MSF Paediatric Care 2024
MSF Paediatric Care 2024
MSF Paediatric Care 2024
Internal document
2024 edition
Acknowledgements
The Paediatric care: clinical and therapeutic guidelines, 1st edition (2023) have been
developed by Médecins Sans Frontières (MSF) under the supervision of the International
Paediatric Working Group, and in close collaboration with other relevant working groups.
These are the first international paediatric guidelines to be produced by MSF and are
partly based on the previous OCP-OCG, and OCBA Paediatric Guidelines originally written
by Marianne Sutton, which they now replace. We also thank Marie-Claude Bottineau and
Myrto Schaefer for their contributions to, and coordination of, the previous guidelines.
MSF would like to express its sincere gratitude to everyone who has contributed to the
development of these guidelines:
International Paediatric Working Group:
Jordan Amor-Robertson, Inma Carreras, Manuel Dewez, Anja Gao, Laurent Hiffler,
Sophie Janet, Hans-Jörg Lang, Jaap Karsten, Daniel Martinez Garcia, Nikola Morton,
Oluwakemi Ogundipe, Roberta Petrucci (Coordinator), Harriet Roggeveen, Neal Russell,
Jiske Steensma, Johanna Thomson, Lisa Umphrey, Ana Victoria Valori.
Other contributors:
Gabriel Alcoba, Haydar Alwash, Mohana Amirtharajah, Valentina Burzio, Roberta Caboclo,
Cristina Carreno, Esther Casas, Arlene Chua, Ana de la Osada, Lynette Dominguez,
Teresa Gadsden, Kerstin Hanson, Christian Heck, Patrick Hérard, Cathy Hewison,
Melissa Hozjan, Rupa Kanapathipillai, Amin Lamrous, John Lawrence, James Lee,
Ian Maconochie, Kathryn Maitland, Mignon McCulloch, Juno Min, Laura Moreto,
Caroline Mwangi, Carolina Nanclares, Lynne Nield, Maura Pedrini, Erwan Piriou,
Anne Pittet, Kirrily de Polnay, Ian Proudfoot, Amulya Reddy, Koert Ritmeijer, Cliff Roberson,
Carla Schwanfelder, Saschveen Singh, Martin Sosa, Esther Sterk, Elisabeth Szumilin,
Malcolm Townsend, Vicky Treacy-Wong, Alejandro Vargas Pieck, Joana van Holthe,
Blandine Vasseur, Cedric Yoshimoto.
International Guidelines Publication team:
Author-coordinators: Nadia Lafferty, Clara van Gulik
Medical Editor: Elisabeth Le Saout
Language editor: Carolina López Vázquez
Lay-out designer: Evelyne Laissu
Published by
Médecins sans Frontières
Médecins Sans Frontières. Paediatric care: clinical and therapeutic guidelines. 2024 edition.
Ref. L010PEDM05E-P
Introduction
Despite a significant reduction in childhood mortality over the last 30 years, under-5 mortality
remains unacceptably high. In 2021, 5 million children under the age of 5 died, almost half of
whom were neonates, representing a global under-5 mortality rate of 38 deaths per 1000 live
births1. If current trends continue, 54 countries will fail to meet the Sustainable Development
Goal target 3.2, which aims to end preventable newborn and child deaths, and to reduce
the under-5 mortality rate to less than 25 deaths per 1000 live births by 20302. Though
data on mortality trends among older children are more limited, each year approximately
800 000 children 5-14 years old die worldwide1. The significance of this for MSF’s work is
evident - more than 80% of under-5 deaths occur in the Sahel and southern Asia1, while over
55% of deaths in the 5–14-year age group occur in sub-Saharan Africa alone3.
The leading causes of death among young children worldwide remain unchanged – pneumonia,
diarrhoea and malaria together accounted for over 1.6 million deaths of children under 5 in
20194, despite the availability of simple and effective treatments for these diseases. In the
older paediatric age groups, global data on cause of death is not reported, but individual
country data implicates the same 3 top killers as for the under-5 age group, with the addition
of injuries, as the leading causes of death in the 5-14-year age group3. An unacceptably large
proportion of childhood deaths could be prevented by access to timely and appropriate
medical care, vaccination and adequate nutrition.
These guidelines have been developed to ensure that children seen in MSF facilities receive
prompt, high-quality care to reduce child mortality. They provide clear, evidence-based clinical
guidance for common paediatric conditions and promote consistency of practice across MSF
facilities. Best practice guidance has been adapted and tailored to ensure alignment with the
medications and equipment that are available in MSF projects.
These guidelines will be updated regularly online as new evidence and guidance becomes
available. As such, new printed editions will be released when necessary. Comments and
feedback should be addressed to the Paediatric Working Group at DL-MSF-PediatricWorkingG
roupInternational@geneva.msf.org.
References
1. The Global Health Observatory. Child mortality and causes of death. The Global Health
Observatory. Accessed November 30, 2023.
https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/child-mortality-
and-causes-of-death
2. Sustainable Development Goal 3 | Department of Economic and Social Affairs. United
Nations. Accessed November 30, 2023.
https://sdgs.un.org/goals/goal3
3. Masquelier B, Hug L, Sharrow D, et al. Global, regional, and national mortality trends in older
children and young adolescents (5–14 years) from 1990 to 2016: an analysis of empirical
data. Lancet Glob Health. 2018;6(10):e1087-e1099.
https://doi.org/10.1016/S2214-109X(18)30353-X
4. Diarrhoea. UNICEF DATA. Accessed November 30, 2023.
https://data.unicef.org/topic/child-health/diarrhoeal-disease/
3
About these guidelines
This is the first international edition of the MSF Paediatric care guidelines. It is the result of the
collective work of numerous internal paediatric guidelines and protocols produced over the
years by dedicated paediatricians and paediatric nurses working in MSF Medical departments,
Operational cells and projects. These guidelines have been developed by the International
Guidelines Publication (IGP) team, in close collaboration with the International Paediatric
Working Group (IPWG) and other relevant working groups.
Objective
The objective of these guidelines is to improve the clinical care of a sick or injured child.
Although predominantly focused on hospital care, they are designed for use in any inpatient
or outpatient healthcare facility with a major paediatric care component. The primary target
audience of these guidelines is general clinicians/physicians and clinical officers with little or
no experience in paediatric care, but they can be used as a support for all healthcare workers
involved in the delivery of medical care for children.
Age range
The Convention on the Rights of the Child defines a child as any human being below the age
of 18 years, however acknowledging that the specific needs of adolescents over 15 years are
complex and require specific expertise, the age range covered in these guidelines is 1 month
to 15 years inclusive.
Definitions
The following WHO definitions for adults, adolescents, children and infants are used in these
guidelinesa:
- A neonate is an infant younger than 4 weeks of age.
- An infant is a child younger than 1 year of age.
- A child is a person 1 to 9 years of age.
- An adolescent is a person 10 to 19 years of age.
- An adult is a person older than 19 years of age.
Antibiotic recommendations
Antimicrobial resistance caused by inappropriate use of antibiotics is a global health problem
and antibiotic stewardship is essential in all contexts. Antibiotic choices are therefore aligned
with the WHO AWaRe (Access, Watch, Reserve) antibiotic handbook1 wherever possible.
a Note that countries may have other definitions under their respective national laws.
4
HIV and tuberculosis in children
Paediatric HIV and tuberculosis are included only briefly in these guidelines as comprehensive
guidance is available in disease-specific MSF guidelines.
Illustrations
All illustrations in these guidelines have been redrawn for consistency or are original drawings.
The majority have been redrawn with permission by Anthony Calvert, from source material
primarily from WHO Hospital Care for Children, MSF publications and from images provided by
David Watson. Figure 8.1 - Dorsal slit procedure and Figure 9.1 - Two bag method for delivery
of IV fluids in DKA are original drawings by Sarah Imani.
References
1. The WHO AWaRe (Access, Watch, Reserve) Antibiotic Book. World Health Organization;
2022. Accessed November 30, 2023.
https://www.who.int/publications-detail-redirect/9789240062382
5
Table of contents
Introduction.............................................................................................................................. 3
About these guidelines............................................................................................................. 4
Abbreviations and acronyms.................................................................................................. 15
Chapter 2: Emergencies
2.1 Resuscitation..................................................................................................................... 27
2.1.1 Basic life support...................................................................................................... 27
2.1.2 Advanced life support.............................................................................................. 32
2.2 Circulatory impairment and shock................................................................................... 35
2.2.1 Classification of circulatory impairment and shock................................................. 35
2.2.2 Clinical features........................................................................................................ 36
2.2.3 Immediate management......................................................................................... 36
2.2.4 Monitoring and further management..................................................................... 38
2.2.5 Further critical care management when intensive care is available........................ 40
2.3 Choking............................................................................................................................. 42
2.4 Anaphylaxis....................................................................................................................... 46
2.4.1 Clinical features and diagnostic criteria................................................................... 46
2.4.2 Management........................................................................................................... 46
2.5 Haemorrhagic shock......................................................................................................... 49
2.5.1 Investigations........................................................................................................... 49
2.5.2 Management........................................................................................................... 49
2.6 Drowning.......................................................................................................................... 50
2.6.1 Pathophysiology....................................................................................................... 50
2.6.2 Management........................................................................................................... 50
2.6.3 Investigations........................................................................................................... 52
2.6.4 Post resuscitation management.............................................................................. 52
2.7 Trauma.............................................................................................................................. 53
2.7.1 Primary survey......................................................................................................... 53
2.7.2 Secondary survey..................................................................................................... 56
2.7.3 Specific injuries........................................................................................................ 57
2.8 Head injury........................................................................................................................ 59
2.8.1 Assessment and initial management....................................................................... 59
2.8.2 Management........................................................................................................... 62
2.8.3 Raised intracranial pressure..................................................................................... 63
2.8.4 Discharge criteria..................................................................................................... 63
6
2.9 Poisoning........................................................................................................................... 64
2.9.1 Diagnosis and approach to the suspected poisoned child....................................... 64
2.9.2 Initial management and approach........................................................................... 65
2.9.3 Toxic agent not known: the toxidromic approach.................................................... 66
2.9.4 Decontamination..................................................................................................... 68
2.9.5 Toxic agent known: specific treatment.................................................................... 69
2.9.6 Prevention................................................................................................................ 71
7
Chapter 4: Respiratory conditions
4.1 Approach to a child with a respiratory complaint......................................................... 125
4.1.1 Respiratory symptoms and signs........................................................................... 125
4.1.2 Management......................................................................................................... 129
4.1.3 Respiratory support............................................................................................... 129
4.2 Croup (laryngotracheitis and laryngotracheobronchitis)............................................................132
4.2.1 Clinical features...................................................................................................... 132
4.2.2 Management......................................................................................................... 132
4.3 Epiglottitis....................................................................................................................... 136
4.3.1 Clinical features...................................................................................................... 136
4.3.2 Management......................................................................................................... 136
4.3.3 Prevention.............................................................................................................. 138
4.4 Bacterial tracheitis.......................................................................................................... 139
4.4.1 Clinical features...................................................................................................... 139
4.4.2 Management......................................................................................................... 139
4.5 Pneumonia...................................................................................................................... 141
4.5.1 Clinical features...................................................................................................... 141
4.5.2 Investigations......................................................................................................... 142
4.5.3 Management......................................................................................................... 143
4.6 Empyema........................................................................................................................ 146
4.6.1 Clinical features...................................................................................................... 146
4.6.2 Management......................................................................................................... 147
4.7 Bronchiolitis.................................................................................................................... 148
4.7.1 Clinical features...................................................................................................... 148
4.7.2 Management......................................................................................................... 148
4.8 Diphtheria....................................................................................................................... 151
4.8.1 Clinical features...................................................................................................... 151
4.8.2 Management......................................................................................................... 152
4.8.3 Prevention.............................................................................................................. 153
4.9 Pertussis (whooping cough)........................................................................................... 154
4.9.1 Clinical features...................................................................................................... 154
4.9.2 Management......................................................................................................... 154
4.9.3 Post-exposure prophylaxis..................................................................................... 156
4.9.4 Prevention.............................................................................................................. 156
4.10 Asthma.......................................................................................................................... 157
4.10.1 Acute exacerbation of asthma............................................................................. 157
4.10.2 General management of asthma......................................................................... 161
4.10.3 Asthma education and action plan...................................................................... 164
4.11 Tuberculosis.................................................................................................................. 166
4.11.1 Stages of infection............................................................................................... 166
4.11.2 Clinical features.................................................................................................... 166
4.11.3 Diagnostic approach............................................................................................ 168
4.11.4 Investigations....................................................................................................... 169
4.11.5 Paediatric diagnostic algorithms.......................................................................... 170
4.11.6 Management....................................................................................................... 173
4.11.7 Prevention and screening.................................................................................... 175
8
4.12 Mastoiditis.................................................................................................................... 177
4.12.1 Clinical features.................................................................................................... 177
4.12.2 Management....................................................................................................... 177
Chapter 6: Cardiology
6.1 Introduction.................................................................................................................... 221
6.2 Cardiac failure................................................................................................................. 222
6.2.1 Clinical signs and assessment................................................................................ 222
6.2.2 Investigations......................................................................................................... 222
6.2.3 Management......................................................................................................... 223
6.2.4 Follow-up............................................................................................................... 224
6.2.5 Treatment of any reversible causes....................................................................... 224
6.3 Acute rheumatic fever.................................................................................................... 225
6.3.1 Diagnosis................................................................................................................ 225
6.3.2 Management......................................................................................................... 226
6.3.3 Prevention.............................................................................................................. 226
6.4 Infantile beriberi............................................................................................................. 227
9
Chapter 7: Neurological disorders
7.1 Neurological assessment................................................................................................ 231
7.2 Acute symptomatic seizures........................................................................................... 233
7.2.1 Terminology........................................................................................................... 233
7.2.2 Clinical features...................................................................................................... 233
7.2.3 Management......................................................................................................... 234
7.2.4 Management if acute seizures resume.................................................................. 238
7.2.5 Management of post-ictal state............................................................................. 238
7.2.6 Follow-up............................................................................................................... 238
7.3 Febrile seizures............................................................................................................... 240
7.3.1 Diagnosis................................................................................................................ 240
7.3.2 Management......................................................................................................... 240
7.4 Epilepsy........................................................................................................................... 241
7.4.1 Assessment and diagnosis..................................................................................... 241
7.4.2 Classification of seizures........................................................................................ 241
7.4.3 Management......................................................................................................... 242
7.4.4 Follow-up and monitoring..................................................................................... 244
7.5 Altered level of consciousness....................................................................................... 245
7.5.1 Clinical features and assessment........................................................................... 245
7.5.2 Management......................................................................................................... 246
10
8.6 Paraphimosis................................................................................................................... 273
8.6.1 Clinical features...................................................................................................... 273
8.6.2 Management......................................................................................................... 273
Chapter 9: Endocrinology
9.1 Diabetes mellitus (type 1).............................................................................................. 281
9.1.1 Diagnosis................................................................................................................ 281
9.1.2 Management......................................................................................................... 282
9.2 Diabetic ketoacidosis...................................................................................................... 283
9.2.1 Diagnosis................................................................................................................ 283
9.2.2 Management......................................................................................................... 284
9.2.3 Management of complications.............................................................................. 289
9.2.4 Resolution of DKA and transition to subcutaneous (SC) insulin............................. 291
9.2.5 Discharge criteria and follow-up............................................................................ 293
9.3 Hypoglycaemia............................................................................................................... 294
9.3.1 Clinical features and assessment........................................................................... 294
9.3.2 Management......................................................................................................... 295
11
11.5 Septic arthritis............................................................................................................... 326
11.5.1 Clinical features.................................................................................................... 326
11.5.2 Management....................................................................................................... 327
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
12.1 Introduction.................................................................................................................. 333
12.2 Re-nutrition (osmotic) diarrhoea................................................................................. 334
12.2.1 Clinical features and assessment......................................................................... 334
12.2.2 Management....................................................................................................... 334
12.3 Refeeding syndrome..................................................................................................... 336
12.3.1 Clinical features and assessment......................................................................... 336
12.3.2 Management....................................................................................................... 337
12.3.3 Prognosis.............................................................................................................. 337
12.4 Paralytic ileus (acute abdominal distension)............................................................... 338
12.4.1 Clinical features and assessment......................................................................... 338
12.4.2 Management....................................................................................................... 338
12.4.3 Monitoring........................................................................................................... 339
12.5 Persistent oedema........................................................................................................ 340
12.5.1 Clinical features and assessment......................................................................... 340
12.5.2 Management....................................................................................................... 340
12.6 Kwashiorkor skin lesions.............................................................................................. 342
12.6.1 Management....................................................................................................... 342
12.6.2 Antibiotics for infected lesions............................................................................. 344
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
14.1 Fever of unknown origin (FUO).................................................................................... 365
14.1.1 Causes.................................................................................................................. 365
14.1.2 Clinical features.................................................................................................... 365
14.1.3 Investigations....................................................................................................... 366
14.1.4 Management....................................................................................................... 366
12
14.2 Leishmaniasis................................................................................................................ 372
14.2.1 Visceral leishmaniasis (kala-azar)......................................................................... 372
14.2.2 Cutaneous leishmaniasis...................................................................................... 374
14.2.3 Post-kala-azar dermal leishmaniasis (PKDL)......................................................... 377
14.3 Noma (cancrum oris).................................................................................................... 378
14.3.1 Clinical features.................................................................................................... 378
14.3.2 Management....................................................................................................... 379
14.3.3 Prognosis.............................................................................................................. 382
14.3.4 Prevention............................................................................................................ 382
13
Appendices
1. Developmental milestones................................................................................................ 429
2. WHO growth charts for children....................................................................................... 432
3. Paediatric vital signs.......................................................................................................... 436
4. Oropharyngeal airway insertion........................................................................................ 438
5. Intraosseous needle insertion........................................................................................... 439
6. Performing a lumbar puncture.......................................................................................... 443
7. Clinical Respiratory Score (CRS)......................................................................................... 446
8. Asthma action plan............................................................................................................ 447
9. How to make a spacer with a plastic bottle....................................................................... 448
10. Inhaler technique using a spacer..................................................................................... 449
11. Sputum specimen collection in children......................................................................... 451
12. WHO rehydration plans A, B and C.................................................................................. 453
13. Glasgow and Blantyre Coma Scales................................................................................. 454
14. Urinary collection procedures......................................................................................... 457
15. Suprapubic aspiration of urine........................................................................................ 463
16. Body surface area estimation in children........................................................................ 466
17. Blood pressure centiles for age....................................................................................... 467
18. F-75 feed volumes in Phase 1.......................................................................................... 468
19. ARV prophylaxis in PMTCT............................................................................................... 469
20. Causes of fever of unknown origin (FUO)........................................................................ 471
21. EVENDOL chart................................................................................................................ 477
22. Daily enteral feed volumes and administration in critically unwell children................... 478
14
Abbreviations and acronyms
15
G5% Glucose (dextrose) 5%
GCS Glasgow Coma Scale
GFR/eGFR Glomerular filtration rate/estimated GFR
Hb Haemoglobin
HIV Human immunodeficiency virus
HR Heart rate
HUS Haemolytic uraemic syndrome
ICU Intensive care unit
IPD Inpatient department
ITFC Inpatient therapeutic feeding centre
IUGR Intrauterine growth retardation
LOC Level of consciousness
LUS Lung ultrasound
MCD Minimal change disease
MUAC Mid-upper arm circumference
MVA Motor vehicle accident
NaCl Sodium chloride
NBM Nil by mouth
NGT Nasogastric tube
NSAID Non-steroidal anti-inflammatory
OGT Orogastric tube
OPD Outpatient department
ORS Oral rehydration salts
PCR Polymerase chain reaction
PIGN Post-infectious glomerulonephritis
POCUS Point-of-care ultrasound
PRBC Packed red blood cells
ReSoMal Rehydration solution for malnutrition
RL Ringer lactate
RR Respiratory rate
SDNS Steroid-dependent nephrotic syndrome
SPA Suprapubic aspirate
SpO2 Oxygen saturation
SRNS Steroid-resistant nephrotic syndrome
SSNS Steroid-sensitive nephrotic syndrome
T1DM Type 1 diabetes mellitus
TB Tuberculosis
US Ultrasound
UTI Urinary tract infection
WBC White blood cells
16
1
Chapter 1:
Paediatric history and clinical examination
1.1 Introduction............................................................................................................. 19
1.2 Taking a paediatric history...................................................................................... 20
1.3 Clinical examination................................................................................................ 22
Chapter 1: Paediatric history and clinical examination
1
1.1 Introduction
This chapter outlines how to take a comprehensive paediatric history and perform a full clinical
examination in a child. It is not always necessary to take a complete history, the scope and
detail are determined by the nature of the presenting complaint and/or the child’s age. For
example, birth and developmental history may provide important information to support the
correct diagnosis and management of a young child, while social and past medical history may
be more relevant in older children. For adolescents, consider that they may prefer to provide
their history or be examined without the presence of their parents/carers.
19
Chapter 1: Paediatric history and clinical examination
Patient profile
– Age (in months for children < 2 years)
– Gender
– Relationship to accompanying adult
Presenting complaint
– Main problem or symptoms
– If child was referred from another facility, note main reason for referral
Medication history
– Current or recent medications
– Traditional treatments used (medicines or procedures, e.g. uvula excision, scarification,
circumcision)
– Known allergies
Birth history
– Maternal age
– Obstetric history:
• Total number of pregnancies and their outcomes
• Complications during pregnancy
• HIV status: if maternal HIV status is positive, note whether adequate prophylaxis for
prevention of mother-to-child transmission (PMTCT) received; if early infant diagnosis
(EID) done, including available results
• Tuberculosis: if maternal tuberculosis or any household TB contacts, note whether
isoniazid prophylaxis was taken and completed
• Malaria
• Nutritional status
• Supplements: folic acid, vitamin D, multivitamins
20
Chapter 1: Paediatric history and clinical examination
1
– Delivery:
• Assisted: by a skilled (or traditional) birth attendant, midwife and/or obstetrician
• Location: at a health facility or at home
– Any problems during delivery:
• Foetal distress
• Use of instruments (e.g. forceps, vacuum)
• Breech, footling breech
• Caesarean section
– Gestational age, birth weight, and Apgar score (if available)
– Any problems with breathing or injuries at birth:
• Admission to neonatal care unit
• Jaundice
• Infection
• Feeding problems
Developmental history
– Age when key milestones achieved and current developmental stage (see Appendix 1)
– School-age child: any specific problems (academically, physically, socially with peers)
– Behavioural concerns for age: aggression, isolation, self-harm, addictions
Family history
– Any illnesses, diseases or conditions in the family, especially amongst children
– Directly ask about: tuberculosis, sickle cell disease, severe anaemia, thalassaemia, epilepsy,
diabetes, hypertension, asthma
Social history
– Ask about the child’s living situation and conditions
– Family structure: primary carer, number of siblings
– School attendance (includes religious school)
– Concerns with safety or food security
– Context: refugee or internally displaced persons (IDP) camp or settlement; area affected by
conflict, epidemic, isolation; part of neglected or targeted population (based on religion,
location, tribe, ethnic group, political affiliation).
21
Chapter 1: Paediatric history and clinical examination
Tips
– Observe the child and their interaction with parents/carers.
– Get down to the child’s level as much as possible; avoid towering over them.
– Try to gain the child’s trust.
– Avoid fully undressing the child – undress partially to expose the area to be examined.
– If the child is calm and not distressed, take the opportunity to examine the cardiac, respiratory
and neurological systems first.
– Leave examinations that can upset the child (e.g. ear, nose, throat and mouth) and
examination of any painful areas until last.
– Examine young children (6 months to 3 years) as much as possible on the parent’s/carer’s
lap.
– Use toys to distract the child during the examination.
– Communicate directly with the child: children 5 to 12 years will usually be co-operative if
they are informed about what is going to be examined and how.
– Respect privacy: adolescents may prefer not to be examined in front of their parents/carers;
ask them their preference.
– Respect local cultural norms regarding gender of patient and clinician performing
examination.
– Be honest: if something is going to hurt, tell the child in a calm fashion.
General appearance
– Note obvious features: well/unwell, active/lethargic, uncomfortable, irritable, distressed, in
pain, malnourished.
– Observe for obvious difficulty breathing, e.g. sitting upright and holding self-up with
extended arms.
– Note any jaundice, anaemia, cyanosis, clubbing, oedema, lymphadenopathy.
– Specifically look for rashes, petechiae, skin turgor (pinch test for dehydration).
22
Chapter 1: Paediatric history and clinical examination
1
Parameter Indication
Cardiovascular
– Measure: Heart rate (HR), blood pressure (BP), capillary refill time (CRT).
– Pulses: brachial in infants, femoral or radial in older children.
– Palpate: location of apex beat, character of apex beat (heaving/thrusting, hyperdynamic,
tapping).
– Auscultate: heart sounds, rhythm, any murmurs.
Respiratory
– Measure: Respiratory rate (RR), oxygen saturation (SpO2), presence of cyanosis.
– Breathing effort: tracheal tug, use of accessory muscles, chest indrawing, nasal flaring.
– Percussion: dullness may indicate consolidation (pneumonia, empyema, pleural effusion);
hyper-resonance may indicate pneumothorax.
– Auscultation: equal/unequal breath sounds; presence of rales, crepitations, stridor (indicates
upper airway obstruction), wheeze or rhonchi; transmitted upper airway noises or voice
sounds.
Abdomen
– Check for distension, visible masses, peristalsis, hernias.
– Palpate abdomen: superficial palpation then deep palpation, noting tenderness (avoid any
known tender area until the end of the exam), rebound tenderness or guarding. If pain
is significant, lightly percuss the abdomen rather than palpating – percussion tenderness
indicates peritonitis.
– Feel for liver and spleen: note any hepatomegaly or splenomegaly and any tenderness.
23
Chapter 1: Paediatric history and clinical examination
– Feel for kidneys: palpate the flank area to check for a renal mass; tap gently with the ulnar
part of your hand to examine for signs of pyelonephritis.
– Auscultate for bowel sounds: overactive bowel sounds are present with gastroenteritis;
bowel sounds are often decreased in appendicitis; absent or tinkling bowel sounds indicate
intestinal obstruction.
– Check for ascites (if clinically relevant): ask the child to lie flat on their back and percuss
from periphery of abdomen towards the umbilicus. If ascites is present, it will be dull to
percussion initially, becoming tympanic towards the umbilicus. Note the level of ascites,
that corresponds to the change in percussion note. Another technique for ascites detection
is to ask the patient or parent/carer to place a hand in the midline of their abdomen, while
the examiner taps one flank side of the abdomen with the palm of their other hand resting
on the opposite flank area; a fluid wave will be felt in the palm of their hand if ascites is
present.
Musculoskeletal
– Ask child to walk and observe gait and any limp.
– Where relevant, examine: the back for kyphosis, lordosis or scoliosis; extremities for any
muscle atrophy; affected joints (range of motion, stability, any swelling or tenderness).
Neurological
– Note level of consciousness (AVPU, see Appendix 3), neck stiffness (nuchal rigidity).
– Tone: check for hypotonia or hypertonia. For infants over 6 months, pull gently by the arms
to a sitting position and check for head lag, too weak to sit or any stiffness.
– Reflexes: test patellar reflex by tapping the patellar tendon with a reflex hammer.
– Ask the child to walk, walk heel-to-toe, and stand on one leg. Note any abnormalities.
– If any neurologic or neuromuscular abnormalities are detected or suspected, perform a full
neurological examination (Chapter 7, Section 7.1) and developmental assessment (compare
to milestones in Appendix 1).
External genitalia
– Check for any hernias, hydroceles (accumulation of fluids inside scrotum) or cryptorchidism
(absence of one or both testes from the scrotum).
– In girls, check and note any scarring or signs of female genital mutilation (be discreet and
sensitive to the context).
– Rectal examination should only be done when there is a specific indication.
24
Chapter 2: 2
Emergencies
2.1 Resuscitation............................................................................................................ 27
2.1.1 Basic life support.............................................................................................. 27
2.1.2 Advanced life support...................................................................................... 32
2.2 Circulatory impairment and shock.......................................................................... 35
2.2.1 Classification of circulatory impairment and shock.........................................35
2.2.2 Clinical features............................................................................................... 36
2.2.3 Immediate management................................................................................. 36
2.2.4 Monitoring and further management.............................................................38
2.2.5 Further critical care management when intensive care is available................40
2.3 Choking.................................................................................................................... 42
2.4 Anaphylaxis.............................................................................................................. 46
2.4.1 Clinical features and diagnostic criteria...........................................................46
2.4.2 Management................................................................................................... 46
2.5 Haemorrhagic shock................................................................................................ 49
2.5.1 Investigations................................................................................................... 49
2.5.2 Management................................................................................................... 49
2.6 Drowning................................................................................................................. 50
2.6.1 Pathophysiology............................................................................................... 50
2.6.2 Management................................................................................................... 50
2.6.3 Investigations................................................................................................... 52
2.6.4 Post resuscitation management...................................................................... 52
2.7 Trauma..................................................................................................................... 53
2.7.1 Primary survey................................................................................................. 53
2.7.2 Secondary survey............................................................................................. 56
2.7.3 Specific injuries................................................................................................ 57
2.8 Head injury............................................................................................................... 59
2.8.1 Assessment and initial management...............................................................59
2.8.2 Management................................................................................................... 62
2.8.3 Raised intracranial pressure............................................................................ 63
2.8.4 Discharge criteria............................................................................................. 63
2.9 Poisoning.................................................................................................................. 64
2.9.1 Diagnosis and approach to the suspected poisoned child...............................64
2.9.2 Initial management and approach.................................................................. 65
2.9.3 Toxic agent not known: the toxidromic approach............................................66
2.9.4 Decontamination............................................................................................. 68
2.9.5 Toxic agent known: specific treatment............................................................69
2.9.6 Prevention........................................................................................................ 71
References Chapter 2..................................................................................................... 72
Chapter 2: Emergencies
2.1 Resuscitation 2
Cardiopulmonary arrest in children usually has a very poor outcome. Paediatric cardiopulmonary
arrest occurs most commonly secondary to respiratory or circulatory failure, and less frequently
due to a primary cardiac cause such as an arrhythmia1, unlike in adults. Primary respiratory
arrest may occur with drowning or poisoning. To optimize survival, imminent cardiopulmonary
arrest can be prevented in a seriously ill or injured child with early and effective resuscitation
by providing basic and/or advanced life support.
Basic life support (BLS) can be performed by any healthcare worker in any setting. The objective
is to rapidly assess for signs of respiratory or circulatory problems and to take immediate steps
to support the airway (A), breathing (B) and circulation (C). Advanced life support (ALS) should
be performed in hospitals and emergency departments with adequate staffing and training.
27
Chapter 2: Emergencies
2.1c - Neutral airway position (< 1 year) 2.1d - Sniffing position (≥ 1 year old)
28
Chapter 2: Emergencies
29
Chapter 2: Emergencies
Chest compressions
– In all infants and children, chest compressions are done on the lower half of the sternum:
• In infants: chest compressions are given just below the inter-nipple line. If one rescuer,
use two fingertips to compress the chest (Figure 2.3a); if two rescuers, use two thumbs by
encircling hands around chest to do compressions (Figure 2.3b). Compress to at least 1/3
of anterior-posterior depth of chest.
• In children: trace the lowest ribs to the middle of the chest to locate the xiphisternum.
Place the heel of one hand on the sternum one finger breadth above the xiphisternum,
ensuring that the fingers are lifted off the chest to avoid restricting chest movement.
Position yourself directly above the child’s chest and, keeping the arm straight, compress
the chest. For larger children, both hands with fingers interlocked can be used.
– Depress sternum by at least 1/3 of anterior-posterior depth of chest (maximum 6 cm1) with
each compression, then release pressure completely. Continue at a rate of 100-120/minute.
– After 15 compressions, repeat head tilt-chin lift and give 2 breaths. If there are two rescuers,
one should remain focused on the airway to maintain the correct position, while the other
carries out chest compressions (and squeezes the ventilation bag if a two-handed ventilation
technique is used).
Figures 2.3 - Hand positions for chest compressions in infants
2.3a - One rescuer technique 2.3b -Two rescuers technique
a New ERC guidance no longer recommends checking for a pulse before starting chest compressions.
30
Chapter 2: Emergencies
Figure 2.4 - Paediatric basic life support algorithm, European Resuscitation Council (ERC)b 2
b Reprinted from European Resuscitation Council Guidelines 2021: Paediatric Life Support, with permission from
European Resuscitation Council. Copyright European Resuscitation Council – www.erc.edu – 2023_NGL_008.
31
Chapter 2: Emergencies
Assess C (circulation)
– Check heart rate (HR); capillary refill time (CRT); blood pressure (BP, only if capacity to be
done quickly and accurately); character of pulse.
– Look for signs of circulatory impairment:
• Weak radial pulse, or severe tachycardiad
• Lower limb temperature gradiente
• CRT of 3 or more seconds.
All 3 signs of circulatory impairment present: the child is in shock.
Slow HR and low BP: the child is decompensating; start BLS.
c If HR capacity is limited, the team leader should be involved in the resuscitation, but preferably only in minor
tasks so as to keep an overview of the resuscitation.
d Severe tachycardia is HR > 180 bpm in children < 12 months, > 160 bpm in children 1 to 5 years, > 140 bpm in
children > 5 years.
e The temperature gradient is assessed by running the back of hand from the toe to the knee; a positive
temperature gradient is defined as a notable temperature change from cold (dorsum of foot) to warm (knee).
32
Chapter 2: Emergencies
Manage C (circulation)
– Obtain vascular access (IV/IO). If unable to get IV access after 3 attempts or maximum
90 seconds, insert IO needle (see MSF Manual of Nursing Care Procedures, Procedure:
Peripheral intravenous catheter for details on gaining IV access and MSF Manual of Nursing
Care Procedures, Procedure: Intraosseous needle, and Appendix 5 for IO access).
– Stop any active bleeding (see Section 2.5).
– Perform rapid tests for haemoglobin (Hb), blood glucose level (BGL), and malaria (in endemic
malaria contexts).
– Check electrolytes, if available.
– Promptly administer fluids and/or blood to improve circulatory volume and perfusion,
depending on underlying cause:
• Circulatory failure or shock: see Section 2.2.
• Anaphylaxis: see Section 2.4.
• Severe bleeding: see Section 2.5.
• Trauma: see Section 2.7.
– Reassess ABC every 15 minutes and monitor and record vital signs frequently (or continuously
if possible) using an early warning system (see MSF Manual of Nursing Care Procedures,
Assessment and vital signs, Charts: Vital sign charts) while identifying underlying diagnosis.
f A painful stimulus can be given by applying supra-orbital pressure at the supraorbital notch or by applying
pressure to the nailbed.
33
Chapter 2: Emergencies
– Check temperature and look for any skin eruptions, rash, purpura, or trauma.
– Complete a focused medical history using SAMPLE:
• Signs and symptoms
• Allergies
• Medication
• Past medical history
• Last meal
• Events leading to presentation.
Cardiopulmonary arrest
If child deteriorates and becomes unresponsive, is not breathing (gasping or intermittent
breaths), and no pulse is felt within 10 seconds (or pulse < 60 beats/min with signs of poor
perfusion), start CPR (see Section 2.1.1 for more details):
– Give 5 initial rescue breaths and begin CPR with a ratio of 15 chest compressions: 2 breaths.
– Continue CPR in the absence of signs of life (moving, coughing, breathing) and concomitantly
obtain IV/IO access. Attach cardiac monitor, if available.
– Administer epinephrine IV/IO: 10 micrograms/kgg every 3 to 5 minutes (see MSF Paediatric
Injectables Handbook and MSF Vasopressor Therapy – Adrenaline protocol for more
detailed administration guidance) without interruption to chest compressions until infant/
child meets criteria to stop resuscitation (see below).
– If cardiac monitoring in place, stop chest compressions briefly to check for electrical activity
every 2 minutes. If there is electrical activity, check briefly for a pulse, minimising any
interruption to chest compressions.
– Treat reversible causes: hypovolaemia, hypoxia, hypoglycaemia, hypothermia, hypo- or
hyperkalaemia, tension pneumothorax.
If there are obvious signs of life or if pulse returns, stop CPR and:
– Follow ABCDE approach to assess and manage the child further.
– Assist ventilation and oxygenation, as necessary.
– Treat precipitating or underlying cause.
– Avoid hypothermia (wrap in blankets, cover head of infants).
When to stop CPR if no response:
– After 10 minutes if still no signs of life, confirmed by the absence of a pulse.
– After 30 minutes if pulse is present but no breathing and no reversible cause has been
identified.
Communication
Communication with family during resuscitation is extremely important and where possible it
is useful to have someone dedicated to keeping the family up to date and explaining what is
happening throughout the resuscitation. This will both reassure the family and allow them to
understand what the medical team is doing.
Effective team work also involves good communication, ensuring clarity of roles and
responsibilities and maintaining a calm, low-stress atmosphere. Closed loop communicationh
is useful in emergencies to avoid misunderstandings. After the resuscitation, it is important
to carefully record the events and any medications that were administered (if not recorded in
real time).
g Solution of 100 micrograms/mL (1:10 000) i.e. dilute 1 mL of adrenaline 1:1000 with 9 mL sodium chloride
0.9%.
h Closed loop communication is when the person receiving the message repeats it back to the person who gave
the message to ensure that it has been correctly understood. It reduces error from ambiguous messages.
34
Chapter 2: Emergencies
Impaired circulation can occur in any severely ill or injured child. Early recognition of
circulatory impairment, identification of the underlying cause and prompt treatment can
prevent progression to shock and be life-saving. Shock is a clinical condition in which there
is inadequate oxygen delivered to the vital organs and tissue, and, if prolonged, results in
irreversible multi-organ failure and death. Mortality in children with shock is extremely high.
In clinical practice, differentiation between circulatory impairment and shock can be difficult.
In addition, the proportion of children with true shock among all those with evidence of
circulatory impairment, is very small2. Evidence has shown that children with circulatory
impairment who do not meet the definition of shock benefit from the same treatment as
those in shock2. Therefore, for the purposes of this chapter, treatment of children is the same
for both circulatory impairment and shock. This chapter does not apply to children in diabetic
ketoacidosis (DKA) (see Chapter 9, Section 9.2), children with circulatory impairment due to
massive haemorrhage (see Section 2.5) or trauma (see Section 2.7) as they have a specific
pathophysiology and different management requirements.
Gastroenteritis,
Fluid loss, inadequate fluid
dehydration, diabetic
intake
ketoacidosis
Intravascular
Hypovolaemic
volume loss Trauma, splenic rupture,
Blood loss/haemorrhage
viral haemorrhagic fevers
Capillary leak Burns, bowel obstruction
Increased capillary
permeability, decreased Sepsis, anaphylaxis
Intravascular vasomotor tone
Distributive
volume shift
Loss of sympathetic tone
Spinal cord injury
leads to vasodilation
Congenital heart
Reduced disease, cardiomyopathy,
Cardiogenic Intrinsic pump failure
cardiac output myocarditis, valvular
disease, arrhythmias
Tension pneumothorax,
Obstructed Extracardiac obstruction of cardiac tamponade,
Obstructive
cardiac output blood flow pulmonary embolism,
coarctation of aorta
35
Chapter 2: Emergencies
The most common causes of circulatory impairment/shock in children which will be covered in
this section are severe dehydration (most often due to diarrhoea), sepsis, and severe anaemia,
and management is tailored to the underlying cause. Severely unwell children may have multiple
potential causes, and management must take into account the different possible underlying
conditions. Careful monitoring during and after stabilisation (or acute management) is vital to
ensure optimal survival and a positive outcome for the child.
Refer to relevant sections for further management of DKA (Chapter 9, Section 9.2) severe
haemorrhage (Section 2.5), trauma (Section 2.7), anaphylaxis (Section 2.4) and underlying
cardiac conditions (Chapter 6, Section 6.2).
a > 180 bpm in children < 12 months, > 160 bpm in children 1 to 5 years, > 140 bpm in children > 5 years.
b The temperature gradient is assessed by running the back of hand from the toe to the knee; a positive
temperature gradient is defined as a notable temperature change from cold (dorsum of foot) to warm (knee).
36
Chapter 2: Emergencies
Emergency management 2
– Move the child to a critical care area (emergency or intensive care) and assess rapidly while
stabilising or resuscitating:
• Take rapid history (SAMPLE) and try to determine underlying cause.
• Obtain age and weight of the child. Measure mid-upper arm circumference (MUAC) and
check for oedema as a rapid assessment for malnutrition.
– Assess and manage Airway and Breathing (see Section 2.1.1 and Section 2.1.2):
• Open airway and administer oxygen > 6 L/min via mask (use non-rebreathing mask if
available).
• Attach pulse oximetry and monitor; aim for SpO2 between 94-98%.
• Assist ventilation and oxygenation with bag-mask ventilation if needed.
– Assess and manage Circulation (see Section 2.1.2):
• Obtain IV/IO access.
• Perform rapid tests for Hb, BGL, malaria (where endemic) and send blood for culture, if
available, and blood group (see MSF Blood transfusion guideline).
• Administer parenteral fluids and/or bloodc IV/IO corresponding to specific cause of
circulatory impairment (see below: Specific management).
– Administer antimalarial treatment if malaria test positive.
– Treat hypoglycaemia (BGL < 3.3 mmol/L or < 60 mg/dL) with 2 mL/kg of glucose (dextrose)
10% IV/IO over 2-3 minutes, or 10 mL/kg via NGT. See Chapter 9, Section 9.3 for further
detail on ongoing management of hypoglycaemia.
– Administer ceftriaxone IV: 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) single dose as
soon as possible, within 1 hour of diagnosed circulatory impairment. Revise need for further
antibiotic treatment once underlying cause identified.
Parenteral fluids must be administered with caution in children with severe febrile
illness, pneumonia, malaria, meningitis, severe acute malnutrition, severe anaemia,
underlying cardiac conditions, renal failure or diabetic ketoacidosis. Adjust rate and volume of
fluid administration in these groups of children according to respective guidance and ensure
that a paediatric infusion set is always used, if available.
Specific management
Sepsis or severe febrile illness
– Administer maintenance fluids with glucose (dextrose) 5%/Ringer lactate (G5%/RL) IV/IO
(or glucose (dextrose) 5%/sodium chloride 0.9% (G5%/NaCl 0.9%) if RL is unavailable). See
Chapter 15, Section 15.2.
– Monitor and record vital signs, neurological status and urine output at least every
15-30 minutes, using an early warning system (see MSF Manual of Nursing Care Procedures,
Assessment and vital signs, Charts: Vital sign charts). Monitor carefully for any signs of fluid
overload.
– If deterioration or no improvement at all after 2 hours of IV fluids and IV antibiotics (as above),
check Hbd and administer a blood transfusion (see below and Chapter 10, Section 10.1.2).
Continue IV maintenance fluids while waiting for blood and stop during transfusion. Restart
IV maintenance fluids after completion of blood transfusion.
– See Chapter 3, Section 3.2 for ongoing management after stabilisation including antibiotic
advice.
c Always ensure bedside verification of ABO compatibility immediately before transfusion using an ABO testing
card.
d Blood transfusion for unresponsive sepsis is not strictly dependent on Hb, however if Hb is above 10 g/dL
transfusion may not be beneficial and decision to transfuse should be based on the balance of potential risks
and benefits.
37
Chapter 2: Emergencies
e Always ensure bedside verification of ABO compatibility immediately before transfusion using an ABO testing
card.
f Ensure temperature is checked and recorded at the time of ordering blood and immediately prior to transfusion
as a minimum.
g Blood transfusion for severe dehydration that is unresponsive to initial fluid resuscitation is not strictly
dependent on Hb, however if Hb is above 10 g/dL transfusion may not be beneficial and decision to transfuse
should be based on the balance of potential risks and benefits.
h Accurate urine output can only be measured if a urinary catheter is in situ or by weighing nappies.
38
Chapter 2: Emergencies
thiamine IV/PO
– Loading dose < 15 years: 100 mg slow IV infusion over 30 minutes once daily for
48 hours.
If IV not possible: give PO/via NGT at the same dose.
– Maintenance dose to be started after 48 hours of IV treatment:
• ≤ 12 years: 25 mg PO once daily for 1 month
• > 12 years: 25 mg PO twice daily for 1 month
39
Chapter 2: Emergencies
i Requires accurate blood pressure measurement. Weak pulse is not a reliable proxy for low blood pressure.
40
Figure 2.5 - Treatment algorithm for circulatory impairment/shock
Critically unwell child with signs of circulatory impairment or shock (one of more of the following):
Weak radial pulse or severe tachycardia*, lower limb temperature gradient, CRT ≥ 3 secs
ABCDE
• Open airways and start oxygen > 6 L/min via mask
• Get IV/IO access and check Hb
• Check BGL and treat if hypoglycaemic
• Malaria test (if endemic) and treat if positive
• Administer ceftriaxone 80 mg/kg single dose**
Sepsis/severe febrile illness Severe anaemia (Hb < 6 g/dL) Severe dehydration
• Give maintenance fluids • Urgent blood transfusion • Start WHO treatment plan C
• Reassess every 15 - 30 mins • Start maintenance fluids or ‘Plan C SAM’
• If no improvement after 2 while awaiting transfusion • Reassess every 15 - 30 mins
hours of IV fluids: recheck • Reassess every 15 - 30 min • If no improvement after 2
Hb and give blood hours of IV fluids: recheck
transfusion***
Hb and give blood
transfusion***
If signs of shock persist after maximum fluids and/or transfusion, see Fluid refractory shock
* > 180 bpm in < 12 months, > 160 bpm 1 to 5 years, > 140 bpm in > 5 years
** Revise necessity of further antibiotic treatment once underlying infection identified.
41
Chapter 2: Emergencies
*** If Hb is above 10 g/dL transfusion may not be beneficial and decision to transfuse should be based on the balance of potential risks and benefits.
2
Chapter 2: Emergencies
2.3 Choking
Effective cough:
– No external manoeuvres are necessary. Encourage the child to continue coughing. Effective
cough means that air is passing in/out of the upper airways and is the most effective way to
dislodge the foreign body. Do not interfere but monitor continuously.
– If the child is stable and there is a concern of a foreign body lodged in the oesophagus or
airway, obtain an x-ray.
Seen on x-ray Not seen on x-ray
Metal (except aluminium) Aluminium
Most animal bones Most wood
Glass Most plastic
Stones Most fish bones
42
Chapter 2: Emergencies
Figure 2.6 - Back blows in an infant Figure 2.7 - Back blows in a child
Re-assess:
– Turn the child around to face you or turn the infant to face upwards (Figure 2.8a to Figure 2.8b)
while continuing to support the body, neck and head, and look for any obvious foreign body
(if visible try to remove carefully, as above).
– Check if airway still obstructed and assess if conscious or not.
• If not conscious, start BLS (see Section 2.1.1).
• If still conscious but airway obstructed, move to Step 2 to give 5 chest thrusts (infant) or
abdominal thrusts (child).
43
Chapter 2: Emergencies
Figures 2.8 - Switching from back blows to chest thrusts in the choking infant
Figure 2.9 - Two-finger chest thrusts (infant) Figure 2.10 - Abdominal thrusts (child)
44
Chapter 2: Emergencies
Re-assess: 2
– Check if airway still obstructed and assess if conscious or not.
– Repeat Steps 1 and 2 continuously, assessing the child’s responsiveness, consciousness and
breathing.
– If at any point the foreign body seems visible, remove it carefully.
– If the foreign body seems to have dislodged or child seems to restart breathing effectively,
lay the child into recovery position and observe for any respiratory distress.
– If child deteriorates or becomes unconscious, start BLS (see Section 2.1.1).
Only discharge when stable and fully alert, and if clinical examination is normal. If the child lost
consciousness at any point during the episode, observe for at least 8 hours and assess prior to
discharge.
45
Chapter 2: Emergencies
2.4 Anaphylaxis
Anaphylaxis is highly likely when either of the following 2 criteria are met within hours:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal
tissue, or both (e.g. generalized urticaria, itching, flushing, swollen lips-tongue-uvula)
AND ≥ 1 of the following:
A. Respiratory symptoms (e.g. dyspnoea, wheeze or bronchospasm, stridor, hypoxia)
B. Low BP or associated symptoms of end-organ dysfunction (e.g. hypotonia, syncope,
incontinence)
C. Severe gastrointestinal symptoms (severe abdominal pain, repetitive vomiting)
OR
2.4.2 Management
– Identify quickly and remove external trigger (e.g. remove bee stinger; stop drug infusion if
potential likely cause).
– Assess and manage ABCDE including specifically:
• Prepare IM epinephrine as part of A.
• Assess for airway swelling: angioedema of lips, tongue, throat (laryngeal oedema). Can
child speak or do they feel they cannot swallow?
• If not breathing or cardiopulmonary arrest, start CPR (Section 2.1.1).
46
Chapter 2: Emergencies
Additional treatment
Any additional treatment should only be given after the initial emergency treatment of
anaphylaxis and should not delay continuation of adrenaline administration in refractory
anaphylaxis13.
– Administer corticosteroid if refractory anaphylaxis or ongoing asthma/shock to prevent or
shorten protracted reactions, using hydrocortisone IM or IV:
1 to 5 months 25 mg
6 months to 5 years 50 mg
6 to 11 years 100 mg
47
Chapter 2: Emergencies
Dose to be administered
Age
over 20 minutes
Follow-up
After an anaphylactic event, provide an explanation to the child and their parents/carers on
the condition, its presentation, recognition, and immediate treatment. If a trigger has been
identified, give advice on allergen avoidance.
48
Chapter 2: Emergencies
Shock in conjunction with clinical signs of haemorrhage (external and/or internal blood loss).
Causes include trauma, gastrointestinal bleeding, splenic rupture (due to severe sickle cell
disease, malaria or trauma) or diffuse bleeding due to haemorrhagic fever or dengue shock.
If there is ongoing significant bleeding, treat as haemorrhagic shock even if Hb ≥ 8 g/dL.
Haemoglobin may initially be normal in haemorrhagic shock as it takes time for the body to
equilibrate and for the haemoglobin level to reflect actual blood lost. Repeat Hb after 30 and
then 60 minutes if it is initially normal.
2.5.1 Investigations
– Hb, FBC, platelets, blood group and Rhesus
– BGL
– Urine dipstick (macroscopic haematuria suggests renal damage)
– Blood lactate, if available
– Electrolytes, urea nitrogen, creatinine, if available
– Prothrombin time (PT), Partial thromboplastin time (PTT), if available
2.5.2 Management
– Stop any obvious life-threatening external bleeding via compression or tourniquet. In the
case of severe trauma, refer to Section 2.7 for trauma management after stabilisation of
haemorrhagic shock.
– Ask or estimate weight of child.
– Assess and manage Airway and Breathing.
– Open airway (support airwas if necessary).
– Administer oxygen > 6 L/min via mask (use non-rebreathing mask if available) aiming for
SpO2 > 94%.
– Assist ventilation and oxygenation with bag-mask ventilation if needed.
– Check Circulation and get IV or IO access. Get blood for cross-matching, bedside ABO
compatibility, and order blood for transfusion.
– Transfuse 20 mL/kg whole blood as fast as possiblea; group O negative or cross-matched
blood, whichever is available faster. Repeat as necessary guided by clinical evolution, Hb,
platelets.
– Administer 20 mL/kg of IV Ringer lactate (or sodium chloride 0.9%) as a rapid bolus if blood is
not immediately available. Repeat bolus if necessary until blood is available for transfusion,
but be cautious as fluids may dilute coagulation factors and worsen bleeding.
– Reassess clinical condition and monitor and record vital signs every 15 minutes during
transfusion.
– Administer tranexamic acid IV: 15 mg/kg (max. 1 g).
– Warm child proactively to ensure temperature > 36.5 °C. Stop any air-conditioning and warm
all fluids and blood products.
– Insert a nasogastric tube (conical tip) open to air.
– Manage underlying cause of haemorrhage.
a Always ensure bedside verification of ABO compatibility immediately before transfusion using an ABO testing
card
49
Chapter 2: Emergencies
2.6 Drowning
2.6.1 Pathophysiology
Even a small amount of water aspirated into the airways causes significant alveolar damage
and surfactant dysfunction, leading to a clinical picture of non-cardiogenic pulmonary oedema
if the child is rescued alive. Clinically, aspiration (and sometimes laryngospasm) leads to
hypoxaemia, which rapidly leads to loss of consciousness, anoxic brain injury and respiratory
arrest. Without immediate rescue and resuscitation, cardiac arrest may result within seconds
or minutes. Hypothermia or ice-water drowning are the exception, where this process can last
an hour20.
2.6.2 Management
Objective is to:
1. Reverse hypoxia and maintain adequate oxygenation.
2. Prevent aspiration.
3. Reverse hypothermia and stabilise body temperature.
50
Chapter 2: Emergencies
Note: the Heimlich manoeuvre or other postural drainage techniques to ‘drain’ water from the 2
lungs lack evidence to demonstrate value and are not recommended. Rescue breaths should
not be delayed in order to carry out such manoeuvres.
e Clothes should be cut off in case of suspected spinal injury to avoid excessive movement of the neck.
51
Chapter 2: Emergencies
Prevent aspiration
– Vomiting is common following drowning and complications due to aspiration occur
frequently in children with altered consciousness.
– If reduced consciousness, insert a nasogastric tube (conical tip) to remove swallowed water
(or debris).
Hypothermia
– Remove wet clothes and dry the child (if not already done).
– Wrap with blankets or survival blanket and minimise exposure.
– If core temperature < 35.5 °C, start active warming where possible:
• Use warmed blankets, heating pads, survival blankets, etc. depending on availability.
• Administer warmed IV fluids or pass IV fluids via a warmer device, if available.
Hypoglycaemia
– Check BGL and treat hypoglycaemia if BGL < 3.3 mmol/L or < 60 mg/dL with 2 mL/kg of
glucose (dextrose) 10% IV/IO over 2-3 minutes, or 10 mL/kg via NGT.
2.6.3 Investigations
– No routine investigations required if asymptomatic and alert.
– Perform FBC, BGL and electrolytes (if available) if altered mental status persists despite
resuscitation (absence of hypoxia) or if initial cause of drowning not known, e.g. traumatic
brain injury, hypoglycaemia, another medical condition.
52
Chapter 2: Emergencies
2.7 Trauma 2
Unintentional trauma, particularly road traffic injuries, falls, drowning, poisoning and burns,
are amongst the leading causes of global deaths amongst children22. Over 95% of injury related
paediatric mortality occurs in low- and middle-income countries. Road traffic injury alone is
the leading cause of death amongst 15- to 19-year-olds and the second leading cause of death
in children 5 to 14 years. Additionally, children are often victims of trauma and violence in
conflict-affected settings23. For drowning (Section 2.6), burns (see MSF Clinical Guidelines)
and poisoning (Section 2.9) refer to respective chapters.
This chapter covers the management of a child with possible multiple severe injuries due to
trauma. The aim is to assess and rapidly identify life-threatening injuries such as24:
– Airway obstruction
– Breathing difficulties with chest injuries
– Circulation problems due to severe bleeding (internal or external)
– Disabilities: head and spinal injury.
53
Chapter 2: Emergencies
– Where feasible, consider the need for a definitive airway (ETT, tracheostomy).
– If not breathing, start bag-mask ventilation while continuing assessment.
Breathing
– Look, listen and feel to assess breathing (see Section 2.1.1).
– If breathing, check if efficient and adequate: assess RR, SpO2, chest movement, intercostal
or subcostal recession, tracheal deviation, air entry or additional sounds on auscultation.
– Administer oxygen > 6 L/min via mask (use non-rebreathing mask if available), aiming for
SpO2 > 94%.
– Examine chest for any bruising, injury (closed or open), and for blood (haemothorax) or air
(pneumothorax) in the pleura (see also Section 2.7.3):
• For tension pneumothorax: insert large bore needle in 2nd intercostal space mid-clavicular
line, or 5th intercostal space mid-axillary line to immediately release tension.
• For pneumothorax or haemothorax: insert a chest drain.
– Insert gastric tube to avoid gastric distension (use orogastric route in the case of head
trauma).
Circulation
– Assess HR, CRT, BP, signs of impaired circulation and shock. Note that even with significant
bleeding, children may initially have normal BP and Hb, with or without tachycardia, but
have an altered mental state indicating circulatory impairment.
– Get IV/IO accessa (use large bore cannulae, ideally 2 sites) and take blood for Group and
crossmatch, Hb and BGL.
– If in shockb, start appropriate treatment:
• Administer 20 mL/kg IV Ringer lactate (or sodium chloride 0.9%) as a rapid bolus.
• If no response or transient response to initial fluid bolus, administer blood transfusion as
for haemorrhagic shock: whole blood 20 mL/kg as rapidly as possible.
– Control any major bleeding:
• Apply direct pressure or compression to any external sites of haemorrhage. Consider
temporary use of a tourniquet or blood pressure cuff if necessary to reduce bleeding
(refer to MSF Tourniquet for Haemorrhage Control protocol).
• For suspected pelvic fracture, stabilise using a pelvic binderc or a folded wrap around the
child at the level of the greater trochanters and secured in place.
• Reduction: immobilise any obvious long-bone fractures using splintsd.
– Administer tranexamic acid IV, 15 mg/kg (max. 1 g) if within 3 hours of injury.
– Initiate surgical consultation for definitive bleeding control if required.
– Once circulation is stabilised, perform ‘Extended Focused Assessment with Sonography in
Trauma’ (EFAST) Point-of-Care Ultrasound (POCUS) exam for patients with blunt abdominal
or chest trauma, if trained (see below for more detail).
Disability
– Assess level of consciousness using AVPU or Glasgow Coma Scale (GCS, see Appendix 13),
and check pupils.
• If unconscious, insert an NGT (or orogastric tube (OGT) if concern of basal skull fracture) if
not already done. Leave on free drainage. Keep nil by mouth (NBM) until alert and stable.
a Note that all fluids or drugs that are administered via IO require application of pressure either manually or via
pump.
b Haemorrhagic shock is most common in trauma, but cardiogenic or neurogenic shock may also be associated.
c EMEQPEBI1M PELVIC BINDER, medium (SAM Sling II)
d EMEQSPLM1190 MOULDABLE SPLINT, 11 x 90 cm; EMEQSPLM1590 MOULDABLE SPLINT, 15 x 90 cm;
EMEQSPLM1145 MOULDABLE SPLINT, 11 x 45 cm
54
Chapter 2: Emergencies
– Check BGL. 2
– Check for active movement of extremities.
– Aim to minimise any further injury to the brain by ensuring adequate oxygenation and
intravascular fluid volume and pressure.
– Administer analgesia.
– Assess temperature and take measures for aggressive hypothermia preventionf: use warming
blankets, fluids and blood warmer, warm the room.
Once the primary survey is completed and life-threatening conditions are stabilised, start
the secondary survey. Continue to assess and monitor ABCDE and if at any time the child
deteriorates, restart the primary survey.
55
Chapter 2: Emergencies
EFAST
Considerations
Outcome
56
Chapter 2: Emergencies
– Flexible spinal skeleton results in possible cervical spine injuries without radiographical signs 2
of fracture.
– Intracranial injuries more common (head size large in proportion to body size in younger age
groups).
– More blood loss with fracture of the long bones or pelvis.
– Initial good compensation to injuries then sudden decompensation.
– Medication and fluid calculations require the weight of the child. If recent weight unknown,
calculate an estimated weight based on age (see below) or use a colour-coded length-based
tape (e.g. Pediatapeg) that provides key drug and fluid doses by length.
Age-based weight estimation:
1 year and below: weight = (age in months/2) + 4
1 to 5 years: weight = (age in years x 2) + 8
6 to 12 years: weight = (age in years x 3) + 7
Note: neither the age-based or tape-based weight estimations can be used accurately in
children with severe acute malnutrition.
Head injury
For head injury, see Section 2.8.
Chest injury
Tension pneumothorax
– Tracheal deviation: pneumothorax is on the side that the trachea is deviated away from.
– Reduced air entry with hyper-resonant percussion on affected side.
– Emergency management required:
• Insert large bore needle into 2nd intercostal space mid-clavicular line, or 5th intercostal
space mid-axillary line to immediately release tension. Hissing sound of air being released
will be heard.
• Follow with insertion of chest drain.
Open pneumothorax
– Usually due to penetrating chest injury which allows air to be sucked into and blown out of
the wound site.
– Cover with a rectangular dressing that is taped on only 3 sides, allowing air to be expelled
during expiration but preventing it from being sucked in during inspiration.
– Follow with insertion of chest drain.
Massive haemothorax
– Reduced chest movement, reduced air entry and dull to percussion on affected side. If
bleeding significant, child may be in shock.
– Treat haemorrhagic shock (see Section 2.5) and insert chest drain prior to surgery (save
blood, if possible, in sterile container/bag for possible autotransfusion).
g Paediatric Triage Smart Tape or alternatives are Broselow tape or PAWPER tape.
57
Chapter 2: Emergencies
Pulmonary contusion
– Significant internal bruising usually due to blunt trauma.
– Hypoxia results from capillary bleeding that fills up alveoli.
– CXR may initially be normal but can later develop into full white-out from widespread
interstitial shadowing.
– Observe carefully, treat with oxygen to maintain SpO2 > 94% and consider respiratory
support where available (see Chapter 4, Section 4.1.3).
Flail chest
– Occurs if there are multiple rib fractures and a section of the rib cage is moving in the
opposite direction to the rest of the chest.
– Less common in younger children due to their mobile chest walls.
– Manage with analgesia (see Chapter 15, Section 15.4) and respiratory support (see Chapter 4,
Section 4.1.3), if necessary and available.
Abdominal injury
– Consider if abdominal pain, bruising, signs of shock or history of a high-risk mechanism of
injury (e.g. handlebar injury to the abdomen, high speed motor vehicle accident, fall from
great height).
– Visceral injuries might present with a negative EFAST and delayed onset of peritonitis. If in
doubt, admit for serial abdominal examinations and obtain surgical consultation early.
– Examine for: abdominal distension or rigidity, tenderness or guarding on palpation, presence
of blood in urethral meatus (if present, do not catheterise).
– Investigate with: POCUS (EFAST) where available to assess for bleeding into the abdomen
(see above). Upright CXR for presence of free air under diaphragm indicating perforated
bowel.
– Treatment: decompress stomach with NGT if not contraindicated. Refer for surgical
exploration or intervention where possible.
Pelvic trauma
– Fracture of the pelvic bone causes massive internal bleeding and there may be injury to the
bladder and bowel.
– Examine: palpate for tenderness by gentle bilateral compression of the iliac crests from
lateral to medial. Assess for abnormal or asymmetric motion, crepitus, and/or pain. Check
urethral meatus for blood and perform rectal exam.
– Investigate: Pelvic x-ray to check for fracture of pelvic ring. POCUS (EFAST) where available
to look for free intraabdominal fluid (bleeding).
– Treatment: treat shock (see Section 2.2) and give analgesia (see Chapter 15, Section 15.4).
Apply pelvic stabiliser (correct level is at anterior superior iliac spines).
– Refer for surgery if open fracture.
58
Chapter 2: Emergencies
Common presentation to emergency departments, of which majority are minor head injuries
but few may have intracranial injury. The patterns of head injury in children differ to those
in adults: developmental level of the child, anatomical variations in the brain/head, the
possibility of inflicted head injury, and the response of the child’s brain to trauma. Delay in
diagnosis and intervention can have significant consequences on patient outcomes, but given
the difficulties in accessing neuroimaging and risks of exposure to radiation, the approach
needs to be systematic and based on risk stratification.
Risk stratification
Use risk stratification to guide management (Table 2.3). A high index of suspicion is required
for younger children due to the difficulty in clinical assessment. Children aged less than 1 year
are at particular risk and need to be assessed very carefully. There is also a greater risk of
inflicted injury in this age group. Patients in the high-risk group are more likely to have a
significant intra-cranial injury that would require neurosurgical intervention therefore referral
is indicated.
59
Chapter 2: Emergencies
60
Chapter 2: Emergencies
Risk stratification
High-risk group
Low- or intermediate-risk group
Or ≥ 2 intermediate-risk factors
NO YES
CT scan and
Observe for at
neurosurgical Normal CT least 6 hours
referral
Any deterioration or
development of any
high-risk sign
Abnormalities
Medical If patient
on CT scan
management remains stable,
should be
and close discharge home
managed as per
observation for with advice to
neurosurgical
at least return if any
advice if
24 hours concern
available
61
Chapter 2: Emergencies
2.8.2 Management
See also Figure 2.11, page 61 for management algorithm.
b Increased ADH secretion can cause water retention, leading to fluid overload.
62
Chapter 2: Emergencies
– Monitor BGL and treat hypoglycaemia (BGL < 3.3 mmol/L or < 60 mg/dL) with 2 mL/kg 2
of glucose (dextrose) 10% IV/IO over 2-3 minutes, or 10 mL/kg via NGT. See Chapter 9,
Section 9.3 for further detail on ongoing management of hypoglycaemia.
– Keep NBM if possible neurosurgical intervention (high risk patients under observation). Do
not insert an NGT if concern of basal skull fracture.
– Administer antibiotic treatment (cefazolin and metronidazole) for penetrating head injury.
Start immediately but do not delay referral.
– Monitor blood electrolytes, if available.
– Deep vein thrombosis (DVT) prophylaxis is not recommended in children.
Alternative: mannitol28,29
63
Chapter 2: Emergencies
2.9 Poisoning
a Various pesticides used in agriculture and insecticides cause both intentional and unintentional poisoning.
b It is estimated that 25% of the world’s crops are affected by mould or fungal growth. Mycotoxin (especially
aflatoxin) poisoning (sometimes acute) is a real public health concern.
64
Chapter 2: Emergencies
Clinical examination 2
– Full clinical examination (see Chapter 1, Section 1.3).
– Look for specific signs and symptoms that may indicate poisoning:
Investigations
– FBC, Hb, BGL
– Electrolytes, serum bicarbonate, urea and creatinine, if available
– Urine dipstick
– ECG, if available
– Chest x-ray, if suspected inhalational exposure
– Toxicology, if available
65
Chapter 2: Emergencies
– Administer high-flow oxygen via face mask, aiming to maintain SpO2 > 94%. Treat with
100% oxygen if suspected carbon monoxide poisoning (e.g. burns, found by heating device);
altered mental state, ‘reddish’ skin and lips.
– Get IV or IO access. If signs of circulatory impairment, treat as shock (see Section 2.2).
– Check BGL and treat hypoglycaemia. See Chapter 9, Section 9.3.
– Manage seizures (see Chapter 7, Section 7.2).
– Consider decontamination if appropriate: for potentially life-threatening ingestions or skin
exposure, refer to Section 2.9.4.
Supportive treatment
– Reassess ABCDE and the child’s clinical condition regularly and provide supportive treatment
accordingly.
