Stages in the management of the sick child ix Chart 1. Stages in the management of the sick child admitted to hospital: summary of key elements x How the manual is organized xi How the manual can be used xii List of abbreviations xiii Chapter 1 Emergency triage assessment and treatment 1.1 Summary of steps in emergency triage assessment and treatment 1.2 Assessment for emergency and priority signs 1.3 Give emergency treatment 1.3.1 How to manage the airway 1.3.2 Other emergency treatment 1.4 Give emergency treatment to the child with severe malnutrition Chart 2. Triage of all sick children Chart 3. How to manage the airway in a choking child Chart 4. How to manage the airway in a child with obstructed breathing Chart 5. How to give oxygen Chart 6. How to position the unconscious child Chart 7. How to give IV fluids rapidly for shock Chart 8. How to give IV fluids for shock in a child with severe malnutrition Chart 9. How to give diazepam (or paraldehyde) rectally for convulsions Chart 10. How to give IV glucose Chart 11. How to treat severe dehydration in an emergency setting Chapter 2 Assessment and diagnosis 2.1 Child presenting with lethargy, unconsciousness or convulsions 2.2 Child presenting with cough or difficult breathing 2.2.1 Conditions presenting without wheeze, stridor or chronic cough 2.2.2 Conditions presenting with wheeze 2.2.3 Conditions presenting with stridor 2.2.4 Conditions presenting with chronic cough 2.3 Child presenting with diarrhoea 2.4 Child presenting with fever 2.4.1 Fever lasting longer than 7 days Chapter 3 Cough or difficult breathing 3.# Foreword
The manual focuses on the inpatient management of the major causes of childhood mortality, such as pneumonia, diarrhoea, severe malnutrition, malaria, meningitis, measles, and related conditions. It complements standard, more comprehensive paediatric textbooks, which should be consulted for information on the management of rarer conditions or complications. Details of the principles underlying the guidelines can be found in technical review papers published by WHO (see References, page 123).
This manual is part of a series of documents and tools that support the Integrated Management of Childhood Illness (IMCI). It is consistent with the IMCI guidelines for outpatient management of sick children. They are applicable in most areas of the world and may be adapted by countries to suit their specific circumstances. WHO believes that their widespread adoption would improve the care of children in hospital and lead to lower case fatality rates.
This manual is for use by doctors, senior nurses and other senior health workers who are responsible for the care of young children at the first referral level in developing countries. It presents up-to-date clinical guidelines, prepared by experts, for both inpatient and outpatient care in small hospitals where basic laboratory facilities and essential drugs and inexpensive medicines are available. In some settings, the manual can be used in large health centres where a small number of sick children can be admitted for inpatient care.
The guidelines require the hospital to have (1) the capacity to carry out certain essential investigations-such as blood smear examinations for malaria parasites, estimations of haemoglobin or packed cell volume and blood glucose, blood grouping and crossmatching, and basic microscopy of CSF and urine-and (2) essential drugs available for the care of seriously ill children (see Appendix 2, page 135). Expensive treatment options, such as new antibiotics or mechanical ventilation, are not described.

# viii ix
Stages in the management of the sick child diagnoses and clinical findings that favour specific diagnoses. After deciding the main diagnosis and any secondary diagnoses or problems, treatment should be planned and started. If there is more than one diagnosis or problem, their treatment recommendations may have to be taken together.
q If the diagnoses or problems require inpatient care, the child's progress in response to treatment in hospital should be monitored. If progress is poor, alternative diagnoses or treatments should be considered.
When the child's condition has improved, a decision should be made on when to discharge the child-and this should be planned for accordingly. Continuing care or follow-up should be arranged in liaison with first-level or community health workers, where appropriate. This process is shown in Chart 1 on page x.
q If the child's diagnoses or problems can be treated with outpatient care, it is important to teach the mother how to give all treatments at home and to advise her when to return with the child in case of an emergency and for follow-up. This manual describes a sequential process for managing sick children as soon as they arrive in hospital, the first stage of which is quick screening (triage) to identify those who need emergency treatment and those who are at special risk and should be given priority, such as very young infants and severely malnourished children.
Every child should be fully assessed. History and examination should consist of both a general or "core" paediatric history and examination, and a "directed" search for symptoms and signs that are relevant to the presenting problems of the child. The nutritional and immunization status of all children should be checked. Feeding should be assessed in all under-2-year-olds and very low weight-for-age children.
The manual focuses on directed assessment, which must include appropriate laboratory investigations, and highlights the symptoms and signs that are related to the major causes of childhood illness and mortality. It does not cover basic paediatric assessment which is taught in medical schools.
Before reaching a diagnosis, all potential differential diagnoses should be considered. The manual presents Tables of the most important differential

# How the manual can be used
This manual can be used for the management of children who present with conditions that require admission to hospital:
q carrying out triage of all sick children (Chapter 1)
q giving treatment in common paediatric emergencies (Chapter 1)
q reaching the correct diagnosis when faced with a child presenting with a specific problem (Chapter 2)
q giving the recommended treatment for the most important paediatric medical problems in developing countries (Chapters 3 to 8)
q giving supportive care (Chapter 9)
q how to monitor the child in hospital (Chapter 10)
q correct discharge procedures and counselling the mother (Chapter 11).

# Sick children who have conditions that can be
managed at home often present with their problem in a local hospital, rather than a first-level health facility. The manual gives guidance on their management:
q carrying out medical assessment and treatment (Chapters 2-6, 8, 9 and 11)
q checking nutritional and immunization status (Chapter 11) q assessment of feeding and nutrition counselling (Chapters 9 and 11)
q counselling the mother on home care and appropriate follow-up (Chapter 11)
q checking paediatric drug dosages (Appendix 2)
q carrying out practical procedures (Appendix 1).

# List of abbreviations

# Emergency triage assessment and treatment
Deaths in hospital often occur within 24 hours of admission. Many of these deaths could be prevented if very sick children are identified soon after their arrival and treatment is started immediately. This chapter outlines a process of rapid triage to determine whether any emergency or priority signs are present. It then describes emergency treatment.
Triage is the process of rapidly screening sick children when they first arrive in hospital and of placing them in one of the following groups:
-those with emergency signs, who require immediate emergency treatment;
-those with priority signs, who should be given priority while waiting in the queue so that they can be assessed and treated without delay;
-non-urgent cases, who have neither emergency nor priority signs.

# Emergency signs include:
q obstructed breathing q severe respiratory distress q central cyanosis q signs of shock (capillary refill longer than 3 seconds; and weak, fast pulse) q coma q convulsions q signs suggesting severe dehydration in a child with diarrhoea (any two of the following: lethargy, sunken eyes, very slow return after pinching the skin)
Children with emergency signs require immediate treatment to avert death.
The priority signs (see below, page 2) identify children who are at a higher risk of dying. These children should be assessed without delay.

# Organization of triage and emergency treatment
Triage should be carried out in the place where the sick child presents at the hospital-before any administrative procedures such as registration. This may require reorganizing the sequence usually followed by patients who arrive in the clinic, e.g. children should be triaged even before their mothers sit in the waiting area. This calls for a nurse to carry out a rapid assessment of each child before weighing and registration.
It is important to carry out rapid triage of children who arrive in the outpatient clinic, especially when the room for emergency treatment is in a separate location. If sick children are brought directly to the paediatric ward, the nurse there must carry out triage and be prepared to move any child with emergency signs rapidly to where help is available and where treatment can be started.
All clinical staff involved in the initial assessment and care of sick children should be trained to carry out triage and, if possible, to give initial emergency treatment. This treatment is based on the use of a limited number of drugs and procedures which can be given safely by nurses and medical assistants after brief training.
The most experienced doctor or health worker should direct the emergency treatment. As the top priority is to give emergency treatment without delay, any trained member of the staff may have to start the emergency treatment while the most experienced person available is called.
After the emergency treatment, the child should be assessed promptly to establish the diagnosis, and given further appropriate treatment (see Chapter 2, page 15, for assessment and diagnosis).

# Summary of steps in emergency triage assessment and treatment
The emergency triage assessment and treatment process is summarized in the Charts on pages 5-14.
First, check for emergency signs. If these signs are found, immediately give the appropriate emergency treatment. Ask and look for any head/neck trauma before positioning the child or moving the head/neck.
Check for emergency signs in two steps:
s Step 1. Check for any airway or breathing problem. If a problem is found, start immediate treatment to restore breathing.
Step 2. Quickly determine if the child is in shock or unconscious or convulsing, or has diarrhoea with severe dehydration. These assessments can be done very quickly and almost simultaneously.
Immediately give emergency treatment if there are positive signs.
These two steps are summarized in Chart 2 on page 5. Most children will not require emergency treatment.
Take careful note if the child is severely malnourished, because this will affect the treatment of shock and dehydration (see section 1.4, page 4, and Chapter 7, page 80).

# If emergency signs are found:
q Call an experienced health professional and others to help, but do not delay starting the treatment. The team needs to stay calm and work together efficiently. The person in charge should assign tasks so that assessment can continue and treatment can be initiated quickly. Other health workers may be required to give the treatment, because a very sick child may need several treatments at once. The experienced health professional should continue assessing the child (see Chapter 2), to identify all underlying problems and develop a treatment plan.
q Carry out emergency investigations (blood glucose, blood smear, haemoglobin). Send blood for typing and cross-matching if the child is in shock, or appears to be severely anaemic, or is bleeding significantly.
q After giving emergency treatment, proceed immediately to assessing, diagnosing and treating the underlying problem.

# If no emergency signs are found:
q Check for priority signs that indicate the child needs immediate assessment and treatment. These signs are:
-visible severe wasting -oedema of both feet -severe palmar pallor -any sick young infant (<2 months old) -lethargy, drowsiness, unconsciousness -continually irritable and restless -major burns -any respiratory distress -child with urgent referral note from another facility.
These children need prompt assessment to determine what further treatment is needed. They should not be asked to wait in the queue. If a child has trauma or other surgical problems, get surgical help.

# If no emergency or priority signs are found:
q Assess and treat the child who will follow the regular queue of non-urgent patients.

