paediatric protocols final

7/27/2019 Paediatric Protocols Final

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Ministry of Health

Republic of Kenya.

Basic Paediatric Protocols

November 2006


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Table of Contents.

Topic Page NumberAcknowledgements / Principles / Policies 3

DrugsBasic Formulary 6Emergency drugs dose charts

Diazepam and Glucose 8 Phenobarbitone and Phenytoin 9

Intravenous antibiotics (age > 7 days) 10Oral antibiotics 11Maintenance Fluid / Feed Volumes not malnourished 12

Emergency care guidelinesTriage 13Infant / Child resuscitation 14Newborn resuscitation 15

Management guidelinesConvulsions 16

Diarrhoea / dehydration 17 Fluids for severe and some dehydration 18

HIV 19Malaria 20

Malaria drug doses 21

Malnutrition 22

Emergency fluids & feed recipes 23 Feeding 24

Meningitis 25Newborn Care

Neonatal Sepsis / Prematurity / VLBW 26


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Foreward.

This pocket book is for use by doctors, clinical officers, senior nurses andother senior health workers who are responsible for the care of youngchildren at the first referral level where basic laboratory facilities andessential drugs are available. The guidelines require the hospital to have:-(1) capacity to do certain essential investigations such as blood smear formalaria parasites, estimation of haemoglobin or packed cell volume, bloodglucose, blood grouping and cross matching, basic microscopy of CSF and

urine, bilirubin determination for neonates, and chest X-rays and (2)essential drugs available for the care of seriously sick children.

These guidelines focus on the inpatient management of the major causesof childhood mortality such as pneumonia, diarrhoea, malaria, severemalnutrition, meningitis, HIV, neonatal and related conditions. The basis ofthese guidelines is the WHO IMCI Book, A Pocket Book of Hospital Carefor Children. This booklet is a result of a workshop in Machakos inFebruary 2004 drawing together experienced paediatricians from theMinistry of Health, Kenyatta National Hospital, KEMRI and the University ofNairobi. It deals with the management of seriously ill children in the first 48hours.

This handy pocket sized booklet will also be useful to students in medicalschools and other training institutions. The simplified algorithms in this bookcan be enlarged and used as job aides in casualty, outpatients, paediatricwards, delivery rooms and newborn units.

Guidelines of this nature will require periodic revision to keep abreast with

new developments and hence continue to deliver quality care to thechildren of this nation.


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Principles of good care:

1) Hospitals must have basic equipment and drugs in stock at all times(see list of essential items).

2) Sick children coming to hospital must be immediately assessed(triage) and if necessary provided with emergency treatment as soonas possible.

3) Assessment of diagnosis and illness severity must be thorough and

treatment must be carefully planned. All stages should beaccurately documented.

4) The protocols provide a minimum, standard and safe approach tomost, but not all, common problems. Care needs to be taken toidentify and treat children with less common problems rather than justapplying the protocols without thinking.

5) The parents / caretakers need to understand what the illness and itstreatment are. They can often then provide invaluable assistancecaring for the child. Being polite to parents considerably improvescommunication.

6) The response to treatment needs to be assessed. For very severely illchildren this may mean regular review in the first 6 12 hours of

admission such review needs to be planned between medical andnursing staff.

7) Correct supportive care particularly adequate feeding - is asimportant as disease specific care.

8) Laboratory tests should be used appropriately and use ofunnecessary drugs needs to be avoided.

9) An appropriate discharge and follow up plan needs to be made whenthe child leaves hospital.

10) Good hand washing practices and good ward hygiene improveoutcomes of admission.


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Specific policies:

9 All admissions should receive Vitamin A unless they have received adose within the last 1 month. (Malnourished children with eye signsreceive repeated doses).