– Protect airways, be particularly attentive in children with reduced consciousness or absence
of cough reflex.
– Administer oxygen if necessary, aiming to maintain SpO2 between 94% - 98%.
– Keep in recovery position and aspirate gastric contents if necessary. Keep NBM until alert.
– Close observation with vital sign monitoring. When clinically indicated and available, repeat
ECG every 6 to 12 hours.
– Start IV maintenance fluids while NBM to ensure adequate hydration. If there are signs of
impaired circulation, treat for shock (Section 2.2).
– Monitor temperature (treat fever with paracetamol if able to confirm paracetamol was not
source of poisoning or no signs suggestive of liver failure such as bleeding).
– Assess urine output. If there are signs of urinary retention, insert urethral catheter carefully.
– If aspiration of gastric contents suspected, start IV antibiotic treatment for pneumonia
(Chapter 4, Section 4.5.3).
66
Chapter 2: Emergencies
Specific management 2
– Seizures: treat with benzodiazepines (see Chapter 7, Section 7.2).
– Clinical signs or suspicion of muscarinic toxidrome: administer atropine.
– Clinical signs or suspicion of cytotoxic toxidrome: administer hydroxocobalamine IV:
70 mg/kg (maximum 5 g) over 15 minutes and sodium thiosulphate IV: 400 mg/kg (1.6 mL/kg)
maximum 50 mL (25% solution) where available.
Management of gastritis or gastrointestinal haemorrhage
– Keep NBM for 24 hours from the time of suspected ingestion or the time symptoms indicating
gastritis or gastrointestinal haemorrhage developed.
– If no signs of further bleeding after 24 hours, introduce oral fluids and monitor over 24 hours.
If this is well tolerated, solid food can be reintroduced.
– Administer omeprazole IV: 0.5 mg/kg slow IV (over 5 minutes) once daily.
– Once tolerating solid food, change to omeprazole PO: 10 mg (weight < 20 kg) or 20 mg
(weight ≥ 20 kg) once daily for 10 days.
Management of hepatic toxicity
– Signs of hepatotoxicity include coagulopathy, encephalopathy, hepatomegaly, and jaundice.
– Administer IV acetylcysteine in an intensive care unit where possible.
acetylcysteine IV: 300 mg/kg in glucose (dextrose) 5% IV perfusion total over 20 hours
• Loading dose: 200 mg/kg over 4 hours
• Followed by 100 mg/kg over next 16 hours
Monitor carefully. Anaphylaxis may occur, particularly in children with a history of
asthma.
– Monitor for signs of coagulopathy (bruising, bleeding, prolonged bleeding time). Only in the
case of active bleeding, administer a single dose of vitamin K slow IV: 1 to 2 mg in infants or
5 mg in children ≥ 12 months.
– Avoid antiplatelet and hepatotoxic drugs (NSAIDS, ibuprofen, paracetamol).
– Administer IV omeprazole as a precaution and treatment of gastrointestinal haemorrhage
(see above).
– Monitor BGL regularly and treat hypoglycaemia. See Chapter 9, Section 9.3.
– If signs of hepatic encephalopathy develop, lactulose may be given:
lactulose PO: < 1 year: 2.5 mL 2 times daily; ≥ 1 year: 10 to 30 mL 3 times daily
c Belladona plant also known as deadly nightshade, including the Datura species.
67
Chapter 2: Emergencies
Common causative
Drug group Common signs
agents
Cholinergic Muscarinic toxidrome Nicotinic toxidrome Organophosphates,
(muscarinic and DUMBELS: MTWtHFSS (days of the pesticides, nerve agents,
nicotinic receptor • Diaphoresis week in English): tobacco, liquid nicotine,
stimulation) • Urination • Mydriasis some mushrooms
• Miosis • Tachycardia
• Bronchorrhoea, • Weakness
bradycardia, • Hypertension
bronchospasm • Fasciculations
• Emesis • Seizures
• Lacrimation • Somnolence
• Salivation, Sweating
Cytotoxics Delayed abdominal pain, nausea, vomiting, Cyanogenic glycosides
altered mental status, seizures, cardiovascular (e.g. poorly processed
collapse, lactic acidosis, multisystem organ cassava)
failure.
Opioids Sedated, respiratory depression, bradycardia, Morphine, codeine,
hypotension, hypothermia, constricted pupils. fentanyl, methadone
Sedatives Reduced mental state, but mostly normal vital Barbiturates,
Hypnotics signs. Possible reduced RR and hypoglycaemia. benzodiazepines, ethanol,
amitraz (pesticide).
Sympathetic nervous Tachycardia (or bradycardia), hypertension, Amphetamines, cocaine,
system stimulants dysrhythmias, dilated pupils, delirium, delusions, decongestants, ephedrine,
paranoia, hyperreflexia, seizures, raised methamphetamines,
temperature, diaphoresis, piloerection. salbutamol
2.9.4 Decontamination
Eye decontamination
– Flush each eye with lukewarm water or sodium chloride 0.9% (≥ 1 L/eye) for 10-15 minutes.
– Refer to ophthalmologist, if available, for examination of the cornea.
68
Chapter 2: Emergencies
– Look for signs of the toxic substance within the gastric aspirates. 2
Caution: if possible caustic ingestion, aspiration or suctioning is contraindicated.
Absorption with activated charcoal36
The most effective way to decontaminate a child with moderate to severe poisoning is activated
charcoal, which can bind most therapeutic drugs and reduce further absorption from the
gastrointestinal tract. However, metals (including iron substances), corrosives, hydrocarbons
(gasoline, kerosene) and alcohols are poorly adsorbed by activated charcoal.
Activated charcoal:
– Can be administered up to 4 hours post ingestion.
– Is contraindicated in a child with reduced level of consciousness (unless intubated).
– Is contraindicated in gastrointestinal haemorrhage or corrosive ingestion.
Use with caution: aspiration of activated charcoal can cause significant morbidity and
even mortality. If giving via NGT, strictly confirm the tube is in the correct position first.
Give activated charcoal as soon as possible, within 4 hours of ingestion or if toxic substance is
found during stomach aspiration:
Paracetamol overdose
– Administer activated charcoal if within 4 hours of ingestion37. Activated charcoal may be less
effective in younger children if liquid paracetamol was consumed.
– Where possible, measure serum paracetamol levels.
– Administer IV acetylcysteine (as above) as an antidote in the following cases:
• Known toxic ingestion: acute ingestion of ≥ 200 mg/kg or repeated supratherapeutic
ingestion of > 100 mg/kg/day, or
• Signs of hepatic toxicity.
Methanol
Refer to MSF Methanol Poisoning protocol.
– Metabolite (formic acid) is highly toxic and responsible for metabolic acidosis.
– Contamination of traditional beverages (intentional or unintentional).
– History: consumption of household products (e.g. windshield liquid wash) or traditionally
made alcoholic contaminated beverages.
69
Chapter 2: Emergencies
– Key signs: tachypnoea (acidosis), blurred vision, abdominal pain, nausea, vomiting; can lead
to blindness, coma, death.
– If symptomatic, administer ethanol (via NGT) which will compete with methanol.
Organophosphates
Refer to MSF Exposure to Chemical Agents Manual.
70
Chapter 2: Emergencies
2.9.6 Prevention 2
Medicines are the most common product that causes accidental poisoning in children, and
particularly so in children under 5 years of age38. This can be avoided by ensuring that medicines
are not left in a place where children can reach them. Medicines should be stored safely in a
place that can be locked or cannot be accessed by children. If available, ask for containers with
child-proof caps. Dispose of any medicines that have expired.
Traditional medicine
If there are multiple cases of suspected poisoning from the use of traditional medicines, try to
identify the products and/or practices that are potentially harmful.
71
Chapter 2: Emergencies
References Chapter 2
1. Van De Voorde P, Turner NM, Djakow J, et al. European Resuscitation Council Guidelines
2021: Paediatric Life Support. Resuscitation. 2021;161:327-387.
https://doi.org/10.1016/j.resuscitation.2021.02.015
2. Houston KA, George EC, Maitland K. Implications for paediatric shock management in
resource-limited settings: a perspective from the FEAST trial. Crit Care. 2018;22(1):119.
https://doi.org/10.1186/s13054-018-1966-4
3. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric Advanced Life
Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation. 2010;122(18_suppl_3).
https://doi.org/10.1161/CIRCULATIONAHA.110.971101
4. Maitland K, Kiguli S, Opoka RO, et al. Mortality after Fluid Bolus in African Children with
Severe Infection. N Engl J Med. 2011;364(26):2483-2495.
https://doi.org/10.1056/NEJMoa1101549
5. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines
for the management of septic shock and sepsis-associated organ dysfunction in children.
Intensive Care Med. 2020;46(S1):10-67.
https://doi.org/10.1007/s00134-019-05878-6
6. Maitland K, Olupot-Olupot P, Kiguli S, et al. Transfusion Volume for Children with Severe
Anemia in Africa. N Engl J Med. 2019;381(5):420-431.
https://doi.org/10.1056/NEJMoa1900100
7. Muraro A, Roberts G, Worm M, et al. Anaphylaxis: guidelines from the European Academy
of Allergy and Clinical Immunology. Allergy. 2014;69(8):1026-1045.
https://doi.org/10.1111/all.12437
8. Simons FER, Clark S, Camargo CA. Anaphylaxis in the community: Learning from the
survivors. J Allergy Clin Immunol. 2009;124(2):301-306.
https://doi.org/10.1016/j.jaci.2009.03.050
9. Tanno LK, Bierrenbach AL, et al. Critical view of anaphylaxis epidemiology: open questions
and new perspectives. Allergy Asthma Clin Immunol. 2018;14(1):12.
https://doi.org/10.1186/s13223-018-0234-0
10. Simons FER, Ebisawa M, Sanchez-Borges M, et al. 2015 update of the evidence base: World
Allergy Organization anaphylaxis guidelines. World Allergy Organ J. 2015;8:32.
https://doi.org/10.1186/s40413-015-0080-1
11. Cardona V, Ansotegui IJ, Ebisawa M, et al. World Allergy Organization Anaphylaxis Guidance
2020. World Allergy Organ J. 2020;13(10):100472.
https://doi.org/10.1016/j.waojou.2020.100472
12. Simons FER, Ardusso LRF, Bilò MB, et al. World Allergy Organization anaphylaxis guidelines:
Summary. J Allergy Clin Immunol. 2011;127(3):587-593.e22.
https://doi.org/10.1016/j.jaci.2011.01.038
13. Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers.
Accessed November 7, 2023.
https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-
treatment
72
Chapter 2: Emergencies
14. Kemp SF, Lockey RF, Simons FER, on behalf of the World Allergy Organization ad hoc 2
Committee on Epinephrine in Anaphylaxis. Epinephrine: the drug of choice for anaphylaxis.
A statement of the World Allergy Organization. Allergy. 2008;63(8):1061-1070.
https://doi.org/10.1111/j.1398-9995.2008.01733.x
15. MedicinesComplete — CONTENT > BNF for Children > Drug: Hydrocortisone. Accessed
November 7, 2023.
https://www.medicinescomplete.com/#/content/bnfc/_164174358?hspl=hydrocostisone
16. Drowning. Accessed November 7, 2023.
https://www.who.int/news-room/fact-sheets/detail/drowning
17. Global Health Estimates. Accessed November 7, 2023.
https://www.who.int/data/global-health-estimates
18. World Health Organization. Global Report on Drowning: Preventing a Leading Killer. World
Health Organization; 2014. Accessed November 7, 2023.
https://iris.who.int/handle/10665/143893
19. World Health Organization. Preventing Drowning: An Implementation Guide. World Health
Organization; 2017. Accessed November 7, 2023.
https://iris.who.int/handle/10665/255196
20. Tipton MJ, Golden FStC. A proposed decision-making guide for the search, rescue and
resuscitation of submersion (head under) victims based on expert opinion. Resuscitation.
2011;82(7):819-824.
https://doi.org/10.1016/j.resuscitation.2011.02.021
21. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. Wilderness
Medical Society Practice Guidelines for the Prevention and Treatment of Drowning.
Wilderness Environ Med. 2016;27(2):236-251.
https://doi.org/10.1016/j.wem.2015.12.019
22. World Health Organization. Injuries and Violence: The Facts 2014. World Health Organization;
2014. Accessed November 7, 2023.
https://iris.who.int/handle/10665/149798
23. Peden M, World Health Organization. World report on child injury prevention. Published
online 2008:211. Accessed November 7, 2023.
https://iris.who.int/handle/10665/43851
24. Primary Trauma Care Course Manual for Trauma Management in Locations with Limited
Resources. Published online December 22, 2015. Accessed November 7, 2023.
https://www.primarytraumacare.org/get-involved/download-resources/
25. Crisp S, Rainbow J. Emergencies in Paediatrics and Neonatology. OUP Oxford; 2013.
26. World Health Organization. Pocket Book of Hospital Care for Children: Guidelines for the
Management of Common Childhood Illnesses. 2nd ed. World Health Organization; 2013.
Accessed November 7, 2023.
https://iris.who.int/handle/10665/81170
27. Dykes EH. Paediatric trauma. Br J Anaesth. 1999;83(1):130-138.
https://doi.org/10.1093/bja/83.1.130
28. Ropper AH. Hyperosmolar Therapy for Raised Intracranial Pressure. N Engl J Med.
2012;367(8):746-752.
https://doi.org/10.1056/NEJMct1206321
73
Chapter 2: Emergencies
29. Qureshi AI, Suarez JI. Use of hypertonic saline solutions in treatment of cerebral edema
and intracranial hypertension: Crit Care Med. 2000;28(9):3301-3313.
https://doi.org/10.1097/00003246-200009000-00032
30. Poison control and unintentional poisoning. Accessed November 7, 2023.
https://www.who.int/data/gho/data/themes/topics/indicator-groups/poison-control-
and-unintentional-poisoning
31. Chemical safety. World Health Organisation. Accessed November 7, 2023.
https://www.who.int/health-topics/chemical-safety
32. WHO Study Group on Tobacco Product Regulation. Accessed November 7, 2023.
https://www.who.int/groups/intox-network-of-poisons-centres
33. Diaz JH. Poisoning by Herbs and Plants: Rapid Toxidromic Classification and Diagnosis.
Wilderness Environ Med. 2016;27(1):136-152.
https://doi.org/10.1016/j.wem.2015.11.006
34. Erickson TB, Thompson TM, Lu JJ. The Approach to the Patient with an Unknown Overdose.
Emerg Med Clin North Am. 2007;25(2):249-281.
https://doi.org/10.1016/j.emc.2007.02.004
35. Harriet Lane Service (Johns Hopkins Hospital), ed. The Harriet Lane Handbook: A Manual
for Pediatric House Officers. Twenty second edition. Elsevier; 2021.
36. Clinical Practice Guidelines : Use of Activated Charcoal in Poisonings. The Royal Children’s
Hospital Melbourne. Accessed November 7, 2023.
https://www.rch.org.au/clinicalguide/guideline_index/Use_of_Activated_Charcoal_in_
Poisonings/
37. Buckley NA, Buckley N, Whyte IM, O’Connell DL, Dawson AH. Activated Charcoal Reduces
the Need for N -Acetylcysteine Treatment After Acetaminophen (Paracetamol) Overdose.
J Toxicol Clin Toxicol. 1999;37(6):753-757.
https://doi.org/10.1081/CLT-100102452
38. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the
American Association of Poison Control Centers’ National Poison Data System (NPDS):
32nd Annual Report. Clin Toxicol. 2015;53(10):962-1147.
https://doi.org/10.3109/15563650.2015.1102927
74
Chapter 3:
Acute febrile illness
3
3
Fever is a physiological response characterized by an elevation of body temperature above
normal daily variation1. It is defined as an axillary temperature of over 37.5 °Ca for all age
groups in this guideline2.
Fever is a common presentation of many paediatric conditions in all age groups. The most
common cause is infection. In children up to 3 years of age, around 80% of cases are due to
a viral infection, however, the younger the child is, the higher the probability that a fever is
due to a severe bacterial infection or sepsis1. Non-infectious causes include inflammatory,
immune-mediated, and neoplastic conditions. When the cause of a fever of less than one
week cannot be identified by history and clinical examination, it is classified as a ‘fever without
source’3.
Fever of unknown origin (FUO) is a diagnosis of exclusion and is defined in children as a
fever lasting more than one week with negative preliminary investigations (see Chapter 14,
Section 14.1).
a The definition of fever is generally accepted as a core temperature of more than 38 °C. Axillary temperature
is not an accurate reflection of core temperature, therefore the cut-off point is lower. It is recommended
to measure temperature when the child is at rest, in a comfortable environment and not wearing excessive
clothing. For accurate readings, the thermometer should be placed over the axillary artery for 3 minutes.
Rectal temperature is not recommended for hygiene and safety purposes.
77
Chapter 3: Acute febrile illness
Table 3.1 - Potential causes of fever with associated symptoms and signs
78
Chapter 3: Acute febrile illness
Anaemia Malaria
Bleeding signs (epistaxis, gingival bleeding, Viral haemorrhagic fevers, leukaemia, severe
haematuria), petechiae malaria, visceral leishmaniasis, dengue
Anaemia, jaundice, generalized body pain Sickle cell disease, malaria, dengue
b Note that in this age group severe infections can also present without fever or with hypothermia.
79
80
Figure 3.1 - Management of febrile infants 1 to 3 months WITHOUT signs of severe bacterial infection or sepsis
Malaria test and Hb, Febrile child > 3 months with fever for ≤ 72 h WITHOUT
if endemic region signs of severe bacterial infection or sepsis
If malnourished,
Search for focus of infection admit and start
Positive Negative on clinical examination amoxicillin PO:
50 mg/kg 2 times
daily for 5 days
Consider other
focus of infection Urine dipstick and Urine dipstick and
also, especially culture if possible culture if possible
if child doesn’t
quickly improve If child clinically
with treatment* well, send home
Negative Positive Negative
with advice on
when to return
Admit for clinical observation and monitoring for Treat for febrile UTI (see Chapter 8,
24 hours, malaria RDT, and search again for focus Section 8.1) and admit if necessary
81
* Children in malaria endemic regions often have concomittant infections.
3
82
Figure 3.2b - Management of febrile children above 3 months of age WITHOUT signs of severe bacterial infection or sepsis with fever > 72 hours
Malaria test and Hb, Febrile child > 3 months with fever > 72 h WITHOUT
if endemic region signs of severe bacterial infection or sepsis
If malnourished,
Search for focus of infection admit and start
Positive Negative (including ears, joints, skin) amoxicillin PO:
50 mg/kg 2 times
daily for 5 days
Chapter 3: Acute febrile illness
Non-pharmacological measures
– Undress the patient.
– Do not wrap children in wet towels or cloths (it increases their discomfort and increases risk
of hypothermia).
– Encourage drinking, especially for young infants continue frequent breastfeeding.
Pharmalogical measures
Give paracetamol and/or ibuprofen as antipyretics. Prescribe for maximum of one day and
re-evaluate need:
– paracetamol PO or via nasogastric tube (NGT): 15 mg/kg (maximum dose 1 g), every 6 to
8 hours as required (maximum 60 mg/kg/day or 4 g/day).
• In the case of SAM: 10 mg/kg, every 8 hours as required.
• IV paracetamol should not be used as an antipyretic, but is reserved for analgesia in the
case of children who are strictly nil by mouth (NBM).
• Paracetamol is not recommended in hepatic disorders
– ibuprofen PO: 10 mg/kg, every 8 hours as required (maximum 30 mg/kg/day) with milk or
food (to reduce the risk of gastrointestinal irritation).
• In the case of SAM: 5 mg/kg, every 8 hours as required. Do not give in Phase I of nutrition
treatment.
• Do not give to children younger than 6 months or with severe dehydration, renal failure,
gastrointestinal bleeding, or haemorragic fevers (including dengue).
Aspirin (acetylsalicylic acid) should not be used in children as an antipyretic due to the
risk of Reye’s syndrome.
Use paracetamol and ibuprofen with caution in malnourished children.
c There is no evidence that reducing fever decreases the morbidity or mortality from febrile illness (even malaria)
or prevents febrile seizures. Nor is there evidence that fever 40 °C or higher is associated with brain damage.
83
Chapter 3: Acute febrile illness
84
Chapter 3: Acute febrile illness
3
Sepsis is a clinical syndrome that usually results from severe bacterial infection, though may also
be caused by viruses and fungi. It is an uncontrolled and toxic systemic response that includes
inflammation, immune dysfunction, impaired circulation in the capillaries and oxygen deficit.
It can lead to multiple organ failure and death within hours in the absence of treatment. Even
with prompt and adequate administration of antibiotics, sepsis can be fatal if advanced vital
organ support, such as artificial ventilation and inotropic support, is unavailable. Bacteria that
commonly cause sepsis include Neisseria meningitidis, Streptococcus pneumoniae, Escherichia
coli, Staphylococcus aureus, Salmonella and Haemophilus influenza type B. In infants less than
3 months old, Listeria monocytogenes should also be considered4. Although sepsis can also
be caused by viruses and fungi, for the purposes of this chapter treatment will be focused on
the management of severe bacterial infection (the most common cause of sepsis in projects
where MSF works).
85
Chapter 3: Acute febrile illness
– Get IV access and start empirical antibiotic treatment as soon as possible, depending on
availabilitya:
First choice:
ampicillin IV: 50 mg/kg every 8 hours + gentamicin IV: 7.5 mg/kg once daily
or benzylpenicillin IV: 50 000 IU/kg (30 mg/kg) every 8 hours (max. 4 MIU or 2.4 g/dose)
+ gentamicin IV: 7.5 mg/kg once daily
Second choice:
ceftriaxone IV: 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) once daily
or cefotaxime IV: 50 mg/kg every 8 hours
or cloxacillin IV: 25 mg/kg every 6 hours + amikacin IV: 15 mg/kg once daily (if infection
with S. aureus and/or gram-negative bacteria and/or antibiotic resistant bacteria is
suspected)
If sepsis with signs of circulatory impairment or shock, treat as septic shock (see Chapter 2,
Section 2.2).
3.2.3 Investigations
– FBC (including differential WBC if possible)
– Blood glucose level (BGL)
– C-reactive protein (CRP), if available
– Malaria RDT, if endemic
– Blood culture (especially if purpuric rash is present)
– Urine dipstick, microscopy and culture, if available
– CXR or lung US if respiratory signs
– LP, if available and not contraindicated
a Empiric treatment with ceftriaxone/cefotaxime may be more appropriate in settings where invasive non-
typhoidal Salmonella are a major cause of bloodstream infection.
86
Chapter 3: Acute febrile illness
– Duration of antibiotic treatment should be determined by the child’s clinical condition and
response to treatment. Continue IV/IM treatment for at least 3 days and switch to oral when
the child is improving and eating and drinking. IV/IM treatment duration is likely to be longer
in younger, sicker children and in malnourished children. When clinically appropriate, switch
to amoxicillin/clavulanic acid (ratio 7:1 or 8:1) PO. Dosage expressed in amoxicillin: 3
• < 40 kg: 50 mg/kg 2 times daily
• ≥ 40 kg:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
Total antibiotic treatment should last for 7 - 10 days.
– If there is no improvement with antibiotic treatment, consider viral or fungal causes of
sepsis.
87
Chapter 3: Acute febrile illness
Epidemiology
The route of transmission varies by organism. Most bacteria that cause brain infections such
as meningococcus, pneumococcus, and Haemophilus influenzae are carried in the human
upper respiratory tract. They can be spread by respiratory droplets or throat secretions. The
incubation period is 4 days on average but can range between 2 and 10 days5. The highest
incidence of disease is registered in the African Meningitis Belt (region of sub-Saharan Africa),
with epidemics of meningococcal (Neisseria meningitidis A or C or W135) and pneumococcal
meningitis, generally occurring in the dry season (between October and April)5. Meningitis
can also propagate where people are living in close quarters (refugee camps, mass gatherings,
overcrowded households).
88
Chapter 3: Acute febrile illness
Diagnosis
Based on history (including immunisations) and clinical examination (including neurological
assessment).
First choice:
ceftriaxone IV: 100 mg/kg every 24 hours (max. 4 g)
or cefotaxime IV: 50 mg/kg every 6 hours
Second choice:
ampicillin IV: 50 mg/kg every 8 hours
or amoxicillin IV: 50 mg/kg every 12 hours
or benzylpenicillin IV: 100 000 IU/kg (60 mg/kg) every 6 hours (max. 4 MIU or 2.4 mg/
dose)
a Kernig sign: child is supine, one hip and knee are flexed to 90 degrees by the examiner, the examiner then
attempts to passively extend child’s knee: positive if there is pain along spinal cord, and/or resistance to knee
extension.
b Brudzinski sign: child is supine with legs extended, the examiner grasps child’s occiput and attempts neck
flexion: positive if there is reflex flexion of child’s hips and knees with neck flexion.
89
Chapter 3: Acute febrile illness
– Consider a lumbar puncture (LP, see below for more detail) if it can be done rapidly (within
30 minutes) and will not delay antibiotic administration (see Appendix 6). Ideally, the LP
should be done before antibiotic administration but if there is any contraindication or
likely delay, it may be performed 2 to 3 days later, once antibiotics have already been
initiatedc.
– Isolate the patient (where possible), ensuring that the patient can be closely monitored.
3.3.3 Investigations
– FBC (including platelets if possible)
– CRP, if available
– BGLd
– Malaria RDT, if endemic
– Blood culture (especially if purpuric rash is present)
– Perform an LP for CSF microscopy, biochemistry and culture, and GeneXpert (where
available).
• Ensure that there are no contraindications to doing an LP and that consent has been given
by the parent/carer.
• Contraindications for LP:
▹ Severe cardiopulmonary instability that potentially requires prompt resuscitation
measures (e.g. shock)
▹ Obvious signs of increased intracranial pressure (ICP), other than bulging fontanelle:
decerebrate or decorticate posturing, absent doll’s eye reflex, abnormal respiratory
pattern, unequal pupil size or dilatation of pupils
▹ Focal neurological signs
▹ Focal seizures or seizures within the last 30 minutes
▹ Bradycardia, hypertension
▹ Obvious bleeding disorder and/or low platelet count (< 80 000 platelets/microlitre)
▹ Skin infection over the site for LP
c CSF gram stain and culture will almost certainly be negative if LP is performed 2-3 days after antibiotics have
been commenced, but WBC, glucose and protein levels may remain abnormal.
d If CSF glucose is available, calculate the ratio of CSF glucose to blood glucose; in bacterial meningitis, it will be
< 0.6 (glucometer cannot be used to test CSF glucose as it is not sufficiently accurate).
90
Table 3.2 - CSF findings and interpretation
Bacterial Usually very Very low:< 40 mg/dL Typically > 1000, 100-500 Gram stain shows
Turbid, cloudy
meningitis elevated (2.2 mmol/L) mainly neutrophils Pandy test positive bacteria
91
3
Chapter 3: Acute febrile illness
Re-examination of CSF
Consider repeating LP if:
– Poor clinical response despite 24 to 36 hours of appropriate antibiotic treatment.
– Persistent or recurrent fever
In the context of a meningitis epidemic, refer to MSF Clinical Guidelines and MSF Management
of epidemic meningococcal meningitis guidelines.
e Increased antidiuretic hormone (ADH) secretion can cause water retention, leading to fluid overload.
92
Chapter 3: Acute febrile illness
– Where CSF culture is available and was taken before antibiotic treatment started, in the
case of a negative culture, consider stopping antibiotic treatment and continue only antiviral
treatment.
Cerebral malaria 3
See Section 3.4.
TB meningitis
See Chapter 4, Section 4.11.6 and MSF Tuberculosis Guidelines.
Cryptococcal meningitis
See Chapter 13, Section 13.2.
3.3.6 Complications
– Persistent fever after 4 to 6 days of treatment, consider:
• Nosocomial infection
• Subdural effusion or empyema
• Cerebral abscess or parameningeal foci of ongoing infection
• Inadequate treatment
– Purpura fulminans and skin necrosis if associated meningococcal septicaemia
– Hearing impairment
– Neurodevelopmental impairment
– Multi-organ involvement due to primary pathogen or secondary to septic shock
– Venous sinus thrombosis
– Persistent seizures, subsequent epilepsy
– Permanent focal neurological deficit
– Hydrocephalus
It is important to explain to the family the possibility of these complications and start to treat
them if they appear while the child is admitted (e.g. physiotherapy exercises to treat impaired
motor function and sensory integrity).
Neuroimaging
Where there is the possibility of neurosurgical intervention, consider CT scan of the head
(where available and can be read) for suspected complications including subdural empyema,
brain abscess, cerebral vascular thrombosis, or hydrocephalus.
f The use of adjuvant dexamethasone has no significant impact on overall mortality in either high- or low-
resource settings, though there is a favourable effect on mortality from meningitis due to S. pneumoniae if
given early in the course of the illness. In high-income settings only, adjuvant dexamethasone has been shown
to reduce hearing loss in meningitis due to H. influenza if given early in the course of the illness7.
93
Chapter 3: Acute febrile illness
12 to 17 years 500 mg
Although systemic fluoroquinolones are not routinely used as a first-line agent in children,
it is reasonable to use a single dose of ciprofloxacin as chemoprophylaxis for meningococcal
disease. Apart from chemoprophylaxis and hygiene measures in overcrowded households, the
best prevention possible is to ensure that most children receive adequate vaccinations against
the major pathogens causing meningitis (Streptococcus pneumoniae, Neisseria meningitidis,
Hib).
94
Chapter 3: Acute febrile illness
3.4 Malaria
3
Malaria is a parasitic infection caused by the protozoa Plasmodium which is transmitted to
humans via the bite of the female Anopheles mosquito. More rarely, malaria can also be
transmitted through transfusion of infected blood and transplacentally. 5 species of Plasmodium
can cause malaria in humans: P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi.
All species may cause uncomplicated malaria, while severe malaria is almost always due to
P. falciparum.
Malaria remains one of the leading causes of morbidity and mortality in children, mostly in
sub-Saharan Africa, despite being both preventable and treatable. In 2021, there were an
estimated 247 million cases of malaria worldwide, with 617 000 estimated deaths due to
malaria. 80% of these deaths were among children under 5 years old8.
Uncomplicated malaria
Defined as a person who presents with symptoms of malaria and has a positive parasitological
test, with no features of severe malaria (below). Signs of uncomplicated malaria are non-
specific with fever (or history of fever), general malaise, fatigue, headache, chills, abdominal
pain and muscle aches. Diarrhoea and vomiting, and pallor (from anaemia) are common in
children with malaria.
Severe malaria
In addition to the features of uncomplicated malaria above, patients present with one or more
of the following clinical or laboratory complications (based on WHO criteria9):
– Impaired consciousness: VPU on AVPU or < 3 on Blantyre Coma Scale (see Appendix 3 and
Appendix 13).
– Prostration: extreme weakness, unable to sit, stand or walk. Inability to feed in infants.
– Multiple seizures: > 2 episodes in 24 hours (generalised or focal onset)
– Acidosis: plasma bicarbonate level < 15 mmol/L or venous plasma lactate ≥ 5 mmol/L.
Acidosis can be suspected clinically in the presence of Kussmaula breathing.
– Hypoglycaemia: blood or plasma glucose < 2.2 mmol/L (< 40 mg/dL)b.
– Severe malarial anaemia:
• Children < 12 years old: Hb ≤ 5 g/dLc or haematocrit < 15%
• Children ≥ 12 years old: Hb < 7 g/dL or haematocrit < 20%
– Renal impairment: Urine output < 0.5 - 1 ml/kg/hr despite adequate hydration
a Kussmaul breathing is regular, rapid, deep, laboured breathing and is highly indicative of metabolic acidosis.
b This is definition of hypoglycaemia for diagnosis of severe malaria and does not correspond to the treatment
threshold, which is < 3.3 mmol/L (< 60 mg/dL).
c This definition is for the purposes of malaria severity classification according to the WHO and does not
necessarily indicate the need for blood transfusion.
95
Chapter 3: Acute febrile illness
3.4.2 Investigations
Parasitological diagnosis of malaria should be confirmed whenever possible using:
– Malaria rapid diagnostic test (RDT). Two different antigen tests exist, HRP2 and pan-pLDH,
which can also exist in combination:
• HRP2 tests are P. falciparum specific, but may stay positive for up to 42 days after the start
of anti-malarial treatment, therefore important to ascertain if patient has been treated
for malaria in the preceding 1-2 months and consider other causes of fevere.
• Pan-pLDH tests detect all species of plasmodium and are slightly less sensitive and specific
than HRP2, but become negative within 2-4 days after the start of treatment.
– Microscopy (thick and thin blood films)f:
• Thick blood films enable parasite detection and quantification.
• Thin blood films enable species identification, quantification and monitoring of
parasitaemia.
If testing is not available, treatment of suspected malaria (especially if severe) should not be
delayed. If malaria RDT is negative in a child with a high clinical suspicion of severe malaria,
treat as such but continue to look for other causes of fever and perform microscopy. If malaria
RDT is negative in a child without signs of severity, repeat RDT and/or microscopy in 2-6 hours
and continue to look for other causes of fever.
In addition to parasitological diagnosis, for all children with suspicion of severe malaria:
– Hb: to check for anaemia
– BGL: to check for hypoglycaemia
– Urine dipstick: to check for haemoglobinuria (indicating haemolysis)
3.4.3 Management
Uncomplicated falciparum malaria
Treatment of uncomplicated falciparum malaria is with artemisinin-based combination therapy
(ACT) given orally for 3 days, and full recovery is expected with prompt treatment. ACTs are
d A child may have several episodes of malaria in one year in high-transmission areas, which quickly leads to
severe anaemia as the Hb does not have time to recover to normal values between episodes.
e There are emerging strains of P.falciparum with genetic mutations to HRP2/3 making these tests less reliable
in affected areas e.g. Sudan.
f Accuracy of interpretation and quantification can be variable depending on the experience of laboratory staff.
96
Chapter 3: Acute febrile illness
Co-formulated tablets
Artesunate/amodiaquine
Blister child 4.5 to < 9 kg, tab of —> 1 tab once daily on D1, D2, D3
AS 25 mg/AQ base 67.5 mg, 3 tab/blister
(AS/AQ)
Blister child 9 to < 18 kg, tab of —> 1 tab once daily on D1, D2, D3
AS 50 mg/AQ base 135 mg, 3 tab/blister
Blister child 18 to < 36 kg, tab of —> 1 tab once daily on D1, D2, D3
AS 100 mg/AQ base 270 mg, 3 tab/blister
Blister child ≥ 36 kg, tab of —> 2 tabs once daily on D1, D2, D3
AS 100 mg/AQ base 270 mg, 6 tab/blister
Co-formulated tablets
Dihydroartemisinin/piperaquine
g Caution with use of primaquine in children with G6PD deficiency as primaquine-induced haemolysis may
occur.
97
Chapter 3: Acute febrile illness
AS/AQ AL
Quinine
The use of quinine PO is no longer recommended in MSF, however continues to be
recommended in some national guidelines in the absence of ACT. Follow local protocols for
dosing and administration.
Non-falciparum malaria
Most malaria in children is due to falciparum, which is the predominant species in Africa.
However, transmission of non-falciparum malaria is high in certain areas of the world,
predominantly in Asia, Central and South America, the Middle East and the Horn of Africa.
Treatment of choice for uncomplicated non-falciparum malaria is with ACT (see above),
h It is not necessary to continue parenteral treatment for minimum 24 hours in this case, and there is no need
to wait 24 hours before starting oral ACT after giving parenteral antimalarials.
98
Chapter 3: Acute febrile illness
however in areas where more than 5% of malaria diagnoses are due to non-falciparum malaria
and chloroquine is still effective, treatment with chloroquine (CQ) PO can be considered for
confirmed P. vivax or P. ovale mono-infection:
– Day 1: 10 mg base/kg once daily
– Day 2: 10 mg base/kg once daily 3
– Day 3: 5 mg base/kg once daily
The benefits of ACT over chloroquine include: quicker parasite clearance; promotion of
simplified protocols for all forms of uncomplicated malaria; longer half-lives of many ACTs
which provide a longer period of suppressive post-treatment prophylaxis against relapse and
reinfection; ensuring treatment of undiagnosed P. falciparum in possible mixed infectionsi.
Relapse can occur with P. vivax and P. ovale due to dormancy of parasites in the liver, therefore
treatment with primaquinej PO 0.25 to 0.5 mg/kg once daily for 14 days in children ≥ 15 kg can
be given to eliminate these parasites after initial treatment with CQ or ACT in all transmission
settings.
Severe malaria
Severe malaria is a medical emergency and all children with severe malaria should be
hospitalised:
– Assess and manage ABCDE (see Chapter 2, Section 2.2).
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress or severe anaemia
(pending transfusion).
– Obtain IV/IO access and take bloods for Hb and BGL, as well as blood culture (if available).
– Treat for hypoglycaemia if BGL < 60 mg/dL (3.3 mmol/L), see Chapter 9, Section 9.3.
– Administer parenteral anti-malarial treatment as soon as possible (see below).
– Administer antibiotic for possible sepsis or severe bacterial infection (see below).
– Treat any seizures (see Chapter 7, Section 7.2).
– Manage specific complications of severe malaria (see below):
• Severe anaemia
• Cerebral malaria
i For confirmed mixed infections (P. falciparum plus P. vivax or P. ovale), ACT is the treatment of choice, as
chloroquine is not effective against P. falciparum.
j Caution with use of primaquine in children with G6PD deficiency as primaquine-induced haemolysis may occur,
consider preventing relapse by giving 0.75 mg/kg once a week for 8 weeks under close medical supervision.
k Post-artemisinin delayed haemolysis (PADH) is a rare phenomenon which can occur 1-3 weeks after initiation
of treatment with injectable artesunate. Clinicians should be aware of this potential complication.
99
Chapter 3: Acute febrile illness
– First dose on admission (H0); second dose 12 hours after admission (H12)l; third dose 24 hours
after admission (H24); and then every 24 hours. If artesunate is unavailable, artemether IM
(should be stored separately and clearly labelled to avoid accidental IV administration):
• First dose: 3.2 mg/kg on admission
• Subsequent doses: 1.6 mg/kg once daily
– The use of quinine IV is no longer recommended in MSF, however continues to be
recommended in some national guidelines if neither artesunate nor artemether are
available. Follow local protocols for dosing and administration.
– Continue parenteral treatment for a minimum of 24 hours (3 doses of artesunate; 2 doses
of artemether) before switching to oral ACT to complete a 3-day course when the child is
improving and able to swallowm.
– Oral ACT can be started at any time after the last artesunate dose, it is not necessary to wait
24 hours before starting oral ACT after giving parenteral antimalarials.
– If the child is never able to tolerate oral treatment, continue parenteral treatment for 7 days.
Rectal artesunate does not count as the first dose of antimalarial treatment in severe
malaria. Any child who received rectal artesunate prior to arrival in hospital should
receive artesunate IV/IM (or artemether IM) as soon as possible, regardless of the time of
administration of rectal artesunate, and should complete a minimum of 24 hours of IV/IM
treatment.
l If the timing of the second dose does not coincide with a regular medication administration round, the second
dose can be administered earlier but never later than 12 hours after the first dose.
m If the child is still on parenteral treatment on day 5, continue until 7 days rather than switching to oral ACT.
100
Chapter 3: Acute febrile illness
Cerebral malaria
Cerebral malaria presents with a reduced level of consciousness (LOC) or coma, which may be
accompanied by seizures, and is a common presentation in young children. Seizures should
be managed in the same way as seizures due to any other cause (see Chapter 7, Section 7.2),
though phenobarbital should be used cautiously and only when respiratory support is available
due to increased risk of respiratory arrest in cerebral malaria. An isolated seizure with full
neurological recovery is likely to be a febrile seizure and is not indicative of cerebral malaria.
Children with cerebral malaria who have focal neurological signs or those who have ongoing
altered LOC following a seizure should be started on maintenance anticonvulsant medication
(see Chapter 7, Section 7.2).
It is impossible to distinguish cerebral malaria from meningitis in the absence of lumbar
puncture results, therefore all children with signs of cerebral malaria should be treated
concomitantly for bacterial meningitis:
– Consider an LP if it can be done rapidly (within 30 minutes) and there are no contraindications
(see Appendix 6). If not, LP can be performed after 2 - 3 days when the child has improvedo.
Antibiotics should not be delayed in order to carry out an LP.
– Start ceftriaxone IV: 100 mg/kg (max. 4 g) every 24 hours.
– Continue IV antibiotics for 10 days if LP confirms meningitis or if it is not possible to carry out
an LP.
– If LP excludes meningitis, continue antibiotics as for sepsis (see page 100).
n Young infants < 2 months of age have a significantly higher normal Hb than older infants (see Table 10.1,
page 299) therefore transfusion thresholds are higher.
o CSF gram stain and culture will almost certainly be negative if LP is performed 2-3 days after antibiotics have
been commenced, but WBC, glucose and protein levels may remain abnormal.
101
Chapter 3: Acute febrile illness
Supportive care
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Monitor BGL regularly and treat for hypoglycaemia if BGL < 60 mg/dL (3.3 mmol/L), see
Chapter 9, Section 9.3.
– Treat fever to improve comfort (see Section 3.1.3).
– Start IV maintenance fluids and/or feeds if tolerated (see Chapter 15, Section 15.2 and
Section 15.5). Restrict IV maintenance fluids to 70% of usual maintenance volume in cerebral
malaria due to the risk of cerebral oedema but be cautious with fluid restriction as children
tend to be dehydrated more than fluid overloaded.
– Monitor and document urine output (using a urinary catheter if possible):
• Aim for urine output ≥ 1 mL/kg/hour.
• Check regularly for haemoglobinuria.
• If no signs of dehydration and urine output < 1 mL/kg/hr for over 6 hours, administer trial
of furosemide IV, 1 mg/kg.
• If no response to furosemide, stop IV fluids and refer for management of renal failure.
– Monitor for signs of fluid overload.
– Provide specific care for children with impaired consciousness:
• Nurse with head elevated and in neutral position.
• Support and open the airway, clearing with suction only if necessary.
• Administer oxygen via face mask, aiming for SpO2 > 92%. Assist ventilation with bag-mask
device if not breathing.
• Regularly monitor neurological status (AVPU) and check pupillary response.
• Re-position child regularly to prevent pressure sores.
• Carry out regular mouth and eye care.
Discharge criteria
Consider discharge from hospital when child is:
– Clinically stable for at least 24 hours
– Tolerating oral ACTs (i.e. not vomiting)
3.4.4 Prognosis
Children with uncomplicated malaria can expect to make a full recovery with appropriate
treatment while mortality from severe malaria is approximately 10-20% even despite prompt
and adequate treatment. Left untreated, malaria is almost always fatal. Neurological sequelae
occur in approximately 15% of children following cerebral malaria and include epilepsy,
impaired cognitive function, neurodisabilities and behavioural disorders16. Children living in
endemic areas are at significant risk of re-infection with malaria, with repeated infections
carrying a higher likelihood of severe anaemia and a greater need for blood transfusion.
102
Chapter 3: Acute febrile illness
3.4.5 Prevention
Prevention of malaria through the use of long-lasting insecticide-treated bed nets and indoor
residual spraying, as well as through strategies such as seasonal malaria chemoprevention
(SMC) and perennial malaria chemoprevention (PMC) (previously known as intermittent 3
preventive treatment (IPT)) in endemic areas can significantly reduce the burden of disease in
children. The new malaria vaccine is an additional tool which, if used in combination with other
interventions, has the potential to alter malaria epidemiology and reduce malaria morbidity
and mortality over the coming years.
103
Chapter 3: Acute febrile illness
3.5 Tetanus
Tetanus is a vaccine-preventable disease that affects the nervous system, causing intensely
painful muscle spasms. Clinical features are due to the release of a potent neurotoxin by the
gram-positive, anaerobic bacterium Clostridium tetani which lives in soil and faeces and can
contaminate wounds, minor cuts or abrasions, and the umbilical stump (in neonates).
Tetanus remains endemic in resource-limited settings with low immunisation coverage, due
to poor hygiene practices during delivery and after birth, inadequate wound care, and lack
of availability of post-exposure prophylaxis. Incidence of tetanus increases following natural
disasters and in conflict and post-conflict contexts, due to disrupted vaccination programmes
and increased tetanus-prone injuries. Globally, tetanus disease burden is underestimated,
as tetanus surveillance systems are not well established in many endemic countries. While
the overall incidence of tetanus is decreasing, it remains responsible for at least 30 000 to
60 000 deaths each year, the majority of which are among neonates17,18,19. Tetanus case
fatality rate remains high in resource-limited settings20, where access to mechanical ventilation
is limited, therefore focus on vaccination programmes is essential to reduce morbidity and
mortality.
Tetanus-prone injuries include puncture wounds, foreign bodies, gunshot wounds, open
fractures, burns, and use of non-sterile instruments for cutting (e.g. umbilical cord), or for
intramuscular or subcutaneous injections.
Characteristic signs
Tetanus toxin interferes with the release of inhibitory neurotransmitters, leading to unopposed
muscle contraction. Initially, this manifests as stiffness before progressing to muscle spasms,
giving rise to the classic features of tetanus (see Figures 3.3, page 105):
– Trismus (‘lock-jaw’) and risus sardonicus (rigid smile) caused by facial spasm
– Opisthotonus
– Stiff neck
– Abdominal rigidity
– Dysphagia
Muscle spasms can be long and intensely painful and are easily triggered by external stimuli
(noise, touch, light). Patients with tetanus are awake and fully conscious.
a Local tetanus affects one extremity or body region and may be due to low toxin load. Cephalic tetanus is
localised to the head and neck, with cranial nerve involvement, and may be misdiagnosed as a stroke. Both
types usually progress to generalised tetanus.
104
Chapter 3: Acute febrile illness
Complications
– Pharyngeal and laryngeal spasms may lead to aspiration, airway obstruction, apnoeic
episodes and respiratory failure.
– In advanced disease, the autonomic nervous system is also affected, causing arrhythmias,
haemodynamic instability, fever, sweating, bowel and bladder dysfunction, and increased
respiratory secretions. The latter can complicate airway management as suctioning may
induce upper airway spasms.
Severity classification
The 'Ablett classification’22 categorises the severity of tetanus as follows:
– Grade I: mild trismus with little or no dysphagia, general rigidity with no spasms, mild or no
respiratory involvement
– Grade II: moderate trismus, marked dysphagia, fleeting spasms with moderate respiratory
involvement
– Grade IIIa: severe trismus, severe dysphagia, major spasms, severe respiratory involvement
– Grade IIIb: features of Grade IIIa with autonomic disturbance
Diagnosis is based on history and classic clinical findings. In mild or localised tetanus, diagnosis
can be challenging. Differential diagnosis may include poisoning (strychnine) or dystonic
reactions to drugs such as phenothiazines and metoclopramide. Always consider the possibility
of associated meningitis and when feasible, perform lumbar puncture for confirmation.
3.5.2 Management
Treatment consists of measures to prevent toxin production and uptake (wound care,
immunoglobulins, antibiotics), control of muscle spasms, and supportive care. For neonates,
see MSF Neonatal Care Guidelines.
b Photos, courtesy of Marianne Sutton, were taken and used with the consent of the respective patients/
parents/carers.
105
Chapter 3: Acute febrile illness
Supportive care
– Admit to an intensive care unit (where available)
– Establish a quiet environment or individual room where external stimuli are minimised
(light, noise and handling) without compromising surveillance and monitoring. Consider eye
shades and ear plugs to reduce stimuli.
– Monitor airway, breathing and circulation closely. Keep suctioning equipmentf and bag and
mask nearby in case of airway obstruction, apnoea or respiratory failure.
– Maintain adequate hydration using IV fluids (see Chapter 15, Section 15.2), as patients will
have increased fluid losses through fever and sweating and are at risk of rhabdomyolysis and
renal failure.
– Ensure adequate caloric intake via NGT (see Chapter 15, Section 15.5) as muscle spasms will
increase energy expenditure. Consider giving frequent, small feeds due to decreased gut
motility.
– Paralytic ileus may occur in severe tetanus with autonomic disturbance (see Chapter 12,
Section 12.3).
– Give adequate analgesia for muscle spasms (consider morphine), as they can be intensely
painful (see Chapter 15, Section 15.4).
– Treat fever, if present, for patient comfort (see Section 3.1.3).
– Where indicated, treat other infections (skin infection, sepsis, omphalitis) and be alert for
nosocomial infections which are frequent during prolonged hospitalisation.
– Administer tetanus vaccination, as recovery from tetanus infection does not confer immunity
(see Section 3.5.3).
c Administration of antitoxin via the intrathecal route has been of interest for several decades and although some
trials suggest benefit, there is currently insufficient evidence to recommend this route over IM administration.
d Some sources suggest higher doses of HTIG, refer to local or national guidelines where they exist.
e There is conflicting evidence on whether the use of antibiotics is truly beneficial in the treatment of tetanus,
however it is common practice to administer them and remains part of recommended treatment.
f Suction with caution, as this can provoke spasms.
106
Chapter 3: Acute febrile illness
Benzodiazepines
Although benzodiazepines are generally effective in controlling rigidity and spasms, they can
cause hypotension and respiratory depression and should therefore be administered under
close surveillance:
– Use diazepam emulsion, where available, rather than diazepam solution for intravenous 3
administration in young children, as it has fewer side effectsg. Dosing recommendations are
the same for both preparations.
– Start diazepam: 0.1 to 0.3 mg/kg by slow IV injection (over 3-5 minutes) every 1 to 4 hours.
Start at the lowest dose and titrate upwards depending on severity and persistence of
spasms, ensuring that adequate breathing is maintained.
– If IV route is not available, consider rectal administration using diazepam solution. Note:
diazepam emulsion should not be used intrarectally.
– If spasms persist despite hourly diazepam at maximum dose, start continuous diazepam
infusion: 0.1 to 0.5 mg/kg/hour. Increase cautiously by 0.1 mg/kg/hour to achieve spasm
control (max. 0.8 mg/kg/hour), ensuring that adequate breathing is maintained.
– Once spasms are controlled and the patient is improving, gradually decrease diazepam
(either hourly bolus or continuous infusion) as tolerated until it can be safely discontinued.
Consider switching to diazepam PO/NGT while weaning as soon as the patient can tolerate
oral/NGT intake. Do not stop treatment abruptly as this can trigger new onset of muscle
spasms.
Benzodiazepines (especially if administered concomitantly with opioids) can cause
respiratory depressionh. Ensure increased nursing care, resuscitation equipment (bag
and mask) and suction is available for immediate use if required and that antidotes are readily
available for emergencies.
In the event of respiratory depression caused by benzodiazepines, administer:
– Flumazenil IV over 15 seconds: 10 micrograms/kg every 1 minute (max 200 micrograms/
dose) as required until adequate breathing resumes.
Magnesium sulphate
Magnesium sulphate is a calcium antagonist that acts as a muscle relaxant and vasodilator and
prevents catecholamine release. It can be helpful in controlling spasms in tetanus in addition
to benzodiazepines25,26 in Ablett Grade IIIa and IIIb tetanus, when benzodiazepines alone do
not adequately control spasmsi. It should be used with caution due to its potential toxicity.
– Ensure child is cared for in a closely monitored environment with ICU level nursing care.
– Administer magnesium sulphate IV via a syringe pump: loading dose 100 mg/kg over
30 minutes followed by continuous IV infusion at 40 mg/kg/hour. Increase infusion rate by
5 mg/kg/hour every 6 hours (max. 100 mg/kg/hour) until spasms are controlled. A syringe
pump is mandatory for administration of magnesium sulphate.
– Regularly monitor and record blood pressure, respiratory rate, heart rate and other vital signs
using an early warning system (see MSF Manual of Nursing Care Procedures, Assessment
and vital signs, Charts: Vital sign charts).
– If available, monitor serum magnesium concentration to maintain levels within the
therapeutic range (2 - 4 mmol/L).
g Diazepam solution can cause pain on injection, thrombophlebitis and contains benzyl alcohol, benzoic acid and
propylene glycol that can be toxic for young children, especially in accumulated doses.
h Minimum respiratory rates in children: < 1 year = 30 breaths/min; 1-5 years = 25 breaths/min; 6-12 years =
20 breaths/min; > 12 years = 14 breaths/min.
i Other medications, such as chlorpromazine and phenobarbital, may be used for spasm control according to
local availability and protocol.
107
Chapter 3: Acute febrile illness
3.5.3 Prevention
Tetanus infection does not induce natural immunity following recovery from the acute illness
and patients can get infected again. All patients with clinical tetanus should therefore receive
tetanus vaccination, either at the time of diagnosis or during convalescence as follows28:
– Patient completely vaccinated: tetanus booster required
– Patient not vaccinated, partially vaccinated (< 3 doses) or status unknown: Begin or complete
the tetanus vaccination schedulej
See MSF Clinical Guidelines for tetanus routine immunisation and post-exposure vaccination.
j Tetanus vaccination schedule: at least 2 doses administered 4 weeks apart, a third dose 6-12 months later, and
additional doses administered according to national recommendations.
108
Chapter 3: Acute febrile illness
3
Enteric fever refers to both typhoid and paratyphoid fever which are bacteraemic febrile
illnesses. Typhoid fever is caused by Salmonella enterica serotype Typhi (formerly S. typhi),
while paratyphoid fever is caused by Salmonella enterica serotypes, Paratyphi A, B, or Ca.
Enteric fevers are endemic on the Indian subcontinent, Southeast Asia, Sub-Saharan Africa and
Latin America29 and mainly affect children under 15 years of age (with a peak between 5 and
9 years of age30). Millions of people are affected by enteric fever every year, with a global case
fatality rate of approximately 1%30. The risk of mortality is 4 times higher in children under
5 compared to over 5 years of age31. Enteric fevers are acquired by the ingestion of food or
water contaminated with excreta of symptomatic or asymptomatic carriers or by direct contact
(contaminated hands), and risk of infection is higher in areas with poor water and sanitation.
Climate change, urbanisation, overcrowded settings, and antibiotic resistance could potentially
increase the global burden of enteric fevers32.
a Note: Non-typhoidal salmonella (NTS) refers to illnesses caused by all other serotypes of Salmonella, and it is
a frequent cause of bacteraemia and anaemia in children living in areas of high malarial transmission.
b Rose spots are 1 to 5 mm, blanching, faint-colour pink macules-papules. They are typically distributed on
the chest, abdomen, and back, and they can persist for 2-3 days. They can rarely appear as haemorrhagic or
vesicular.
109
Chapter 3: Acute febrile illness
Differential diagnosis
The differential diagnosis of enteric fever is broad, with the main differential diagnoses
being malaria, bacterial gastroenteritis, amoebiasis, brucellosis, leptospirosis, leishmaniasis,
tuberculosis, and dengue fever.
3.6.2 Diagnosis
Diagnosis is made based on thorough medical history and full clinical examination. Culture
remains the gold standard for diagnosis but is rarely available in resource-limited settings,
therefore a diagnosis of presumptive enteric fever should be made if the following are present:
– Child appears toxic or severely unwell and/or
– Lives in an endemic area and has fever lasting over 1 week without other obvious cause,
and/or
– Severe abdominal pain
It is important to rule out malaria, in endemic regions, and acute abdomen e.g. appendicitis
(see Chapter 5, Section 5.4).
Possible investigations that can be performed:
– Blood culture (diagnostic)
– Stool or urine culture (may indicate chronic carriage rather than acute infection)34
– FBC: relative leucopenia (normal or slightly low white blood cell count despite bacteraemia)35.
Leucocytosis in the third week of illness should raise the suspicion of intestinal perforation
or an alternative diagnosis. Mild anaemia and thrombocytopenia are common.
– Widal-Felix agglutination reaction: not recommended due to poor specificity and sensitivity,
however this test is still used in certain endemic countries as it is cheap. It should not be
performed before the second week of illness. Two samples must be collected 10-15 days
apart to detect an increase in antibodies.
3.6.3 Management
Children with suspected severe enteric fever (systemic illness, unable to drink or eat, not
tolerating oral medications, altered consciousness, prolonged fever, organ system dysfunction)
should be admitted to hospital, and isolated if possible (see MSF Manual of Nursing Care
Procedures for IPC guidance). Uncomplicated cases can be managed as outpatients, with
advice on recognition of danger signs and when to seek medical attention.
Supportive care for severe cases includes:
– Oxygen if necessary to maintain saturations ≥ 92%
– Maintenance IV fluids if unable to eat or drink (see Chapter 15, Section 15.2)
– Treatment of fever (see Section 3.1.3)
– Treatment of pain if present (do not give analgesics systematically as may mask symptoms
of peritonitis)
110
Chapter 3: Acute febrile illness
– Monitoring and recording of vital signs as often as required using an early warning system
(see MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
Antibiotic treatment 3
Antibiotic choice is complicated by the spread of multi-resistant strains (increasing resistance
to first-line antibiotics: chloramphenicol, ampicillin and cotrimoxazole) and has led to the
frequent use of fluoroquinolones. Fluoroquinolone resistance is now also increasing and is
currently endemic in Asia, particularly South Asia and East Asia, with increasing resistance
reported in the Middle East36. Data from African settings is limited but reported rates of
fluoroquinolone and multidrug resistance are increasing, particularly in Democratic Republic
of Congo (DRC), Tanzania, Ghana, Kenya, Uganda and Nigeria36,37. Culture and antibiotic
susceptibility studies are therefore critical to guiding treatment, but they are rarely available in
resource-limited settings: empiric treatment on the assumption of fluoroquinolone resistance
is therefore prudent. If available, recent regional data on susceptibility of isolated strains can
help to guide treatment where local antibiograms are not available. It is important to note that
fever may persist for 4 to 5 days after the start of effective treatment, therefore ongoing fever
alone is not an indication to change antibiotic treatment.
Uncomplicated cases
First choice Azithromycin PO: 10 to 20 mg/kg (max. 1 g) once daily for 7 days
Alternative Cefixime PO: 10 mg/kg (max. 200 mg), 2 times daily for 10-14 days
c Start parenteral treatment and switch to oral route as soon as possible once the patient improves, to complete
recommended total days of treatment.
111
Chapter 3: Acute febrile illness
If peritonitis is suspected, add metronidazole IV: 10 mg/kg (max. 500 mg) every 8 hours for
7-10 days, unless meropenem is usedd. If no improvement in 48 hours, or perforation is
suspected make the patient NBM, place an NGT and leave on free drainage and refer for
surgical review where possible.
In the case of enteric fever with severe systemic symptoms (shock, coma) in children older
than 3 months, add dexamethasone IV: initial dose 1 mg/kg followed by 0.25 mg/kg every
6 hours for a total of 48 hours (8 doses).
Relapse may occur, even in immunocompetent individuals. It usually occurs 2–3 weeks after
the resolution of the fever and should be treated with a second, longer course of antibiotics.
3.6.4 Prevention
WHO recommends vaccination with the typhoid conjugate vaccine in endemic regions38:
– Routine vaccination: a single dose of 0.5 ml IM at the same time as other vaccines
administered at the age of 9 months or in the second year of life.
– Catch-up vaccination (same dose) up to 15 years of age: according to national
recommendations.
112
Chapter 3: Acute febrile illness
3.7 Measles
3
Measles is an epidemic-prone, highly contagious viral infection that mainly affects children.
It is caused by a paramyxovirus virus (Morbillivirus) and is spread by the airborne route via
large respiratory droplets. Measles is a vaccine-preventable disease and immunisation
against measles is included in all vaccination calendars worldwide. Despite this, measles was
responsible for more than 140 000 deaths in 2018, the majority of whom were children under
5 years old39. Children with malnutrition are especially vulnerable to measles and at risk of
developing severe complications, with measles mortality as high as 15%40.
Measles is a notifiable disease, and all cases should be reported to local or national public
health authorities.
Prodromal phase
– High fever (39-40 ⁰C)
– Classic triad of cough (usually non-productive), coryza (runny nose) and conjunctivitis (red,
watery eyes).
– Koplik’s spots: tiny bluish-white spots on an erythematous base found on the inside of the
cheeks which are pathognomonic of measles. They typically appear 1-2 days before the
onset of rash but can be hard to see and may not be observed in all patients with measles.
– Usually lasts for 2 to 4 days.
Eruptive phase
– Erythematous, blanching maculopapular rash that starts on the face and spreads in a
descending manner to the neck, trunk, abdomen and lower limbs over the course of 3 to
4 days.
– Fever subsides as the rash reaches the feet, and the rash subsequently recedes in the same
order as it appeared.
– Usually lasts for 4 to 7 days.
– Desquamation (peeling) of the skin around 1 to 2 weeks after the rash is common.
Any child presenting with fever, rash and one of cough, coryza or conjunctivitis should be
considered a clinical measles suspect.
Complications
Acute complications of measles are frequent and are the cause of the majority of deaths from
measles. The most common acute complications affecting children are:
– Respiratory: pneumonia (with or without empyema), otitis media, croup (laryngotracheo
bronchitis)
– Gastrointestinal: diarrhoea (with or without dehydration), stomatitis
– Ocular: purulent conjunctivitis, keratitis, xerophthalmia (due to vitamin A deficiency
exacerbated by measles)
– Neurological: febrile seizures, encephalitis (rare)
113
Chapter 3: Acute febrile illness
Post-infectious complications occur after initial resolution of measles but may also be fatal:
– Malnutrition: provoked or exacerbated by measles
– Immunosuppression: temporary immune depression following measles that increases the
risk of severe illness from respiratory infections and diarrhoea.
– Noma (gangrenous gingivostomatitis): a non-specific complication of measles associated
with extremely high mortality rates (see Chapter 14, Section 14.3).
– Subacute sclerosing pan-encephalitis (SSPE): a rare complication of measles, this progressive
degenerative disease occurs several years (average 7 years) after infection with measles.
Investigations
– Collect samples (usually serum, throat swab or urine sample) to send to relevant reference
laboratory (see MSF Collection, storage and transport of samples from field to reference
laboratory) for detection of IgM antibodies. Check local protocols for sample collection prior
to sampling.
– After confirmation of measles outbreak, it is not necessary to take samples from every
suspected case if they meet the clinical case definition and have had contact with known
measles cases.
3.7.2 Management
Uncomplicated measles
Most children with measles can be managed at home with advice on eye, nose and mouth
care, nutrition, fever management and recognition of signs of complications.
Antibiotics
Systematic antibiotic prophylaxis for uncomplicated cases is not recommended by WHO.
However, systematic antibiotic prophylaxisa for uncomplicated measles in children under
5 years old is recommended by MSF in most projects where they work due to the additional
risks inherent to such contexts i.e. situations where identification and/or treatment of
superimposed bacterial infections may not be possible (due to difficult access to healthcare,
limited capacity of health services) and where there is a high prevalence of vulnerable people.
Vitamin A
Give vitamin A to all acute measles cases under 5 years old, regardless of previous recent
vitamin A administration:
– Infants < 6 months: 50 000 IU once daily for 2 days
– Infants 6 to 11 months: 100 000 IU once daily for 2 days
– Children 12 to 59 months: 200 000 IU once daily for 2 days
This is usually the only systematic treatment required for children with uncomplicated measles.
A third dose should be given to children with signs of vitamin A deficiency (xeropthalmia,
corneal ulceration), 4 to 6 weeks laterb.
Conjunctivitis
Non-purulent conjunctivitis with clear, watery discharge does not require specific treatment,
simply wash the eyes 2 times daily with clean water. If purulent or cloudy discharge present,
treat for superimposed bacterial infection with tetracycline 1% eye ointment 2 times daily for
7 days.
114
Chapter 3: Acute febrile illness
Complicated measles
Admit all children with measles who have malnutrition and those with acute symptoms that
cannot be managed at home, including:
– Moderate or severe respiratory distress
– Stridor
3
– Inability to feed (due to extensive oral lesions, vomiting, lethargy)
– Altered consciousness or seizures
– Moderate or severe dehydration
– Corneal lesions (pain, erosion, opacity, photophobia)
Infection prevention and control measures
– Isolate suspected cases to a single room with dedicated nursing staff and equipment to
reduce the risk of cross-infection.
– Ensure transmission-based precautions are taken, including correct use of personal
protective equipment (PPE).
– If multiple cases, group together with other cases in a separated area from other patients
(cohorting).
– Cases should remain isolated until 4 days after the appearance of the rash, as they are still
infectious during this time.
Supportive care
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress.
– Ensure adequate fluid and calorie intake (risk of weight loss). Give small and frequent oral
feeds if possible. Some patients need NGT feeding or IV maintenance fluids (see Chapter 15,
Section 15.2 and Section 15.5).
– Give vitamin A PO systematically, as above.
– Test for malaria in endemic areas, and treat if RDT positive.
– Treat fever, if required, for patient comfort (see Chapter 3, Section 3.1.3).
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– If conjunctivitis, wash the eyes with clean water 2 times daily.
– Administer tetracycline 1% eye ointment, as above, if purulent or cloudy eye discharge
present.
– Wash the mouth with salted water 4 times daily, if possible.
– Keep skin clean and dry and monitor for signs of infection.
– Manage pain with adequate analgesia (see Chapter 15, Section 15.4).
Treatment of specific complications
Empiric antibiotic treatment should be started early if there is a suspicion of a superimposed
bacterial infection40. Refer to the relevant chapter for management of specific complications:
– Pneumonia (see Chapter 4, Section 4.5)
– Empyema (see Chapter 4, Section 4.6)
– Croup (laryngotracheobronchitis, see Chapter 4, Section 4.2)
– Dehydration (see Chapter 5, Section 5.3)
– Seizures (see Chapter 7, Section 7.2)
– Sepsis or severe bacterial infection (see Chapter 3, Section 3.2)
– Urinary tract infection (see Chapter 8, Section 8.1)
Refer to MSF Management of a measles epidemic for:
– Outbreak investigation and surveillance methods
– Mass vaccination campaigns
115
Chapter 3: Acute febrile illness
3.7.3 Prevention
– Vaccination is highly effective at preventing infection with measles and two doses confers
life-long immunity.
– Measles vaccine can be monovalent but is frequently combined with rubella and mumps in
a single MMR vaccine.
– Measles vaccine is part of routine childhood immunisation (as part of the Expanded
Programme on Immunisation) with primary dose at 9-12 months and second dose at
15-18 months.
– Catch-up vaccination (missed routine vaccination) should be done at any opportunity in
unvaccinated individuals.
116
Chapter 3: Acute febrile illness
3
Orbital cellulitis is an infection within the orbit of the eye, affecting the muscular and adipose
tissues posterior to the orbital septum (therefore called post-septal). It is a clinical emergency
requiring urgent referral for surgical management where possible. Major complications include
intracranial infection (abscess, empyema, meningitis), irreversible damage to the optic nerve,
loss of vision, or venous sinus thrombosis41.
Predisposing factors include sinusitis, otitis media, complicated periorbital cellulitis, orbital
trauma (e.g. fractured orbit) and foreign bodya.