# Assessment for emergency and priority signs
s Assess airway and breathing Does the child's breathing appear obstructed? Look and listen to determine if there is poor air movement.
Obstructed breathing can be due to blockage of the airway by the tongue, a foreign body or severe croup.
Is there respiratory distress? Is the child having trouble getting breath so that it is difficult to talk, eat or breastfeed?
Is there severe respiratory distress? Does the child's breathing appear very laboured? Is the child tiring?
Is there central cyanosis? This is indicated by a bluish/purplish discoloration of the tongue and the inside of the mouth.
s Assess circulation (for shock)
Is the child's hand cold? If so, check the capillary refill. Is it 3 seconds or longer? Apply pressure to whiten the nail of the thumb or the big toe for 3 seconds. Determine the capillary refill time from the moment of release until total recovery of the pink colour.
If capillary refill is longer than 3 seconds, check the pulse. Is the pulse weak and fast? If the radial pulse is strong and not obviously fast, the child is not in shock. If you cannot feel a radial pulse of an infant (less than 1 year old), feel the brachial pulse or, if the infant is lying down, the femoral pulse. If you cannot feel the radial pulse of a child, feel the carotid. If the room is very cold, rely on the pulse to determine whether the child may be in shock.
s Assess for coma or convulsions (or other abnormal mental status)
Is the child in coma? The level of consciousness can be assessed rapidly by the AVPU scale: A-the child is awake and Alert, or V-responds to Voice, or Presponds to Pain (e.g. pinching or pulling frontal hair), or U-Unconscious. If there is no response, ask the mother if the child has been abnormally sleepy or difficult to wake. If she confirms this, the child is in coma (unconscious) and needs emergency treatment.
Is the child convulsing? Are there spasmodic repeated movements in an unresponsive child?
Is the child lethargic? Does the child appear drowsy and show no interest in what is happening?
Is the child continually irritable or restless? A child who is continually irritable or restless cannot be calmed.
s Assess for severe dehydration if the child has diarrhoea Does the child have sunken eyes? Do the eyes appear unusually sunken in their sockets? Ask the mother if the child's eyes are more sunken than usual.
Does a skin pinch go back very slowly (longer than 2 seconds)? Pinch the skin of the abdomen halfway between the umbilicus and the side. Pinch for 1 second, then release and observe.
s Rapidly assess for severe malnutrition Does the child have visible severe wasting? Such children appear very thin and have no fat. Look for severe wasting of the muscles of the shoulders, arms, buttocks and thighs or visible rib outlines.
Does the child have oedema of both feet? Press with the thumb for a few seconds on the top of each foot. The child has oedema if an impression remains in the foot when you lift your thumb.
s Assess for severe anaemia Look for severe palmar pallor. Look at the palms. Hold the child's palm open by grasping it gently from the side. Do not stretch the fingers backward as this could cause pallor by blocking the blood supply. Compare the colour of the child's palm with your own palm or the palm of the mother. If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor and may have severe anaemia.
s Identify all sick young infants (<2 months old)
s Assess for a major burn s Identify all children urgently referred from another facility

# Give emergency treatment
The charts that follow comprise a triage chart which presents a summary of the triage process, followed by charts which give detailed guidelines for emergency treatments named in the treatment boxes of the triage chart. After giving these emergency treatments to children with emergency signs, proceed immediately to assessing, diagnosing and treating the underlying problem. Give the next highest priority for assessment and treatment to children with priority signs.
Children with neither emergency nor priority signs can wait in the regular queue.

# How to manage the airway
Emergency treatment is described in Charts 3 and 4.
The treatment differs depending on whether there is a foreign body causing respiratory obstruction (Chart 3) or some other cause for the obstruction or respiratory distress (Chart 4).
If a foreign body is causing the obstruction, the treatment depends on the age of the child.

# For infants:
q Lay the infant on one arm or on the thigh in a head-down position. q Give five blows to the infant's back with the heel of the hand. q If the obstruction persists, turn the infant over and give five chest thrusts with two fingers, 1 finger's breadth below the nipple level in the midline. q If the obstruction persists, check the infant's mouth for any obstruction which can be removed. q If necessary, repeat this sequence with back slaps again.

# For older children:
q While the child is sitting, kneeling or lying, give five blows to the child's back with the heel of the hand.
q If the obstruction persists, go behind the child and pass your arms around the child's body; form a fist with one hand immediately below the sternum; place the other hand over the fist and thrust sharply upwards into the abdomen. Repeat this up to five times. q If the obstruction persists, check the child's mouth for any obstruction which can be removed. q If necessary, repeat the sequence with back slaps again.
If respiratory obstruction is not caused by a foreign body, then manage the airway as in Chart 4 and assess the child fully to identify the cause of the obstruction. Chart 4 describes action which will open the child's airway and prevent the tongue from falling back to obstruct the pharynx.
The best head positions are "neutral" in the infant and "sniffing" in the child, as shown in Chart 4. Once this has been done, it is important to check the patency of the airway by:
-looking for chest movements -listening for breath sounds, and -feeling for breath.
If neck trauma is suspected, the head-tilt/chin-lift manoeuvre may make the cervical spine injury worse.
The safest airway intervention is the jaw thrust without head tilt (see figure in Chart 4). Ideally a second health worker should be made responsible for maintaining stabilization of the neck. This can also be achieved as described in Chart 6 by securing the child's head to a firm board after the breathing obstruction has been relieved.

# Other emergency treatment
Details of other emergency treatments are given in Charts 5 to 11 and in appropriate sections of other chapters in this manual.

# Give emergency treatment to the child with severe malnutrition
During the triage process, all children with severe malnutrition will be identified as having priority signs, which means that they require prompt assessment and treatment. The case-fatality rate in these children can be high, so it is important that they are assessed promptly by an experienced senior health worker and treatment started as soon as possible.
Chapter 7 (page 80) presents guidelines for the management of severely malnourished children.
A few children with severe malnutrition will be found during triage assessment to have emergency signs.
q Those with emergency signs for "airway and breathing" and "coma or convulsions" should receive emergency treatment (see charts on pages 6-14).
q Those with signs of severe dehydration but not shock should not be rehydrated with IV fluids. This is because the diagnosis of severe dehydration is difficult in severe malnutrition and is often misdiagnosed. Giving IV fluids puts these children at risk of overhydration and death from heart failure. Therefore, these children should be rehydrated orally using the special rehydration solution for severe malnutrition (ReSoMal). See Chapter 7 (page 80).
q Those with signs of shock are assessed for further signs (lethargic or unconscious). This is because in severe malnutrition the usual emergency signs for shock may be present even when there is no shock.
-If the child is lethargic or unconscious, keep warm and give 10% glucose 5 ml/kg IV (see Chart 10, page 13), and then IV fluids (see Chart 8, page 11, and the Note given below).
-If the child is alert, keep warm and give 10% glucose (10 ml/kg) by mouth or nasogastric tube, and proceed to immediate full assessment and treatment. See Chapter 7 for details.
Note: When giving IV fluids, treatment for shock differs from that for a well-nourished child. This is because shock from dehydration and sepsis are likely to coexist and these are difficult to differentiate on clinical grounds alone. Children with dehydration respond to IV fluids (breathing and pulse rates fall, faster capillary refill). Those with septic shock and no dehydration will not respond. The amount of fluid given should be guided by the child's response. Avoid overhydration. Monitor the pulse and breathing at the start and every 5-10 minutes to check if improving or not. Note that the type of IV fluid also differs in severe malnutrition, and the infusion rate is slower.
All severely malnourished children require prompt assessment and treatment to deal with serious problems such as hypoglycaemia, hypothermia, severe infection, severe anaemia and potentially blinding eye problems. It is equally important to take prompt action to prevent some of these problems, if they were not present at the time of admission to hospital.

# ANY SIGN POSITIVE
Note If a child has trauma or other surgical problems, get surgical help or follow surgical guidelines

# EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for emergency laboratory investigations (glucose, malaria smear, Hb)
Check for head/neck trauma before treating child-do not move neck if cervical spine injury possible. s Infants  lay the infant on your arm or thigh in a head down position  give 5 blows to the infant's back with heel of hand  if obstruction persists, turn infant over and give 5 chest thrusts with 2 fingers, one finger breadth below nipple level in midline (see diagram)

# Back slaps Chest thrusts
 if obstruction persists, check infant's mouth for any obstruction which can be removed  if necessary, repeat sequence with back slaps again s Children  give 5 blows to the child's back with heel of hand with child sitting, kneeling or lying  if the obstruction persists, go behind the child and pass your arms around the child's body; form a fist with one hand immediately below the child's sternum; place the other hand over the fist and pull upwards into the abdomen (see diagram); repeat this Heimlich manoeuvre 5 times  if the obstruction persists, check the child's mouth for any obstruction which can be removed  if necessary, repeat this sequence with back slaps again   Attach Ringer's lactate or normal saline-make sure the infusion is running well.

# Heimlich manoeuvre in a choking older child

# Slapping the back to clear airway obstruction in a choking child
 Infuse 20 ml/kg as rapidly as possible.
Volume of Ringer's lactate or normal saline solution Age/weight (20 ml/kg) 2 months (<4 kg) 75 ml 2-<4 months (4-<6 kg) 100 ml 4-<12 months (6-<10 kg) 150 ml 1-<3 years (10-<14 kg) 250 ml 3-<5 years (14-19 kg) 350 ml

# Reassess child after appropriate volume has run in
Reassess after first infusion: If no improvement, repeat 20 ml/kg as rapidly as possible. Reassess after second infusion: If no improvement, repeat 20 ml/kg as rapidly as possible. Reassess after third infusion:
If no improvement, give blood 20 ml/kg over 30 minutes.

# Reassess after fourth infusion:
If no improvement, see treatment guidelines.
After improvement at any stage (pulse slows, faster capillary refill), go to Chart 11, page 14.
If the child is severely malnourished, the fluid volume and rate are different-see Chart 8.

