This publication on WHO recommendations related to child health is one of four in a series; the others relate to newborn, maternal and adolescent health. The objective of this document is to make available WHO recommendations on child health in one easy-to-access document for WHO staff, policy-makers, programme managers, and health professionals. The compilation can also help better define gaps to prioritize guideline updates.  What health behaviours should a mother/caregiver practise (or not practise)?
WHO produces guidelines according to the highest international standards for guideline development. The main principles are transparency and minimizing bias in every step of the process. The process of developing guidelines is documented in WHO Handbook for guideline development. 1 The development process includes the synthesis and assessment of the quality of evidence, and is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. GRADE categorizes the quality (or certainty) of the evidence underpinning a recommendation as high, moderate, low or very low.
 High: further research is very unlikely to change our confidence in the estimate of effect;  Moderate: further research is likely to have an impact on our confidence in the effect;  Low: further research is very likely to have an important impact on our confidence in the effect and is likely to change the estimate of effect;
 Very low: any estimate of effect is very uncertain.
Once the quality of the body of evidence on benefits and harms has been assessed, an expert group formulates the recommendations using a structured evidence to decision framework. When determining whether to recommend an intervention or not, the expert group carefully considers the balance of benefits and harms of an intervention, and other factors such as values and preferences of persons affected by the recommendation, stakeholders' perceptions of the acceptability and feasibility of the options and interventions, resource implications, the importance of the problem, and equity and human rights considerations.
The expert group then decides on the strength of the recommendation -strong or conditional. A strong recommendation is one where the desirable effects of adhering to the recommendation outweigh the undesirable effects. Recommendations that are conditional or weak are made when the expert group is less certain about the balance between the benefits and harms or disadvantages of implementing a recommendation. Conditional recommendations generally include a description of the conditions under which the end-user should or should not implement the recommendation.
The quality of evidence and strength of the recommendation, as well as the link to the source, are included in this publication. Different expert groups may employ different terminology in the guideline processes. We suggest the Reader refer to the Source where more details are available.
In this publication we have indicated publications which are New -published after 2013 and Update -to indicate that the recommendation has been revised since 2013.
Promotion of child health and prevention of childhood illnesses

# IMMUNIZATION 2 UPDATE Bacillus Calmette-Guerin (BCG)
  In countries with a high burden of TB, a single dose of BCG vaccine should be given to all infants as soon as possible after birth. Since severe adverse effects of BCG vaccination are extremely rare even in asymptomatic, HIV-positive infants, all healthy neonates should be BCG-vaccinated, even in areas endemic for HIV. However, where resources permit, long-term follow-up of BCG-vaccinated infants of known HIV-positive mothers is desirable for early treatment, should disseminated BCG disease occur in children with rapid development of immunodeficiency. Infants and children with symptomatic human immunodeficiency virus (HIV) or those known to have other immunodeficiency states should not be BCG vaccinated.
In cases where infants have been exposed to smear-positive pulmonary TB shortly after birth, BCG vaccination should be delayed until completion of 6 months of prophylactic isoniazid treatment. Countries with a low burden of TB may choose to limit BCG vaccination to neonates and infants of recognized high-risk groups for the disease or to skin-test negative older children. In some low-burden populations, BCG vaccination has been largely replaced by intensified case detection and supervised early treatment.
Diphtheria   The primary series of DTwP (whole cell)-or DTaP (acellular)-containing vaccines should be administered in 3 doses, starting as early as 6 weeks of age, and given with a minimum interval of 4 weeks. Where resources permit, additional doses can be given after the completion of the primary series. (Strong recommendation, high quality evidence). Source

# Haemophilus influenzae type B (HiB)
  WHO recommends the inclusion of conjugate Hib vaccines in all infant immunization programmes. The use of Hib vaccines should be part of a comprehensive strategy to control pneumonia including exclusive breastfeeding for six months, hand washing with soap, improved water supply and sanitation, reduction of household air pollution, and improved case manage ment at community and health facility levels.

