
359
AND TABLES
______________________________________________________________________________________
360
AND TABLES
______________________________________________________________________________________
361
AND TABLES
______________________________________________________________________________________
362
AND TABLES
______________________________________________________________________________________
363
AND TABLES
______________________________________________________________________________________
364
AND TABLES
______________________________________________________________________________________
365
AND TABLES
______________________________________________________________________________________
366
AND TABLES
______________________________________________________________________________________
367
AND TABLES
______________________________________________________________________________________
368
AND TABLES
______________________________________________________________________________________
369
AND TABLES
______________________________________________________________________________________
370
AND TABLES
______________________________________________________________________________________
371
AND TABLES
______________________________________________________________________________________
372
AND TABLES
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373
AND TABLES
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374
AND TABLES
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375
AND TABLES
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376
AND TABLES
______________________________________________________________________________________
377
AND TABLES
______________________________________________________________________________________
378
AND TABLES
______________________________________________________________________________________
379
AND TABLES
______________________________________________________________________________________
380
AND TABLES
______________________________________________________________________________________
381
AND TABLES
______________________________________________________________________________________
382
AND TABLES
______________________________________________________________________________________
383
AND TABLES
______________________________________________________________________________________
49.9 WHO DIARRHOEA MANAGEMENT CHART PLAN A
 3. CONTINUE FEEDIND
 4. WHEN TO RETURN
384
AND TABLES
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49.9 WHO DIARRHOEA MANAGEMENT CHART PLAN B
1. Give extra fluid

2. Give zinc supplements
3. Continue feeding SEE TREATMENT PLAN A
4. When to return
49.9 WHO DIARRHOEA MANAGEMENT CHART PLAN C
385
AND TABLES
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49.10 TANZANIA VACCINATION SCHEDULE
386
AND TABLES
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at birth 1 mo 2 mo 3 mo 9 mo* 1 yr.* 6-7 yr.
BCG X X
If no scar
DPT-HB-Hib X X X X X
Polio X X X X X
Measles X
* at the age of 9 months and 12 months 100.000 U Vitamin A are given orally
PREVENTION OF NEONATAL TETANUS

Make sure every non-immunized woman in the reproductive age is vaccinated. Non-immunized
pregnant women should be
vaccinated at least twice. Consider giving 750 U ATS to newborn if non-immunized mother born under
less hygienic circumstances.
387
AND TABLES
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49.11 WHO PEDIATRIC CLINICAL STAGING OF HIV/AIDS
388
AND TABLES
______________________________________________________________________________________
49.12 PMTCT REGIMEN
389
AND TABLES
______________________________________________________________________________________
(NACP GUIDELINES 2008)
390
AND TABLES
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MINIMUM ANTIRETROVIRAL REGIMENS TO PREVENT MTCT
391
PAEDIATRICS, KCMC 50 NEONATAL RESUSCITATION
___________________________________________________________
50 NEONATAL RESUSCITATION
(ADAPTED FROM THE APP TEXTBOOK OF NEONATAL
RESUCITATION, 5TH EDITION)
Neonatal resuscitation should be planned for before the delivery of any
baby. Anticipation and preparation are as important as the resuscitation
itself.
50.1 BASIC EQUIPMENT NEEDED

Manikin/blanket Oxygen tubing
Radiant warmer Oxygen mask
Gloves Oxygen source
Bulb syringe/suction device Laryngoscope
Suction tubes Endotracheal tube
(Size 8-9 and 3.5FG) (Size: Term 14FG, Pre 12fr)
Stethoscope Clock (showing seconds)
Shoulder roll Syringes
Towel to dry baby Ambu bag
50.2 DRUGS FOR RESUSCITATION