# Chart 8. How to give IV fluids for shock in a child with severe malnutrition
Give this treatment only if the child has signs of shock and is lethargic or has lost consciousness:
 Insert an IV line (and draw blood for emergency laboratory investigations)
 Weigh the child (or estimate the weight) to calculate the volume of fluid to be given  Give IV fluid 15 ml/kg over 1 hour. Use one of the following solutions (in order of preference):
-Ringer's lactate with 5% glucose (dextrose); or -half-normal saline with 5% glucose (dextrose); or -half-strength Darrow's solution with 5% glucose (dextrose); or, if these are unavailable, -Ringer's lactate. If there are signs of improvement (pulse and breathing rates fall):
-give repeat IV 15 ml/kg over 1 hour; then -switch to oral or nasogastric rehydration with ReSoMal (see page 83), 10 ml/kg/h up to 10 hours;
-initiate refeeding with starter F-75 (see page 85).
If the child fails to improve after the first 15 ml/kg IV, assume the child has septic shock:
-give maintenance IV fluid (4 ml/kg/h) while waiting for blood;
-when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over 3 hours (use packed cells if in cardiac failure); then -initiate refeeding with starter F-75 (see page 85).
If the child deteriorates during the IV rehydration (breathing increases by 5 breaths/min or pulse by 25 beats/min), stop the infusion because IV fluid can worsen the child's condition.

# Chart 9. How to give diazepam (or paraldehyde) rectally for convulsions
Give diazepam rectally:
 Draw up the dose from an ampoule of diazepam into a tuberculin (1 ml) syringe.
Base the dose on the weight of the child, where possible. Then remove the needle.
 Inser t the syringe into the rectum 4 to 5 cm and inject the diazepam solution.
 Hold buttocks together for a few minutes.
Diazepam given rectally Paraldehyde given 10 mg/2ml solution rectally Age/weight Dose 0.1ml/kg Dose 0.3-0.4 ml/kg 2 weeks to 2 months (< 4 kg) 0.3 ml 1.0 ml 2-<4 months (4-<6 kg) 0.5 ml 1.6 ml 4-<12 months (6--<10 kg) 1.0 ml 2.4 ml 1-<3 years (10-<14 kg) 1.25 ml 4 ml 3-<5 years (14-19 kg) 1.5 ml 5 ml
If convulsion continues after 10 minutes, give a second dose of diazepam rectally (or give diazepam intravenously if IV infusion is running).
If convulsion continues after another 10 minutes, give a third dose of diazepam or give paraldehyde rectally (or phenobarbital IV or IM).
If high fever:  Sponge the child with room-temperature water to reduce the fever.  Do not give oral medication until the convulsion has been controlled (danger of aspiration).
Use phenobarbital (200 mg/ml solution) in a dose of 20 mg/kg to control convulsions in infants <2 weeks of age: Weight 2 kg-initial dose: 0.2 ml, repeat 0.1 ml after 30 minutes if convulsions Weight 3 kg-initial dose: 0.3 ml, repeat 0.15 ml after 30 minutes continue } Chart 10. How to give IV glucose  Insert IV line and draw blood rapidly for emergency laboratory investigations  Check blood glucose. If low (<2.5 mmol/litre (45 mg/dl) in a well nourished or <3 mmol/litre (55 mg/dl) in a severely malnourished child) or if dextrostix is not available:
 Give 5 ml/kg of 10% glucose solution rapidly by IV injection
Volume of 10% glucose solution Age/weight to give as bolus (5 ml/kg)
Less than 2 months (<4 kg) 15 ml 2-<4 months (4-<6 kg) 25 ml 4-<12 months (6-<10 kg) 40 ml 1-<3 years (10-<14 kg) 60 ml 3-<5 years (14-<19 kg) 80 ml  Recheck the blood glucose in 30 minutes. If it is still low, repeat 5 ml/kg of 10% glucose solution.
 Feed the child as soon as conscious.
If not able to feed without danger of aspiration, give:
-IV containing 5-10% glucose (dextrose), or -milk or sugar solution via nasogastric tube.
To make sugar solution, dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water.
Note: 50% glucose solution is the same as 50% dextrose solution or D50. If only 50% glucose solution is available: dilute 1 part 50% glucose solution to 4 parts sterile water, or dilute 1 part 50% glucose solution to 9 parts 5% glucose solution.
Note: For reliable results, take great care with the dextrostix test. The strip must be stored in its box, at 2-3 C, avoiding sunlight or high humidity. A drop of blood should be placed on the strip (it is necessary to cover all the reagent area). After 60 seconds, the blood should be washed off gently with drops of cold water and the colour compared with the key on the bottle or on the blood glucose reader. (The exact procedure will vary with different strips.)

# Chart 11. How to treat severe dehydration in an emergency setting
If the child is in shock, first follow the instructions in Charts 7 and 8 (pages 10 and 11). Switch to the present chart when the child's pulse becomes slower or the capillary refill is faster. If possible, observe the child for at least 6 hours after rehydration to be sure that the mother can maintain hydration by giving the child ORS solution by mouth.

# Assessment and diagnosis
After triage assessment for emergency and priority signs, every child should be fully assessed by taking a history and carrying out an examination and appropriate investigations. In addition to a general (or "core") paediatric history and examination as taught in medical schools, particular attention should be paid to "directed" signs and symptoms relating to the most common childhood illnesses. This chapter presents the key symptoms and signs to look for in children with specific problems. It focuses on directed symptoms and signs, which are particularly useful in deciding between different possible diagnoses. Once the diagnosis or diagnoses have been made, the treatment guidelines in Chapters 3 to 8 should be consulted.

# Relationship to the IMCI approach
The guidelines presented in this manual follow the same sequence as the IMCI (Integrated Management of Childhood Illness) training materials on caring for outpatient sick children. Thus, the guidelines on managing a lethargic or unconscious child or children with convulsions (IMCI's "general danger signs") are followed by guidelines for children with cough or difficult breathing, diarrhoea, and fever. The diagnoses also closely match the IMCI classifications, except that the expertise and investigative capabilities in a hospital setting allow classifications like "very severe disease" or "very severe febrile disease" to be defined more precisely, making possible such diagnoses as very severe pneumonia, severe malaria, and meningitis. Classifications for conditions such as pneumonia and dehydration follow the same principles as the IMCI. Young infants (aged 1 week to 2 months) are considered separately (see Chapter 6), as in the IMCI approach. The severely malnourished child is also considered separately (see Chapter 7), because these children require special attention and treatment if the high mortality is to be reduced.
All children must be examined fully so that no important sign will be missed.

# Laboratory investigations
The following five basic laboratory investigations should be available in all small hospitals which provide paediatric care in developing countries:
q haemoglobin or packed cell volume (PCV) q blood smear for malaria q blood glucose q microscopy of CSF and urine q blood grouping and cross-matching.
For hospitals that care for sick newborns (under 1 week old), blood bilirubin would also be an essential investigation.
Indications for these tests are outlined in the appropriate sections of this manual. Other investigations (such as chest X-ray and stool microscopy) are not considered essential, but could help in complicated cases.

# Differential diagnoses
After the assessment has been completed and before making the diagnosis or diagnoses, consider the various conditions that could cause the child's illness.
A list of possible differential diagnoses should be drawn up. This helps to ensure that wrong assumptions are not made, a wrong diagnosis is not chosen, and rare problems are not missed. Remember that a sick child often has more than one diagnosis or clinical problem requiring treatment.
The Tables in this chapter list the differential diagnoses for common problems and give details of the symptoms, examination findings and results of laboratory investigations, which can be used to determine the main diagnosis and any secondary diagnoses.
The four most common presenting acute problems are:
q a child who is unconscious, lethargic or convulsing (page 16) q a child with cough or difficult breathing (page 18), plus assessment of conditions presenting with wheeze or presenting with stridor q a child with diarrhoea (page 23) q a child with fever (page 25).
The common problems that present less acutely are: q a child with a chronic cough (30 days or more) (page 22) q a child with fever lasting longer than 7 days (page 26).
For some conditions such as pneumonia and dehydration, the Tables will help to assess their severity because this determines the treatment and whether the child should be admitted to hospital or treated at home. These Tables on classification by severity should be used in the same manner as in the IMCI outpatient guidelines-first consider whether the child's clinical signs fit in the top row of the Table. If the child has signs compatible with more than one row, select the more severe classification.
Where appropriate, some sections give separate attention to problems specific to young infants. The treatment of children with severe malnutrition is considered separately (see Chapter 7, page 80), because there are some important differences in their treatment and care.
After the main diagnosis and any secondary diagnoses or problems have been determined, treatment should be planned and started. Once again, if there is more than one diagnosis or problem, the treatment recommendations for all of them may have to be taken together. It may be necessary to review the list of differential diagnoses again at a later stage after observing the response to treatment, or in the light of new clinical findings. The differential diagnosis of meningitis may include encephalitis, cerebral abscess or tuberculous meningitis. If these are common in your area, consult a standard textbook of paediatrics for further guidance.
b A lumbar puncture should be delayed if there are signs of raised intracranial pressure (see pages 62, 74). A positive lumbar puncture is one where CSF examination shows an abnormal number of white cells (>100 polymorphonuclear cells per ml). A cell count should be carried out, if possible. However, if this is not possible, then a cloudy CSF on direct visual inspection could be considered positive.
(Confirmation is given by a low CSF glucose (0.4 g/litre), organisms identified by Gram stain or a positive culture, where these are available.)
c Low blood glucose is <2.5 mmol/litre (45 mg/dl), or <3.0 mmol/l (54 mg/dl) in a severely malnourished child.

# Child presenting with lethargy, unconsciousness or convulsions
Special attention should be given to a child who presents with lethargy, unconsciousness or convulsions, as described below.
Determine if there is a history of:
q head injury q drug overdose or toxin ingestion q convulsions: How long do they last? Have there been previous febrile convulsions?
In the case of an infant less than 1 week old, consider:
q birth asphyxia q birth injury.