Peri-orbital cellulitis is an infection of the eye lid and surrounding skin anterior to the orbital
septum (therefore called pre-septal)42. Predisposing factors include upper respiratory tract
infections, sinusitis, local trauma, insect bites and foreign bodyb.
Neither orbital nor peri-orbital cellulitis involve the ocular globe itself.
The most common causes of both conditions are Streptococcus pneumoniae, H. influenzae type
B (Hib), Moraxella catarrhalis, Staphylococcus aureus, Group-A beta haemolytic Streptococcus,
anaerobes (especially when odontogenic source) and Gram-negative bacilli (especially
post-trauma)43. Consider Neisseria gonorrhoea and Chlamydia trachomatis infections in
neonatal presentation (see MSF Neonatal Care guidelines). Consider Mucorales, Aspergillus,
Mycobacterium tuberculosis, in immunosuppressed children.
117
Chapter 3: Acute febrile illness
Differential diagnosis
– Allergic reaction (bilateral findings and/or painless oedema in a non-febrile child)
– Insect bite (unilateral macular spot on the eyelid)
– Conjunctivitis (mild oedema, eye secretions)
3.8.2 Management
If the patient presents with symptoms or signs of potential severe bacterial infection or sepsis,
treat as such (see Section 3.2).
Orbital cellulitis
– This is a medical emergency and requires urgent treatment.
– Admit and start IV antibiotic treatment as soon as possible:
ceftriaxone IV: 100 mg/kg loading dose on D1, then 50 mg/kg every 12 hours (daily max.
4 g if < 50 kg; max. 2 g if ≥ 50 kg)
+
cloxacillin IV: < 40 kg: 25 to 50 mg/kg every 6 hours (max. 8 g daily)
≥ 40 kg: 2 g every 6 hours
– Refer for surgical intervention urgently (where possible) for all cases of severe orbital
cellulitis or if there is suspected intracranial involvement.
– If signs of clinical improvement (reduction in swelling, erythema) after at least 5 days of
IV antibiotics, switch to amoxicillin/clavulanic acid (ratio 7:1 or 8:1) PO to complete 10 to
14 days of treatment (until erythema resolves). Dosage expressed in amoxicillin:
• < 40 kg: 50 mg/kg 2 times daily
• ≥ 40 kg:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
– Where surgery is not available and there is no clinical improvement after 48 hours of
treatment, suspect an orbital abscess and seek ophthalmological expert advice.
In case of pain or fever, give paracetamol (see Section 3.1.3).
Peri-orbital cellulitis
Mild: treat with oral amoxicillin/clavulanic acid (ratio 7:1 or 8:1) PO for 7 to 10 days. Dosage
expressed in amoxicillin:
– < 40 kg: 50 mg/kg 3 times daily
– ≥ 40 kg:
• Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
• Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
Monitor as outpatient and explain to parent/carer signs of increasing severity and when to
seek immediate medical consultation.
Moderate: moderate swelling, difficult (but possible) to open the eye, systemically unwell
(fever, malaise). Treat with ceftriaxone IV: 50 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg)
once daily. Switch to oral treatment as above when clinically improving (after at least 48 hours
of IV treatment) to complete 7-10 days total treatment.
Severe: < 3 months age, significant swelling, unable to do adequate eye exam, no Hib vaccine.
Treat as per orbital cellulitis (above).
118
Chapter 3: Acute febrile illness
YES
NO
NO
NO
NO
119
Chapter 3: Acute febrile illness
References Chapter 3
1. National Collaborating Centre for Women’s and Children’s Health (UK). Feverish Illness
in Children: Assessment and Initial Management in Children Younger Than 5 Years. Royal
College of Obstetricians and Gynaecologists (UK); 2013. Accessed November 20, 2023.
http://www.ncbi.nlm.nih.gov/books/NBK247907/
2. Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss B. Fever in Children: Pearls and Pitfalls.
Children. 2017;4(9):81.
https://doi.org/10.3390/children4090081
3. Arora R, Mahajan P. Evaluation of Child with Fever Without Source. Pediatr Clin North Am.
2013;60(5):1049-1062.
https://doi.org/10.1016/j.pcl.2013.06.009
4. Overview | Fever in under 5s: Assessment and Initial Management | Guidance | NICE.
NICE; 2019. Accessed November 20, 2023.
https://www.nice.org.uk/guidance/ng143
5. Meningitis. World Health Organisation. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/meningitis
6. Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book (2021): Report of the
Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
https://doi.org/10.1542/9781610025225
7. Brouwer MC, McIntyre P, Prasad K, Van De Beek D. Corticosteroids for acute bacterial
meningitis. Cochrane Acute Respiratory Infections Group, ed. Cochrane Database Syst Rev.
2015;2018(11).
https://doi.org/10.1002/14651858.CD004405.pub5
8. Fact sheet about malaria. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/malaria
9. World Health Organization. Guidelines for the Treatment of Malaria. 3rd ed. World Health
Organization; 2015. Accessed November 20, 2023.
https://iris.who.int/handle/10665/162441
10. WHO Guidelines for Malaria. World Health Organization; 2023. Accessed November 20, 2023.
https://www.who.int/publications-detail/guidelines-for-malaria
11. Nyirenda TS, Mandala WL, Gordon MA, Mastroeni P. Immunological bases of increased
susceptibility to invasive nontyphoidal Salmonella infection in children with malaria and
anaemia. Microbes Infect. 2018;20(9-10):589-598.
https://doi.org/10.1016/j.micinf.2017.11.014
12. Takem EN, Roca A, Cunnington A. The association between malaria and non-typhoid
Salmonella bacteraemia in children in sub-Saharan Africa: a literature review. Malar J.
2014;13(1):400.
https://doi.org/10.1186/1475-2875-13-400
13. Mooney JP, Galloway LJ, Riley EM. Malaria, anemia, and invasive bacterial disease: A
neutrophil problem? J Leukoc Biol. 2019;105(4):645-655.
https://doi.org/10.1002/JLB.3RI1018-400R
14. Church J, Maitland K. Invasive bacterial co-infection in African children with Plasmodium
falciparum malaria: a systematic review. BMC Med. 2014;12(1):31.
https://doi.org/10.1186/1741-7015-12-31
120
Chapter 3: Acute febrile illness
15. Maitland K, Olupot-Olupot P, Kiguli S, et al. Transfusion Volume for Children with Severe
Anemia in Africa. N Engl J Med. 2019;381(5):420-431.
https://doi.org/10.1056/NEJMoa1900100
16. Christensen SS, Eslick GD. Cerebral malaria as a risk factor for the development of epilepsy
and other long-term neurological conditions: a meta-analysis. Trans R Soc Trop Med Hyg.
3
2015;109(4):233-238.
https://doi.org/10.1093/trstmh/trv005
17. Tetanus. World Health Organisation. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/tetanus
18. Yen LM, Thwaites CL. Tetanus. The Lancet. 2019;393(10181):1657-1668.
https://doi.org/10.1016/S0140-6736(18)33131-3
19. Kyu HH, Mumford JE, Stanaway JD, et al. Mortality from tetanus between 1990 and 2015:
findings from the global burden of disease study 2015. BMC Public Health. 2017;17(1):179.
https://doi.org/10.1186/s12889-017-4111-4
20. Thwaites L. Tetanus. UpToDate. Published June 2022.
https://www.uptodate.com/contents/tetanus
21. Pinkbook: Tetanus | CDC. Published October 19, 2022. Accessed November 20, 2023.
https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html
22. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth.
2001;87(3):477-487.
https://doi.org/10.1093/bja/87.3.477
23. Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-
based review. Crit Care. 2014;18(2):217.
https://doi.org/10.1186/cc13797
24. Tetanus. One Health Trust. Accessed November 20, 2023.
https://africaguidelines.onehealthtrust.org/treatment/neonatal-and-pediatric/tetanus/
25. Shanbag P, Mauskar A, Masavkar S. Intravenous magnesium sulphate infusion as first-line
therapy in the control of spasms and muscular rigidity in childhood tetanus. Paediatr Int
Child Health. 2019;39(3):201-207.
https://doi.org/10.1080/20469047.2018.1542884
26. Thwaites C, Yen L, Loan H, et al. Magnesium sulphate for treatment of severe tetanus: a
randomised controlled trial. The Lancet. 2006;368(9545):1436-1443.
https://doi.org/10.1016/S0140-6736(06)69444-0
27. Ceneviva GD, Thomas NJ, Kees-Folts D. Magnesium sulfate for control of muscle rigidity
and spasms and avoidance of mechanical ventilation in pediatric tetanus: Pediatr Crit Care
Med. 2003;4(4):480-484.
https://doi.org/10.1097/01.PCC.0000090015.03962.8B
28. World Health Organization. Current recommendations for treatment of tetanus during
humanitarian emergencies : WHO technical note. Published online 2010. Accessed
November 20, 2023.
https://iris.who.int/handle/10665/70219
29. Crump JA, Mintz ED. Global Trends in Typhoid and Paratyphoid Fever. Clin Infect Dis.
2010;50(2):241-246.
https://doi.org/10.1086/649541
121
Chapter 3: Acute febrile illness
30. Stanaway JD, Reiner RC, Blacker BF, et al. The global burden of typhoid and paratyphoid
fevers: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Infect Dis.
2019;19(4):369-381.
https://doi.org/10.1016/S1473-3099(18)30685-6
31. Britto C, Pollard AJ, Voysey M, Blohmke CJ. An Appraisal of the Clinical Features of
Pediatric Enteric Fever: Systematic Review and Meta-analysis of the Age-Stratified Disease
Occurrence. Clin Infect Dis. 2017;64(11):1604-1611.
https://doi.org/10.1093/cid/cix229
32. Typhoid. World Health Organisation. Accessed November 20, 2023.
https://www.who.int/health-topics/typhoid
33. Azmatullah A, Qamar FN, Thaver D, Zaidi AK, Bhutta ZA. Systematic review of the global
epidemiology, clinical and laboratory profile of enteric fever. J Glob Health. 2015;5(2):020407.
https://doi.org/10.7189/jogh.05.020407
34. Basnyat B, Qamar FN, Rupali P, Ahmed T, Parry CM. Enteric fever. BMJ. Published online
February 26, 2021:n437.
https://doi.org/10.1136/bmj.n437
35. Kumar S, Rizvi M, Berry N. Rising prevalence of enteric fever due to multidrug-resistant
Salmonella: an epidemiological study. J Med Microbiol. 2008;57(10):1247-1250.
https://doi.org/10.1099/jmm.0.2008/001719-0
36. Wain J, Hendriksen RS, Mikoleit ML, Keddy KH, Ochiai RL. Typhoid fever. The Lancet.
2015;385(9973):1136-1145.
https://doi.org/10.1016/S0140-6736(13)62708-7
37. Browne AJ, Kashef Hamadani BH, Kumaran EAP, et al. Drug-resistant enteric fever worldwide,
1990 to 2018: a systematic review and meta-analysis. BMC Med. 2020;18(1):1.
https://doi.org/10.1186/s12916-019-1443-1
38. Burki T. Typhoid conjugate vaccine gets WHO prequalification. Lancet Infect Dis.
2018;18(3):258.
https://doi.org/10.1016/S1473-3099(18)30087-2
39. Measles. World Health Organisation. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/measles
40. World Health Organization. Guide for Clinical Case Management and Infection Prevention
and Control during a Measles Outbreak. World Health Organization; 2020. Accessed
November 20, 2023.
https://iris.who.int/handle/10665/331599
41. Clinical Practice Guidelines : Periorbital and orbital cellulitis. The Royal Children’s Hospital
Melbourne. Accessed November 20, 2023.
https://www.rch.org.au/clinicalguide/guideline_index/Periorbital_and_orbital_cellulitis/
42. Wald ER. Periorbital and Orbital Infections. Pediatr Rev. 2004;25(9):312-320.
https://doi.org/10.1542/pir.25-9-312
43. Sanford Guide | Antimicrobial Stewardship. Accessed November 20, 2023.
https://www.sanfordguide.com/
122
Chapter 4:
Respiratory conditions
4
Children of all age groups frequently present with respiratory symptoms, however, the most
common causes vary significantly between age groups and in the presence of underlying
conditions. Acute respiratory infection is the most common cause, with pneumonia accounting 4
for over 800,000 deaths in under 5-year-olds worldwide every year1. Additionally, annually
over 1 million children become symptomatic with tuberculosis2. Malnutrition, poor hygiene
and sanitation, and indoor and outdoor air pollution are all factors that may exacerbate
respiratory conditions in children.
Children presenting with a respiratory emergency, including acute respiratory distress,
obstructed upper airway, acute exacerbation of asthma, and hypoxia, need urgent assessment
and prompt management as critical deterioration can be rapid.
This chapter will cover the most common respiratory conditions that require hospital-level
care. For simple respiratory and ear, nose and throat (ENT) conditions that can be managed in
an out-patient department (OPD) setting and/or at home, refer to MSF Clinical Guidelines. For
OPD follow-up for longer term management of asthma, see Section 4.10.2.
History
– Take a comprehensive history of the presenting symptoms or signs, including onset, duration,
pattern, severity, precipitating and alleviating factors, associated features, previous episodes,
etc.
– Use direct questioning to gather descriptive factors relevant to the symptom:
Sore throat Impact on swallowing, drinking. Change to voice or cry. Bad breath.
125
Chapter 4: Respiratory conditions
Systemic symptoms Fever; rigors; night sweats; loss of appetite; headache; vomiting
and diarrhoea; weight loss
– Ask about past medical history including asthma, chronic respiratory or cardiac conditions,
surgical history and other medical co-morbidities as well as vaccination history (particularly
diphtheria, pertussis, measles, Haemophilus influenzae type B, pneumococcus vaccines).
– Family history: ask if there are any household members diagnosed with TB (or been in
contact with someone with TB); any smokers; parental HIV status; known cystic fibrosis.
– Social history: living conditions (draughts, damp, overcrowding, sanitation), indoor/outdoor
air pollution (check if cooking fire within living quarters), smoking.
Examination
Perform a full clinical examination (Chapter 1) and specific respiratory examination:
– General: overall appearance, position, activity level, ability to speak or cry, any obvious
acute respiratory distress or cyanosis, and vital signs.
– Expose the child’s chest and, where possible, position them at a 45-degree angle (semi-
sitting position).
– Observation: look for deformities, asymmetry, scars or signs of trauma; and rate, rhythm
and depth of breathing.
– Palpation: tracheal position, bilateral chest expansion, bone tenderness. Palpate for any
enlarged lymph nodes (adenopathy) in the retro-auricular, submandibular, supraclavicular,
and axillary areas.
– Percussion: across chest including supraclavicular, infraclavicular, bilateral chest wall (upper,
middle and lower), axillary regions for dullness or hyper-resonance.
– Auscultation: listen throughout both lung fields for presence or absence of breath sounds
and any additional sounds.
– Conduct a brief full-body examination paying attention to face, neck, hands and legs.
– Test for sinus tenderness by tapping the upper molars or the frontal or maxillary sinuses
with one finger.
– Use an otoscope to examine the tympanic membranes and the throat.
126
Chapter 4: Respiratory conditions
On observation
Central cyanosis: blue discolouration seen Low levels of oxygen in central arterial
on the tongue and lips. blood
Peripheral cyanosis: blue discolouration Low levels of oxygen in peripheral arterial 4
seen in nail beds of hands and/or feet. blood
Signs of respiratory distress: Pathologies of lung tissue or airways
• Grunting: a low, short repetitive noise on e.g. pneumonia (Section 4.5), asthma
expiration (Section 4.10), bronchiolitis (Section 4.7),
• Nasal flaring: nostrils widen on inspiration empyema (Section 4.6)
• Intercostal retraction: muscles between or
ribs pull inwards during inspiration. Cardiac pathologies (Chapter 6)
• Subcostal retraction (chest wall
retractions): inferior thoracic wall
depresses on inspiration as the superior
abdomen expands.
• ‘Head bobbing’ due to use of accessory
muscles: use of muscles in neck/
abdomen to assist inspiration.
Barking cough Croup (Section 4.2)
Stridor: abnormal, high pitched sound on Upper airway obstruction e.g. croup,
inspiration. epiglottitis (Section 4.3)
Barrel shaped chest: a rounded or bulging Chronic respiratory disease e.g. asthma
chest. (Section 4.10), cystic fibrosis, tuberculosis
(Section 4.11)
Clubbing: thickening of the tissue at the Tuberculosis (Section 4.11), chronic
base of the fingernails. respiratory disease
On palpation
On percussion
127
Chapter 4: Respiratory conditions
On auscultation
Evaluate severity of respiratory distress (if present) using clinical signs. The Clinical Respiratory
Score, (see Table 4.1 and Appendix 7) is a simple scoring system that can be used to guide
the assessment of respiratory distress and response to treatment. Based on the total score
obtained, the child can be classified as having mild, moderate or severe respiratory distress.
Table 4.1 - Clinical Respiratory Score (CRS) (adapted for the purposes of these guidelines from:
see references3,4)
Assess Score 0 Score 1 Score 2
Respiratory rate Age < 2 months: < 50 Age < 2 months: 50-60 Age < 2 months: > 60
(breaths/minute) Age 2-11 months: < 40 Age 2-11 months: 40-50 Age 2-11 months: > 50
Age 1-5 years: < 30 Age 1-5 years: 30-40 Age 1-5 years: > 40
Age > 5 years: < 20 Age > 5 years: 20-30 Age > 5 years: > 30
Based on the total score obtained, 3 categories of respiratory distress are possible:
Mild (≤ 3), Moderate (4-7), Severe (8-12)
128
Chapter 4: Respiratory conditions
Investigations
Peak flow assessment, chest X-ray or sputum samples can help to confirm or guide diagnosis.
Where relevant, these are described in further detail in disease-specific texts throughout the
chapter.
Consider cardio-pulmonary Point-of-Care Ultrasound (POCUS):
– Requires dedicated intensive training and should not be performed by untrained or
inexperienced clinicians.
– Indications: dyspnoea, hypoxia 4
– Perform 12-zone lung ultrasound (LUS) to evaluate for signs of consolidation, pleural
effusion/ empyema, pulmonary oedema, and to rule out pneumothorax.
– Can also be used for ultrasound-guided procedures (thoracocentesis) with appropriate
training only. Include 5-view cardiac exam if applicable.
4.1.2 Management
Refer to disease or syndrome specific management in respective sub-chapters.
Oxygen therapy
Essential treatment for hypoxia and is indicated when oxygen saturation (SpO2) is < 92% in
stable patients, aiming to maintain SpO2 ≥ 92%. A higher threshold is used in emergency
management of critically unwell children and for specific conditions where there is impaired
delivery of oxygen to body tissues, such as in severe anaemia, severe sepsis, sickle cell disease
129
Chapter 4: Respiratory conditions
and severe heart failure5, where the aim is to maintain SpO2 ≥ 94%. Oxygen can be delivered
via a simple oxygen mask, a non-rebreathing mask, or via nasal cannulae (see Chapter 15,
Section 15.1 for more information on when to use each oxygen delivery method). Always use
the minimum flow of oxygen possible to achieve desired oxygen saturations according to the
device used. Weaning should be considered in children who are stable or clinically improving
when SpO2 is consistently ≥ 92%, if continuously monitored, or ≥ 92% on at least two separate
consecutive readings taken several hours apart. Oxygen should be prescribed, with target SpO2
indicated to allow for nurse-led weaning and adjustment of flow rates to meet the desired
target. See also MSF Manual of Nursing Care Procedures, Procedure: Oxygen therapy.
Humidification
No humidification is needed for standard oxygen flow rates. Humidification is only needed if
the patient receives high flow rates for more than 2 hours. High flow rates are > 2 L/min for
1 month to < 2 years old, > 4 L/min for 2 to 12 years old, and > 6L/min for over 12 years old.
Standard flow rates via nasal cannula by age
2 to 12 years 2 to 4 L/min
a HFNC is not yet widely available in MSF projects. It should be noted that standard oxygen concentrators alone
cannot be used to administer safe and effective HFNC.
b Note: ‘Home-made’, improvised or locally-adapted bubble CPAP devices should not be used in MSF projects.
Only validated CPAP machines that have been designed for this purpose should be used.
130
Chapter 4: Respiratory conditions
Administer CPAP only where intensive medical care is available with appropriately trained
staff, medical devices, and a validated local user protocol. The use of CPAP with certain patient
groups or where intensive medical care is limited carries a risk and may be harmful9. Ensure all
safety precautions are implemented as per local protocol.
131
Chapter 4: Respiratory conditions
Common respiratory infection amongst children with peak incidence between 6 months and
3 years (though may rarely occur in infants as young as 3 months old and in older children
up to 7 years of age), with a characteristic inspiratory stridor and barking cough. It is most
often caused by parainfluenza virus type 1, but also by respiratory syncytial virus (RSV) or
adenovirus; other viral infections have been known less commonly to cause croup (including
measles, influenza, coronaviruses). In most cases it is mild and self-limiting, though secondary
bacterial infection, significant upper airway obstruction or respiratory distress may occur.
Croup is also called laryngotracheitis, or laryngotracheobronchitis if accompanied by wheezing.
It is called laryngitis when hoarseness is the only symptom, as in older children. Spasmodic
croup is characterised by the sudden onset of inspiratory stridor at night, short duration
(several hours) and sudden cessation. Spasmodic croup recurs frequently and is also called
"allergic croup."
4.2.2 Management
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress.
– Manage according to severity of croup.
– Treat fever for the child’s comfort.
– Antibiotic treatment is not routinely required as most croup cases are of viral aetiology.
Consider antibiotic treatment in clinical conditions where a secondary bacterial infection is
suspected.
Mild croup
– No stridor at rest, no signs of severe respiratory distress, drinking well, SpO2 > 94%.
– Give one dose of dexamethasone PO: 0.15 - 0.6 mg/kga (maximum dose 16 mg) or alternatively
prednisolone PO: 1 mg/kg.
– Discharge home with advice to parents/carers to ensure adequate hydration and to return
if condition deteriorates.
a 0.15 mg/kg of dexamethasone is the preferred dose for children who are easily able to return to hospital in
case of deterioration or return of symptoms. If access to healthcare is difficult, the higher dose of 0.6 mg/kg
should be used.
132
Chapter 4: Respiratory conditions
Differential diagnoses
Ensure other causes of stridor and/or respiratory distress are differentiated, including
epiglottitis, bacterial tracheitis, diphtheria, peritonsillar and retropharyngeal abscesses and
foreign body aspiration (see Table 4.2 and Figure 4.1a to Figure 4.1c, pages 134 and 135).
Table 4.2 - Comparative table of upper airway conditions (adapted for the purposes of these
guidelines from: see references10,11)
Croup Epiglottitis Bacterial tracheitis
Incidence Common Rare Less common
Aetiology Parainfluenza type 1 H. influenzae type B S. aureus, Moraxella
Respiratory syncytial catarrhalis,
virus (RSV) M. pneumoniae,
Adenovirus S. pyogenes,
S. pneumoniae
Age 6 months - 3 years 1-7 years 6 months - 14 years
Onset of stridor Progressive Very rapid Rapid
Fever Low grade/variable High High
Cough Common Less common Common
Dysphagia No Yes Rare
Drooling No Yes Rare
Voice Hoarse Muffled, dull Normal to very
hoarse
133
Chapter 4: Respiratory conditions
Figures 4.1 - Neck x-ray features of conditions causing stridor a) normal b) croup c) epiglottitis
4.1a - Normal lateral neck x-ray, childd
4.1b - Croup
e
AP neck x-ray, child : Lateral neck x-ray, childf:
b X-rays are not usually indicated in croup or bacterial tracheitis, however findings may support diagnosis when
unclear. See also Figure 4.1a to Figure 4.1c.
c Oedematous and enlarged epiglottis which is seen on lateral soft-tissue radiograph of the neck and has the
shape of a thumb.
d Case courtesy of Ian Bickle (image reversed from original), Radiopaedia.org, rID: 80232.
https://radiopaedia.org/cases/80232
e Case courtesy of Michael Sargent, Radiopaedia.org, rID: 6086. https://radiopaedia.org/cases/6086
f Case courtesy of Frank Gaillard (image reversed from original), Radiopaedia.org, rID: 6258.
https://radiopaedia.org/cases/6258
134
Chapter 4: Respiratory conditions
4.1c - Epiglottitis
Lateral neck x-ray, adultg:
135
Chapter 4: Respiratory conditions
4.3 Epiglottitis
Inflammation of the epiglottis and supraglottic tissue which can rapidly progress to upper
airway obstruction and become life-threatening.
This is an upper airway medical emergency. Call for a senior clinician or an anaesthetist
where available.
Aetiology
– Bacterial infection12: Haemophilus influenzae type B (Hib) most common (unless Hib vaccine
coverage is high), S. aureus including MRSA are increasingly the most common cause where
Hib vaccination coverage is high, other H. influenzae strains, and streptococci.
– Less commonly viral (influenza A13) or fungal infection.
– Non-infectious causes: injury due to burns/inhalation of smoke or toxic substances, or
ingestion of a foreign body or toxic substance.
Epiglottitis caused by infection occurs mostly in younger children between 1 and 7 years of
age, though again, Hib vaccine coverage may shift this to older age groups.
4.3.2 Management
Airway management
Securing the airway is a life-saving intervention in epiglottitis with airway obstruction but
carries significant risk. Senior medical staff (anaesthesia and intensive care) with extensive
136
Chapter 4: Respiratory conditions
experience in paediatric airway management should be consulted early. In the absence of the
required skills and/or equipment, refer the patient to a facility with such capacity as soon as
possible.
Initial basic airway management
– Manage patient in an intensive care or resuscitation area where staff have capacity to carry
out emergency resuscitation, if necessary.
– Ensure close observation and monitor and record vital signs as often as required using an
early warning system (see MSF Manual of Nursing Care Procedures, Assessment and vital 4
signs, Charts: Vital sign charts).
– Keep the child calm with minimal disturbance.
– Do not lie the child down, keep in a seated position.
– Administer oxygen, if possible, without distressing the child (see Chapter 15, Section 15.1).
– Get IV access and start IV maintenance fluids (see Chapter 15, Section 15.2), and administer
antibiotic treatment (see below). Avoid agitating the child with multiple attempts at IV
access.
– Consider a trial of nebulised epinephrine (see Section 4.2.2 for dosing). Stop immediately if
any deterioration or if the nebulisation upsets and aggravates the childa. Consider croup as
differential diagnosis if significant response to epinephrine nebuliser.
– If the child stops breathing, administer bag and mask ventilation with high-flow oxygen until
airway is secured.
Advanced airway management
– In the case of imminent airway obstruction, endotracheal intubation should be attempted
only under the following conditions:
• By senior medical staff with extensive experience in paediatric airway management.
• In an operating theatre under general anaesthesia.
• In the presence of a surgeon capable of performing an emergency surgical airway should
intubation attempts fail.
– Patients recovering from epiglottitis may be extubated when repeated direct laryngoscopy
at 24- to 48-hour intervals indicates reduced size and inflammation of the epiglottis.
Antibiotic treatment
– Administer IV ceftriaxone and IV clindamycin, or alternatively high-dose IV amoxicillin/
clavulanic acid for 5 days.
– Avoid IM route (may agitate the child and precipitate a respiratory arrest), consider only if
unable to obtain prompt IV access.
– Switch to PO amoxicillin/clavulanic acid treatment to complete a total of 7 to 10 days
treatment, when child tolerating oral intake, has reduced fever and respiratory distress, and
SpO2 stable.
a Evidence of efficacy is very limited, however in contexts where advanced airway interventions are limited,
a nebuliser can be attempted, assessing carefully for any positive effect and any signs of worsening airway
obstruction. Nebulised epinephrine may cause a rebound deterioration of airway obstruction so should be
trialled with caution and very close monitoring.
137
Chapter 4: Respiratory conditions
4.3.3 Prevention
H. influenzae type B (Hib) vaccine should be administered according to the national immunisation
programme (commonly at 2, 4 and 6 months, plus booster at 12 to 15 months). The Hib vaccine
does not cover all strains that may cause epiglottitis, but it is 90 to 95% effective14.
138
Chapter 4: Respiratory conditions
Secondary bacterial infection of the trachea resulting in mucopurulent exudates that may
cause obstruction of the upper airway and become life-threatening11. It is uncommon, but
may occur as a secondary infection following an acute viral respiratory illness. Consider as a 4
differential in young children presenting with upper airway obstruction or viral croup that is
not improving.
Commonly isolated bacterial pathogens include: S. aureus (including MRSA)16, S. pneumoniae,
group A Streptococcus, and Haemophilus influenzae strains17,18,19. Viral pathogens isolated
that may have been the primary infection include parainfluenza, influenza A and B, measles,
RSV20.
Occurs primarily between 6 months and 14 years of age, most commonly between 3 and
8 years11.
Investigations
Concurrent pneumonia or chest x-ray (CXR) abnormalities are found in at least 50% of case
series22. Consider a chest and lateral neck x-ray where it may be useful.
CXR: recommended once child is stable enough to exclude concurrent pneumonia.
Lateral neck x-ray: oedematous tracheal walls with subglottic narrowing, with or without
intraluminal membranes11.
4.4.2 Management
– Assess and manage for ABCDE as needed. Secure airway if necessary.
• If severe airway obstruction or impending respiratory failure, consider intubation if
advanced ICU and airway management available (see Section 4.3.2).
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress.
– Administer bag and mask ventilation if necessary.
139
Chapter 4: Respiratory conditions
– If stridor present, administer a trial of nebulised epinephrinea (see Section 4.2.2 for dose).
– If wheezing, administer a trial of nebulised salbutamol (see Section 4.10.1 for dose).
– Stop immediately if any deterioration or if the nebulisation upsets and aggravates the child.
Consider croup as differential diagnosis if significant response to epinephrine nebuliser.
– Get IV access and start IV maintenance fluids to ensure adequate hydration. Avoid agitating
the child with multiple attempts at IV access.
– Administer combined antibiotic treatment with IV ceftriaxone and clindamycin23. Avoid IM
route (may agitate the child and precipitate a respiratory arrest), consider only if unable to
obtain prompt IV access.
– Treat high fever with antipyretics for the comfort of the child.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Continue IV antibiotic treatment for at least 5 days. If the clinical condition has improved
(low or no fever, less respiratory distress, improved SpO2) and child tolerating oral intake,
switch to oral antibiotic treatment with amoxicillin/clavulanic acid PO (ratio 7:1 or 8:1) to
complete 10 days of treatment24.
a Evidence of efficacy is very limited, however in contexts where advanced airway interventions are limited,
a nebuliser can be attempted, assessing carefully for any positive effect and any signs of worsening airway
obstruction. Nebulised epinephrine may cause a rebound worsening of airway obstruction so should be
trialled with caution and very close monitoring.
140
Chapter 4: Respiratory conditions
4.5 Pneumonia
Aetiology
Pneumonia in children is most commonly community acquired. Infectious organisms can be
viral, bacterial, fungal or parasitic. Common pathogens vary widely by context, region, age, and
underlying clinical conditions (e.g. severe acute malnutrition (SAM), HIV infection, sickle cell
anaemia). Immunisation with H. influenzae type B (Hib) and pneumococcal conjugate vaccines
have reduced pneumonia where vaccine coverage is high, however the following infections
still impact millions of children worldwide:
– Bacterial: Hib, Streptococcus pneumoniae, Salmonella spp., Klebsiella pneumonia,
Staphylococcus aureus, Streptococcus pyogenes, Mycobacterium tuberculosis
– Viral: Respiratory syncytial virus (RSV), Influenza A and B, adenoviruses, parainfluenza,
measles, coronaviruses, human metapneumovirus
– Atypical bacteria: Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella
pneumophila (common in older children)
– Opportunistic fungal: Pneumocystis jirovecii (in HIV infected), Aspergillus spp
– Aspiration pneumonia caused by oral anaerobic flora
Non-infectious causes include foreign body inhalation, acid or other toxic fluid aspiration, or
exposure to chemical toxins.
Diagnosis is based on history, clinical features and examination, and where available, a chest
x-ray and/or lung ultrasound may be supportive. Assess the severity of pneumonia and
respiratory signs using the CRS (see Table 4.1 and Appendix 7) to promptly provide respiratory
support if needed and administer antibiotic treatment.
141
Chapter 4: Respiratory conditions
Examination
Perform a full clinical assessment and examination, including:
– Adequacy of oxygenation (vital signs, SpO2, cyanosis, neurological state/level of
consciousness).
– Level of respiratory distress (see Table 4.1), effort/exhaustion, need for respiratory support.
– Percussion: dullness appears on the affected side.
– Auscultation: decreased breath sounds, bronchial breath sounds, inspiratory crackles
(crepitations) may appear over the affected lobe or lung.
Signs of severe pneumonia include:
– Central cyanosis or oxygen saturations (SpO2 < 90% in room air)
– Severe respiratory distress (see Table 4.1)
– Altered level of consciousness
– Inability to drink or breast feed
– Vomiting everything (all foods and liquids)
– Appears severely ill, toxic or septic
Examine and/or investigate for any underlying causes including tuberculosis (see Section 4.11),
malnutrition, malaria (see Chapter 3, Section 3.4). In children with recurrent pneumonia or
poor response to treatment, check for HIV infection.
Complications
If the child has bacterial pneumonia (such as staphylococcal pneumonia), it can lead to
empyema (see Section 4.6). Dehydration can also be a complication of severe pneumonia if
the child becomes too lethargic to drink.
4.5.2 Investigations
– FBC, Hb, blood glucose level (BGL)
– CRP, if available
– Chest X-ray (CXR), or lung ultrasound:
• There is significant overlap in radiographic findings between different aetiologies of
pneumonia (e.g. viral vs bacterial pneumonia), and findings are often non-specific.
• A lobar pneumonia (homogeneous consolidation of an entire lobe of lung) is most
commonly bacterial (see Figure 4.2).
142
Chapter 4: Respiratory conditions
• Consider follow-up CXR (or lung ultrasound) if there is no improvement with antibiotics,
clinical deterioration, or suspicion of complications (such as empyema).
• Note that immunocompromised children may have normal chest radiographs despite
having severe pneumonia.
– Consider sickle cell disease screening in high prevalence contexts.
– Malaria RDT in endemic areas
– TB screening: microscopy and culture, or GeneXpert, if available (see Section 4.11 for further
investigations if TB suspected)
– HIV testing: see note above 4
– Blood culture (if severe pneumonia or signs of systemic illness)
Figure 4.2 - CXR features of lobar pneumonia
Frontal CXR, childa:
Dense homogeneous consolidation in the right upper lobe with air bronchograms,
highly suggestive of bacterial pneumonia.
4.5.3 Management
Indications to admit for hospitalisation:
– Less than 6 months of age
– Clinically severe pneumonia
– Severe acute malnutrition
– Concerns regarding the ability of the parents/carers to treat or if the parents/carers cannot
bring the child back for a follow-up examination
Severe pneumonia
– Assess and manage ABCDE (see Chapter 2, Section 2.2) and admit for close observation,
ideally to an ICU, if available.
– Administer oxygen via face mask, aiming for SpO2 between 94 - 98%.
– If necessary, increase level of respiratory support (see Section 4.1.2).
– Administer antibiotics (see following page).
– Treat fever and pain to improve comfort (see Chapter 15, Section 15.4).
– Administer anti-malarial treatment if malaria test positive.
– Monitor and record vital signs and BGL as often as required using an early warning system
(see MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
143
Chapter 4: Respiratory conditions
Antibiotic treatment
– Administer ampicillin (or amoxicillin) IV (or IM) 50 mg/kg every 8 hours + gentamicin IV (or
IM) 7.5 mg/kg every 24 hours.
– For children over 5 years old or if suspicion of atypical pneumonia in any age group, add
azithromycin PO 10 mg/kg once daily for 5 days.
– Continue IV antibiotic treatment for 48 hours and re-assess clinical condition:
• Child clinically improvedb and tolerating oral intake: replace IV with PO amoxicillin/clavulanic
acid (ratio 7:1 or 8:1) to complete 7 days treatment. Dosage expressed in amoxicillin:
▹ < 40 kg: 50 mg/kg 2 times daily
▹ ≥ 40 kg:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
• If child not clinically improved after 48 hours, change to cefotaxime IV 50 mg/kg every
8 hours or ceftriaxone IV (or IM) 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) every
24 hours. Consider treating for empyema (see Section 4.6) in children with measles
complicated by pneumonia who do not improve quickly with antibiotics.
• If condition deteriorates, or if MRSA suspected, add clindamycin IV 10 mg/kg every
8 hours. If atypical pneumonia suspected add azithromycin PO 10 mg/kg once daily for
5 days. Switch to oral antibiotic (as above) when child has improved and is tolerating oral
intake. If IV clindamycin administered, oral switch to clindamycin PO, 10 mg/kg 3 times
daily.
Suspected aspiration pneumonia:
– Administer ceftriaxone IV (dose as above) + metronidazole IV 10 mg/kg every 8 hours for
72 hours.
– Alternatively, administer clindamycin IV 10 mg/kg every 8 hours as an alternative to
metronidazole, or amoxicillin/clavulanic acid IV:
• 1 to 3 months of age: 30 mg/kg every 12 hours
• > 3 months of age: 30 mg/kg every 8 hours
– If clinical improvement and tolerating oral intake, replace IV with PO amoxicillin/clavulanic
acid (dose as above) to complete 7 days treatment.
b Improvement is indicated by the following: improved respiratory distress, diminished fever, improvement in
SpO2 level or less oxygen is required to maintain saturation, improved ability to drink and or eat and improved
activity.
c Increased ADH secretion in respiratory conditions can cause water retention, leading to fluid overload.
144
Chapter 4: Respiratory conditions
Discharge criteria
Consider discharge from hospital when child is:
– Clinically improving, with no fever for at least 24 hours
– Able to tolerate oral intake
– Maintaining oxygen saturations ≥ 92% in room air
– Tolerating oral antibiotics
– Going home to an environment where completion of treatment can be assured
4
Pneumonia with no signs of severity
Children older than 6 months:
– Give oral amoxicillin 30 mg/kg 3 times daily.
– Treat for fever if the child is uncomfortable.
– Follow-up after 48 to 72 hours and assess clinical condition:
• Improvement: complete amoxicillin PO for a total of 5 days.
• No improvement: complete amoxicillin PO for a total of 5 days and add azithromycin PO:
10 mg/kg once daily for 5 days.
• Clinically worse: admit for further investigations and management.
145
Chapter 4: Respiratory conditions
4.6 Empyema
Empyema is a collection of pus in the space between the lung and the inner surface of the chest
wall (pleural space). It is a complication of a bacterial pneumonia, most often staphylococcal
pneumonia and can often occur as a complication of measles. In children presenting with
empyema, evaluate with history and examination if there are any indications of underlying
tuberculosis (TB) as a differential diagnosis.
Investigations
– CXR and/or lung ultrasound, if available, to visualise fluid (see Figure 4.3). Check for any
radiological signs of TB.
– Pleural aspiration (ultrasound-guided ideally): check fluid appearance (colour, blood-stained,
straw-coloured, translucency, etc) and perform Gram stain and culture, if available.
– Tuberculosis screening: microscopy and culture or GeneXpert where available.
– Malaria RDT (in endemic areas).
– Check Hb
– CRP, where available
– Blood culture
Figure 4.3 - CXR features of a loculated pleural effusion (empyema)
Supine AP CXR, adulta:
Lenticular shaped loculated pleural collection forming an obtuse angle with the chest wall
(marked-up on right-hand image), characteristic of empyema.
146
Chapter 4: Respiratory conditions
4.6.2 Management
– Admit, preferably to an ICU facility, for treatment and stabilisation.
– Treat any fever to improve the patient’s comfort and give analgesia if pain (such as chest
pain) is present (see Chapter 15, Section 15.4).
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress.
– If the child is in severe respiratory distress, nil-by-mouth is recommended.
– Administer antibiotic treatment.
– Ensure adequate fluid and calorie intake and monitor BGL over the first 24 to 48 hours, as 4
there is a risk of dehydration and hypoglycaemia.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
Antibiotic treatment
– Administer ceftriaxone IV 80 mg/kg (max. 4g if < 50 kg; max. 2g if ≥ 50 kg) every 24 hours (or
cefotaxime IV 50 mg/kg every 8 hours) and cloxacillin IV 25 mg/kg every 6 hours.
– Alternatively, administer amoxicillin/clavulanic acid IV (dosage expressed in amoxicillin):
• 1 to 3 months of age: 30 mg/kg every 12 hours
• > 3 months of age: 30 mg/kg every 8 hours
– Continue for at least 7 days of parenteral (IV) treatment and until afebrile for 3 days.
– Then switch to oral antibiotic treatment (if able to take oral medication):
amoxicillin/clavulanic acid (ratio 7:1 or 8:1) PO to complete a minimum of 14 days of
treatmentb.
Dosage expressed in amoxicillin:
• < 40 kg: 50 mg/kg 2 times daily
• ≥ 40 kg:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
– If confirmed MRSA or no improvement after 48 hours: replace cloxacillin with clindamycin IV
10 mg/kg every 8 hours.
– If slow improvement despite antibiotics, consider tuberculosis (see Section 4.11 and MSF
Tuberculosis Guidelines).
Surgical drainage
Small empyemasc do not require surgical drainage. However, for large empyemasd or empyema
that does not respond to antibiotics, the definitive treatment is removal of pus through the
placement of a chest tube (thoracostomy)26:
– If clinician familiar with the procedure and anaesthesia/surgery is available, proceed to
insert a chest drain under anaesthesia in the operating room.
– If surgery/anaesthesia is not available but a clinician trained to perform the procedure is, insert
a chest drain under sedation. Refer to MSF Standards for Paediatric Procedural Sedation.
– If there is no possibility to insert a chest drain due to lack of trained staff, consider referral.
– As a last option, if no trained staff are available and referral is not an option, perform
repeated pleural punctures for pus drainage.
– Upright chest x-ray (if available and the child is stable) is recommended after placement
of a chest drain or after pleural puncture to confirm position of the drain and exclude a
pneumothorax.
147
Chapter 4: Respiratory conditions
4.7 Bronchiolitis
Acute inflammation and oedema of the smaller airways (bronchioles) of the lower respiratory
tract that occurs commonly in young children up to 2 years of age. The majority of cases are
caused by an infection with the respiratory syncytial virus (RSV), though other viral infections
may also trigger it (e.g. rhinovirus, parainfluenza, adenovirus, coronavirus)27,28. Though
bronchiolitis is a self-limiting illness which is usually uncomplicated in previously healthy
children RSV-associated lower respiratory tract infections are one of the most common reasons
for hospital admission and a significant cause of mortality amongst children29. Infants at risk
of severe bronchiolitis or complications include those with a history of being preterm or low
birth weight, < 3 months of age, and those with underlying respiratory, cardiac or neurological
conditions30.
Investigations
Chest x-ray: not routinely recommended; consider if there is clinical deterioration, if there is
a suspected superimposed bacterial infection or pneumonia, or if other differential diagnosis
suspected.
Lung ultrasound: consider if available and trained staff present.
4.7.2 Management
There is no specific treatment for the viral infection triggering bronchiolitis, however some
children may need hospital admission for supportive management.
Children with clinical signs of severe illness should be admitted:
– Inability to feed (feeding less than 50% of usual volume) or dehydration
– Apnoea
– Moderate to severe respiratory distress (see Table 4.1)
– Oxygen saturations persistently below 92% (at rest, when feeding or when sleeping)
– Lethargy
– Central cyanosis31.
148
Chapter 4: Respiratory conditions
Consider admission if feasible for all children at risk of severe disease: chronic lung
disease, prematurity (particularly < 32 weeks), congenital heart disease, < 3 months of age,
neuromuscular disorders.
Respiratory support
– Position the child around 10 to 30 degrees upright to support breathing.
– Administer oxygen if SpO2 < 92% in room air or severe respiratory distress.
– More advanced respiratory support, such as HFNC or CPAP, may be required if there is no
improvement with oxygen via nasal prongs (see Section 4.1.3). 4
– Continuous or near-continuous monitoring (RR, HR, SpO2) where feasible and if nursing
ratios allow, especially in very young infants or those with severe respiratory distress.
– Saline nasal drops and gentle nasal suctioning, especially pre-feeds (see MSF Manual of
Nursing Care Procedures, Procedure: Nasopharyngeal and Oropharyngeal Suctioning).
– Bronchodilators are not routinely recommended in the treatment of bronchiolitis, as
infant airways are not usually responsive to this treatment. However, in severe respiratory
distress, a trial of inhaled bronchodilators (salbutamol or epinephrine, see Section 4.10.1
and Section 4.2.2, respectively, for dosing) can be administered and continued if there is
clear evidence of improvement.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
a Increased ADH secretion in respiratory conditions can cause water retention, leading to fluid overload.
149
Chapter 4: Respiratory conditions
Discharge criteria
Consider discharge from hospital when the child is30,32:
– Maintaining oxygen saturations persistently ≥ 92% without supplemental oxygen (for at
least 4 hours), including during sleep.
– Tolerating feeds.
– Clinically stable with no signs of moderate or severe respiratory distress.
150
Chapter 4: Respiratory conditions
4.8 Diphtheria
Investigations
– Collect swab samples before starting antibiotic treatment (see MSF Collection, storage and
transport of samples from field to reference laboratory):
• Swab affected areas: throat (tonsils, pharyngeal mucosa, soft palate, exudate, ulcer, etc.)
and nasopharynx, for culture (and sensitivity) to isolate C. diphtheriae.
– PCR test (detection of diphtheria toxin gene) if available.
151
Chapter 4: Respiratory conditions
4.8.2 Management
Infection prevention and control measures
– Ensure transmission-based precautions are taken, including correct use of personal
protective equipment (PPE).
– Admit to a separated area or with physical distance from other admitted children with
dedicated nursing staff and equipment to reduce the risk of cross-infection.
– If multiple cases, group together with other cases in a separated area from other patients
(cohorting).
– Cases can remain infectious up to 8 weeks after initial infection. Antibiotic treatment can
reduce infectiousness to 6 days.
Laryngitis or pharyngitis
20 to 40 000
or duration < 48 hours
IM or IV infusion in 250 mL
Rhinopharyngitis 40 to 60 000 of sodium chloride 0.9% in 2
to 4 hours for doses of more
Severe disease (respiratory than 20 000 units.
distress, shock), cervical 80 to 100 000
oedema or duration ≥ 48 hours
Antibiotic treatment
– Start as soon as possible without waiting for bacteriological confirmation.
– Give for 14 days or according to length of treatment recommended by the national protocol:
First-line:
azithromycin PO 10 to 12 mg/kg once daily (max. 500 mg daily)
Alternatively:
erythromycin PO
< 40 kg: 10 to 15 mg/kg (max. 500 mg) 4 times daily
≥ 40 kg: 500 mg 4 times daily
or
phenoxymethylpenicillin (penicillin V) PO:
< 40 kg: 10 to 15 mg/kg (max. 500 mg) 4 times daily
≥ 40 kg: 500 mg 4 times daily
152
Chapter 4: Respiratory conditions
– Administer via IV or IM if the child is unable to take oral treatment. Switch to oral antibiotic
treatment as soon as possible. Complete a total of 14 days of treatment.
benzylpenicillin (penicillin G) IM or slow IV
25 000 IU/kg (15 mg/kg) every 6 hours (max. 4 MIU or 2.4 g per day)
Alternatively:
procaine benzylpenicillin IM
< 25 kg: 50 000 IU/kg (50 mg/kg) once daily (max. 1.2 MIU or 1.2 g daily)
≥ 25 kg: 1.2 MIU (1.2 g) once daily
4
Never administer procaine benzylpenicillin by IV injection or infusion.
If penicillin-allergy:
erythromycin IV infusion (60 minutes)
12.5 mg/kg every 6 hours (max. 2 g daily)
– Evaluate and manage respiratory distress or any airway obstruction. In case of stridor and/or
respiratory distress and/or bull neck, administer dexamethasone IV, 0.6 mg/kg loading dose
followed by 0.1 mg/kg every 6 hours (max. 10 mg per dose). Intubation or tracheotomy may
be necessary with severe upper airway obstruction (see local protocols).
– Update vaccination status before hospital discharge. If the patient has been administered
DAT and can receive adequate home-based follow-up after hospital discharge, wait 3 weeks
after administration of DAT before vaccination.
Refer to MSF Clinical Guidelines, Diphtheria for:
– Management of close contacts and antibiotic prophylaxis
– Outbreak surveillance methods
4.8.3 Prevention
– Vaccination prevents severe disease though it does not prevent transmission.
– Clinical disease does not confer immunity, therefore vaccination should be part of case
management.
– Diphtheria vaccine is part of routine childhood immunisation (EPI):
• 3 doses of conjugate vaccine containing the higher potency (D) formulation of diphtheria
toxoid as soon as possible as of 6 weeks of age and at 4 week intervals.
• D booster: between 12 and 23 months, then between 4 and 7 years.
• Booster with a vaccine containing a reduced dose (d) of diphtheria toxoid: between 9 and
15 years35.
– Catch-up vaccination (missed routine vaccination):
• 1 to 6 years: 3 doses of D conjugate vaccine at least 4 weeks apart.
• 7 years and above: 3 doses of d conjugate; 4 weeks between dose 1 and 2, then at least
6 months between dose 2 and 3. Administer 2 subsequent booster doses containing d at
least 4 weeks apart.
153
Chapter 4: Respiratory conditions
A highly contagious, acute respiratory illness caused by the bacterium Bordetella pertussis, with
a high mortality in infants. The incubation period for B. pertussis is usually 9 to 10 days and it
is transmitted via airborne droplets36. The risk of transmission is greatest during the catarrhal
phase and patients with pertussis are considered infectious until they have completed 5 days
of appropriate antibiotic treatment or 21 days if not treated.
Pertussis is a vaccine-preventable disease and immunisation against pertussis is included in all
vaccination calendars worldwide.
Pertussis is a notifiable disease, and all cases should be reported to local or national public
health authorities.
4.9.2 Management
Admit children who37:
– Are 3 months or younger.
– Have signs of severe illness (severe respiratory distress, apnoea, cyanosis, pneumonia,
seizures/impaired consciousness).
– Are unable to feed.
154
Chapter 4: Respiratory conditions
Antibiotic treatment
Indications include:
– Infants < 6 months
– Within 3 weeks of onset of cough
– Consider antibiotic treatment if child requires admission:
azithromycin PO:
< 6 months: 10 mg/kg once daily for 5 days
≥ 6 months: 10 mg/kg (max. 500 mg) single dose on day 1, then 5 mg/kg (max. 250 mg)
once daily from day 2 to day 5
Alternative:
co-trimoxazole PO: 20 mg/kg SMX + 4 mg/kg of TMP 2 times daily for 14 days
or
erythromycin PO: 15 mg/kg 3 times a day for 7 to 14 daysa
Supportive care
– Place the child in a semi-reclining position.
– Administer respiratory support via bag and mask ventilation in case of apnoea that does not
quickly resolve with external stimulation.
– Administer oxygen if SpO2 < 92% in room air, in severe respiratory distress or if recurrent
apnoeasb.
– Do not perform any deep suction (as it increases the risk of paroxysmal cough). If secretions
are present, gently wipe the mouth and the nose with gauze.
– Ensure adequate fluids and calorie intake (risk of weight loss). Give small and frequent oral
feeds if possible. Some patients need nasogastric feeding or IV maintenance fluids (see
Chapter 15, Section 15.2 and Section 15.5).
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Record weight, and strictly monitor urine output and oral intake.
– Do not administer salbutamol, corticosteroids or antitussives.
a 7 days of treatment with erythromycin is sufficient in the majority of cases though there is a small risk of
relapse compared to 14 days of treatment.
b Use of oxygen via nasal prongs may provide enough stimulation to prevent apnoea, however oxygen itself is
not an adequate treatment for apnoea.
155
Chapter 4: Respiratory conditions
Discharge criteria
Most infants will continue to have coughing spells after discharge. Minimum criteria for
discharge include the following:
– No apnoea or oxygen supplementation needed in last 48 hours.
– Coughing episodes tolerated without becoming hypoxic and/or bradycardic.
– Ability to feed enough to gain weight.
– Family can care for child at home and are comfortable with the child's condition.
Consider food supplements for several weeks after discharge, especially if weight loss occurs
during hospital stay.
4.9.4 Prevention
Routine vaccination with polyvalent vaccines containing pertussis antigens (e.g. DTP, or DTP +
Hep B, or DTP + Hib + Hep B) from the age of 6 weeks or according to national protocol.
Neither vaccination nor natural disease confers lasting immunity. Booster doses are necessary
to reinforce immunity and reduce the risk of developing disease and transmitting it to young
children.
c Macrolides should be used with caution in pregnancy and avoided in the first trimester of pregnancy due to
increased risk of congenital malformations.
156
Chapter 4: Respiratory conditions
4.10 Asthma
Consider asthma in a child that presents with cough, wheeze and shortness of breath or difficulty
breathing. Asthma is a chronic disorder that can have an acute and severe presentation, or
present with a longer history of recurring or persisting mild symptoms. Children or parents/ 4
carers may have noticed that the symptoms are present or worse at night or during exercise.
Although asthma-like symptoms with cough and wheezing present frequently in younger
children in association with a viral respiratory illness, the diagnosis of asthma is generally
considered in children over 5 years of age.
Asthma is a chronic inflammatory process of the airways in which smooth muscle constriction,
mucous plugs and/or wall thickening causes narrowing of the airways, thereby restricting the
flow of air in the lungs. Treatment is with bronchodilators (to re-open the airways) and steroids
(for their anti-inflammatory effects) to reverse the symptoms. Longer term management and
prevention of acute attacks should be supported with patient and family education.
Asthma often coexists with atopy and allergies40.
Severe or
Mild Moderate
life-threatening
157
Chapter 4: Respiratory conditions
Severe or
Mild Moderate
life-threatening
– Administer oxygen via nasal cannula at the same time as the nebulisera, aiming for SpO2
between 94 - 98%.
– After 3 combined nebulisers, continue with nebulised salbutamol alone every 20 minutes
(i.e. continuously), assessing for improvement between each dose without stopping the
continuous nebuliser.
– If a nebuliser is not available, administer inhaled bronchodilators via a spacer, ensuring
that every puff is inhaled separately and effectively. Repeat combined inhalers every 10 to
20 minutes up to 3 times in total, then continue with salbutamol inhaler alone:
a Unless nebuliser driven by oxygen, in which case supplementary administration of oxygen via nasal cannula is
not necessary.
158
Chapter 4: Respiratory conditions
– Start IV maintenance fluids (and consider adding potassium, see Chapter 15, Section 15.2.3).
– Start corticosteroidsb as soon as possible43,44:
– After stabilisation, or in case of need of magnesium sulphate, transfer the child to ICU
immediately.
– If no improvement or deterioration despite nebulisers and corticosteroid, administer
magnesium sulphate IV: 40 mg/kg (max. 2 g) diluted in sodium chloride 0.9% over 20 minutes
using a syringe pump:
• Continuous monitoring (or every 10 minutes) including BP must be available and feasible
(risk of hypotension).
• Assess neurological status every 10 minutes for at least first hour.
• In case of hypotension, add a bolus of Ringer lactate IV: 10 mL/kg over 20 minutes.
– If no improvement after 20 minutes of magnesium sulphate, administer epinephrine IM/SC:
0.01 mg/kg (see MSF Vasopressor Therapy - Adrenaline protocol). Repeat after 20 minutes
if needed.
– When the child starts to improve, stop continuous nebuliser and start weaning down
the salbutamol (follow weaning steps described below in management of moderate
exacerbation) and oxygen while monitoring SpO2. Duration of prednisolone at discharge is
to complete 5 days total as for management of moderate exacerbation.
– Monitor and record vital signs at least every 30 minutes using an early warning system
(see MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
– If the child deteriorates again within 1 hour of stopping continuous salbutamol, restart
continuous salbutamol every 20 minutes for 1 hour and then reassess.
Moderate exacerbation
– Administer combined nebulised or inhaled bronchodilators using the same dosing as for
severe exacerbation, and repeat every 20 minutes until clinical improvement, up to 3 doses
in total.
– Administer oxygen via nasal cannula, aiming for SpO2 between 94 - 98%.
– Give prednisolone PO: 1 to 2 mg/kg (max. 40 mg). Alternatively, dexamethasone PO: 0.3 to
0.6 mg/kg (max. 16 mg).
– Reassess clinical condition and severity after each combined bronchodilator dose.
Inhaled bronchodilators are preferred for moderate exacerbations if correct, effective
delivery using a spacer can be guaranteed. If inhaler delivery technique is in doubt,
nebulisers should be administered.
b Oral corticosteroids are preferred to IM/IV where oral route is possible. Only administer parenteral
corticosteroids if the child is vomiting, or respiratory distress is too severe to allow safe administration of oral
medication.
159
Chapter 4: Respiratory conditions
Mild exacerbation
– Administer salbutamol inhaler 4 to 6 puffs via spacer and reassess.
– Repeat same dose of salbutamol inhaler every 20 minutes if child remains symptomatic, up
to 3 doses total and reassess:
• No improvement and/or child requires oxygen, treat as for moderate exacerbation.
• Improvement: aim to administer salbutamol inhaler at 4-hourly intervals and observe for
any symptoms between treatments. If needed, administer salbutamol inhaler earlier and
note the interval spacing.
– When child has remained stable with minimal or no wheeze 4 hours after the last salbutamol
inhaler treatment, review for discharge home.
– On discharge, provide an Asthma Action Plan (see Appendix 8) and oral prednisolone 1 to
2 mg/kg (max 40 mg) to complete 3 days, or oral dexamethasone 0.3 to 0.6 mg/kg (max
16 mg) to complete 2 days.
Note: At any suitable moment, complete history, perform full clinical examination and relevant
diagnostics to identify potential underlying trigger, e.g. infection, and treat accordingly.
160
Chapter 4: Respiratory conditions
Discharge home
Clinical criteria:
– Stable in room air and minimal respiratory distress on 4-hourly salbutamol (ideally at least
2 doses at 4-hourly interval).
Medication:
– Oral corticosteroids to complete 3 or 5 days according to severity.
– Salbutamol inhaler (4 to 6 puffs):
• Home on 4-hourly during waking hours and as needed or up to 4-hourly during sleeping 4
hours for first 48 to 72 hours.
• Wean down salbutamol inhaler as tolerated, aiming to stop between days 5 and 7 after
discharge.
• Ensure spacer given together with inhaler and that child/family know how to use it
correctly (see Appendix 9 and Appendix 10).
– Assess need for controller medication and provide if necessary.
Follow-up:
– Organise outpatient follow-up (see Section 4.10.3).
– Provide basic asthma education (recognition of exacerbation, management, when to seek
medical consultation).
– Provide an Asthma Action Plan (see Appendix 8).
Diagnosis of asthma
– Presence of typical symptoms and history characteristic of asthma, after excluding other
diagnoses.
– Response to inhaled bronchodilators e.g. salbutamol inhaler or nebuliser.
– It is recommended to determine a diagnosis of asthma only in children 5 years of age and
above.
161
Chapter 4: Respiratory conditions
– In children under 5 years, viral upper respiratory tract infections can cause similar symptoms
to asthma (recurrent wheezing, cough) without the child necessarily having asthma. Consider
a diagnosis of asthma and whenever possible refer for further evaluation in children < 5 years
with recurrent wheezing if45:
• Cough or wheezing during sleep or associated with environmental irritants.
• Symptoms exacerbated by exercise, laughing, or without a concomitant upper respiratory
infection.
• History of allergy.
• Response after 2 to 3 months of controller treatment (suggested trial of beclomethasone
0.05 mg/puff, 1 puff 2 times daily, and refer for further management if good response seen).
Differential diagnoses to consider or exclude:
– Bronchiolitis (if < 2 years; usually not responsive to salbutamol)
– Bacterial tracheitis (more inspiratory stridor than expiratory wheezing)
– Foreign body aspiration (often unilateral or focal wheezing, history or CXR diagnosis)
– Cardiac disease and congestive heart failure
– Pulmonary oedema
– TB
– Congenital anomalies (CCAM, bronchomalacia, tracheomalacia)
– Gastro-oesophageal reflux (infants)
– Lymphocytic Interstitial Pneumonia in HIV positive children
Investigations
– CXR, if available: non-specific findings include hyperinflation of the lungs, bronchial wall
thickening, and patchy atelectasis; CXR can also be normal.
– Lung ultrasound (if available and trained clinicians present) to exclude other differential
diagnoses (e.g. pneumonia, pulmonary oedema).
Management
– Assess symptom frequency and start treatment with salbutamol inhaler, with or without a
low-dose inhaled corticosteroid (ICS) such as beclomethasone, according to frequency (see
Table 4.4).
– Ensure spacer given together with inhaler and that child/family know how to use it correctly
(see Appendix 9 and Appendix 10).
– Check and eliminate trigger factors if possible.
– Evaluate after 4 to 8 weeks to assess asthma control and response.
– Adjust therapy according to clinical evaluation plus a stepwise treatment approach.
Table 4.4 - Assessment and initial treatment of asthma45
Asthma symptoms
Infrequent Frequent Troublesome Severe
≥ 2 days/month Most days,
Symptoms < 2 days/month Most days
but not daily throughout the day
Night-time
- - ≥ 1/week ≥ 1/week
awakenings
162
Chapter 4: Respiratory conditions
Table 4.5 - Asthma maintenance treatment drug table for children > 5 years old 4
Asthma medication Dosing and indication
Salbutamol Metered dose inhaler (0.10 mg/puff)
Short-acting beta 2-agonist Rapid relief of asthma symptoms and bronchoconstriction:
(SABA) bronchodilator • Onset of action: within minutes
• Duration of action: ± 4 hours
• 4 puffs as needed; maximum 4 times daily
Prophylaxis of exercise-induced bronchoconstriction:
2 puffs, 5 to 20 minutes before exercise.
Salmeterol Metered dose inhaler (0.025 mg/puff)
Long-acting beta 2-agonist • 5 to 11 years: 2 puffs 2 times daily
(LABA) bronchodilator • 12 years and older: 2 puffs 2 times daily, up to maximum
4 puffs 2 times daily if severe
Must always be used with an ICS (risk if used alone)46
Beclomethasone dipropionate Metered dose inhaler (0.05 mg or 0.10 mg/puff)
Inhaled corticosteroid (ICS) • Low-dose ICS:
0.05 mg/puff, 1 to 2 puffs 2 times daily
0.10 mg/puff, 1 puff 2 times daily
• Medium-dose ICS:
0.05 mg/puff, 2 to 4 puffs 2 times daily
0.10 mg/puff, 1 to 2 puffs 2 times daily
ICS is the most effective long-term control therapy but
may have long-term adverse effects at high doses. Patients
should be maintained on the lowest possible dose of ICS.
Reduce dose slowly, 25 to 50% at a time.
Montelukast Oral tablet (as alternative to LABA if poor response to
Leukotriene receptor LABA)
antagonist (LTRA) • 5 years: 4 mg once daily in the evening
• 6 to 12 years: 5 mg once daily in the evening
• > 12 years: 10 mg once daily in the evening
Budesonide/Formoterol Budesonide 80 micrograms/Formoterol 4.5 micrograms/
Combination ICS-LABA puff, for use in children over 5 years.
• Low dose:
1 puff = 80 micrograms budesonide/4.5 micrograms
formoterol, 2 times daily
• Medium dose:
2 puffs = 160 micrograms budesonide/9 micrograms
formoterol, 2 times daily
163
Chapter 4: Respiratory conditions
– Assess understanding and acceptance of use of inhalers and provide counselling and
information where there are misconceptions or concerns.
– Check inhaler and spacer technique – all inhaler treatments in children should be administered
via a spacer (see Appendix 9 and Appendix 10).
– Do not step-up if the child is unwell or breathless during the visit - treat as an acute
exacerbation.
– Step-up asthma treatment if there are persistent symptoms (e.g. persistent cough), between
every 4 to 8 weeks.
– Step-up if asthma is poorly controlled i.e. using a reliever inhaler > 3 times per week, waking
at night with symptoms more than once a week.
– If asthma still not well controlled with Step 4 treatment, seek or refer for specialist advice.
– Step-down if well controlled for 3 months. Decision on which drug to stop first and at what
rate depends on the severity of asthma, treatment side effects, time on current dose,
beneficial effects achieved, and patient preference.
– Inhaled corticosteroids are the most effective long-term control therapyc. When able to
step down, reduce dose gradually 25 to 50% at a time until lowest dose of inhaled steroids
reached with child stable.
c Note that antihistamines, antitussives, mucolytics, oral salbutamol/salbutamol syrup are not recommended
for asthma treatment.
164
Chapter 4: Respiratory conditions
165
Chapter 4: Respiratory conditions
4.11 Tuberculosis
Active TB
Before immunity is established, bacilli from the primary focus or from a nearby lymph node
can be transported and disseminated throughout the body. Secondary foci can develop in this
way, particularly in the lungs, lymph nodes, serous membranes, meninges, bones and kidneys.
As for primary infection, these foci usually resolve or are contained by an effective immune
response.
Different factors can reduce the immune response and lead to reactivation of TB and
multiplication of the bacilli in one or more of these foci. This reactivation or progression of
primary or secondary foci results in active TB51. After exposure, the risk of TB infection and
progression to active TB is high in children under 5 years old52. Progression to active TB is
rapid (within 12 months) in children under 2 years53, and HIV is a significant risk factor for
developing TB in children under 1 year54.
166
Chapter 4: Respiratory conditions
Pulmonary TB
Signs of pulmonary TB in children include:
– Prolonged cough (more than 2 weeks), often without sputum production
– Weight loss
– Anorexia
– Fatigue
– Haemoptysis
– Shortness of breath 4
– Fever
– Night sweats
Signs and symptoms generally evolve in a chronic, insidious manner. In endemic areas, the
diagnosis of PTB should be considered in any child presenting with respiratory symptoms
lasting more than 2 weeks. Children less than 10 years old are not considered infectious unless
they have extensive lung involvement and/or cavitary PTB.
Extrapulmonary TB
Extrapulmonary TB (EPTB) occurs when there is active TB infection in areas of the body
outside of the lung parenchyma, including the lymph nodes, meninges, bones and joints,
abdomen, serous membranes and kidneys. In young children, miliary and meningeal TB are
more frequently seen, while in older children TB lymphadenitis and osteoarticular TB are more
common.
Lymph node TB
Particularly common in older children, with the following characteristics:
– Painless, non-inflammatory adenopathy
– Frequently cervical, but axillary and mediastinal also common
– Multiple (often bilateral), or single, enlarged nodes
– Chronic evolution leading to fistulation
Tuberculous pleural effusion
One of the most common forms of EPTB, it is often asymptomatic if small and frequently
occurs concurrently with PTB. Constitutional symptoms are as for PTB, and shortness of breath
and unilateral chest pain occur when the effusion is large.