# WHO RECOMMENDATIONS ON CHILD HEALTH
Recommended schedule: WHO recommends that any one of the following Hib immunization schedules may be followed:   3 primary doses without a booster (3p);   2 primary doses plus a booster (2p+1);   3 primary doses with a booster (3p+1). In countries where the peak burden of severe Hib disease occurs in young infants, providing 3 doses of vaccine early in life may confer a greater benefit.
Booster dose: In some settings (e.g. where the greatest disease morbidity and mortality occur later, or where rate reductions of disease are not fully sustained after the routine use of Hib vaccine), it might be advantageous to give a booster dose by following either a 2p+1 or 3p+1 schedule. Age at first dose: Because serious Hib disease occurs most commonly in children aged between 4 months and 18 months, immunization should start from 6 weeks of age, or as early as possible thereafter. Interval between doses: The interval between doses should be at least 4 weeks if 3 primary doses are given, and at least 8 weeks if 2 primary doses are given. Booster doses should be administered at least six months after completion of the primary series.
Interrupted schedule/late commencement: If the schedule has been interrupted, vaccination should be resumed without repeating the previous dose. Children who start vaccination late, but are aged under 12 months, should complete the vaccination schedule (e.g. have 3 primary doses or 2 primary doses plus a booster). When a first dose is given to a child older than 12 months of age, only one dose is recommended. Hib vaccine is not required for healthy children after 5 years of age. Source

# Hepatitis A
  WHO recommends that vaccination against hepatitis A be integrated into the national immunization schedule for children aged 1 year if indicated on the basis of incidence of acute hepatitis A, change in the endemicity from high to intermediate, and consideration of cost-effectiveness. (Strong recommendation, high quality evidence). Source

# Hepatitis B
  All infants should receive their first dose of hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. (Strong recommendation, moderate quality evidence). Source
To complete the primary series the birth dose should be followed by two doses, e.g. at the time of the first and third doses of DTP vaccine, or, if programmatically more convenient, by three doses coinciding with DTP or other routine infant vaccinations. Minimum interval between doses is four weeks. (Strong recommendation, high quality evidence). Source
  Children aged 6-23 months, because of a high burden of severe disease in this group, should be considered a target group for influenza immunization when sufficient resources are available and with due consideration for competing health priorities and operational feasibility. (Strong recommendation, high quality evidence). Source

# Japanese encephalitis
  Japanese encephalitis immunization should be integrated into Expanded Programmes on Immunization in all areas where Japanese encephalitis constitutes a public health problem. (Strong recommendation, high quality evidence). Source

# PROMOTION OF CHILD HEALTH AND PREVENTION OF CHILDHOOD ILLNESSES
  Measles vaccines are recommended for all susceptible children and adults for whom measles vaccination is not contraindicated. On-time delivery of the first dose remains the highest programme priority, but reaching all children with 2 well recorded doses of measles vaccine should be the standard for all national immunization programmes. The second dose can be administered through routine services or given periodically through mass campaigns to defined age groups. Measles elimination requires  95% nation-wide coverage with both doses. To achieve reduction of measles mortality immunization coverage should be  90% at the national level and  80% in each district. Where measles transmission is high, the first dose of measles containing vaccine (MCV1) should be given at 9 months of age, but also to all unvaccinated children over this age. Where transmission is low, MCV1 administration at 12 months of age is preferable. MCV2 may be added to the routine immunization schedule in countries that regularly achieve > 80% national MCV1 coverage. Countries that do not meet this criterion should rather prioritize improving MCV1 coverage and conducting high quality follow-up campaigns. Where MCV1 is given at 9 months of age, the routine MCV2 should be administered at 15-18 months of age. In countries with very low measles transmission and MCV1 administered at 12 months, the optimal time for routine MCV2 (e.g. between age 15-18 months -school entry) depends on programmatic considerations. In countries with moderate to weak health systems, regular measles immunization campaigns can protect children who do not have access to routine health services. Measles vaccination should be routinely given to potentially susceptible, asymptomatic HIV-infected children and adults.
To limit the impact of measles outbreaks, WHO encourages thorough surveillance and risk assessment and rapid response, including expanded use of vaccination. Careful safety surveillance of possible adverse events must remain a key component of all immunization programmes. Source