# Laboratory investigations
If meningitis is suspected and the child has no signs of raised intracranial pressure (unequal pupils, rigid posture, paralysis of limbs or trunk, irregular breathing), perform a lumbar puncture.
In a malarious area, prepare a blood smear.
If the child is unconscious, check the blood glucose.
Check the blood pressure (if a suitable paediatric cuff is available) and carry out urine microscopy if possible (see Table 1, page 16).
It is important to determine the length of time a child has been unconscious and his/her AVPU score (see page 2). This coma scale score should be monitored regularly. In young infants (less than 1 week old), note the time between birth and the onset of unconsciousness.
Other causes of lethargy, unconsciousness or convulsions in some regions of the world include dengue haemorrhagic fever, typhoid, and relapsing fever (see below, Fever-differential diagnosis, page 25).

# Young infants
In young infants (less than 2 months old), consider the following differential diagnoses (Table 2):

# Child presenting with cough or difficult breathing

# Conditions presenting without wheeze, stridor or chronic cough
Most episodes of cough are due to the common cold, with each child having several episodes a year. The commonest severe illness presenting with cough or difficult breathing is pneumonia, which should be considered first in any differential diagnosis. However, there are other important causes of cough or difficult breathing which should not be forgotten (Table 3). The conditions listed in this section generally present without wheeze, stridor or chronic cough.
Pay particular attention to the following:
q cough -duration in days -paroxysms with whoops or vomiting or central cyanosis q exposure to someone with tuberculosis (or chronic cough) in the family q immunization history: DPT, measles, BCG q history of choking or sudden onset of symptoms q known HIV infection q personal or family history of asthma.

# Examination General
q central cyanosis q grunting q nasal flaring q severe palmar pallor q head nodding (a movement of the head synchronous with inspiration indicating use of accessory muscles in severe respiratory distress) q raised jugular venous pressure (JVP) q wheeze q stridor.
q respiratory rate (make a count during 1 minute when the child is calm) fast breathing: <2 months old: 60 breaths aged 2-12 months: 50 breaths aged 12 months to 5 years: 40 breaths q lower chest wall indrawing q apex beat displaced/trachea shifted from midline q gallop rhythm of heart on auscultation q percussion signs of pleural effusion (stony dullness) or pneumothorax (hyper-resonance) q auscultation-coarse crackles or bronchial breath sounds.
Note: lower chest wall indrawing occurs when the lower chest wall goes in when the child breathes in; if only the soft tissue between the ribs or above the clavicle goes in when the child breathes, this is not lower chest wall indrawing Abdomen q lymphadenopathy q enlarged liver or spleen.

# Laboratory investigation
q blood smear q haemoglobin.
An infant under 1 week of age can have severe respiratory distress without cough, see section 6.1, page 74.

# Young infants
In the young infant consider, in addition, the following differential diagnosis (see Table 4, page 20).

# Assessing the severity of pneumonia
The severity of pneumonia in children aged 1 week to 5 years must be assessed in order to decide on treatment (see Table 5, page 20).

# Conditions presenting with wheeze
In the first 2 years of life, wheezing is mostly caused by acute viral respiratory infections such as bronchiolitis or coughs and colds. After 2 years of age, most wheezing is due to asthma. Sometimes children with pneumonia present with wheeze. It is  important always to consider pneumonia as a diagnosis, particularly in the first 2 years of life. In a child who has a more chronic illness, a tuberculous abscess causing pressure on the child's airway may cause wheeze. Table 6 presents the differential diagnosis.
q previous episodes of wheeze q response to bronchodilators q asthma diagnosis or long-term treatment for asthma.
q wheezing on expiration q prolonged expiration q resonant percussion note q hyperinflated chest q rhonchi on auscultation.

# Response to rapid-acting bronchodilator
If the cause of the wheeze is not clear, or if the child has fast breathing or chest indrawing in addition to wheeze, give a rapid-acting bronchodilator and assess after 30 minutes. Response to a rapid-acting bronchodilator helps to determine the underlying diagnosis and treatment.
Give the rapid-acting bronchodilator by one of the following methods:
q nebulized salbutamol q salbutamol by a metered dose inhaler with spacer device

# Conditions presenting with stridor
The major causes of severe stridor are viral croup (caused by measles or other viruses), diphtheria, foreign body, and trauma to the larynx (Table 7).
Bacterial tracheitis and acute epiglottitis are very rare in developing countries. In a child who has a more chronic illness, a tuberculous abscess causing pressure on the child's upper airway may cause stridor.
q first episode or recurrent episode of stridor q history of choking q stridor present soon after birth.
q bull neck appearance q grey pharyngeal membrane q blood-stained nasal discharge q stridor present even when the child is quiet.
Treatment guidelines for various causes of stridor are indicated below:
q viral croup (page 37) q diphtheria (page 38) q measles croup (pages 64-67) q foreign body (page 42).

# Conditions presenting with chronic cough
Chronic cough is one that lasts for 30 days or more.
q duration of coughing q nocturnal cough  For details on the management of other diagnoses (such as acute epiglottitis, lung abscess, bronchiectasis and congenital anomalies in the respiratory tract), see a standard paediatrics textbook.

# Child presenting with diarrhoea History
A careful feeding history is essential in the management of a child with diarrhoea. Also, inquire into the following: q diarrhoea -number of days -blood in stools q local reports of cholera outbreak q recent antibiotic or other drug treatment q attacks of crying with pallor in infant.

# Look for:
q signs of some dehydration or severe dehydration:
-restlessness or irritability -lethargy/reduced level of consciousness -sunken eyes -skin pinch returns slowly or very slowly -thirsty/drinks eagerly, or drinking poorly or not able to drink q blood in stool q signs of severe malnutrition q abdominal mass q abdominal distension.
Diarrhoea in an infant less than 1 week of age is seldom an isolated problem. It should always be considered as a sign of neonatal sepsis (see section 6.1, page 74).
In managing a child with diarrhoea it is important to remember typhoid fever (see section 5.5, page 67), surgical conditions such as intussusception, antibiotic-associated diarrhoea and colitis.
Table 9 presents the differential diagnoses.

# Young infants
In young infants, blood in the stools may indicate a surgical condition (see standard textbook of paediatrics). Consider also the following:

# Assessing dehydration
In all children with diarrhoea, decide if dehydration is present and give appropriate treatment (see Table 10).
Treatment guidelines for the most common important types of diarrhoea in the young child in developing countries are indicated below: For details on the management of other causes of diarrhoea (e.g. acute intussusception, antibioticrelated diarrhoea, and haemorrhagic disease of the newborn), see a standard paediatrics textbook.
q acute (

# Child presenting with fever
Special attention should be paid to the following in children presenting with fever: History q duration of fever q residence in or recent travel to an area with Plasmodium falciparum transmission q skin rash
q stiff neck q haemorrhagic skin rash-purpura, petechiae q skin sepsis-cellulitis or skin pustules q discharge from ear/red immobile ear-drum on otoscopy q severe palmar pallor q refusal to move joint or limb q local tenderness q fast breathing.

# Laboratory investigations
q blood smear q LP if signs suggest meningitis (with no signs of raised intracranial pressure).

# Differential diagnosis
There are three major categories of children presenting with fever:
q fever due to infection without localized signs (no rash) (see Table 11). q fever due to infection with localized signs (no rash) (see Table 12). q fever with rash (see Table 13). Some causes of fever are only found in certain regions (e.g. dengue haemorrhagic fever, relapsing fever). Other fevers are seasonal (e.g. malaria, meningococcal meningitis) or can occur in epidemics (measles, meningococcal meningitis, typhus).

# CHAPTER 2. ASSESSMENT AND DIAGNOSIS
Treatment guidelines for the most common important medical causes of fever in a young child in developing countries are indicated below:
For a child aged 2 months to 5

# Fever lasting longer than 7 days
As there are many causes of prolonged fever, it is important to know the most common causes in a given area. Investigations for the most likely cause can then be started and treatment decided. Sometimes there has to be a "trial of treatment", e.g. for suspected tuberculosis or salmonella infections; if the child improves, this confirms the suspected diagnosis.
Take a history as for fever (see above, page 24). In addition, ask if the child has a chronic illness such as rheumatoid arthritis or malignancy which may cause persistent fever.
Fully undress the child and examine the whole body for any localizing signs of infection:
q stiff neck (meningitis) q red tender joint (septic arthritis or rheumatic fever) q fast breathing or chest indrawing (pneumonia or severe pneumonia) q petechial rash (meningococcal disease or dengue) q maculopapular rash (viral infection or drug reaction) q throat and mucous membranes (throat infection) q red/painful ear with immobile ear-drum (otitis media) q jaundice or anaemia (malaria or septicaemia) q spine and hips (osteomyelitis)

# Laboratory investigations
Where available, perform the following:
q blood films for malaria parasites q full blood count, including platelet count, and examination of a thin film for cell morphology q urinalysis q Mantoux test (note: it is often negative in a child with tuberculosis who has severe malnutrition or miliary tuberculosis) q chest X-ray q blood culture q HIV testing (if the fever has lasted for more than 30 days and there are other reasons to suspect HIV infection) q lumbar puncture (if there are signs of meningitis).

# Differential diagnosis
Review all the conditions included in Tables 11- 13 above. In addition, consider the following causes for a fever lasting longer than 7 days (see Table 14).

# CHAPTER 2. ASSESSMENT AND DIAGNOSIS
For details on the management of infective endocarditis, rheumatic fever, abscess, brucellosis, and regional causes of fever such as relapsing fever, typhus and other rickettsial infections, see a standard paediatrics textbook.
Pneumonia, an infection of the lungs, is usually caused by viruses or bacteria. Most serious episodes are caused by bacteria. It is usually not possible, however, to determine the specific cause by clinical features or chest X-ray. Pneumonia is classified as very severe, severe or non-severe, based on the clinical features, with specific treatment for each of them. Antibiotic therapy is needed in all cases. Severe and very severe pneumonia require additional treatment, such as oxygen, to be given in hospital.

# Very severe pneumonia
Cough or difficult breathing plus at least one of the following:
q central cyanosis q inability to breastfeed or drink, or vomiting everything q convulsions, lethargy or unconsciousness q severe respiratory distress (e.g. head nodding, see page 18).
In addition, some or all of the other signs of pneumonia or severe pneumonia may also be present, such as:
Admit the child with very severe pneumonia to hospital.