TB meningitis
Most common in children under 2 years old and in HIV-infected patients. Typically has subacute,
insidious course over days or weeks. Symptoms include:
– Headaches
– Irritability
– Fever
– Vomiting
– Altered mental status
– Meningeal syndrome (stiff neck, photophobia and headache)
TB of bones and joints
TB can affect the vertebrae and intervertebral disks, causing destruction and deformation of
the spine (Pott’s disease), most commonly affecting the thoracic spine. Localised back pain
is the main symptom, and neurological complications can develop. TB may also affect the
joints (commonly the hips, knees, elbows and wrists) causing a chronic painless mono-arthritis
accompanied by joint destruction.
167
Chapter 4: Respiratory conditions
Abdominal TB
Less common and difficult to diagnose. Presents as ascites resulting from peritoneal TB
infection, sometimes accompanied by an abdominal mass (often in the right lower quadrant),
pain and diarrhoea. Constitutional symptoms may be present.
Disseminated or miliary TB
Generalised massive infection caused by haematogenous diffusion of M. tuberculosis
throughout the body. It occurs most commonly in children, young adults and HIV-infected
patients. In children, the risk of meningitis is high55. Clinical picture is characterised by:
– Deterioration over days or weeks
– Simultaneous involvement of multiple organs
– Marked wasting
– Headache
– Constant high fever
– Miliary findings on CXR
– Moderate hepatosplenomegaly (occasional)
History of exposure to TB
Establish if the child has had contact with a confirmed or presumed index case. Children are at
higher risk of TB if:
– The index case is a household or close contact
– The index case has PTB, sputum smear-positive or with cavities on chest x-ray
– The exposure to the index case occurred in the past 12 months.
168
Chapter 4: Respiratory conditions
If a TB index case is identified, their resistance profile should be assessed, as children often
have the same resistance profile as the index case.
Whenever TB is diagnosed in children, it is important to detect the index case if not already
identified, as well as any other undiagnosed cases in the household or close contacts.
Ask for symptoms suggestive of TB:
– Cough for more than 2 weeks
– Fever for more than 2 weeks
– Night sweats that soak the bed or clothes 4
– Weight loss or poor/no weight gain
– Fatigue, reduced playfulness, loss of appetite
– Haemoptysis (rare in children)
– Non-painful, enlarged cervical, submandibular, or axillary lymph nodes
– Rapid breathing
Clinical examination
Carry out a thorough physical examination, looking specifically for the following suggestive
signs:
– Fever, tachypnoea, tachycardia
– Weight loss, growth curve flattening, underweight or malnourished according to weight for
height and/or mid-upper arm circumference
– Abnormal pulmonary auscultation
– Signs of respiratory distress (see Section 4.1).
– Lethargy, altered mental status (may indicate TB meningitis)
– Signs of EPTB:
• Highly suggestive: angular deformity of the spine; loss of ability to walk, cervical lymph
node with fistula formation.
• Requiring further investigation: sub-acute meningitis not responding to antibiotic
treatment; ascites; lymph node without fistula formation; non-painful enlarged joint.
HIV status should be assessed in all children with presumed or confirmed TB.
4.11.4 Investigations
The following investigations should be performed in children suspected of PTB or EPTB
whenever possible. For children at high risk of TB or death from TB and for whom investigations
are unavailable (or results are not immediately available) treatment should not be delayed:
– HIV status should be assessed in all children with presumed or confirmed TB.
– Bacteriological tests: Rapid molecular tests (RMTs) should be performed on respiratory, stool
or extrapulmonary (EP) specimens as the initial diagnostic test. As the sensitivity of Xpert
MTB/RIF Ultra is higher than that of Xpert MTB/RIF, preferably use this for the detection of
TB and rifampicin-resistance.
• Sputum samples can be difficult to collect in children who may be unable or unwilling
to spontaneously expectorate. Explanation and encouragement are important. Chest
clapping may help expectoration, but if unsuccessful, respiratory specimens can be
obtained by invasive procedures such as sputum induction or gastric aspiration (see
Appendix 11). These procedures should only be used if the specimen is collected for
rapid molecular tests, culture or genome sequencing. These procedures should not be
performed for smear microscopy.
169
Chapter 4: Respiratory conditions
• Stool specimens (which may contain swallowed sputum) are an alternative to respiratory
specimens for the diagnosis of PTB in children. Respiratory specimens are more likely
to give positive results but the use of stool specimens can avoid invasive collection
procedures.
• For children at risk of drug-resistant TB (DR-TB) i.e. those with contact with a DR-TB case
or coming from a high DR-TB prevalence area, multiple specimens (respiratory, stool and
EP) should be tested with RMTs. Every effort should be made to perform culture and
phenotypic drug susceptibility test.
– Lateral flow urine lipoarabinomannan assay (LF-LAM): LF-LAM should be performed in
HIV-infected children: with signs and symptoms of TB; with advanced HIV disease who are
seriously ill or hospitalised; or with low CD4 count.
– Medical imaging:
• Chest x-ray (CXR) is particularly useful when bacteriological tests are not available or
negative. CXR is also useful to assess the severity of TB and to determine the eligibility for
the 4-month drug-susceptible regimen. Children with PTB usually have abnormalities on
CXR, however a normal CXR does not rule out TB. Children who do not have CXR as part of
their initial evaluation should have a CXR done as soon as possible if started on treatment
for TB to assist with evaluation and treatment duration.
• Ultrasound: can be useful in the diagnosis of EP-TB including lymph node TB, pleural TB,
abdominal TB and pericardial TB.
Tuberculin skin test (TST): a positive test may be one element among many to establish the
diagnosis of active TB, however it is has many limitations, especially in children who have
received the BCG vaccination where false positives are common56.
For more information on sampling and testing procedures, see MSF Tuberculosis Guidelines.
Clinical follow-up
The diagnosis may not be made at the first consultation. Follow-up after one to two weeks is
often needed including reassessment of symptoms suggestive of TB, physical examination and
growth assessment (see Section 4.11.3).
Particularly suggestive of TB are:
– Persistent of worsening pneumonia despite non-TB antibiotic treatment
– No weight gain or weight loss despite nutritional support or treatment
– Persistent fever after other causes have been ruled out or treated (e.g. malaria)
– Persistent or worsening fatigue, reduced playfulness, loss of appetite.
170
Chapter 4: Respiratory conditions
NO
NO
Persistant or worsening symptoms? Exit
YES
YES NO
Sum A Sum B
YES NO
Sum A + Sum B > 10?
Start TB treatment
171
Chapter 4: Respiratory conditions
NO
NO
Persistant or worsening symptoms? Exit
YES
YES NO
Sum
YES NO
Sum > 10?
Start TB treatment(c)
172
Chapter 4: Respiratory conditions
4.11.6 Management
A combination of several anti-tuberculous drugs is needed to treat TB and prevent the emergence
of resistance. The following section outlines the initial conventional treatment regimen for
children under 10 years old with drug-susceptible TB (DS-TB). For further information on the
treatment of TB in children including individual drug profiles, alternative regimens and drug-
resistant TB (DR-TB) regimens, as well as for all treatment regimens in older children, see MSF
Tuberculosis Guidelines.
4
Fixed dose combinations and paediatric formulations
DS-TB drugs (also referred to as first-line drugs) include Isoniazid (H); Rifampicin (R);
Pyrazinamide (Z); Ethambutol (E); Rifabutin (Rfb); and Rifapentine (P). Paediatric formulations
should be used where possible, and fixed dose combinations (FDCs) of several TB drugs are
preferred due to improved adherence. The following two quality assured FDC formulations
exist for children:
– Isoniazid/Pyrazinamide/Rifampicin (HZR): H50 mg/Z150 mg/R75 mg
– Isoniazid/Rifampicin (HR): H50 mg/R75 mg
Where paediatric formulations are not available, manipulation of adult formulations is
required:
– Preferably use scored tablets.
– Ensure that tablets/capsules can be split, crushed or opened.
– If tablets must be crushed (or capsules opened) a fraction of the powder corresponding to
the required dose should be mixed with food or liquids immediately before giving the drug.
Any remaining powder should be discarded.
Treatment of drug-susceptible TB
DS-TB treatment is indicated:
– When susceptibility to rifampicin and isoniazid is confirmed by drug susceptibility testing
(DST), or
– If the probability of resistance to rifampicin and/or isoniazid is low:
• While waiting for DST results for rifampicin and/or isoniazid,
• When susceptibility to rifampicin is confirmed and susceptibility to isoniazid cannot be
tested.
The probability of resistance is considered low in the following situations:
– No previous TB treatment
– No contact with a DR-TB patient
– The patient comes from an area of low prevalence of resistance according to drug resistance
surveys.
Conventional DS-TB regimens in children vary according to the severity of disease and the
infection site (see Table 4.6, page 174). 4-month regimens should be used for non-severe TB
in children and adolescents aged between 3 months and 16 years. In eligible children, if there
is not complete resolution of symptoms after 4 months of treatment and/or there is no weight
gain, further investigation is needed. Treatment can be extended to 6 months if causes of non-
response to treatment (including DR-TB, non-adherence and non-TB disease) are ruled out or
unlikely. For dosing, see Table 4.7, page 174.
173
Chapter 4: Respiratory conditions
Ethambutol can be removed from the 4- and 6-month regimens in non-HIV infected children
living in areas where the prevalence of HIV and/or isoniazid resistance is low with:
– PTB microscopy smear-negative, or
– Extra- or intra-thoracic lymph node TB58.
For spinal TB, rest and back support bracing are indicated in addition to drug therapy.
Table 4.7 - Dosing of TB drugs
Drugb Dose
Isoniazid (H) Child < 30 kg: 10 mg/kg (7 to 15 mg/kg) once daily (max. 300 mg daily
Child ≥ 30 kg: 5 mg/kg (4 to 6 mg/kg) once daily (max. 300 mg daily)
Rifampicin (R) Child < 30 kg: 15 mg/kg (10 to 20 mg/kg) once daily (max. 600 mg daily
Child ≥ 30 kg: 10 mg/kg (8 to 12 mg/kg) once daily (max. 600 mg daily)
Pyrazinamide Child < 30 kg: 35 mg/kg (30 to 40 mg/kg) once daily (max. 2000 mg daily
(Z) Child ≥ 30 kg: 25 mg/kg (20 to 30 mg/kg) once daily (max. 2000 mg daily)
Ethambutol (E) 15 to 25 mg/kg once daily (max. 1200 mg daily)
See MSF Tuberculosis Guidelines for dosing charts according to weight, contraindications and
side effects of TB drugs.
a Symptoms requiring hospitalisation include signs of severe respiratory disease or distress, severe acute
malnutrition, fever > 39C, severe pallor, irritability or lethargy.
b Dose reduced in renal or hepatic insufficiency, see MSF Tuberculosis Guidelines for details.
174
Chapter 4: Respiratory conditions
Adjunctive therapy
– Pyridoxine (vitamin B6) prophylaxis is indicated for all patients at risk of peripheral neuropathy
i.e. children with HIV, malnutrition, diabetes, chronic hepatic disease or renal impairment.
– Corticosteroid therapy is indicated for:
• TB meningitis59 and pericarditis60
• Treatment and prevention of TB-associated immune reconstitution inflammatory
syndrome (TB-IRIS), see Chapter 13, Section 13.4.3 for more detail.
4
TB meningitis:
dexamethasone IV: 0.6 mg/kg (max. 16 mg) once daily for 4 weeks, tapered off over
4 weeks
TB pericarditis:
prednisolone PO: 1.5 mg/kg (max. 60 mg) once daily for 4 weeks, tapered off over 6 weeks
c WHO definitions61: A household contact is a person who shared the same enclosed living space for one or
more nights or for frequent or extended periods during the day with the index patient during the 3 months
before the start of treatment; A close contact is a person who does not live in the household but who shared
an enclosed space, such as a social gathering place, workplace or facility, with a TB case for extended periods
during the day during the 3 months before the current disease episode commenced.
175
Chapter 4: Respiratory conditions
Patients who screen positive i.e. have symptoms or signs of TB, should be referred for active
TB diagnosis (see Section 4.11.3, Section 4.11.4 and Section 4.11.5). Patients who screen
negative are unlikely to have active TB and should be referred for latent TB diagnosis and/or
treatment. To demonstrate LTBI, either a tuberculin skin test (TST) or an interferon gamma
release assay may be performed. These tests are not mandatory in children under 5 years
who are a household contact of a TB case, or in HIV-infected children. In such cases, treatment
for LTBI can be commenced without confirmation. Recommended and alternative treatment
regimens for LTBI are outlined in Table 4.8.
Table 4.8 - LTBI regimens in children
Recommended
Age Dosing Alternative regimens
regimens
Child isoniazid daily for isoniazid PO once daily: rifampicin PO once daily
< 2 years 6 months (6H) < 30 kg: 10 mg/kg (7 to 15 mg/kg) for 4 months (4R):
≥ 30 kg: 5 mg/kg (4 to 6 mg/kg) < 30 kg: 15 mg/kg
(max. dose 300 mg daily) ≥ 30 kg: 10 mg/kg
(max. dose 600 mg)
OR isoniazid PO once daily:
isoniazid and < 30 kg: 10 mg/kg (7 to 15 mg/kg)
rifampicin daily for ≥ 30 kg: 5 mg/kg (4 to 6 mg/kg)
3 months (3HR) (max. dose 300 mg daily)
+
rifampicin PO once daily:
< 30 kg: 15 mg/kg
≥ 30 kg: 10 mg/kg
(max. dose 600 mg daily)
176
Chapter 4: Respiratory conditions
4.12 Mastoiditis
Infection in the mastoid cavities that is usually a secondary complication of acute otitis media
(AOM). Like AOM, it is most common in children under 2 years of age. Often there is a history
of AOM or recurrent AOM, though mastoiditis can be the first presentation of AOM. If severe 4
and untreated, it may lead to life-threatening complications.
Common pathogens are S. pneumoniae, S. pyogenes, and Staphylococcus aureus (including
methicillin-resistant S. aureus).
4.12.2 Management
– Admit to hospital for IV antibiotic treatment and management of any complications.
– Refer to Ear, Nose, Throat specialist where possible for advice and to determine if surgical
intervention is necessary.
– Clean the ear canal: wipe any drainage with a cotton swab or clean tissue or gauze.
– Treat fever and pain.
– First line antibiotics recommended are ceftriaxone IV: 80 mg/kg (max. 4g if < 50 kg; max. 2 g
if ≥ 50 kg) every 24 hours and clindamycin IV: 10 mg/kg every 8 hours.
• If clindamycin is not available, add cloxacillin IV: 50 mg/kg every 6 hours.
• If pseudomonas confirmed on culture, add ciprofloxacin PO: 15 mg/kg (max. 750 mg)
2 times daily.
177
Chapter 4: Respiratory conditions
– Switch to oral antibiotic when there is clear improvement (no fever for at least 24 hours,
reduced pain and swelling) and continue treatment for a total of 4 weeks:
178
Chapter 4: Respiratory conditions
References Chapter 4
1. Pneumonia in Children Statistics - UNICEF DATA. UNICEF DATA. Accessed November 20,
2023.
https://data.unicef.org/topic/child-health/pneumonia/
2. Tuberculosis (TB). World Health Organisation. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/tuberculosis
3. Nayani K, Naeem R, Munir O, et al. The clinical respiratory score predicts paediatric
4
critical care disposition in children with respiratory distress presenting to the emergency
department. BMC Pediatr. 2018;18(1):339.
https://doi.org/10.1186/s12887-018-1317-2
4. Asthma/Recurrent Wheezing Clinical Guideline | Clinical Standards | Texas Children’s
Hospital. Texas Children’s Hospital. Published January 2019. Accessed November 20, 2023.
https://www.texaschildrens.org/sites/default/files/uploads/documents/outcomes/
standards/AcuteAsthma.pdf
5. World Health Organization. Oxygen Therapy for Children: A Manual for Health Workers.
World Health Organization; 2016. Accessed November 20, 2023.
https://iris.who.int/handle/10665/204584
6. Brink FT, Duke T, Evans J. High-Flow Nasal Prong Oxygen Therapy or Nasopharyngeal
Continuous Positive Airway Pressure for Children With Moderate-to-Severe Respiratory
Distress?*: Pediatr Crit Care Med. 2013;14(7):e326-e331.
https://doi.org/10.1097/PCC.0b013e31828a894d
7. Kwon JW. High-flow nasal cannula oxygen therapy in children: a clinical review. Clin Exp
Pediatr. 2020;63(1):3-7.
https://doi.org/10.3345/kjp.2019.00626
8. Hardavella G, Karampinis I, Frille A, Sreter K, Rousalova I. Oxygen devices and delivery
systems. Breathe. 2019;15(3):e108-e116.
https://doi.org/10.1183/20734735.0204-2019
9. McCollum ED, Mvalo T, Eckerle M, et al. Bubble continuous positive airway pressure
for children with high-risk conditions and severe pneumonia in Malawi: an open label,
randomised, controlled trial. Lancet Respir Med. 2019;7(11):964-974.
https://doi.org/10.1016/S2213-2600(19)30243-7
10. Rosquelles PV, Cubells CL. Diagnóstico y tratamiento de la laringitis en Urgencias.
https://www.aeped.es/sites/default/files/documentos/06_laringitis.pdf
11. Al-Mutairi B, Kirk V. Bacterial tracheitis in children: Approach to diagnosis and treatment.
Paediatr Child Health. 2004;9(1):25-30.
https://doi.org/10.1093/pch/9.1.25
12. McEwan J, Giridharan W, Clarke RW, Shears P. Paediatric acute epiglottitis: not a disappearing
entity. Int J Pediatr Otorhinolaryngol. 2003;67(4):317-321.
https://doi.org/10.1016/S0165-5876(02)00393-2
13. O’Bryant SC, Lewis JD, Cruz AT, Mothner BA. Influenza A–Associated Epiglottitis and
Compensatory Pursed Lip Breathing in an Infant. Pediatr Emerg Care. 2019;35(11):e213-e216.
https://doi.org/10.1097/PEC.0000000000001589
14. Baiu I, Melendez E. Epiglottitis. JAMA. 2019;321(19):1946.
https://doi.org/10.1001/jama.2019.3468
179
Chapter 4: Respiratory conditions
15. Woods CR. Epiglottitis (supraglottitis): Clinical features and diagnosis. UpToDate. Published
November 2022.
https://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-
diagnosis
16. Hopkins A, Lahiri T, Salerno R, Heath B. Changing Epidemiology of Life-Threatening Upper
Airway Infections: The Reemergence of Bacterial Tracheitis. Pediatrics. 2006;118(4):
1418-1421.
https://doi.org/10.1542/peds.2006-0692
17. Jones R, Santos JI, Overall JC. Bacterial tracheitis. JAMA. 1979;242(8):721-726.
https://doi.org/10.1001/jama.1979.03300080019018
18. Liston SL. Bacterial Tracheitis. Arch Pediatr Adolesc Med. 1983;137(8):764.
https://doi.org/10.1001/archpedi.1983.02140340044012
19. Kasian GF, Bingham WT, Steinberg J, et al. Bacterial tracheitis in children. CMAJ Can Med
Assoc J J Assoc Medicale Can. 1989;140(1):46-50.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1268533/pdf/cmaj00182-0048.pdf
20. Edwards KM, Dundon MC, Altemeier WA. Bacterial tracheitis as a complication of viral
croup: Pediatr Infect Dis J. 1983;2(5):390-391.
https://doi.org/10.1097/00006454-198309000-00015
21. Britto J, Habibi P, Walters S, Levin M, Nadel S. Systemic complications associated with
bacterial tracheitis. Arch Dis Child. 1996;74(3):249-250.
https://doi.org/10.1136/adc.74.3.249
22. Han B, Dunbar J, Striker T. Membranous laryngotracheobronchitis (membranous croup).
Am J Roentgenol. 1979;133(1):53-58.
https://doi.org/10.2214/ajr.133.1.53
23. Woods CR. Bacterial tracheitis in children: Treatment and prevention. UpToDate. Published
January 2023.
https://www.uptodate.com/contents/bacterial-tracheitis-in-children-treatment-and-
prevention
24. DeBlasio D, Real FJ. Tracheitis. Pediatr Rev. 2020;41(9):495-497.
https://doi.org/10.1542/pir.2019-0181
25. Pneumonia in children. World Health Organisation. Accessed November 20, 2023.
https://www.who.int/news-room/fact-sheets/detail/pneumonia
26. Bradley JS, Byington CL, Shah SS, et al. The Management of Community-Acquired Pneumonia
in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the
Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin
Infect Dis. 2011;53(7):e25-e76.
https://doi.org/10.1093/cid/cir531
27. Mansbach JM, McAdam AJ, Clark S, et al. Prospective Multicenter Study of the Viral Etiology
of Bronchiolitis in the Emergency Department. Acad Emerg Med. 2008;15(2):111-118.
https://doi.org/10.1111/j.1553-2712.2007.00034.x
28. Gökçe Ş, Kurugöl Z, Koturoğlu G, Çiçek C, Aslan A. Etiology, Seasonality, and Clinical Features
of Viral Respiratory Tract Infections in Children Hospitalized With Acute Bronchiolitis: A
Single-Center Study. Glob Pediatr Health. 2017;4:2333794X1771437.
https://doi.org/10.1177/2333794X17714378
180
Chapter 4: Respiratory conditions
29. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due
to respiratory syncytial virus in young children: a systematic review and meta-analysis. The
Lancet. 2010;375(9725):1545-1555.
https://doi.org/10.1016/S0140-6736(10)60206-1
30. Piedra PA. Bronchiolitis in infants and children: Clinical features and diagnosis. UpToDate.
Published October 2023.
https://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-
features-and-diagnosis 4
31. Recommendations | Bronchiolitis in Children: Diagnosis and Management | Guidance |
NICE. NICE; 2015. Accessed November 20, 2023.
https://www.nice.org.uk/guidance/ng9/chapter/1-Recommendations
32. Caffrey Osvald E, Clarke JR. NICE clinical guideline: bronchiolitis in children. Arch Dis
Child - Educ Pract Ed. 2016;101(1):46-48.
https://doi.org/10.1136/archdischild-2015-309156
33. Diphtheria: Vaccine Preventable Diseases Surveillance Standards. World Health Organization;
2018. Accessed November 20, 2023.
https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-
standards-diphtheria
34. Plotkin SA, Orenstein WA, Offit PA, eds. Plotkin’s Vaccines. Seventh edition. Elsevier; 2018.
35. Diphtheria vaccines: WHO position paper – August 2017. Accessed November 20, 2023.
https://www.who.int/publications/i/item/who-wer9231
36. Pertussis: Vaccine Preventable Diseases Surveillance Standards. World Health Organization;
2018. Accessed November 20, 2023.
https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-
standards-pertussis
37. Yeh S. Pertussis infection in infants and children: Treatment and prevention. UpToDate.
Published December 2021.
https://www.uptodate.com/contents/pertussis-infection-in-infants-and-children-
treatment-and-prevention
38. Pertussis and Postexposure Antimicrobial Prophylaxis (PEP) | CDC. Published September
16, 2022. Accessed November 20, 2023.
https://www.cdc.gov/pertussis/pep.html
39. Fan H, Gilbert R, O’Callaghan F, Li L. Associations between macrolide antibiotics prescribing
during pregnancy and adverse child outcomes in the UK: population based cohort study.
BMJ. Published online February 19, 2020:m331.
https://doi.org/10.1136/bmj.m331
40. Van Aalderen WM. Childhood Asthma: Diagnosis and Treatment. Scientifica. 2012;2012:1-18.
https://doi.org/10.6064/2012/674204
41. Scarfone RJ. Acute asthma exacerbations in children younger than 12 years: Emergency
department management. UpToDate. Published November 2022.
https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-younger-
than-12-years-emergency-department-management
42. New South Wales Health Clinical Practice Guidelines: Infants and Children - Acute
Management of Asthma. New South Wales Government. Accessed November 20, 2023.
https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2012_056
181
Chapter 4: Respiratory conditions
43. Alangari A. Corticosteroids in the treatment of acute asthma. Ann Thorac Med. 2014;9(4):187.
doi:10.4103/1817-1737.140120.
Available at: https://pubmed.ncbi.nlm.nih.gov/25276236/
44. Becker JM, Arora A, Scarfone RJ, et al. Oral versus intravenous corticosteroids in children
hospitalized with asthma. J Allergy Clin Immunol. 1999;103(4):586-590.
https://doi.org/10.1016/S0091-6749(99)70228-9
45. 2021 GINA Report, Global Strategy for Asthma Management and Prevention. Global
Initiative for Asthma; 2021. Accessed November 20, 2023.
https://ginasthma.org/archived-reports/
46. 2020 GINA Pocket Guide for Asthma Management and Prevention. Global Initiative for
Asthma; 2020.
https://ginasthma.org/archived-reports/
47. Scottish Intercollegiate Guidelines Network, British Thoracic Society. SIGN 158 | British
Guideline on the Management of Asthma | A National Clinical Guideline; 2019. Accessed
November 21, 2023.
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
48. WHO Consolidated Guidelines on Tuberculosis: Module 5: Management of Tuberculosis
in Children and Adolescents. World Health Organization; 2022. Accessed November 21,
2023.
https://www.who.int/publications-detail-redirect/9789240046764
49. Global Tuberculosis Report 2021. World Health Organization; 2021. Accessed November 21,
2023.
https://www.who.int/publications-detail-redirect/9789240037021
50. Dodd PJ, Yuen CM, Sismanidis C, Seddon JA, Jenkins HE. The global burden of
tuberculosis mortality in children: a mathematical modelling study. Lancet Glob Health.
2017;5(9):e898-e906.
https://doi.org/10.1016/S2214-109X(17)30289-9
51. Ai JW, Ruan QL, Liu QH, Zhang WH. Updates on the risk factors for latent tuberculosis
reactivation and their managements. Emerg Microbes Infect. 2016;5(1):1-8.
https://doi.org/10.1038/emi.2016.10
52. WHO Operational Handbook on Tuberculosis: Module 5: Management of Tuberculosis
in Children and Adolescents. World Health Organization; 2022. Accessed November 21,
2023.
https://www.who.int/publications-detail-redirect/9789240046832
53. Marais BJ, Gie RP, Schaaf HS, et al. The natural history of childhood intra-thoracic
tuberculosis: a critical review of literature from the pre-chemotherapy era [State of the
Art]. Int J Tuberc Lung Dis. 2004;8(4):392-402.
https://www.ingentaconnect.com/content/iuatld/ijtld/2004/00000008/00000004/
art00002
54. Hesseling AC, Cotton MF, Jennings T, et al. High Incidence of Tuberculosis among HIV‐
Infected Infants: Evidence from a South African Population‐Based Study Highlights the
Need for Improved Tuberculosis Control Strategies. Clin Infect Dis. 2009;48(1):108-114.
https://doi.org/10.1086/595012
55. Sharma SK, Mohan A, Sharma A. Miliary tuberculosis: A new look at an old foe. J Clin Tuberc
Mycobact Dis. 2016;3:13-27.
https://doi.org/10.1016/j.jctube.2016.03.003
182
Chapter 4: Respiratory conditions
56. Farhat M, Greenaway C, Pai M, Menzies D. False-positive tuberculin skin tests: what is the
absolute effect of BCG and non-tuberculous mycobacteria? [Review Article]. Int J Tuberc
Lung Dis. 2006;10(11):1192-1204.
https://www.ingentaconnect.com/content/iuatld/ijtld/2006/00000010/00000011/
art00003
57. World Health Organization. Guidelines for Treatment of Drug-Susceptible Tuberculosis
and Patient Care. 2017 update. World Health Organization; 2017. Accessed November 21,
2023.
https://iris.who.int/handle/10665/255052
4
58. World Health Organization. Guidance for National Tuberculosis Programmes on the
Management of Tuberculosis in Children. 2nd ed. World Health Organization; 2014.
Accessed November 21, 2023.
https://iris.who.int/handle/10665/112360
59. Prasad K, Singh MB, Ryan H. Corticosteroids for managing tuberculous meningitis. Cochrane
Database Syst Rev. 2016;2016(4).
https://doi.org/10.1002/14651858.cd002244.pub4
60. Wiysonge CS, Ntsekhe M, Thabane L, et al. Interventions for treating tuberculous pericarditis.
Cochrane Infectious Diseases Group, ed. Cochrane Database Syst Rev. 2017;2017(9).
https://doi.org/10.1002/14651858.CD000526.pub2
61. WHO Consolidated Guidelines on Tuberculosis: Module 2: Screening: Systematic Screening
for Tuberculosis Disease. World Health Organization; 2022. Accessed November 21, 2023.
https://www.who.int/publications-detail-redirect/9789240022676
183
Chapter 5:
Gastrointestinal conditions
5
5.1 Vomiting................................................................................................................. 187
5.1.1 Assessment.................................................................................................... 187
5.1.2 Management................................................................................................. 188
5.2 Diarrhoea............................................................................................................... 189
5.2.1 Acute diarrhoea............................................................................................. 189
5.2.2 Specific considerations for children with malnutrition...................................192
5.2.3 Persistent diarrhoea....................................................................................... 192
5.3 Dehydration........................................................................................................... 194
5.3.1 Non-malnourished children........................................................................... 194
5.3.2 Children with severe acute malnutrition (SAM).............................................198
5.4 Approach to a child with acute abdominal pain...................................................202
5.4.1 Identifying underlying cause.......................................................................... 202
5.4.2 Initial management....................................................................................... 204
5.5 Intussusception...................................................................................................... 205
5.5.1 Clinical features............................................................................................. 205
5.5.2 Management................................................................................................. 206
5.6 Acute appendicitis................................................................................................. 207
5.6.1 Clinical features............................................................................................. 207
5.6.2 Management................................................................................................. 207
5.7 Bowel Obstruction................................................................................................. 209
5.7.1 Clinical features............................................................................................. 209
5.7.2 Causes of acute bowel obstruction................................................................210
5.8 Pyloric stenosis...................................................................................................... 213
5.8.1 Clinical features............................................................................................. 213
5.8.2 Management................................................................................................. 213
References Chapter 5................................................................................................... 215
Chapter 5: Gastrointestinal conditions
5.1 Vomiting
5.1.1 Assessment
– Evaluate the history and clinical condition carefully to identify the cause of vomiting. 5
• Consider: age of child; duration of vomiting; characteristics (projectile, episodic/waves,
continuous), associated nausea, diarrhoea, abdominal pain, headaches; colour of vomit
(bilious, yellowish, blood-stained), presence of fever.
• Relevant medical history e.g. diabetic ketoacidosis, recent head injury, possible ingestion
of toxins, poisons or traditional/herbal medicines.
– Assess for presence of any signs of concern (see Table 5.1).
Table 5.1 - Characteristics of vomiting and possible aetiology
Characteristic of vomit or vomiting Potential indication or cause
Signs of concern
Bilious (greenish-yellow) Acute bowel obstruction, see Section 5.7
Projectile Pyloric stenosis (infants < 6 weeks), see
Section 5.8
Blood-stained Oesophageal varices, oesophageal injury
(Mallory-Weiss tear due to repetitive
vomiting), gastritis or gastric ulcer.
Protracted vomiting and acute abdominal Enteric (typhoid and paratyphoid) fever, see
distension/tenderness and fever Chapter 3, Section 3.6
Rapid onset, associated with other signs Anaphylaxis (post ingestion), see Chapter 2,
of anaphylaxis (skin, respiratory, cardiac) Section 2.4
Associated headache or when waking up Raised intracranial pressure
Associated head injury Intracranial haemorrhage causing raised
ICPa
Associated with blood in stools Intussusception (infants), see Section 5.5
Associated with fever Appendicitis (see Section 5.6),
gastroenteritis (see Section 5.2), urinary
tract infection (see Chapter 8, Section 8.1),
malaria (see Chapter 3, Section 3.4), acute
pharyngitis
Vomit contains abnormal contents Ingestion of toxin, poison, traditional/herbal
medicine (see Chapter 2, Section 2.9);
severe helminth infection
187
Chapter 5: Gastrointestinal conditions
Investigations
– Haemoglobin (Hb)
– Blood glucose level (BGL)
– Malaria test, if endemic
– Electrolytes, if available
Conduct specific investigations according to differential diagnosis based on history and clinical
presentation.
5.1.2 Management
– Treat the underlying cause (see Table 5.1, page 187).
– Urgently refer any child suspected of acute bowel obstruction, intussusception, appendicitis,
or raised intracranial pressure for surgical consideration.
– Correct any dehydration and electrolyte abnormalities.
– Antiemetics are rarely necessary unless vomiting is incessant and/or causing significant
dehydration or electrolyte imbalance. A single dose of ondansetron PO, 100 to
150 micrograms/kg (max. 8 mg) can be given if the following conditions are met:
• Acute surgical abdomen excluded (see Section 5.4)
• Failed trial of ORS
• Confident in diagnosis of acute gastroenteritis
188
Chapter 5: Gastrointestinal conditions
5.2 Diarrhoea
Diarrhoea is defined as passage of 3 or more loose or watery stools in a 24-hour period. It is the
second leading cause of under-5 deaths in children worldwide and the main underlying cause
of malnutrition. Children may present critically unwell with severe dehydration or bacterial
sepsis associated with diarrhoea. Malnourished or immune-compromised children (such as
due to HIV infection) are particularly at risk of death1.
In resource-limited settings, infectious gastroenteritis is the main pathology causing diarrhoea 5
(often associated with vomiting). Less commonly, children may present with diarrhoea as an
associated symptom of another illness, such as:
– Influenza, measles, haemorrhagic fever, HIV and malaria.
– Serious bacterial infections: pneumonia, urinary tract infection, meningitis and sepsis.
– Surgical emergencies: intussusception or appendicitis.
Diarrhoea is also a common side effect of antibiotics in children, therefore it is important to
ask about current or recent antibiotic use.
In all children presenting with diarrhoea, take a comprehensive history and always include
assessment of dehydration in the clinical examination. Examine a fresh stool to determine
whether the diarrhoea is watery or bloody (containing visible blood).
Diarrhoea that has continued for ≥ 14 days is classified as persistent diarrhoea (Section 5.2.3).
189
Chapter 5: Gastrointestinal conditions
Assessment
– Evaluate the history and clinical condition carefully to try to identify the cause of the acute
diarrhoea.
• Consider: frequency per day, consistency of stool (loose, watery, mucous or blood-
streaked, rice-water appearance), associated with fever, vomiting, abdominal pain.
• Relevant medical history e.g. HIV infection, recent use of antibiotics, traditional medicines.
• Epidemiological factors such as other members of household with same symptoms, or in
context of known epidemic.
– Assess for presence of dehydration and severity (refer to Section 5.3).
– Assess for any secondary complications:
• Hypoglycaemia
• Signs of electrolyte imbalance
• Excess weight loss or malnutrition
Investigations
Most children with acute diarrhoea do not need any investigations, however the following
may be helpful:
– Hb, BGL
– Malaria test, if endemic
– Stool examination, with or without culture, if symptoms not typical of acute gastroenteritis.
Management
– Take and note the baseline weight (if not already done).
– If breastfeeding, continue if child keen to drink and alert.
– Admit children with severe diarrhoeaa or signs of critical illness, even if no evidence of
dehydration, especially if malnourished.
– Assess degree of dehydration and manage according to severity (see Section 5.3).
– Prevent dehydration in children with no dehydration (see below).
– Prevent malnutrition: continue with unrestricted usual diet. See below for breastfed infants.
– Do not give anti-diarrhoeal drugs or antiemetics.
– Treat the underlying condition, if known.
– Give zinc sulfate (see page 191 for dosing).
– Antibiotic treatment:
• Not indicated in most cases of acute watery diarrhoea, with the exception of suspected
cholera in certain cases only (see Management of a cholera epidemic, MSF).
• Indicated in acute bloody diarrhoea, as Shigellosis is the most common cause.
Prevention of dehydration
Children with simple diarrhoea and no dehydration can be treated at home with measures to
prevent dehydration:
– Explain to parents/carers how to replace fluids lost in diarrhoea by giving ORS 10 mL/kg
(5 mL/kg in children with SAM) after each loose stool (see Table 5.3 and Appendix 12).
– Breastfed children: encourage frequent feeds for as long as the child wants. ORS should be
given between feeds.
– Non-breastfed children: encourage the child to take additional ORS or clean water if the
child seeks it in addition to recommended amount of ORS.
190
Chapter 5: Gastrointestinal conditions
Non-malnourished SAM
Weight mL of ORS to be given mL of ORS to be given
(10 mL/kg) (5 mL/kg)
< 5 kg 50 25
5 to < 10 kg 100 50
10 to 20 kg 200 100
zinc sulfate PO
• < 6 months: 10 mg once daily for 10 days
• 6 months to 5 years: 20 mg once daily for 10 days
Place the half-tablet or full tablet on a teaspoon, add a bit of water to dissolve it, and give
the entire spoonful to the child.
In malnourished children who are receiving therapeutic milk or RUTF, supplementation with
zinc sulfate is unnecessary.
Antibiotic treatment
– Diarrhoea without blood:
• Most are caused by viruses unresponsive to antibiotics.
• Antibiotic treatment is indicated in the case of cholera or giardiasis:
▹ Cholera: the most important part of treatment is rehydration. In the absence of
resistance (perform antibiotic-sensitivity testing at the beginning of an outbreak),
antibiotic treatment shortens the duration of diarrhoea. See Management of a cholera
epidemic, MSF.
▹ Giardiasis: give tinidazole PO 50 mg/kg (max. 2 g) single dose or metronidazole PO
30 mg/kg once daily for 3 days.
– Diarrhoea with blood:
Treat empirically for Shigellosis (amoebiasis is much less common).
• If the child is unwell:
▹ Admit and stabilise.
▹ Administer ceftriaxone IV/IM: 50 to 100 mg/kg once daily (max. 4 g if < 50 kg; max. 2 g
if ≥ 50 kg) for 3 days.
▹ If no improvement (treatment failure defined by persistent fever, grossly bloody
stools or unchanged stool frequency by day 3 of treatment), consider antibiotic-
resistant infection or an alternative cause such as amoebiasis (see Section 5.2.3) or
C. difficile.
191
Chapter 5: Gastrointestinal conditions
Prevention
– Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severity of
diarrhoea episodes.
– When the child is weaned, preparation and storage of food are associated with the risk of
contamination by faecal micro-organisms: discourage bottle-feeding; food must be cooked
well; milk or porridge must never be stored at room temperature.
– Access to sufficient amounts of clean water and personal hygiene (washing hands with soap
and water before food preparation and before eating, after defecation etc.) are effective
methods of reducing the spread of diarrhoea.
– In countries with a high rotavirus diarrhoea fatality rate, the WHO recommends routine
rotavirus vaccination in children between 6 weeks and 24 months of age3.
192
Chapter 5: Gastrointestinal conditions
– Giardiasis:
• More common in children < 5 years.
• Suspect G. lamblia in cases of diarrhoea (sudden in onset; initially may be watery),
malaise, nausea/vomiting, foul-smelling and fatty stools (steatorrhea), abdominal cramps
and bloating and weight loss; fever occurs occasionally.
– Amoebiasis:
• Can cause both persistent and bloody diarrhoea in children, but it is not common.
Investigations
– Examine stools for Giardia, Cryptosporidium, and Entamoeba histolytica.
5
Management
– Same admission criteria as for acute diarrhoea.
– Prevent and/or treat dehydration if present according to severity (see above and Section 5.3).
– Assess for malnutrition and refer for management of acute malnutrition if identified.
– Prevent malnutrition by encouraging good dietary intake and breastfeeding for infants.
– Give zinc sulfate (as page 191).
– Give empiric antiparasitic treatment:
albendazole PO:
12 - 23 months: 200 mg once daily for 3 daysb
≥ 24 months: 400 mg once daily for 3 days
mebendazole PO:
≥ 12 months and > 10kg: 100 mg 2 times daily for 3 days
Amoebiasis
– Antiparasitic treatment should be given when motile Entamoeba histolytica amoebae are
found in stools or if a correct shigellosis treatment has been ineffective.
– Give tinidazole PO 50 mg/kg (max. 2 g daily) for 3 days or metronidazole PO 15 mg/kg 3 times
daily for 5 days
– Refer to MSF Clinical Guidelines, Chapter 3 for further information.
Giardiasis
– Give tinidazole PO 50 mg/kg (max. 2 g) single dose or metronidazole PO 30 mg/kg once daily
for 3 days.
– Refer to MSF Clinical Guidelines, Chapter 6 for further information.
If diarrhoea lasts for more than 4 weeks (chronic diarrhoea), consider non-infectious causes.
b Albendazole is not systematically recommended to children less than 12 months, but can be given on a case-
by-case basis according to clinician assessment at the same dose as for children 12 - 23 months.
193
Chapter 5: Gastrointestinal conditions
5.3 Dehydration
Dehydration results from loss of water and salt from the body in excess of replacement.
Young children are at greater risk of dehydration as they are unable to independently replace
their fluid losses or to clearly communicate their needs. Dehydration may be associated
with electrolyte disturbance and, if prolonged, can lead to reduced end-organ perfusion
and shock. The most common causes of dehydration in children are diarrhoea and vomiting,
with dehydration being the main contributor to death from diarrhoea. In addition, children
are particularly susceptible to dehydration from severe burns due to their large body surface
area relative to their weight.
Management of dehydration depends on the underlying cause and degree of dehydration.
For children with fluid loss due to burns refer to MSF Clinical Guidelines, Chapter 10 and for
diabetic ketoacidosis refer to Chapter 9, Section 9.1.
194
Chapter 5: Gastrointestinal conditions
Management
Children with no dehydration do not require admission. Most children with some dehydration
can be managed at home after an initial period of observation (4 to 6 hours) to ensure that
they are able to tolerate adequate oral rehydration therapy.
Admit:
– All children with severe dehydration.
– Children < 4 months of age and/or < 4 kg weight with some dehydration.
– Children with some dehydration if there is no possibility for short-term observation while
starting rehydration treatment.
Manage according to degree of dehydration using WHO treatment plan A, B or C4 (see
also Appendix 12). Reassess the child’s hydration and clinical condition regularly – clinical
improvement is the best indicator of treatment response.
195
Chapter 5: Gastrointestinal conditions
196
Chapter 5: Gastrointestinal conditions
– In addition, if tolerated, give extra ORS to replace fluids lost with each loose stool according
to plan A (below).
– Assess the degree of dehydration at the end of the fluid resuscitation (3 hours for children,
6 hours for infants). Continue further rehydration according to degree of dehydration
following the appropriate treatment plan (A, B or C).
– If hypokalaemia or, where potassium monitoring not available, if child develops signs of
hypokalaemia including general fatigue, muscle cramps and weakness, abdominal distension
and polyuria, treat for moderate hypokalaemia with 7.5% potassium chloride syrup for 2 days
(see also Chapter 15, Section 15.3):
– Show the parent/carer how to give ORS in small, frequent quantities e.g. using a teaspoon
or syringe for infants and young children (5 ml every 5 minutes), regular sips from a cup for
older children.
– If child vomits ORS, encourage child to take smaller volumes or sips.
– In addition to rehydration with treatment plan B, give extra ORS to replace fluids lost with
each loose stool according to plan A (below).
– Reassess degree of dehydration after 4 hours and continue with appropriate treatment plan.
If dehydration has resolved, management with plan A can continue at home.
– Explain to the parent/carer how to reassess regularly for signs of dehydration and continue
treatment with ORS after loose stools at home.
197
Chapter 5: Gastrointestinal conditions
Management
Children with SAM and no dehydration do not require admission, unless diarrhoea is severeb
or there are signs of critical illness. In this case, admit for monitoring and management with
‘Plan A SAM’. Admit children with SAM and some or severe dehydration for close monitoring,
and manage according to degree of dehydration using treatment plans specifically adapted for
SAM (see below and Figure 5.3)c. Ideally, continue therapeutic milk at scheduled feeding hours
in addition to rehydration fluids.
Oral rehydration should be used in preference to IV fluids in the management of dehydration
of any severity in children with SAM. Target weights are used to guide treatment and are
198
Chapter 5: Gastrointestinal conditions
calculated on the basis of assumed percentages of body water lost depending on the degree of
severity of dehydration. Reassess the child’s hydration and clinical condition regularly – clinical
improvement is the best indicator of treatment response.
199
Chapter 5: Gastrointestinal conditions
– If the child is ready for discharge, explain to the parent/carer how to reassess regularly for
signs of dehydration and continue treatment with ORSg after loose stools at home.
Fluid overload
– Monitor continuously for signs of fluid overload:
• Increased RR by ≥ 10 breaths/min from initial RR, or
• Increased HR by ≥ 20 beats/min from initial HR.
Plus any one of the following:
• New or worsening hypoxia (decrease in SpO2 by > 5%)
• New onset of rales and/or pulmonary oedema (fine crackles in lung fields)
• New galloping heart rhythm
• Increased liver size (liver size must have been marked with pen on arrival)
• New peripheral oedema and/or puffy eyelids.
– Management if signs of fluid overload present:
• Stop IV fluids or ReSoMal.
• Consider administration of furosemide IV: 0.5 mg/kg, especially if IV fluids given (repeat
once if necessary).
• Place child into semi-sitting position and ensure high-flow oxygen via non-rebreathing mask.
• Monitor every 15 minutes until child has been stable for at least one hour.
200
Figure 5.3 - Management of dehydration in children with SAM (excluding cholera cases)
Child with severe acute malnutrition (SAM) and dehydration
201
*** If Hb is above 10 g/dL transfusion may not be beneficial and decision to transfuse should be based on the balance of potential risks and benefits.
5
Chapter 5: Gastrointestinal conditions
Abdominal pain is a common presentation in children and has a wide range of medical and
surgical causes. Gastroenteritis is the most common non-surgical cause of abdominal pain
in children (see Section 5.1 and Section 5.2), but surgical causes must be ruled out early to
prevent unnecessary morbidity and mortality. This chapter will focus on the ‘acute abdomen’ –
sudden and severe abdominal pain that may indicate a surgical emergency. It is estimated that
around 30% of global disease burden could be addressed surgically, however the provision of
available, affordable, timely and safe paediatric surgical care is often scarce in resource-limited
settings6,7,8.
a Mesenteric adenitis is a benign lymphadenopathy of the abdominal lymph nodes that commonly occurs after
a viral infection.
202
Chapter 5: Gastrointestinal conditions
203
Chapter 5: Gastrointestinal conditions
Investigations
– FBC including haemoglobin (Hb)
– BGL
– Electrolytes, if available
– Urine for microscopy
– Consider pregnancy test, if applicable
– Abdominal x-ray: obtain supine and left lateral decubitus views to evaluate acute conditions.
– Consider POCUS, if equipment and trained staff available: can be helpful in detecting free
fluid in the abdomen, especially when there is sudden clinical deterioration9.
Note that while the presence of x-ray and/or US signs may confirm pathology or support a
diagnosis, their absence does not rule it out.
Refer for urgent surgical review, identify the underlying cause and treat accordingly (see
Section 5.5, Section 5.6 and Section 5.7).
204
Chapter 5: Gastrointestinal conditions
5.5 Intussusception
Intussusception occurs when one segment of the intestine invaginates into a more distal
segment. In approximately 90% of cases, this occurs at the ileocaecal junction11. It is the most
common cause of bowel obstruction in infants, with a mean incidence of 74 per 100,00012.
Although mostly seen in infants and young children (typical age range is 6 to 36 months), it
can occur in older children as well, when there is a pathologic ‘lead point’ such as lymphoma,
Meckel’s diverticulum, polyps, parasites or Henoch-Schönlein purpuraa. If the obstruction is not
corrected, the vascular supply of the bowel may become compromised, resulting in intestinal 5
ischemia and possible perforation. In high-income countries, death from intussusception is
rare, generally less than 1%, but in low- and middle-income countries (LMICs), between 6 and
25% of children who reach surgical care die13.
Investigations
– Consider POCUS, if equipment and trained staff availableb: typically, a ‘target sign’ lesion
(concentric circles resembling a doughnut) is seen in ileocolic intussusception, with one
segment of bowel telescoping into another part. The outer wall is thickened and hypoechoic
in transverse axis14.
a Henoch-Schönlein purpura (HSP) is a common systemic vasculitis in children of unknown cause, that presents
with a rash and arthritis/arthralgia, abdominal pain or nephritis.
b Although ultrasound has high diagnostic accuracy for intussusception, positive results are user-dependent and
require high levels of training.
205
Chapter 5: Gastrointestinal conditions
5.5.2 Management
– Assess and manage ABCDE.
– Ensure initial stabilisation as for acute abdomen (see Section 5.4.2).
– Refer for surgical review and definitive treatment with either:
• Radiographic barium or air enema
• Surgical reduction: in LMICs reduction is typically only partially accomplished due to
progressive ischaemia of the intussuscepted bowel, which ultimately requires resection.
• Hydrostatic reduction by warm saline enema under real-time sonography guidance, if
there are no contraindications (such as perforation, or ischemia on Doppler) and if the
ultrasonographer is skilled15,16.
In LMIC, treatment with radiological reduction is less available and operative intervention is
more common (nearly 90%)12,17. Additionally, if the patient has had symptoms of abdominal
pain for more than 24 hours, the risk of perforation of the intestine on attempted reduction by
air, barium or warm saline enema increases considerably.
Ileo-ileal intussusception of the small intestine is often transient in nature and may reduce
spontaneously without intervention, especially in younger children.
206
Chapter 5: Gastrointestinal conditions
Appendicitis is one of the most common causes of acute abdomen in children worldwide.
Typical age of presentation is 5 to 15 years with less than 5% of patients being under 5 years
old. Intraluminal obstruction of the appendix (by faecal matter, lymph nodes, foreign bodies,
parasites), leads to bacterial overgrowth and infection of the appendix. The classic pain
of appendicitis is due to local peritonitis overlying the inflamed appendix. Perforation is a
common complication if left untreated.
5
Investigations
– WBCs may be elevated
– CRP, if available
– Consider POCUS, if equipment and trained staff available: an experienced sonographer or
POCUS practitioner may identify an inflamed enlarged appendix on ultrasound, however
sensitivity is low therefore this may be used to confirm the diagnosis, but not to exclude it.
5.6.2 Management
– Assess and manage ABCDE.
– Ensure initial stabilisation as for acute abdomen (see Section 5.4.2).
a Pain may also localise to the pelvis or suprapubic region, depending on the exact position of the appendix.
207
Chapter 5: Gastrointestinal conditions
208
Chapter 5: Gastrointestinal conditions
This is a paediatric surgical emergency. In sub-Saharan Africa, the overall mortality rate of
acute intestinal obstruction has been reported around 15%, with higher rates in neonates
(20-70%)20. Prognosis of acute bowel obstruction is improved by prompt diagnosis and
management, including good peri-operative care.
Diagnostic investigations
– Abdominal X-ray (supine and erect, or left lateral decubitus for infants and patients unable
to stand): dilated bowel loops with air-fluid levels may indicate obstruction but can also be
seen with an ileus. Assess for pneumoperitoneum in case of perforation (see Figure 5.4).
– Consider POCUS, if equipment and trained staff available: may show fluid filled (hypoechoic),
dilated (> 2.5 cm) bowel loops with abnormal peristalsis.
a Pica is an eating disorder that causes people to eat items that are not usually considered as food, such as dirt,
clay and paper. This can lead to the formation of a tightly packed mass of partially digested or undigested
foreign material, known as a bezoar.
209
Chapter 5: Gastrointestinal conditions
Management
Emergency stabilisation as for acute abdomen in Section 5.4.2 and definitive treatment
depending on underlying cause.
Figure 5.4 - AXR showing pneumoperitoneum secondary to intestinal perforation
5.4a - Upright AP viewb, infantc 5.4b - Left lateral decubitus view, infantd
Free air can be seen Free air can be seen between the liver
under the diaphragm (arrows) and right lateral abdominal wall (arrows)
b If an upright view cannot be obtained (e.g. in neonates or infants), a left lateral decubitus view is needed to
exclude pneumoperitoneum. Pneumoperitoneum cannot be excluded on a supine view.
c Case courtesy of Hidayatullah Hamidi, Radiopaedia.org, rID: 60388, https://radiopaedia.org/cases/60388.
d Image courtesy of Juno Min.
210
Chapter 5: Gastrointestinal conditions
mesenteric vein and artery are wrapped around each other21) which is a highly sensitive and
specific indicator of midgut volvulus22, though diagnosis is rarely made on ultrasound. After
stabilisation, urgent surgical intervention is required to de-torse the volvulus and reposition
the caecum/colon and small intestines to prevent recurrence. Time spent in stabilisation or
transport to a surgical centre should be minimised, as ischaemia of the entire midgut can
progress to necrosis within 1-2 hours.
albendazole PO
12 – 23 months: 200 mg once daily for 3 dayse
≥ 24 months: 400 mg once daily for 3 days
mebendazole PO
≥ 12 months and > 10kg: 100 mg 2 times daily for 3 days
e Albendazole is not systematically recommended to children less than 12 months, but can be given on a case-
by-case basis according to clinician assessment at the same dose as for children 12 – 23 months.
211
Chapter 5: Gastrointestinal conditions
212
Chapter 5: Gastrointestinal conditions
Investigations
– BGL
– Electrolytes, if available
– Creatinine, if available
– Consider POCUS, if equipment and trained staff available: Ultrasound has a high diagnostic
accuracy for pyloric stenosis but positive results are user dependent and require a high
level of training. A hypertrophic pyloric muscle of > 3 mm and a pyloric canal length of
≥ 15 mm are considered diagnostic27.
5.8.2 Management
– Assess and manage ABCDE.
– Check BGL and correct hypoglycaemia if present (see Chapter 9, Section 9.3).
– Start IV maintenance fluids if no signs of dehydration, with added potassium if evidence of
urine output. Correct any dehydration and/or electrolyte disturbance (see Section 5.3 and
Chapter 15, Section 15.3).
– Place the child NBM and insert NGT (conical tip) to be kept on free drainage.
– Refer for urgent surgical review and definitive treatment once fully rehydrated and electrolyte
disturbance corrected:
• Surgical pyloromyotomy is the gold standard and should be performed as soon as the
child has received adequate fluid resuscitation and abnormalities of electrolytes have
been corrected.
213
Chapter 5: Gastrointestinal conditions
214
Chapter 5: Gastrointestinal conditions
References Chapter 5
1. Diarrhoeal disease: WHO fact sheet. World Health Organisation. Accessed December 1,
2023.
https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
2. Kotloff KL, Nataro JP, Blackwelder WC, et al. Burden and aetiology of diarrhoeal disease in
infants and young children in developing countries (the Global Enteric Multicenter Study,
GEMS): a prospective, case-control study. The Lancet. 2013;382(9888):209-222.
https://doi.org/10.1016/S0140-6736(13)60844-2
3. Weekly epidemiological record/Relevé épidémiologique hebdomadaire 1st February 2013,
88th year/1er février 2013, 88e année. 2013;5(88):49-64.
5
https://www.nitag-resource.org/sites/default/files/989018b9e380f70ab07522155f36c9f8c9515d9a_1.
pdf
4. World Health Organization. Pocket Book of Hospital Care for Children: Guidelines for the
Management of Common Childhood Illnesses. 2nd ed. World Health Organization; 2013.
Accessed November 7, 2023.
https://iris.who.int/handle/10665/81170
5. Guideline: Updates on Paediatric Emergency Triage, Assessment and Treatment: Care of
Critically-Ill Children. World Health Organization; 2016. Accessed December 1, 2023.
http://www.ncbi.nlm.nih.gov/books/NBK350528/
6. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation
from the provider perspective. Lancet Glob Health. 2015;3:S8-S9.
https://doi.org/10.1016/S2214-109X(14)70384-5
7. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and
solutions for achieving health, welfare, and economic development. The Lancet. 2015;
386(9993):569-624.
https://doi.org/10.1016/S0140-6736(15)60160-X
8. Poenaru D. The burden of pediatric surgical disease in low-resource settings: Discovering it,
measuring it, and addressing it. J Pediatr Surg. 2016;51(2):216-220.
https://doi.org/10.1016/j.jpedsurg.2015.10.065
9. Singh Y, Tissot C, Fraga MV, et al. International evidence-based guidelines on Point of Care
Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working
Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit
Care. 2020;24(1):65.
https://doi.org/10.1186/s13054-020-2787-9
10. Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Early Analgesia for Children With
Acute Abdominal Pain. Pediatrics. 2005;116(4):978-983.
https://doi.org/10.1542/peds.2005-0273
11. Salazar JH, Nghia “Jack” Vo. Intussusception in children. UpToDate. Published July 2022.
https://www.uptodate.com/contents/intussusception-in-children
12. Jiang J, Jiang B, Parashar U, Nguyen T, Bines J, Patel MM. Childhood Intussusception:
A Literature Review. Cameron DW, ed. PLoS ONE. 2013;8(7):e68482.
https://doi.org/10.1371/journal.pone.0068482
215
Chapter 5: Gastrointestinal conditions
13. Clark AD, Hasso-Agopsowicz M, Kraus MW, et al. Update on the global epidemiology of
intussusception: a systematic review of incidence rates, age distributions and case-fatality
ratios among children aged < 5 years, before the introduction of rotavirus vaccination. Int J
Epidemiol. 2019;48(4):1316-1326.
https://doi.org/10.1093/ije/dyz028
14. Lin-Martore M, Kornblith A, Kohn M, Gottlieb M. Diagnostic Accuracy of Point-of-Care
Ultrasound for Intussusception in Children Presenting to the Emergency Department: A
Systematic Review and Meta-analysis. West J Emerg Med. 2020;21(4).
https://doi.org/10.5811/westjem.2020.4.46241
15. Flaum V, Schneider A, Gomes Ferreira C, et al. Twenty years’ experience for reduction
of ileocolic intussusceptions by saline enema under sonography control. J Pediatr Surg.
2016;51(1):179-182.
https://doi.org/10.1016/j.jpedsurg.2015.09.022
16. Talabi AO, Famurewa OC, Bamigbola KT, Sowande OA, Afolabi BI, Adejuyigbe O. Sonographic
guided hydrostatic saline enema reduction of childhood intussusception: a prospective
study. BMC Emerg Med. 2018;18(1):46.
https://doi.org/10.1186/s12873-018-0196-z
17. Steele AD, Patel M, Cunliffe NA, Bresee JS, Borgstein E, Parashar UD. Workshop on
intussusception in African countries – Meeting report. Vaccine. 2012;30:A185-A189.
https://doi.org/10.1016/j.vaccine.2011.10.004
18. Colvin JM, Bachur R, Kharbanda A. The Presentation of Appendicitis in Preadolescent
Children: Pediatr Emerg Care. 2007;23(12):849-855.
https://doi.org/10.1097/pec.0b013e31815c9d7f
19. Seyi-Olajide JO, Ezidiegwu U, Ameh EA. Burden of Complicated Intra-Abdominal
Infections in Children in Nigeria: Recent Experience and Systematic Review. Surg Infect.
2020;21(6):501-508.
https://doi.org/10.1089/sur.2020.118
20.Adamou H, Magagi IA, Habou O, Adakal O, Ganiou K, Amadou M. Acute Mechanical Intestinal
Obstruction in Children at Zinder National Hospital, Niger: Aetiologies and Prognosis. Afr J
Paediatr Surg AJPS. 2017;14(3):49-52. doi:10.4103/ajps.AJPS_96_16.
Available at: https://pubmed.ncbi.nlm.nih.gov/29557351/
21. Sivitz AB, Lyons R. Mid-Gut Volvulus Identified by Pediatric Emergency Ultrasonography.
J Emerg Med. 2013;45(5):e173-e174.
https://doi.org/10.1016/j.jemermed.2013.05.048
22. Nguyen HN, Kulkarni M, Jose J, et al. Ultrasound for the diagnosis of malrotation and
volvulus in children and adolescents: a systematic review and meta-analysis. Arch Dis Child.
2021;106(12):1171-1178.
https://doi.org/10.1136/archdischild-2020-321082
23. Koizumi M, Sata N, Kaneda Y, et al. Optimal timeline for emergency surgery in patients with
strangulated groin hernias. Hernia. 2014;18(6):845-848.
https://doi.org/10.1007/s10029-014-1219-7
24. Soil-transmitted helminth infections. Accessed December 1, 2023.
https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections
216
Chapter 5: Gastrointestinal conditions
25. Mishra P, Agrawal A, Joshi M, Sanghvi B, Shah H, Parelkar S. Intestinal obstruction in children
due to Ascariasis: A tertiary health centre experience. Afr J Paediatr Surg. 2008;5(2):65.
doi:10.4103/0189-6725.44178.
Available at: https://journals.lww.com/ajps/fulltext/2008/05020/intestinal_obstruction_
in_children_due_to.2.aspx
26. MacMahon B. The Continuing Enigma of Pyloric Stenosis of Infancy: A Review. Epidemiology.
2006;17(2):195-201.
https://doi.org/10.1097/01.ede.0000192032.83843.c9
27. Vinycomb T, Vanhaltren K, Pacilli M, Ditchfield M, Nataraja RM. Evaluating the validity
of ultrasound in diagnosing hypertrophic pyloric stenosis: a cross‐sectional diagnostic
accuracy study. ANZ J Surg. 2021;91(11):2507-2513. 5
https://doi.org/10.1111/ans.17247
28. Wu SF, Lin HY, Huang FK, et al. Efficacy of Medical Treatment for Infantile Hypertrophic
Pyloric Stenosis: A Meta-analysis. Pediatr Neonatol. 2016;57(6):515-521.
https://doi.org/10.1016/j.pedneo.2016.02.005
217
Chapter 6:
Cardiology
6.1 Introduction
The diagnosis and management of cardiac conditions in children in resource-limited settings are
challenging, with lack of access to tools to confirm diagnosis, delayed presentation, and when
specialised paediatric cardiac surgery is required for definitive treatment. Where available and
feasible for the family to access, referral to a paediatric cardiologist is recommended as early
as possible. Consider early involvement of a paediatric cardiologist for consultation, even at
a distance, including remote support for imaging interpretation for diagnosis. For example,
healthcare staff trained in point of care ultrasound (POCUS) can take key images of the heart
and share these by telemedicine or other communication tools with a cardiologist who can
make the diagnosis and provide management guidance1.
In these guidelines, the focus is on guiding diagnosis and supportive management for acute 6
cardiac presentations within the means of lower-resource settings.
221
Chapter 6: Cardiology
Outside of contexts with access to advanced medical diagnostic capacity, the true incidence
of cardiac failure amongst children is not well documented. However, as many children do not
have access to early diagnosis, presentation is often in the late stages of cardiac failure, with a
significant burden in terms of morbidity and mortality2.
Underlying causes that lead to cardiac failure include cardiac, extra-cardiac or iatrogenic
conditions:
– Cardiac conditions: congenital heart disease (CHD), cardiomyopathies (inherited or
acquired)a, acute rheumatic fever, cardiac arrhythmias.
– Extra-cardiac conditions: sepsis, severe anaemia, thiamine deficiency, severe acute
malnutrition (particularly in young infants).
– Iatrogenic: fluid overload due to large parenteral fluid administration over a short period.
Diagnosis is based on history and clinical examination. Radiological and laboratory investigations
can support diagnosis, identify underlying cause, and/or determine prognosis.
6.2.2 Investigations
– Haemoglobin (Hb): to assess for anaemia
Where readily available and of reliable quality, the following investigations can aid diagnosis,
management and/or prognosis:
– Electrolytes, renal function and liver function tests.
a Abnormality of the ventricular myocardium resulting from overload or congenital heart disease.
222
Chapter 6: Cardiology
– Chest x-ray: to assess heart size, pulmonary oedema, septal linesb (or Kerley B lines) and
pleural effusions.
– Point-of-Care ultrasound (POCUS): perform 12-zone lung exam to evaluate for signs of
bilateral pulmonary oedema and/or pleural effusions. Perform 5-view cardiac exam to
evaluate for signs of acute volume overload and/or decreased cardiac function4.
– Cardiac ultrasound: to assess cardiac structure, chamber volumes/diameters, wall thickness,
ventricular systolic/diastolic function, and pulmonary pressures.
– Throat swab or streptococcal serology.
6.2.3 Management
– Assess and manage ABCDE (see Chapter 2, Section 2.1).
Supportive management
– Start oxygen therapy (or non-invasive ventilation (NIV) if needed – see Chapter 4, 6
Section 4.1.3) when SpO2 < 90% in children with acyanotic CHD or with cardiomyopathy.
Note that in cyanotic CHD, oxygen may have little effect in raising SpO2, oxygen therapy (if
required) should be guided by target saturations as indicated by the clinician.
– Start IV maintenance fluids if unable to tolerate adequate oral or nasogastric tube (NGT)
fluid intake, restricted to 70% of usual maintenance volume (see Chapter 15, Section 15.2).
Switch to PO/NGT fluids as soon as child can safely tolerate oral intake (see Chapter 15,
Section 15.5).
– Ensure nutritional support and nutrition supplementation.
– Reduction of salt is recommended for children with oedema and fluid retention.
Diuretics
– Fluid retention can be treated with diuretics.
– Give oral furosemide, gradually increasing the dose if necessary. In the case of severe oedema
and/or the child cannot tolerate oral medication, administer furosemide IV:
furosemide PO
• 1 month to 11 years: 1 mg/kg 2 times daily
Increased if necessary up to 2 mg/kg up to 4 times daily if requiredc.
• ≥ 12 years: 20 to 40 mg once daily
furosemide IV
• 1 month to 11 years: 0.5 to 1 mg/kg every 8 hours (max. 40 mg/dose)
Increased if necessary up to 2 mg/kg every 8 hours (max. 40 mg/dose)c.
• ≥ 12 years: 20 to 40 mg every 8 hours as required.
spironolactone PO
0.5 to 1.5 mg/kg up to 2 times daily
b Horizontal lines reaching out from peripheral edge of lung, seen in the costophrenic angle, representing
thickened interlobular septa that result from chronic congestive cardiac failure.
c For high doses of > 3 mg/kg/day, ensure potassium monitoring, if available. If potassium monitoring is not
possible, consider providing routine oral potassium supplementation (2 mmol/kg/day).
223
Chapter 6: Cardiology
enalapril PO
6.2.4 Follow-up
– Discharge of the child can be considered once the child is stable on oral treatment, not
requiring supplemental oxygen and able to eat and drink.
– For children discharged on cardiac medication, arrange follow-up within 3 to 6 months.
Where available, arrange follow-up with a cardiology specialist.
– Most children will require lifelong medical management of cardiac failure if corrective
surgery or cardiac transplantation is not feasible or available.
– Regular follow-up is required to assess the need for increasing or adjusting dosage of
medication as the cardiac condition progresses.
– Inform parents/carers to bring child back to hospital if there are signs of increased respiratory
distress, cyanosis, and/or oedema.