 Epinephrine: IV 0.01-0.03mg/kg/dose.
 Naloxone: IV or IM 0.1mg/kg (for reversal of opiate induced
respiratory depression in cases where mother was given opioid
anesthetic agent. Repeat dose every 2-3 minutes as needed. May
need to repeat every 1-2hours)
 10% glucose solution (can be made by mixing 1 part 50% glucose
solution with 9 parts of 5% glucose solution)
389
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50.3 PROCEDURE
Like all resuscitation, neonatal resuscitation follows the basic ABC
protocol
Airway (position and clear)
Breathing (stimulate to breath)
Circulation (assess heart rate and colour)
Drugs
Knowledge of the newborns gestational age, muscle tone, breathing and

the characteristics of the amniotic fluid are helpful in the resuscitation but
time should not be wasted on these delaying the actual resuscitation.
STEP A (Airway):
o Provide warmth
o Position the head to open the airway; clear the airway as
necessary
o Dry the skin, stimulate the baby to breathe, and reposition the
head to open the airway.
o Evaluation: After about 30 seconds, evaluate heart rate, breathing
and colour. If the newborn is not breathing adequately (has
apnoea or is gasping), has a heart rate of <100bpm, or appears
blue (cyanotic), proceed to step B.
o
STEP B (Breathing)
o If the baby has apnoea or Heart rate<100 bpm, provide positive
pressure ventilation. If cyanotic, you may give supplemental
oxygen.
o Evaluation: After about 30 seconds of ventilation and/or
supplemental oxygen, evaluate the newborn again. If the heart
rate is <60 bpm, you proceed to step C.
390
___________________________________________________________
STEP C (Circulation):
o You support Circulation by starting chest compressions while
continuing positive pressure ventilation.
o Evaluation: After about 30 seconds of chest compressions and
positive pressure ventilation, you evaluate the newborn again. If
the heart rate is still below 60bpm, you proceed to step D.
STEP D (Drug):
o You administer epinephrine as you continue positive-pressure
ventilation and chest compressions.
o Evaluation: If the heart rate remains below 60bpm, the actions in
step C and D are continued and repeated.
SEE SCHEMA ON FOLLOWING PAGE
391
___________________________________________________________
392
INDEX
Note: * Diseases as well as main symptoms and procedures
can be used as an entry.
* The pagenumbering referred to in this index regards the
page at which the chapter or paragraph starts.
A
Abdominal mass 41.8,p 263
Age -weight-height table 49.7, p 357
AIDS 8, p 40
Amoebiasis 2, p 6
Anaemia 12, p 75
Anaphylactic shock 45.2, p 307
Apgar score 34.2, p 224
Apnoea of the premature 35.3, p 228
Appendicitis 41.6, p 260
Arthritis, septic 29, p 187
Ascaris lumbricoides, treatment 10.6, p 61
Ascites and hepato- or splenomegaly 26, p 170
Ascites in TB 4.4, p 19
Asphyxia newborn 34, p 223
Asthma 24, p 160
B
Bacterial infections newborn 38, p 236
Bloodpressure, normal values 49.4, p 352
Bloodtransfusion, indications 12.6, p 79
Bone pain in osteomyelitis 29.3, p 189
Bradycardia 19.6, p 137
Bronchial asthma 24, p 160
Bronchiolitis 24, p 160
Burkitt’s Lymphoma 11.1, p 66
Burns 43, p 285
C
Cardiac arrhythmias 19, p 131
Cardiogenic shock 45.2, p 307
Cardiopulmonary resuscitation 50, p 389
Care of the newborn 32, p 208
Cephalhematoma 32.3, p 210
Cerebral malaria 9, p 51
Cerebral palsy 16, p 115
Cholera, antibiotics in 3.6, p 16
Chorea in rheumatic fever, 20.5, p 140