9 All newborn admissions aged < 14 days should receive Vitamin K unlessit has already been given.

9 Routine immunization status should be checked and missed vaccinesgiven before discharge.

Admission and Assessment:

9 All admitted children must be weighed, the weight recorded and used forcalculation of drug doses.

9 Respiratory rates must be counted for 1 minute.9 Conscious level should be assessed on all children admitted using the

AVPU scale where:o A = Alert and responsiveo V = responds to Voice orVerbal instructions, eg turns head to

mothers call. These children may sti ll be lethargic or unable todrink / breastfeed (prostrate).

o P = responds to Pain appropriately. In a child older than 9 months a

painful stimulus such as rubbing your knuckles on the childs sternumshould result in the child pushing the hand causing the pain away. Ifthe child manages this but does not respond to a voice they are inthis P category. If the child only lifts or bends the arms but is not ableto locate the hand causing the pain they have failed this test and areunconscious. In a child 9 months and youngerthey do not reliablylocate a painful stimulus, in these children if they bend the armstowards the pain and make a vigorous, appropriate cry they respondto pain = P. Children in this categorymust be lethargic or unableto si t up or dr ink / breastfeed (prostrate).

o U = Unconscious, cannot push a hand causing pain away or fail tomake a response at all


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Basic Paediatric Formulary.

Essential Drugs Doses

Adrenaline 1 in 1000 0.01ml / kg s.c. for severe asthma

Adrenaline 1 in 10,000 To make this strength dilute 1 ml of 1 in 1000adrenaline in 9 mls water for injection to make10mls. Give 0.1ml/kg in resuscitation.

Albendazole Age < 2yrs, 200mg stat, Age 2yrs, 400mg statAminophylline- iv Newborn Loading dose 6mg/kg iv over 1 hour or

rectal, Maintenance (or oral): Age 0-7 days -2.5mg/kg 12hrly, Age 7-28 days 4mg/kg 12hrly.

Asthma: 6mg/kg iv first doseover 30 mins then5mg/kg 6hrly

Aminophylline - oral Asthma: 6mg/kg 6hrlyAmoxicillin See separate chart

Artemether- Lumefantrine See separate chart

Benzyl Penicillin (X-pen) See separate chart

Ceftriaxone See separate chart

Chloramphenicol - injectionSee separate chartChloramphenicol - oral See separate chart

Clotrimazole 1% Apply paint / cream daily

Dexamethasone For severe croup 0.6mg/kg stat

Flucloxacillin - injection See separate chart

Flucloxacillin - oral See separate chart

240mg/5ml syrup 480mg tabsWeight12hrly 12hrly

3-6 kg 2mls 1/4

Co-trimoxazole (4mg/kgTrimethoprim & 20mg/kgsulphamethoxazole)

7-9 kg 3.5mls 1/2

10-14 kg 6mls 1


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Iron tabs / syrup 200mg tabs Syrup 100mg/5mls200mg Ferrous sulphate tabs

WeightOnce daily Once daily

3-6 kg - 1ml100mg /5mls Ferrousfumarate syrup 7-9 kg 1/4 1.25ml

10-14 kg 1/2 2mls

15-20 kg 1/2 2.5mls

Mebendazole (age > 1yr) 100mg bd for 3 days or 500mg stat

Metronidazole - oral See separate chart

Morphine


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8

Emergency drugs Diazepam and Glucose.

Diazepam(The whole syringe barrel of a 1ml or 2ml syr inge should be inserted

gently so that pr DZ is given at a depth of approx. 5cm)

Glucose,5mls/kg of 10% glucose over 5 - 10 minutes

iv iv pr pr ivWeight,(kg)

Dose,0.3mg/kg

mls of10mg/2mlsolution

Dose,0.5mg/kg

mls of 10mg/2mlsolution

Total Volume of 10%Glucose

To make 10% glucose

3.00 1.0 0.20 1.5 0.3 15

4.00 1.2 0.25 2.0 0.4 205.00 1.5 0.30 2.5 0.5 25

6.00 1.8 0.35 3.0 0.6 30

7.00 2.1 0.40 3.5 0.7 35

8.00 2.4 0.50 4.0 0.8 40

9.00 2.7 0.55 4.5 0.9 45

10.00 3.0 0.60 5.0 1.0 50

11.00 3.3 0.65 5.5 1.1 55

50% Glucose and water

for injection:

10 mls syringe:9 2 mls 50% Glucose9 8 mls Water

20 mls syringe:

9 4 mls 50% Glucose9 16 mls Water

12.00 3.6 0.70 6.0 1.2 60

13.00 3.9 0.80 6.5 1.3 65

14.00 4.2 0.85 7.0 1.4 70

15.00 4.5 0.90 7.5 1.5 7516.00 4.8 0.95 8.0 1.6 80

17.00 5.1 1.00 8.5 1.7 85

18.00 5.4 1.10 9.0 1.8 90

19.00 5.7 1.15 9.5 1.9 95

20.00 6.0 1.20 10.0 2.0 100

50% Glucose and 5%Glucose:

10 mls syringe:9 1 mls 50% Glucose9 9 mls 5% Glucose

20 mls syringe:9 2 mls 50% Glucose9 18 mls 5% Glucose


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9

Anticonvulsant drug doses and adminstration.