# Meningococcal vaccines
  WHO recommends that countries completing mass vaccination campaigns introduce meningococcal A conjugate vaccine into the routine childhood immunization programme within 1-5 years following campaign completion, along with a one-time catch-up campaign for birth cohorts born since the initial mass vaccination and which would not be within the age range targeted by the routine immunization programme. In areas where coverage with meningococcal A conjugate vaccine is less than 60%, periodic campaigns could be 1 Meningitis Vaccine Project. (, accessed December 2014). Considered to complement routine vaccination, as herd protection may not be sufficient to protect those who are not immunized.
  WHO recommends a 1-dose schedule with vaccine administration by deep intramuscular injection, preferably in the anterolateral aspect of the thigh at 9-18 months of age based on local programmatic and epidemiologic considerations. Any children who miss vaccination at the recommended age should be vaccinated as soon as possible thereafter. If in a specific context there is a compelling reason to vaccinate infants younger than 9 months, a 2-priming dose infant schedule should be used starting at 3 months of age, with doses at least 8 weeks apart. MenAfriVac 5 g should be used for routine immunization of those 3 to 24 months of age. MenAfriVac 10 g should be used for catch-up and periodic campaigns from 12 months of age onwards unless bridging studies have been conducted and show that MenAfriVac 5 g can be used in older age groups. The need for a booster dose has not been established.
  Data on co-administration with other vaccines has been evaluated and found to be acceptable for diphtheria toxoid, tetanus toxoid, whole cell pertussis, hepatitis B, Haemophilus influenzae type b, oral poliovirus, yellow fever, measles and rubella vaccines.
No evidence exists for co-administration with rotavirus vaccine, pneumococcal conjugate vaccine or inactivated polio vaccine; however, absence of data should not discourage co-administration. Source Pertussis   All children worldwide, including HIV-positive individuals, should be immunized against pertussis. Protection can be obtained after a primary series of vaccination with either whole cell pertussis (wP) or Accelular pertussis (aP) vaccine. Although local and systemic reactogenicity are more commonly associated with wP-containing vaccines, both vaccines have excellent safety records. A switch from wP to aP vaccines for the primary schedule should only be considered if additional periodic booster or maternal immunization can be assured and sustained.
  National programmes currently administering wP vaccination should continue to use wP vaccines for primary vaccination series. National programmes currently using aP vaccine may continue using this vaccine but should consider the need for additional booster doses and additional strategies such as maternal immunization in case of resurgence of pertussis.
The following vaccine dosing schedules and ages of administration are recommended:
-Recommends a 3-dose primary series, with the first dose administered as early as 6 weeks subsequent doses should be given 4-8 weeks apart, at age 10-14 weeks and 14-18 weeks last dose of the recommended primary series should ideally be completed by 6 months for those who have not completed the primary schedule, vaccine may be given later than 6 months of age, at any age and at the earliest opportunity national programmes using alternate primary vaccination schedules with adequate surveillance should continue using these schedules and continue to monitor disease trends   This schedule should provide protection for at least 6 years for countries using wP vaccine.
For countries using aP vaccine, protection may decline appreciably before 6 years of age. recommends a bivalent OPV (bOPV) birth dose (a zero dose) followed by a primary series of 3 bOPV doses and at least 1 IPV dose. The primary series consisting of 3 bOPV doses plus 1 IPV dose can be initiated from the age of 6 weeks with a minimum interval of 4 weeks between the bOPV doses. If 1 dose of IPV is used, it should be given from 14 weeks of age (when maternal antibodies have diminished and immunogenicity is significantly higher) and can be co-administered with a bOPV dose.
  The primary series can administered according to the regular schedules of national immunization programmes, for example at 6, 10, and 14 weeks (bOPV1, bOPV2, bOPV3+IPV), or at 2, 4, and 6 months (bOPV1, bOPV2+IPV, bOPV3 or bOPV1, bOPV2, bOPV3+IPV). Both OPV and IPV may be co-administered with other infant vaccines. For infants starting the routine immunization schedule late (age >3 months) the IPV dose should be administered at the first immunization contact along with bOPV and the other routinely recommended vaccines. In countries with high vaccination coverage (e.g. 90%-95%) and low importation risk (neighboring countries and major population movement all having similarly high coverage) an IPV-bOPV sequential schedule can be used when vaccine-associated paralytic poliomyelitis (VAPP) is a significant concern.