224
Chapter 6: Cardiology
225
Chapter 6: Cardiology
6.3.2 Management
– If heart failure is present, follow management in Section 6.2.
– Eradicate GAS infection with antibiotics:
– Treat associated arthritis with NSAIDf for at least 2 to 3 weeks and then decrease the dose
progressively over 2 weeks.
aspirin PO
50 to 100 mg/kg once daily
If unable to take aspirin or cardiac signs persist, replace with a steroid:
prednisolone PO
1 to 2 mg/kg once daily
6.3.3 Prevention
– Children who have had ARF have a high risk of another episode of ARF, and with each
recurrence severity of RHD is increased causing further valvular damage.
– In children with recurrent episodes of ARF, long-term antibiotic prophylaxis with a monthly
injection of benzathine benzylpenicillin or oral penicillin 2 times daily (doses above) is
recommended up to 5 or 10 years where it is feasible (refer to national protocol where
available).
f Aspirin is recommended for use in children only in the setting of anti-platelet action and for the treatment of
arthritis associated with acute rheumatic fever. It is not recommended in children for fever or pain.
226
Chapter 6: Cardiology
Aphonic form
– Less severe and usually presents later between 4 to 7 months of age.
– Starts with cough and dyspnoea. The crying becomes hoarse until there is a loss of voice.
– Untreated cases advance into acute congestive cardiac failure and respiratory distress, and
eventually death within days.
Management
– Treat promptly with injectable thiamine which can rapidly reverse clinical signs5:
thiamine IV/PO
• Loading dose < 15 years: 100 mg slow IV infusion over 30 minutes once daily for
48 hours
If IV not possible: Give PO/via NGT at the same dose.
• Maintenance dose to be started after 48 hours of IV treatment:
▹ ≤ 12 years: 25 mg PO once daily for 1 month
▹ > 12 years: 25 mg PO 2 times daily for 1 month
227
Chapter 6: Cardiology
References Chapter 6
1. Muhame RM, Dragulescu A, Nadimpalli A, et al. Cardiac point of care ultrasound in resource
limited settings to manage children with congenital and acquired heart disease. Cardiol
Young. 2021;31(10):1651-1657.
https://doi.org/10.1017/S1047951121000834
2. Ahmed H, VanderPluym C. Medical management of pediatric heart failure. Cardiovasc
Diagn Ther. 2021;11(1):323-335.
https://doi.org/10.21037/cdt-20-358
3. Kantor PF, Lougheed J, Dancea A, et al. Presentation, Diagnosis, and Medical Management
of Heart Failure in Children: Canadian Cardiovascular Society Guidelines. Can J Cardiol.
2013;29(12):1535-1552.
https://doi.org/10.1016/j.cjca.2013.08.008
4. Russell FM, Ehrman RR, Cosby K, et al. Diagnosing Acute Heart Failure in Patients With
Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol. Stahmer SA,
ed. Acad Emerg Med. 2015;22(2):182-191.
https://doi.org/10.1111/acem.12570
5. Dinicolantonio JJ, Lavie CJ, Niazi AK, O’Keefe JH, Hu T. Effects of thiamine on cardiac function
in patients with systolic heart failure: systematic review and metaanalysis of randomized,
double-blind, placebo-controlled trials. Ochsner J. 2013;13(4):495-499.
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865826/
6. Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention,
diagnosis and management of acute rheumatic fever and rheumatic heart disease. Med J
Aust. 2021;214(5):220-227.
https://doi.org/10.5694/mja2.50851
7. Hiffler L, Rakotoambinina B, Lafferty N, Martinez Garcia D. Thiamine Deficiency in Tropical
Pediatrics: New Insights into a Neglected but Vital Metabolic Challenge. Front Nutr. 2016;3.
https://doi.org/10.3389/fnut.2016.00016
8. Thiamine deficiency and its prevention and control in major emergencies. Published online
1999.
https://www.who.int/publications/i/item/WHO-NHD-99.13
9. Duggan C, Watkins JB, Walker WA, eds. Nutrition in Pediatrics: Basic Science, Clinical
Application. 4th ed. BC Decker; 2008.
https://openlibrary.org/books/OL11988152M/Nutrition_in_Pediatrics
10. Shah S, Wald E. Type B Lactic Acidosis Secondary to Thiamine Deficiency in a Child With
Malignancy. Pediatrics. 2015;135(1):e221-e224.
https://doi.org/10.1542/peds.2014-2289
228
Chapter 7:
Neurological disorders
For a child presenting with a possible neurological impairment or deficit, perform a more
detailed neurological examination in addition to a full clinical examination (Chapter 1,
Section 1.3).
In the case of reduced level of consciousness, seizures, any neck stiffness (nuchal rigidity),
manage as a medical emergency and refer to Chapter 2 for initial resuscitation and
management.
In young children, cooperation for a neurological examination can be challenging. In a well
child, start by observing the child play and interact with their parents/carers.
– Assess development for age: speech, behaviour, gross motor (crawling, walking), fine motor
(playing with small objects). See Appendix 1 for more detail on developmental milestones.
– If the child can walk, ask to walk around, walk heel-to-toe, stand on one leg. Note any
abnormalities.
– Observe for any abnormal movements, fasciculations, obvious weakness or asymmetry of 7
movement.
– Examine pupils and eye movements.
Carry out a complete neurological examination, by assessing tone, power and reflexes. Consider
examination of cranial nerves if relevant.
Tone
– Tone is the inherent resistance of the muscle to passive movement and is involuntary. Usually
a person’s limb can be freely moved around by an examiner, with only slight resistance.
– Muscles with low tone show no resistance to passive movement and are usually described
as hypotonic or flaccid, while muscles with increased tone show high resistance to passive
movement and are described as hypertonic or spastic.
– Infants1: In infants muscle tone and strength are assessed together. Assess position of the
infant when supine, usually arms and legs are flexed when at rest and move spontaneously.
Pull gently by the arms to a sitting position and check for head lag, usually the head will lag
initially and then come into the midline once in a seated position. Hold the infant under
the arms, the infant with normal muscle tone and strength will flex their hips to 90 degrees
(as though in a seated position). Normal truncal and shoulder girdle tone and strength will
prevent the infant from slipping through the examiner’s hands.
– Children: Assess tone by passively flexing and extending a patient’s limb and assessing the
resistance or opposed muscle contraction. Usually, resistance to extension of limbs is felt
beyond 90 degrees.
Power
– Power is the strength of the muscle when maximally contracted and is voluntary.
– Assess power by asking the patient to move their limb against resistance, starting with
gravity then an active external resistance, e.g. opposition by the examiner2. Assessing power
in young infants is difficult and often assessed along with tone (see above).
231
Chapter 7: Neurological disorders
Reflexes
– Tendon reflexes are used to identify possible upper or lower motor neuron lesions.
– Assess tendon reflexes by tapping lightly on the tendon with a tendon hammer, with the
limb relaxed and the joint at a 90 degree angle.
– Common tendon reflexes that can be tested in children include the patellar reflex (knee) and
the achilles reflex (ankle). Biceps, triceps, brachioradialis (wrist) and jaw reflexes can also be
tested.
– Tendon reflexes are described as normal, absent/diminished or exaggerated/brisk.
– Primitive or developmental reflexes, e.g. Moro reflex and asymmetric tonic neck reflex, should
be assessed in young infants. These are indicators of brain maturation and abnormalities
may indicate specific conditions such as cerebral palsy2.
232
Chapter 7: Neurological disorders
In children, a seizure may occur due to epilepsy, but more commonly it is provoked or triggered
by acute conditions, such as infections (severe malaria, meningitis), metabolic disorders
(hypoglycaemia, hyponatraemia), head injury, poisoning, intracranial tumours or other space-
occupying lesions, bleeding, or stroke. For seizures associated with a fever > 38 °C in young
children, see Febrile seizures in Section 7.3.
7.2.1 Terminology
Seizure: a paroxysmal disorder presenting as intermittent, repetitive involuntary movements
of part of or the entire body, usually accompanied with loss of consciousness or awareness.
Seizures result from a temporary disturbance in brain function “due to abnormal excessive or
synchronous neuronal activity in the brain”3.
Epilepsy: at least 2 unprovoked (or reflex) seizures occurring > 24 hours apart4. Unprovoked
7
means a seizure that occurs without an acute or reversible cause.
Status epilepticus (SE): a condition in which a seizure lasts for more than 5 minutes without
self-termination, therefore requiring treatment with anti-epileptic drugs (AEDs)5. If seizures
persist beyond 30 minutes despite the use of two AEDs, patients are considered to have
refractory SE which can have long-term consequences including neuronal death, neuronal
injury, and alteration of neuronal networks6. Non-convulsive status epilepticus is when altered
conscious level is the main manifestation of a prolonged seizure without visible convulsions
(not the same as post-ictal state).
Post-ictal state: altered consciousness, drowsiness, confusion, nausea, hypertension,
hemiparesis, headache, or other disorienting symptoms immediately after a seizure. This may
last for 5 to 30 minutes. Usually the child does not remember the seizure episode.
The use of anticonvulsants, e.g. phenobarbital, during the seizure may leave the child sedated
for longer after the seizure.
Acute repetitive seizures: 3 or more seizures in 24 hours.
233
Chapter 7: Neurological disorders
Investigations
– Malaria RDT
– Blood glucose level (BGL)
– Full blood count (FBC) including haemoglobin (Hb)
– Electrolytes, if available
– Blood culture if febrile and/or suspicion of sepsis
– Lumbar puncture (LP), if suspicion of meningitis: perform only when child is stable and no
longer having seizures (see Appendix 6 for details on how to perform an LP).
7.2.3 Management
Aim to quickly and simultaneously provide care that stabilises the patient, identify any
precipitating conditions, stop any ongoing seizure, and/or manage the post-ictal state.
Most seizures are self-limiting and last a few seconds or minutes, but anticonvulsant treatment
is required for ongoing seizures when:
– Seizure lasts ≥ 5 minutes (or ongoing and duration unknown).
– 2 or more seizures within 5 minutes.
234
Chapter 7: Neurological disorders
If ongoing seizure
See also Figure 7.1 page 239.
Alternative:
phenobarbital 20 mg/kg (max. 1 g) slow IV infusion via syringe pump over 20 minutes
If seizure persists at the end of the infusion, repeat with half dose:
phenobarbital 10 mg/kg over 20 minutes
a Programmatic considerations include cost (levetiracetam is more expensive than phenobarbital), safe
administration of phenobarbital, availability of drug, validation by MoH, and comparative ease of administration.
235
Chapter 7: Neurological disorders
sodium valproate IV
20 mg/kg (max. 1.5 g) over 5 minutes.
If seizure persists at the end of the injection, repeat once at the same dose (max. total
sodium valproate 40 mg/kg or 3 g)7.
Caution: anticonvulsants can cause respiratory depression and apnoea. Admit immediately to
an emergency or intensive care unit for close monitoring. Basic resuscitation equipment must
be kept at the bedside including bag and mask, oxygen and suction.
b Sodium valproate is contraindicated in girls and women of child-bearing age due to increased risk of neural
tube defects and other congenital malformations. Sodium valproate is not recommended in children less than
2 years old due to an increased risk of fatal hepatotoxicity.
c Note that if the patient has an acute reversible condition but meets one of the other indications, they should
be started on maintenance treatment as recommended for that indication.
236
Table 7.1 - Maintenance treatment dosage after acute seizure
Maintenance dose
Drug Side effectsd Comments
(PO whenever possible)
1-11 months: 5 to 6 mg/kg once daily Respiratory depression Decrease dosage by 50% if severe
1-5 years: 6 to 8 mg/kg once daily Apnoea acute kidney injury
6-12 years: 4 to 6 mg/kg once daily Hypotension
phenobarbital > 12 years: 1 to 3 mg/kg once daily Lethargy
PO/IV Start 12 hours after the loading dose Hepatic dysfunction
If age unknown, start at 5 mg/kg once daily (or
divided into 2 times daily) for children estimated
< 12 years
2.5 mg/kg 2 times daily Hypotension Contraindication: cardiopathy
Start 12 hours after the loading dose Bradycardia, arrhythmia Consider only if none of the other
Hepatitis recommended medicines are available,
phenytoin
Hyperglycaemia due to its poor safety profile and the
PO/IV
Anaemia need for cardiac monitoring
Hypersensitivity reactions,
including skin rash
< 6 months: 7 mg/kg 2 times daily Irritability Decrease dosage by 50% if severe
levetiracetam 6 months-15 years: 10 mg/kg 2 times daily Nausea & vomiting acute kidney injury
PO/IV
Start 12 hours after the loading dose
PO: 5 to 7.5 mg/kg 2 times daily (max. 600 mg/dose) Hepatotoxicity Contraindication: liver disease (or
IV: 2.5 to 4 mg/kg every 6 hours (hyperammonaemia, mild suspected metabolic disease), children
sodium valproate
Start 6-8 hours after the loading dose elevation of liver enzymes) < 2 years, girls of child-bearing agee
Teratogenic
d Several anticonvulsant medications (namely carbamazepine, phenobarbital, phenytoin and levetiracetam) can cause a rare but serious syndrome known as DRESS (drug
reaction with eosinophilia and systemic symptoms). It is important to be aware of this reaction which appears several weeks after the initiation of treatment and can be fatal.
e Sodium valproate is contraindicated in girls and women of child-bearing age due to increased risk of neural tube defects and other congenital malformations. Sodium valproate
237
Chapter 7: Neurological disorders
is not recommended in children less than 2 years old due to an increased risk of fatal hepatotoxicity.
7
Chapter 7: Neurological disorders
Monitoring
– Place child in recovery position and ensure airways patent.
– Monitor and record vital signs (including conscious level and SpO2) every 15 minutes initially
then as often as required using an early warning system (see MSF Manual of Nursing Care
Procedures, Assessment and vital signs, Charts: Vital sign charts). Careful attention should
be given to respiratory monitoring, especially if anticonvulsants were administered.
– Cardiac monitoring (HR, rhythm, BP) every 15 minutes if phenytoin administered.
7.2.6 Follow-up
– Short seizures that respond to treatment usually do not result in any complications and
do not need follow-up. Prolonged seizures (> 1 hour) can be fatal or result in long-term
neurologic sequelae (e.g. cerebral palsy).
– Long-term anticonvulsant treatment may not always be necessary in a first unprovoked
seizure in a child8, but inform parents/carers to monitor carefully for further seizure events
and seek medical care if they occur.
– Arrange follow-up for further management if the child:
• Requires prolonged maintenance therapy (> 72 hours for some indications and > 7 days for
those with neurological injury)
• Continues to have recurrent unprovoked seizures
• Has a suspected severe acute neurological insult.
238
Chapter 7: Neurological disorders
239
Chapter 7: Neurological disorders
Seizure associated with a fever > 38 °C usually in children 6 months to 5 years9. The fever is
usually caused by a concurrent illness (commonly a viral infection) or recent vaccination, but
the seizure itself is not directly linked to the trigger of the fever.
Febrile seizures are common, occurring in 2 to 4% of children under 5, but usually self-limiting
with no long-term neurologic consequences. There may be a family history. Seizures may occur
before, during or after a high fever and controlling the fever has no effect on preventing a
febrile seizure occurring. Most are simple, do not last longer than 15 minutes, are generalised
and will occur only once in 24 hours. Complex febrile seizures may occur where the child can
have focal signs, prolonged seizures (> 15 minutes), or have multiple seizures within a 24-hour
period.
7.3.1 Diagnosis
– Take a full history from parents/carers about the seizure (onset, duration, signs, awareness)
and of any recent or current illness (or signs and symptoms) including presence of fever.
– Ask about any previous febrile seizures and any other medical history.
– Take a medication history including antipyretics given (dose and timing).
– Once seizure stopped, perform a complete clinical examination to identify cause of fever.
Investigations
– FBC, Hb, BGL
– Malaria RDT, if endemic
– Consider LP if child < 1 year, has meningeal signs or appears severely unwell.
7.3.2 Management
Most febrile seizures will stop spontaneously within 5 minutes.
– Manage ABCDE and administer oxygen via face mask. Place child in recovery position.
– If not breathing, start resuscitation (see Chapter 2, Section 2.1).
– Check BGL: if < 60 mg/dL (< 3.3 mmol/L) administer 2 mL/kg glucose (dextrose) 10% IV.
– Administer anticonvulsant treatment as per seizure algorithm in Figure 7.1 page 239 if:
• Seizure lasts ≥ 5 minutes (or ongoing and duration unknown).
• 2 or more seizures within 5 minutes.
– If seizures stop, treat as per post-ictal state (see Section 7.2.5).
– Treat fever and start treatment of the source of the fever.
– If no anticonvulsant treatment was needed, observe for at least 6 hours. Child can be
discharged home with paracetamol, treatment of source of fever if applicable, and
information on fever management.
– Prophylactic long-term anticonvulsants are not indicated in simple febrile seizures, even if
they are recurrent.
In the case of complex febrile seizures, provide counselling to the parents/carers to monitor
further episodes as they require evaluation for epilepsy if there is recurrence10.
240
Chapter 7: Neurological disorders
7.4 Epilepsy
241
Chapter 7: Neurological disorders
Investigations
– FBC, Hb, BGL
– Electrolytes, if available
– Malaria RDT, if endemic
– Cranial US
– Electroencephalogram (EEG), if available but not routinely needed. A normal EEG does not
rule out epilepsy but an EEG can support the classification of seizure type outlined in Table 7.2.
– Electrocardiogram (ECG), if available, for older children.
7.4.3 Management
Treatment is long-term or life-long with the goal to minimise seizure occurrence and maintain
quality of life. Support and counselling for the child and their family is required for effective
management, as strict adherence to antiepileptic drugs (AEDs) is the best way to minimise
seizure occurrence. Most seizures occur randomly and are unprovoked, but in some cases
there is a specific trigger to seizures e.g. flashing lights or loud noises. In these rare cases,
identification and avoidance of the trigger can help to control seizure occurrence. Lack of
sleep, acute illness and use of mind-altering substances can lower the seizure threshold in
children with epilepsy.
Guiding principles to starting antiepileptic drug (AED) treatment (see Table 7.3):
– Establish the diagnosis and type or classification of seizure.
– Start initially with the preferred AED according to the seizure type and age of the child (see
Table 7.3).
– If seizures continue despite an optimal dose of first-line AED, consider changing to second
choice AED.
– Combination therapy should be considered when treatment with 2 different AEDs used
separately (in monotherapy) has failed.
– If the AED needs to be changed, introduce the new AED at its starting dose and slowly
increase to its mid-range, then start to slowly decrease the dose of the first AED.
– If a patient is seizure-free for 2 years, consider stopping the AED slowly (over 3 months) with
close supervision. If seizures recur at home, ask the patient to resume the AED at the last
dose taken and seek medical attention.
Table 7.3 - Antiepileptic drug choice by seizure type
Generalised onset Focal onset
Normal/impaired
Impaired awareness
awareness
Drug choice
Motor Non-motor Motor/non-motor
Focal to bilateral
Tonic-clonic, myoclonic, atonic Absence
tonic-clonic
< 2 years old: levetiracetam
≥ 2 years old: sodium valproate ≥ 2 years old:
1st choice carbamazepine
or levetiracetam (if girl of sodium valproate
childbearing agea)
a Sodium valproate is contraindicated in girls and women of child-bearing age due to increased risk of neural
tube defects and other congenital malformations. Sodium valproate is not recommended in children less than
2 years old due to an increased risk of fatal hepatotoxicity.
242
Chapter 7: Neurological disorders
Normal/impaired
Impaired awareness
awareness
Drug choice
Motor Non-motor Motor/non-motor
Focal to bilateral
Tonic-clonic, myoclonic, atonic Absence
tonic-clonic
For antiepileptic drug starting and maintenance dosing, see Table 7.412,13.
Carbamazepine: give 2 times daily, morning and evening. After starting initial dosing,
maintenance dose should be reached within 8 days.
7
Phenobarbital: ideally aim to give once daily at bedtime (reduces drowsiness as adverse effect
during the day). Daily administration for 14 to 21 days is needed for a steady phenobarbital
level in the blood. Seizures occurring during this period do not indicate treatment failure.
– Child ≤ 11 years: start with 2 times daily dosing for 2 weeks before increasing dose. Aim to
move to once daily dosing when seizures controlled.
– Child ≥ 12 years: start with once daily dosing for 2 weeks before increasing the dose.
Phenytoin: give 2 times daily, morning and evening, for children 11 years and younger. Can be
given once daily for children 12 years and older. Small increments in the dosing can lead to
significant changes in concentration, therefore increases should be by 25 to 30 mg.
Table 7.4 - Antiepileptic drug and dosages
Child 1 month to 11 years
AEDd
Initial Step-up Maintenance
Increase by 2.5 to 5 mg/kg 5 mg/kg 2-3 times daily
carbamazepine 2.5 mg/kg 2 times daily
every 3-7 days (up to max. 20 mg/kg/day)
1 to 1.5 mg/kg 2 times 2.5 to 4 mg/kg 1-2 times
phenobarbital Increase by 2 mg/kg daily
daily daily
1.5 to 2.5 mg/kg 2 times Adjusted according to 2.5 to 5 mg/kg 2 times
phenytoin
daily response daily (max. 300 mg daily)
sodium 5 to 7.5 mg/kg 1-2 times 12.5 to 15 mg/kg 2 times
Increase gradually
valproatec daily (max. 600 mg/dose) daily
b Certain AEDs can exacerbate absence seizures or are known to be ineffective therefore there is no place for
carbamazepine, phenytoin or phenobarbital in the treatment of absence epilepsy.
c Sodium valproate is contraindicated in girls and women of child-bearing age due to increased risk of neural
tube defects and other congenital malformations. Sodium valproate is not recommended in children less than
2 years old due to an increased risk of fatal hepatotoxicity.
d Several anticonvulsant medications (namely carbamazepine, phenobarbital, phenytoin and levetiracetam) can
cause a rare but serious syndrome known as DRESS (drug reaction with eosinophilia and systemic symptoms).
It is important to be aware of this reaction which appears several weeks after the initiation of treatment and
can be fatal.
243
Chapter 7: Neurological disorders
e Several anticonvulsant medications (namely carbamazepine, phenobarbital, phenytoin and levetiracetam) can
cause a rare but serious syndrome known as DRESS (drug reaction with eosinophilia and systemic symptoms).
It is important to be aware of this reaction which appears several weeks after the initiation of treatment and
can be fatal.
f Sodium valproate is contraindicated in girls and women of child-bearing age due to increased risk of neural
tube defects and other congenital malformations. Sodium valproate is not recommended in children less than
2 years old due to an increased risk of fatal hepatotoxicity.
244
Chapter 7: Neurological disorders
An altered level of consciousness (LOC) is any deviation from being fully awake and responsive.
There are many underlying medical conditions or traumatic events that can cause a change in
the level of consciousness. It represents an acute and potentially life-threatening emergency,
requiring prompt intervention to preserve life and brain function.
In children, the most common causes include infections (meningitis, malaria), metabolic
disturbances (hypoglycaemia, diabetic ketoacidosis (DKA), electrolyte imbalance), seizures,
poisoning (toxins or medications) and head injury.
AVPU V, P or U P or U
GCS < 15 ≤8
Assess for the underlying cause taking a history while stabilising the child:
– Recent medical history: excess irritability, headache, fever, malaria, infection/illness, head
trauma/accidents
– Past medical history: epilepsy/seizures, diabetes, birth asphyxia, developmental delay.
– Drug history: any medication, traditional remedies, exposure to toxins
a Agitation in children is a symptom that requires a full history, examination (where possible) and diagnosis.
Medical and social history are particularly important to identify potential contributing factors which may
include a combination of medical, surgical and/or emotional factors.
b A painful stimulus can be given by applying supra-orbital pressure at the supraorbital notch or by applying
pressure to the nailbed.
245
Chapter 7: Neurological disorders
7.5.2 Management
Initial emergency management
– Assess and manage ABCDE and note vital signs including temperature.
– Support and open the airway (stabilise cervical spine if trauma is suspected).
– Clear airways (suction) only if necessary.
– Administer oxygen via mask (aim for SpO2 > 92%). Assist ventilation with bag-mask device if
not breathing.
– Obtain vascular access (IV/IO) and administer IV fluids if signs of circulatory impairment or
shock present (Chapter 2, Section 2.2).
– Perform a quick evaluation of neurological status (using AVPU scale, see above) and check
pupillary response.
– Check BGL:
• BGL < 60 mg/dL (3.3 mmol/L), treat for hypoglycaemia (Chapter 9, Section 9.3).
• BGL > 200 mg/dL or known diabetes, consider diabetic ketoacidosis and manage
accordingly (Chapter 9, Section 9.1). Check urine for ketones.
– Expose the entire body and look for signs of sepsis, meningitis, trauma, etc.
Once stable, conduct a full clinical examination to identify the underlying cause and treat.
Specific management
– If V, P, or U, evaluate GCS and further neurological assessment including posture/tone,
movements, reflexes. Check for signs of meningitis or encephalitis. Recheck AVPU (or GCS)
every 30 minutes; if GCS 12 to 14, recheck every hour.
– If head trauma suspected, see Chapter 2, Section 2.8 for further management after
stabilisation.
– If seizures are present or known epilepsy, treat accordingly (Section 7.2).
– Check haemoglobin if any pallor present.
– Check RDT malaria in endemic areas and start treatment if positive (Chapter 3, Section 3.4).
– Perform a lumbar puncture if meningitis suspected (and no contraindications).
– If high fever and/or sepsis/meningitis suspected, obtain blood cultures and start antibiotic
treatment with ceftriaxone IV/IM 100 mg/kg (max. 4 g) every 24 hours. Adjust antibiotic
treatment if needed once specific cause and/or pathogen identified. (See Chapter 3,
Section 3.2 for sepsis and Section 3.3 for meningitis).
– Admit the patient to the ICU and provide supportive care (nursing care, oxygen, fluid
maintenance, monitoring).
– If poisoning suspected (pin-point pupils, excess salivation, flushing, severe agitation,
hypertension, vomiting), refer to Chapter 2, Section 2.9).
Agitation
Children who are agitated require specific and cautious assessment and management15:
– Try to calm the situation by moving to a safe, quiet space.
– Remain calm and maintain a neutral but empathetic tone.
– Use clear, simple language that is adapted to the child’s age and developmental stage.
– Be honest and explain in advance what you are doing or what is going to happen.
246
Chapter 7: Neurological disorders
Medications
If these methods do not help to calm the situation and there is significant agitation, with
a risk of harm to the patient or others, consider administration of sedative or antipsychotic
medicationsd. Provide age-appropriate information to the child or adolescent prior to
medication administration, taking into account the level of agitation. The goal of medication is
calming, not sedating, so that the child can be further evaluated. The choice of medication is
dependent on underlying cause.
Oral route is preferred whenever possible, and oral risperidone or diazepam are usually
sufficient to manage agitation in children. Parenteral administration should be reserved for
violent or uncooperative patients or if there is no response to oral medicatione:
c Children with developmental disabilities are particularly vulnerable to side effects from sedative and
antipsychotic medications.
d Caution with all sedative and antipsychotic medication if renal or hepatic impairment suspected.
e Administration of parenteral medication to children for behavioural disturbance involves significant and
serious risks, both medical and psychological, and should only be done under the supervision and guidance of
an experienced clinician.
247
Chapter 7: Neurological disorders
248
Chapter 7: Neurological disorders
Adolescents and children may have more severe reactions to medications used for rapid
sedation, therefore they should be closely monitored after administration, with vital signs
measurement every 15 minutes for the first hour. Ensure that a clear explanation of any urgent
medication administration is given to the child or adolescent after the acute agitation has
passed and their mental state has improved.
In the event of respiratory depression caused by benzodiazepines, administer:
– Flumazenil IV over 15 seconds: 10 micrograms/kg every 1 minute (max. 200 micrograms/
dose) as required until adequate breathing resumes.
249
Chapter 7: Neurological disorders
References Chapter 7
1. Bodamer OA. Approach to the infant with hypotonia and weakness. UpToDate. Published
online August 2021.
https://www.uptodate.com/contents/approach-to-the-infant-with-hypotonia-and-
weakness
2. Kotagal S, Morse AM. Detailed neurologic assessment of infants and children. UpToDate.
Published online August 2022.
https://www.uptodate.com/contents/detailed-neurologic-assessment-of-infants-and-
children
3. Fisher RS, Boas WVE, Blume W, et al. Epileptic Seizures and Epilepsy: Definitions Proposed
by the International League Against Epilepsy (ILAE) and the International Bureau for
Epilepsy (IBE). Epilepsia. 2005;46(4):470-472.
https://doi.org/10.1111/j.0013-9580.2005.66104.x
4. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE Official Report: A practical clinical
definition of epilepsy. Epilepsia. 2014;55(4):475-482.
https://doi.org/10.1111/epi.12550
5. Epilepsies in Children, Young People and Adults. National Institute for Health and Care
Excellence (NICE); 2022. Accessed October 9, 2023.
http://www.ncbi.nlm.nih.gov/books/NBK581165/
6. Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus -
Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015;
56(10):1515-1523.
https://doi.org/10.1111/epi.13121
7. Singh A, Stredny CM, Loddenkemper T. Pharmacotherapy for Pediatric Convulsive Status
Epilepticus. CNS Drugs. 2020;34(1):47-63.
https://doi.org/10.1007/s40263-019-00690-8
8. Wilmshurst JM, Gaillard WD, Vinayan KP, et al. Summary of recommendations for the
management of infantile seizures: Task F orce R eport for the ILAE Commission of Paediatrics.
Epilepsia. 2015;56(8):1185-1197.
https://doi.org/10.1111/epi.13057
9. Millichap JJ. Clinical features and evaluation of febrile seizures. UpToDate. Published online
May 2021.
https://www.uptodate.com/contents/clinical-features-and-evaluation-of-febrile-seizures
10. Patterson KP, Baram TZ, Shinnar S. Origins of Temporal Lobe Epilepsy: Febrile Seizures and
Febrile Status Epilepticus. Neurotherapeutics. 2014;11(2):242-250.
https://doi.org/10.1007/s13311-014-0263-4
11. Epilepsy. Accessed October 9, 2023.
https://www.who.int/news-room/fact-sheets/detail/epilepsy
12. World Health Organization. mhGAP Intervention Guide for Mental, Neurological and
Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action
Programme (mhGAP). version 2.0. World Health Organization; 2016. Accessed October 9,
2023.
https://iris.who.int/handle/10665/250239
250
Chapter 7: Neurological disorders
13. MedicinesComplete - CONTENT > BNF for Children > Drug: Phenobarbital. Accessed
October 9, 2023.
https://www.medicinescomplete.com/#/content/bnfc/_197439058?hspl=phenobarbital
14. MedicinesComplete - CONTENT > BNF for Children > Drug: Levetiracetam. Accessed
October 9, 2023.
https://www.medicinescomplete.com/#/content/bnfc/_695768521?hspl=lecetiracetam
15. Gerson R, Malas N, Feuer V, et al. Best Practices for Evaluation and Treatment of Agitated
Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the
American Association for Emergency Psychiatry. West J Emerg Med. 2019;20(2):409-418.
https://doi.org/10.5811/westjem.2019.1.41344
251
Chapter 8:
Renal and genitourinary tract
Upper urinary tract infection (UTI), or pyelonephritis, is an infection of the kidney and is a
common cause of fever in infants and young children. It is more common in children with
underlying anatomical or obstructive abnormalities, therefore investigation is always required.
The most common causative pathogen is Escherichia coli, followed by other enterobacteria.
Cystitis, which is an infection of the lower urinary tract (i.e. the bladder and urethra), is more
common in uncircumcised male infants, and in females under the age of 4. It is not associated
with fever or other systemic signs and does not usually require admission, therefore is not
discussed here.
Complications
Recurrent upper UTIs can lead to scarring of the kidneys and decreased kidney function.
Usually, there is an underlying structural abnormality or dysfunctional reason for recurrent
upper UTIs.
255
Chapter 8: Renal and genitourinary tract
8.1.2 Investigations
– Urine dipsticka (see Table 8.1 for interpretation of results). To avoid contamination of the
sample and false positive results, obtain urine specimens using the most sterile technique
possible1 in one of the following ways:
• ‘Clean-catch’ sample: wash hands and clean the child’s genital area with a clean, water-
soaked gauze. Ask the parent/carer to watch and wait until the child starts to urinate
and then catch the urine directly into a sterile container (see Appendix 14.1 for more
detail). Offer drinks to encourage the child to pass urine. This is the preferred method
in children who are not severely unwell, but in practice can be difficult to successfully
achieve. Contamination rates are approximately 25%.
• Urine collection bag: after cleaning (as above), affix the paediatric urine collection bag
and wait until the child passes urine (see Appendix 14.2 for more detail). Bag specimens
can be used to rule out UTI, but if positive, another method should be used to verify
results due to the possibility of false positives. Urine from a bag specimen should not be
sent for culture as contamination rates can be high depending on the quality of cleaning.
• In-out catheter: after cleaning (as above), use a urinary catheter to collect urine directly
into a sterile container by briefly inserting it and removing it as soon as urine is obtained
(see Appendix 14.3 for full procedure). This is the preferred method if non-invasive ‘clean-
catch’ is unsuccessful; contamination rates are approximately 10%.
• Suprapubic aspirate (SPA): collect urine directly from the bladder by inserting a needle
through the abdominal wall under ultrasound guidance (see Appendix 15 for full procedure).
This is the preferred method in severely unwell young children but should only be performed
by staff trained in the procedure; contamination rates are approximately 1%.
– Urine microscopy and culture, if available – identify and quantify pyuria (white blood cells
(WBC) in urine) and/or bacteriuria (bacteria in the urine).
– Blood culture if under 2 years old.
– CRP, if available.
– Urea and electrolytes, if available and signs of severe infection.
– Consider renal ultrasound (US), see below for criteria.
Table 8.1 - Interpretation of urine dipstick results (adapted from NICE2)
3 months -
Dipstick results Under 3 months 3 years and older
< 3 years
Leukocyte
esterase and Treat as UTI and send urine for microscopy and culture
nitrite positive
Leukocyte
esterase negative
Treat as UTI and send urine for microscopy and culture
and nitrite
positive
Treat as UTI only if clinical
Leukocyte symptoms strongly suggest
Treat as UTI and send urine for
esterase positive it, otherwise send urine
microscopy
and nitrite for microscopy and culture
and culture
negative to confirm before starting
treatment
a In areas where urinary schistosomiasis is endemic, consider this as a diagnosis in children with macroscopic or
microscopic haematuria detected by urine dipstick.
256
Chapter 8: Renal and genitourinary tract
3 months -
Dipstick results Under 3 months 3 years and older
< 3 years
Treat as sepsis
Leukocyte
and send urine for Do not treat as UTI and do not send urine for
esterase and
microscopy and microscopy and culture
nitrite negative
culture
8.1.3 Management
Infants less than 3 months old
Admit all infants less than 3 months old with a febrile upper UTI to hospital:
– Administer ceftriaxone IV/IM: 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) every 24 hours
(or cefotaxime IV 50 mg/kg every 8 hours).
– Alternatively, administer gentamicin IV: 7.5 mg/kg every 24 hours or amikacin 15 mg/kg every
24 hours. If the infant is very unwell, consider concomitant administration of ceftriaxone (or
cefotaxime) and gentamicin (or amikacin).
– Start IV maintenance fluids if not tolerating oral intake (see Chapter 15, Section 15.2).
– Give paracetamol as antipyretic and analgesic, as required for comfort (see Chapter 15,
Section 15.4).
– Monitor and record vital signs and urine output as often as required using an early warning
system (see MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts:
Vital sign charts).
8
– Reassess and adjust antibiotic treatment according to urine and blood culture results, if/
when available.
– Duration of parenteral antibiotic treatment should be determined by the infant’s clinical
condition and response to treatment. Continue IV/IM treatment for at least 48-72 hours and
when the infant is improving and feeding well, switch to:
• amoxicillin-clavulanic acid (co-amoxiclav) PO (ratio 7:1 or 8:1) 50 mg/kg of the amoxicillin
component, 2 times daily, or
• ciprofloxacin PO: 10 to 20 mg/kg (max. 750 mg) 2 times daily.
– Total antibiotic treatment should last for 7 days.
Renal imaging
Where feasible, renal US is recommended in all children with confirmed upper UTI to exclude
structural abnormalities that may predispose them to the risk of recurrence. It is particularly
indicated in the following cases2,4:
– Under 2 years old with first febrile UTI
– Any age with recurrent febrile UTIs (≥ 2 episodes of febrile UTI)
257
Chapter 8: Renal and genitourinary tract
8.1.4 Follow-up
Routine follow-up is not required for children with first febrile upper UTI and normal renal
US. However, children who have had an upper UTI are at risk of recurrence; families should
therefore be instructed on the signs that may indicate a repeat infection. Upper UTI is a risk
factor for renal scarring, with approximately 15% of children developing renal scarring after a
first upper UTI5. Likelihood of renal scarring is increased with recurrent upper UTI but can be
minimised with prompt treatment.
258
Chapter 8: Renal and genitourinary tract
8.2.2 Investigations
– Urine dipstick (blood and protein positive)
– Urine microscopy
– Blood creatinine (at least baseline measurement) and electrolytes, if available
8.2.3 Management
PIGN is usually a self-limiting illness that requires supportive treatment only. Management
is focused on eradication of the nephritogenic strain and treatment of fluid overload, which
causes the clinical complications of PIGN:
– Give oral antibiotics if evidence of ongoing acute streptococcal infection:
• phenoxymethylpenicillin (Penicillin V) PO for 10 days
▹ < 1 year: 125 mg 2 times daily
▹ 1 to < 6 years: 250 mg 2 times daily
▹ 6 to < 12 years: 500 mg 2 times daily
▹ ≥ 12 years: 1 g 2 times daily
a Proteinuria in PIGN is typically less than that seen in nephrotic syndrome. If proteinuria is in nephrotic range
(> 3+ on dipstick), consider nephrotic syndrome as a possible alternative diagnosis.
259
Chapter 8: Renal and genitourinary tract
Overall prognosis is good in the majority of cases, with rapid resolution of symptoms once
supportive care has been started although urine abnormalities may persist for several months.
Some children with PIGN are unresponsive to supportive care and have a reduction in renal
function that requires short-term dialysis. These children should be referred for ongoing
management, where possible.
b Insensible fluid loss is the amount of body fluid lost through the skin and respiratory tract that is not easily
measurable. Estimated daily insensible losses are calculated according to body weight as follows: 1-10 kg =
25 mL/kg; > 10-20 kg = 12.5 mL/kg; > 20 kg = 5 mL/kg.
260
Chapter 8: Renal and genitourinary tract
261
Chapter 8: Renal and genitourinary tract
Oedema Oedema of the face, followed by Oedema of the hands and feet
legs followed by the face
Ascites and generalised oedema Ascites rare
common Generalised oedema depends on
severity
Complications
Complications of nephrotic syndrome are rare but significant. Immune deficiency occurs due
to reduced concentrations of serum immunoglobulins and complement factors and impaired
ability of the body to produce specific antibodies. This leads to increased susceptibility to
serious bacterial infections such as peritonitis, pneumonia and empyema (particularly due
to Strep. pneumoniae), which are the leading cause of death in children with nephrotic
syndrome11. Other complications include increased coagulability leading to thromboembolism;
renal insufficiency and hypovolaemia. Growth restriction may be secondary to prolonged and
repeated courses of steroids in recurrent or persistent nephrotic syndrome.
8.3.2 Investigations
– Urine dipstick:
• Perform urine dipstick test on two separately obtained urine samples.
• Protein > 3+ is diagnostic, along with hypoalbuminaemia.
• In case of haematuria (macro or microscopic ≥ 2+), consider glomerulonephritis and other
causes such as schistosomiasis, in endemic areas.
– Blood tests, if available:
• Creatinine and blood urea nitrogen (BUN)
• Serum sodium (hyponatremia is possible)
• Serum albumin concentration: less than 30 g/L is diagnostic, along with proteinuria.
• Cholesterol (hyperlipidaemia): raised in nephrotic syndrome, can help to differentiate
between nephrotic and nephritic syndrome in mixed presentations.
• FBC: increased Hb and Hct due to haemoconcentration, thrombocytosis.
8.3.3 Management
The mainstay of treatment for idiopathic nephrotic syndrome is corticosteroid therapy, with
patients being classified as having either steroid-sensitive nephrotic syndrome (SSNS) or
steroid-resistant nephrotic syndrome (SRNS). 80-90% of children have SSNS and will respond
to treatment within 4 weeks12,13. Children who do not respond to treatment (SRNS) should be
referred for specialist input, as management can be challenging. Renal biopsy is not necessary
262
Chapter 8: Renal and genitourinary tract
before starting steroids for idiopathic nephrotic syndrome, as response to steroids is more
indicative of long-term outcome than changes on biopsy. Steroids should be started on any
child who meets the diagnostic criteria for presumptive nephrotic syndrome (see above), and
has the following clinical criteria:
– Between 1 and 10 years old
– No ongoing bacterial infection (also exclude HIV, Hep B and syphilis)
– Active TB excluded or treatment already initiated.
Management of oedema
– Restrict sodium and fluid intake: exclude salt from any meals if generalised oedema is present
and restrict fluid intake to match urine output and insensible lossesf. Exercise caution with
fluid restriction in hot climates to avoid dehydration and renal failure.
a Relapse is defined as the reappearance of proteinuria > 3+ for more than 3 consecutive days at any time after
successful steroid treatment.
b Lower steroid doses may provide similar rates of remission, however there is no consensus to date.
c FR is defined as > 2 relapses within 6 months of initial response, or > 4 relapses in any 12-month period.
d SDNS is defined as two consecutive relapses during corticosteroid treatment, or within 14 days of stopping
treatment.
e SRNS is defined as failure to achieve complete remission after 8 weeks of corticosteroid treatment.
f Insensible fluid loss is the amount of body fluid lost through the skin and respiratory tract that is not easily
measurable. Estimated daily insensible losses are calculated according to body weight as follows: 1-10 kg =
25 mL/kg; > 10-20 kg = 12.5 mL/kg; > 20 kg = 5 mL/kg.
263
Chapter 8: Renal and genitourinary tract
– Diuretic therapy: children with nephrotic syndrome are often intravascularly deplete, despite
their appearance, therefore diuretics should be used with extreme caution to prevent further
intravascular depletion and shock. In cases of anasarca (massive generalised oedema with
skin breakdown and ascites) without signs of intravascular volume depletion (tachycardia,
cold/clammy extremities, oliguria), cautiously give furosemide PO/IV 1 mg/kg 1 or 2 times
daily to stimulate diuresis and reduce oedema.
Management of complications
Children should be evaluated daily for the appearance of signs and symptoms of infection. For
guidance on the management of specific infections refer to the following chapters: pneumonia
(Chapter 4, Section 4.5), empyema (Chapter 4, Section 4.6), peritonitis (Chapter 5, Section 5.4),
sepsis (Chapter 3, Section 3.2) and meningitis (Chapter 3, Section 3.3).
Immunisation
Ensure routine immunisations are up to date to minimise the risk of serious bacterial infections.
In particular:
– Administer conjugate pneumococcal vaccination (see MSF Essential Drugs).
– Postpone live vaccinations (e.g. measles, polio, BCG) until prednisolone dose is below
1 mg/kg daily (or below 2 mg/kg on alternate days)19.
– Vaccinate household members with live vaccines, if possible, ensuring child is protected
from gastrointestinal, urinary and respiratory secretions of vaccinated contacts for 3-6 weeks
after vaccination, through rigorous attention to hygiene.
8.3.4 Prognosis
Overall prognosis is good for children with SSNS, with steady resolution of symptoms once
steroids have been started. However, relapse occurs in 70-90% of children at least once13
with 40-50% of children showing steroid dependency and relapsing as soon as steroids are
tapered12. Complications associated with the use of repeated, prolonged steroid therapy
include obesity, short stature, decreased bone density, cataracts, hypertension, adrenal
suppression and behavioural changes20. Children with SRNS should be referred for specialist
management as their clinical course can be complex.
264
Chapter 8: Renal and genitourinary tract
Acute kidney injury (AKI), previously referred to as acute renal failure, is a sudden decrease
in kidney function that compromises the normal regulation of fluid, electrolytes and the
acid-base balance. This results in fluid overload, uraemia, hypertension, hyperkalaemia,
hyperphosphatemia, hypocalcaemia and metabolic acidosis. It is a relatively common
complication among hospitalised sick children and is associated with longer lengths of stay
and higher mortality.
Pre-renal
Pre-renal AKI results from decreased kidney perfusion, usually due to loss of circulating
volume. The most frequent cause in children is dehydration secondary to gastroenteritis, but
acute blood loss, burns and dehydration due to diabetic ketoacidosis (DKA) are also common
causes. Pre-renal AKI may also be due to profound hypotension in an acutely unwell child.
Decreased blood supply to the kidneys leads to reduced glomerular filtration rate (GFR) and 8
concentrated urine.
Renal (intrinsic)
Includes any pathology affecting the kidney itself. Causes are numerous and diverse, including:
– Acute post-infectious glomerulonephritis (PIGN), with or without nephrotic syndrome (see
Section 8.2 and Section 8.3 respectively).
– Acute tubular necrosis (ATN), e.g. after birth asphyxia or after prolonged acute pre-renal
kidney injury. Recovery from ATN is often preceded by a polyuric phase (abnormally high
urine output) and can take days to weeks.
– Nephrotoxicity due to medications (e.g. gentamicin, NSAIDs) or venom (e.g. certain herbs or
snake bites)
– Sepsis, due to a combination of haemodynamic, inflammatory and immune mechanisms
– Malaria, due to haemolysis and high parasitaemia (usually reversible with prompt and
adequate malaria treatment)
– Haemolytic Uraemic Syndrome (HUS)
– G6PD deficiency
– Sickle cell disease
Post-renal
Also known as obstructive uropathy, as it is caused by an obstruction to the outflow of urine
from the kidneys. In children, this is most commonly caused by posterior urethral valves (in
boys only) but can also be due to kidney or bladder calculi or any other obstruction including
trauma.
265
Chapter 8: Renal and genitourinary tract
8.4.3 Investigations
Investigations confirm the diagnosis and help to differentiate between pre-renal, renal and
post-renal causes (see Table 8.3).
– Urinalysis, including urinary protein
– Blood pressure monitoring
– Urinary sodium and osmolality, if available
– Blood tests, if available: Urea, creatininec and electrolytes, blood urea nitrogen (BUN), FBC,
coagulation, blood gases (for bicarbonate and pH) and liver function tests
– Estimated GFR (eGFR): calculated using the formula 0.41 x height (cm) / creatinine (mg/dL).
Normal eGFR is 80 – 120 mL/min/m2.
– Renal ultrasound, if available: ideally to exclude hydronephrosis, but as a minimum to see if
the bladder is full.
– ECG or cardiac monitoring, if available: to monitor T waves.
Table 8.3 - Typical findings in investigation of AKI (adapted from NHSGGC Guidelines22)
Urinary osmolality
> 500 < 300 < 350
(milliosmoles)
Urinary sodium
< 10 > 40 > 40
(mmol/L)
a Oliguria is defined as a urine output of < 1 mL/kg/hr in infants or < 0.5 mL/kg/hr in children; anuria is defined
as no urine output or urine output of < 1 mL/kg/day.
b Polyuria is defined as a urine output of > 3 mL/kg/hr.
c Normal values of serum creatinine vary by age and gender, see local lab references for normal ranges.
266
Chapter 8: Renal and genitourinary tract
Possible structural
abnormality e.g. Obstruction of urinary
Renal ultrasound Empty bladder horseshoed or tract (full bladder),
absent kidney, renal hydronephrosis
parenchymal disease.
8.4.4 Management 8
Management of underlying cause
Treatment of the underlying cause of AKI usually restores kidney function to normal.
Pre-renal
– Correct any dehydration, hypovolaemia or acute blood loss (see Chapter 2, Section 2.2 and
Section 2.5 and Chapter 5, Section 5.3).
– Treat shock or circulatory impairment contributing to hypotension (see Chapter 2, Section 2.2).
Renal (intrinsic)
– Manage PIGN (and nephrotic syndrome if present). See Section 8.2 and Section 8.3 respectively.
– Remove any nephrotoxic medications.
– Provide supportive care (e.g. fluid management, pain control, nutritional support) for
conditions that do not have definitive treatment, to allow time for natural resolution and
recovery of kidney function (e.g. ATN, nephrotoxic kidney injury, HUS).
– Treat sepsis (see Chapter 3, Section 3.2).
– Treat malaria (see Chapter 3, Section 3.4).
Post-renal
– Relieve urinary outflow obstruction, e.g. insert urinary cathetere in boys with suspected
or confirmed posterior urethral valves. Children often become temporarily polyuric
after relieving urinary outflow obstruction – measure urine output and replace fluid and
electrolytes as needed (see Chapter 15, Section 15.2 and Section 15.3).
– Refer for definitive surgical management.
d Horseshoe kidney is when the kidneys are fused together at the lower end, creating the shape of a ‘U’ or
horseshoe.
e If urinary catheter is unavailable, a small NG tube can be used to relieve urinary outflow obstruction temporarily
for emergency relief.
267
Chapter 8: Renal and genitourinary tract
Symptomatic management
Until the underlying cause can be identified and treated, symptomatic management is required.
This can be complex and challenging.
Fluid overload
– Fluid restriction: daily fluid requirements should only be to replace losses i.e. urine, vomiting,
diarrhoea and insensible lossesf. If significant fluid overload (displaced apex beat, distended
neck veins, pulmonary oedema, severe hypertension), restrict intake to replacement of
insensible losses only.
– Administer furosemide IV 2-5 mg/kg over 1 hour. May be repeated if there is a good diuretic
response (max. 1 g per day).
– Monitor and record blood pressure and fluid balance accurately at least 2 times daily.
– Weigh patient daily.
– Do not add potassium to oral or IV fluid intake.
Hypertension
– Measure blood pressure when the child is at rest and relaxed and ensure correct sized
cuff is used to avoid over or underestimated readingsg (see MSF Manual of Nursing Care
Procedures, Procedure: Haemodynamic assessment).
– Start amlodipine PO 0.1 mg/kg once daily if blood pressure is over the 95th centile for age
(see Appendix 17). Monitor blood pressure carefully for 1-2 hours after administration.
Increase to 0.2 mg/kg once daily if necessary.
– Treat hypertension as an emergency if there are signs of hypertensive crisis (headache,
blurred vision, seizures) or if blood pressure is 20 mmHg over the 95th centile for age.
Untreated hypertensive crisis can lead to cerebral haemorrhage, blindness and death:
• Administer furosemide IV 1-2 mg/kg over 3 to 5 minutes if fluid overloaded.
• Start labetalol via continuous IV infusion at a rate of 0.5-1 mg/kg/hr. Monitor blood
pressure every 15 minutes and increase dose gradually according to response up to a
maximum of 3 mg/kg/hr. Aim for a gradual reduction in BP until BP is ≤ 95th centile for age
(see Appendix 17). Labetalol may cause bronchoconstriction therefore should be avoided
in children with asthma or chronic lung disease. If labetalol is unavailable, atenolol PO
1-2 mg/kg once daily can be given as an alternative.
Hyperkalaemia
– Repeat serum potassium urgently to verify results, ideally via venepuncture to avoid
sampling haemolysis which will result in an inaccurately high potassium.
– Avoid potassium-rich foods (e.g. bananas, oranges, raisins, tomatoes, avocados, nuts).
– Use only fresh blood for transfusion (if required).
– Treat hyperkalaemia when K+ > 6 mmol/L, especially if there are signs of hyperkalaemia on
ECG (peaked T waves, wide QRS complex, arrythmias):
• Administer nebulised salbutamol to promote potassium uptake into cells:
▹ < 5 years: 2.5 mg
▹ ≥ 5 years: 5 mg
• Administer calcium gluconate 10% IV 0.5 mL/kg (max. 10 mL) over 3 minutes to stabilise
cardiac muscle excitability.
f Insensible fluid loss is the body fluid lost through the skin and respiratory tract that is not easily measurable.
Estimated daily insensible losses are calculated according to body weight as follows: 1-10 kg = 25 mL/kg;
> 10-20 kg = 12.5 mL/kg; > 20 kg = 5 mL/kg.
g Blood pressure cuff should be 2/3 of the length of the upper arm. A blood pressure cuff that is too small will
give a falsely high blood pressure reading, while one that is too large will give a falsely low reading.
268
Chapter 8: Renal and genitourinary tract
• If central venous access in situ, and the patient can be cared for in an ICU environment
with adequate monitoring and staffing levels, administer a mixed infusion of glucose
(dextrose) 50% 2 mL/kg and short-acting insulin 0.05 IU/kg in the same syringe over
5 to 10 minutes using a syringe pump, to promote intracellular potassium shift. Close
monitoring of blood glucose level (BGL) is required before, during and after infusion
(within an hour of administration), as insulin can cause a rapid fall in BGL.
Other considerations
– Ensure medication dosages are adapted according to renal function where necessary, and
stop all nephrotoxic drugs (e.g. gentamicin, and NSAIDs).
– If the patient has metabolic acidosis, and blood gas analysis and adequate monitoring are
available, consider correction with sodium bicarbonate according to local protocol.
– Optimise caloric value in any nutritional intake as children with AKI are in a hypercatabolic
state (see Chapter 15, Section 15.5). The majority of calories should be given as carbohydrates.
– Consider referral for dialysis if no improvement despite the above measures and correction
of the underlying cause, or seek specialist support to assist with insertion of a peritoneal
dialysis catheter if transfer is not possible.
8.4.5 Prognosis
The prognosis of AKI is directly dependent on the underlying cause and its potential for
resolution, however, children who have suffered AKI from any cause are at risk of developing
irreversible chronic or even end-stage renal failure which may occur years after the original 8
insult. Annual follow-up is recommended to monitor blood pressure and check urine dipstick
for proteinuria.
269
Chapter 8: Renal and genitourinary tract
Acute painful scrotum may indicate a serious underlying problem and should be promptly
evaluated to exclude conditions that may impact the viability of the testis. It is a common
complaint in young and adolescent boys. Potential causes of acute painful scrotum include
testicular torsion, epididymitis, trauma, orchitis, strangulated inguinal hernia and torsion of
the testicular appendages, with the latter being the most common cause23. Other conditions
can cause referred pain to the scrotum, including urinary tract infection, urethritis, renal calculi
and intra-abdominal pathologies.
Scrotal examination
Inspection
Look for any obvious swellings, lesions, trauma or discharge. Identify the presence of a ‘blue
dot’ which indicates ischaemia in torsion of the testicular appendages.
Palpation
Gently palpate the testis to identify the following:
– Tenderness: palpation may reveal a specific point of tenderness suggestive of testicular
appendage torsion or epididymitis, or more generalised testicular or scrotal tenderness
seen in testicular torsion.
– Position, orientation, and size of testis.
– Texture and character of testis, e.g. firm vs normal (hard-boiled egg); fixed vs mobile.
– Swellings of testis or surrounding tissue, e.g. any associated or reactive hydrocoele.
Transillumination
Transilluminate any identified swellings to differentiate between solid and cystic or fluid-filled
swellings. Fluid-filled swellings such as hydrocoeles will glow bright red (transilluminate) when
a light is shone through them, while solid masses will appear dark.
Reflexes
Test for presence or absence of the cremasteric reflex on the affected side by stroking the
inside of the upper thigh. Elevation of the testis on the same side indicates a positive reflex.
Consider testicular torsion in the absence of cremasteric reflex.
Table 8.4 outlines the main features of the three most common causes of acute painful scrotum
in children.
270
Chapter 8: Renal and genitourinary tract
Table 8.4 - Differentiation of main causes of acute painful scrotum (adapted from UpToDate25)
Torsion of testicular
Testicular torsion Epididymitis
appendages
Specific scrotal Testis high in scrotum Palpable hard tender Swelling localised
features and may be lying mass at superior or to epididymis;
transverse due to inferior pole of testis Inflammatory nodule
twisting of cord; testis in an otherwise soft on epididymis may be
hard on palpation; testicle; ‘Blue dot’ sign; palpable
reactive hydrocoele Reactive hydrocoele
common; cremasteric occasionally 8
reflex absent on side of
torsion
Clues in the Previous self-resolving Recent increase in size Recent viral infection,
history episodes of similar pain of testes (pre-pubertal especially in pre-
(intermittent torsion); enlargement); more pubertal boys
more common in common in winter
winter
Complications
Testicular torsion that is not promptly identified and treated can lead to significant ischaemia
of the affected testicle such that it is no longer viable and requires removal. Irreversible
ischaemia and necrosis can occur in as little as 6 hours from onset23, depending on the degree
of torsion, therefore testicular torsion is considered a surgical emergency.
271
Chapter 8: Renal and genitourinary tract
8.5.2 Investigations
– Urinalysis and culture
– Gram stain (with or without culture) of any discharge
– Doppler ultrasound of scrotum: may show a hypoechoic testis with reduced or no perfusion
in testicular torsion.
8.5.3 Management
Management depends on the most likely cause, as outlined below.
Testicular torsion
If testicular torsion is suspected, urgent surgical referral is required for surgical detorsion and
orchidopexy (fixation of the testicle in the scrotum). If emergency surgery is not available, or
if there is likely to be a long delay in referral, manual detorsion should be attempted to try to
restore blood flow and increase the chances of maintaining viability of the testis while the
patient awaits surgery26:
– Give adequate analgesia and sedation (see Chapter 15, Section 15.4).
– Lie the patient on his back.
– Stand at the patient’s feet and rotate affected testicle away from the midline, outwards
towards the thigh (medial to lateral) at least one complete 360-degree rotation. More than
one rotation may be necessary to fully detorse the testicle, as torsion of more than 360
degrees is possible.
– Re-evaluate the patient for signs of successful detorsion such as instant relief of pain due to
rapid return of blood flow to the testis, and lower position of the testis in the scrotum.
– If there is no relief of pain or the pain worsens during the procedure, attempt to rotate the
testicle in the opposite direction (lateral to medial).
Surgical exploration is necessary even after clinically successful manual detorsion, to ensure
complete resolution and to prevent recurrence by performing a bilateral orchidopexy.
Epididymitis
Treatment depends on likelihood of associated sexually transmitted infection and/or urinary
tract infection. If there is pyuria or positive urine culture, antibiotic treatment should be given
for urinary tract infection (see Section 8.1). Epididymitis with negative urinalysis and culture is
most likely a post-viral inflammatory process and is therefore treated conservatively with rest
and analgesia27,28,29.
272
Chapter 8: Renal and genitourinary tract
8.6 Paraphimosis
Paraphimosis refers to a retracted foreskin that cannot be returned to its normal anatomical
position over the glans of the penis. When the foreskin is left retracted for some time, it creates
a circumferential restrictive band of tissue that causes congestion and subsequent oedema of
the glans, further limiting the ability to reduce the foreskin30. It only occurs in non-circumcised
or partially circumcised males.
Complications
If left untreated, affected tissues become increasingly oedematous and ischaemia ensues,
causing local skin necrosis. In very rare cases penile necrosis, gangrene and autoamputation
may occur.
8.6.2 Management
Paraphimosis should be considered a urologic emergency, requiring urgent reduction of the
foreskin to its anatomical position to prevent further swelling and complications. Adequate
analgesia is crucial to facilitate manipulation, and parenteral analgesia may be required.
a Partial phimosis, when the preputial opening is too small to easily fit over the glans, is usually physiologic in
young boys but may also occur after infection, inflammation, or trauma. Up to 10% of uncircumcised males will
have physiologic phimosis at 3 years of age.
273
Chapter 8: Renal and genitourinary tract
Technique32,33
– Analgesia:
• Apply lidocaine 2% gel or EMLA creamb to the glans and distal penile shaft 30-60 minutes
before the procedure and cover in plastic wrap to keep the cream in place.
• Consider parenteral analgesia or procedural sedation (see MSF Standards for Paediatric
Procedural Sedation) if extreme pain limits ability to perform reduction procedures.
– Reduction of oedema:
• Encircle the glans with a gloved hand and apply even, circumferential pressure for several
minutes to reduce swelling.
• Alternatively, wrap a self-adhesive bandage around the penis approximately 3 times,
starting at the glans and continuing up the penile shaft. The first layer should be loosely
wrapped with subsequent layers becoming tighter to exert a constant, steady pressure.
The wrap should be left in place for 10-15 minutes before removal.
• Application of a swab soaked with glucose (dextrose) 50% for 1 hour may be a useful adjunct
to reduce swelling by osmosis. In the absence of glucose (dextrose) 50%, granulated sugar
can be poured onto the swollen glans and foreskin and kept in place with a glove or swab
until swelling subsides (1-2 hours)34.
• The 'iced-glove’ method can also be used to reduce swelling35, though re-evaluation every
15-20 minutes is essential to prevent cold and/or ischaemic injury. Fill a glove with ice and
close with a knot then invaginate the thumb of the glove by sliding it over the shaft of the
penis so that the ice surrounds the penis31,36.
– Manual reduction of foreskin:
• Paraphimosis reduction should be attempted only after swelling has begun to subside via
the chosen method (see above).
• Place two thumbs on glans penis and position index and long fingers immediately behind
swollen constricting ring of foreskin.
• Apply gentle consistent traction on the ring of foreskin to ease foreskin back over the
glans while exerting counterpressure on the glans with the thumbs.
• The constricting ring should come over the glans along with the foreskin.
If manual reduction fails, refer for surgical reduction without delay. If surgery is unavailable or
there is likely to be a long delay in referral, a dorsal slit procedure should be attempted:
– Ensure adequate analgesia (see above) including procedural sedation (see MSF Standards
for Paediatric Procedural Sedation) and penile block, if possible.
– Disinfect and drape the area.
– Using a scalpel, make a 1-2 cm longitudinal incision on the dorsal aspect of the penile shaft
(see Figure 8.1):
• Start the incision just above the tight ring of constricted foreskin behind the swelling and
transect the tight ring of skin (Option 1A).
• Begin the incision superficially and gradually cut deeper until the ring is released, without
removing any skin.
• There should be a palpable and visible release of the paraphimotic ring if successful, and
an associated reduction in swelling.
• If done correctly, the released ring opens up to create a diamond shaped incision
(Option 1, B) that can then be sutured horizontally (Option 1C).
• If the ring is not completely released, or there is too much swelling of the foreskin, extend
the incision to the edge of the foreskin to open it completely (Option 2A and 2B).
274
Chapter 8: Renal and genitourinary tract
– Roll the foreskin over the glans to completely reduce the paraphimosis once the ring is cut.
If necessary, manually decompress residual swelling before/during this step to help reduce
the paraphimosis.
– Suture the edges of the incision with absorbable sutures, depending on the shape and size
of the incision after reduction of the foreskin over the glans (Option 1C or Option 2C).
– Following dorsal slit procedure, consider referral for circumcision.
Post-reduction care
Following successful reduction of paraphimosis, patients and parents/carers should be advised:
– Not to retract the foreskin for a few days.
– That only the child should retract his foreskin for cleaning and should avoid irritants.
– To ensure that the foreskin is immediately replaced over the glans after retraction.
– That circumcision is usually unnecessary unless paraphimosis is recurrent or surgery was
required to reduce the paraphimosis.
275
Chapter 8: Renal and genitourinary tract
References Chapter 8
1. Kaufman J. How to… collect urine samples from young children. Arch Dis Child - Educ Pract
Ed. 2020;105(3):164-171.
https://doi.org/10.1136/archdischild-2019-317237
2. Recommendations | Urinary tract infection in under 16s: diagnosis and management
| Guidance | NICE. Published July 27, 2022. Accessed October 23, 2023.
https://www.nice.org.uk/guidance/ng224/chapter/Recommendations
3. Recommendations | Pyelonephritis (acute): antimicrobial prescribing | Guidance | NICE.
Published October 31, 2018. Accessed April 18, 2022.
https://www.nice.org.uk/guidance/ng111/chapter/Recommendations
4. Shaikh N, Hoberman A. Urinary tract infections in infants older than one month and children
less than two years: Acute management, imaging and prognosis. UpToDate. Published
May 2021.
https://www.uptodate.com/contents/urinary-tract-infections-in-infants-older-than-one-
month-and-children-less-than-two-years-acute-management-imaging-and-prognosis
5. Kaufman J, Temple-Smith M, Sanci L. Urinary tract infections in children: an overview of
diagnosis and management. BMJ Paediatr Open. 2019;3(1):e000487.
https://doi.org/10.1136/bmjpo-2019-000487
6. Post-Streptococcal Glomerulonephritis: For Clinicians | CDC. Published July 13, 2023.
Accessed October 23, 2023.
https://www.cdc.gov/groupastrep/diseases-hcp/post-streptococcal.html
7. Niaudet P. Poststreptococcal glomerulonephritis. UpToDate. Published May 2021.
https://www.uptodate.com/contents/poststreptococcal-glomerulonephritis
8. Bakhiet YM, Mudi A, Khumalo T, Moonsamy G, Levy C. Idiopathic nephrotic syndrome in
South African children. Afr Health Sci. 2018;17(4):1130.
https://doi.org/10.4314/ahs.v17i4.22
9. El Bakkali L, Rodrigues Pereira R, Kuik DJ, Ket JCF, Van Wijk JAE. Nephrotic syndrome in
The Netherlands: a population-based cohort study and a review of the literature. Pediatr
Nephrol. 2011;26(8):1241-1246.
https://doi.org/10.1007/s00467-011-1851-8
10. Niaudet P. Clinical manifestations, diagnosis and evaluation of nephrotic syndrome in
children. UpToDate. Published May 2023.
https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-
nephrotic-syndrome-in-children
11. Niaudet P. Complications of nephrotic syndrome in children. UpToDate. Published July
2020.
https://www.uptodate.com/contents/complications-of-nephrotic-syndrome-in-children
12. Niaudet P. Long-Term Outcome of Children with Steroid-Sensitive Idiopathic Nephrotic
Syndrome. Clin J Am Soc Nephrol. 2009;4(10):1547-1548.
https://doi.org/10.2215/CJN.05950809
13. Larkins N, Kim S, Craig J, Hodson E. Steroid-sensitive nephrotic syndrome: an evidence-based
update of immunosuppressive treatment in children. Arch Dis Child. 2016;101(4):404-408.
https://doi.org/10.1136/archdischild-2015-308924
276
Chapter 8: Renal and genitourinary tract
14. Basu B, Bhattacharyya S, Barua S, Naskar A, Roy B. Efficacy of body weight vs body surface
area-based prednisolone regimen in nephrotic syndrome. Clin Exp Nephrol. 2020;24(7):
622-629.
https://doi.org/10.1007/s10157-020-01875-y
15. Saadeh SA, Baracco R, Jain A, Kapur G, Mattoo TK, Valentini RP. Weight or body surface area
dosing of steroids in nephrotic syndrome: is there an outcome difference? Pediatr Nephrol.