Weight(kg)

Phenobarb,Loading dose,

15mg/kg

Phenobarb,maintenance,

5mg/kg daily(high dose

chronic therapy)

Phenobarbmaintenance

2.5mg/kg daily(starting dose acute

febrile illness)

Phenytoin,loading dose,

15mg/kg

Phenytoin,maintenance

5mg/kg daily

im / oral im / oral im / oral Oral / ng Oral / ng

2.0 30 10 5

2.5 37.5 12.5 6.25

Tablets may be crushed and putdown ngt if required.

3.0 45 15 7.5 45 154.0 60 20 10 60 20

5.0 75 25 12.5 75 25

6.0 90 30 15 90 30

7.0 105 35 17.5 105 35

8.0 120 40 20 120 40

9.0 135 45 22.5 135 4510.0 150 50 25 150 50

11.0 165 55 27.5 165 55

12.0 180 60 30 180 60

13.0 195 65 32.5 195 65

14.0 210 70 35 210 70

15.0 225 75 37.5 225 75

16.0 240 80 40 240 80

17.0 255 85 42.5 255 85

18.0 270 90 45 270 90

19.0 285 95 47.5 285 95

20.0 300 100 50 300 100


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10

Intravenous / intramuscular antibiotic doses Ages 7 days and older.

Weight(kg)

Penicillin*(50,000iu/kg)

Ampicillin orFlucloxacillin

(50mg/kg)

Chloramphenicol(25mg/kg)

Gentamicin(7.5mg/kg)

Ceftriaxone(50mg/kg)

Metronidazole(7.5mg/kg)

iv / im iv / im iv / im im iv / im iv

6 hrly 8 hrly6hrly - meningitis8hrly V.S. LRTI 24 hrly

Meningitis -12 hrlyOther 24 hrly

12 hrly < 1m, 1m 8 hrly

3.0 150,000 150 75 20 150 20

4.0 200,000 200 100 30 200 30

5.0 250,000 250 125 35 250 35

6.0 300,000 300 150 45 300 45

7.0 350,000 350 175 50 350 50

8.0 400,000 400 200 60 400 60

9.0 450,000 450 225 65 450 65

10.0 500,000 500 250 75 500 75

11.0 550,000 550 275 80 550 80

12.0 600,000 600 300 90 600 90

13.0 650,000 650 325 95 650 95

14.0 700,000 700 350 105 700 105

15.0 750,000 750 375 110 750 110

16.0 800,000 800 400 120 800 12017.0 850,000 850 425 125 850 125

18.0 900,000 900 450 135 900 135

19.0 950,000 950 475 140 950 140

20.0 1,000,000 1000 500 150 1000 150

*NB. Double Penicillin doses if treating Meningitis and age > 1 month


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11

Oral antibiotic doses

Amoxicillin, oral,

25mg/kg/dose

Cloxacillin /

Flucloxacillin15mg/kg/dose

Chloramphenicol

25mg/kg/dose

Ciprofloxacin

15mg/kg/dose

Metronidazole

7.5mg/kg/dose

mls susp125mg/5ml

250mgcaps or

tabs

mls susp125mg/5ml

250mg capsor tabs

mls susp125mg/5ml

250mgcaps

250mg tabs 200mg tabs

Weightkg 12 hrly 12 hrly 8 hrly 8 hrly 6 hrly 6 hrly

8 hrly(for 3 days)