Chorea-(athetosis) in CP, 16.3, p 117
Cleft palate, lip 41.10, p 265
Coma 44a, p 295
Congenital clubfoot 41.20, p 270
Congestive cardiac failure 19a, p 131
Convulsions newborn 36, p 232
Convulsions, seizures 15 p 104
Cryptococcal meningitis 8.6, p 46
Cryptorchism 41.19, p 270
Cyanotic heartdisease 41.14, p 267
Cystitis, 31, p 203
D
Dehydration, degree of 3 p 12
Diabetic coma 44b, p 302
Diaphragmatic hernia 41.12, p 266
Diarrhoea, management plan WHO 49.9 ,p 381
Diarrhoea, persistent 3.2, p 11
Diarrhoea with blood 3.2, p 10
Diarrhoea with fever 3.2, p 10
Diarrhoea without blood 3.2, p 11
Diarrhoeal diseases 3, p 10
Digitalis, digitalis toxicity 19a.6, p 135
Diphtheria 22, p 146
Drugdosage for children 48, p 331
Druglist 48.4, p 333
Dysentery, amoebic 2.3, p 6
E
Eczema 28.3, p 181
Empyema, lung abscess 23.6, p 158
Enterobius vermicularis, treatment 10.6, p 61
Epiglottitis, acute 22, p 146
Epilepsy 15, p 104
Exchange transfusion 40.5, p 247
Eye diseases 17, p 121
Eye injuries 17.6, p 125
F
Fallot tetralogy 41.14, p 267
Febrile convulsions 15.2 p 104
Febrile convulsions, management 15.6 p 112
Fever combined with hepato- or splenomegaly 26, p 170
Fever of unknown origin, AIDS 8, p 40
Fever of unknown origin, Otitis media 18, p 127
Fever of unknown origin, Osteomyelitis 29, p 187
Fever of unknown origin, TB 4, p 18
Fever of unknown origin, UTI 31, p 203
Fungal infections skin 28, p 184
G
Gastric lavage 47.9, p 327
Gastrointestinal haemorrhage 41.7, p 261
Gastroschisis 41.16, p 269
Giardiasis, antiprotozoica for 3.6, p 17
Glomerulonephritis 30, p 193
Glue ears 18, p 127
Gonorrhoeic conjunctivitis neonate 17.2 p 121
Gram stain 47.10, p 328
H
Haemolytic Jaundice 25, p 165
Haemorrhage, gastrointestinal 41.7, p 261
Head circumference boys 49.6, p 355
Head circumference girls 49.7, p 356
Helminthiasis 10, p 57
Hepatic failure 27, p 174
Hepatitis 25, p 165
Hepatomegaly 26, p 170
Hepatosis 25, p 165
Hookworm, treatment 10.6, p 61
Hydrocephalus 41.21, p 272
Hyperkalaemia, treatment 30.6, p 198
Hyperpyrexia in malaria 9.6, p 55
Hypertension, renal 30.3, p 194
Hypertension, renal,treatment 30.6, p 196
Hypoglycaemia in malaria 9.3 p 56
Hypoglycaemia in malnutrition 13.6, p 85
Hypoglycaemia in pertussis 5.3, p 29
Hypoglycaemia, malaria,treatm. 9.6, p 56
Hypoglycamia in SFD newborn 33.2, p 217
Hypokalaemia, treatment 27.6, p 177
Hypoplastic anaemia, treatment 12.6, p 79
Hypospadia 41.18, p 270
Hypothermia in malnutrition 13.6, p 86
Hypovolemic shock 45.6, p 310
I
Ileus, newborn 41.3, p 254
Ileus, obstructive infants/children 41.4, p 256
Ileus, paralytic in peritonitis 41.5, p 258
Impetigo 28, p 179
Intestinal haemorrhage, typhoid fever 1.6, p 4
Intestinal obstruction infant child 41.4, p 256
Intestinal obstruction newborn 41.3, p 254
Intestinal perforation,typhoid fever 1.6, p 4
Intoxications 42, p 279
Intramuscular injection 47.7, p 325
Intraosseous infusion 47.8, p 326
Intrauterine growth chart 49.2, p 349
Intravenous fluid therapy 46, p 313
Intussusception 41.4, p 256
J
Jaundice combined with hepato- or splenomegaly 26, p 170
Jaundice infants, children 25, p 165
Jaundice newborn 40, p 244
K
Kwashiorkor 13, p 84
L
Laboratory values (normal) 49.3, p 350
Liver abscess, amoebic 2.3, p 7
Loefler syndrome, treatment 10.6, p 64
Low birth weight infants 33, p 215
Lower airway obstruction 24, p 160
Lumbar puncture 47.6, p 323
Lymphadenitis in diphtheria 22.3, p 147
Lymphadenitis in tonsillitis 21, p 144