 Where a sequential IPV-bOPV schedule is used, the initial administration of 1 or 2 doses of IPV should be followed by 2 doses of bOPV to ensure both sufficient levels of protection in the intestinal mucosa and a decrease in the burden of VAPP. For sequential IPV-bOPV schedules, WHO recommends that IPV be given at 2 months of age (e.g. a 3-dose IPV-bOPV-bOPV schedule), or at 2 months and 3-4 months of age (e.g. a 4-dose IPV-IPV-bOPV-bOPV schedule) followed by at least 2 doses of bOPV. An IPV-only schedule may be considered in countries with both sustained high immunization coverage and the lowest risk of both wildstrain polio viruses (WPV) importation and transmission. A primary series of 3 doses of IPV should be administered beginning at 2 months of age. If the primary series begins earlier (e.g. with a 6, 10 and 14-week schedule) then a booster dose should be given after an interval of 6 months (for a 4-dose schedule). To mitigate the risk of undetected transmission, WHO recommends that endemic countries and countries with a high risk of WPV importation should not switch to an IPV-only or a sequential IPV-bOPV schedule at this time. The 3 bOPV+1 IPV schedule as currently recommended should be adopted and supplemental immunization activities should continue to support intensive efforts to eliminate poliovirus transmission. A sequential IPV-bOPV schedule or IPV-only schedule can be considered in order to minimize the risk of VAPP, but only after a thorough review of local epidemiology. Polio vaccine (IPV or bOPV) may be administered safely to asymptomatic HIV-infected infants. HIV testing is not a prerequisite for vaccination. bOPV is contraindicated in severely immunocompromised patients. These populations can safely receive IPV. 1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within a half-hour of birth.
- Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
- Give newborn infants no food or drink other than breastmilk unless medically indicated.
- Practise rooming in -allow mothers and infants to remain together -24 hours a day.
- Encourage breastfeeding on demand.
- Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Acceptable medical reasons for use of breast-milk substitutes   Nearly all women are able to breastfeed. In rare infant and maternal conditions, formula and/or foods other than breast milk may be required for short-or long-term feeding. (See document on web site for specific conditions.) -Promotion of handwashing with soap after defecation and handling of human or animal faeces and before food preparation and eating, along with the provision of soap, are recommended for people with HIV and their households. (Strong recommendation, good quality evidence). Source -Household-based water treatment methods that are effective in reducing diarrhoea and the storage of water in containers that inhibit manual contact are recommended for people with HIV and their households. (Strong recommendation, high quality evidence). Source -Proper disposal of faeces in a toilet, latrine, or at a minimum, buried in the ground is recommended for people with HIV and their households. (Strong recommendation, good quality evidence). Source -Vitamin A supplementation is recommended for all HIV-infected and -exposed infants and children aged 6 months to 5 years, in doses given every 6 months (100 000 IU for those aged 6-12 months and 200 000 IU for those aged > 12 months). -For infants less than six months of age:
- Commercial infant formula milk as long as home conditions outlined in Recommendation #5 are fulfilled;
- Expressed, heat-treated breast milk (see Recommendation #6).
Home-modified animal milk is not recommended as a replacement food in the first six months of life.
-For children over six months of age:
- Commercial infant formula milk as long as home conditions outlined in Recommendation#5 are fulfilled;
- Animal milk (boiled for infants under 12 months), as part of a diet providing adequate micronutrient intake;
- Meals, including milk-only feeds, other foods and combination of milk feeds and other foods, should be provided four or five times per day. All children need complementary foods from six months of age.
(Strong recommendation, low quality evidence). Source   Mothers known to be HIV-infected should only give commercial infant formula milk as a replacement feed to their HIV-uninfected infants or infants who are of unknown HIV status, when specific conditions are met: a. safe water and sanitation are assured at the household level and in the community; and b. the mother or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant; and c. the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and d. the mother or caregiver can, in the first six months, exclusively give infant formula milk; and e. the family is supportive of this practice; and f. the mother or caregiver can access health care that offers comprehensive child health services.
(Strong recommendation, low quality evidence). Source   Mothers known to be HIV-infected may consider expressing and heat-treating breast milk as an interim feeding strategy:
in special circumstances such as when the infant is born with low birth weight or is otherwise ill in the neonatal period and unable to breastfeed; or when the mother is unwell and temporarily unable to breastfeed or has a temporary breast health problem such as mastitis; or to assist mothers to stop breastfeeding; or if antiretroviral drugs are temporarily not available.
(Weak recommendation, very low quality evidence). Source   If infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first six months of life and continue breastfeeding as per the recommendations for the general population, that is, up to two years or beyond.
(Strong recommendation, moderate quality evidence). Source