8 hrly

3.0 5 1/2 2.5 1/4 4

4.0 5 1/2 2.5 1/4 4 1/4

5.0 5 1/2 5 1/4 6 1/4 1/4

6.0 5 1/2 5 1/2 6 1/4 1/4

7.0 7.5 1/2 5 1/2 8 1/2 1/2

8.0 7.5 1/2 5 1/2 8 1/2 1/29.0 7.5 1 5 1/2 8 1/2 1/2

10.0 10 1 5 1 12 1 1/2 1/2

11.0 10 1 10 1 12 1 1 1/2

12.0 10 1 10 1 12 1 1 1/2

13.0 10 1 10 1 12 1 1 1/2

14.0 15 1 1/2 10 1 12 1 1 115.0 15 1 1/2 10 1 15 1 1 1

16.0 15 1 1/2 10 1 15 1 1 1

17.0 15 1 1/2 10 1 15 1 1 1

18.0 15 1 1/2 10 1 15 1 1 1

19.0 20 2 10 1 15 1 1 1

20.0 20 2 10 1 2 1 1


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Initial Maintenance Fluids / Feeds Normal Renal Function.

Note: Children should receive 1-2 mmol / kg / day of potassium

Feeding should start as soon as safe and infants may rapidly increase to150mls/kg/day of feeds as tolerated (50% more than in the chart).

Add 50mls 50% dextrose to 450mls Half Strength Darrows to makeHSD/5% dextrose a useful maintenance fluid.

Drip rates are in drops per minute

Weight,kg

Volume in24hrs

Rate inmls / hr

Drip rate -adult iv set,

20 drops = 1ml

Drip rate -paediatric burette

60 drops = 1ml

3hrly bolusfeed

volume

3 300 13 4 13 40

4 400 17 6 17 50

5 500 21 7 21 60

6 600 25 8 25 75

7 700 29 10 29 90

8 800 33 11 33 100

9 900 38 13 38 110

10 1000 42 14 42 125

11 1050 44 15 44 130

12 1100 46 15 46 140

13 1150 48 16 48 140

14 1200 50 17 50 150

15 1250 52 17 52 150

16 1300 54 18 54 160

17 1350 56 19 56 160


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Emergency Signs:If history of trauma ensure cervical spine is protected.

Airway &Breathing

9 Obstructed breathing9 Central Cyanosis9 Severe respiratory distress

9Weak / absent breathing

Immediate transfer to

emergency area:9 Start Life support

procedures9 Give oxygen9 Weigh if possible

CirculationCold Hands with:9 Capillary refill >

3seconds9 Weak + fast pulse

9Slow ( 39.50C9Trauma major trauma9Pain child in severe pain9Poisoning mother reports poisoning

Front of the Queue -Clinical review assoon as possible:

Diarrhoea with sunken eyes assessment / treatment for severe dehydration


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Basic Life Support Cardio-respiratory collapse.

Call for Help! - Rapidly move child to emergency area

1) Position head to open airway, 2) Clear airway if obstructed

Assess breathing look, listen, feel for 5 seconds

Support airway

Continue oxygen

Give 5 rescue breaths with bag andmask if chest doesnt move check

airway open and mask fit and repeat.

After at least 2 good breaths

Check the pulse for 10 seconds

Pulse palpable

and >60bpm

1) Continue airway / breathingsupport & oxygen,

2) Look for signs of dehydration

/ poor circulation and giveemergency fluids asnecessary,

3) Consider treatinghypoglycaemia

No or weak, slow pulse

Give 15 chest compressions thencontinue giving 15 chest compressionsfor each 2 breaths for 1 minute.

Re-assess ABC

No breathing Adequate breathing

No change


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Neonatal Resuscitation Call for help!

Dry baby with clean cloth andplace where the baby will bewarm.

If baby floppy / blue / apnoeic suck oro-pharynx under direct vision. Do not suck

right down the throat as this can make thebaby stop breathing and bradycardic.

Use a correctly fitting mask

and give the baby 5 goodinflation breaths.

Position the head of the babyin the neutral position to openthe airway.

Check the heart rate (femoralpulse, cord pulsation or bylistening)

Continue to bag at about 30breaths per minute making

There is no need to slap the baby,

drying is enough.

Make sure the chest moves up with

each press on the mask and in a

very small baby make sure the

chest does not move too much. Aimfor 2 secs inspiration, 0.5 secs

expiration for first 5 breaths.

Compress the chest (1cmbelow the line connectingthe nipples on the sternum)pushing down 1.5 cm at a rate

f 100 i t

If HR < 60 bpm CALLfor help!

A

A

A

B

C

Meconium

Breathing / Crying / Act ive / Pink?

Routine care.

YesNo


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Treatment of convulsions.