# Antibiotic therapy
q Give chloramphenicol (25 mg/kg IM or IV every 8 hours) until the child has improved. Then continue orally 3 times a day for a total course of 10 days.
q If chloramphenicol is not available, give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM once a day) for 10 days.
q If the child does not improve within 48 hours, switch to gentamicin (7.5 mg/kg IM once a day) and cloxacillin (50 mg/kg IM or IV every 6 hours), as described below for staphylococcal pneumonia. When the child improves, continue cloxacillin (or dicloxacillin) orally 4 times a day for a total course of 3 weeks.

# Oxygen therapy
Give oxygen to all children with very severe pneumonia using nasal prongs, a nasal catheter, or a nasopharyngeal catheter. Use of nasal prongs is the best method for delivering oxygen to young infants. Face masks or head masks are not recommended.
Oxygen supplies need to be available continuously at all times. A comparison of the different methods of oxygen administration and diagrams showing their use is given in section 9.5, page 109.
Continue with oxygen until the signs of hypoxia (such as severe lower chest wall indrawing, breathing rate of 70/minute, head nodding, or cyanosis) are no longer present. There is no value in giving oxygen after this time. Nurses should check every 3 hours that the catheter or prongs are not blocked with mucus and are in the correct place and that all connections are secure.
The two main sources of oxygen are cylinders and oxygen concentrators. It is important that all equipment is checked for compatibility and properly maintained, and that staff are instructed in their correct use.
The child should be checked by nurses at least every 3 hours and by a doctor at least twice a day. In the absence of complications, within two days there should be signs of improvement (breathing not so fast, less indrawing of the lower chest wall, less fever, and improved ability to eat and drink).
If the child has not improved after two days, or if the child's condition has worsened, look for complications or other diagnoses. If possible, obtain a chest X-ray. The most common complications are given below.
Staphylococcal pneumonia. This is suggested by rapid clinical deterioration despite treatment, by a pneumatocoele or pneumothorax with effusion on chest X-ray, numerous Gram-positive cocci in a smear of sputum, or heavy growth of S. aureus in cultured sputum or empyema fluid. The presence of septic skin pustules or soft tissue infection supports the diagnosis.
q Treat with cloxacillin (50 mg/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM or IV once a day). When the child improves, continue cloxacillin orally 4 times a day for a total course of 3 weeks. Note that cloxacillin can be substituted by another anti-staphylococcal antibiotic such as oxacillin, flucloxacillin, or dicloxacillin.
Empyema. This is suggested by persistent fever, and physical and chest X-ray signs of pleural effusion. Diagnosis and management are described in section 3.1.4, page 33.
A child with persistent fever for more than 14 days and signs of pneumonia should be evaluated for tuberculosis. If another cause of the fever cannot be found, a trial of anti-tuberculosis

# Normal chest X-ray Lobar pneumonia of the right lower zone indicated by a consolidation (X-ray)

# Staphylococcal pneumonia. Typical features include pneumatocoeles on the right side of the illustration, and an abscess with an air-fluid level on the left side of the illustration (X-ray).

# Pneumothorax. The right lung (left side of the illustration) is collapsed towards the hilus, leaving a transparent margin around it without lung structure. In contrast, the right side (normal) demonstrates markings extending to the periphery (X-ray).
Appearance of miliary tuberculosis: widespread small patchy infiltrates throughout both lungs: "snow storm appearance" (X-ray).

# Hyperinflated chest. Features are an increased transverse diameter, ribs running more horizontally, a small contour of the heart, and flattened diaphragms (X-ray).
treatment, following national guidelines, may be required (see section 3.6, page 41).
HIV infection and pneumonia. Most episodes of pneumonia in HIV-positive children have the same etiology and respond to the same treatment as in HIVnegative children (see Chapter 8, page 92). However, in an infant, a chest X-ray showing interstitial pneumonia suggests infection with Pneumocystis carinii.
Treat with high doses of cotrimoxazole (8 mg/kg of trimethoprim and 40 mg/kg of sulfamethoxazole IV every 8 hours or orally 3 times a day) for 3 weeks.

# Severe pneumonia
Cough or difficult breathing plus at least one of the following signs:
q lower chest wall indrawing q nasal flaring q grunting (in young infants).
Check that there are no signs of very severe pneumonia, such as:
q central cyanosis q inability to breastfeed or drink q vomiting everything q convulsions, lethargy or unconsciousness q severe respiratory distress.
In addition, some or all of the other signs of pneumonia may also be present:
-fast breathing: age <2 months: 60/minute age 2-12 months: 50/minute age 12 months to 5 years: 40/ minute -chest auscultation signs of pneumonia: -decreased breath sounds -bronchial breath sounds -crackles -abnormal vocal resonance (decreased over a pleural effusion, increased over lobar consolidation -pleural rub.
A routine chest X-ray rarely gives information which will change the management of severe pneumonia and is therefore not recommended.
Admit or refer the child to hospital.

# Antibiotic therapy
q Give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) for at least 3 days.
q When the child improves, switch to oral amoxicillin (15 mg/kg 3 times a day). The total course of treatment is 5 days.
q If the child does not improve within 48 hours, or deteriorates, switch to chloramphenicol (25 mg/ kg every 8 hours IM or IV) until the child has improved. Then continue orally for a total course of 10 days.

# Oxygen therapy
If readily available, give oxygen to any child with severe lower chest wall indrawing or a respiratory rate of 70/minute. See section 9.5 (page 109).

# Supportive care
See above (page 30), as described for very severe pneumonia.
The child should be checked by nurses at least every 6 hours and by a doctor at least once a day. Record the respiratory rate and temperature, and note the child's level of consciousness and ability to drink or breastfeed. In the absence of complications, within two days there should be signs of improvement (slower breathing, less chest indrawing, less fever, and improved ability to eat and drink).
See above (page 30), as described for very severe pneumonia.

# Pneumonia (non-severe)
On examination, the child has cough or difficult breathing and fast breathing:
-age < 2 months: 60/minute -age 2-12 months: 50/minute -age 12 months to 5 years: 40/minute.
Check that the child has none of the signs of severe or very severe pneumonia given above in sections 3.1.1 and 3.1.2.
In addition, other signs of pneumonia (on auscultation) may be present: crackles, reduced breath sounds, or an area of bronchial breathing.
Treat the child as an outpatient.
q Give cotrimoxazole (4 mg/kg trimethoprim/20 mg/ kg sulfamethoxazole twice a day) for 5 days or amoxicillin (15 mg/kg 3 times a day) for 5 days.
q Give the first dose at the clinic and teach the mother how to give the other doses at home.
Encourage the mother to feed the child. Advise her to bring the child back after 2 days, or earlier if the child becomes more sick or is not able to drink or breastfeed. When the child returns:
q If the breathing has improved (slower), there is less fever, and the child is eating better, complete the 5 days of antibiotic treatment. q If the breathing rate, fever and eating have not improved, change to the second-line antibiotic and advise the mother to return again in 2 days. q If there are signs of severe or very severe pneumonia, admit the child to hospital and treat according to the guidelines described above.

# Pleural effusion and empyema
A child with severe or very severe pneumonia may develop pleural effusion or empyema. On examination, the chest is dull to percussion and breath sounds are reduced or absent over the affected area. A pleural rub may be heard at an early stage before the effusion is fully developed.
A chest X-ray shows fluid on one or both sides of the chest. When empyema is present, fever persists despite antibiotic therapy and the pleural fluid is cloudy or frankly purulent.

# Failure to improve
If fever and other signs of illness continue, despite adequate chest drainage and antimicrobial therapy, assess for possible tuberculosis. A trial of antituberculosis therapy may be required (see section 3.6, page 41).

# Cough or cold
These are common, self-limited viral infections that require only supportive care. Antibiotics should not be given. Wheeze or stridor occur in some children, especially infants. Most episodes end within 14 days. Cough lasting 30 days or more may be caused by tuberculosis, asthma, pertussis or symptomatic HIV infection (see Chapter 8).
q cough q nasal discharge q mouth breathing q fever.
The following are absent:
-fast breathing -lower chest wall indrawing -stridor when the child is calm -general danger signs.
Wheezing may occur in young children (see section 3.3, page 34).
Treat the child as an outpatient.
q Soothe the throat and relieve the cough with a safe remedy, such as a warm, sweet drink. q Relieve high fever of 39C (102.2F) with paracetamol, if this is causing distress to the child. q Clear secretions from the child's nose before feeds using a cloth soaked in water, which has been twisted to form a pointed wick.
Do not give any of the following:
-an antibiotic (they are not effective and do not prevent pneumonia) -remedies containing atropine, codeine or codeine derivatives, or alcohol (these may be harmful) -medicated nose drops.
Advise the mother to: q feed the child q watch for fast or difficult breathing and return, if either develops q return if the child becomes more sick, or is not able to drink or breastfeed.

# Conditions presenting with wheeze
Wheeze is a high-pitched whistling sound near the end of each expiration. It is caused by spasmodic narrowing or inflammation of the distal airways. To hear a wheeze, even in mild cases, place the ear next to the child's mouth and listen to the breathing while the child is calm, or use a stethoscope to listen for wheezes or rhonchi.
Bronchiolitis is a lower respiratory viral infection, which typically is most severe in young infants, occurs in annual epidemics, and is characterized by airways obstruction and wheezing. Respiratory syncytial virus is the most important cause. Secondary bacterial infection may occur and is common in some settings. The management of bronchiolitis is therefore similar to that of pneumonia. Episodes of wheeze may occur for months after an attack of bronchiolitis, but eventually will stop.
Typical features of bronchiolitis, on examination, include:
q wheezing which is not relieved by bronchodilators q hyperinflation of the chest, with increased resonance to percussion q lower chest wall indrawing q fine crackles or rhonchi on auscultation of the chest q difficulty in feeding, breastfeeding or drinking owing to respiratory distress.
Most children can be treated at home, but those with the following signs should be treated in hospital:
Signs of severe or very severe pneumonia (see sections 3.1.1 and 3.1.
q central cyanosis q inability to breastfeed or drink, or vomiting everything q convulsions, lethargy or unconsciousness q severe lower chest wall indrawing q nasal flaring q grunting (in young infants).