# Interventions to support infant feeding practices by mothers living with HIV
Can facility-and community-based interventions improve the quality of infant feeding practices among mothers living with HIV?
  National and local health authorities should actively coordinate and implement services in health facilities and activities in workplaces, communities and homes to protect, promote and support breastfeeding among women living with HIV.
(Strong recommendation, high quality of evidence). Source
Guiding practice statements (A guiding practice statement is made to encourage action or clarify an issue of concern. It addresses an area of suboptimal practice and provides a contingency and guidance to health workers regarding how to respond to a specific challenge.)

# PROMOTION OF CHILD HEALTH AND PREVENTION OF CHILDHOOD ILLNESSES
When mothers living with HIV do not exclusively breastfeed   Mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practising mixed feeding is not a reason to stop breastfeeding in the presence of ARV drugs.
When mothers living with HIV do not plan to breastfeed for 12 months   Mothers living with HIV and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.

# Antiretroviral drugs for post-exposure prophylaxis
An HIV post-exposure prophylaxis regimen with two antiretroviral drugs is effective, but three drugs are preferred. -In settings where malaria and/or severe bacterial infections are highly prevalent, cotrimoxazole prophylaxis should be continued until adulthood, irrespective of whether ART is provided (conditional recommendation, moderate-quality evidence).
-In settings with low prevalence for both malaria and bacterial infections, co-trimoxazole prophylaxis may be discontinued for children 5 years of age and older who are clinically

# NEW Sugar Intakes
  WHO recommends a reduced intake of free sugars throughout the lifecourse (strong recommendation).
-In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation).
-WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake (conditional recommendation).
  Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.
  For countries with a low intake of free sugars, levels should not be increased.

# PROMOTION OF CHILD HEALTH AND PREVENTION OF CHILDHOOD ILLNESSES
  Higher intakes of free sugars threaten the nutrient quality of diets by providing significant energy without specific nutrients.
  These recommendations were based on the totality of evidence reviewed regarding the relationship between free sugars intake and body weight (low and moderate quality evidence) and dental caries (very low and moderate quality evidence).
  Increasing or decreasing free sugars is associated with parallel changes in body weight, and the relationship is present regardless of the level of intake of free sugars. The excess body weight associated with free sugars intake results from excess energy intake.
The recommendation to limit free sugars intake to less than 10% of total energy intake is based on moderate quality evidence from observational studies of dental caries.
  The recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality evidence from ecological studies in which a positive doseresponse relationship between free sugars intake and dental caries was observed at free sugars intake of less than 5% of total energy intake.
  The recommendation to further limit free sugars intake to less than 5% of total energy intake, which is also supported by other recent analyses is based on the recognition that the negative health effects of dental caries are cumulative, tracking from childhood to adulthood. Because dental caries is the result of lifelong exposure to a dietary risk factor (i.e. free sugars), even a small reduction in the risk of dental caries in childhood is of significance in later life; therefore, to minimize lifelong risk of dental caries, the free sugars intake should be as low as possible.
  No evidence for harm associated with reducing the intake of free sugars to less than 5% of total energy intake was identified. Although exposure to fluoride reduces dental caries at a given age, and delays the onset of the cavitation process, it does not completely prevent dental caries, and dental caries still progresses in populations exposed to fluoride. Intake of free sugars is not considered an appropriate strategy for increasing caloric intake in individuals with inadequate energy intake if other options are available. These recommendations do not apply to individuals in need of therapeutic diets, including for the management of severe and moderate acute malnutrition. Specific guidelines for the management of severe and moderate acute malnutrition are being developed separately. with low HIV prevalence, give amoxicillin at least 40mg/kg per dose twice daily for 3 days.
with high HIV prevalence, give amoxicillin of at least 40mg/kg per dose twice daily for 5 days. Antibiotic treatment for very severe pneumonia   Children aged 2-59 months with very severe pneumonia should be treated with parenteral ampicillin (or penicillin) and gentamicin as a first line treatment.
-Ampicillin: 50 mg/kg, or Benzyl penicillin: 50 000 units per kg IM/IV every 6 hours for at least 5 days -Gentamicin: 7.5 mg/kg IM/IV once a day for at least 5 days Preventing relapse in P. vivax or P. ovale malaria   The G6PD status of patients should be used to guide administration of primaquine for preventing relapse. (Good practice statement)   To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants aged < 6 months, women breastfeeding older infants unless they are known not to be G6PD defcient, and people with G6PD defciency) with a 14-day course (0.25-0.5 mg/kg bw daily) of primaquine in all transmission settings. (Strong recommendation, high-quality evidence)   In people with G6PD defciency, consider preventing relapse by giving primaquine base at 0.75 mg/kg bw once a week for 8 weeks, with close medical supervision for potential primaquineinduced haemolysis. (Conditional recommendation, very low-quality evidence)   When G6PD status is unknown and G6PD testing is not available, a decision to prescribe primaquine must be based on an assessment of the risks and benefits of adding primaquine. (Good practice statement). Source