Convulsions in the first 1 month of life should be treated with Phenobarbitone

20mg/kg stat, a further 5-10mg/kg can be given within 24 hours of the loadingdose with maintenance doses of 5mg/kg daily.

Age > 1 month.

Child

convulsing formore than 5minutes

Child having 3rd

convulsion lasting


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Diarrhoea / GE protocol (excluding severe malnutrition).Antibiotics are NOT indicated unless there is dysentery orpersistent diarrhoea and provenamoebiasis or giardiasis. Diarrhoea > 14 days may be complicated by intolerance of ORS

worsening diarrhoea if seen change to iv regimens.All cases to receive Zinc.

i)

History of diarrhoea / vomiting, age > 2 months

SEVERE Dehydration.(Plan C)Unable to drink orAVPU< A plus:9 sunken eyes

9 return of skin pinch 2secs

iv Step 1 - 30mls/kgRingers over 30 mins ifage 12m, over 60 minsif age < 12m.

CHECK for SHOCK.Cold hands plus pulse weak/ absent and either:

Capillary refill > 3 secs

AVPU < ANB if Hb


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18

Urgent Fluid management Child WITHOUT severe malnutrition.*

Plan C Step 1 Plan C Step 2 Plan B - 75mls/kg

30mls/kg Ringers 70mls/kg Ringers or ng ORS Oral / ng ORS

Weightkg

Shock,20mls/kg

Ringers orSaline

Immediately

Age


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HIV who to test and how to manage.

Discuss HIV testing if the child has 3 or more key criteria:

9 History of 2 or more episodes of persistent diarrhoea9 Family history of TB within 5 years or confirmed HIV infection in parent(s).9 Weight < 3% weight for age (below low weight line on RTH card)9 Lymphadenopathy > 1cm at 2 or more sites9 Oral thrush (age > 2 months)

9 Pneumonia at presentation

Other signs that should make you consider the diagnosis of HIV include:Shingles (Herpes Zoster), persistent unexplained fever, chronic parotitis.Children being treated for TB should be HIV screened.

Immediate Treatment.

1) Treat the presenting problems in the same way as for an HIV negativechild.

2) If the child is known to be HIV positive on admission and presents withvery severe pneumonia consider treatment for Pneumocystispneumonia immediately.

3) If Pneumocystis is suspected after admission establish HIV status

before treating Pneumocystis pneumonia.

Signs suggesting Pneumocystis pneumonia include:9 Fast breathing (especially very high rates > 70 bpm)9 Hypoxia / cyanosis9 Absence of crackles and wheeze9 Age < 12 months

9 Bilateral interstitial infiltrates on chest X ray are sometimes seen.

Treat and prevent Pneumocystis pneumonia with Co-trimoxazole (CTZ)

Weight CTZ syrup CTZ Tabs Frequency


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Malaria Treatment in malaria endemic areas.

If a high quality blood slide is negative then only children in coma or those

with severe anaemia should be treated presumptively for malaria.

Coma AVPU = U

Unable to drink /breastfeed AVPU = Vor P, and / or,Respiratory distress withsevere anaemia orwithacidotic breathing

Fever, none of the severe signsabove, able to drink / feed, AVPU =A & reliablemalaria test result:(If lab unreliable and there is feverassume child has malaria & give oralantimalarial)

Treat with iv or im Quinine:1. Loading, 15mg/kg (im or iv over 3hrs) then,2. 12 hrly doses 10mg/kg (im or iv over 2hrs).3. Treat hypoglycaemia.

4. Maintenance fluids / feeds.5. If weak pulse AND capillary refill >3secs

give 20mls/kg Ringers until pulserestored (use blood for resuscitation ifHb


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Anti-malarial drug doses - ** Please check the tablets.

200 mg Quinine Sulphate = 200mg Quinine Hydrochloride or Dihydrochloride200 mg Quinine Sulphate = 300mg Quinine Bisuphate

The table below assumes the use of a 200mg Quinine Sulphate tablet.

If the tablets are 300mg Quinine sulphate or dihydrochloride then thetable is NOT appropriate.