# OR signs of respiratory distress:
q obvious discomfort in breathing q difficulty in drinking, feeding or talking.

# Antibiotic treatment
q If treated at home, give cotrimoxazole (4 mg/kg trimethoprim/20 mg/kg sulfamethoxazole twice a day) or amoxicillin (15 mg/kg 3 times a day) orally for 5 days.
q If there is respiratory distress but the child is able to drink and there is no central cyanosis, give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) for at least 3 days. When the child improves, switch to oral amoxicillin (15 mg/kg 3 times a day). The total course of treatment is 5 days.
q If there are signs of very severe pneumonia (central cyanosis or inability to drink), give chloramphenicol (25 mg/kg IM or IV every 8 hours) until the child improves. Then continue by mouth 3 times a day for a total of 10 days.
Give oxygen to all children with wheezing and severe respiratory distress (as for pneumonia: see sections 3.1.
A hospitalized child should be assessed by a nurse every 6 hours (or every 3 hours, if there are signs of very severe illness) and by a doctor at least once a day. Monitor oxygen therapy as described on page 111. Watch especially for signs of respiratory failure, i.e. increasing hypoxia and respiratory distress leading to exhaustion.
If the child fails to respond to oxygen therapy, or the child's condition worsens suddenly, obtain a chest X-ray to look for evidence of pneumothorax. Tension pneumothorax associated with severe respiratory distress and shift of the heart requires immediate relief by placing a needle in the affected area to allow the air that is under pressure to escape. (Following this, continuous air exit should be assured by inserting a chest tube with an underwater seal until the air leak closes spontaneously and the lung expands).
Asthma is a chronic inflammatory condition with reversible airways obstruction. It is characterized by recurrent episodes of wheezing, often with cough, which respond to treatment with bronchodilators and anti-inflammatory drugs. Antibiotics should be given only when there are signs of pneumonia.
History of recurrent episodes of wheezing, often with cough. Findings on examination may include: q
If the child has central cyanosis or is unable to drink, admit to hospital and treat with oxygen, rapid-acting bronchodilators and other drugs, as described below.
In children admitted to hospital, give oxygen, a rapidacting bronchodilator, and a first dose of steroids (oral or IV) promptly. A positive response to these should be seen in 30 minutes, i.e. less respiratory distress, and better air entry on auscultation. If this does not occur, give the rapid-acting bronchodilator at up to 1-hourly intervals. If there is no response after 3 doses of rapid-acting bronchodilator, add IV aminophylline.
Give oxygen to all children with asthma, whose difficulty in breathing interferes with talking, eating or breastfeeding. See guidelines above in section 3.3.1.

# Rapid-acting bronchodilators
Give the child one of the three rapid-acting bronchodilators-nebulized salbutamol, salbutamol by metered-dose inhaler with a spacer device, or subcutaneous epinephrine (adrenaline), as described below.
(1) Nebulized salbutamol
The driving source for the nebulizer must deliver at least 6-9 litres/minute. Recommended methods are an air compressor or oxygen cylinder. If neither is available, use a durable and easy-to-operate footpump, although this is less effective.
child's condition improves. If necessary in severe cases, it can be given hourly. Some infants and young children cooperate better when a face mask is attached to the spacer instead of the mouthpiece.
If commercial devices are not available, a spacer device can be made from a plastic cup or a 1-litre plastic bottle. These require 3-4 puffs of salbutamol and the child should breathe from the device for up to 30 seconds.
(3) Subcutaneous epinephrine (adrenaline)
If the above two methods of delivering salbutamol are not available, give a subcutaneous injection of epinephrine (adrenaline)-0.01 ml/kg of 1:1000 solution (up to a maximum of 0.3 ml), measured accurately with a 1 ml syringe (for injection technique, see Appendix 1, A1.1, page 124). If there is no improvement after 20 minutes, repeat the dose once.

# Oral bronchodilators
Once the child has improved to be discharged, oral salbutamol (syrup or tablets) can be given if inhaled salbutamol is not available. The dose is: age 2-12 months: 1 mg 6-8 hourly age 12 months to 5 years: 2 mg 6-8 hourly.
If a child has a severe acute attack of wheezing and a history of recurrent wheezing, give oral prednisolone, 1 mg/kg once a day, for 3 days. If the child remains

# Use of nebulizer and face mask to give bronchodilator treatment

# Use of spacer device and face mask to give bronchodilator treatment
Place the bronchodilator solution and 2-4 ml of sterile saline in the nebulizer compartment and treat the child until the liquid is almost all used up. The dose of salbutamol is 2.5 mg (i.e. 0.5 ml of the 5 mg/ml nebulizer solution). This can be given 4-hourly, reducing to 6-8 hourly once the child's condition improves. If necessary in severe cases, it can be given hourly.
(2) Salbutamol by metered-dose inhaler with a spacer device Spacer devices with a volume of 750 ml are commercially available. Introduce two puffs (200 micrograms) into the spacer chamber. Then place the child's mouth over the opening in the spacer and allow normal breathing for 3-5 breaths. This can be repeated 4-hourly, reducing to 6-8 hourly after the very sick, continue the treatment until improvement is seen. Steroids are not usually required for the first episode of wheezing.
If a child does not improve after 3 doses of a rapidacting bronchodilator plus oral prednisolone, give IV aminophylline-initial dose of 5-6 mg/kg (up to a maximum of 300 mg), followed by a maintenance dose of 5 mg/kg every 6 hours. Weigh the child carefully and give the IV dose over at least 20 minutes and preferably over 1 hour.
Intravenous aminophylline can be dangerous in an overdose or when given too rapidly. Omit the initial dose if the child has already received any form of aminophylline in the previous 24 hours. Stop giving it immediately if the child starts to vomit, has a pulse rate >180/min, develops a headache, or has a convulsion. If IV aminophylline is not available, aminophylline suppositories are an alternative.
Antibiotics should not be given routinely for asthma or to a child with asthma who has fast breathing without fever. Antimicrobial treatment is indicated, however, when there is persistent fever and other signs of pneumonia (see section 3.1, page 29).

# Supportive care
Ensure that the child receives daily maintenance fluids appropriate for his/her age (see page 108). Encourage breastfeeding and oral fluids. Encourage adequate complementary feeding for the young child, as soon as food can be taken.
A hospitalized child should be assessed by a nurse every 3 hours, or every 6 hours as the child shows improvement (i.e. decreased breathing rate, less lower chest wall indrawing, and less respiratory distress), and by a doctor at least once a day. Record the respiratory rate and watch especially for signs of respiratory failure-increasing hypoxia and respiratory distress leading to exhaustion. If the response to treatment is poor, give salbutamol more frequently, up to once every 60 minutes. If this is ineffective, give aminophylline. Monitor oxygen therapy as described on page 30.
If the child fails to respond to the above therapy, or the child's condition worsens suddenly, obtain a chest X-ray to look for evidence of pneumothorax. Treat as described on page 35.

# Wheeze with cough or cold
Most first episodes of wheezing in children aged <2 years are associated with cough and cold. These children are not likely to have a family history of atopy (e.g. hay fever, eczema, allergic rhinitis) and their wheezing episodes become less frequent as they grow older. The wheezing, if troublesome, often responds to oral salbutamol treatment at home.

# Conditions presenting with stridor
Stridor is a harsh noise during inspiration, which is due to narrowing of the air passage in the oropharynx, subglottis or trachea. If the obstruction is severe, stridor may also occur during expiration.

# Viral croup
Mild croup is characterized by:
q fever q a hoarse voice q a barking or hacking cough q stridor that is heard only when the child is agitated.
Severe croup is characterized by: q stridor when the child is quiet q rapid breathing and indrawing of the lower chest wall.
Mild croup can be managed at home with supportive care, including encouraging oral fluids, breastfeeding or feeding, as appropriate.
A child with severe croup should be admitted to hospital for treatment as follows:
- Oxygen. Give oxygen to all children with lower chest wall indrawing, using nasal prongs only. Do not use a nasopharyngeal or a nasal catheter because they can provoke paroxysms of coughing. Continue with oxygen therapy until the lower chest wall indrawing is no longer present, after which there is no value in giving oxygen. Every 3 hours, the nurse should check that the prongs are in the correct place and not blocked with mucus, and that all connections are secure. See section 9.5 (page 109) for further details.

# Supportive care
q If the child has fever (39 C or higher) which appears to be causing distress, give paracetamol. q Encourage breastfeeding and oral fluids. Avoid parenteral fluids, which are usually not required. q Encourage the child to eat as soon as food can be taken. q Avoid using mist tents which are not effective.
They separate the child from the parents and make observation of the child's condition very difficult.
The child's condition, especially respiratory status, should be assessed by nurses every 3 hours and by doctors twice a day. The child should occupy a bed close to the nursing station, so that any sign of incipient airway obstruction can be detected as soon as it develops.
Diphtheria is a bacterial infection which can be prevented by immunization. Infection in the upper airway or nasopharynx produces a grey membrane which, when present in the larynx or trachea, can cause stridor and obstruction. Nasal involvement produces a bloody discharge. Diphtheria toxin causes muscular paralysis and myocarditis, which is associated with increased mortality.
Carefully examine the child's nose and throat and look for a grey, adherent membrane, which cannot be wiped off with a swab. Great care is needed when examining the throat, as this may precipitate complete obstruction of the airway. A child with pharyngeal diphtheria may have an obviously swollen neck, termed a 'bull neck'.
Antibiotics. Any child with suspected diphtheria should be given procaine penicillin (50 000 units/kg IM) daily for 7 days.
Antitoxin. Give 40 000 units of diphtheria antitoxin (IM or IV) immediately, because delay can lead to increased mortality. As there is a small risk of a serious allergic reaction to the horse serum in this product, an initial intradermal test to detect hyper-

# Pharyngeal membrane of diphtheria. Note: the membrane extends beyond the tonsils and covers the adjacent pharyngeal wall.