Lymphadenitis TB 4, p 18
Lymphadenopathy combined with hepato- or splenomegaly 26,p 170
Lymphadenopathy, generalised in AIDS 8.3, p 42
M
Malaria 9, p 50
Malignancies, common tumours 11, p 65
Marasmus 13, p 82
Measles 6, p 32
Meconium aspiration 35.4, p 230
Meningitis 14, p 96
Meningitis newborn 38, p 236
Meningocele 41.22, p 170
Myelomeningocele 41.21, p 274
Myocarditis in typhoid fever 1.6, p 4
N
Necrotizing enterocolitis newborn 39, p 242
Neonatal respiratory disorders 35, p 226
Neonatal tetanus 37, p 233
Nephrosis 30, p 193
Nephroblastoma 11.4, p 70
O
Obstructive jaundice 25, p 166
Oedema in CCF 19, p 131
Oedema in Kwashiorkor 13.3, p 83
Oedema, renal 30.3, p 194
Oesophageal atresia 41.11, p 265
Omphalocele 41.15, p 268
Ophthalmia neonatorum 17.2, p 121
ORS in diarrhoea 3.4, p 14
ORS in PEM + diarrhoea 13.6, p 87
Osteomyelitis 29, p 187
Otitis media 18, p 127
Oxygen therapy 47.1, p 318
P
Paediatric surgery 41, p 251
Papular urticaria 28, p 180
Patent ductus arteriosus 41.13, p 267
Pericarditis, suppurative 41.2, p 252
Peritoneal dialysis 47.5, p 321
Peritoneal infusion 47.4, p 321
Peritoneal tap 47.4, p 321
Peritonitis 41.5, p 258
Pertussis 5, p 28
Phototherapy 40.5, p 247
Pierre Robin syndrome, 35.4, p 229
Pleural tap 47.2, p 319
Pneumocystis jiroveci (carinii) pneumonia 8.6, p 47
Pneumonia 23, p 151
Pneumothorax,newborn 35.4, p 230
Poisoning 42, p 279
Preterm, premature 33, p 215
Protein Energy malnutrition 13, p 82
Prune belly syndrome 41.17, p 269
Pulse rate, normal values 49.5, p 354
Pyelonephritis 31, p 203
Pyloric stenosis 41.4, p 256
R
Rabies 7, p 36
Rehabilitation, Community Rehab.Programme 16.7 p 120
Rehydration in diarrhoea 3.3, p 12
Renal failure 30, p 193
Respiratory distress syndrome 35.2, p 227
Resuscitation newborn 50, p 389
Rheumatic fever 20, p 139
Rheumatic heart disease 20, p 139
S
Scabies 28, p 180
Schistosomiasis, treatment 10.6, p 60
Seizures, convulsions 15 p 104
Septic arthritis 29,p 187
Septic shock, treatment 45.6, p 311
Septicaemia, treatment 14.8, p 102
Shigella, antibiotics in 3.6, p 16
Shock 45, p 307
Sickle cell anaemia, treatment 12.6, p 80
Small for date, 33, p 215
Spastic paresis in CP, 16.3, p 116
Spina bifida 41.21, p 274
Splenomegaly 26, p 170
Strongyloides stercoralis, treatment 10.6, p 63
T
Talipes equinovarus 41.20, p 270
Tapeworms, treatment 10.6, p 63
Tetralogy of Fallot, 41.14, p 267
Tonsillitis 21, p 144
Toxoplasma infection in AIDS 8.6, p 46
Tracheo-oesophageal fistula, 41.11, p 265
Transient tachypnoea of the newborn 35.4, p 230
Trichuris trichiuria, treatment 10.6, p 63
Tuberculin test, 4.6 p 22
Tuberculosis 4, p 18
Tumours (common) 11, p 65
Typhoid fever 1, p 1
U
Urinary tract infection 31, p 203
Urine, collection 31.5, p 204
V
Vaccination schedule Tanzania 49.10, p 384
Viral Croup 22, p 146
W
Wheezing, prolonged expiration 24, p 160
White pupil 17.5, p 124
Wilms Tumour 11.2, p 70
X
Xerophthalmia 17.4, p 123
Z
Ziehl Neelsen staining 47.11, p 329,
Since its start in 1971 until today the Department Paediatrics & Child Health
of the Kilimanjaro Christian Medical Centre, teaching and referral hospital for
Northern Tanzania, has written and continuously updated its management
schedules. Such protocols have proven to be an invaluable tool promoting
both uniformity of treatment and practical scientific argumentation among
staff members and students.
The department, through its Continuing Paediatric Education Programme,