# Acute bacterial meningitis
Antibiotics for treatment of acute bacterial meningitis   Children with acute bacterial meningitis should be treated empirically with 3rd generation cephalosporins.
-Ceftriaxone: 50mg/kg per dose IV every 12 hours or 100 mg/kg once daily, or -Cefotaxime: 50mg/kg per dose every 6 hours for 10-14 days.
(Strong recommendation, moderate quality evidence). Source   Where it is known that there is no significant resistance to chloramphenicol and beta lactam antibiotics among bacteria-causing meningitis follow national guidelines or choose any of the following two regimens:
-Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours plus ampicillin: 50 mg/kg IM (or IV) every 6 hours OR -Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours plus benzyl penicillin: 60 mg/kg (100 000 units/kg) every 6 hours IM (or IV).

# Typhoid fever
Antibiotics for treatment of typhoid fever   Children with typhoid fever should be treated with a fluoroquinolone (i.e. Ciprofloxacin, Gatifloxacin, Ofloxacin, and Perfloxacin) as a first line treatment for 7-10 days.
iprofloxacin: orally 15 mg/kg/dose twice daily for 7-10 days.
(Strong recommendation, moderate quality evidence). Source   If the response to treatment is poor, consider drug-resistant typhoid, and treat with a second line antibiotic like 3rd generation cephalosporins or azithromycin.
-Cetriaxone (IV): 80 mg/kg per day for 5-7 days, OR -Azithromycin: 20 mg/kg per day for 5-7 days.  weight-for-height/length is -2 Z-score and they have had no oedema for at least 2 weeks, or mid-upper-arm circumference is 125 mm and they have had no oedema for at least 2 weeks. -Benzyl penicillin: 50 000 U/kg IM/IV every 6 hours, or ampicillin: 50 mg/kg IM/IV every 6 hours for 2 days, then oral amoxicillin: 15 mg/kg per dose every 8 hours for 5 days.
-Gentamicin: 7.5 mg/kg IM/IV once daily for 7 days. have appetite and reduced oedema and are therefore ready to move into the rehabilitation phase, they should transition from F-75 to ready-to-use therapeutic food over 2-3 days, as tolerated. The recommended energy intake during this period is between 100-135 kcal/ kg per day. The optimal approach for achieving this is not known and may depend on the number and skills of staff available to supervise feeding and monitor the children during rehabilitation. Two options for transitioning children from F-75 to ready-to use therapeutic food are suggested:
-Start feeding by giving ready-to-use therapeutic food as prescribed for the transition phase. Let the child drink water freely. If the child does not take the prescribed amount of ready-to-use therapeutic food, then top up the feed with F-75. Increase the amount of ready-to-use therapeutic food over 2-3 days until the child takes the full requirement of ready-to-use therapeutic food.
-Give the child the prescribed amount of ready-to-use therapeutic food for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of ready-to-use therapeutic food in the first 12 hours then stop giving the readyto-use therapeutic food and give F-75 again. Retry the same approach after another one to two days until the child takes the appropriate amount of ready-to-use therapeutic food to meet energy needs. (Strong recommendation, very low quality evidence). Source   In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation phase: Children who have been admitted with complicated severe acute malnutrition and are achieving rapid weight gain on F-100 should be changed to ready-to-use therapeutic food and observed that they accept the diet before being transferred to an outpatient programme.  a. Should be breastfed where possible and the mothers or female caregivers should be supported to breastfeed the infants. If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate. If this is not possible wet-nursing 9 should be encouraged.
b. Should be provided a supplementary feed:
i. Supplementary suckling approaches should, where feasible, be prioritized;