2011;26(12):2167-2171.
https://doi.org/10.1007/s00467-011-1961-3
16. Hahn D, Samuel SM, Willis NS, Craig JC, Hodson EM. Corticosteroid therapy for nephrotic
syndrome in children. Cochrane Kidney and Transplant Group, ed. Cochrane Database Syst
Rev. Published online August 31, 2020.
https://doi.org/10.1002/14651858.CD001533.pub6
17. Webb NJ, Woolley RL, Lambe T, et al. Sixteen-week versus standard eight-week prednisolone
therapy for childhood nephrotic syndrome: the PREDNOS RCT. Health Technol Assess.
2019;23(26):1-108.
https://doi.org/10.3310/hta23260
18. Emma F, Montini G, Gargiulo A. Equations to estimate prednisone dose using body weight.
Pediatr Nephrol. 2019;34(4):685-688.
https://doi.org/10.1007/s00467-018-4127-8
19. Radhakrishnan J, Cattran DC. The KDIGO practice guideline on glomerulonephritis: reading
between the (guide)lines—application to the individual patient. Kidney Int. 2012;82(8):
840-856. 8
https://doi.org/10.1038/ki.2012.280
20. Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic
syndrome. Pediatr Nephrol. 2022;37(1):37-47.
https://doi.org/10.1007/s00467-021-04985-1
21. Olowu WA, Niang A, Osafo C, et al. Outcomes of acute kidney injury in children and adults
in sub-Saharan Africa: a systematic review. Lancet Glob Health. 2016;4(4):e242-e250.
https://doi.org/10.1016/S2214-109X(15)00322-8
22. Ramage I. Acute renal failure in paediatrics (management and investigation). Published
November 2020. Accessed October 18, 2023.
https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/kidney-
diseases/acute-renal-failure-in-paediatrics-management-and-investigation/
23. Pomajzl AJ, Leslie SW. Appendix Testis Torsion. In: StatPearls. StatPearls Publishing; 2023.
Accessed October 18, 2023.
http://www.ncbi.nlm.nih.gov/books/NBK546994/
24. Brenner JS, Aderonke O. Evaluation of non-traumatic sctoral pain or swelling in children
and adolescents. UpToDate. Published November 2021.
https://www.uptodate.com/contents/evaluation-of-nontraumatic-scrotal-pain-or-
swelling-in-children-and-adolescents
25. Brenner JS, Aderonke O. Causes of scrotal pain in children and adolescents. UpToDate.
Published April 2022.
https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents
26. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006;74(10):1739-1743.
https://www.aafp.org/pubs/afp/issues/2006/1115/p1739.html
277
Chapter 8: Renal and genitourinary tract
27. Santillanes G, Gausche-Hill M, Lewis RJ. Are Antibiotics Necessary for Pediatric Epididymitis?:
Pediatr Emerg Care. 2011;27(3):174-178.
https://doi.org/10.1097/PEC.0b013e31820d647a
28. Gkentzis A, Lee L. The aetiology and current management of prepubertal epididymitis.
Ann R Coll Surg Engl. 2014;96(3):181-183.
https://doi.org/10.1308/003588414X13814021679311
29. Cristoforo TA. Evaluating the Necessity of Antibiotics in the Treatment of Acute Epididymitis
in Pediatric Patients: A Literature Review of Retrospective Studies and Data Analysis.
Pediatr Emerg Care. 2021;37(12):e1675-e1680.
https://doi.org/10.1097/PEC.0000000000001018
30. Samm BJ, Dmochowski RR. Trauma injuries and conditions affecting the penis, scrotum,
and testicles. Postgrad Med. 1996;100(4):187-200.
https://doi.org/10.3810/pgm.1996.10.101
31. Tews M. Paraphimosis: Clinical manifestations, diagnosis, and treatment. UpToDate.
Published May 2020.
https://www.uptodate.com/contents/paraphimosis-clinical-manifestations-diagnosis-
and-treatment
32. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000;62(12):
2623-2626, 2628.
https://www.aafp.org/pubs/afp/issues/2000/1215/p2623.html
33. Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited:
Point of technique and review of the literature. J Pediatr Urol. 2013;9(1):104-107.
https://doi.org/10.1016/j.jpurol.2012.06.012
34. González Fernández M, Sousa Escandón MA, Parra Muntaner L, López Pacios JC. Azúcar:
tratamiento de elección en la parafimosis irreductible [Sugar: treatment of choice in
irreducible paraphimosis]. Actas Urol Esp. 2001;25(5):393-395.
https://doi.org/10.1016/S0210-4806(01)72638-1
35. Mackway-Jones K, Teece S. Best evidence topic reports. Ice, pins, or sugar to reduce
paraphimosis. Emerg Med J EMJ. 2004;21(1):77-78.
https://emj.bmj.com/content/21/1/77.long
36. Houghton GR. The ‘iced-glove’ method of treatment of paraphimosis. Br J Surg. 2005;
60(11):876-877.
https://doi.org/10.1002/bjs.1800601110
278
Chapter 9:
Endocrinology
Type 1 diabetes mellitus (T1DM) is caused by destruction of beta pancreatic cells that produce
insulin, leading to an absolute insulin deficiency. It most commonly presents in childhood, with
a first peak of onset between 4 and 6 years of age and a second peak between 10 and 14 years of
age. T1DM is an autoimmune disease that is thought to be triggered by various environmental
factors in people with a genetic predisposition. It is one of the most common chronic diseases
in childhood, though there is wide geographical and ethnic variation in incidence1. Prognosis
depends on availability of treatment, with significantly reduced life expectancy in children and
young adults with untreated or poorly controlled diabetes.
Clinical features
Most commonly, children present with general malaise and lethargy, and careful history elicits
the classic triad of:
– Polyuria (increased urination)
– Polydipsia (increased drinking)
– Weight loss
If symptoms go unrecognized, acidosis ensues, and the patient will present in diabetic
ketoacidosis requiring emergency treatment (see Section 9.2).
Complications
Hypoglycaemia is a common complication for children with T1DM on treatment (see 9
Section 9.3). Long-term complications from poorly controlled diabetes include neuropathy,
retinopathy, nephropathy, and cardiovascular disease.
9.1.1 Diagnosis
The diagnosis of diabetes is based on the presence of one of the following diagnostic criteria,
in patients presenting with classic signs and symptoms2:
Test Result
Fasting blood glucose = no calorific intake for at least 8 hours; 2-h post-load blood glucose = performed 2 hours
after ingestion of 1.75 g/kg oral glucose; Random blood glucose = measurement at any time during the day;
Glycosylated haemoglobin (HbA1c) = reflects average glycaemia over the previous 10-12 weeks.
281
Chapter 9: Endocrinology
9.1.2 Management
T1DM is a chronic illness that requires lifelong treatment with insulin (see Section 9.2.4 for
more detail on insulin initiation and titration). Age-appropriate education for the child, as well
as general education for the parent/carer, is an important part of the management plan and
information should be repeated at every opportunity to ensure sufficient understanding of the
disease and how to manage complications.
Education on the following is required:
– Basic understanding of T1DM and its cause (highlighting that it is not caused by poor diet)
– Dietary intake
– Insulin administration
– Monitoring of blood glucose level (BGL) using a blood glucose monitor
– Hypoglycaemia symptoms and management
– Hyperglycaemia and ketosis detection and management
– Sick-day management
Refer children with newly diagnosed diabetes for long-term follow-up, depending on local
resources, and arrange:
– At least once-weekly follow-up for the first month.
– Home glucose monitoring. Each patient should be provided with a glucometer and enough
strips for a minimum of three BGL measurements per day until the medical visit. A notebook
should be provided to record the BGL measurements taken.
Refer to local or national guidelines, where available, for more detail on education material
and long-term follow-up.
282
Chapter 9: Endocrinology
9.2.1 Diagnosis
Check if known T1DM. Enquire about any interruption to or inadequate insulin therapy. If not
previously diagnosed with diabetes, enquire about symptoms of T1DM, including polydipsia,
polyuria, fatigue, irritability, vomiting, abdominal pain, weight loss and family historya. 9
DKA is diagnosed when all of the following 3 criteria are present:
– BGL ≥ 200 mg/dL (≥ 11.1 mmol/L)
– Ketonuria (++ or more)
– Plus, one or more of the following clinical features:
• Kussmaul breathingb (deep, rapid, sighing)
• Fruity breath
• Decreased level of consciousness
• Signs of dehydration
• Abdominal pain and/or vomiting
• Shock
Where possible, confirm metabolic acidosis: serum bicarbonate < 15 mmol/L or blood pH < 7.3.
Consider any precipitating factors:
– Infections (e.g. pneumonia, malaria, urinary tract infections)
– Major surgical conditions (e.g. acute abdomen)
a Family history of T1DM increases the likelihood of diabetes, however many children with T1DM have no family
history of the condition.
b Kussmaul breathing is deep, laboured breathing that is usually rapid but respiratory rate may be normal. It is a
form of hyperventilation which aims to remove carbon dioxide in response to metabolic acidosis.
283
Chapter 9: Endocrinology
9.2.2 Management
Treatment objectives are:
– Resuscitation and correction of shock
– Fluid replacement
– Insulin to reduce glucose gradually, aiming for an hourly glucose reduction of maximum
90 mg/dL/hr (5 mmol/L/hr)
– Maintenance of potassium concentration
– Identification and management of underlying condition or precipitating factors.
284
Chapter 9: Endocrinology
Fluid replacement
Once resuscitation is complete, start IV fluid administration. Add potassium chloride (KCl) to
IV fluids only once urine output has been confirmed. Together with appropriate maintenance
fluid requirements, standard fluid infusion calculations in DKA include: a 7.5% deficit to be
replaced over 48 hours; or, if considered to be in severe DKA (and/or confirmed with pH < 7.1),
a 10% deficit replaced over 48 hours (see Table 9.1 and Table 9.2 below)4.
Two-bag method
– Prepare two bags of IV fluid solutions with different glucose concentrations but identical
electrolyte content (see Step 1 below).
• IV fluid bag #1 has no added glucose.
• IV fluid bag #2 has added glucose.
– Ringer lactate (RL) is the preferred IV fluid, if not available, use sodium chloride 0.9% (NaCl
0.9%) as alternative.
– Ensure each bag of IV fluid is labelled with date, time, amount of KCl added (only add KCl if
urine output is confirmed) and signature of the person making the fluid bag.
– Set up a two-bag system to allow each bag to be run either separately, or at the same time,
without having to manipulate the IV line (see Figure 9.1 below):
• Hang both IV fluid bags, connect each to a paediatric infusion set and prime the IV lines.
• Connect the end of each paediatric infusion set to the same IV cannula using a 3-way
stopcock.
• Turn the 3-way stopcock as required depending on whether both bags are running
simultaneously or separately.
– Adjust the rates of each bag of IV fluid to respond to changes in BGL (see Step 2 page 286).
285
Chapter 9: Endocrinology
286
Chapter 9: Endocrinology
3 kg 9 17 18 22 kg 48 96 108
4 kg 11 22 24 23 kg 50 99 111
5 kg 14 28 30 24 kg 51 102 114
6 kg 17 33 37 25 kg 52 104 117
7 kg 20 39 43 26 kg 54 107 120
8 kg 22 44 49 27 kg 55 109 123
9 kg 25 50 55 28 kg 56 112 126
10 kg 28 56 61 29 kg 57 114 129
9
11 kg 30 59 65 30 kg 59 117 133
12 kg 32 63 69 31 kg 60 119 136
13 kg 33 66 73 32 kg 61 122 139
14 kg 35 70 77 33 kg 63 125 142
15 kg 37 73 81 34 kg 64 127 145
16 kg 39 77 85 35 kg 65 130 148
17 kg 40 81 89 36 kg 66 132 151
18 kg 42 84 94 37 kg 68 135 154
19 kg 44 88 98 38 kg 69 137 157
287
Chapter 9: Endocrinology
Speed (mL/hr)
Weight
Half Standard High
41 kg 73 145 166
42 kg 74 148 170
43 kg 75 150 173
44 kg 77 153 176
45 kg 78 155 179
46 kg 79 158 182
47 kg 80 160 185
48 kg 82 163 188
49 kg 83 166 191
50 kg 84 168 194
51 kg 86 171 197
52 kg 87 173 200
53 kg 88 176 203
54 kg 89 178 207
55 kg 91 181 210
Insulin therapy
– Once shock corrected, and one hour after starting IV fluid replacement, start IV insulind. Add
50 IU of soluble insulin to 49.5 mL sodium chloride 0.9% to make a total of 50 mL. Ensure
insulin preparation is double checked by two qualified healthcare professionals.
By syringe pump:
• < 2 years, insulin IV: 0.05 IU/kg/hour (lower dose)
• ≥ 2 years, insulin IV: 0.1 IU/kg/hour (higher dose)
d Ensure insulin is double-checked by 2 staff to ensure medicine safety. Both the syringe and line should be
changed at least once every 24 hours.
288
Chapter 9: Endocrinology
– If no syringe pump is available, administer insulin IM: 0.1 to 0.2 IU/kg every two hours,
depending on age (as above).
– Note: subcutaneous route is not recommended for DKA treatment due to varied absorption
from poor perfusion.
– Decrease insulin dose if BGL decreases too rapidly (> 90 mg/dL/hr or > 5 mmol/L/hr) despite
adjusting the fluid rates using the two-bag method.
– Stop insulin if BGL < 70 mg/dL (< 4 mmol/L) and does not improve with adjustment of IV
fluids rates and restart insulin once BGL ≥ 90 mg/dL (≥ 5 mmol/L).
– Insulin administration must be continued while ketonuria remains present, and glucose
intake should be increased as necessary to allow this.
– Consider increasing insulin for children on the lower dose of insulin if BGL does not decrease
over 4 hours:
• Increase to 0.1 IU/kg/hour if using IV syringe pump.
• Increase to 0.2 IU/kg every 2 hours if administering via IM injection.
Hypoglycaemia
Hypoglycaemia is a common and dangerous complication.
– Monitor BGL hourly while on insulin infusion and treat promptly when BGL < 60 mg/dL
(< 3.3 mmol/L), see Section 9.3 for treatment of hypoglycaemia.
– Verify insulin and IV fluids are correctly prepared and administered.
289
Chapter 9: Endocrinology
• Vomiting
• Headache
Minor criteria • Lethargy or not easily rousable
• Diastolic blood pressure > 90 mmHg
• Age < 5 years
Treatment
– Manage A and B:
• Support airways.
• Administer oxygen via mask with reservoir bag (if available).
– Assess C and check BGL: exclude hypoglycaemia or shock as a cause for change in neurological
condition.
– Insert NGT and leave on free drainage.
– Raise the head of the bed by 15 to 30 degrees (> 40 degrees can worsen raised intracranial
pressure (ICP)).
– Consider reducing IV fluids to 70% of current fluid rate.
– Consider giving hyper-osmolar solutions (if available and staff trained in its use):
Alternative, mannitol IV: 0.5 to 1 g/kg over 10 to 15 minutes. Repeat after 30 minutes if
no response.
e Cheyne-Stokes respiration manifests as a cycle of fast, shallow breathing that becomes deeper and slower
before leading to periodic apnoea before the cycle begins again.
290
Chapter 9: Endocrinology
insulinSC: 0.3 to 0.8 IU/kg over 24 hours, in divided doses (depending on regimen
chosen, see below for details)
– Administer first SC short-acting insulin 1 to 2 hours before stopping the insulin infusion.
– Start regular SC insulin at the next mealtime and administer it pre-meal.
– Measure BGL before each meal (pre-prandial) and at night (2 am) to monitor response and
allow adjustment of insulin regime during hospital stay.
– Allow at least 48 hours to identify pattern before adjusting insulin dose unless the change is
needed to avoid an obvious risk of hypoglycaemia or significant hyperglycaemia.
– Hospitalisation is recommended for at least 1 week to ensure BGL stabilisation and to provide
diabetes education to patient and parents/carers. Introduce the idea of home glucose
monitoring in preparation for continuation on discharge. Where feasible, all patients with
diabetes should be discharged home with a blood glucose monitor and testing strips.
f Start at lowest dose and increase as necessary during the hospital stay to achieve optimal glycaemic control
before discharge.
g Long-acting insulins are not yet readily available in MSF projects but should be used in preference where
available.
291
Chapter 9: Endocrinology
Before breakfast 2 IU 4 IU
– Adjust insulin dosing according to morning and evening BGL measurements to achieve BGL
stabilization prior to discharge (see Table 9.4).
– Where home glucose monitoring is not possible in the twice-daily dosing regimen, consider
intermediate acting insulin only.
h Premixed combinations of intermediate and short-acting insulin: INSULIN HUMAN, BIPHASIC 30-70 IU/mL,
10 mL, vial L (Lilly), DINJINSHB1VL; INSULIN HUMAN, BIPHASIC 30-70 IU/mL, 10 mL, vial N (Novo Nordisk),
DINJINSHB1VN; INSULIN HUMAN, BIPHASIC 30-70 IU/mL, 10 mL, vial S (Sanofi), DINJINSHB1VS. It is not
recommended to switch the patient from insulin type or brand.
292
Chapter 9: Endocrinology
< 80 mg/dL 80-200 mg/dL > 200-250 mg/dL > 250 mg/dL
(< 4.5 mmol/L) (4.5-11 mmol/L) (> 11-14 mmol/L) (> 14 mmol/L)
293
Chapter 9: Endocrinology
9.3 Hypoglycaemia
Defined as a blood glucose concentration that is too low to maintain normal brain function.
Hypoglycaemia cannot be identified by a specific blood glucose level (BGL)8 as the threshold
triggering a neurological response occurs across a range of values. For diagnostic purposes,
the cut-off point to treat hypoglycaemia is BGL ≤ 60 mg/dL (3.3 mmol/L).
Hypoglycaemia is a medical emergency and untreated can lead to serious neurological
consequences, including irreversible disability9.
There are many conditions that can cause hypoglycaemia. Common causes include:
– Severe infection (e.g. sepsis, malaria)
– Gastroenteritis (vomiting and/or diarrhoea)
– Dehydration
– Malnutrition
– Lack of dietary intake (e.g. during acute illness)
– Iatrogenic (e.g. incorrect administration of IV fluids, quinine therapy for malaria)
– Incorrect management of a patient with known diabetes
– Intoxication (e.g. alcohol, drugs, traditional remedies)
– Congenital disorders (e.g. adrenal insufficiency, growth hormone deficiency, metabolic
disorders)
294
Chapter 9: Endocrinology
– Midline defects (e.g. a single central incisor, cleft lip or palate, umbilical hernia) and
microphallus or undescended testicles in boys may indicate hypopituitarism and/or growth
hormone deficiency.
– Hepatomegaly is common feature of some metabolic disorders.
– Hyperpigmentation suggests primary adrenal insufficiency.
Check BGL on admission of all severely sick children, or at any time during admission if there is
clinical deterioration, or lack of intake.
Where BGL is not available, treat for hypoglycaemia if clinically suspected to avoid adverse
consequences.
In malaria-endemic regions, perform a malaria rapid test.
9.3.2 Management
Treatment of hypoglycaemia varies with the degree of hypoglycaemia and the associated
symptoms.
For children with an altered level of consciousness:
– Assess and manage ABCDE (see Chapter 2, Section 2.1).
– Obtain IV or IO access.
– Administer 2 mL/kg bolus of glucose (dextrose) 10% IV/IO over 2 to 3 minutes (do not use
undiluted glucose (dextrose) 50%a). If there is a delay in obtaining IV/IO access, administer
10 mL/kg of glucose (dextrose) 10% via NGT (sit the child upright).
– After the bolus, in non-malnourished children, start IV maintenance fluids with glucose
(dextrose) 5%/Ringer lactate (G5%/RL), unless already on maintenance G5%/RL, in which
case increase maintenance to glucose (dextrose) 10%/Ringer lactate (G10%/RL).
– Repeat BGL in 30 minutes: if still hypoglycaemic repeat IV bolus of 2 mL/kg glucose (dextrose)
10% and, in non/malnourished children, increase maintenance to G10%/RL. 9
For children who are conscious, able to drink and swallow safely, give treatment orally:
– Give a sugar-containing drink or snack by mouth, such as: 1 to 2 teaspoons of table sugar
moistened with water, or 60 mL fruit juice, milk, therapeutic milk (if SAM) or breast milk, or
5 to 10 mL honey (only if > 1 year old), or 10 mL/kg of glucose (dextrose) 10% orally or via
NGT (with child in semi-sitting position), or 1 mL/kg of glucose (dextrose) 50% under the
tongue.
– Feed the child as soon as possible.
– Repeat BGL in 15 to 30 minutes: if the child is still hypoglycaemic, administer 2 mL/kg bolus
of glucose (dextrose) 10% IV and start IV maintenance fluids with G5%/RL.
If recurrent hypoglycaemia AND adrenal insufficiency is suspected, check the electrolytes if
available, and consider hydrocortisone 5 mg/kg IV (max 100 mg).
Monitoring
– Repeat BGL every 30 minutes until BGL is stable between 70 and 120 mg/dL (3.9 to
6.7 mmol/L) for two subsequent measurements.
– Thereafter, check BGL every 2 to 3 hours until it is stable for another two consecutive
measurements.
a Glucose (dextrose) 50% (G50%) solution is too viscous and irritant to be used in children. Where glucose
(dextrose) 10% (G10%) solution is not available, remove 100mL of glucose (dextrose) 5% (G5%) from a 500mL
bottle or bag, then add 50 mL of G50% to the remaining 400 mL of G5% to obtain 450 mL of G10% solution.
295
Chapter 9: Endocrinology
References Chapter 9
1. Levitsky LL, Misra M. Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus
in children and adolescents. UpToDate. Published January 2023.
https://www.uptodate.com/contents/epidemiology-presentation-and-diagnosis-of-type-
1-diabetes-mellitus-in-children-and-adolescents
2. World Health Organization. Classification of Diabetes Mellitus. World Health Organization;
2019. Accessed October 24, 2023.
https://iris.who.int/handle/10665/325182
3. Usher-Smith JA, Thompson M, Ercole A, Walter FM. Variation between countries in the
frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a
systematic review. Diabetologia. 2012;55(11):2878-2894.
https://doi.org/10.1007/s00125-012-2690-2
4. BSPED |BSPED DKA Guidelines. Accessed October 24, 2023.
https://www.bsped.org.uk/clinical-resources/bsped-dka-guidelines/
5. Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence
and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr. 2005;146(5):
688-692.
https://doi.org/10.1016/j.jpeds.2004.12.041
6. Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical Practice Consensus Guidelines 2018:
Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes.
2018;19:155-177.
https://doi.org/10.1111/pedi.12701
7. ISPAD, LFAC, IDF. Pocket Book for Management of Diabetes in Childhood and Adolescence
in Under-Resourced Countries. 2nd ed. International Diabetes Federation; 2017. Accessed
October 24, 2023.
https://www.ispad.org/page/ISPADIDFLFaC
8. Thornton PS, Stanley CA, Leon DDD, et al. Recommendations from the Pediatric Endocrine
Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants,
and Children. J Pediatr. 2015;167(2):238-245.
https://doi.org/10.1016/j.jpeds.2015.03.057
9. Leon-Crutchlow DDD, Lord K. Approach to hypoglycaemia in infants and children. UpToDate.
Published May 2022.
https://www.uptodate.com/contents/approach-to-hypoglycemia-in-infants-and-children
296
Chapter 10:
Haematology
10.1 Anaemia
Anaemia is defined as a haemoglobin (Hb) level below the age-specific reference value (see
Table 10.1). Severe anaemia is defined as Hb < 6 g/dL for children over 2 months of agea.
Table 10.1 - Definition of anaemia1
Age Hb level defining anaemia
< 2 months < 13.5 g/dL
2 to < 6 months < 9.5 g/dL
6 to 59 months < 11 g/dL
5 to 11 years < 11.5 g/dL
12 to 14 years < 12 g/dL
< 12 g/dL (girls)
15 years and above
< 13 g/dL (boys)
Anaemia can result from a reduction in red blood cell production, blood loss, or increased
haemolysis (see Table 10.2). In tropical settings, the causes are often multiple and overlapping
e.g. malnutrition and malaria.
In infants < 1 year of age, causes can be congenital, including:
– Maternal malaria and HIV: both cause IUGR, which is associated with anaemia.
– Maternal iron deficiency during pregnancy
– Preterm delivery
– Haemoglobinopathies and G6PD deficiency 10
Table 10.2 - Causes of anaemia
a For definition of severe anaemia in infants less than 2 months, see MSF Neonatal Care guidelines.
b Post-artemisinin delayed haemolysis (PADH) is a rare phenomenon which can occur 1-3 weeks after initiation
of treatment with injectable artesunate. Clinicians should be aware of this potential complication.
299
Chapter 10: Haematology
Investigations
– Hb
– Full blood count (FBC), if available
– In malaria-endemic regions, malaria RDT or thick and thin blood films
300
Chapter 10: Haematology
– If sickle cell anaemia suspected, the following tests should be done before blood transfusionc
(see also Section 10.2):
• Sickle scan (lateral flow RDT that can detect both sickle cell disease and trait)
• Emmel test if sickle scan not available (ideally confirmed by electrophoresis, where
available)
– Blood group and crossmatch (in case of need for transfusion), including mothers’ blood
group for infants less than 4 monthsd.
10.1.2 Management
Anaemia itself may not always require treatment. Management of the underlying cause or
condition resulting in anaemia may likely correct anaemia, and a blood transfusion is often not
necessary in a clinically stable child.
Indications for blood transfusion (excluding infants < 2 monthse):
– Profound anaemia: Hb < 4 g/dL, or
– Complicated severe anaemia: Hb ≥ 4 and < 6 g/dL with one or more signs of decompensation:
• Increased work of breathing (see Chapter 4, Section 4.1.1)
• Altered level of consciousness (see Chapter 7, Section 7.5.1)
• Circulatory impairment/shock (see Chapter 2, Section 2.2.1)
– Complicated severe anaemia: Hb ≥ 4 and < 6 g/dL with evidence of ongoing blood loss:
• Haemoglobinuria (indicating intravascular haemolysis)2
• Visible bleeding (external bleeding, haematemesis, melaena, haematuria)
Note that malaria, sickle cell disease (SCD) and sepsis are not considered to be independent
anaemia severity criteria in otherwise stable children, therefore are not indications for
transfusion unless accompanied by one of the complications outlined above. See relevant
chapters for specific transfusion criteria for children with circulatory impairment/shock
(Chapter 2, Section 2.2.3) and certain complications of SCD (Section 10.2), as these may differ
from the above.
Infants < 2 months of age with anaemia should be managed as for neonates, see MSF Neonatal 10
Care Guidelines.
Initial management
– Stop any major or evident bleeding or haemorrhage (see Chapter 2, Section 2.7).
– Assess and manage ABCDE; resuscitate and stabilise (refer to Chapter 2, Section 2.1).
– Check Hb and identify any clinical signs of severity.
– Take blood for group and save, or crossmatching if transfusion required (see below).
– If history of previous transfusions or any indication of SCD, take a blood sample for testing
before transfusionc.
– Administer oxygen if clinical signs of severity, aiming for saturations ≥ 94%.
– Check axillary temperature, weight/age.
c Tests for SCD can give false results if performed within 8 weeks of a blood transfusion.
d Blood should be compatible with both the infant’s and the mother’s ABO and Rh group until 4 months of age
(see MSF Neonatal Care guidelines for more detail).
e Young infants < 2 months of age have a significantly higher normal Hb than older infants (see Table 10.1
page 299) therefore transfusion thresholds are higher. In this age group, transfusion should be considered
if Hb less than 8 g/dL in term neonates (less than 7 g/dL in preterm neonates) or if Hb less than 10 g/dL with
clinical signs of intolerance to anaemia.
301
Chapter 10: Haematology
Profound anaemia (Hb < 4 g/dL) or complicated severe anaemia (Hb 4 - < 6 g/dL with
signs of decompensation or ongoing blood lossf)
– Urgent blood group and crossmatch (if not already done), including mothers’ blood group
for infants less than 4 monthsg.
– Start treatment of underlying cause (e.g. malaria).
– Administer blood transfusionh, calculating volume according to the presence or absence of
fever2, as follows:
• No fever (≤ 37.5 °C) from the time of ordering blood to the time of transfusioni: administer
30 mL/kg whole blood over 4 hours or 15 mL/kg packed red blood cells (PRBC) over
3 hours.
• Fever (> 37.5 °C) at any point from the time of ordering blood to the time of transfusioni:
administer 20 mL/kg whole blood over 4 hours or 10 mL/kg PRBC over 3 hours.
– Depending on volume required, transfusion rate may exceed the usual recommendation
of maximum 5 mL/kg/hr. Use one or more adult units of whole blood or PRBC. See MSF
Manual of Nursing Care Procedures, SOP Paediatric Transfusion Set – Blood burette and SOP
Using a Syringe Pump for Small Volume Blood Transfusions for more details on paediatric
transfusion administration.
– Monitor children closely during transfusion for any transfusion reaction and for signs of
overload, especially malnourished children who are at increased risk of fluid overload.
– Recheck Hb routinely once between 8-24 hours after the transfusion is complete3, or at any
other time if ongoing signs of decompensation or blood loss once transfusion is complete.
– Depending on the Hb level and signs of decompensation and/or ongoing blood loss (as
above) repeat transfusion may be necessary. Check for signs of fluid overload before starting
another transfusion - furosemide between transfusions is not indicated unless signs of fluid
overload are present.
f These criteria do not apply in haemorrhagic shock, for which transfusion volumes are different (see Chapter 2,
Section 2.5).
g Blood should be compatible with both the infant’s and the mother’s ABO and Rh group until 4 months of age
(see MSF Neonatal Care guidelines for more detail).
h Always ensure bedside verification of ABO compatibility immediately before transfusion using an ABO testing
card.
i Ensure temperature is checked and recorded at the time of ordering blood and immediately prior to transfusion
as a minimum.
302
Chapter 10: Haematology
– If Hb increases to > 6 g/dL, continue with treatment of underlying cause and observation.
– Once clinically stable, consider iron and folic acid supplementation (see below).
Although malaria is by far the principal cause of severe anaemia in most MSF contexts, outside
of malaria-endemic regions the main causes of severe anaemia may be diverse. For anaemia
associated with burns, trauma or surgery follow specific guidance (See Chapter 2, Section 2.7
for trauma). If the child has known sickle cell disease with complications such as acute chest
crisis, acute splenic sequestration or cerebral vascular accident, see Section 10.2.
Iron supplementation
Start empiric treatment with iron supplementation in all children with anaemia where the
underlying cause is not evidentj and continue for 3 months:
– Iron combined with folic acid is the preferred option where available. Doses are expressed
in elemental ironk:
• 1 month to < 6 years: 1.5 to 3 mg/kg two times daily
• 6 to < 12 years: 65 mg two times daily
• ≥ 12 years: 65 mg two to three times daily
– In the case of moderate or severe anaemia, start iron only once the child is clinically stable
as it can exacerbate infection during acute illness. Folic acid alone can be started in the
meantime:
• < 1 year old: 2.5 mg once daily
• ≥ 1 year old: 5 mg once daily
– In endemic regions for hookworms, treat with albendazole in children over 6 months old
prior to commencing iron:
• Weight < 10 kg: 200 mg as a single dose
• Weight ≥ 10 kg: 400 mg as a single dose
– In malaria-endemic areas, iron combined with folic acid should only be given where malaria
prevention programmes and antimalarial treatments are widely availablel.
– For children with SAM, see specific dosing in Section 10.1.3.
10
10.1.3 Specific considerations in children with SAM
Indications for blood transfusion and transfusion volumes are the same for children with or
without severe acute malnutrition (SAM), however children with SAM are more susceptible to
volume overload therefore should be very carefully monitored.
For children with SAM admitted with moderate or severe anaemia and receiving ready to use
therapeutic food (RUTF), give iron/folic acid PO at discharge from ITFCm:
– Weight > 8 kg: 1/2 tablet once daily
– Weight ≤ 8 kg: none needed as there is enough iron and folic acid in RUTF.
j Note: Iron is contraindicated in a child who has known or suspected SCD, thalassaemia, or has received multiple
transfusions within a year.
k 140 mg/5ml syrup contains approximately 45 mg/5ml of elemental iron; 200 mg tablets of ferrous fumarate or
ferrous sulfate (with or without folic acid) contain approximately 65 mg or elemental iron (+/- 400 micrograms
of folic acid).
l Iron-folate supplementation increases the risk of clinical malaria in malaria-endemic areas where neither
prevention nor antimalarial treatments are available.
m Treatment is different to children without SAM to adjust for micronutrients contained in RUTF.
303
Chapter 10: Haematology
Sickle cell disease (SCD) is a genetic disorder producing an abnormal variant of the adult
haemoglobin (Hb). The abnormal haemoglobin (HbS) results in distortion of the red blood cells
into a classic ‘sickle’ shape, in response to a variety of triggers including dehydration, hypoxia,
infection and increased temperature4. This leads to increased destruction of red blood cells
(haemolysis), an increase in blood viscosity and obstruction of capillaries (causing vaso-
occlusive events)5. In SCD, the child inherits an HbS gene from at least one parent, and another
abnormal haemoglobin variant from the other parent (such as HbC or Hb beta thalassemia).
Sickle cell anaemia (HbSS), the most common and most severe form of SCD, occurs when a
child inherits an HbS gene from each parent.
Global data is lacking, but SCD is estimated to affect around 300,000 children born per year6.
It is most prevalent in sub-Saharan Africa (affecting up to 3% of births), though also present
amongst children born of Mediterranean (including Middle East region) and Indian origin7.
The highest prevalence of sickle cell anaemia is in the malaria-endemic zones of sub-Saharan
Africa, where it contributes significantly to under-5 deaths8.
Sickle cell trait occurs when a child inherits a sickle gene from one parent and a normal gene
from the other parent; carriers are usually asymptomatic.
304
Chapter 10: Haematology
Investigations
– Hb
– FBC and reticulocyte count, if available
– Consider blood group and crossmatch
– In malaria-endemic regions, malaria RDT
– Diagnosis of SCD:
• All testing must be done either on blood taken prior to transfusion or at least 8 weeks
after the last transfusion.
• Sickle Scan (lateral flow RDT that can detect both sickle cell disease and trait) is
recommended as first line point-of-care test. A positive Sickle Scan result is enough to
make the diagnosis, electrophoresis is not necessary to confirm the diagnosis unless
required by national guidelines.
• Emmel test can be performed as a screening test if Sickle Scan is not available. A positive
Emmel test does not confirm the diagnosis of SCD due to low sensitivity and specificity
and inability to differentiate between sickle cell trait and disease. Confirmation using Hb
electrophoresis is recommended, where available.
• Hb electrophoresis is the gold standard diagnostic tool, but is often unavailable.
Management
– Assess and stabilise ABCDE.
– Assess pain severity and start analgesia without delay, ideally within 30 minutes of arrival4,9
(see Chapter 15, Section 15.4).
– Admit if pain is uncontrolled, or moderate to severe and requiring opioid analgesia.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Administer oxygen if oxygen saturation in air is ≤ 95%4,9.
– Evaluate for dehydration and ensure adequate hydration:
• Encourage drinking fluids. If the patient is not able to drink, start IV maintenance fluids
until oral intake has improved (see Chapter 15, Section 15.2). Consider NGT if IV access is
difficult or refused.
• Correct any dehydration (see Chapter 5, Section 5.3).
– If fever present (> 37.5 °C), manage as for febrile illness below.
– Blood transfusion is not routinely indicated unless there are other clinical indications for
transfusion (see Section 10.1.2).
305
Chapter 10: Haematology
Management
– In addition to admission based on clinical condition, admit to hospital all children with
known SCD or suspected SCD and any of the following criteria:
• Age < 2 years
• Fever of ≥ 38.5 °C
• Presence of acute anaemia (fall of 2 g/dL below patient’s baseline Hb value, or Hb < 6 g/dL
where baseline unknown9).
• Signs of acute haemolysis, splenic sequestration or other co-existing complications.
– Assess and stabilise ABCDE.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Treat presumed bacterial infection according to likely cause (all patients with SCD who
present with fever should be started on antibiotics):
• Pneumonia: refer to Chapter 4, Section 4.5.
• Meningitis: refer to Chapter 3, Section 3.3.
• Acute osteomyelitis: refer to Chapter 11, Section 11.4.
• Unknown source of infection or sepsis: refer to Chapter 3, Section 3.2.
– Evaluate for dehydration and ensure adequate hydration:
• Encourage drinking fluids. If the patient is not able to drink, start IV maintenance fluids
until oral intake has improved (see Chapter 15, Section 15.2). Consider NGT if IV access is
difficult or refused.
• Correct any dehydration (see Chapter 5, Section 5.3).
– If malaria RDT positive, treat malaria in addition to bacterial infection.
– Treat pain if present.
– Monitor for the appearance of acute anaemia.
– Change to oral antibiotics once the patient shows signs of improvement (afebrile, can eat
and drink) and discharge home to complete oral treatment.
– Complete oral antibiotic treatment in hospital if:
• Less than 2 years old
• Presence of acute anaemia (fall of 2 g/dL below patient’s baseline Hb value, or Hb < 6 g/dL
where baseline unknown9.
306
Chapter 10: Haematology
Management
– Assess and stabilise ABCDE.
– Admit to hospital.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Assess regularly for severe anaemia and bronchospasm.
– Administer oxygen via face mask, aiming for SpO2 between 94 - 98%.
– Ensure adequate hydration as for VOC. If oral intake is insufficient, start IV maintenance
fluids (see Chapter 15, Section 15.2) while monitoring for fluid overload. If signs of fluid
overload, administer one dose of furosemide IV.
– Give adequate pain relief (see Chapter 15, Section 15.4).
– Ensure deep breathing exercises focusing on the inspiration phase (alveolar distension, e.g.
with an incentive spirometer) every 1 to 2 hours while awake.
– Administer antibiotic treatment even if no fever present:
a The goal of exchange transfusion is to reduce circulating levels of HbS to relieve symptoms, rather than to treat
anaemia.
307
Chapter 10: Haematology
Management
– Assess and stabilise ABCDE.
– Admit to hospital.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Treat malaria if present.
– Assess for complications of SCD.
– In addition to standard transfusion criteria (see Section 10.1.2), administer blood transfusionb
for the following complications of SCD presenting with acute anaemia (a drop in Hb of 2 g/dL
below baseline, or Hb < 6 g/dL if baseline is unknown)9:
• Acute splenic sequestration (see Section 10.2.6)
• Symptomatic ACS (see Section 10.2.4)
• Cerebral vascular accident (stroke) (see Section 10.2.8)
– If blood transfusion required, transfuse according to guidance in Section 10.1.2.
– Monitor Hb at 24 and 48 hours. Further transfusions may be necessary if haemolysis is
ongoing.
– If blood transfusion not required but Hb 4 - < 6 g/dL, monitor closely according to advice in
Section 10.1.2.
Management
– Assess and stabilise ABCDE.
– If signs of circulatory impairment or shock, see Chapter 2, Section 2.2.
– Admit to hospital.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Blood group and crossmatch; order blood.
– Administer blood transfusion (see Section 10.1.2 and Section 10.2.5).
b Consider referral for exchange transfusion in symptomatic severe ACS (defined as oxygen saturation < 90%
despite supplemental oxygen) and cerebral vascular accident (stroke) to reduce circulating HbS9,12.
308
Chapter 10: Haematology
Management
– Assess and stabilise ABCDE.
– Admit to hospital.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Treat malaria or associated bacterial infection if present.
– Administer blood transfusion only if standard transfusion criteria present (see Section 10.1.2)
– Repeat Hb every other day. An increasing reticulocyte count and a gradual increase of the
Hb indicates improvement. Monitor patient until their baseline Hb has been reached.
10
10.2.8 Stroke
Sudden onset of weakness, impairment of language and sometimes seizures or coma and
results in adverse motor and cognitive sequelae. It is secondary to stenosis or occlusion of the
internal carotid or middle cerebral artery, but acute chest syndrome, acute aplastic crisis or
other acute anaemic events may precipitate events.
Management
– Assess and stabilise ABCDE.
– Admit to hospital.
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Administer blood transfusion (see Section 10.1.2) if acute anaemia present (see
Section 10.2.5).
– Consider referral for exchange transfusionc, which is the treatment of choice for ischaemic
stroke in SCD9,12.
c The goal of exchange transfusion is to reduce circulating levels of HbS to relieve symptoms, rather than to treat
anaemia.
309
Chapter 10: Haematology
– Transfer the patient to a specialized facility for further management (including prophylactic
therapy to prevent recurrences with transfusion programme, hydroxyurea).
– If the patient is awaiting transfer or if transfer is not possible:
• Oxygen continuously, to maintain the SpO2 > 94%.
• Treat seizures if present.
• After transfusion administer IV maintenance fluids for hydration (see Chapter 15, Section 15.2).
10.2.9 Priapism
– Sustained, unwanted, painful erection lasting several hours.
– Usually affects teenagers and adults but may affect younger boys.
– Prompt recognition and initiation of conservative medical management may resolve the
swelling and limit the need for more aggressive and invasive intervention. Delayed diagnosis
and treatment can result in necrosis and irreversible erectile dysfunction.
Ambulatory management
Ensure children know how to manage priapism early at home to prevent severe acute priapism.
– Home measures include:
• Drinking fluids
• Application of warm compresses
• Gentle exercise, e.g. walking
• Regular urination
• Attempting ejaculation
• Pain control
– Seek hospital care if erection lasts for longer than 2 hours.
– Consult clinician if episodes of intermittent priapism occur more than two times per month.
Basic knowledge
310
Chapter 10: Haematology
Routine follow-up
– Between crises, regular OPD consultations every 1 to 3 months (until 4 years of age), then
every 3 to 6 months for 5 years of age and above:
• Assess for chronic complications (see Table 10.3).
• Ensure adherence to regular medications and that immunisations are up to date.
• Check nutritional status and psychosocial situation.
• Ensure reproductive counselling for girls of reproductive age (increased risk of VOC during
pregnancy/childbirth, higher incidence of intrauterine growth restriction, foetal and
perinatal loss and pre-eclampsia). 10
– After a crisis: as often as necessary, according to the clinical course.
– Paracetamol for home use in case of pain.
311
Chapter 10: Haematology
mefloquine PO
> 6 months and > 5 kg: 5 mg base/kg (max. 250 mg) once weekly
Do not use to treat malaria.
d Note that conversely, sickle cell trait confers a partial protection from malaria (though children with sickle cell
trait should still be tested for malaria if they present with clinical symptoms consistent with malaria).
312
Chapter 10: Haematology
References Chapter 10
313
Chapter 11:
Bone and joint problems
11
Chapter 11: Bone and joint problems
11.1 Introduction
This chapter explores common bone and joint problems in children that typically have an
underlying pathology or cause. It does not cover immobile or painful limbs due to trauma
(e.g. fractures) which is outside the scope of these guidelines, with the exception of toddler’s
fracture, non-accidental injury (NAI) and pulled elbow which require specific management in
children.
11
317
Chapter 11: Bone and joint problems
Limp is a common presentation in children and has a wide range of potential causes. Limp can
be due to pain, weakness or deformity. Transient synovitis and minor trauma are the most
common non-infectious causes of limp in children, however certain conditions are more likely
in specific age-groups (see Table 11.1). Infectious causes (osteomyelitis (see Section 11.4),
septic arthritis (see Section 11.5), tuberculosis (see Chapter 4, Section 4.12), brucellosis, Lyme
disease), bone malignancies and haematological disease should be considered in all children.
The hip and knee are the most commonly affected joints, though pain in either of these joints
may be due to pathology in the other. Limp may be also be caused by referred pain from
another origin (testicular torsion, appendicitis, psoas abscess etc.) or may be neurological
(hemiplegia, spinal injury/compression).
Table 11.1 - Age-specific non-infectious causes of limp
318
Chapter 11: Bone and joint problems
Examine the joints above and below the affected joint to exclude pathology in these joints
causing referred pain. Also ensure that an abdominal +/- genital examination are performed
in case of referred pain.
Investigations
– Full blood count (FBC)
– X-ray of affected limb/joint: useful in the diagnosis of fractures, DDH, primary bone tumours,
SUFE and Perthes’, though advanced imaging, such as CT scan or MRI, may be required to
confirm diagnosis.
– Ultrasound: used to detect joint effusions, but cannot differentiate between infection, blood
and reactive fluid. Fluid can be aspirated under ultrasound guidance. May show periosteal
reaction suggestive of osteomyelitis.
Toddler’s fracture
Spiral fracture of the tibia caused by a twisting injury with rotational force when a child trips,
stumbles or falls, common in ambulatory infants and young children. Toddler’s fractures may
occur after relatively minor trauma therefore parents/carers may not be aware of when/how
the injury took place. Localised tenderness at the tibial fracture site is often present but may
be difficult to elicit. Treatment is conservative with immobilisation to reduce discomfort.
Perthes’ disease
Avascular necrosis of part or all of the femoral head. Typically seen in children aged 4 to
9 years, and three times more common in boys than in girls. Usually mild symptoms with
insidious onset of a painless limp or activity-related leg pain (may be referred to thigh or knee).
Internal rotation and abduction of the hip on examination are mild to moderately limited. The
younger the child and the less femoral head involved, the better the prognosis. Treatment in
the majority of cases is reduced mobilisation and activity, however more severe cases may
require bedrest with traction. If unrecognised and untreated, severe osteoarthritis may occur
later in life.
319
Chapter 11: Bone and joint problems
Non-accidental injury
Usually suspected by the pattern of injury (e.g. bruising in unusual places or in an infant who
is not yet mobile), delay in seeking medical attention, changeable or implausible history, or
a mechanism of injury inconsistent with examination findings. There may be prior history of
injuries or neglect. Cases should be handled with care, and with early involvement of the
psychosocial team, if available. Follow local child protection pathways if concerns are raised
and consider safeguarding procedures for other children at home, who may still be in a
vulnerable environment.
Tuberculous arthritis
Tuberculosis (TB) can cause arthritis in the spine, hips and knees through hematogenous
spread of bacilli from other TB foci. Tuberculous arthritis is usually ‘cold’, i.e. the skin over
the painful, swollen joint is the same temperature as the rest of the skin, and not warm as in
other infective conditions. The history is usually less acute than septic arthritis and there may
be systemic symptoms of TB such as fever, night sweats and weight loss. Diagnosis is made
clinically or by analysis of exudate removed during joint aspiration, if possible (acid and alcohol
fast bacilli (AAFB) and GeneXpert). Treatment for TB should be started as soon as possible (see
Chapter 4, Section 4.11).
320
Chapter 11: Bone and joint problems
A pulled elbow is a common minor injury in young children. It occurs when a child’s arm is
pulled, twisted or stretched abruptly, causing the radius to partially slip out of the annular
ligament at the elbow (subluxation). It commonly occurs in young children being pulled back
from a potentially dangerous situation by a parent/carer or older sibling. Subluxation of the
radial head causes restricted movement and pain on elbow flexion, pronation and supination.
The child typically keeps the arm immobile, in a slightly flexed and pronated position. Pain is
only elicited on movement.
There are two main techniques to reduce a pulled elbow. The first is hyper-pronation, in which
pressure is applied over the radial head, whilst hyperpronating the arm. The second technique
is supination-flexion, in which again pressure is applied over the radial head, whilst the arm is
supinating and then flexed at the elbow. There is low quality evidence that the hyperpronation
technique has a better success rate at first attempt reduction that the supination technique1.
If history is not typical of a pulled elbow, but there is potential for another diagnosis such as a
fracture, the manoeuvre should not be attempted. Ultrasound can help to detect signs of an
effusion/raised fatpad, suggesting a fracture rather than a pulled elbow.
11
321
Chapter 11: Bone and joint problems
11.4 Osteomyelitis
Osteomyelitis is an infection of the bone that is usually bacterial in origin. In children, acute
infection most commonly occurs by haematogenous spread (bacteraemia), but can also be
due to direct trauma to the bone (e.g. open fractures, war wounds), or from an infected site
near the bone (e.g. mouth, skin ulcer). Typically, infection affects the metaphysis of the long
bones, especially the femur and tibia, but any bone may be affected and pelvic osteomyelitis,
though rare, is seen in children. Though multiple sites can be affected, infection tends to be
limited to one site. Incidence is higher in children under 5 and is twice as common in boys2.
In haematogenous spread, Staphylococcus aureus is the most likely cause, but other common
pathogens include Kingella kingae, Group A and B streptococci, Streptococcus pneumonia,
E. coli and Haemophilus influenza B (if not immunised). Methicillin-resistant Staphylococcus
aureus (MRSA) is not infrequent. In children with sickle cell disease (SCD), infection by
Salmonella spp is most common followed by other gram-negative organisms.
The following factors increase the risk of developing osteomyelitis:
– Medical: malnutrition, sickle cell disease, HIV, tuberculosis, Buruli ulcer, cellulitis, dental
infections, post-malaria infection.
– Surgical/trauma: open fractures, penetrating or puncture wounds (including bites), surgical
procedures with insertion of pins or screws.
322
Chapter 11: Bone and joint problems
Investigations
– FBC
– Inflammatory markers: Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP)a, if
available
– Blood culture, if available, or any other material for culture (e.g. deep tissue, bone collected
during debridement).
– X-ray (AP and lateral view): localised, deep, soft tissue swelling appears on day 2 to 3, though
initially may be normal. Late signs include osteopenia, lytic lesions and periosteal reaction
which are evident from 10 to 21 days3. Osseous sequestrum (intraosseous abscess): sign of
chronic osteomyelitis.
– Ultrasound: may help identify joint effusion and differentiate from septic arthritis.
– Screen for SCD and consider potential TB contacts.
11.4.2 Management
Immobilisation of the affected extremity may relieve pain and prevent fractures, but
prolonged antibiotic treatment is the mainstay of management for acute osteomyelitis from
haematogenous spread:
– If the patient is stable, obtain blood cultures and any other culture material before starting
antibiotics, but avoid any delay in giving antibiotics.
– Administer empiric antibiotic treatment to cover the most likely pathogens (as outlined in
Section 11.4)4. Second choice antibiotics are used instead of, rather than in addition to, first
choice antibiotics if first choice is unavailable, if there is a high clinical suspicion of infection
with a gram-negative organism (e.g. in sickle cell disease), or if there is non-response to first-
line treatment:
• First choice: cloxacillin IV: 25 mg/kg every 6 hours (for S. aureus)
• Second choice:
▹ amoxicillin/clavulanic acid (co-amoxiclav) IV: 30 mg/kg of the amoxicillin component,
every 8 hours (or 50 mg/kg of the amoxicillin component, every 12 hours) OR
▹ cefazolin IV: 25 mg/kg every 12 hours OR
▹ ceftriaxone IV: 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) every 24 hours (for
Salmonella spp. or Enterobacterales) OR
▹ cefotaxime IV: 50 mg/kg every 8 hours (for Salmonella spp. or Enterobacterales) OR
▹ clindamycin IV: 10 mg/kg every 8 hours (for community-acquired methicillin resistant 11
S. aureus (CA-MRSA)b.
– Doses of antibiotics for acute osteomyelitis are generally higher than for other conditions.
– Antibiotic treatment should be tailored as culture results become available, due to the large
number of potential pathogens, including antibiotic resistant ones e.g. MRSA.
The duration of parenteral antibiotic treatment is variable and depends largely on clinical
evolution5. There is growing evidence that shorter courses of parenteral antibiotics (< 7 days)
have similar outcomes to prolonged courses if acute osteomyelitis is detected and treated
early, avoiding the need for long-term IV access and hospitalisation6,7,8. Antibiotics should
be administered parenterally until symptoms and signs decrease (usually around 3-5 days),
before switching to oral antibiotics to complete 3 weeks of total treatment in uncomplicated
osteomyelitis. Ongoing fever and raised CRP (where available) are indications to continue
parenteral treatment for longer9.
a The combination of raised CRP and ESR is the most sensitive indication of osteomyelitis.
b In contexts where prevalence of clindamycin resistance to CA-MRSA is known to be high, consider vancomycin
as an alternative.
323
Chapter 11: Bone and joint problems
– Patients with sickle cell disease: ensure antibiotics cover Salmonella spp (ceftriaxone or
cefotaxime are the preferred options), which is the most likely pathogen.
– Immunocompromised patients: prolong oral treatment to give a minimum of 6 weeks of
total treatment.
– Patients presenting with, or suspected of having, subperiosteal abscess or other purulent
collection: in addition to antibiotics, surgical debridement is required to remove the infected
tissue.
– All patients with osteomyelitis resulting from an inadequately treated open fracture should
be referred for surgical debridement.
Switch to oral antibiotic treatment when all of the following are met:
– At least 3 days of parenteral treatment completed
– Clinical improvement
– Afebrile for at least 72 hours
– Able to take oral medication without a problem in the hospital
– Parent/carer able to reliably give medication to the child.
If response to treatment is not as expected, re-evaluate the child and adjust antibiotic
treatment. Always consider and exclude tuberculosis (see Chapter 4, Section 4.11).
324
Chapter 11: Bone and joint problems
Investigations
– FBC
– Inflammatory markers: ESR and CRP, if available
– Blood culture, if available
– X-ray (AP and lateral view): sequestrum formation (intraosseous abscess, seen as representing
fragments of devitalized bone).
Management
– Mainstay of treatment is surgical removal (debridement) of the sequestrum and the dead
tissue around it, as the necrotic tissue serves as a source of infection, as well as any associated
abscess.
– Surgery may be relatively straightforward if the sequestrum is localized and not affecting the
growth plates or joints, however it can be very complex when associated with pathological
fracture, bone loss, growth disruption, joint involvement and severe soft tissue damage11.
Therefore, the patient should be referred to an experienced surgical team.
– Antibiotics should be administered (as for acute osteomyelitis, above) in addition to surgical
debridement as it is difficult to ensure that there is no residual infection unless deep tissue
samples can be taken and sent for microbiology, which is rarely possible in resource-limited
settings. Complex cases may require prolonged antibiotic treatment for several months as
well as extensive wound management.
– Recurrent or TB osteomyelitis also requires surgery; these cases should be discussed with
experienced clinicians.
Follow-up
– Monitor symptoms: fever and pain with movement should improve within 7 days (usually as
soon as 3 to 4 days).
– Start physical therapy, if available.
– If possible, follow-up at 2 weeks and 3 months after discharge.
11
325
Chapter 11: Bone and joint problems
Septic arthritis is a serious joint infection that can lead to devastating complications, with
potential joint destruction in a period of days if left untreated. It has a higher incidence in
children less than 4 years old. The knee and hip are the most commonly affected joints,
especially in younger children, but septic arthritis can affect any synovial joint12.
Like osteomyelitis, microorganisms (bacteria, fungi, viruses) can enter the joint space by
haematogenous spread, direct inoculation or extension of a contiguous focus of infection. Most
cases of septic arthritis are caused by bacteria and usually result from haematogenous spread
of Staphylococcus aureus from an open wound or mucosal lesion. The bacterial pathogens
responsible are the same as for osteomyelitis (see Section 11.4).
Examination
Examine all joints including the overlying skin, not only those visibly affected. Carry out passive
movements slowly and carefully as septic arthritis causes extreme pain in the affected joint
during passive movement. Identify any joint swelling or warmth, reduced joint movement or
antalgic position.
Investigations
– FBC
– Inflammatory markers: ESR and CRP, if available
– Blood culture, if available
– X-ray: look for joint space widening, joint effusion, soft tissue swelling or subluxation or
dislocation of joint.
– Ultrasound, if available: useful to determine if fluid is present in the joint and in guiding
needle aspiration of the joint.
– Arthrocentesis: aspiration of synovial fluid under anaesthesia and strict asepsis (in the
operating room if possible). WBC > 50,000/mm3 in synovial fluid confirms septic arthritis
and synovial fluid should be sent for culture. If pus is aspirated and trained personnel are
present, a formal drainage can be done.
326
Chapter 11: Bone and joint problems
11.5.2 Management
Septic arthritis is an orthopaedic emergency and requires prompt treatment:
– Administer empiric antibiotics IV as for osteomyelitis (see Section 11.4.2).
– Refer for surgical intervention to irrigate and drain the joint. If surgical referral is not an
option, it may be possible to successfully treat septic arthritis with antibiotics alone13, with
or without serial aspiration. This should be discussed with a senior clinician.
– Immobilise the joint for 24-48 hours to provide pain relief and decrease local irritation.
– Carefully mobilise the joint after 48 hours and start physical therapy, if available, to prevent
the development of fibrous adhesions.
– Antibiotic treatment should be tailored as culture results become available.
– Continue parenteral antibiotics until there are signs of clinical improvement (usually more
than 7 days, unless uncomplicated), before switching to oral antibiotics to complete 3 weeks
of total treatment. CRP, where available, is a useful indicator of response to treatment.
– Ensure adequate pain management, including regular pain assessment and administration
of analgesia, as required (see Chapter 15, Section 15.4).
Switch to oral antibiotic treatment when all of the following are met:
– At least 5-7 days of parenteral treatment completed
– Clinical improvement
– Afebrile for at least 72 hours
– Able to take oral medication without a problem in the hospital
– Parent/carer able to reliably give medication to the child.
If response to treatment is not as expected, re-evaluate the child and adjust antibiotic
treatment. Always consider and exclude tuberculous arthritis (see Section 11.2.2).
11
327
Chapter 11: Bone and joint problems
References Chapter 11
1. Krul M, Van Der Wouden JC, Kruithof EJ, Van Suijlekom-Smit LW, Koes BW. Manipulative
interventions for reducing pulled elbow in young children. Cochrane Bone, Joint and
Muscle Trauma Group, ed. Cochrane Database Syst Rev. 2017;2017(7).
https://doi.org/10.1002/14651858.CD007759.pub4
2. Peltola H, Pääkkönen M. Acute Osteomyelitis in Children. N Engl J Med. 2014;370(4):
352-360.
https://doi.org/10.1056/NEJMra1213956
3. Krogstad PA. Haematogenous osteomyelitis in children: Evaluation and diagnosis. UpToDate.
Published July 2020.
https://www.uptodate.com/contents/hematogenous-osteomyelitis-in-children-
evaluation-and-diagnosis
4. Castellazzi L, Mantero M, Esposito S. Update on the Management of Pediatric Acute
Osteomyelitis and Septic Arthritis. Int J Mol Sci. 2016;17(6):855.
https://doi.org/10.3390/ijms17060855
5. Grimbly C, Odenbach J, Vandermeer B, Forgie S, Curtis S. Parenteral and oral antibiotic
duration for treatment of pediatric osteomyelitis: a systematic review protocol. Syst Rev.
2013;2(1):92.
https://doi.org/10.1186/2046-4053-2-92
6. Bachur R, Pagon Z. Success of Short-Course Parenteral AntibioticTherapy for Acute
Osteomyelitis of Childhood. Clin Pediatr (Phila). 2007;46(1):30-35.
https://doi.org/10.1177/0009922806289081
7. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged Intravenous
Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in
Children. Pediatrics. 2009;123(2):636-642.
https://doi.org/10.1542/peds.2008-0596
8. Le Saux N, Howard A, Barrowman NJ, Gaboury I, Sampson M, Moher D. Shorter courses of
parenteral antibiotic therapy do not appear to influence response rates for children with
acute hematogenous osteomyelitis: a systematic review. BMC Infect Dis. 2002;2(1):16.
https://doi.org/10.1186/1471-2334-2-16
9. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute
paediatric osteomyelitis: A systematic review of the literature. J Bone Joint Surg Br.
2012;94-B(5): 584-595.
https://doi.org/10.1302/0301-620X.94B5.28523
10. Woods CR, Bradley JS, Chatterjee A, et al. Clinical Practice Guideline by the Pediatric
Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline
on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.
J Pediatr Infect Dis Soc. 2021;10(8):801-844.
https://doi.org/10.1093/jpids/piab027
11. Jones HW, Beckles VLL, Akinola B, Stevenson AJ, Harrison WJ. Chronic haematogenous
osteomyelitis in children: AN UNSOLVED PROBLEM. J Bone Joint Surg Br. 2011;93-B(8):
1005-1010.
https://doi.org/10.1302/0301-620X.93B8.25951
328
Chapter 11: Bone and joint problems
12. Wall C, Donnan L. Septic arthritis in children. Aust Fam Physician. 2015;44(4):213-215.
13. Gigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis
and septic arthritis in children: a systematic review of systematic reviews. Eur Rev Med
Pharmacol Sci. 2019;23(2 Suppl):145-158.
https://doi.org/10.26355/eurrev_201904_17484
11
329
Chapter 12:
Medical complications specific to children
with severe acute malnutrition (SAM)
12
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
12.1 Introduction
This chapter covers the management of medical conditions specific to children with severe
acute malnutrition (SAM). These include re-nutrition (osmotic) diarrhoea, refeeding syndromea,
paralytic ileus, persistent oedema, and kwashiorkor skin lesions. More details on each of these
conditions can be found in this chapter. Details of routine and nutritional management of
children 1-59 months of age with SAM can be found in the MSF ITFC Nutritional Care Protocol
2021, Children 1-59 months: Inpatient. In older malnourished children, refer to local protocols
for routine nutritional management.
Children with acute malnutrition are also more prone to certain clinical conditions that
occur in all children, whether malnourished or not. In many cases, management will be the
same for both malnourished and non-malnourished children. For specific considerations on
their management, refer to the appropriate chapter in these guidelines or other relevant
guidelines: circulatory impairment and shock (see Chapter 2, Section 2.2), sepsis (see
Chapter 3, Section 3.2), hypoglycaemia (see Chapter 9, Section 9.3), hypothermia (see
Chapter 2, Section 2.6), dehydration (see Chapter 5, Section 5.3), fluid overload (see Chapter 5,
Section 5.3.2), diarrhoea (see Chapter 5, Section 5.2), severe anaemia (see Chapter 10,
Section 10.1), pain management (see Chapter 15, Section 15.4), candidiasis (see MSF Clinical
Guidelines, Chapter 3), thiamine deficiency (see Chapter 6, Section 6.4), and ophthalmic
complications (conjunctivitis, xeropthalmia) (see MSF Clinical Guidelines, Chapter 5).
12
a Rarely, refeeding syndrome can occur in children who do not meet the anthropometric criteria for malnutrition
but have endured a period of prolonged starvation.
333
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Diarrhoea is a frequent presentation in acutely malnourished children, and causes are many
(see also Chapter 5, Section 5.2). Re-nutrition or osmotic diarrhoea is specific to children
with malnutrition and is common in children with SAM receiving therapeutic foods. It may be
caused by premature transition to higher osmolarity milk or to food (i.e. when starting initial
treatment with F-75, or when transitioning from F-75 to F-100 or RUTFa), or by a temporary
lactose intolerance secondary to malnutrition or infective pathogens.
12.2.2 Management
Management is based on modification of the therapeutic feeding regime to slowly allow
the child’s body to adapt to the solute load and composition of therapeutic milk. Treatment
differs depending on whether diarrhoea starts in Phase 1 or Transition phase of nutritional
treatment.
Phase 1
– Carefully monitor feeding and ensure that milk is given slowly and not rushed.
– In order of preference from least to most complex, the following solutions can be tried:
• Fraction feeds: divide the volume of feed into two or four equal parts and give in small
portions every 15 to 30 minutes to finish the feed over one hour. Carefully monitor feeding
and ensure that the feed is not rushed or forced.
• Increase feed frequency: if no improvement with fractioning feeds, divide the 24-hour
feed volume to give feeds every 1-2 hours rather than the usual 3-hourly feeds, allowing
smaller volumes to be given each time.
• Continuous feeding: if no improvement with increasing feed frequency, consider giving
feeds continuously via orogastric or nasogastric tube (OGT/NGT) using gravity or a pump
(see MSF Manual of Nursing Care Procedures, SOP – Enteral Nutrition Administration
Methods).
• Dilute feeds: if no improvement with fractioning feeds, increasing feed frequency or giving
continuous feeding, dilute F-75 by adding 30 mL of extra water to 100 mL of F-75 milk to
reduce osmolarity. Continue for a few feeds only (until improvement of diarrhoea) before
changing back to F-75, as nutritional content of diluted F-75 is inadequate for extended
use.
– If re-nutrition diarrhoea persists despite all of the above measures, screen the child for TB
and HIV (even if already done). Consider the possibility of lactose intolerance, though this is
very rare.
334
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Transition phase
– If diarrhoea occurs after receiving RUTF or F-100, immediately after starting transition,
transition phase has probably been started too early. Return to phase 1 with F-75 for 24 to
48 hours.
– If there are irregular and/or inconsistent bouts of loose stool after being in transition phase
for a day or so, increase the length of stay in transition phase until resolution of the problem
(likely to improve spontaneously). If no resolution, return to phase 1 with F-75 for 24 to
48 hours.
If diarrhoea persists for more than 72 hours, in the absence of another obvious explanation for
diarrhoea (e.g. otitis media, pneumonia, UTI), consider other infective causes of diarrhoea and
treat accordingly (see Chapter 5, Section 5.2.1).
12
335
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
336
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
12.3.2 Management
– Transfer to ICU where available (or in-patient area with increased monitoring and nursing
care, depending on project capacity).
– Return to (or continue with) phase 1 treatment for SAM with F-75 therapeutic milk.
– Under the guidance of an experienced clinician, consider (see also Section 12.2.2):
• Reducing feed volumes and/or
• Fractioning feeds and/or
• Reducing the speed of feed administration.
– Where feasible and able to monitor electrolytes, correct electrolyte imbalances (see
Chapter 15, Section 15.3).
– If critically unwell, start empiric broad-spectrum IV antibiotic treatment: ceftriaxone IV/IM
80 mg/kg (max. 4 g if < 50 kg; max 2 g if ≥ 50 kg) every 24 hours.
– In cases of severe paralytic ileus, see Section 12.4.
– Assess fluid status closely.
– Administer thiamine as follows:
Loading dose:
• < 15 years: 100 mg slow IV infusion over 30 minutes once daily for 48 hours
If IV not possible: give PO/via NGT at the same dose.
Maintenance dose: to be started after 48 hours of IV treatment
• ≤ 12 years: 25 mg PO once daily for 1 month
• > 12 years: 25 mg PO 2 times daily for 1 month
12.3.3 Prognosis
Refeeding syndrome is associated with high mortality, ranging from 30-71% even in high-
resource settings3,4. Prevention, through strict adherence to feeding protocols, and early
detection of refeeding syndrome are critical to reducing morbidity and mortality from the
condition.
12
337
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
12.4.2 Management
– Assess and manage ABCDE.
– Make the child nil-by-mouth (NBM), insert NGT and leave on free drainage (attach to catheter
bag or other waterproof bag).
– Take a full history and carry out thorough clinical examination of abdomen.
– Get surgical review, where possible.
– Measure abdominal circumference at start of treatment and every 4 hours until resolution
of condition.