# Bull neck-a sign of diphtheria due to enlarged lymph nodes in the neck
sensitivity should be carried out, as described in the instructions.
Oxygen. Avoid using oxygen unless there is incipient airway obstruction. Signs such as severe indrawing of the lower chest wall and restlessness are more likely to indicate the need for tracheostomy (or intubation) than oxygen. Moreover, the use of nasal prongs or a nasal or nasopharyngeal catheter can upset the child and precipitate obstruction of the airway. However, oxygen should be given, if there is incipient airway obstruction and a tracheostomy is deemed necessary and is to be performed.
Myocarditis and paralysis may occur 2-7 weeks after the onset of illness. Signs of myocarditis include a weak, irregular pulse and evidence of heart failure. Refer to standard paediatric textbooks for details of the diagnosis and management of myocarditis.

# Public health measures
q Nurse the child in a separate room using staff who are fully immunized against diphtheria. q Give all immunized household contacts a diphtheria toxoid booster. q Give all unimmunized household contacts one IM dose of benzathine penicillin (600 000 units to those aged 5 years; 1 200 000 units to those aged >5 years). Immunize them with diphtheria toxoid and check daily for 5 days for any signs of diphtheria.
Pertussis, a respiratory infection characterized by bronchitis which resolves slowly, is most severe in young infants who have not yet been immunized.
After an incubation period of 7-10 days, the child develops fever, usually with a cough and nasal discharge which clinically are indistinguishable from a common cough and cold. In the second week, there is paroxysmal coughing which can be recognized as pertussis. The episodes of coughing can continue for 3 months or longer. The child is infectious for a period of 2 weeks up to 3 months after the onset of illness.
Suspect pertussis if a child has been having a severe cough for more than two weeks, especially if the disease is known to be occurring locally. The most useful diagnostic signs are:

# CHAPTER 3. COUGH OR DIFFICULT BREATHING

# Subconjunctival haemorrhages prominent on the white sclera

# Child with tracheostomy tube in position
Tracheostomy/intubation. Tracheostomy should be performed only by experienced staff, if there are signs of incipient airway obstruction, such as severe lower chest wall indrawing and restlessness. If obstruction occurs, an emergency tracheostomy should be carried out. Orotracheal intubation is an alternative, but may dislodge the membrane and fail to relieve the obstruction.

# Supportive care
q If the child has fever (39 C or 102.2F) and this appears to be causing distress, give paracetamol. q Encourage the child to eat and drink. If there is difficulty in swallowing, nasogastric feeding is required. q Avoid frequent examinations or disturbing the child unnecessarily.
The child's condition, especially respiratory status, should be assessed by nurses every 3 hours and by doctors twice a day. The child should occupy a bed close to the nursing station, so that any sign of incipient airway obstruction can be detected as soon as it develops.
q paroxysmal coughing followed by a whoop when breathing in, often with vomiting q subconjunctival haemorrhages q child not immunized against pertussis.
Young infants may not whoop; instead, the cough may be followed by suspension of breathing (apnoea) or cyanosis, or apnoea may occur without coughing. Also, examine the child for signs of pneumonia and ask about convulsions.
Treat mild cases in children aged 6 months at home with supportive care. Admit infants aged <6 months to hospital; also admit any child with pneumonia, convulsions, dehydration, severe malnutrition, or prolonged apnoea or cyanosis after coughing.
q Give oral erythromycin (12.5 mg/kg four times a day) for 10 days. This does not shorten the illness but reduces the period of infectiousness. q If there is fever, give oral chloramphenicol (25 mg/ kg three times a day) for 5 days to treat possible secondary pneumonia. Follow the other guidelines for severe pneumonia (see section 3.1.2, page 32). If chloramphenicol is not available, give cotrimoxazole, as described for pneumonia (nonsevere) (see section 3.1.3, page 32).
Give oxygen to children who have spells of apnoea or cyanosis, or severe paroxysms of coughing. Use nasal prongs, not a nasopharyngeal catheter or nasal catheter which can provoke coughing. Place the prongs just inside the nostrils and secure with a piece of tape just above the upper lip. Care should be taken to keep the nostrils clear of mucus since this blocks the flow of oxygen. Set a flow rate of 1-2 litres/min (0.5 litre/min in young infants). Humidification is not required with nasal prongs.
Continue oxygen therapy until the above signs are no longer present, after which there is no value in continuing with oxygen. The nurse should check, every 3 hours, that the prongs or catheter are in the correct place and not blocked with mucus, and that all connections are secure. See section 9.5 (page 109) for further details.

# Airway management
During paroxysms of coughing, place the child head down and prone, or on the side, to prevent any inhaling of vomitus and to aid expectoration of secretions.
q If the child has cyanotic episodes, clear secretions from the nose and throat with brief, gentle suction. q If apnoea occurs, clear the airway immediately with gentle suction, give manual respiratory stimulation or bag ventilation, and administer oxygen.

# Supportive care
q Avoid, as far as possible, any procedure that could trigger coughing, such as application of suction, throat examination, and use of a nasogastric tube. q Do not give cough suppressants, sedatives, mucolytic agents or antihistamines. q If the child has fever (39 C or higher) which appears to be causing distress, give paracetamol. q Encourage breastfeeding or oral fluids. If the child cannot drink, pass a nasogastric tube and give small, frequent amounts of fluid to meet the child's maintenance needs (see pages 105-108). If there is respiratory distress, give maintenance fluids IV to avoid the risk of aspiration and reduce triggering of coughing. Ensure adequate nutrition by giving smaller, more frequent feeds. If there is continued weight loss despite theses measures, feed the child by nasogastric tube.
The child should be assessed by nurses every 3 hours and by the doctor once a day. To facilitate observation for early detection and treatment of apnoeic or cyanotic spells, or severe episodes of coughing, the child should occupy a bed in a place close to the nursing station where oxygen is available. Also, teach the child's mother to recognize apnoeic spells and to alert the nurse if this should occur.
Pneumonia. This most common complication of pertussis is caused by secondary bacterial infection or inhalation of vomited material. Signs suggesting pneumonia include fast breathing between coughing episodes, fever, and the rapid onset of respiratory distress. Treat pneumonia in children with pertussis as follows:
q Give chloramphenicol (dose: 25 mg/kg every 8 hours) for 5 days. q Give oxygen as described for the treatment of very severe pneumonia (see sections 3.1.1 and 9.5, pages 30 and 109).
Convulsions. These may result from anoxia associated with an apnoeic or cyanotic episode, or toxin-mediated encephalopathy. If a convulsion does not stop within two minutes, give an anticonvulsant (diazepam or paraldehyde), following guidelines in Chapter 1 (Chart 9, page 12).
Malnutrition. Children with pertussis may become malnourished as a result of reduced food intake and frequent vomiting. Prevent malnutrition by ensuring adequate feeding, as described above, under "supportive care".
Haemorrhage and hernias. Subconjunctival haemorrhage and epistaxis are common during pertussis. No specific treatment is needed. Umbilical or inguinal hernias may be caused by violent coughing. Do not treat them unless there are signs of bowel obstruction, but refer the child for surgical evaluation after the emergency.

# Public health measures
Give DPT immunization to any child in the family who is not fully immunized and to the child with pertussis. Give a DPT booster to previously immunized children. Give erythromycin (12.5 mg/kg 4 times a day) for 5 days to any infant in the family who is aged <6 months and has fever or other signs of a respiratory infection.
Most children infected with Mycobacterium tuberculosis do not develop tuberculosis disease. The only evidence of infection may be a positive skin test. The development of tuberculosis disease depends on the competence of the immune system to resist multiplication of the M. tuberculosis infection. This competence varies with age, being least in the very young. HIV and malnutrition lower the body's defences, and measles and whooping cough temporarily impair the strength of the immune system. In the presence of any of these conditions, tuberculosis disease can develop more easily.
Tuberculosis is most often severe when the disease is located in the lungs or meninges. Bones, joints, abdomen, cervical lymph nodes, ear, eye, and skin may also be affected. Many children present only with failure to grow normally, weight loss or prolonged fever. Cough for more than 30 days can also be a presenting sign; in children, however, sputumpositive tuberculosis is rarely diagnosed.
The risk of tuberculosis is increased when there is an active case (infectious, smear-positive tuberculosis) in the same house, or when the child is malnourished, has HIV/AIDS, or has had measles in the past few months. Consider tuberculosis in any child with:
q A history of:
-unexplained weight loss or failure to grow normally; -unexplained fever, especially when it continues for more than 2 weeks; -chronic cough (i.e. cough for more than 30 days, with or without a wheeze); -exposure to an adult with probable or definite pulmonary infectious tuberculosis.
q On examination:
-fluid on one side of the chest (reduced air entry, stony dullness to percussion); -enlarged non-tender lymph nodes or a lymph node abscess, especially in the neck; -signs of meningitis, especially when these develop over several days and the spinal fluid contains mostly lymphocytes and elevated protein; -abdominal swelling, with or without palpable lumps; -progressive swelling or deformity in the bone or a joint, including the spine.
Try to obtain specimens for preparation of smears for microscopic examination of acid-fast bacilli (Ziehl-Nielsen stain) and for culture of tubercle bacilli. Possible specimens include three consecutive early morning gastric aspirates, CSF (if clinically indicated), and pleural fluid and ascites fluid.
Owing to low detection rates by these methods, a positive result would confirm tuberculosis, but a negative result does not exclude the disease.
Obtain a chest X-ray (see figures on page 31). A diagnosis of tuberculosis is supported when a chest X-ray shows a miliary pattern of infiltrates or a persistent area of infiltrate or consolidation, often with pleural effusion.
Perform a PPD (tuberculin) skin test. The test is usually positive in children with pulmonary tuberculosis (10-mm reaction is suggestive of tuberculosis; <10 mm in a child, previously immunized with BCG, is equivocal). However, the PPD test may be negative in children with tuberculosis who have HIV/AIDS or when there is miliary disease, severe malnutrition or recent measles.
Give a full course of treatment to all confirmed or highly suspected cases. When in doubt, e.g. in a child highly suspected of tuberculosis or who fails to respond to treatment for other likely diagnoses, give treatment for tuberculosis. Treatment failures for other diagnoses include antibiotic treatment for apparent bacterial pneumonia (when the child has pulmonary symptoms), or for possible meningitis (when the child has neurological symptoms), or for intestinal worms or giardiasis (when the child fails to thrive or has diarrhoea or abdominal symptoms).
Follow the treatment recommended by the national tuberculosis programme. Inform this programme and arrange for adequate monitoring. If national recommendations are not available, follow the WHO guidelines which are given below.
- In the majority of cases of childhood tuberculosis (i.e. in the absence of smear-positive pulmonary tuberculosis or severe disease), give: Details of the regimen and dosage for each of the above drugs is given in Appendix 2, section A2.2, page 138.
Precautions: Avoid streptomycin, where possible, in children because the injections are painful, irreversible auditory nerve damage may occur, and there is a risk of spreading HIV due to improper handling of the needle and syringe. Avoid ethambutol in a child who is unable to report a deterioration in sight or colour perception due to optic neuritis, which can occur as an adverse effect. Avoid thioacetazone in a child who is known to be HIV-infected or when the likelihood of HIV infection is high, because severe (sometimes fatal) skin reactions can occur.
Confirm that the medication is being taken as instructed, by direct observation of each dose. Monitor the child's weight gain (daily) and temperature (twice daily) in order to check for resolution of the fever. These are signs of the response to therapy. When treatment is given for suspected tuberculosis, improvement should be seen within one month. If this does not happen, tuberculosis is unlikely and the treatment should be stopped.