Forim Quinine take 1ml of the 2mls in a 600mg Quinine suphate iv vial andadd 5mls water for injection this makes a 50mg/ml solution. Do not givemore than 3mls per injection site. (See nursing chart for more detail)

Quinine loading,15mg/kg

Quinine,maintenance, 10mg/kg

iv infusion / im iv infusion / imWeightkg Once only 12 hrly

Quinine, tabs, 10mg/kg200mg QN sulphate**

8 hourly

3.0 45 30 1/4

4.0 60 40 1/4

5.0 75 50 1/4

6.0 90 60 1/2

7.0 105 70 1/28.0 120 80 1/2

9.0 135 90 1/2

10.0 150 100 3/4

11.0 165 110 3/4

12.0 180 120 3/4

13.0 195 130 3/414.0 210 140 3/4

15.0 225 150 1

16.0 240 160 1

17 0 255 170 1


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Symptomatic severe malnutrition.

Admit to hospital if there is a history of illness and either of:

9 Visible severe wasting (buttocks)9 Oedema and low weight for age or other signs of

Kwashiorkor (flaky paint skin / hair changes).

Step 1

Check glucose and treat if 30 mins after admission.)

Step 2 Check for hypothermia, axillary temperature


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Emergency Fluid management in Severe Malnutrition

Shock: Reduced consciousness, absent, slow (


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24

Feeding children with severe malnutrition use EBM & / or infant formula if aged < 6 months.1) If respiratory distress or oedema get worse or the jugular veins are engorged reduce feed volumes.2) When appetite returns (and oedema much improved) change from F75 to F100, for the first 2 days use the same feed volumes as for

F75. Then give at least the minimum F100 volume and continue increasing feeds by 10mls per feed stopping when the child is not

finishing the feeds or if the maximum is reached.F75 acute feeding F100 catch-up feeding

No or moderate oedema Severe oedema, even face3 hourly feed

volumeWeight(kg)

Total Feeds/ 24 hrs

3 hourly feedvolume

Total Feeds/ 24 hrs

3 hourly feedvolume

Total Feeds/ 24 hrs Min Max

3.0 390 50 300 40 450 55 803.5 455 60 350 45 525 65 95

4.0 520 65 400 50 600 75 110

4.5 585 75 450 60 675 85 120

5.0 650 80 500 65 750 95 135

5.5 715 90 550 70 825 105 150

6.0 780 100 600 75 900 115 1656.5 845 105 650 85 975 125 175

7.0 910 115 700 90 1050 135 190

7.5 975 120 750 95 1125 140 205

8.0 1040 130 800 100 1200 150 220

8.5 1105 140 850 110 1275 160 230

9.0 1170 145 900 115 1350 170 2459.5 1235 155 950 120 1425 180 260

10.0 1300 160 1000 125 1500 190 275

10.5 1365 170 1050 135 1575 200 285

11.0 1430 180 1100 140 1650 210 300

11.5 1495 185 1150 145 1725 215 315

12.0 1560 195 1200 150 1800 225 330


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Meningitis investigation and treatment.

Age 60 days and history of fever

LP must be done if theres one of:9 Coma, inability to drink / feed,

AVPU = P or U.9 Stiff neck,9 Bulging fontanelle,

9 Fits if age 6years,

9 Evidence of partial seizures

Immediate LP to view byeye +/- laboratoryexamination even if malariaslide positive unless: Child requires CPR.

Pupils respond poorly tolight,

Skin infection at LP site

9 Agitation / irritability,

9 Any seizures

Do an LP unless completelynormal mental state after

febrile convulsion. Reviewwithin 8 hours and LP ifdoubt persists.

Meningitis unlikely, investigate other causes of fever.

Interpretation of LP and treatment definitions:Either Bedside examination:9 Looks cloudy in bottle (turbid) and not a blood stained tap,And / or Laboratory examination wi th one or more of (if possible):9 White cell count > 10 x 106/L9 Gram positive diplococci or Gram negative cocco-bacilli,

Classify as definite meningitis:1) Chloramphenicol, PLUS,2) Penicillin,Minimum 10 days of treatment iv / im.St id t i di t d

One of:9 Coma,

No

No

Yes

Yes

No to allYes to one


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Neonatal Sepsis / Prematurity / LBW / Jaundice

Age < 60 days

One or more of:9 No spontaneous movement

/ unconscious9 Inability to feed,

9 Convulsions / abnormalmovements

9 Stiff neck9 Bulging fontanelle9 High pitched cry9 Apnoeas,

1) Check for hypoglycaemia,treat if unable to measureglucose.