– Start glucose (dextrose) 5%-Ringer lactate (G5%-RL) IV at maintenance rate (see Chapter 15,
Section 15.2):
• Add 5 mL of potassium chloride 15% (2 mmol/mL) to a 500 mL bag (see also Chapter 15,
Section 15.2).
• Continue for 6 hours with careful monitoring (see below).
338
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Loading dose:
• < 15 years: 100 mg slow IV infusion over 30 minutes once daily for 48 hours
If IV not possible: give PO/via NGT at the same dose.
Maintenance dose: to be started after 48 hours of IV treatment
• ≤ 12 years: 25 mg PO once daily for 1 month
• > 12 years: 25 mg PO 2 times daily for 1 month
– Administer antibiotic treatment: ceftriaxone IV (IM): 80mg/kg (max. 4 g if < 50 kg; max 2 g if
≥ 50 kg) every 24 hours and metronidazole IV 10 mg/kg every 8 hours.
– In regions with a high helminth burden, consider giving antihelminth treatment:
albendazole PO
• 12 – 23 months: 200 mg once daily for 3 daysa
• ≥ 24 months: 400 mg once daily for 3 days
mebendazole PO
• ≥ 12 months and > 10kg: 100 mg 2 times daily for 3 days
12.4.3 Monitoring
– Monitor and record vital signs at least every hour using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– Look for signs of improvement in intestinal function:
• Decreasing abdominal circumference (measurement)
• Visible peristalsis
• Stool/flatus output
• Return of bowel sounds on auscultation
– Monitor blood glucose level (BGL) every 4 hours and correct hypoglycaemia if needed.
Review after 6 hours of management:
– Improvement (signs of intestinal motility present after 6 hours):
• Give 5 mL/kg of F-75 therapeutic milk as a trial.
• After one hour, gently aspirate the gastric residual, measure the volume and discard:
▹ If the volume aspirated is the same as, or more than the volume introduced, stop F-75
trial and wait another 6 hours before attempting to re-feed. 12
▹ If the volume aspirated is less than the volume introduced, re-administer 5 mL/kg
of F-75, and gradually increase the amount of F-75 at each 3-hourly feed until the
child reaches their full feed volume (for F-75 feed volume calculations, see MSF ITFC
Nutritional Care Protocol 2021, Children 1-59 months: Inpatient, and Appendix 18.
▹ Discontinue IV maintenance fluids when the child reaches 50% of their full feed volume.
– No improvement (no sign of intestinal motility after 6 hours):
• Continue IV fluids at same rate and measure BGL every 4 hours.
• If no improvement after another 6 to 8 hours, refer for surgical input where available.
a Albendazole is not systematically recommended to children less than 12 months but can be given on a case-
by-case basis according to clinician assessment.
339
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Oedema associated with malnutrition (including refeeding syndrome) usually reduces and
improves within approximately 4 days of starting therapeutic nutritional treatment. If oedema
persists beyond 4 days, investigation is required to rule out other underlying medical causes.
Investigations
– Hb to check for anaemia
– HIV and TB screening, if not already done
– Urine dipstick, to exclude renal causes of oedema
12.5.2 Management
– If non-adherent to prescribed therapeutic feeding regime, reinforce the importance of giving
the prescribed volume of milk at the designated times.
– Treat any identified underlying causes.
– Reassess dehydration status and management. Check for any new signs of fluid overload
and manage accordingly (see Chapter 5, Section 5.3.2).
– Make sure only therapeutic food is given to the child and that no traditional treatments are
used.
340
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
If potential underlying medical causes have been ruled out or treated, consider the following
modifications to the nutritional management:
– Continue Phase 1 with F-75 therapeutic milk for at least one more week.
– For children newly diagnosed with HIV and/or TB where treatment has just been started,
switch to Transition phase, as improvement in oedema may not be seen until after 2 weeks.
Monitor closely in Transition phase for signs of intolerance or worsening of the clinical
condition, including oedema.
12
341
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Skin lesions are a common feature of kwashiorkor and the underlying cause is not fully
understood. Different types of lesions can develop and may at times be present simultaneously.
The lesions are characterized by hypo- or hyper-pigmentation, desquamation that flakes or
peels, and in extreme cases ulceration that may spread to any area of the body.
Epidermal ulceration gives way to exudative open skin lesions, resembling burns. This can lead
to loss of fluid and heat, with an associated risk of hypothermia.
Lesions can easily become infected. As acutely malnourished patients do not exhibit a standard
inflammatory reaction, typical signs of infection such as pus formation and fever are often
absent. Superinfection is thus more difficult to detect, and specific measures must be taken to
prevent and to treat it.
12.6.1 Management
Management should follow a systematic and holistic approach to wound care. This means
the whole patient should be assessed and not just the lesion(s). Assessment should be
methodological and with special attention to pain management – this is especially relevant
for children with kwashiorkor. The following is a summary of important steps in management
of kwashiorkor skin lesions. For full details on management, including detailed advice on
dressings, see MSF OCB Wound Care Protocol and Kwashiorkor Wounds protocols.
342
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
b All kwashiorkor patients, including those without skin lesions or wounds, should have daily skin hydration. This
can be done by a parent/carer after appropriate instruction.
c See following items in MSF catalogue: EHOEMATTF1-, EHOECUSG001, EPHYCUSGLU+
d See following items in MSF catalogue: SDREEAHC3S-, SDRETAPA1F25
343
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
Pain management
Kwashiorkor skin lesions are extremely painful and distressing for the child and their family.
Regular analgesia may be required for children with extensive, open skin lesions and a pain
assessment should be done routinely every day, as well as prior to wound care procedures
(see Chapter 15, Section 15.4). Consider dressing changes in theatre under anaesthesia for
extensive lesions.
Malnourished children often heal more slowly than non-malnourished children, therefore it
is important to monitor lesions carefully and frequently to look for evidence of improvement
after starting antibiotics. Lack of immediate improvement does not always indicate treatment
failure.
e Clinical improvement includes decreased wound pain, redness and heat and reduction/absence of pus.
344
Chapter 12: Medical complications specific to children with severe acute malnutrition (SAM)
References Chapter 12
1. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and
treat it. BMJ. 2008;336(7659):1495-1498.
https://doi.org/10.1136/bmj.a301
2. Persaud-Sharma D, Saha S, Trippensee AW. Refeeding Syndrome. In: StatPearls. StatPearls
Publishing; 2023. Accessed October 30, 2023.
http://www.ncbi.nlm.nih.gov/books/NBK564513/
3. Friedli N, Baumann J, Hummel R, et al. Refeeding syndrome is associated with increased
mortality in malnourished medical inpatients: Secondary analysis of a randomized trial.
Medicine (Baltimore). 2020;99(1):e18506.
https://doi.org/10.1097/MD.0000000000018506
4. Vignaud M, Constantin JM, Ruivard M, et al. Refeeding syndrome influences outcome
of anorexia nervosa patients in intensive care unit: an observational study. Crit Care.
2010;14(5):R172.
https://doi.org/10.1186/cc9274
5. Chisti MJ, Shahid AS, Shahunja KM, et al. Ileus in children presenting with diarrhea and severe
acute malnutrition: A chart review. Vinetz JM, ed. PLoS Negl Trop Dis. 2017;11(5):e0005603.
https://doi.org/10.1371/journal.pntd.0005603
12
345
Chapter 13:
HIV Infection
13
Chapter 13: HIV Infection
13.1 Introduction
In 2021, 1.68 million children under 15 years of age were living with HIV worldwide (of whom
88% in sub-Saharan Africa), but only 52% were receiving anti-retroviral treatment (ART)1.
Without any intervention, it is estimated that up to 52% of children who are vertically infected
with HIV will die before the age of 2 years old2. Thus, early infant diagnosis (EID) and ART
are crucial to improving the survival of HIV-infected children. Access to EID has improved
significantly in recent years, but still only around 30% of infants with vertically acquired HIV
infection are diagnosed and treated within the recommended timeframe3.
Natural history
The vast majority of children with HIV are infected during pregnancy, childbirth or breastfeeding.
The very young age at which they are infected and an inability to mount a sufficient immune
response, results in a persistently high viral load with devastating clinical consequences.
Vertically acquired HIV infection advances rapidly in young children, with direct damage to the
immune system from the virus itself, as well as the secondary effects of recurrent and severe
acute infections, underlying chronic infection, susceptibility to malnutrition, and poor growth
and development.
This chapter covers the basic management of a sick HIV-exposed or infected child requiring
inpatient care. For comprehensive guidance on the management of children living with HIV
refer to national guidelines (where available), other MSF guides (e.g. MSF HIV/TB Clinical
Guide for Primary Care, Paediatric HIV handbook) and/or WHO resources3.
13
349
Chapter 13: HIV Infection
The 2021 WHO “Consolidated guidelines on HIV prevention, testing, treatment, service delivery
and monitoring: recommendations for a public health approach” includes the following3:
– In high HIV burden settingsa, all children admitted for inpatient care should routinely be
tested for HIV unless HIV status is already known.
– In low HIV burden settings, all children admitted for inpatient care should routinely be tested
for HIV if:
• Biological parent known to have (or suspected to have died of) HIV infection or an
undiagnosed long-term illness
• Presence of malnutrition
• Recurrent infection, fever of unknown origin, poor response to treatment
• Diagnosis of tuberculosis
– All HIV-infected children and adolescents should be commenced on ART (regardless of WHO
clinical stage and CD4 cell count) on the day of diagnosis or within 7 days thereof, except
in the case of cryptococcal meningitis, when ART should be delayed for 4 weeks after the
induction phase of treatment.
– In children diagnosed with tuberculosis, ART should be started as soon as possible within
2 weeks of starting TB treatment, except in the case of TB meningitis (delay ART for 4 weeks).
a High-burden HIV settings are those where HIV prevalence in the adult population ≥ 1%.
350
Chapter 13: HIV Infection
13.3 Diagnosis
Consider an underlying HIV infection in any sick child who presents with malnutrition,
recurrent or severe infections, tuberculosis, persistent fever or who does not improve despite
appropriate treatment for their presumed diagnosis.
Diagnosis of HIV infection can be confirmed in all children 18 months of age and over (or
3 months after cessation of breastfeeding, whichever comes later) with a simple rapid
diagnostic test (RDT) for HIV antibodies. Refer to WHO or national diagnostic algorithms where
available. For infants and children younger than 18 months of age, or those who are breastfed
beyond 18 months, DNA PCR, ideally as point-of-care nucleic acid testing (NAT), is required to
make a diagnosis of HIV. Refer to Table 13.1 below and national guidelines for more detail on
testing and diagnosis of HIV in children under 18 months of age.
Pre-test information should be provided to the parents/carers and/or child (depending on age)
prior to testing.
Table 13.1 - Diagnosis of HIV in infants and children 18 months and younger
Assess exposure
Timing of DNA PCR/NAT
(if HIV status of mother unknown)
a If repeat NAT negative, perform a third NAT to determine final diagnosis. Continue treatment until results of
third NAT are available – if negative, treatment can be stopped.
b If DNA PCR/NAT is unavailable or it is not possible to test all babies with unknown exposure using DNA PCR/NAT,
HIV RDT can be used instead as a screening tool for exposure to HIV. However, HIV RDT only reliably identifies
exposure in infants < 4 months; in infants and children 4-18 months, a positive HIV RDT establishes exposure
but a negative HIV RDT does not fully rule out exposure, therefore DNA PCR/NAT testing may still be required.
351
Chapter 13: HIV Infection
13.4 Management
The following section outlines the management of infants and children with confirmed HIV
infection.
a Breastfeeding is not contraindicated in babies born to HIV positive mothers. To mitigate the risk of transmission
of HIV through breastmilk, maternal viral load should be suppressed through ART. If it is not possible to
suppress maternal viral load, consideration should be given to continuation of infant prophylaxis beyond the
6- or 12- week period, in accordance with national guidance.
352
Table 13.2 - Opportunistic infections and conditions in children living with HIV
Pneumocystis Pneumocystis Common in children under 1 year Administer oxygen via facemask, aiming for SpO2 between 94 - 98%.
pneumonia (PCP) jirovecii Respiratory distress and hypoxaemia Supportive care with fluids and feeds if needed (see Chapter 15,
Acute or sub-acute onset Section 15.2 and Section 15.5 respectively).
Fever can be high, but often afebrile High-dose co-trimoxazole PO (or IV) for 21 days:
Non-productive cough 50 mg/kg SMX + 10 mg/kg TMP, 2 times daily
Feeding difficulties in infants or 25 mg/kg SMX + 5 mg/kg TMP, 4 times daily
Chest usually clear on auscultation +
For severe cases:
CXR: Diffuse interstitial infiltration,
prednisolone PO: 1 mg/kg 2 times daily for 5 days, then 1 mg/kg once
hyperinflation, pneumothorax or normal
daily for 5 days, then 0.5 mg/kg once daily for 5 days.
(20%). Effusion very uncommon with PCP.
Continue co-trimoxazole prophylaxis (see Table 13.4) after treatment
completion
Lymphoid Lympho- Slow onset: cough, dyspnoea, hypoxaemia Improvement with ART.
Interstitial proliferative (SpO2 < 92%).
Symptomatic management if needed:
Pneumonitis (LIP) infiltrate Often enlarged lymph nodes, spleen and
• Inhaled bronchodilators for wheeze (see Chapter 4, Section 4.10.1).
chronic parotitis.
Children > 3 years • Steroids may be useful. If no response observed after 1 month,
May find wheeze, clubbing, signs of right
discontinue by weaning gradually over 2 months.
heart failure.
CXR: Bilateral reticulonodular infiltrate.
Similar appearance to miliary TB, but
more irregular distribution and clinically
distinct: child with LIP may look well, child
with TB is usually more ill with fever and
weight loss.
353
Chapter 13: HIV Infection
13
354
Condition Causes Clinical features Management
Mycobacterium Mycobacterium Weight loss, fatigue, unremitting fever, Combined treatment of at least 2 drugs:
avium complex avium complex chronic diarrhoea, wasting, abdominal azithromycin 10 mg/kg once daily (clarithromycin may be used as an
(MAC) pain alternative)
Enlarged lymph nodes, hepatomegaly, +
anaemia, unresolving pulmonary infiltrate ethambutol 15 to 25 mg/kg once daily
Chapter 13: HIV Infection
Cryptococcal Cryptococcus Older children (> 12 years old) Delay initiation of ART for 4-6 weeks after starting antifungal
meningitis neoformans, treatment.
Fever, headache, lethargy, irritability,
especially with
abnormal cry, poor feeding, vomiting, Single high dose amphotericin B IV: 10 mg/kg
low CD4
neck stiffness, convulsions, bulging +
fontanelle 14 days of treatment with:
flucytosine PO: 25 mg/kg four times daily
Serum CrAg positive
+
CSF findings: fluconazole PO: 12 mg/kg once daily (max. 800 mg/day)
Opening pressure – very elevated
then consolidation regimen: fluconazole PO alone
CSF aspect – clear
6 – 12 mg/kg once daily (max. 800 mg/day) for 8 weeks
Specific tests - Indian ink +; crypto Ag +
WBC - < 800, mainly lymphocytes Maintenance regimen: fluconazole PO: 6 mg/kg once daily until CD4
Protein (mg/dL) – 20-500, Pandy neg > 200 cells/mm3 and viral load (VL) suppression on ART.
Glucose (mg/dL) – low < 45
Repeated therapeutic lumbar puncture should be done if raised
intracranial pressure (headache, vomiting, visual disturbance) to keep
pressure < 20 mm H2O. Remove 1 mL/kg, max. 25 mL per puncture.
Condition Causes Clinical features Management
HIV This is a diagnosis of exclusion. Early initiation of ART reduces viral damage to the brain.
encephalopathy ART may improve some established clinical features.
At least one of the following, progressing
Develops during over two months in the absence of
first 2 years of life another illness:
• Loss or failure to attain developmental
milestones, loss of intellectual capacity
• Microcephaly: head circumference
< 5th percentile for age, or stagnation
and failure of head circumference to
grow
• Motor deficits: symmetrical spastic
paresis, increased reflexes (pyramidal
tract motor deficit), gait disturbance
or ataxia. Facial motor signs such as
abnormal eye movements
Focal neurological Stroke due to Stroke: sudden onset, no signs of raised Stroke: supportive treatment (see Chapter 15)
deficits HIV associated intracranial pressure (ICP)
CNS tumour: supportive treatment (see Chapter 15) and management
vasculitis or
CNS tumour: sudden or progressive of raised ICP (see Chapter 2, Section 2.8.3).
coagulopathy
onset with signs of raised ICP (severe
Toxoplasmosis
CNS tumour headache, vomiting) and no improvement
pyrimethamine + sulfadiazine + folic acid for 6 weeks
after at least 10 days of treatment for
Cerebral or high dose co-trimoxazole for 6 weeks (see above dosing for PCP)
toxoplasmosis.
toxoplasmosis Treatment response is expected within 10 days. Secondary
Toxoplasmosis: rare in children; may occur prophylaxis is needed after treatment (see Table 13.4).
Tuberculosis
in severely immune suppressed children In settings where neuroimaging is not available, consider empiric
(tuberculoma,
not on CTX. May or may not have signs of treatment trial of high dose co-trimoxazole for all HIV-infected children
vasculitis)
raised ICP. who present with a focal deficit, with or without raised ICP.
355
Chapter 13: HIV Infection
13
356
Condition Causes Clinical features Management
Persistent Pathogens More than 3 stools per day – bloody or Rehydration as required depending on assessment (see Chapter 5,
diarrhoea specific to watery Section 5.3).
(> 14 days) advanced HIV:
Dehydration – assess severity: recent Chronic diarrhoea has a high associated mortality in HIV patients.
Chapter 13: HIV Infection
or
Bacteria weight loss, reduced conscious level, Urgent ART is needed.
Chronic diarrhoea
MAC (see above) sunken eyes, reduced skin tone, thirst.
(> 28 days) If no pathogen identified, antibiotic trial for 7 days:
Protozoa Malnutrition and wasting High dose co-trimoxazole PO (see above dosing for PCP)
Cryptosporidium, +
Stool analysis on three separate samples
Isospora metronidazole PO: 15 mg/kg 3 times daily
If available: WBC and CD4
MAC (see above)
If Isospora belli confirmed by stool analysis:
co-trimoxazole PO: 50 mg/kg SMX + 10 mg/kg TMP, 2 times daily for
10 days, followed by 25 mg/kg SMX + 5 mg/kg TMP, 2 times daily for
3 weeks.
Chapter 13: HIV Infection
Table 13.3 - Simplified dosing of child-friendly FDCs in children 4 weeks and older (excluding
adolescents ≥ 30 kg)3
ABC/3TC Dolutegravir
(2 times daily) (once daily)
Weight
60/30 mg 120/60 mg 600/300 mg 10 mg 50 mg
dispersible tab dispersible tab tab dispersible tab tab
1 tab, morning ½ tab, morning
3 to < 6 kg – ½ tab –
and evening and evening
1½ tabs, morning ½ tab morning,
6 to < 10 kg – 1½ tabs –
and evening 1 tab evening
2 tabs, morning 1 tab, morning
10 to < 14 kg – 2 tabs –
and evening and evening
2½ tabs, morning 1 tab morning,
14 to < 20 kg – 2½ tabs –
and evening 1½ tabs evening
3 tabs, morning 1½ tabs, morning
20 to < 25 kg – 3 tabs 1 tab
and evening and evening
½ tab, morning
25 to < 35 kg – – – 1 tab
and evening
13
In children < 18 months of age with known HIV exposure who are admitted critically unwell or
with a presumptive infection (particularly an opportunistic infection), start ART while waiting
for the DNA PCR/NAT results. Ensure follow-up of DNA PCR/NAT results and final confirmation
of diagnosis of HIV in all children starting presumptive treatment (see Section 13.3).
b Abacavir (ABC), lamivudine (3TC), dolutegravir (DTG), tenofovir (TDF), lopinavir/ritonavir (LPV/r), efavirenz
(EFV), zidovudine (AZT)
c https://paedsarvdosing.org/?sfvrsn=c32f09d7_10
357
Chapter 13: HIV Infection
Side effects
ART medications have a number of side effects which should be monitored at each follow-up.
Almost all ARVs can cause mild constitutional symptoms such as headache, nausea and
fatigue. In addition, specific potential side effects include renal impairment (TDF), anaemia
(AZT), neutropenia (AZT), hepatic impairment (NVP; LPV/r; EFV; DTG; TB-HIV co-treatment),
hypersensitivity reactions (ABC; NVP; EFV), CNS disturbance (EFV), and mitochondrial toxicity
(3TC; AZT; ABC; TDF).
d Prophylaxis against pneumonia (especially PCP), cerebral toxoplasmosis, certain types of diarrhoea, malaria,
severe bacterial infections (strep pneumoniae, haemophilus influenzae, salmonella, legionella, nocardia,
methicillin sensitive staphylococcus aureus and many gram-negative bacilli).
358
Chapter 13: HIV Infection
200/40 mg
100/20 mg 400/80 mg 800/160 mg
Weight per 5 mL oral
dispersible tab scored tab scored tab
suspension
13
359
Chapter 13: HIV Infection
Refer to MSF Prevention of mother-to-child transmission of HIV Guidelines for full details on
PMTCT.
– All HIV-exposed infants should receive ART:
• Infants who are at high riska of acquiring HIV should receive AZT and NVP prophylaxis
once daily until 6 weeks of age, regardless of whether they are breastfed or formula fed.
• In high-risk breastfed infants, AZT and NVP prophylaxis (or NVP alone) should be continued
for an additional 6 weeks (total of 12 weeks of infant prophylaxis).
• For low-risk breastfed infants (i.e. whose mothers are receiving ART and have a suppressed
VL at least 4 weeks prior to delivery), give only NVP once daily for 6 weeks.
• For infants receiving replacement feeding whose mothers are receiving ART, give NVP
once daily (or AZT 2 times daily) for 4-6 weeks.
See also Appendix 19 for more detail, including dosing of ARV prophylaxis in PMTCT.
a A high-risk infant is defined as an infant whose mother was first identified as HIV-infected at delivery or in the
postpartum period, infected during pregnancy or breastfeeding, received less than 4 weeks of ART prior to
delivery, or did not achieve viral suppression by the time of delivery.
360
Chapter 13: HIV Infection
– Ensure referral to HIV and/or maternal-child health services has been established.
– Continuity of ART and close follow-up and monitoring is vital for children growing up with
HIV.
13
361
Chapter 13: HIV Infection
References Chapter 13
1. Paediatric care and treatment. UNICEF DATA. Accessed October 30, 2023.
https://data.unicef.org/topic/hivaids/paediatric-treatment-and-care/
2. Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected
and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. The Lancet.
2004;364(9441):1236-1243.
https://doi.org/10.1016/S0140-6736(04)17140-7
3. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and
Monitoring: Recommendations for a Public Health Approach. World Health Organization;
2021.
https://www.who.int/publications/i/item/9789240031593
362
Chapter 14:
Fever of unknown origin (FUO) and
neglected tropical diseases (NTDs)
14
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
There is no widely agreed definition of fever of unknown origin (FUO), also known as persistent
fever, in children1. FUO is a diagnosis of exclusion, therefore the clinical definition of FUO in
children for the purposes of these guidelines is: fever at least once per day for more than
7 days, with no confirmed diagnosis after initial comprehensive assessment that includes a
detailed history, thorough clinical examination, and appropriate laboratory investigations.
Given the lack of a consensus definition, the incidence of FUO in children is uncertain.
14.1.1 Causes
Causes of FUO in children are numerous. Infectious diseases (viral, bacterial, parasitic or fungal)
are the most commonly identifiable causes, followed by rheumatologic diseases (most commonly
juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus) and neoplastic disorders2.
The remainder are caused by various conditions including Kawasaki disease, inflammatory bowel
disease, immunodeficiencies, factitious fever, and drugs (see Appendix 20 for a comprehensive list
of causes). For infectious causes, consider the epidemiology of the area as well as clinical features
to guide the differential diagnosis. As potential causes of FUO are many, a systematic approach to
the patient is required. Exclude the most common causes of FUO (TB, HIV, undiagnosed malaria,
enteric fever, pneumonia) before investigating for other conditions.
365
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
14.1.3 Investigations
Initial baseline investigations for all children with FUO:
– Full blood count (FBC), including Hb
– Blood glucose level (BGL)
– Malaria RDT and blood film
– Urine dipstick and culture, if available
– Blood culture, if available
– HIV testing
– Mantoux testing, if available
– Liver and renal function tests, if available
– Radiology:
• CXR (to check the lungs but also the hila and mediastinum)
• If CXR is not available, ultrasound of chest can be performed, although ultrasound is
limited in evaluation for TB in children. Paediatric TB is commonly characterized by hilar
and/or mediastinal lymph nodes, which are difficult to visualize on ultrasound.
• Abdominal ultrasound
Further investigations to be considered depending on clinical suspicion, evolution and
availability (see Figure 14.1):
– Recombinant kinesin antigen (rK39) testa (for visceral leishmaniasis)
– Leishmania DAT (direct agglutination test)
– TB screening: microscopy and culture, or GeneXpert where available (see Chapter 4,
Section 4.11 for further investigations if TB suspected).
– Urinary microscopy for schistosomiasis
– Stool microscopy and culture
– LP for CSF examination: biochemistry, Gram stain and culture, GeneXpert
– RDT for HIV, HBV, HCV
– Card Agglutination Test for Trypanosomiasis (CATT)
– Rose Bengal test for brucellosis
– Rickettsia IgM
– Cardiac ultrasound
14.1.4 Management
After exclusion of the most common causes of FUO, management is guided by the principal
symptoms and signs, and the organ systems affected (see Figure 14.1). Ensure close clinical
monitoring and revise diagnosis daily based on new or evolving clinical signs and symptoms.
If, after careful and detailed assessment (thorough history of symptoms, exposure, family and
past medical history; head to toe clinical examination; baseline and targeted investigations),
no source or obvious cause is identified, use empiric treatment to cover several common
pathogens while continuing to investigate:
– If hospitalised due to severity of symptoms:
• ceftriaxone IV: 50 - 80 mg/kg (max. 4 g if < 50 kg; max. 2 g if ≥ 50 kg) every 24 hours
+
• doxycycline PO: 2 - 2.2 mg/kg (max. 100 mg) 2 times daily (or azithromycin PO: 10 mg
once daily in children < 8 years)
– If treated as outpatient: doxycycline PO (or azithromycin PO in children < 8 years)
a Useful antigen in ELISA assays with high sensitivity and specificity in immunocompetent patients in the Indian
subcontinent. The sensitivity is lower and more variable in East Africa and Brazil, although specificity remains
high. This antigen rapid test requires minimal equipment and is easy to use.
366
Figure 14.1 - Algorithm for the management of a child with FUO
Admit to hospital and perform baseline investigations: FBC, Hb, BGL, malaria
RDT and blood film, urine dipstick, HIV test and, if available:
Urine culture, Blood culture, liver and renal function tests, TB screening,
baseline radiology (CXR/lung US and abdominal US)
Does the child have signs YES Treat as per sepsis protocol
of severe infection? (see Chapter 3, Section 3.2)
NO
Main sign/
Potential cause Clues in history or examination Investigations (if available) Management
symptom
Hepatomegaly Visceral Leishmaniasis Known endemic area; sandfly bite; Leishmaniasis rapid test (rK39) or See Section 14.2
and/or serology (DAT); pancytopenia on
Splenomegaly FBC; raised CRP
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
367
14
368
Main sign/
Potential cause Clues in history or examination Investigations (if available) Management
symptom
Hepatomegaly Viral hepatitis Previous blood transfusion (B/C/D); HBV and HCV RDTs See MSF Clinical Guidelines,
and/or sexual contact (B/C/D); poor hygiene Chapter 8
Splenomegaly practices (A/E); jaundice
Schistosomiasis Swimming/bathing in infected water Urine dipstick, urine and stool See MSF Clinical Guidelines,
(rivers/lakes); fever and rash with microscopy Chapter 6
bronchospasm (Katayama fever)
Amoebic or bacterial liver Poor hygiene practices; lack of access to Abdominal US; leucocytosis on See MSF Clinical Guidelines,
abscess clean water FBC; raised CRP Chapter 3
Human African Sub-Saharan Africa only; known Card Agglutination Test for See MSF Clinical Guidelines,
Trypanosomiasis endemic area; tsetse fly bite; sleeping Trypanosomiasis (CATT) Chapter 6
pattern
Leptospirosis Exposure to domestic animals/rodents; CXR; Blood smear; raised CRP See MSF Clinical Guidelines,
recent heavy rain/flooding; tropical/ Chapter 7
subtropical; biphasic fever; ‘red eyes’
Brucellosis Exposure to livestock; drinking Rose Bengal test, blood culture See MSF Clinical Guidelines,
unpasteurised milk; rural areas Chapter 7
Borreliosis (Tick-Borne or Known endemic area; tick bite – Blood smear See MSF Clinical Guidelines,
Louse-Borne Relapsing temperate regions of Africa, rural; Chapter 7
Fever) body lice – Horn of Africa, epidemic in
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
b Atypical/fungal lung infections include legionella and histoplasmosis. See also Appendix 20.
Main sign/
Potential cause Clues in history or examination Investigations (if available) Management
symptom
Cardiac Endocarditis Poor dentition; recent procedure Blood culture and cardiac US Follow local guidance
American American continent; known endemic Blood microscopy, ECG, CXR See MSF Clinical Guidelines,
Trypanosomiasis (Chagas area (rural); triatomine bug faeces; Chapter 6
disease) severe constipation
Kawasaki disease Desquamation of hands and feet Clinical diagnosis, cardiac US Follow local guidance
Abdominal Enteric fever (typhoid Poor hygiene practices; lack of access Blood culture; abdominal US; See Chapter 3, Section 3.6
pain/diarrhoea and paratyphoid) to clean water; known endemic area; leucopenia; raised CRP
relative bradycardia; salmon rash
Amoebic or bacterial liver Poor hygiene practices; lack of access to Abdominal US; leucocytosis on See MSF Clinical Guidelines,
abscess clean water FBC; raised CRP Chapter 3
HIV Previous blood transfusion; mother sick HIV testing See Chapter 13 and HIV
or known HIV positive guidelines
TB Known endemic area; close contact with TB screening See Chapter 4, Section 4.11
suspected/known case and MSF TB Guidelines
Genitourinary Pyelonephritis Recent UTI; congenital renal problem Urine dipstick See Chapter 8, Section 8.1
Schistosomiasis Recent swimming/bathing in infected Urine dipstick, urine and stool See MSF Clinical Guidelines,
water (rivers/lakes) microscopy Chapter 6
Genital infections Recent sexual activity/assault Genital swabs, urine dipstick See MSF Clinical Guidelines,
Chapter 9
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
369
14
370
Main sign/
Potential cause Clues in history or examination Investigations (if available) Management
symptom
Neurological Malaria Known endemic area; no bed net; rainy Malaria RDT +/- blood film See Chapter 3, Section 3.4
season
Meningitis (incl. TB) Missed immunisations; known Lumbar puncture See Chapter 3, Section 3.3,
epidemic-prone area Chapter 4, Section 4.11 and
MSF TB Guidelines
Mastoiditis/intracranial Recent otitis media Clinical diagnosis, CT head See Chapter 4, Section 4.12
abscess
Tetanus Missed immunisations; dirty wound Clinical diagnosis See Chapter 3, Section 3.5
(soil)
Leptospirosis Exposure to domestic animals/rodents CXR, Blood smear See MSF Clinical Guidelines,
Chapter 7
Human African Sub-Saharan Africa only, known endemic Card Agglutination Test for See MSF Clinical Guidelines,
Trypanosomiasis area; tsetse fly bite Trypanosomiasis (CATT) Chapter 6
HIV Previous blood transfusion; mother sick HIV testing See Chapter 13 and HIV
or known HIV positive guidelines
Dermatological/ Rickettsiosis Insect bite (ticks, rat fleas, mites); Rickettsia IgM See MSF Clinical Guidelines,
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Erysipelas/cellulitis Infected wound site Clinical diagnosis See MSF Clinical Guidelines,
Chapter 4
Kawasaki disease Desquamation of hands and feet Clinical diagnosis, cardiac US Follow local guidance
Main sign/
Potential cause Clues in history or examination Investigations (if available) Management
symptom
Musculoskeletal Osteomyelitis Missed immunisations; known SCD; FBC, blood culture, limb x-ray See Chapter 11, Section 11.4
recent IO access; puncture wound
Septic arthritis Missed immunisations; open wound FBC, blood culture, joint US See Chapter 11, Section 11.5
Brucellosis Exposure to livestock; drinking Rose Bengal test, blood culture See MSF Clinical Guidelines,
unpasteurised milk; rural areas Chapter 7
TB Known endemic area; close contact with TB screening See Chapter 4, Section 4.11
suspected/known case and MSF TB Guidelines
Rheumatic/neoplasm Chronic symptoms Blood smear Consider referral
Multiorgan Sepsis FBC, blood culture See Chapter 3, Section 3.2
(including
TB Known endemic area; close contact with TB screening See Chapter 4, Section 4.11
weight loss, skin
suspected/known case and MSF TB Guidelines
rash)
HIV Previous blood transfusion; mother sick HIV testing See Chapter 13 and HIV
or known HIV positive guidelines
Rickettsiosis Insect bite (ticks, rat fleas, mites); Rickettsia IgM See MSF Clinical Guidelines,
‘inoculation eschar’: painless, black, Chapter 7
crusted lesion with erythemartous halo
at bite
Borreliosis Known endemic area; tick bite – Blood smear See MSF Clinical Guidelines,
temperate regions of Africa, rural; Chapter 7
body lice – Horn of Africa, epidemic in
cold season, overcrowding and poor
sanitation
Leptospirosis Exposure to domestic animals/rodents CXR, Blood smear See MSF Clinical Guidelines,
Chapter 7
Rheumatic/neoplasm Chronic symptoms Blood smear Consider referral
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
371
14
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
14.2 Leishmaniasis
A neglected tropical disease caused by protozoa of the genus Leishmania and transmitted by
the bite of an infected sandfly. There are different types of leishmaniasis:
– Visceral leishmaniasis (or kala-azar) (VL): most severe form
– Cutaneous leishmaniasis (CL)
– Muco-cutaneous leishmaniasis (MCL)
– Disseminated cutaneous leishmaniasis (DCL)
Clinical features
Onset of signs and symptoms are usually insidious:
– Intermittent fever (generally lasting > 2 weeks) associated with (over a period of weeks to
months):
• Malaise
• Poor appetite
• Weight loss
• Abdominal tension, minimally tender or painless splenomegaly (with or without
hepatomegaly)
• Pallor or severe anaemia due to bone marrow suppression, splenic sequestration, and
haemolysis
– Thrombocytopenia: spontaneous bleeding from the nasal mucosa (epistaxis), gingiva, or
other sites.
Less commonly, fever may be associated with rapidly progressive signs.
Suspect VL in any child presenting with a history of prolonged fever (more than 2 weeks) with
splenomegaly and/or lymphadenopathy and/or wasting.
Complications include: hepatic dysfunction, jaundice, marked cachexia, diffuse oedema,
chronic diarrhoea and malabsorption, or rarely, disseminated intravascular coagulation6,7.
Secondary bacterial infections can develop due to immunosuppression, pneumonia being
among the most common and a frequent cause of death.
Differential diagnosis includes other causes of fever of unknown origin (see Section 14.1).
372
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Investigations8,9
– FBC (anaemia, neutropenia, thrombocytopenia)
– BGL
– Recombinant kinesin antigen (rK39) testa (first choice diagnostic test)
– Leishmania DAT (direct agglutination test)
– Malaria RDT (where endemic)
– Renal and liver function tests, if available.
Note: where VL is endemic, serum antibodies may be positive among children with subclinical
infection or those who have recovered after successful treatment. In addition, very young
infants may be serologically positive due to maternal antibodies if the mother had VL in
pregnancy. Serological tests should only be used, therefore, in symptomatic patients without a
history of VL treatment. VL relapse can only be diagnosed by tissue aspirate microscopy from
the spleen, bone marrow or lymph node.
Serum antibodies may be low or undetectable in severely immunocompromised children (e.g.
those with HIV). In these cases, diagnosis should be made on the basis of clinical suspicion if
parasitological confirmation through microscopy of tissue aspirates is not possible.
Management
– Admit to hospital and manage any complications (anaemia, thrombocytopenia, intercurrent
infections, e.g. malaria, pneumonia, TB, HIV, diarrhoea).
– Assess nutritional status. If malnourished, refer appropriately.
– Start VL treatment according to national guidelines where implemented/available or follow
treatment by region below.
– Ensure information and education provided from admission to parents/carers and child that
the treatment is long and must be followed regularly.
– Any cases of suspected VL should be notified.
East Africa
– For children < 2 years old OR with other severe disease (liver, renal, or cardiac diseases, HIV
co-infection, severe malnutrition, very poor general condition), administer:
First-line:
• pentavalent antimonial IM or slow IV
20 mg/kg once daily for 17 days
• + paromomycin IM
15 mg (equivalent to 11 mg base)/kg once daily for 17 days
Second-line in case of relapse:
• liposomal amphotericin B (AmBisome™) IV infusion
3 to 5 mg/kg once daily for 6 to 10 days, up to a total dose of 30 mg/kg 14
a Useful antigen in ELISA assays with high sensitivity and specificity in immunocompetent patients in the Indian
subcontinent. The sensitivity is lower and more variable in East Africa and Brazil, although specificity remains
high. This antigen rapid test requires minimal equipment and is easy to use.
373
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Liposomal amphotericin B requires strict cold chain during transportation, storage under
25 ⁰C and protection from light. It must not be diluted with saline solutions or mixed
with other electrolytes or medicines.
b Allometric dosing based on weight, height and gender is recommended for more accurate dosing in children
under 30 kg to prevent underdosing. For advice on individual dosing, refer to specialist clinician.
374
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
In the Americas, species include Leishmania mexicana and amazonesis, and with increased
risk of mucosal CL, braziliensis and guyanensis. Around 15.5% (with a range of < 5% to 47%
between countries) of cases were reported to be in children ≤ 10 years of age5.
Clinical features
– Erythematous papule appears at site of the sandfly bite, which enlarges to a nodule,
extending and deepening to form a scabbed ulcer (painless, unless there is secondary
bacterial or fungal infection).
– Single lesions are more frequent (40 to 75%) in children14 and in around 35 to 48% cases are
located on the head and neck.
– Lesions usually heal spontaneously, leaving a scar and life-long protection.
Diagnosis is usually clinical in endemic areas, and based on having at least 2 of the following
criteria for suspected CL:
Investigations
Microscopy:
– Identification of parasites in Giemsa-stained smears or culture.
– Take sample for the smear using fine needle aspiration (FNA) or skin scraping from the
nodule or active margin/raised edge of the ulcer or lesion. FNA is more sensitive and less
painful.
Management15
Treatment options are limited for children with most guidance based on extrapolation from
adult treatments (and data)10. Antimonial treatment can be toxic in children. Ensure all
effort is made to obtain parasitological confirmation and assess risk-benefit on a case-by-
case basis.
Safe and effective intra-lesional injection is sometimes not possible with a resisting child. In
those situations, it may be safer to treat the child with IM injections, or to leave the child
untreated.
Indications for treatment include if lesions are:
– Severe enough to justify systemic treatment
– Located on the face, active (with raised edges), and large
– Early (usually nodular), where treatment may prevent lesion enlarging. 14
– On a joint (e.g. wrist, elbow, knee, ankles)
– Causing a loss of function (e.g. on fingers, elbow, knee or toes).
– Lupoid (usually chronic)
– Persistent active (> 6 months)
375
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Pentavalent antimonial
meglumine antimoniate or sodium stibogluconate (SSG)
Secondary infection
Most common pathogens are streptococci and staphylococci.
Examine all lesions carefully for secondary infection as it may not be evident. Palpate whole
lesion thoroughly as often infection is under the thick crust.
– Consider if one or more of the following signs and symptoms:
• Ulcerating, weeping or purulent discharge (may be hidden under the crust).
• Lesion is painful.
• Swelling or oedema around the lesion.
• Red from inflammation.
– Often good cleaning and light debridement is sufficient, but if necessary, start oral antibiotics.
Concomitant treatment with antimonials:
– Intralesional antimonial treatment: treat secondary bacterial infection before starting
antimonial treatment. If intralesional treatment already started, postpone further
intralesional treatment until antibiotic treatment completed.
– IM antimonial treatment: antibiotic treatment can start/continue simultaneously, combined
with daily wound care.
c If the patient has more than 3 lesions, but all lesions are less than 2 cm, intralesional treatment could still be
considered.
376
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Mucocutaneous leishmaniasis
Occurs in Latin America and, more rarely, in Africa (Ethiopia, Sudan).
14
377
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Noma, also known as cancrum oris, is a necrotising gingivitis that causes rapid destruction of
the tissues of the mouth and face. It most frequently occurs in young children, with peak age
of onset between 2 to 6 years16. It affects all tissues of the face from soft tissue to bone and
is fatal in 90% of cases in the acute phase without treatment. Sequelae for survivors include
significant disfigurement and functional problems with eating and speaking due to trismus
and loss of facial tissue. Data are lacking on the exact incidence and prevalence of the disease
due to high mortality in the acute phase of the illness and the social stigma of the visible
sequelae which mean that many cases remain hidden and unaccounted for. Estimates from
1998 indicate that there are approximately 140 000 new cases of noma per year16, though this
is likely to be an underestimation. The majority of cases occur in sub-Saharan Africa.
The exact pathophysiology of noma remains unclear, but an altered oral microbiota is strongly
linked with the disease17. It thought to be due to a polymicrobial infection of anaerobic
commensal oral pathogens which become pathogenic when the immune system is weakened.
Both Fusobacterium necrophorum and Prevotella intermedia have been implicated in noma
pathogenesis, however the exact role they play has been inconsistently described17. Risk
factors for noma include malnutrition, poverty, recent measles or other immuno-suppressive
infection, proximity to livestock, weaning from breastmilk, and poor oral hygiene. It is not a
contagious disease.
378
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
Stages 1 and 2 are reversible, while stages 3-5 are irreversible and lead to permanent damage
to facial tissues.
14.3.2 Management
Management depends on the stage of the disease when it is detected. Early stages can be
managed in the community but from stage 2 onwards, inpatient treatment is necessary.
a Add half a teaspoon of table salt to a cup/glass of warm water and dissolve. Use the salted water to rinse the
mouth and then spit, it should not be swallowed.
379
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
First choice:
amoxicillin PO: 100 mg/kg, 2 times daily
+ metronidazole PO: 15 mg/kg, 2 times daily
Alternative:
amoxicillin/clavulanic acid (ratio 7:1 or 8:1) PO
Dosage expressed in amoxicillin:
• < 40 kg: 50 mg/kg 2 times daily
• ≥ 40 kg:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
Stage 2: Oedema
– Admit the child to hospital.
– Correct any dehydration (see Chapter 5, Section 5.3).
– Administer IV antibiotics without delay:
First choice:
amoxicillin-clavulanic acid (co-amoxiclav) IV: 50 mg/kg every 6 hours for 14 days
+ gentamicin slow IV: 5 mg/kg every 24 hours for 5-7 days
+ metronidazole IV: 15 mg/kg every 12 hours for 14 days
Alternative:
ampicillin IV: 100 mg/kg every 6 hours for 14 days
+ gentamicin + metronidazole as above
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
b If, for practical reasons, the patient is unlikely to receive their 3rd dose 4-6 weeks later, it is possible to give the
3rd dose from day 8 onwards.
380
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
381
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
14.3.3 Prognosis
If patients survive the acute stages of the disease, they are left with life-changing sequelae
that can ostracise them from their communities. Trismus and loss of facial tissue, especially
the lips, cause difficulties with eating, drinking and speech. Survivors often have salivary leak
and open holes in their faces, leaving them socially outcast or obliged to cover their faces in
public. If surgery is available, survivors usually require multiple reconstructive surgeries and
both functional and cosmetic outcomes are variable. Trismus may recur despite surgery.
14.3.4 Prevention
Noma is a multifactorial disease that continues to exist in places with extreme poverty and
malnutrition. However, there are some prevention measures that can reduce the likelihood of
the disease, including:
– Increasing awareness of the disease in communities.
– Promotion of exclusive breastfeeding for the first 6 months of life and continuation until
2 years or older.
– Practising good oral hygiene.
– Using clean water for drinking and oral hygiene.
– Early recognition and treatment of simple gingivitis and acute necrotising gingivitis.
– Regular vitamin A supplementation in communities.
– Measles vaccination.
– Zinc supplementation for diarrhoeal disease.
– Systematic deworming in communities.
– Nutritional screening and treatment of children at risk.
– Routine oral examination of children at each medical visit.
382
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
References Chapter 14
1. Haidar G, Singh N. Fever of Unknown Origin. Longo DL, ed. N Engl J Med. 2022;386(5):
463-477.
https://doi.org/10.1056/NEJMra2111003
2. Chow A, Robinson JL. Fever of unknown origin in children: a systematic review. World
J Pediatr. 2011;7(1):5-10.
https://doi.org/10.1007/s12519-011-0240-5
3. Aronson N, Herwaldt BL, Libman M, et al. Diagnosis and Treatment of Leishmaniasis: Clinical
Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American
Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis. 2016;63(12):1539-1557.
https://doi.org/10.1093/cid/ciw742
4. Kafetzis D. An overview of paediatric leishmaniasis. J Postgrad Med. 2003;49(1):31.
https://doi.org/10.4103/0022-3859.930
5. Bern C. Visceral leishmaniasis: Clinical manifestations and diagnosis. UpToDate. Published
February 2022.
https://www.uptodate.com/contents/visceral-leishmaniasis-clinical-manifestations-and-
diagnosis
6. De Santana Ferreira E, De Souza Júnior VR, De Oliveira JFS, Costa MFH, Da Conceição De
Barros Correia M, De Sá AF. Rare association of consumptive coagulopathy in visceral
leishmaniasis: A case report. Trop Doct. 2021;51(1):120-122.
https://doi.org/10.1177/0049475520967239
7. Scalzone M, Ruggiero A, Mastrangelo S, et al. Hemophagocytic lymphohistiocytosis and
visceral leishmaniasis in children: case report and systematic review of literature. J Infect
Dev Ctries. 2016;10(01):103-108.
https://doi.org/10.3855/jidc.6385
8. World Health Organization. Control of the leishmaniases: report of a meeting of the WHO
Expert Commitee on the Control of Leishmaniases, Geneva, 22-26 March 2010. World
Health Organization; 2010. Accessed November 13, 2023.
https://iris.who.int/handle/10665/44412
9. Chappuis F, Rijal S, Soto A, Menten J, Boelaert M. A meta-analysis of the diagnostic
performance of the direct agglutination test and rK39 dipstick for visceral leishmaniasis.
BMJ. 2006;333(7571):723.
https://doi.org/10.1136/bmj.38917.503056.7C
10. Uribe-Restrepo A, Cossio A, Desai MM, Dávalos D, Castro MDM. Interventions to treat
cutaneous leishmaniasis in children: A systematic review. Laouini D, ed. PLoS Negl Trop Dis.
2018;12(12):e0006986.
https://doi.org/10.1371/journal.pntd.0006986
11. Pan American Health Organization. Leishmaniasis: Epidemiological Report of the Americas
2018.
https://iris.paho.org/handle/10665.2/34856
14
12. Norouzinezhad F, Ghaffari F, Norouzinejad A, Kaveh F, Gouya MM. Cutaneous leishmaniasis
in Iran: Results from an epidemiological study in urban and rural provinces. Asian Pac J Trop
Biomed. 2016;6(7):614-619.
https://doi.org/10.1016/j.apjtb.2016.05.005
383
Chapter 14: Fever of unknown origin (FUO) and neglected tropical diseases (NTDs)
13. Aksoy M, Doni N, Ozkul HU, et al. Pediatric Cutaneous Leishmaniasis in an Endemic Region
in Turkey: A Retrospective Analysis of 8786 Cases during 1998-2014. Pimenta PF, ed. PLoS
Negl Trop Dis. 2016;10(7):e0004835.
https://doi.org/10.1371/journal.pntd.0004835
14. Blanco VM, Saravia NG, Cossio A, Martinez JD. Clinical and Epidemiologic Profile of
Cutaneous Leishmaniasis in Colombian Children: Considerations for Local Treatment. Am
J Trop Med Hyg. 2013;89(2):359-364.
https://doi.org/10.4269/ajtmh.12-0784
15. Manual for Case Management of Cutaneous Leishmaniasis in the WHO Eastern
Mediterranean Region. WHO Regional Publications, Eastern Mediterranean Series; 2014.
Accessed November 13, 2023.
https://www.who.int/publications/i/item/9789290219453
16. Information Brochure for Early Detection and Management of Noma. WHO, Regional Office
for Africa; 2017. Accessed November 13, 2023.
https://iris.who.int/handle/10665/254579
17. Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, et al. Risk factors for noma disease: a 6-year,
prospective, matched case-control study in Niger. Lancet Glob Health. 2013;1(2):e87-e96.
https://doi.org/10.1016/S2214-109X(13)70015-9
384
Chapter 15:
Supportive care in hospital
15
Chapter 15: Supportive care in hospital
Oxygen is an essential treatment for hypoxia and is indicated when oxygen saturation is < 92%
in stable patients, aiming to maintain SpO2 ≥ 92%. A higher threshold is used in emergency
management of critically unwell children and for specific conditions where there is impaired
delivery of oxygen to body tissues1.
Administer oxygen in the following situations:
– During resuscitation: all children regardless of SpO2, aiming for SpO2 ≥ 94%
– Critically unwell children: if SpO2 < 94%, aiming for SpO2 94 - 98%
– Children with impaired delivery of oxygen to body tissues, e.g. severe anaemia, severe
sepsis, sickle cell disease, severe heart failure: if SpO2 < 94%, aiming for SpO2 94 - 98%
– Stable children: if SpO2 < 92%, aiming for SpO2 ≥ 92%
387
Chapter 15: Supportive care in hospital
Table 15.1 - Standard, high and maximum flow rates via NC by age
To apply, attach NC tubing to the child’s face with tapeb and/or secure behind the ears (see
Figure 15.2).
Figure 15.1 - Nasal cannula tubing Figure 15.2 - Attachment of NC to the face
Simple mask
Delivers oxygen via a mask covering the mouth and nose, secured with an elastic band around
the head (see Figure 15.3). Recommended for initial oxygen delivery in acute presentation
and/or when oxygen delivery via NC is insufficient. Standard flow rates of 5 to 10 L/min will
deliver between 35-60% of oxygen. There are two holes in the mask (see diagram) that allow
air to mix with oxygen delivered via the tubing and for exhaled air to escape the space in the
mask. A minimum flow rate of 5 L/min must be ensured to avoid rebreathing exhaled carbon
dioxide.
a High-flow nasal cannula (HFNC) systems allow greater flow rates to be delivered via specially designed
circuits, however these are not yet widely available in MSF fields. It should be noted that standard oxygen
concentrators alone with NC cannot be used to administer safe and effective HFNC respiratory support. See
Chapter 3, Section 3.1.3 for more detail.
b Use of a foam tape or hydrocolloid dressing can be used to protect the skin, particularly for malnourished
children or those at risk of skin breakdown.
388
Chapter 15: Supportive care in hospital
15.1.2 Monitoring
Children receiving oxygen therapy should be monitored closely. Where possible, apply
continuous saturation monitoring, ensuring that appropriate alarm parameters have been set
on the monitoring device. Otherwise monitor and record saturations along with vital signs as
often as required using an early warning system (see MSF Manual of Nursing Care Procedures,
Assessment and vital signs, Charts: Vital sign charts).
15
389
Chapter 15: Supportive care in hospital
15.1.3 Weaning
Weaning off oxygen should be considered in children who are stable or clinically improving
when:
– If continuously monitored: SpO2 is consistently ≥ 92% for at least 3 hours.
– If intermittently monitored: SpO2 ≥ 92% on at least two separate consecutive readings taken
several hours apart.
Oxygen should be prescribed, with target SpO2 indicated to allow for nurse-led weaning and
adjustment of flow rates to meet the desired target.
See also MSF Manual of Nursing Care Procedures, Procedure: Oxygen therapy.
390
Chapter 15: Supportive care in hospital
Maintenance fluids should be administered to all children for whom oral intake is medically
contraindicated, including children with an altered level of consciousness who cannot eat or
drink (most often Glasgow Coma Score < 8 or PU on AVPU scale), intractable vomiting despite
nasogastric feeding, or severe respiratory distress from malaria, asthma, pneumonia or
bronchiolitis. Maintenance fluids preserve body water homeostasis by covering physiologic
daily fluid losses (sweating, urination, breathing) but are not sufficient for replacement of
excessive additional losses (e.g. profuse diarrhoea), or to rehydrate a clinically dehydrated
child (see Chapter 5, Section 5.3).
Some children receiving maintenance fluids may require an increased glucose concentration in
maintenance fluids due to repeated hypoglycaemia (see Chapter 9, Section 9.3) and require a
glucose (dextrose) 10% (G10%)-RL (or G10%-NaCl 0.9%) solution (see Table 15.2).
391
Chapter 15: Supportive care in hospital
b A paediatric infusion set should be used to administer maintenance fluids at rates less than 60 mL/hr. In
paediatric infusion sets, 1 mL = 60 drops therefore the rate in mL/hr is the same as the rate in drops/min. For
volumes over this rate, an adult infusion set may be used.
392
Chapter 15: Supportive care in hospital
Maintenance fluid rates may need to be reduced in critically unwell children with specific
pathologies that require fluid restriction, such as when there is suspicion of raised intracranial
pressure, e.g. meningitis (see Chapter 3, Section 3.3), cerebral malaria (see Chapter 3, Section 3.4),
head injury (see Chapter 2, Section 2.8); or increased ADH secretion, e.g. severe pneumonia
(see Chapter 4, Section 4.5), severe bronchiolitis (see Chapter 4, Section 4.7). In these cases, a
restriction of 70% of total calculated maintenance fluid is often advised (see Table 15.4).
Table 15.4 - Infusion rates by weight for restricted maintenance fluids (70%)
Administer G5%-RL (or G5%-NaCl 0.9%)
(Amounts rounded for ease of administration)
Weight Rate of infusion Weight Rate of infusion
(kg) in mL/hourc (kg) in mL/hour
3 10 22 45
4 15 23 45
5 15 24 45
6 20 25 45
7 20 26 45
8 25 27 45
9 25 28 50
10 30 29 50
11 30 30 50
12 30 31 50
13 35 32 50
14 35 33 50
15 35 34 50
16 35 35 55
17 40 36 55
18 40 37 55
19 40 38 55
20 40 39 55
21 40 40 55
c A paediatric infusion set should be used to administer maintenance fluids at rates less than 60 mL/hr. In
paediatric infusion sets, 1 mL = 60 drops therefore the rate in mL/hr is the same as the rate in drops/min. For
15
volumes over this rate, an adult infusion set may be used.
393
Chapter 15: Supportive care in hospital
intravenous fluids in MSF settings should not be taken lightly. Potassium is a potentially lethal
medication and can cause cardiac arrest in children if administered in excess of requirements.
Great care is required when adding potassium to IV fluids, as miscalculation of the required
amount can lead to massive differences in potassium dose. Even at therapeutic doses,
potassium is irritant to veins (causing burns and thrombophlebitis) if administered too quickly
or through small veins. KCl should never be injected directly into the vein.
Where feasible, KCl should be added to maintenance fluids according to instructions in
Table 15.5 and the MSF Paediatric Injectables Handbook. Make sure the child is urinating to
ensure that there is no renal failure before adding KCl to fluids and always ensure that the
potassium additions are checked by two senior members of nursing/medical staff. Carefully
label IV fluids bags containing potassium with the date, time and the amount of KCl added, as
well as the signatures of those preparing the medication (see Figure 15.5).
The potassium requirement for children is 2–3 mmol/kg/day. The addition of 2–3 mmol KCl to
100 mL of IV fluids (20–30 mmol KCl per litre) allows an appropriate amount of potassium to
be delivered when giving standard rate maintenance fluids. In diabetic ketoacidosis, potassium
requirements are higher, and should be 40 mmol KCl per litre (see Chapter 9, Section 9.2).
One 10-mL ampoule of KCl 15% contains 20 mmol = 2 mmol/mL. Always double check
that the ampoules contain 10 mL of KCl 15%, as content and manufacturer may vary.
Figure 15.5 - Example of bag label for maintenance fluids with added KCl
Child’s name:________________________
394
Chapter 15: Supportive care in hospital
15.2.4 Monitoring
Regardless of the maintenance fluid administered, a child on intravenous fluids must be
carefully monitored and have a record of fluid balance kept, aiming for a neutral fluid balance
(see MSF Nursing Care Manual of Procedures, Fluid balance chart: User Guide). Ensure that
the volume of any additional fluids administered with medication or as IV flushes is included
in the fluid balance calculation, as this may be quite significant.
In addition, children on IV fluids should be monitored for fluid overload. Signs of fluid overload
are:
– Increased RR by ≥ 10 breaths/minute from initial RR, or
– Increased HR pulse rate by ≥ 20 beats/min from initial HR
PLUS any one of the following:
– New or worsening hypoxia = decrease in SpO2 by > 5%
– New onset of rales and/or pulmonary oedema (fine crackles in lung fields)
– New galloping heart rhythm
– Increased liver size (liver must have been marked with pen prior to fluid administration)
– New peripheral oedema and/or puffy eyelids.
Management if signs of fluid overload present:
– Stop all fluids.
– Administer furosemide IV: 0.5 mg/kg (repeat once if necessary).
– Place child into semi-sitting position and ensure high-flow oxygen via non-rebreathing mask.
– Monitor every 15 minutes until child has been stable for at least one hour.
IV maintenance fluids should be administered for as short a time as possible to minimise
the risk of electrolyte abnormalities (see Section 15.3). In addition, early feeding improves
outcomes in critically unwell children, therefore aim to start enteral feeding and wean down
IV fluids as soon as possible (see Section 15.5).
15
395
Chapter 15: Supportive care in hospital
Hospitalised children, especially those who are critically unwell and/or receiving IV fluids are
at risk of electrolyte abnormalities. Children with malnutrition have an even higher likelihood
of developing electrolyte abnormalities during inpatient treatment, particularly associated
with refeeding syndrome (see Chapter 12, Section 12.3). Electrolyte abnormalities are most
commonly seen in children with gastrointestinal symptoms, especially persistent vomiting
and/or diarrhoea; renal disease, such as acute kidney injury (AKI); and endocrine disturbance,
such as diabetic ketoacidosis (DKA).
Abnormalities of sodium, potassium and calcium are the most common treatable electrolyte
imbalances and manifest with specific symptoms, though these may go undetected until life-
threatening signs and symptoms develop.
Notes
– For Na, K, Cl, HCO3, and glucose, mmol/L equal to mEq/L.
– iCa = ionized calcium is physiologically active (or free) calcium and makes up 40 to 45% of
total serum calcium.
a Normal values of serum creatinine vary by age and gender, see local lab references for more specific ranges.
396
Chapter 15: Supportive care in hospital
Clinical features
Children are usually asymptomatic if serum sodium is > 125 mmol/L. Below this level, symptoms
include the following:
– Nausea
– Malaise
– Headache
– Lethargy
– Seizures may occur below 120 mmol/L (severe hyponatraemia) and lead to irreversible
neurological damage
– In extreme cases, brain herniation may occur leading to respiratory and cardiac arrest and,
ultimately, death.
Investigations
– Blood urea and electrolytes (UE) to confirm sodium level
– Blood glucose level (BGL)
– Blood gas, if available
– Serum and urine osmolality, if available
15
397
Chapter 15: Supportive care in hospital
Management
Treatment of hyponatraemia depends on severity of symptoms and fluid status, with emergency
treatment required if the child has reduced conscious level or seizures. Correction should be
done slowly to prevent osmotic demyelination syndromeb.
– Mild to moderate hyponatraemia:
• Serum sodium 120 - 134 mmol/L and asymptomatic
• Monitor and record vital signs as often as required using an early warning system (see
MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
• Treatment depends on fluid status (adapted from RCH Melbourne Clinical Practice
guidelines3):
Sodium
Fluid status Treatment Monitoring
level
Treatment for
130 - 134 dehydration with oral
mmol/L rehydration solution (see
Chapter 5, Section 5.3)
Hypovolaemia/
Measure serum sodium
dehydration
Administer maintenance levels 12 hourly
< 130 fluids with G5%-NaCl (or 4-6 hourly
mmol/L 0.9% at full rate (see if Na < 125 mmol/L)
Section 15.2) Ensure correction rate no
more than 8 mmol/L
Restrict total fluid in 24 hours
intake to 50-70% Monitor for CNS
maintenance volume, symptoms (new or
Hypervolaemia 120 - 134 ideally in enteral intake ongoing)
or euvolaemiac mmol/L rather than IV fluids.
If IV fluids required,
ensure G5%-NaCl 0.9% is
administered.
NaCl 3% PO:
3 - 5 mmol/kg/day (or 6 – 10 mL/kg/day) in 4 to 6 divided doses
NB. NaCl 3% contains 30 g/L of sodium which is equivalent to 0.5 mmol/mL
b Osmotic demyelination syndrome is diffuse demyelination of the brain that can be irreversible, leading to
profound permanent neurological symptoms such as dysarthria, confusion and coma.
c Euvolaemia = a normal circulatory or blood fluid volume in the body.
398
Chapter 15: Supportive care in hospital
• If mildly symptomatic but without seizures or altered conscious level, calculate volume
of NaCl 0.9% required to correct sodium deficit and replace over 48 hours, ensuring
correction rate of no more than 8 mmol/L in 24 hours:
Volume of NaCl 0.9% (mL) required = 3.9 x weight (kg) x (Target Na – Real Na)
NB. If (Target Na – Real Na) is greater than 16 mmol, correction should be done over a
longer period to ensure that correction rate does not exceed 8 mmol/24 hours
• Repeat serum sodium levels every 4-6 hours until ≥ 125 mmol/L, then monitor 12 hourly
until normal.
• Treat likely underlying cause in addition to correction with hypertonic saline (e.g. correct
any dehydration (see Chapter 5, Section 5.3), restrict fluids if hypervolaemic).
– Severe hyponatraemia with seizures or altered conscious level:
• Medical emergency requiring urgent treatment.
• Treat any seizures (see Chapter 7, Section 7.2).
• Administer NaCl 3% IV: 3-5 mL/kg over 15-30 minutes using a syringe pump and, ideally, via
a central line (see MSF Paediatric Injectables Handbook for more detailed administration
guidance). Can be repeated if ongoing seizures or Na < 125 mmol/L.
• Repeat serum sodium level, aiming to correct serum sodium by no more than 2 mmol/L
per hour in the first 3-4 hours.
• Once seizures stop, calculate volume of NaCl 0.9% required to correct sodium deficit and
replace over 48 hours, ensuring correction rate of no more than 12 mmol/L in 24 hours
including the hypertonic saline bolus(es). Consider giving oral NaCl 3% as an alternative
(as above) if asymptomatic following NaCl 3% IV bolus(es).
• Repeat serum sodium levels every 4-6 hours until ≥ 125 mmol/L, then monitor 12 hourly
until normal.
• Treat the underlying cause, e.g. dehydration (see Chapter 5, Section 5.3), hypervolaemia.
Hypernatraemia
Raised serum sodium is due either to a water deficit or sodium excess. It is seen commonly in
children who are dehydrated due to gastroenteritis and burns. See Table 15.8 for a full list of
potential causes. It is typically classified as mild, moderate or severe and treatment depends
on severity.
Table 15.8 - Causes of hypernatraemia
Water deficit
Sodium excess
(fluid loss/dehydration)
399
Chapter 15: Supportive care in hospital
Clinical features
– Lethargy
– Weakness
– Altered level of consciousness
– Irritability
– Seizures
– Muscle cramps
– Depressed deep tendon reflexes
– Respiratory failure
Investigations
– Blood UE to confirm sodium level
– BGL
Management
Treat dehydration or hypovolaemic shock, if present, before correcting hypernatraemia (see
Chapter 2, Section 2.2). Ensure that sodium levels are repeated after any IV fluids have been
administered to accurately guide specific treatment. Aim to reduce sodium levels no faster
than 10 mmol/L in 24 hours to reduce the risk of cerebral oedema.
– Mild hypernatraemia:
• Serum sodium 146 - 149 mmol/L
• Manage the underlying cause and repeat serum sodium in 4-6 hours
– Moderate hypernatraemia:
• Serum sodium 150 - 169 mmol/L
• Monitor and record vital signs as often as required using an early warning system (see
MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
• Calculate free water deficit (FWD) based on an estimated requirement of 4 mL/kg of fluid
to reduce serum sodium by 1 mmol/L:
400
Chapter 15: Supportive care in hospital
Clinical features
– Ascending muscle weakness or paralysis
– Abdominal distension
– Anorexia
– Nausea and vomiting
– Constipation (secondary to paralytic ileus)
– Cardiac arrhythmias
Investigations
– Blood UE to confirm potassium level
– BGL
– Blood gas, if available
– Electrocardiogram (ECG)
Management
Treatment of hypokalaemia depends on the severity.
– Mild, asymptomatic hypokalaemia:
• Potassium 3 - 3.4 mmol/L
• Usually doesn’t require specific treatment
• Correct underlying cause and recheck potassium level in 2-3 hours.
– Moderate hypokalaemia:
• Potassium 2.5 - 2.9 mmol/L
• Treat with potassium orally for 2 days:
• Repeat potassium level 2 hours after oral administration and at the end of treatment.
– Severe hypokalaemia:
• Potassium < 2.5 mmol/L or patients with symptomatic hypokalaemia
• Monitor and record vital signs as often as required using an early warning system (see
MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts).
15
401
Chapter 15: Supportive care in hospital
First choice - for stable patients who are able to take oral medication
7.5% potassium chloride syrup (1 mmol K+/mL) PO for 2 days:
• < 45 kg: 2 mmol/kg (2 mL/kg) once daily
• ≥ 45 kg: 30 mmol (30 mL) 3 times daily
Second choice - for patients unable to take oral medication
15% potassium chloride solution (2 mmol K+/mL) IV:
0.2 mmol/kg/hr (max. 10 mmol/hr) for 3 hours
Each mmol of potassium is diluted in 25 mL of NaCl 0.9%
Infusion may be repeated if severe symptoms persist or if serum potassium remains
< 3 mmol/L.
• Repeat potassium level 1 hour after the end of the infusion or two hours after oral
administration.
Hyperkalaemia
Hyperkalaemia is relatively common in hospitalised children and is defined as a serum
potassium above 5.5 mmol/L. It occurs in children with renal failure, in diabetic ketoacidosis
in extensive trauma and may be iatrogenic in children receiving IV fluids supplemented with
potassium.