# Public health measures
Notify the case to the responsible district health authorities. Ensure that treatment monitoring is carried out, as recommended by the national tuberculosis programme. Check all household members of the child (and, if necessary, school contacts) for undetected cases of tuberculosis and arrange treatment for any who are found.

# Foreign body inhalation
Nuts, seeds or other small objects may be inhaled, most often by children under 4 years of age. The foreign body usually lodges in a bronchus (more often in the right) and can cause collapse or consolidation of the portion of lung distal to the site of blockage. Choking is a frequent initial symptom. This may be followed by a symptom-free interval of days or weeks before the child presents with persistent wheeze, chronic cough or pneumonia, which fails to respond to treatment. Small sharp objects can lodge in the larynx causing stridor or wheeze. Rarely, a large object lodging in the larynx could cause sudden death from asphyxia, unless an emergency tracheostomy is done.
Inhalation of a foreign body should be considered in a child with the following signs:
q sudden onset of choking, coughing or wheezing; or q segmental or lobar pneumonia which fails to respond to antibiotic therapy (note also differential diagnosis of tuberculosis-see above, section 3.6).
Examine the child for:
q unilateral wheeze;
q an area of decreased breath sounds which is either dull or hyper-resonant on percussion; q deviation of the trachea or apex beat.
Obtain a chest X-ray at full expiration to detect an area of hyper-inflation or collapse, mediastinal shift (away from the affected side), or a foreign body if it is radio-opaque.
Emergency first aid. Attempt to dislodge and expel the foreign body. The management depends on the age of the child. See Chart 3, page 6.

# For infants:
q Lay the infant on one arm or on the thigh in a head-down position. q Give five blows to the infant's back with the heel of the hand. q If the obstruction persists, turn the infant over and give five chest thrusts with two fingers, 1 finger's breadth below the nipple level in the midline. q If the obstruction persists, check the infant's mouth for any obstruction which can be removed. q If necessary, repeat this sequence with back slaps again.

# For older children:
q While the child is sitting, kneeling or lying, give five blows to the child's back with the heel of the hand. q If the obstruction persists, go behind the child and pass your arms around the child's body; form a fist with one hand immediately below the sternum; place the other hand over the fist and thrust sharply upwards into the abdomen (Heimlich manoeuvre, see page 6). Repeat this up to five times. q If the obstruction persists, check the child's mouth for any obstruction which can be removed. q If necessary, repeat the sequence with back slaps again.
Once this has been done, it is important to check the patency of the airway by:
q looking for chest movements q listening for breath sounds, and q feeling for breath.
If further management of the airway is required after the obstruction is removed, see Chart 4, page 7. This describes actions which will keep the child's airway open and prevent the tongue from falling back to obstruct the pharynx while the child recovers.
Later treatment. If a foreign body is suspected, refer the child to a hospital where diagnosis is possible and the object can be 'removed' by bronchoscopy. If there is evidence of pneumonia, begin treatment with chloramphenicol (25 mg/kg every 8 hours), as for very severe pneumonia (see section 3.1.1, page 29), before attempting to remove the foreign body.

# Heart failure
Heart failure causes fast breathing and respiratory distress. Underlying causes include congenital heart disease (usually in the first months of life), acute rheumatic fever, myocarditis, suppurative pericarditis with constriction, infective endocarditis, severe anaemia and severe malnutrition (see page 80). Heart failure can be precipitated or worsened by fluid overload, especially when giving salt-containing IV fluids.
The most common signs of heart failure, on examination, are:
q tachycardia (heart rate >160/minute in a child under 12 months old; >120/minute in a child aged 12 months to 5 years) q gallop rhythm with basal crackles q enlarged, tender liver Severe palmar pallor may be present if severe anaemia is the cause of the heart failure.
If the diagnosis is in doubt, a chest X-ray can be taken and will show an enlarged heart.
For details on the treatment of the underlying heart disease, consult a standard paediatrics textbook. The main measures for treatment of heart failure in nonseverely malnourished children are as follows.
q Diuretics. Give furosemide (frusemide): a dose of 1 mg/kg should cause increased urine flow within 2 hours. For faster action, give the drug IV. If the initial dose is not effective, give 2 mg/kg and repeat in 12 hours, if necessary. Thereafter, a single daily dose of 1-2 mg/kg orally is usually sufficient.

# Raised jugular venous pressure (JVP)-a sign of heart failure
q Digoxin. If there is congenital heart disease, give oral digoxin (see Appendix 2, section A2.9, page 143). q Supplemental potassium. Supplemental potassium is not required when furosemide is given alone for treatment lasting only a few days. When digoxin and furosemide are given, or if furosemide is given for more than 5 days, give oral potassium (3-5 mmol/kg/day). q Oxygen. Give oxygen if the child has a respiratory rate of 70/min, shows signs of respiratory distress, or has central cyanosis. See section 9.5, page 109.

# Supportive care
q Avoid the use of IV fluids, where possible, especially those containing sodium (NaCl). q Support the child in a semi-seated position with head and shoulders elevated and lower limbs dependent. q Relieve any fever with paracetamol to reduce the cardiac workload.
The child should be checked by nurses every 6 hours (3 hourly whilst on oxygen therapy) and by doctors once a day. Monitor both respiratory and pulse rates, liver size, and body weight to assess the response to treatment. Continue treatment until the respiratory and pulse rates are normal and the liver is no longer enlarged.

# CHAPTER 4 Diarrhoea
This chapter gives treatment guidelines on the management of the most important conditions presenting with diarrhoea in children aged 1 week to 5 years. Guidelines are given for acute diarrhoea (with severe, some or no dehydration), persistent diarrhoea, and dysentery. Management of diarrhoea in young infants under 2 months old is described in section 6.3 (page 77), and in severely malnourished children in sections 7.2 and 7.3 (pages 81-89).
The two essential elements in the management of all children with diarrhoea are rehydration therapy and continued feeding.
During diarrhoea there is an increased loss of water and electrolytes (sodium, potassium and bicarbonate) in the liquid stool. Water and electrolytes are also lost through vomit, sweat, urine and breathing. Dehydration occurs when these losses are not adequately replaced and a deficit of water and electrolytes develops. The degree of dehydration is graded according to symptoms and signs that reflect the amount of fluid lost (see sections 2.3 and 4.1). The rehydration regimen is selected according to the degree of dehydration.
During diarrhoea, a decrease in food intake and nutrient absorption and increased nutrient requirements often combine to cause weight loss and failure to grow. The child's nutritional status declines and any pre-existing malnutrition is made worse. In turn, malnutrition can make the diarrhoea more severe, more prolonged and more frequent, compared with diarrhoea in non-malnourished children. This vicious circle can be broken by giving nutrient-rich foods during the diarrhoea episode and when the child is well.
Antibiotics should not be used routinely. They are reliably helpful only for children with bloody diarrhoea (probable shigellosis), suspected cholera with severe dehydration, and other serious non-intestinal infections such as pneumonia. Antiprotozoal drugs are rarely indicated. "Antidiarrhoeal" drugs and anti-emetics should not be given to young children with acute or persistent diarrhoea; they do not prevent dehydration or improve nutritional status and some have dangerous, sometimes fatal, sideeffects.

# Acute diarrhoea
For all children with diarrhoea, hydration status should be classified as severe dehydration, some dehydration or no dehydration (see sections 4.1.1, 4.1.2 and 4.1.3) and appropriate treatment given.

# Severe dehydration
Children with severe dehydration require rapid IV rehydration with close monitoring, which is followed by oral rehydration once the child starts to improve sufficiently. In areas where there is a cholera outbreak, give an antibiotic effective against cholera (see page 46).
The treatment guidelines in this section are for severely dehydrated children who are not severely malnourished. The assessment and management of severely malnourished children with diarrhoea is described in Chapter 7 (sections 7. s Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. s Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children). s Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.
s Refer URGENTLY to hospital for IV treatment. s If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip.
s Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). s Reassess the child every 1-2 hours:
-If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. -If hydration status is not improving after 3 hours, send the child for IV therapy. s After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.
NOTE: If possible, observe the child for at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.
Children with severe dehydration should be given rapid IV rehydration followed by oral rehydration therapy.
q Start IV fluids immediately. While the drip is being set up, give ORS solution if the child can drink.
Note: The best IV fluid solution is Ringer's lactate solution (also called Hartmann's Solution for Injection). If Ringer's lactate is not available, normal saline solution (0.9% NaCl) can be used. 5% glucose (dextrose) solution on its own is not effective and can be dangerous if given quickly.
q Give 100 ml/kg of the chosen solution divided as shown in Table 15.