2) Start gentamicin andpenicillin (see chart),

3) Give oxygen if cyanosed /RR > 60 bpm.4) Give Vitamin K if born at

home or not given onmaternity.

5) Keep warm.6) Maintain feeding by mouth

or ngt, use iv fluids only ifrespiratory distress orsevere abdominaldistension (see chart).

Yes

No

Jaundice:

No

Yes

1) If back arching or fisting orvery high bilirubin considertransfer for exchange, doseptic screen and startphototherapy

2) If j di l b t

One or more of:9 Temp > 380C or < 35.50C9 History of difficult breathing,9 Lower chest wall indrawing,9 Respiratory rate > 60 bpm,

9 Grunting,9 Cyanosis,9 Pus from ear,9 Pus from umbilicus and

redness of abdominal skin9 Age < 7 days, unwell and

rupture of membranes >24hours.

Do LP unless severerespiratory distress

No

Yes

No


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Duration of Treatment for Neonatal / Young Infant Sepsis.

Growth, Vitamins and Minerals:

Babies should gain about 10g / kg of body weight every day after the first 7 days of life. If theyare not check that the right amount of feed is being given.

All infants aged < 14 days should receive Vitamin K on admission if not already given.

Al l premature infants (< 36 weeks or < 2kg) should receive:

2.5 mls of multivitamin syrup daily once full milk feeding has started (2 wks)

2.5mls of ferrous fumarate suspension daily starting at 4-6 weeks of age for 12 wks.

Problem Days of treatment

Signs of YoungInfant Infection in achild breast feedingwell.

Antibiotics could be stopped after 48 hours if the child isfeeding well without fever and has no other problem andLP, if done, is normal.

The child can go home with oral treatment to complete 5days in total. Advise the mother to return with the child ifproblems recur.

Skin infection withsigns of generalisedillness such as poorfeeding

IV / IM antibiotics could be stopped after 48 hours if thechild is feeding well without fever and has no otherproblem and LP, if done, is normal.

Oral antibiotics should be continued for a further 5 days.

Clinical orradiological

pneumonia.

IV / IM antibiotics should be continued for a minimum of 5days or until completely well.

For positive LP see below.Severe NeonatalSepsis with coma /inability to feed.

The child should have had an LP.

IV / IM antibiotics should be continued for a minimum of 7days or until completely well if the LP is clear

Neonatal meningitisor severe sepsis and

no LP performed

IV / IM antibiotics should be continued for a minimum of14 days.

If Gram negative meningitis is suspected treatmentshould be iv for 3 weeks.


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28

A. Nasogastric 3 hrly feed volumes for babies on full volume feeds(No RDS or asphyxia on Day 1)

Weig

ht(kg

)

1.7to1.8

1.9to2.0

2.1to2.2

2.3to2.4

2.5to2.6

2.7to2.8

2.9to3.0

3.1to3.2

3.3to3.4

3.5to3.6

3.7to3.8

3.9to4.0

Day 1 14 15 17 18 20 21 23 24 26 27 29 30

Day 2 18 20 22 24 26 28 30 32 34 36 38 40

Day 3 23 25 28 30 33 35 38 40 43 45 48 50

Day 427 30 33 36 39 42 45 48 51 54 57 60

Day 5 32 35 39 42 46 49 53 56 60 63 67 70

Day 6 36 40 44 48 52 56 60 64 68 72 76 80

Day 7 41 45 50 54 59 63 68 72 77 81 86 90

B. Intravenous fluid rates in mls / hour for sick newborns on FULL volume iv fluids.

Weig

ht(kg)

1.1-1

.2

1.3-1

.4

1.5-1

.6

1.7-1

.8

1.9-2

.0

2.1-2

.2

2.3-2

.4

2.5-2

.6

2.7-2

.8

2.9-3

.0

3.1-3

.2

3.3-3

.4

3.5-3

.6

3.7-3

.8

3.9-4

.0

Day 1 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10

Day 2 4 5 5 6 7 7 8 9 9 10 11 11 12 13 13Day 3 5 6 7 8 8 9 10 11 12 13 13 14 15 16 17

Day 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Day 5 7 8 9 11 12 13 14 15 16 18 19 20 21 22 23

Day 6 8 9 11 12 13 15 16 17 19 20 21 23 24 25 27

Day 7 9 11 12 14 15 17 18 20 21 23 24 26 27 29 30 NB. For 3 hourly feeds if weight


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29

Intravenous / intramuscular antibiotics aged < 7 days

Penicillin

(50,000iu/kg)

Ampicillin /

Cloxacillin(50mg/kg)

Gentamicin

(3mg/kg


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ARI / pneumonia protocol for children aged 2 months to 4yrs.