Investigations
– Blood UE to confirm potassium level
– BGL
– Blood gas, if available
– Electrocardiogram (ECG)
Management
Treatment of hyperkalaemia depends on the severity:
– Repeat serum potassium urgently to verify results, ideally via venepuncture to avoid
sampling haemolysis which will result in an inaccurately high potassium.
– Stop all IV infusions containing potassium immediately.
– Avoid potassium-rich foods (e.g. bananas, oranges, raisins, tomatoes, avocados, dried fruits
and nuts).
– Use only fresh blood for transfusion (if required).
402
Chapter 15: Supportive care in hospital
– Monitor and record vital signs as often as required using an early warning system (see MSF
Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign charts).
– If hyperkalaemia with K+ ≤ 6 mmol/L, continue with above measures only and monitor
serum potassium again after 2 hours.
– If hyperkalaemia with K+ > 6 mmol/L, especially if there are signs of hyperkalaemia on ECG
(peaked T waves, wide QRS complex, arrythmias), actively treat as follows:
• Administer nebulised salbutamol to promote potassium uptake into cells:
< 5 years: 2.5 mg nebuliser, repeated after 1 to 2 hours if necessary
≥ 5 years: 5 mg nebuliser, repeated after 1 to 2 hours if necessary
• Administer calcium gluconate 10% IV 0.5 mL/kg (max. 10 mL) over 3 minutes to stabilise
cardiac muscle excitability.
• If central venous access in situ, and the patient can be cared for in an ICU environment with
adequate monitoring and staffing levels, administer a mixed infusion of glucose (dextrose)
50% 2 mL/kg and short-acting insulin 0.05 IU/kg in the same syringe over 5-10 minutes,
using a syringe pump, to promote intracellular potassium shift. Close monitoring of BGL
is required before, during and after infusion (within an hour of administration), as insulin
can cause a rapid fall in BGL.
• Repeat serum potassium hourly until stable and within therapeutic range.
Clinical features
– Tetany
– Neuromuscular irritability with weakness
– Paraesthesia, cramps, fatigue
– Altered level of consciousness
– Seizures
– Cardiac arrhythmias
– Trousseau’s sign: carpopedal spasm after arterial occlusion of an extremity for 3 minutes
– Chvostek’s sign: muscle twitching on percussion of the facial nerve
Investigations
– Blood UE
– Blood gas, if available
– Electrocardiogram (ECG), if severe hypocalcaemia
Management
Specific treatment of hypocalcaemia depends on severity and is required if iCad < 4 mg/dL
(< 1 mmol/L).
15
d iCa = ionized calcium is physiologically active (or free) calcium and makes up 40 to 45% of total serum calcium.
403
Chapter 15: Supportive care in hospital
• < 20 kg:
0.5 mL/kg (max. 10 mL) by slow IV injection over 5-10 minutes, then 2 to 4 mL/kg
(max. 40 mL) by continuous IV infusion over 24 hours
(dilute in 100 mL of glucose (dextrose) 5%, NaCl 0.9% or Ringer lactate)
• ≥ 20 kg:
10 mL by slow IV injection over 5-10 minutes, then 40 mL by continuous IV infusion
over 24 hours
(dilute in 250 mL or 500 mL of glucose (dextrose) 5%, NaCl 0.9% or Ringer lactate)
404
Chapter 15: Supportive care in hospital
Pain is an unpleasant sensory and emotional experience associated with actual or possible
tissue damage. Assessing the presence and severity of pain in children can be challenging,
especially in infants and younger children. Being unable to communicate verbally about pain
does not exclude that the child is experiencing pain and needs appropriate analgesia. Pain
assessment should be routine in all paediatric hospital care and treatment adequately tailored
and adapted.
15.4.1 Assessment
– Take a history and examine the child.
– Try to assess where the pain is (adjust to child’s age and understanding).
– In older children, ask to describe the pain:
• Character: sharp, dull, stabbing, burning, cramping, spasmodic, radiating, etc.
• Pattern: sudden, intermittent, chronic; at rest, at night, on movement, etc.
• Aggravating or relieving factors
• Associated symptoms.
– Assess intensity with a validated pain assessment tool to rate the ‘pain score’, recording
the score and the tool used. Use a self-reporting tool as preference, but where necessary a
behavioural assessment tool can be used, both in accordance to age, cognitive ability, and
level of consciousness or sedation. Choose the pain tool that is most adapted and accepted
according to context.
– Assess adequacy of treatment: use same pain assessment tool for consistency and re-
evaluate and record pain intensity after every treatment to monitor and adjust analgesia
adequately.
– If not already known, identify the underlying cause of the pain and treat if possible.
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
Pain Pain Possible
Pain
15
405
Chapter 15: Supportive care in hospital
Figure 15.7 - Wong-Baker FACES® Pain Rating Scalea (3 years and above)
Scoring
Items
0 1
Brow bulge no yes
Eye squeezed shut no yes
Accentuated nasolabial fold no yes
Open mouth no yes
406
Chapter 15: Supportive care in hospital
Scoring
FLACC Scale
0 1 2
Occasional grimace Frequent to constant
No particular
Face or frown, withdrawn, frown, clenched jaw,
expression or smile
disinterested quivering chin
Normal position Kicking,
Legs Uneasy, restless, tense
or relaxed or legs drawn up
Lying quietly, normal Squirming, shifting
Activity Arched, rigid or jerking
position, moves easily back and forth, tense
Crying steadily,
No cry Moans or whimpers,
Cry screams or sobs,
(awake or asleep) occasional complaint
frequent complaints
Reassured by
occasional touching, Difficult to console
Consolability Content, relaxed
hugging or being or comfort
talked to, distractible
15.4.2 Management
– Relieve pain according to type (acute or chronic) and intensity.
– Where possible and appropriate, treat underlying cause.
– Non-pharmacologic measures (e.g. cognitive, behavioural, physical and supportive therapies)
help control pain by providing comfort or an element of distraction from the physical pain
(see Table 15.11). Two interventions are more effective than one. Use in combination with
pharmacologic treatment. See also MSF Manual of Nursing Care Procedures, Procedure:
Pain management.
15
407
Chapter 15: Supportive care in hospital
Analgesics
– Use oral analgesics whenever possible (better tolerated, fewer side effects, safer).
– Identify step on the three-step ladder that corresponds to pain score (see Table 15.12).
Table 15.12 -Three-step ladder
– Select analgesia corresponding to step on the three-step ladder (see Table 15.13 for analgesic
drug dosing). For moderate and severe pain, give regular analgesia over 24 hours, including
sufficient analgesia to allow the child to sleep through the night and to avoid breakthrough
pain:
b Tramadol is not approved for use in children < 12 years in some countries due to the risk of increased opioid
toxicity including life-threatening respiratory depression. If oral morphine is not available, tramadol may be
considered in hospitalised children < 12 years under close medical supervision at a dose of 1 to 2 mg/kg every
6 to 8 hours (max. 400 mg/day).
408
Chapter 15: Supportive care in hospital
– Adjust choice of opioid according to age and by monitoring efficacy of the analgesia given.
– For acute pain, start with immediate-release oral morphine.
– For chronic pain, low doses of sustained-release oral morphine are preferred.
c Tramadol is not approved for use in children < 12 years in some countries due to the risk of increased opioid
toxicity including life-threatening respiratory depression. If oral morphine is not available, tramadol may be
considered in hospitalised children < 12 years under close medical supervision at a dose of 1 to 2 mg/kg every
15
6 to 8 hours (max. 400 mg/day).
409
Chapter 15: Supportive care in hospital
< 6 months 0.05 mg/kg 0.05 mg/kg 5 to 10 mins until pain controlled
≥ 6 months
0.1 mg/kg 0.05 mg/kg 5 to 10 mins until pain controlled
< 50 kg
Dilution: see MSF Paediatric Injectables Handbook for details on dilution and administration.
– Move up or down the pain ladder depending on pain intensity and type of pain (Figure 15.9):
• Acute pain, surgical or trauma-related pain: intensity of pain higher initially but will then
decrease. Strategy is to move down the ladder.
• Chronic pain, cancer-associated pain: background pain with increase in intensity. Strategy
is to move up the ladder.
– Anticipate and treat adverse effects of analgesia. Constipation is especially common when
opioids are used, give laxatives routinely to prevent constipation when opioids are used for
> 3 days.
– Be aware of contraindications to analgesic medications.
410
Chapter 15: Supportive care in hospital
Contraindications
Severe respiratory distress and the risk of or known seizures (epilepsy, head
Tramadol injury, meningitis)
Do not give tramadol with or shortly before or after morphine.
d Tramadol is not approved for use in children < 12 years in some countries due to the risk of increased opioid
toxicity including life-threatening respiratory depression. If oral morphine is not available, tramadol may be
15
considered in hospitalised children < 12 years with malnutrition under close medical supervision.
411
Chapter 15: Supportive care in hospital
Management
gabapentin PO
– 6 to 11 years: 5 mg/kg/day once daily. Titrate dose over 3 days, increasing 5 mg/kg/day.
Maximum dose: 15 mg/kg/day given in three divided doses.
– ≥ 12 years: D1: 300 mg once daily; D2: 300 mg 2 times daily; D3: 300 mg 3 times daily.
After D3: titrate dose as required, increasing by 300 mg/day at 2-day intervals until D10 and
subsequently at 3 day intervals up to a maximum of 3600 mg in three divided doses.
amitriptyline PO
– 6 to 11 years: start at 0.5 mg/kg at bedtime. Gradually titrate up once a week up to maximum
of 1 mg/kg. Maximum dose: 75 mg daily.
– ≥ 12 years: week 1: 25 mg once daily at bedtime; week 2: 50 mg once daily at bedtime;
week 3: 75 mg once daily at bedtime. Maximum dose: 75 mg daily. Avoid in patients at risk
of self-harm.
Dual treatment is recommended9,10. In cases of mild neuropathic pain, clinicians may consider
starting gabapentin or amitriptyline in isolation depending on patient risk factors. Monitor
closely for the development of suicidal thoughts and evaluate response to treatment after 2 to
4 weeks. Neither medication should be stopped abruptly.
412
Chapter 15: Supportive care in hospital
– Local topical anaesthetics can be used in inpatient and emergency care settings:
• Dermal creame: use with planned procedures e.g. lumbar puncture.
▹ Apply half of a 4 g tube of EMLA cream (lidocaine/prilocaine) to the skin. Cover the
cream with an occlusive dressing and wait for 45 to 60 minutes. Analgesic effects last
for up to 4 hours after removal of the cream.
▹ Adverse reactions: transient skin irritation
• Subcutaneous injection of lidocaine 1% may be used for minor surgical procedures by
staff trained in the procedure.
▹ Infiltrate lidocaine 1% SC: 3 mg/kg/injection (max. 5 mg/kg/injection) in the area
involved with a small-bore needle (e.g. 25 Gauge needle). Do not use as IV.
– For procedures that require a stronger analgesia/sedation, such as ketamine, trained
staff and protocols need to be available (refer to MSF Standards for Paediatric Procedural
Sedation).
15
e Transitory Z code DEXTZFR0063; mixture of lidocaine 2.5% and prilocaine 2.5% in a cream base
413
Chapter 15: Supportive care in hospital
Nutritional support is an essential element of paediatric critical care for all children, both non-
malnourished and malnourished, following initial resuscitation. Ideally, nutritional support in
hospital should be provided orally (i.e. eating and drinking), but this is not feasible in critically
unwell children. Enteral nutrition via oro/nasogastric tube (O/NGT)a is therefore used to
allow timely introduction of nutritional support. O/NGTs should be used for as short a time as
possible, as the goal is to get the child back on a nutritionally appropriate oral diet as soon as
safely possible (see MSF Hospital Food Service Management Protocol).
Early introduction of enteral nutrition has been shown to be beneficial in critically unwell
children, leading to reduced infections (particularly pneumonia), and a likely reduction
in mortality11,12,13. Enteral nutrition should therefore be started as soon as the child is
haemodynamically stable i.e. has received appropriate fluid resuscitation for circulatory
impairment.
Intravenous fluids have limited nutritional value and maintain adequate hydration, blood sugar
levels and electrolyte balance in the short term only. Children recovering from critical illness
have a considerable risk of developing nutritional deficiencies, therefore the use of exclusive
IV fluids should be limited to the first 24-48 hours of critical illness.
While the principles of nutritional support for critically unwell children are the same for both
malnourished and non-malnourished children, the enteral nutrition products and volume
of feeds are not. Ensure that nutritional assessment is carried out before starting enteral
feeding in critically unwell children, if not already done at admission. This chapter will focus
on nutritional support for the non-malnourished critically unwell child. For advice on enteral
feeding in critically unwell malnourished children from 1-59 months, refer to the MSF ITFC
Nutrition Care Protocol 2021b. For older critically unwell malnourished children, refer to local
protocols.
a In some contexts, naso-duodenal, jejunostomy and gastrostomy tubes may be used, though much less
common.
b Specific advice on the management of children with moderate acute malnutrition in Note 5.6 of this protocol.
414
Chapter 15: Supportive care in hospital
Children with a reduced level of consciousness have reduced protective airway reflexes (e.g.
gagging/coughing) therefore are at greater risk of regurgitation of gastric contents. This is
not a contraindication to the introduction of enteral feeds but necessitates close monitoring
and a more cautious approach to avoid aspiration of stomach contents into the airway and
lungs, causing an aspiration pneumonia. The position of the O/NGT should be verified after
insertion and before each use (see MSF Manual of Nursing Care Procedures, SOP – Gastric
Tubes: Maintenance).
Breastmilk 70 90
415
Chapter 15: Supportive care in hospital
f Only to be used if neither of the first two products are available. See MSF ITFC Nutrition Care Protocol 2021 for
preparation guidance.
416
Chapter 15: Supportive care in hospital
while in other patients stress factors during the acute phase can lead to hypermetabolism and
significantly increased energy expenditure, especially with fever or burns. It is therefore difficult
to accurately estimate energy requirements without risking either over- or underfeeding,
both of which can have adverse effects on recovery13. Overfeeding in particular during the
acute phase can exacerbate the catabolic stress response and impair recovery. Resting energy
expenditure is therefore used as a proxy for energy requirement during the acute phase of
critical illness. In the stable and recovery phases of critical illness, energy provision should be
gradually increased to ensure minimal loss of lean body mass.
15.5.5 Calculating target daily enteral feed volumes in the acute phase of critical
illness
Use the following steps to calculate the target volume of enteral feed required daily to meet
energy needs during the acute phase of critical illness (up to maximum 7 days).
Step 1: Calculate the estimated daily energy requirements according to weight (see Schofield
energy equation, Table 15.17).
Step 2: Choose the most appropriate/available enteral nutrition product (see Table 15.15). If
the patient is fluid restricted, consider hypercaloric feeds (children) or fortification of breastmilk
(infants) to meet energy needs without exceeding target enteral fluid volumes.
Step 3: Calculate and prescribe the target daily acute phase enteral feed volume according to
the calorie content of the chosen enteral nutrition product.
417
Chapter 15: Supportive care in hospital
418
Chapter 15: Supportive care in hospital
Step 3: Increase to 70% of target daily acute phase enteral feed volume and reduce IV fluids
accordingly. If tolerated, continue for 6-12 hours.
Step 4: Increase to target daily acute phase enteral feed volume. If tolerated, stop IV fluids
and provide remaining daily enteral fluid intake in the form of water via O/NGT in 30-60 mL
aliquotsg.
g Do not give water to infants under 6 months old. In infants under 6 months old, continue to gradually increase
enteral feeds as tolerated until full enteral feed volume has been reached (see Table 15.16 for standard enteral
feed calculations in infants) and continue to reduce IV fluids accordingly until they can be stopped.
15
h Consider consulting the MSF telemedicine platform for specific case by case advice.
419
Chapter 15: Supportive care in hospital
Paediatric palliative care aims to relieve suffering and improve the quality of life for children
with life-threatening illnesses, as well as to provide support to their families. Although
palliative care is often started when curative options have been exhausted, it can also be
provided alongside potentially curative treatments. It is not synonymous with end-of-life care
and should be a component of any care plan for children with significant life-limiting illnesses.
The aim of palliative care is to promote comfort and dignity to children with serious health
problems, regardless of whether their illness can be cured or not, and palliative care may take
place in hospital or at home. It encompasses physical, psychosocial, and spiritual support and
requires the input of a multidisciplinary team. End-of-life care is a component of palliative care
that occurs in the last hours or days of life.
In humanitarian and low-resource settings, palliative care may be required more frequently for
conditions that may be curable in other contexts with more advanced healthcare. Common
conditions in children that require palliative care include congenital cardiac anomalies and
other congenital anomalies, malignancies, critical illness or injury where recovery is unlikely,
chronic or degenerative conditions for which there is no definitive treatment (e.g. HIV,
muscular dystrophies), and severe neurological conditions. Palliative care should be integrated
into care early in paediatric critical illness, as it is often difficult to predict prognosis and
eventual outcome in children. A child’s developmental stage will heavily influence all aspects
of palliative care.
This chapter will briefly outline the main components of paediatric palliative care – symptom
management; communication; and psychosocial support. For a comprehensive guide to
paediatric palliative care, refer to MSF OCBA Palliative Care Programmatic and Clinical
Guidelines. For more guidance on psychosocial support in palliative care, refer to MSF Mental
Health and Psychosocial Support Guideline, Chapter 13.
Examination
Carry out a complete physical examination, paying particular attention to inside the mouth
and ears, presence of lymph nodes and skin problems (especially nappy area and scalp).
420
Chapter 15: Supportive care in hospital
Management
Symptom management should be holistic, including both pharmacological and non-
pharmacological options. Ensure thorough assessment of symptoms, treat any treatable
causes, give medications to control symptoms at age-appropriate dosing (preferably via oral
route), and consider social, psychological or spiritual factors which may impact symptom
management. If palliative care will take place at home, adequate planning is required to ensure
that good-quality care is provided.
a The provision of oxygen in palliative care is for comfort only, i.e. to minimise symptoms of respiratory distress.
It is not necessary to target a certain saturation level or to administer high flows which may cause discomfort.
b Metoclopramide can induce severe extra-pyramidal side-effects in children therefore should be used with
15
caution and for maximum of 5 days. It is contraindicated in children less than 1 year old.
421
Chapter 15: Supportive care in hospital
15.6.2 Communication
Communication with the child
Good communication is essential when providing palliative care. Language and methods of
communication should be adapted to the child’s level of development and understanding.
Important discussions and sharing of sensitive information should only take place after
consultation and agreement with parents/carers/families. Honesty is a key component of
communication with children, and it is important not to lie, even when faced with difficult
questions. Children are often aware that they are dying, even if no-one tells them directly,
and they will pick up on the worried faces of their parents/carers and healthcare team. We
may inadvertently cause more worry and anxiety by failing to talk about this, as children may
imagine a situation that is worse than reality when faced with uncertainty.
Some important points to remember when communicating with children:
– Engage with children non-verbally before starting to speak to them to build trust, e.g. smile,
offer a toy, engage in play/drawing with them.
– Get down to their level to make them feel more comfortable, e.g. sit on the bed or floor.
– Maintain a distance that allows the child to feel safe, leaving them to come closer when they
are ready.
– Use language that is appropriate for their developmental age.
– Talk to the child with their parents/carers unless otherwise requested and allow them to sit
on their parent’s/carer’s lap or stay near them if they want to.
– Ensure that you speak directly to the child as well as the parents/carers.
– Be honest and don’t make promises that are unrealistic.
– Listen to the child when they speak and don’t rush them or interrupt if they are unable to
express themselves easily.
– Don’t give information to the child without their parent’s/carer’s permission.
422
Chapter 15: Supportive care in hospital
care. Reassure families that palliative care does not mean that there that is nothing more that
can be done, but that it aims to make the child more comfortable by treating pain and other
symptoms. Explain to families if options are available for providing palliative care at home, so
that they can decide if this would be best for their child and their family. Provision of palliative
care at home may not be possible, but families should still be offered the option of taking their
child home to provide whatever care they can in their home environment, if this is what they
feel is best for them and their child.
If it seems likely that the child will not survive, there are key steps that should be followed to
inform a family that death is expected:
1) Open the conversation by introducing yourself and asking permission to talk about their
child’s current condition.
2) Assess their understanding of the illness and their child’s condition.
3) Ask about how much information they would like to know about their child’s condition and
likely prognosis, both short- and long-term.
4) Share the prognosis sensitively but clearly and allow the family time to process this
information.
5) Assess goals by asking the family what they would like to do for their child, considering the
information they have just received.
6) Establish a plan, recommending a focus on symptom control, comfort and allowing the
child to be close to their loved ones.
7) Close the conversation by reassuring the family that you are available for support or further
information and ensure that they have a way to contact a member of the team whenever
they need to.
8) Record all conversations with families and patients in the patient’s medical file and
communicate to the rest of the team during handover processes so that all medical staff
are aware of the plan.
423
Chapter 15: Supportive care in hospital
424
Chapter 15: Supportive care in hospital
References Chapter 15
1 World Health Organization. Oxygen Therapy for Children: A Manual for Health Workers.
World Health Organization; 2016. Accessed November 20, 2023.
https://iris.who.int/handle/10665/204584
2. WHO Recommendations on Child Health: Guidelines Approved by the WHO Guidelines
Review Committee. World Health Organization; 2017. Accessed November 29, 2023.
https://www.who.int/publications-detail-redirect/WHO-MCA-17.08
3. The Royal Children’s Hospital Melbourne : Clinical Practice Guidelines - Hyponatraemia.
The Royal Children’s Hospital Melbourne. Accessed November 29, 2023.
https://www.rch.org.au/clinicalguide/guideline_index/Hyponatraemia/
4. Beltramini A, Milojevic K, Pateron D. Pain Assessment in Newborns, Infants, and Children.
Pediatr Ann. 2017;46(10).
https://doi.org/10.3928/19382359-20170921-03
5. Fournier-Charrière E, Tourniaire B, Carbajal R, et al. EVENDOL, a new behavioral pain scale
for children ages 0 to 7 years in the emergency department: Design and validation. Pain.
2012;153(8):1573-1582.
https://doi.org/10.1016/j.pain.2012.02.024
6. Beltramini A, Galinski M, Chabernaud JL, et al. Pain Assessment in Children Younger Than
8 Years in Out-of-Hospital Emergency Medicine: Reliability and Validity of EVENDOL Score.
Pediatr Emerg Care. 2019;35(2):125-131.
https://doi.org/10.1097/PEC.0000000000000953
7. Nicholas M, Vlaeyen JWS, Rief W, et al. The IASP classification of chronic pain for ICD-11:
chronic primary pain. Pain. 2019;160(1):28-37.
https://doi.org/10.1097/j.pain.0000000000001390
8. Howard RF, Wiener S, Walker SM. Neuropathic pain in children. Arch Dis Child. 2014;
99(1):84-89.
https://doi.org/10.1136/archdischild-2013-304208
9. Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ. 2009;
339(aug12 1):b3002-b3002.
https://doi.org/10.1136/bmj.b3002
10. Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms,
and treatment. Lancet Neurol. 2010;9(8):807-819.
https://doi.org/10.1016/S1474-4422(10)70143-5
11. Australasian Society of Parenteral and Enteral Nutrition. Australian and New Zealand
Paediatric Critical Care - Nutrition Support Guideline. 2023.
htt ps : / /c u sto m . c ve nt . co m / F E 8 A D E 3 6 4 6 E B 4 8 9 6 B C EA 8 2 3 9 F 1 2 D C 5 7 7 / f i l e s /
863fd86399ba4c3ab82da757faffa5c1.pdf
12. Tume LN, Valla FV, Joosten K, et al. Nutritional support for children during critical illness:
European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine
and nutrition section position statement and clinical recommendations. Intensive Care
Med. 2020;46(3):411-425.
https://doi.org/10.1007/s00134-019-05922-5 15
425
Chapter 15: Supportive care in hospital
13. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care
Medicine and American Society for Parenteral and Enteral Nutrition. J Parenter Enter Nutr.
2017;41(5):706-742.
https://doi.org/10.1177/0148607117711387
14. Therapeutic milk technical bulletin | UNICEF Supply Division. Accessed November 29, 2023.
https://www.unicef.org/supply/documents/therapeutic-milk-technical-bulletin
15. Nager AL, Wang VJ. Comparison of Nasogastric and Intravenous Methods of Rehydration in
Pediatric Patients With Acute Dehydratio. Pediatrics. 2002;109(4):566-572.
https://doi.org/10.1542/peds.109.4.566
16. Oakley E, Borland M, Neutze J, et al. Nasogastric hydration versus intravenous hydration for
infants with bronchiolitis: a randomised trial. Lancet Respir Med. 2013;1(2):113-120.
https://doi.org/10.1016/S2213-2600(12)70053-X
17. Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous
rehydration therapy in children with diarrhoea. BMJ. 1991;303(6799):393-396.
https://doi.org/10.1136/bmj.303.6799.393
18. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive
care unit. Clin Nutr. 2019;38(1):48-79.
https://doi.org/10.1016/j.clnu.2018.08.037
426
Appendices
2 Months 4 Months
Physical & Movement Cognitive Communication/Language Social & Emotional Physical & Movement Cognitive Communication/Language Social & Emotional
Holds head up when Follows past midline Laughs and vocalises Smiles responsively and Holds head steady without Looks at their hands with Makes sounds back when Smiles on his own to get
on tummy (sounds other than crying) spontaneously support when held. interest. caregiver talks to them. caregiver’s attention.
Watches caregiver as
Moves both arms and they move Reacts to loud sounds Looks at caregiver’s face Brings hands to mouth. Turns head towards the Looks at caregiver, moves,
legs sound of caregiver’s voice. or makes sounds to get or
Pushes up on keep their attention.
Opens hands briefly elbows/forearms when on
tummy
© OCP Paediatrics, L&D and BKL 2023 © OCP Paediatrics, L&D and BKL 2023
6 Months 9 Months
Physical & Movement Cognitive Communication/Language Social & Emotional Physical & Movement Cognitive Communication/Language Social & Emotional
Leans on hands to support Puts things in their mouth Takes turns making Knows familiar people. Gets to a sitting position by Bangs two things together. Lifts arms to be picked up. Looks when you call their
themselves when sitting. to explore them. sounds with caregiver . themselves. name.
Laughs. Looks for objects when
Pushes up with straight Reaches to grab a toy Moves things from one hand dropped out of sight Reacts when caregiver
arms when on tummy. they want. to their other hand. (like toy). leaves (looks, reaches for
caregiver, cries).
Rolls from tummy to back. Closes lips to show they Sits without support
don’t want more food.
© OCP Paediatrics, L&D and BKL 2023 © OCP Paediatrics, L&D and BKL 2023
Appendix 1
429
Reprinted with permission from OCP Paediatrics, L&D and BKL
430
12 Months 15 Months
Appendix 1
Physical & Movement Cognitive Communication/Language Social & Emotional Physical & Movement Cognitive Communication/Language Social & Emotional
18 Months 24 Months
Physical & Movement Cognitive Communication/Language Social & Emotional Physical & Movement Cognitive Communication/Language Social & Emotional
e
Give It to m
Mu
aw
!
Walks without holding on to Copies you doing Tries to say three or more words Moves away from you but looks Walks up steps Plays with more than Says at least two words together, Notices when others are hurt or
anyone or anything. chores, like sweeping besides “mama” or “dada”. to make sure caregiver is close. one toy at the same like “More milk”. upset, like pausing or looking
sad when someone is crying.
with a broom. Points to show something Kicks a ball time, like putting toy
Feeds themselves with Follows one-step directions food on a toy plate. Points to at least two body parts
interesting. Looks at caregivers face to see
their fingers. Plays with toys in a without any gestures, like giving when you ask them to show you. how to react in a new situation.
you the toy, when you say, Helps caregiver to dress
simple way, like “Give it to me!” Uses more gestures than just
Climbs on and off a couch pushing a toy car. themselves by pushing arm
through sleeve or lifting up foot. waving and pointing, like blowing
or chair without help a kiss or nodding “YES”.
© OCP Paediatrics, L&D and BKL 2023 © OCP Paediatrics, L&D and BKL 2023
My
n
is An ame
Duck ton Ruumm
Rummm
Cuac
!
Takes some clothes off by Uses things to pretend, Says two or more words, with Plays next to other children
themselves, like loose like feeding a block to a one action word, like “Doggie and sometimes plays with Puts on some clothes by Draws a circle when Speech all understandable Interactive play
pants or an open jacket. doll as if it were food. run!”. them. themselves, like loose you show them how.
pants or a jacket.
Jumps off the ground with Follows two-step Names things in a book when
both feet. instructions like “Put you point and ask, “What is
the toy down and close this?”.
the door!”.
© OCP Paediatrics, L&D and BKL 2023 © OCP Paediatrics, L&D and BKL 2023
48 Months 60 Months
Physical & Movement Cognitive Communication/Language Social & Emotional Physical & Movement Cognitive Communication/Language Social & Emotional
...an
ok d th
Mama lo .. the en,
af ! ca
at my le ...4. flew t
...3. awa
1...2 y!
Counts to 10.
Pretends to be something
Holds pencil or crayon Draws a person with Talks about at least one thing else during play (teacher, Hops on one foot. Uses words about time, like Tells a story they heard or Follows rules or takes turns
between fingers and three parts that happened during their day, superhero, dog). “yesterday”, “tomorrow” or made up with at least two when playing games with
like “I played soccer!”. other children.
thumb, not a fist. “morning” and “night”. events
Tells what comes next Asks to go play with children, e.g., a cat was stuck in a
if none are around, like ”Can I Sings, dances or acts for you.
Catches a large ball in a well-known story. Answers simple questions like, Pays attention for 5 to 10 tree and a man saved it.
“What is a coat for?” or “What is play with Alex?”.
most of the time. minutes during activities
a crayon for?”.
Names four colours Avoids danger, like not jump (e.g., during story telling time
from tall heights. or making arts and crafts)
© OCP Paediatrics, L&D and BKL 2023 © OCP Paediatrics, L&D and BKL 2023
431
Appendix 2
2.1 Weight for age – girls (birth to 6 months and birth to 5 years)
432
Appendix 2
433
Appendix 2
2.4 Weight for age – boys (birth to 6 months and birth to 5 years)
434
Appendix 2
435
Appendix 3
Oxygen saturation
Temperature (⁰C)
Normal range %
AVPU
AVPU to assess level of consciousness in childrena
A Alert
U Unresponsive
a Blantyre and Glasgow Coma Scales can also be used to assess conscious level in children but are more complex
and less useful in emergency situations (see Appendix 13).
b A painful stimulus can be given by applying supra-orbital pressure at the supraorbital notch or by applying
pressure to the nailbed.
436
Appendix 3
AVPU is used for emergency assessment of neurological status as it is a quick and simple tool.
It is used to screen for any deviation from normal level of consciousness. Any score below ‘A’
is abnormal and should prompt a more detailed neurological assessment and evaluation of
conscious level e.g. Glasgow Coma Scale (see Appendix 13). Scores of ‘P’ or ‘U’ indicate coma.
Blood pressure
Normal blood pressure for children according to agec
Systolic Diastolic
Systolic
Age (50th to 90th (50th to 90th
hypotension
percentile for age) percentile for age)
c BP ranges correspond to an average of male and female data for children with height between 25th and
75th centile for age. Data adapted from Tables 4 and 5 of reference:
Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High
Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.
https://doi.org/10.1542/peds.2017-1904
437
Appendix 4
An oropharyngeal airway can be used in an unconscious child to lift the tongue and pharyngeal
soft tissues off the posterior pharynx to maintain a patent airway.
To choose the correctly sized oral airway, hold it along the side of the child's face with the
flange at the corner of the mouth (Figure 4.1). The tip of the airway should reach the angle of
the mandible. It should be inserted in the same direction as its final position, using a tongue
depressor to push the tongue to the floor of the mouth to avoid pushing the device into the
base of the tongue. Once in place, it allows air to flow into the airway unobstructed (Figure 4.2).
438
Appendix 5
5. Provide privacy
439
Appendix 5
Procedure
20. Place the needle at a 90° angle from the bone and
insert the intraosseous needle with a rotating
mechanism through the skin/subcutaneous
tissue until bone is reached.
Then STOP
440
Appendix 5
441
Appendix 5
442
Appendix 6
A lumbar puncture (LP) is a relatively simple and safe procedure, but it is frightening for most
children and their parents/carers. Be sure to explain the procedure and urgent indications to
the parent/carer and provide reassurance to both the child and parents/carers.
LP is indicated to confirm a diagnosis of meningitis or encephalitis and should only be performed
if a laboratory is available and capable of analysing any cerebrospinal fluid (CSF) collected for
microscopy and biochemistry as a minimum. If available, culture and GeneXpert should also
be performed. LP should only be carried out by a clinician trained to do so.
Treatment with antibiotics should not be delayed in order to perform an LP. Ideally an LP
should be performed before antibiotic administration but if there are any contraindications
or if performing the procedure is likely to delay antibiotic administration by more than 30
minutes, administer antibiotics first. Results of an LP performed up to 2-3 days after antibiotic
administration can still be useful.
Contraindications
Ensure that there are no contraindications to LP and that consent has been obtained from the
patient or parent/carer.
Contraindications to LP are:
– Severe cardiopulmonary instability that potentially requires prompt resuscitation measures
(e.g. shock)
– Obvious signs of increased intracranial pressure (ICP), other than bulging fontanelle:
decerebrate or decorticate posturing, absent doll’s eye reflex, abnormal respiratory pattern,
unequal pupil size or dilatation of pupils
– Focal neurological signs
– Focal seizures or seizures within the last 30 minutes
– Bradycardia, hypertension
– Obvious bleeding disorder and/or low platelet count (< 80 000 platelets/microlitre)
– Skin infection over the site for LP
Equipment
You will need two people to perform this procedure – one trained clinician to carry out the LP,
and one assistant to hold the child in the correct position.
Equipment includes:
– Spinal needle for LP, 22 G (0.7 x 40 mm)
– Antiseptic solution for skin
– Sterile gloves
– Surgical mask
– 4 x 4 sterile compresses
– Lidocaine 1% (without epinephrine)
– Tubes for collection of CSF (non-sterile red-top blood tubes can be used if you are not
obtaining a CSF culture).
443
Appendix 6
Positioning
The most important determinant of a successful lumbar puncture is how well the child is held.
Ensure that the child is held firmly enough to keep them still but comfortable. The spine should
be curled as much as possible to open the vertebral spaces, with attention to avoid over-
flexion of the neck which can cause respiratory compromise. Watch the patient carefully to
ensure that their breathing remains regular and calm. Monitor oxygen saturations throughout
the procedure.
Young children should be held lying down (Figure 6.1), while an older child can be held either
lying down or sitting up (Figure 6.2). Feel for the posterior-superior iliac crests on each side
and visualise an imaginary line running between the iliac crests – this line intersects the spine
at approximately the fourth lumbar vertebrae (L4). Feel for the intervertebral spaces of L3-4
and L4-5 and mark the chosen space by pressing the fingernail lightly into the skin overlying
the space to leave a small indentation.
Figure 6.1 - Positioning and holding a child on their side for LP
444
Appendix 6
Procedure
Wash and disinfect your hands with an alcohol-based solution. Put on sterile gloves and take
standard precautions. Disinfect the insertion site in a large circular motion from centre to
periphery using antiseptic solution. Carefully palpate again the chosen intravertebral space
(either L3-4 or L4-5) without touching any non-sterilised skin. Administer local anaesthetic
(see Chapter 15, Section 15.4.6).
Needle insertion and CSF collection
– Hold the needle in your dominant hand.
– Advance the needle slowly through the spinous ligaments, aiming slightly towards the
umbilicus (see Figure 6.3).
– Once a slight “pop” is felt, remove the stylet slowly.
– Place the stylet on a sterile surface for later reinsertion.
– Let CSF drip out slowly and collect 1–2 mL, according to laboratory capabilities.
– If no CSF comes out, rotate the needle slowly; if there still is no CSF, reinsert the stylet and
advance very slowly (1 mm) and repeat the procedure.
– Note the pressure, colour, and clarity of the CSF flow.
– Once CSF has been collected, replace the stylet prior to removing the needle.
– Apply compression to the area and apply a small protective dressing.
Figure 6.3 - Needle insertion for LP
Monitoring
Monitor the child for 1–3 hours post-procedure. Vital signs, including AVPU, should be taken
immediately post-procedure and then as often as required using an early warning system
(see MSF Manual of Nursing Care Procedures, Assessment and vital signs, Charts: Vital sign
charts). Ensure the sterile dressing is in place, clean and intact. The dressing should stay on
at least for 48 hours. The child should lie down for few hours after the procedure, then can
remain in a position of comfort. They should not be too active (no running, jumping, dancing,
excitement), but movement is not limited. Advise the parent/carer to call for help if any of
the following occur: fever, altered level of consciousness or abnormal behaviour, headache,
nausea/vomiting.
445
Appendix 7
The Clinical Respiratory Score (CRS) is a simple scoring system that can be used to guide
the assessment of respiratory distress and response to treatment. Based on the total score
obtained, the child can be classified as having mild, moderate or severe respiratory distress.
Respiratory rate Age < 2 months: < 50 Age < 2 months: 50-60 Age < 2 months: > 60
(breaths/minute) Age 2-11 months: < 40 Age 2-11 months: 40-50 Age 2-11 months: > 50
Age 1-5 years: < 30 Age 1-5 years: 30-40 Age 1-5 years: > 40
Age > 5 years: < 20 Age > 5 years: 20-30 Age > 5 years: > 30
Based on the total score obtained, 3 categories of respiratory distress are possible:
Mild (≤ 3), Moderate (4-7), Severe (8-12)
1. Nayani K, Naeem R, Munir O, et al. The clinical respiratory score predicts paediatric critical care disposition in
children with respiratory distress presenting to the emergency department. BMC Pediatr. 2018;18(1):339.
https://doi.org/10.1186/s12887-018-1317-2
2. Asthma/Recurrent Wheezing Clinical Guideline | Clinical Standards | Texas Children’s Hospital. Texas Children’s
Hospital. Published January 2019. Accessed November 20, 2023.
https://www.texaschildrens.org/sites/default/files/uploads/documents/outcomes/standards/AcuteAsthma.
pdf
446
Appendix 8
ASTHMA
ACTION PLAN
all inhalers should
be used
with a SPACER
Your child is in
RED ZONE if they have
• Seek medical care immediately
ANY of these: at the clinic/hospital
447
Appendix 9
Copied with permission from MSF Manual of Nursing Care Procedures, Annex – How to make
a spacer with a plastic bottle.
If no commercially produced spacer available within the project, a plastic one can be made from a 500ml plastic
bottle.
A very similar process can be followed for producing a plastic spacer with mouthpiece.
448
Appendix 10
Copied with permission from MSF Manual of Nursing Care Procedures, SOP – Medication
administration by inhalation using a spacer.
MSF Manual of Nursing Care Procedures
Pre-procedure
3. Explain procedure to patient or caregiver, ensuring the patient/caregiver understands why he/she is
receiving the treatment, the risks and benefits of receiving the medication and what the possible side
effects are. Allow patient/caregiver to ask questions and obtain verbal consent
4. Ensure the patient does not have any known allergies to medications
11. Confirm the patient’s identity and check that it matches the medical prescription
13. If necessary, clear the upper airways by asking the patient to blow his/her nose or clearing the
patient’s nose
14. Remove mouthpiece cover from inhaler and shake the inhaler well for 2-5 seconds
16. Ask the patient to create a seal with their mouth over the mouthpiece or ensure that the mask
covers the nose and mouth and apply gently to the face to create a seal
17. Ask the patient to slightly tilt their head backwards while inhaling slowly and deeply. Press down on
the canister to deliver the medication
18. If possible, the patient should hold his/her breath for 10 seconds and then breathe out.
If this is not possible, follow the next step
19. If patient unable to hold breath, instruct the patient to breathe normally for 4-6 breaths
20. If more than one dose/puff is needed, wait 30 seconds while the patient breathes normally, shake
the inhaler and repeat steps 16-19
22. If the medication administered was a corticosteroid, ensure the patient rinses his/her mouth with
water 2 minutes after administration
Post-procedure
24. Take apart the spacer, clean the mouthpiece or facemask and spacer and allow to air dry
25. Document administration and assessment findings in the patient’s file
450
Appendix 11
451
Appendix 11
a If an electric suction device is used, the suction pressure should be 80-100 mmHg for children 1-11 months;
100-120 mmHg for children 1-10 years.
452
Appendix 12
– In addition, give extra ORS to replace fluids lost with each loose stool according to plan A
(above).
– Reassess degree of dehydration after 4 hours and continue with appropriate treatment plan.
If dehydration has resolved, management with plan A can continue at home.
453
Appendix 13
454
Appendix 13
455
Appendix 13
456
Appendix 14
2. Confirm the patient’s identity and check that it matches the medical request
3. Explain procedure to patient or caregiver in their preferred language and why they require the
procedure and the benefits and risks of receiving it. Allow the patient/caregiver to ask questions and
obtain verbal consent
4. Obtain a history of the illness
5. Ask whether the patient/caregiver is able to collect the sample on their own
10. Perform hand hygiene. If patient requires assistance, put on non-sterile gloves and other PPE
11. Ask the patient/caregiver to wash their own hands before urine collection
12. If the patient can do the collection independently, explain the procedure and collection process
13. Allow the patient to use the latrine/toilet. If none are available, provide privacy and give the patient a
bedpan or urinal
14. Retract the foreskin (if patient male) or separate the labia (if patient female) and clean the skin
surrounding the urethral meatus with soap and water or 0.9% sodium chloride
15. Ask the patient to begin voiding first stream of urine into the toilet or bedpan/urinal
457
Appendix 14
17. Once the urine container is sufficiently full, allow the patient to continue voiding in the latrine/toilet or
bedpan/urinal. Close the urine pot, touching only the outside
18. Allow the patient to perform personal and hand hygiene
19. If needed, transfer the urine from the urine pot into a labelled analysis tube
Post-procedure
20. If excess urine was collected in a bedpan/urinal/pot, dispose of urine correctly in the dirty utility (sluice
room)/toilet or as per local procedure
21. Clean/disinfect tray/trolley, urine pot and bedpan/urinal, if needed
458
Appendix 14
2. Confirm the patient’s identity and check that it matches the medical request
3. Explain procedure to patient or caregiver in their preferred language and why they require the
procedure and the benefits and risks of receiving it. Allow the patient/caregiver to ask questions and
obtain verbal consent.
4. Obtain a history of the illness
5. Provide privacy
17. Check every 20-30 minutes if the patient has urinated to obtain fresh sample and avoid overfilling.
18. Once 10-15 ml of urine in the bag, perform hand hygiene and apply non-sterile gloves/PPE
19. Using a non-touch technique, carefully remove the bag from the skin and transfer sample into the
urine pot and close the lid
460
Appendix 14
Pre-procedure
1. Perform hand hygiene
3. Provide privacy
4. Explain procedure to patient or caregiver in his/her preferred language, including what the urinary catheter
is for, why they require it and the benefits and risks of inserting one. Agree on a stop signal with the patient
that can be used to indicate that he/she wishes to stop the procedure.
Procedure
11. Perform hand hygiene
13. Place the sterilie drape on the top shelf of the dry trolley. Using a non-touch technique, open and prepare
the equipment onto the sterile drape.
For male patients: with the non-dominant hand, lift the penis at a 60-90° angle and retract the foreskin (if
present). This hand will remain here throughout the rest of the procedure
23. Using a non-touch technique, use the dominant hand to disinfect the insertion site with the appropriate
antiseptic and sterile gauze. If available, use sterile forceps
24. Place the open end of the catheter inside the sterile kidney dish and place the sterile kidney dish between
the patients legs, holding the tip of the catheter to remain sterile
25. For female patients: using the dominant hand introduce the tip of the catheter into the urethra in an
upward and backward direction. Advance the catheter until urine drains and then advance another 6-8cm
For male patients: with the non-dominant hand holding the penis firmly at a 60-90° angle, insert the tip of
the catheter into the urethra and slowly advance the catheter. Once urine flows, advance catheter another
6-8 cm. If resistance is felt at the external sphincter, pause for 10-20 seconds and instruct the patient to
breathe deeply and evenly. Increase the traction on the penis slightly and apply steady, gentle pressure on
the catheter while the patient exhales or while giving a cough
26. If no urine flows, or resistance is still felt, stop the procedure, remove catheter and discard. Re- attempt
with a new sterile catheter that has been lubricated as above.
27. Use the bed pan to collect large amounts of urine from the bladder
28. If collecting urine for laboratory analysis, use sterile collection pot and obtain sample from the end of
catheter
29. Note the colour, odour, clarity and quantity of urine drained into the kidney dish
Post-procedure
31. Remove towel/draw sheet, assist patient to replace underwear or gown over genitals and ensure the bed
linen is not soiled (if soiled or wet, replace with clean dry linen)
32. Ensure waste is disposed of according to local procedure.
Remove sterile gloves and PPE, discard single-use items.
33. Perform hand hygiene
462
Appendix 15
Suprapubic bladder aspiration (SPA) is a safe and effective method for obtaining urine specimens
in infants and children younger than 2 years when a urinary tract infection is suspected. It is
the most reliable way to obtain an uncontaminated urine sample for culture and avoids delay
in administration of antibiotics for unwell febrile children while awaiting a clean-catch sample.
SPA should be performed by an experienced clinician who is trained in the procedure, ideally
with the support of ultrasound to maximise success.
Contraindications
Ensure that there are no contraindications to SPA and that consent has been obtained from
the patient or parent/carer.
Contraindications to SPA are:
– Obvious or unexplained bleeding disorder
– Abdominal distension
– Massive organomegaly
– Skin infection over the site for SPA
Equipment
You will need two people to perform this procedure – one trained clinician to carry out the
SPA, and one assistant to hold the child in the correct position.
Equipment includes:
– 22G or 23G needle
– 3 mL or 5 mL syringe
– Antiseptic solution for skin
– Sterile gloves
– 4 x 4 sterile compress
– Urine specimen pot
– POCUS machine, if available and staff trained in its use
Preparation
To ensure maximum success, ensure that the child has not urinated in the last 30 minutes.
If they have, give fluids (water by mouth or IV maintenance fluids if unable to drink, see
Chapter 15, Section 15.2) and wait 30 minutes before performing the procedure. Check that
the bladder is dull to percussion before starting the procedure or use POCUS, if available, to
confirm that the bladder is full. If the bladder is empty, SPA is not recommended.
463
Appendix 15
Position
With the child in the supine position, use one arm to hold the legs extended in a frog-leg
position and the other on the upper abdomen/torso to keep the child still. Only get the child
into position and remove the nappy immediately before the procedure to avoid stimulating
urination. Occlude the urethral opening just before needle insertion because the procedure
will stimulate urination in many children.
Procedure
– Identify the puncture site by visualising a line between the umbilicus (belly button) and
pubic symphysis. The site for needle insertion is in the midline, about 1-2 cm above the
pubic symphysis, approximately at the lower abdominal crease (see Figure 15.1).
Figure 15.1 - Landmarks to identify needle insertion site
464
Appendix 15
Post-procedure care
– Apply a light dressing to cover the puncture site.
– No specific post-procedure care is required.
Complications
– Microscopic haematuria is common and not a concern.
– Rare complications include bladder haematoma, macroscopic haematuria, bladder
haemorrhage, intestinal perforation.
465
Appendix 16
Body surface area can be estimated based on weight alone using the following tables,
reproduced from reference1.
Body weight Surface area Body weight Surface area Body weight Surface area
(kg) (m2) (kg) (m2) (kg) (m2)
2 0.16 17 0.71 40 1.3
2.5 0.19 18 0.74 41 1.3
3 0.21 19 0.77 42 1.3
3.5 0.24 20 0.79 43 1.3
4 0.26 21 0.82 44 1.4
4.5 0.28 22 0.85 45 1.4
5 0.3 23 0.87 46 1.4
5.5 0.32 24 0.9 47 1.4
6 0.34 25 0.92 48 1.4
6.5 0.36 26 0.95 49 1.5
7 0.38 27 0.97 50 1.5
7.5 0.4 28 1.0 51 1.5
8 0.42 29 1.0 52 1.5
8.5 0.44 30 1.1 53 1.5
9 0.46 31 1.1 54 1.6
9.5 0.47 32 1.1 55 1.6
10 0.49 33 1.1 56 1.6
11 0.53 34 1.1 57 1.6
12 0.56 35 1.2 58 1.6
13 0.59 36 1.2 59 1.7
14 0.62 37 1.2 60 1.7
15 0.65 38 1.2
16 0.68 39 1.3
1. Sharkey I, Boddy AV, Wallace H, et al. Body surface area estimation in children using weight alone: application
in paediatric oncology. Chemotherapy Standardisation group of the United Kingdom Children’s Cancer Study
Group. Br J Cancer. 2001;85(1):23-28.
https://doi.org/10.1054/bjoc.2001.1859
466
Appendix 17
467
Appendix 18
Copied with permission from MSF ITFC Nutritional Care Protocol 2021, Children 1-59 months:
ANNEXInpatient,
5 – QU ICK158.
page TABLE: CALCULATING AMOUNTS OF F-75 IN PHASE 1
Nutritional Care Protocol – Children 1-59 months – Inpatient – MSF June 2021 158
468
Appendix 19
a Treatment success is best defined by maternal viral load < 1000 copies/mL during the last 6 months of
pregnancy, at delivery and during breastfeeding.
b Defined as a new HIV diagnosis in a pregnant or breastfeeding woman with a previous negative test during
pregnancy.
c AZT = zidovudine; 3TC = lamivudine; NVP = nevirapine.
469
Appendix 19
Table 19.2 - Simplified ARV prophylaxis for high-risk neonates and infantsd
Age Simplified prophylaxis for high-risk neonate and infant
AZT 60 mg/3TC 30 mg/NVP 50 mg:
Birth to 6 weeks
¼ tab, two times daily
AZT 60 mg/3TC 30 mg: Plus NVP 50 mg:
> 6 to 12 weeks 1 tab, two times daily ½ tab, once daily
Or NVP 50 mg alone: ½ tab, once daily
Standard WHO recommended (2016) ARV prophylaxis regimen for high-risk neonates
To be used if part of the national recommendation. Where available, give NVP and AZT
combined regimen from birth to 12 weeks. Adjust dose according to birth weight for LBW
neonates receiving ARV prophylaxis at or around birth (see Table 19.3).
Table 19.3 - WHO recommended ARV prophylaxis for high-risk neonates and infants
NVP 10 mg/mL syrup AZT 10 mg/mL syrup
Birth weight or age
or 50 mg tablet or 60 mg tablet
≥ 1.5 to < 2 kg 2 mg/kg*, 4 mg/kg*,
and ≥ 35 weeks GAe once daily two times daily
1 mL syrup, 1 mL syrup,
≥ 2 to < 2.5 kg
once daily two times daily
≥ 2.5 kg 1.5 mL syrup, 1.5 mL syrup,
Birth to 6 weeks once daily two times daily
½ tab or 2 mL syrup, 1 tab,
> 6 to 12 weeks once daily two times daily
Or NVP alone, according to weight
* For low birthweight (LBW) neonates, the dose is expressed in mg/kg in order to be very precise (less than 1 mL).
– If this is too complicated for the mother, choose the simplified regimen above.
– If appropriate formulations are not available, give NVP alone from birth to 12 weeks.
In addition, for all HIV-exposed neonates and infants start cotrimoxazole prophylaxis from
4 to 6 weeks of age and continue until HIV infection has been excluded (see Chapter 13,
Section 13.4.4).
d This simplified prophylactic regimen has not been formerly evaluated yet but has been discussed with WHO
experts who recognize the importance of simplicity for success.
e Note: Very preterm neonates will need further reduced doses.
470
Appendix 20. Causes of fever of unknown origin (FUO)
Table 20.1 - Typical pathogens causing FUO according to clinical diagnosis. Adapted from reference1
Infectious causes
Clinical diagnosis Non-infectious causes
Bacterial Viral Parasitic Fungal
Systemic; sepsis; shock Gram-positive: S. pyogens, Dengue, HIV, VHF Malaria HLH
S. aureus, Pneumococcus. MAS
Gram-negative: N. meningitidis, Acute leukaemia/
enteric Gram-negatives, lymphoma
Pseudomonas spp. Neuroblastoma
Rickettsial agents (RMSF, Drug fever
Ehrlichiosis) Lupus
Meningitis; Leptospirosis, M. tuberculosis, Lymphocytic Naegleria spp., Cryptococcus, Ruptured
parameningeal C. tetani choriomeningitis, HIV Baylisascaris, coccidiodomyses, craniopharyngioma
infection (mastoiditis, Trypanosoma brucei histoplasma, IVIG use
subdural/epidural gambiense or blastomyces NSAID use
abscess) rhodesiense
Cervical lymphade- Non-group A Streptococcus: EBV, CMV, HIV, Toxoplasmosis, Kikuchi-Fujimoto
nopathy (predominant); Groups C and G Adenovirus African and American disease
pharyngitis/tonsillitis; Arcanobacterium; trypanosomiasis HLH
peritonsillar or Fusobacterium, other Kawasaki disease
parapharyngeal abscess anaerobes ALPS
Endocarditis; HACEK bacteria, Bartonella, American Kawasaki disease
pericarditis; peripheral Coxiella, Legionella, CONS, trypanosomiasis Rheumatic disease
venous infection Streptobacillus, Enterococci, PAN
enteric gram-negative bacteria, Postinfectious
S. aureus, pyogenic organisms, SLE
Mycobacteria
Appendix 20
471
472
Infectious causes
Clinical diagnosis Non-infectious causes
Bacterial Viral Parasitic Fungal
Appendix 20
Abbreviations: VHF, viral hemorrhagic fever; RMSF, Rocky Mountain spotted fever; CONS, coagulase negative staphylococci; HACEK, Haemophilus, Aggregatibacter, Cardiobacterium,
Eikenella, Kingella; HSV, Herpes simplex virus; UTI, Urinary tract infections, ALPS, autoimmune lymphoproliferative syndrome; GABS, Group AB hemolytic Streptococcus; IBD,
Inflammatory bowel disease; HLH, Hemophagocytic Lymphohistiocytosis, MAS, macrophage activation syndrome; IVIG, intravenous immune globulin, NSAID, Non-steroidal anti-
inflammatory drugs, PAN, polyarteritis nodosa, JIA, Juvenile idiopathic arthritis, HIB, Haemophilus influenzae type B.
Table 20.2 - Vector-borne and zoonotic causes of FUO
Epidemiology/
Cause History Clinical findings Laboratory Treatment
exposures
Brucella Sustained fever Worldwide, mainly Hepato- Rose-Bengal test Children < 8 years:
Brucella patterns, night sweats, rural areas animal splenomegaly, and/ (RBT), co-trimoxazole PO, 20 mg/kg
chills, asthenia, joint or animal products or lymphadenopathy mild elevation of SMX (max. 800 mg) + 4 mg TMP/
and muscle pain. (unpasteurized milk/ hepatic enzymes, kg (max. 160 mg), 2 times daily
Osteoarticular pain: cheese, insufficiently lymphocytopenia + rifampicin PO, 15-20 mg/kg
sacroiliitis, arthritis, cooked/raw meat) (max. 600 mg) once daily for
orchitis. 6 weeks (or gentamicin IM,
Meningoencephalitis 5 mg/kg once daily for 2 weeks).
Children ≥ 8 years:
doxycycline PO, 2-2.2 mg/kg
(max. 100 mg) 2 times daily for
6 weeks
+ rifampicin (or gentamicin), as
above.
Leptospirosis Mild form: high Animal urine Relative bradycardia, Thrombocytopenia Mild form:
Leptospira fever, rigors, myalgia, (rodents), bulbar conjunctivitis, Proteinuria doxycycline PO, 2-2.2 mg/kg
headache, anorexia, contaminated soil pharyngeal Pyuria (max. 100 mg) 2 times daily for
abdominal pain, nausea, or water, infected hyperemia Granular casts 7 days.
vomiting, cough, chest animal tissue Alternatively, azithromycin PO,
pain. Chest X- ray: small 10 mg/kg (max. 500 mg) once
Flooding nodular densities on D1, then 5 mg/kg (max.
Severe form (Weil’s 250 mg) once daily on D2
syndrome): onset and D3, especially in children
same as mild + < 8 years old.
acute hepatorenal
manifestations, Severe form:
jaundice, oligo-anuria, ceftriaxone IV, 80-100 mg/kg
purpura, ecchymosis, (max. 2 g) once daily for 7 days.
epistaxis, hemoptysis, Alternatively, benzylpenicillin
myocarditis, pericarditis. IV, 50 000 IU (30 mg)/kg (max.
2 MIU or 1200 mg) every
6 hours for 7 days.
Appendix 20
473
474
Epidemiology/
Cause History Clinical findings Laboratory Treatment
exposures
Appendix 20
Schistosomiasis Acute infection Contaminated water Lymph-node Eosinophilia, Children over 4 years old:
Schistosoma (Katayama fever): enlargement Hematuria praziquantel PO, 40 mg/kg
(haematobium, sudden onset of single dose. Give pre-treatment
mansoni, japonicum) fever, urticaria and prednisolone for 7 days in
angioedema, chills, Katayama fever.
myalgias, arthralgias,
dry cough, diarrhea,
abdominal pain, and
headache.
Borrelia/Relapsing Febrile episodes Body lice, Splenomegaly, Blood smear for doxycycline PO, 4 mg/kg (max.
fever separated by Cold climate/season, bleeding signs, spirochetes 100 mg) single dose
afebrile periods of Overcrowding, jaundice, or
Louse borne
approximately 7 days. Poor sanitation neurological erythromycin PO
(epidemic): Borrelia
symptoms 250 mg single dose (< 5 years
recurrentis High fever, headache, old);
asthenia, diffuse pain, 500 mg single dose (≥ 5 years
anorexia, abdominal old)
pain, vomiting, diarrhea or
azithromycin PO, 10 mg/kg (max.
500 mg) single dose
Borrelia/Relapsing Fever, headache, Temperate/ warm Splenomegaly Blood smear for doxycycline PO, 2-2.2 mg/kg
fever asthenia, muscle regions Hepatomegaly spirochetes, (max. 100 mg) 2 times daily for
and bone pain, Rural areas in SSA Conjunctival CSF analysis for 7-10 days
Tick borne (epidemic):
photophobia, cough hyperemia spirochetes if CNS or
Borrelia duttoni
Cranial nerve palsies, Lymphadenopathy involvement azithromycin PO, 10 mg/kg
meningitis (max. 500 mg) once daily for
7-10 days, especially in children
Fever lasts 3-6 days < 8 years old
and re-appears after or
7-10 days ceftriaxone IV, 50-75 mg/
kg (max. 2 g) once daily for
10-14 days, if CNS involvement
Epidemiology/
Cause History Clinical findings Laboratory Treatment
exposures
Q Fever Flu-like symptoms Contact with farm Minimal auscultatory Elevated liver doxycycline PO, 2-2.2 mg/kg
Coxiella burnetii (fatigue, headache, animals (cattle, abnormalities, enzymes, (max. 100 mg) 2 times daily for
myalgias) with a goats, sheep) Hepatomegaly thrombocytopenia 14 days or
prolonged fever or
(1-3 weeks), Consumption of raw co-trimoxazole PO, 2-10 mg/kg
hepatitis, pneumonia, milk of the trimethoprim component
endocarditis 2 times daily (max. 320 mg/
24 hours) for 14 days (especially
in children < 8 years old)
Amoebic abscess Right upper quadrant More frequent young Hepatomegaly Leukocytosis, tinidazole PO, 50 mg/kg (max.
Entamoeba histolytica pain, fever (38.5 to adults elevated alkaline 2 g) once daily for 5 days
39.5ºC) phosphatase and or
hepatic enzymes metronidazole PO, 15 mg/kg
Cough, sweating, 3 times daily for 5-10 days
malaise, weight loss,
anorexia, and hiccup
Cat scratch disease Cutaneous lesion at Scratch or bite from Regional Nonspecific tests, azithromycin PO, 10 mg/kg
Bartonella henselae the site of inoculation an infected cat, lymphadenopathy, Serology (max. 500 mg) once on D1, then
that evolves through exposure to cat fleas, hepato- 5 mg/kg (max. 250 mg) once
vesicular, erythematous, contact with cat splenomegaly, or daily for 4 days
and papular phases saliva through broken ocular manifestation
with enlarged lymph skin or mucosal
nodes proximal to the surfaces (i.e., mouth
inoculation site. and eyes).
Visceral involvement
(liver, spleen) is rare but
presents with persistent
fever, abdominal pain,
and/or weight loss
Parinaud oculo-
glandular syndrome,
Neuroretinitis,
encephalopathy.
Appendix 20
475
476
Epidemiology/
Cause History Clinical findings Laboratory Treatment
exposures
Appendix 20
African tick bite fever Mild headache, Rural Africa Patients with severe Liver function tests doxycycline PO, 2.2 mg/kg
Rickettsia africae fever, myalgias, infections may have mildly abnormal, (max. 100 mg) 2 times daily for
solitary or multiple neurologic, cardiac, thrombocytopenia 5-7 days (or until 3 days after
eschars with regional ocular, or renal disappearance of fever).
lymphadenopathy complications.
Generalized rash In severe infections, add a
Mediterranean (vesicular or Mediterranean area loading dose of doxycycline PO,
spotted fever maculopapular) 4.4 mg/kg (max. 200 mg) on D1
Ricketssia conorii overlooked or before continuing twice daily
completely absent. dosing as above.
Long-lasting subacute
neuropathy and
myocarditis
Fever, headache,
maculopapular rash
with eschar or black
necrotic scabbed lesion
(tache noire) at the site
of the inoculating tick
bite.
1. Chusid MJ. Fever of Unknown Origin in Childhood. Pediatr Clin North Am. 2017;64(1):205-230.
https://doi.org/10.1016/j.pcl.2016.08.014
Appendix 21
Note everything you observe, even if you think the symptoms are not due to pain but to fear, tiredness or illness severity.
Analgesic
Name sign sign Following assessments
sign Assessment at admission
moderate strong and/or after analgesic3
sign weak
or present or present
absent or at rest 1 during examination2
about half almost R R R R
transient
the time all the time (R) or mobilization (M) M M M M
Vocal or verbal expression
cries and/or screams and/or moans
0 1 2 3
and/or complains of pain
Facial expression
furrowed forehead and/or frown, furrowed
0 1 2 3
or bulging brow and/or tense mouth
Movements
restlessness, agitation and/or rigidity
0 1 2 3
and/or muscular tenseness
Postures
unusual and/or antalgic posture and/or
0 1 2 3
protection of the painful area and/or immobility
Interaction with the environment
can be comforted and/or interested in normal low very low absent
playing and/or interacts with people 0 1 2 3
Remarks Total /15
Signature
1
At rest (R): observe the child from a distance, before performing any examination or procedure, at rest, ensuring the best possible conditions of safety and comfort, for example with his/her parents, when he/she is playing.
2
During examination or mobilization (M): assess pain during examination or mobilization or palpation of the painful area by nurse or by doctor.
3
Reassess pain regularly after analgesic administration: wait 30 to 45 minutes if analgesic is administered by oral or rectal route, 5 to 10 minutes if administered by IV route. Note whether the child is at rest (R) or mobilized (M).
Pain 2012, 153: 1573-1582. Contact: elisabeth.fournier-charriere@bct.aphp.fr - © 2011 - Evendol Group Graphic design: Zid et Zen communication - zidetzen@club-internet.fr
Reprinted with permission from authors of original paper1. Copyright Evendol Group. More
information at https://pediadol.org/.
Score rating:
– Score 1/15 to 3/15: mild pain
– Score 4/15 to 7/15: moderate pain
– Score 8/15 to 15/15: severe pain
1. Fournier-Charrière E, Tourniaire B, Carbajal R, et al. EVENDOL, a new behavioral pain scale for children ages
0 to 7 years in the emergency department: Design and validation. Pain. 2012;153(8):1573-1582.
https://doi.org/10.1016/J.pain.2012.02.024
477
Appendix 22
The following tables give target daily enteral feed volumes during the acute phase of critical
illness only (up to maximum of 7 days), calculated using the Schofield energy equations which
estimate basal metabolic rate (BMR). All volumes have been rounded for ease of administration.
Enteral feeds using these calculations should only be continued in infants and children who are
unable to eat and drink by mouth, up to a maximum of 7 days. As soon as they improve, feeds
should be increased in infants and children should be commenced on full oral feeds as per
usual diet.
Acute phase
Weight 30% of 50% of 70% of Target
Feed
(kg) 3-hourly feed 3-hourly feed 3-hourly feed 3-hourly feed
volume (mL) volume (mL) volume (mL) volume (mL)
3 8 15 18 30
4 12 20 28 40
Expressed 5 15 25 35 50
breastmilk/ 6 18 30 42 60
standard
infant 7 20 35 50 70
formula 8 24 40 56 80
9 28 45 62 90
10 30 50 70 100
a For standard enteral fluid volumes in infants, see Chapter 15, Table 15.16.
478
Appendix 22
a) Target daily enteral feed volumes according to weight in the acute phase of critical illness
8 440
9 500
10 555
11 620
Isocaloric enteral nutrition
product (1 kcal/mL)/F-100
12 675
13 740
17 790
15 850
Acute phase
Weight
Feed 30% of 50% of 70% of Target
(kg)
3-hourly feed 3-hourly feed 3-hourly feed 3-hourly feed
volume (mL) volume (mL) volume (mL) volume (mL)
8 15 28 40 55
9 20 32 45 65
Isocaloric 10 20 35 50 70
enteral
11 25 40 55 80
nutrition
product
12 25 42 60 85
(1 kcal/mL)/
F-100 13 28 48 65 95
14 30 50 70 100
15 32 52 75 105
479
Appendix 22
a) Target daily enteral feed volumes according to weight in the acute phase of critical illness
12 775 730
13 800 750
14 825 770
Isocaloric enteral
nutrition product 15 845 790
(1 kcal/mL)/F-100
16-19 900 840
Acute phase
12 30 30 50 45 70 65 95 90
13 30 30 50 50 70 70 100 95
Isocaloric
enteral 14 30 30 55 50 75 70 105 95
nutrition
15 30 30 55 50 75 70 105 100
product
(1 kcal/ 16-19 35 30 60 55 80 75 115 105
mL)/F-100
20-24 40 35 65 60 90 85 125 120
480
Appendix 22
a) Target daily enteral feed volumes according to weight in the acute phase of critical illness
Acute phase
481
Belgium Médecins Sans Frontières/Artsen Zonder Grenzen
46 Rue de l’Arbre Bénit, 1050 Brussels
Tel.: +32 (0)2 474 74 74
Fax: +32 (0)2 474 75 75
E-mail: info@brussels.msf.org