conducts an outreach programme for the region and beyond. The major
activity of this programme is visits to hospitals and health centres where it
conducts hands on training (including bedside teaching) and various support
services.
This seventh edition of what has become famous as the “Blue Book” has
provided an inexpensive resource for clinicians and continues a legacy that
has been the backbone of seminars, teaching visits and of training within
KCMC and beyond. It is of great value to the busy clinician, who needs a
quick reference for effective and efficient treatment of sick children and
guidance in the decision whether and when the child needs to be referred.
ISBN 90-805753-1-3
KCMC
PAEDIATRIC
MANAGEMENT SCHEDULES
AT HOSPITAL LEVEL
MARK SWAI, RAIMOS OLOMI,

GRACE KINABO
and other KCMC paediatricians, past and present
CPEP- KCMC PAEDIATRICS

MOSHI, TANZANIA 7th
edition 2009

Blue Book

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KCMC

MARK SWAI, RAIMOS OLOMI,

Raimos M. S. Olomi MD, M.Med MPH

Mark E. P. Swai MD, M.Med Msc

Grace D. Kinabo MD, M.Med

Martina Oneko MD, M.Med

Levina J. Msuya MD, M.Med

Aisa M. Shayo MD, M.Med

Blandina T. Mmbaga MD, M.Med

Anaelia Siya Temu MD

Mark Waziri MBChB

CONSULTANTS FROM OTHER DEPARTMENTS WITH MAJOR

Prof. Elisante J. Massenga, Consultant

Dr Bernadeta Shillio, Consultant Ophthalmologist.

Dr Aveline Matasha, Consultant ENT surgeon.

CPEP is an organ of the KCMC paediatric department which aims at

7th edition 2009

The necessity to produce the seventh edition of this

The management schedule focus on inpatient and out-

About twenty years after the frst edition, KCMC has

This is however the frst time that only Tanzanian

It is my wish therefore to congratulate all fellow

BLOOD DISEASES (III)

NUTRITIONAL DISEASES (IV)

15. Convulsions ……………………………………………........ 104

CIRCULATION TRACT DISEASES (IX)

RESPIRATORY TRACT DISEASES: ARI (X)

DIGESTIVE TRACT DISEASES (XI)

SKIN DISEASES (XII)

GENITO-URINARY TRACT DISEASES (XIV)

THE NEWBORN (XV)

CONGENITAL ANOMALIES AND SURGERY (XVII)

ACCIDENTS, POISONING (XIX)

42. Intoxications………………………………………………..... 279

49. CHARTS AND TABLES

50. Neonatal Resuscitation……………………………………...389

MAIN POINTS IN HEALTH EDUCATION

1.3 SIGNS AND SYMPTOMS

General Headache Apathy Mental confusion

If poor response to Chloramphenicol by 48 hours

In case of resistance or no response in 5 days change to 3rd

Relapses may occur, 10-20%. Usually 2 weeks after

2.3 SIGNS AND SYMPTOMS

2.4 IMPORTANT ACTIONS TO BE TAKEN BEFORE

BLOOD - ESR almost always high.

TREATMENT OF AMOEBIC DYSENTERY

TREATMENT OF LIVER ABSCESS AND OTHER

MAIN POINTS IN HEALTH EDUCATION

DIARRHOEA WITH BLOOD

DIARRHOEA WITHOUT BLOOD

3.3 SIGNS AND SYMPTOMS

Vomiting, watery stools (3 or more per day), melaena, fever.

ASSESSMENT OF DEGREE DEHYDRATION (WHO)

ADDITIONAL IMPORTANT CRITERIA USED FOR CLINICAL

No dehydration Some dehydration Severe dehydration

Urine normal Small amount no urine for 6 h

Mouth, tongue wet Dry very dry

Pulse normal Faster very fast, weak

Fontanel (infants) normal Sunken very sunken

3.4 IMPORTANT ACTIONS TO BE TAKEN BEFORE

REHYDRATION WITH ORS SOLUTION AT HEALTH CENTRE

ORAL REHYDRATION WORKS ON THE PHYSIOLOGICAL MECHANISM

Na < 120 mmol/l = hypotonic dehydration.