History of cough or difficultbreathing, age > 60 days.

Cyanosis, inability to

drink / breast feed,or AVPU = V, P orU, (often + otherrespiratory signs*)

Lower chest wallindrawing, AVPU=A

Age 2 11 months:Respiratory rate 50,Age 12 months:Respiratory rate 40

Wheeze

Very Severe Pneumonia

Oxygen,Chloramphenicol, OR,Penicillin AND Gentamicin.

Severe Pneumonia Benzyl Penicillin ALONE

Pneumonia Amoxycillinif previously had co-trimoxazole for this illness.If no pre-treatment give co-trimoxazole.

Y

Y

Wheeze

Y

Y

No pneumonia,probable URTI.

N

N

N

Wheeze


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Pneumonia treatment failure definitions.

HIV infection may underlie treatment failure testing helps the child.

See HIV page for indications for PCP treatment.

Treatment failure definition Action required

Any time.

Progression of severe pneumoniato very severe peumonia(development of cyanosis orinability to drink in a child withpneumonia without these signs onadmission)

Change treatment from Penicillinto: Chloramphenicol or continuePenicillin and add gentamicin.

Obvious cavitation on CXR Treat with Cloxacillin andgentamicin iv for Staph. Aureus or

Gram negative pneumonia.48 hours

Very severe pneumonia childgetting worse, re-assessthoroughly, get chest X ray if notalready done (looking for empyema/ effusion, cavitation etc).

Add cloxacillin iv to pen and gent.If on chloramphenicol alonecontinue for 5 days.Suspect PCP especially if 380C9 Respiratory rate >60 bpm

a) If only on penicillin change toChloramphenicol, if already onChloramphenicol or Penicillin /


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Possible asthma admission management of the wheezy child.

Wheeze + Cyanosis,inability to drink /breast feed or AVPU= V, P or U. (Rarelysevere asthma canpresent with a silentchest consider atrial of treatment in a

known asthmatic)

Wheeze + Lowerchest wall indrawing.

Severity = Very Severe:9 Oxygen

9 Nebulised salbutamol hourly untilimproving then 4 hourly.*

9 If 3 x 1 hourly doses givenconsider adding Aminophylline.

9 Antibiotics as for Very Severepneumonia

9 Start oral (prednisolone) or ivsteroids

Severity = Severe:9 Oxygen if obvious use of other

accessory muscles.

9 Immediate Salbutamol by inhaler+ spacer or nebuliser and repeat4 hourly.

9 Antibiotics as for Severepneumonia

9 Start oral prednisolone

Y

Y

N

Wheeze + history of cough ordifficult breathing.

Y

Wheeze, feeding OK,but +Age 2 11 months:Respiratory rate 50,Age 12 months:

N

Severity = Mild:9 Oral salbutamol if recurrent

wheeze and age > 6 months.

Y


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33

Emergency estimation of childs weight from their age.

Child looks wellnourished, average

size for age

Age

EstimatedWeight (kg)

1 3 weeks 3.0

4 - 7 weeks 4.0

2 - 3 months 5.0

4 - 6 months 7.07 to 9 months 9.0

10 to 12 months 10.0

1 to 2 yrs 11.0

2 to 3 yrs 13.0

3 to 4 yrs 15.0

4 to 5 yrs 17.0

Child looks obviouslyunderweight findage but step back 2age /weightcategories and usethe weightappropriate for thisyounger age-group.

Eg. Child thin and age

10 months, use theweight for a 4-6month well nourishedchild.

If there is severe

malnutrition thischart will beinaccurate.

All babies and childrenadmitted to hospitalshould be weighed andthe weight recorded inthe medial record and on

the Child Health Card.

Estimate the weightfrom the age only ifimmediate life supportis required or thepatient is in shock.

As soon as possiblecheck the weight andcorrect it.

paediatric protocols final

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