ii. For infants with SAM but no oedema, expressed breast milk should be given, and where this is not possible, commercial (generic) infant formula or F-75 or diluted F-100 10 may be given either alone or as the supplementary feed together with breast milk;
iii. For infants with SAM and oedema, infant formula or F-75 should be given as a supplement to breast milk.
c. Should not be given undiluted F-100 at any time (due to the high renal solute load and risk of hypernatraemic dehydration).
d. If there is no realistic prospect of being breastfed, should be given appropriate replacement feeds such as commercial (generic) infant formula with relevant support to enable safe preparation and use, including at home when discharged; e. Assessment of physical and mental health status of mothers or caretakers should be promoted and relevant treatment or support provided.
(Strong recommendation, very low quality evidence). Source   Infants less than 6 months of age who were admitted to inpatient care can be transferred to outpatient care when: a. All clinical conditions or medical complications including oedema are resolved, and b. The infant has good appetite, is clinically well and alert, and c. Weight gain on either exclusive breastfeeding or replacement feeding is satisfactory e.g. above the median of the WHO growth velocity standards or more than 5gm/kg per day for at least 3 successive days, and All potential wet-nurses should be tested for HIV.
10 Prepared F-100 should be further diluted by adding 30% water.
  For infants less than 6 months of age with SAM who do not require inpatient care or whose caretakers decline admission for assessment and treatment: a. Counselling and support for optimal infant and young child feeding should be provided based on general infant and young child feeding recommendations including for lowbirth-weight infants.
b. Weight gain of the infant should be monitored weekly to observe changes;
c. If the infant does not gain weight, or loses weight while the mother or caregiver is receiving support for breastfeeding, then infants should be referred to inpatient care; d. Assessment of physical and mental health status of mothers or caretakers should be promoted and relevant treatment or support provided. -Infants diagnosed in the first year of life (strong recommendation, moderate-quality evidence).
-Children living with HIV 1 year old to less than 10 years old (conditional recommendation, low-quality evidence). blood glucose blood sodium (in children with severe dehydration or diarrhoea)
lumbar puncture in febrile children with signs of meningitis (Strength of recommendation strong, Quality of evidence very low). Source -Lumbar puncture should be considered for any infant or child who appears severely ill (e.g. high fever with altered consciousness or seizure) and with any of the following:
- age < 18 months (especially < 6 months);
- complex febrile seizures (prolonged, focal or recurrent during the same febrile illness);
- antimicrobials were given before assessment;
- not vaccinated against Haemophilus influenza type b or Streptococcus pneumoniae or with unknown immunization status   They should be given 10-20 mL/kg body weight (bw) of isotonic crystalloid fluids over 30-60 min.
  They should be fully assessed, an underlying diagnosis made, receive,other relevant treatment and their condition monitored.
  The child should be reassessed at the completion of infusion and during subsequent hours to check for any deterioration:
-If the child is still in shock, consider giving a further infusion of 10 mL/kgbw over 30 min.
-If shock has resolved, provide fluids to maintain normal hydration status only (maintenance fluids).
 Dried blood spot specimens using venous or capillary whole blood can be used to determine the HIV viral load. A threshold of 1000 copies/mL can be used to determine virological failure when using dried blood spot samples, as defined for testing in plasma (conditional recommendation, low-quality evidence)